Scandinavian Journal of Urology. 2014; 48: 466–473
ORIGINAL ARTICLE
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Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: a prospective randomized study
MOHAMED G. SOLIMAN1, MOHAMED ABO FARHA1, AHMED S. EL ABD1 & HUSSEIN ABDEL HAMEED2 & SAMIR EL GAMAL1 1
Urology Department, Tanta University, Tanta, Egypt, and 2Urology Department, Fayoum University, Fayoum, Egypt
Abstract Objective. The aim of this study was to compare the outcomes of dorsal onlay urethroplasty using buccal mucosa graft (BMG) versus penile skin flap (PSF) in the repair of long anterior urethral strictures. Material and methods. Patients with long anterior urethral strictures were randomized to receive either dorsal onlay BMG urethroplasty or PSF urethroplasty. All patients were evaluated preoperatively and during follow-up with the International Prostate Symptom Score (IPSS) and uroflowmetry. Success was reported when there were no obstructive symptoms on IPSS, with a peak urinary flow rate (Qmax) of at least 15 ml/s. Failure was reported in patients with obstructive symptoms, Qmax less than 15 ml/s and evidence of recurring stricture on urethrography. Results. The study included 19 and 18 patients in the BMG and PSF groups, respectively. The mean operative time was significantly shorter in the BMG than in the PSF group. The success rate was higher in the BMG than in the PSF group (89.5% vs 83.3%), but not statistically significant different. The PSF group included one case of extensive skin loss, three cases with superficial skin necrosis and two with minor penile torsion. In the BMG group, there were three cases of perioral numbness and another three had increased salivation. The incidence of troublesome postvoid urinary dribbling was significantly higher in the PSF than in the BMG group. After 6 months of urethroplasty, patient satisfaction was statistically significantly higher in the BMG than in the PSF group. Conclusions. BMG and PSF dorsal onlay urethroplasty had similar success rates. However, BMG is technically easier, takes less operative time and has a potential advantage in reducing postoperative morbidity, therefore leading to satisfaction for most patients.
Key Words: anterior urethral strictures, buccal mucosa graft, dorsal onlay, penile skin flap, urethroplasty
Introduction Urethral stricture is a complicated disease that represents a therapeutic challenge [1]. Each segment of the urethra is prone to this condition; each has its own particular type of stricture and is treated using different techniques according to varying circumstances [2]. Complex strictures of the anterior urethra that cannot be treated by means of excision and reanastomosis are best treated with substitution urethroplasty [3,4]. Traditionally, penile skin flaps (PSFs) were considered the most reliable tissue for urethroplasty [5].
Recently, the successful use of free grafts has renewed the search for ideal urethral substitutes [6]. Of these free grafts, buccal mucosa has emerged as one of the most reliable and popular grafts for patch urethroplasty because of its unique physical characters, as it is hairless and easy to harvest [7–9]. In addition, oral mucosa has immunological properties similar to those of the urothelium, making it less prone to infection [8,10]. The usual practice was to place this graft on the ventral aspect of the urethra [11]. In 1998, Barbagli et al. introduced dorsally placed grafts for the first time and postulated that dorsal placement is
Correspondence: M. Soliman, Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt. Tel: +20 181369517. Fax: +20 403400881. E-mail: [email protected]
(Received 21 August 2013; revised 28 November 2013; accepted 23 January 2014) ISSN 2168-1805 print/ISSN 2168-1813 online 2014 Informa Healthcare DOI: 10.3109/21681805.2014.888474
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Anterior urethral stricture repair advantageous because the underlying corpora gives better mechanical support to the graft as well as the blood supply [8]. However, the best means of substitution urethroplasty remains controversial, and the superiority of one technique over another has not yet been clearly defined [12]. This is attributed to a lack of prospective randomized and other well-conducted trials on the management of urethral stricture disease [13]. As a consequence, the level of evidence on the surgical treatment of urethral strictures and the guidelines on which technique to use in each particular circumstance is low [14]. The aim of this study was to compare the outcomes of dorsal onlay urethroplasty using buccal mucosa graft (BMG) or PSF in the repair of long anterior urethral stricture, in order to identify the best substitution material for this challenging problem on a prospective, randomized basis. Material and methods This prospective, randomized study was performed in the Urology Department, Tanta University, Egypt, and was approved by the institutional ethics review board. All patients provided written consent before enrolment. The study included patients aged at least 18 years with long anterior urethral stricture (>2 cm) not amenable to anastomotic urethroplasty in whom the aetiology was considered to be inflammatory, idiopathic or postinstrumentation (catheter or endoscopy). In total, 37 patients were subjected to substitution urethroplasty and were randomized to receive either dorsal onlay BMG or PSF. The randomization list was concealed from the investigators during the study to avoid selection bias as subjects were enrolled. Patients with balanitis xerotica obliterans, unhealthy penile skin or oral mucosal pathology, and recurrent cases who had undergone more than one previous internal urethrotomy or dilatation, or had a history of urethroplasty were excluded from the study. All patients were evaluated preoperatively with complete history taking including International Prostate Symptom Score (IPSS), sexual function, physical examination, urine analysis, urinary tract ultrasound with postvoid residual urine estimation, uroflowmetry, retrograde urethrography (RUG) and voiding cystourethrography (VCUG).
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et al. [15]. The urethra was completely mobilized from the corpora cavernosa and rotated 180 degrees (Figure 1). The strictured tract was opened along its dorsal surface, extending the incision for about 1 cm both proximally and distally into the normal urethral lumen. The urethra was calibrated proximal and distal to the strictured segment and a BMG or PSF was applied as a dorsal onlay over 16 Fr silicone catheter using 5-0 polyglactin sutures (Figures 2 and 3). In the PSF group, either a circumpenile or a longitudinal vascular skin flap was harvested, according to the stricture site. In the other group, the BMG was harvested from one cheek or from one cheek and the lower lip, depending on stricture length, and the procedure was achieved by a two-team approach (the perineal team exposes the stricture, while the other simultaneously harvests the graft from the mouth). A prophylactic broad-spectrum antibiotic (cefotax) was administered 2 h before surgery and continued for 5 days postoperatively. In the BMG group, mouth washes with povidone–iodine oral solution were started 2 days before graft harvesting and continued postoperatively for 2 days. The catheter was removed 3 weeks postoperatively when no extravasation was detected on voiding cystourethrography; otherwise, the catheter was kept for another 2 weeks. Follow-up consisted of careful history taking including IPSS, sexual function and uroflowmetry at 3, 6, 12 and 18 months and every year subsequently. An RUG was ordered to rule out recurrence of the stricture if the patient had obstructive symptoms on IPSS and the peak urinary flow rate (Qmax) was found to be less than 15 ml/s on uroflowmetry. Clinical outcome was considered a success when
Technique The surgical technique used for dorsal onlay urethroplasty was the one previously described by Barbagli
Figure 1. Complete mobilization and exposure of the urethra. Inset: Rotation of the urethra and line of incision along the dorsal surface of the bulbopendulous urethra.
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Strictured segment opened
Figure 2. Opening of the strictured segment.
there were no obstructive symptoms on IPSS, with Qmax of 15 ml/s or higher. Failure was reported in patients with obstructive symptoms, Qmax less than 15 ml/s and evidence of recurring stricture on RUG with any subsequent postoperative instrumentation, including dilatation. Statistical analysis Differences between the two groups were analysed statistically with the SPSS program, version 11.0. Demographic data were analysed by the Student’s
Catheter
t test. Categorical variable were analysed by the chisquared test. Two-tailed p values less than 0.05 were considered statistically significant. Results In total, 37 patients (19 patients in the BMG group and 18 patients in the PSF group) were included in this study. The preoperative parameters were comparable between the two groups. The causes of stricture in this series were: postinstrumentation in six and five patients, postinflammatory in five and six
Flab or graft
Figure 3. Suture of the graft or flap to the urethra.
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Anterior urethral stricture repair patients, and idiopathic in eight and six patients in the BMG and PSF groups, respectively. The site of stricture was pendulous, bulbar and bulbopendulous strictures in nine, 13 and 15 patients, respectively. The mean age of the patients was 37 years (range 18– 52 years) and 36.2 years (21–50 years) in the BMG and PSF groups, respectively. Mean stricture length in the BMG group was 5.6 cm (range 3.5–12.5 cm) and in the PSF group 5.4 cm (4–12 cm), with no statistically significant difference between the two groups (p > 0.05) (Table I). Mean follow-up was 24.2 months (range 12– 50 months) and 25.1 months (range 14–61 months) in the BMG and PSF groups, respectively. All patients completed at least 1 year of follow-up (Table II). In the BMG group, mucosa used for substitution urethroplasty was obtained from a single cheek in 11 patients and from a single cheek and the lower lip in eight patients. In the PSF group, the technique used was a circumferential flap in 14 cases and longitudinal in four cases. The mean operative time was significantly shorter in the BMG group (155 ± 6.2 min) than in the PSF group (218.5 ± 15.1 min) (p < 0.001). The mean hospital stay was 4.5 days (range 4–6 days) in the BMG group and 5 days (4–7 days) in the PSF group, with no statistically significant difference (p > 0.05) (Table II). The Qmax was improved in the BMG group from an average of 8.6 ml/s preoperatively to 22.3 ml/s postoperatively, while in the PSF group the Qmax increased from an average of 9.3 ml/s preoperatively to 23.3 ml/s postoperatively. However, IPSS decreased from a mean of 22.8 preoperatively to 4.2 postoperatively in Table I. Preoperative parameters in the buccal mucosa graft (BMG) and penile skin flap (PSF) groups. BMG
PSF
p
No. of patients
19
Mean age (years)
37 (18–52)
18 36.2 (20–51)
NS
Mean stricture length (cm)
5.6 (3.5–12.5)
5.4 (4–12)
NS
Mean IPSS
22.8
23.2
NS
Mean Qmax (ml/s)
8.6
9.3
Cause of stricture
NS NS
Postinstrumentation
6
5
Postinflammatory
5
6
Idiopathic
8
6
Pendulous
5
4
Bulbous
6
7
Bulbopendulous
8
7
Site of stricture
NS
IPSS = International Prostate Symptom Score; Qmax = peak urinary flow rate; NS = not significant (p > 0.05).
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Table II. Outcomes in the buccal mucosa graft (BMG) and penile skin flap (PSF) groups.
Mean operative time (min)
BMG
PSF
p
155 ± 6.2
218.5 ± 15.1
< 0.001
Mean hospital stay (days)
4.5 (4–6)
5 (4–7)
NS
Mean follow-up (months)
24.2 (12–50)
25.1 (14–61)
NS
Success rate
17 (89.5%)
15 (83.3%)
NS
Mean IPSS
4.2
5.3
NS
Mean Qmax (ml/s)
22.3
23.3
NS
Preference by patient
16 (84.2%)
12 (66.7%)
< 0.05
Early postoperative complications
NS
Haematoma
1 (5.3%)
1 (5.5%)
Wound infection
1 (5.3%)
1 (5.5%) 3 (33.3%)
Penile skin problems Superficial necrosis
0
Skin loss
0
1 (5.5%)
Penile torsion
0
2 (11%)
Perioral numbness
3 (15.8%)
0
Increased salivation
3 (15.8%)
0
Troublesome postvoid dribbling
3 (15.8%)
6 (33.3%)
Oral morbidity
< 0.05
IPSS = International Prostate Symptom Score; Qmax = peak urinary flow rate; NS = not significant (p > 0.05).
the BMG group and decreased from a mean of 23.3 preoperatively to 5.3 postoperatively in the PSF group (Table II). At 12 months’ follow-up, the mean Qmax was 20.8 ml/s and 21.5 ml/s, while the mean IPSS was 5.4 and 6.1 in the BMG and PSF groups, respectively. The overall success rate was 86.5% (32 patients out of 37), including 17 patients in the BMG group (89.5%) (Figure 4A,B) and 15 patients in the PSF group (83.3%) (Figure 5A,B). The difference between the two groups was not statistically significant (p > 0.05). In both pendulous and bulbopendulous stricture, success was achieved in 11 out of 13 cases (84.6%) and in nine out of 11 cases (81.8%) in the BMG and PSF groups, respectively, with no significant difference (p > 0.05). In bulbous stricture, success was achieved in all cases of BMG and in six out of seven cases of PSF (85.7%), with no significant difference (p > 0.05) (Table II). With regard to early postoperative complications, the rates of both haematoma and minor wound infection were similar in the two groups (Table II). With the exception of one case of extensive skin loss that required a split-thickness skin graft, all complications specific to the PSF group were minor with no
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A
B
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Figure 4. Retrograde urethrography: (A) preoperatively; (B) 6 months later, after buccal mucosa graft technique.
subsequent problems (three cases with superficial skin necrosis that healed within 1 month postoperatively and two cases with minor penile torsion that did not interfere with sexual intercourse) (Table II). Only 24 out of 37 patients who were sexually potent preoperatively reported no significant negative effects on erectile function postoperatively. In the BMG group, six patients (31.6%) had minor oral complications: three cases complained of perioral numbness and another three had increased salivation. All of the patients were recovered within 1 month postoperatively (Table II). Nine patients developed some degree of postvoid dribbling postoperatively. This symptom was considered bothersome if patients needed manual urethral compression after voiding to empty residual urine. The rate of incidence of troublesome postvoid urine dribbling was significantly higher in the PSF than in the BMG group (three vs six cases, p < 0.05) (Table II). Postoperative recurrence was reported in five patients (13.5%), comprising two in the BMG group (one with a history of pendulous and another with bulbopendulous stricture) and three in the PSF group (one with a history of pendulous, one with bulbopendulous and one with bulbous urethral stricture). All the recurrent cases were reported during the first
A
12 months postoperatively. Also, they all had a ring stricture that was managed successfully with internal urethrotomy, except for one patient with long segment stricture in the PSF group who was managed with ventral onlay BMG urethroplasty. After 6 months of urethroplasty, 16 patients (84.2%) in the BMG group were satisfied and said that they would recommend this procedure to another patient, as opposed to only 12 patients (66.7%) in the PSF group. The difference between groups was statistically significant (p < 0.05). Discussion Open urethroplasty is considered the gold standard for anterior urethral stricture repair [16]. However, there is still controversy about the superiority of different surgical techniques [1,17,18]. For anterior urethral stricture, the recommended surgical technique for repair should be selected according to stricture length. Primary end-to-end anastomosis is suggested for stricture less than 2 cm as it has the highest chance of success (>90%) [12,19]. However, with longer stricture, the impact of urethral shortening on penile curvature during erection becomes a major concern and so it becomes necessary to carry out a substitution technique [10].
B
Figure 5. Retrograde urethrography: (A) preoperatively; (B) 6 months later, after penile skin flap technique.
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Anterior urethral stricture repair When considering the substitution urethroplasty, there are two main issues in the current controversy: the use of oral mucosa versus penile skin and the use of dorsal versus ventral placement of the graft or flap [20]. For pendulous urethral stricture repair, PSFs were preferred in the era when grafts were exclusively applied on the ventral aspect. It was believed that because of the relative deficiency of covering tissues in the penile urethra and poor vascularity of this segment, there was reduced potential for the survival of ventrally applied free grafts, with subsequent poor outcomes [21]. Later, Barbagli et al. described the dorsal onlay graft for augmentation urethroplasty where graft was dorsally sutured to the corpora cavernosa [22]. This allows better acquisition of a richer blood supply, with better graft survival and better outcome. Following Barbagli’s series, several authors described the use of buccal mucosa placed in a dorsal onlay fashion and reported good outcomes [6,23,24]. Dubey et al. reported a series of 43 patients undergoing dorsal onlay BMG urethroplasty for pendulous strictures, 28 of which were single-stage operations and 15 two-stage procedures, with respective success rates of 85.7% and 86.7% [23]. In another study comparing dorsal onlay BMG and penile skin graft (PSG) for pendulous stricture, Barbagli et al. found a higher rate of success (82% vs 78%) when using BMG compared with PSG [25]. Similarly, in patients with pendulous and bulbopendulous strictures in the present study, success was achieved in 84.6% and 81.8% in the BMG and PSF groups, respectively. In a similar study by Dubey et al. on repair of strictures involving the pendulous urethra, BMG and PSF urethroplasty provided comparable outcomes [6]. The bulbar urethra is well known to be the most reliable portion of the urethra as an ideal graft bed owing to its rich vascularity, and hence oral mucosa graft urethroplasty represents the most widespread method for the repair of its stricture [20,26]. Barbagli et al. showed that placement of the grafts on the ventral and dorsal surface of the bulbar urethra provided comparable success rates (83% and 85%, respectively) [27]. Other articles described the use of buccal mucosa placed in a dorsal onlay fashion and reported up to 100% success rates [28]. Various success rates have been achieved with the previous technique and include 75%, 87% and 98% success in studies by Xu et al., Dubey et al. and Pansadoro et al., respectively [29–31]. In a large retrospective study of 375 patients comparing dorsal onlay BMG and PSG for bulbar stricture, the authors reported a higher rate of success
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(82.8% vs 59.6%) when using BMG compared with PSG [32]. Raber et al. [4] reported 85% success in BMG versus 76% in PSG in a series that included 30 patients (13 had dorsal onlay BMG and 17 had PSG). However, no statistically significant differences were found between the two arms. Similarly, in patients with bulbar stricture in this study, success was achieved in all cases of BMG and in six out of seven cases of PSF (85.7%), but again with no significant difference (p > 0.05). Several other series reported that both penile skin and oral mucosa are excellent materials for substitution urethroplasty of the anterior urethra stricture repair, with a comparable success rate [6,33]. In 2005, Alsikafi et al. reported 84% success rate with PSG versus 87% with BMG urethroplasty [33]. Similarly, in a randomized controlled trial, Dubey et al. reported comparable success rates for the two techniques (85.8% for PSF vs 89.9% for BMG) [6]. These results are in complete agreement with the present results (83.3% for PSF vs 89.5% for BMG). From the technical point of view, in the study by Dubey et al., BMG urethroplasty was reported to be technically easier and to require significantly less operative time. The mean operative time in the BMG group was significantly less than in the PSF group (162 vs 224 min) [6]. Similarly, in the present series, the mean operative time was significantly shorter in the BMG (155 min) than in the PSF group (218.5 min) (p < 0.001). In Dubey’s series, the hospital stay was shorter in the BMG than in the PSF group [6]. Similarly, in this series, the mean hospital stay was 4.5 days in the BMG versus 5 days in the PSF group, but with no statistically significant difference (p > 0.05). With regard to short-term complications following the two procedures, it was reported that postoperative morbidity is higher in patients managed with PSF urethroplasty than in those with BMG urethroplasty [6]. The reported incidence of superficial penile necrosis following PSF urethroplasty in various studies varies between 4% and 27% [6,34]. Dubey et al. reported an incidence of superficial penile skin necrosis of 27.2% following PSF urethroplasty, which healed with conservative measures within 6 weeks of surgery and with only one patient having extensive skin loss. Similarly, in the present series, three patients (33.3%) had superficial skin necrosis and only one patient had extensive skin loss that required a split-thickness skin graft. Penile torsion was reported in two patients in Dubey’s series after PSF urethroplasty [6]. This is in agreement with the present series, where penile torsion was also reported in two cases. All of the cases
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of penile torsion in both series were mild and did not interfere with sexual intercourse. Short-term complications after BMG urethroplasty are generally temporary and not bothersome [35]. In the BMG group in the study reported here, six patients (31.6%) had minor oral complications: three complained of perioral numbness and another three had increased salivation. All patients recovered within 1 month. Similarly, Dubey et al. reported that 25.7% in the BMG group had minor oral morbidity [6]. However, in the present series, the rates of both haematoma and minor wound infection were similar in the PSF and BMG groups (two cases in each group), in agreement with findings reported by Dubey et al. [6]. Postvoid dribbling represent the most common long-term complication, owing to various grades of sacculation of the patch [24]. Dubey et al. reported bothersome postvoid dribbling following both techniques; however, it was significantly lower in the BMG urethroplasty group than in patients with PSFs (14.8% vs 32.14%, p < 0.001) [6]. This is similar to the present results, where the incidence rate of troublesome postvoid urine dribbling was significantly higher in the PSF than in the BMG group (33.3% vs 15.8%, p < 0.05). In another study, bothersome postvoid dribbling was reported in 8% and 7% in patients with BMG and PSF urethroplasty, respectively, with no significant difference [4]. Whether sexual function is affected by urethroplasty is still a matter of controversy. Erickson et al. reported that no statistically significant difference was seen in patient erectile function before and after anterior urethroplasty [36]. Similarly, Feng et al., in their systemic review and meta-analysis, conclude that for anterior urethroplasty, only bulbar anastomosis has a higher incidence of erectile dysfunction postoperatively [37]. The present results are in accordance with these results, in that no significant effect on patient erectile function was reported postoperatively. In this series, after 6 months of urethroplasty, 16 patients (84.2%) in the BMG group were satisfied and said that they would recommend this procedure to other patients, as opposed to only 12 patients (66.7%) in the PSF group, with a statistically significant difference (p < 0.05). These results are in agreement with those reported by Dubey et al., where the degree of patient satisfaction was significantly higher in those undergoing BMG urethroplasty [6]. In conclusion, BMG and PSF dorsal onlay urethroplasty have similar success rates. However, BMG is technically easier, takes less operative time and has a potential advantage in reducing postoperative morbidity, therefore leading to satisfaction in most of the patients.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References [1] Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol 2008;54:1031–41. [2] Hosseini J, Kaviani A, Hosseini M, Mazloomfard MM, Razi A. Dorsal versus ventral oral mucosal graft urethroplasty. Urol J 2011;8:48–53. [3] Mundy AR. The long-term results of skin inlay urethroplasty. Br J Urol 1995;75:59–61. [4] Raber M, Naspro R, Scapaticci E, Salonia A, Scattoni V, Mazzoccoli B, et al. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa for repair of bulbar urethral stricture: results of a prospective single center study. Eur Urol 2005;48:1013–17. [5] Mundy AR, Stephenson TP. Pedicled preputial patch urethroplasty. Br J Urol 1988;61:48–52. [6] Dubey D, Vijjan V, Kapoor R, Srivastava A, Mandhani A, Kumar A, et al. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol 2007;178:2466–9. [7] Venn SN, Mundy AR. Early experience with the use of buccal mucosa for substitution urethroplasty. Br J Urol 1998;81:738–40. [8] Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol 1998;160:1307–9. [9] Pansadoro V, Emiliozzi P, Gaffi M, Scarpone P. Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures. J Urol 1999;161:1501–3. [10] Kane CJ, Tarman GJ, Summerton DJ, Buchmann CE, Ward JF, O’Reilly KJ, et al. Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction. J Urol 2002;167:1314–17. [11] Wessells H. Ventral onlay graft techniques for urethroplasty. Urol Clin North Am 2002;29:381–7; vii. [12] Peterson AC, Webster GD. Management of urethral stricture disease: developing options for surgical intervention. BJU Int 2004;94:971–6. [13] Barbagli G, Lazzeri M. Can reconstructive urethral surgery proceed without randomised controlled trials? Eur Urol 2008;54:709–11. [14] Lumen N, Hoebeke P, Oosterlinck W. Urethroplasty for urethral strictures: quality assessment of an in-home algorithm. Int J Urol 2010;17:167–74. [15] Barbagli G, Selli C, di Cello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol 1996;78:929–32. [16] Morey A. Urethral stricture is now an open surgical disease. J Urol 2009;181:953–4. [17] Mundy AR, Andrich DE. Urethral strictures. BJU Int 2011; 107:6–26. [18] Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol 2011;59:797–814. [19] Barbagli G, Palminteri E, Lazzeri M, Guazzoni G. Anterior urethral strictures. BJU Int 2003;92:497–505. [20] Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. Current controversies in reconstructive surgery of the anterior urethra: a clinical overview. Int Braz J Urol 2012; 38:307–16; discussion 316.
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Anterior urethral stricture repair [21] Wessells H, McAninch JW. Use of free grafts in urethral stricture reconstruction. J Urol 1996;155:1912–15. [22] Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty. J Urol 1996;155:123–6. [23] Dubey D, Kumar A, Mandhani A, Srivastava A, Kapoor R, Bhandari M. Buccal mucosal urethroplasty: a versatile technique for all urethral segments. BJU Int 2005;95:625–9. [24] Andrich DE, Mundy AR. Substitution urethroplasty with buccal mucosal-free grafts. J Urol 2001;165:1131–3; discussion 1133–4. [25] Barbagli G, Morgia G, Lazzeri M. Retrospective outcome analysis of one-stage penile urethroplasty using a flap or graft in a homogeneous series of patients. BJU Int 2008;102:853–60. [26] Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology 1996; 48:194–8. [27] Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M. Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique? J Urol 2005;174:955–7; discussion 957–8. [28] Barbagli G, De Stefani S, Sighinolfi MC, Annino F, Micali S, Bianchi G. Bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. Eur Urol 2006;50:467–74. [29] Dubey D, Kumar A, Bansal P, Srivastava A, Kapoor R, Mandhani A, et al. Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques. BJU Int 2003;91:215–18.
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[30] Xu YM, Qiao Y, Sa YL, Wu DL, Zhang XR, Zhang J, et al. Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection. Eur Urol 2007;51:1093–8; discussion 1098–9. [31] Pansadoro V, Emiliozzi P, Gaffi M, Scarpone P, DePaula F, Pizzo M. Buccal mucosa urethroplasty in the treatment of bulbar urethral strictures. Urology 2003;61:1008–10. [32] Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar urethroplasty: retrospective analysis of the results in 375 patients. Eur Urol 2008;53:828–33. [33] Alsikafi NF, Eisenberg M, McAninch JW. Long-term outcomes of penile skin graft versus buccal mucosal graft for substitution urethroplasty of the anterior urethra. J Urol 2005;173:87. [34] Webster GD, Robertson CN. The vascularized skin island urethroplasty: its role and results in urethral stricture management. J Urol 1985;133:31–3. [35] Kamp S, Knoll T, Osman M, Hacker A, Michel MS, Alken P. Donor-site morbidity in buccal mucosa urethroplasty: lower lip or inner cheek? BJU Int 2005;96:619–23. [36] Erickson BA, Granieri MA, Meeks JJ, Cashy JP, Gonzalez CM. Prospective analysis of erectile dysfunction after anterior urethroplasty: incidence and recovery of function. J Urol 2010;183:657–61. [37] Feng C, Xu YM, Barbagli G, Lazzeri M, Tang C, Fu Q, et al. The relationship between erectile dysfunction and open urethroplasty: a systematic review and meta-analysis. J Sex Med 2013;10:2060–7.
ORIGINAL ARTICLE
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Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: a prospective randomized study
MOHAMED G. SOLIMAN1, MOHAMED ABO FARHA1, AHMED S. EL ABD1 & HUSSEIN ABDEL HAMEED2 & SAMIR EL GAMAL1 1
Urology Department, Tanta University, Tanta, Egypt, and 2Urology Department, Fayoum University, Fayoum, Egypt
Abstract Objective. The aim of this study was to compare the outcomes of dorsal onlay urethroplasty using buccal mucosa graft (BMG) versus penile skin flap (PSF) in the repair of long anterior urethral strictures. Material and methods. Patients with long anterior urethral strictures were randomized to receive either dorsal onlay BMG urethroplasty or PSF urethroplasty. All patients were evaluated preoperatively and during follow-up with the International Prostate Symptom Score (IPSS) and uroflowmetry. Success was reported when there were no obstructive symptoms on IPSS, with a peak urinary flow rate (Qmax) of at least 15 ml/s. Failure was reported in patients with obstructive symptoms, Qmax less than 15 ml/s and evidence of recurring stricture on urethrography. Results. The study included 19 and 18 patients in the BMG and PSF groups, respectively. The mean operative time was significantly shorter in the BMG than in the PSF group. The success rate was higher in the BMG than in the PSF group (89.5% vs 83.3%), but not statistically significant different. The PSF group included one case of extensive skin loss, three cases with superficial skin necrosis and two with minor penile torsion. In the BMG group, there were three cases of perioral numbness and another three had increased salivation. The incidence of troublesome postvoid urinary dribbling was significantly higher in the PSF than in the BMG group. After 6 months of urethroplasty, patient satisfaction was statistically significantly higher in the BMG than in the PSF group. Conclusions. BMG and PSF dorsal onlay urethroplasty had similar success rates. However, BMG is technically easier, takes less operative time and has a potential advantage in reducing postoperative morbidity, therefore leading to satisfaction for most patients.
Key Words: anterior urethral strictures, buccal mucosa graft, dorsal onlay, penile skin flap, urethroplasty
Introduction Urethral stricture is a complicated disease that represents a therapeutic challenge [1]. Each segment of the urethra is prone to this condition; each has its own particular type of stricture and is treated using different techniques according to varying circumstances [2]. Complex strictures of the anterior urethra that cannot be treated by means of excision and reanastomosis are best treated with substitution urethroplasty [3,4]. Traditionally, penile skin flaps (PSFs) were considered the most reliable tissue for urethroplasty [5].
Recently, the successful use of free grafts has renewed the search for ideal urethral substitutes [6]. Of these free grafts, buccal mucosa has emerged as one of the most reliable and popular grafts for patch urethroplasty because of its unique physical characters, as it is hairless and easy to harvest [7–9]. In addition, oral mucosa has immunological properties similar to those of the urothelium, making it less prone to infection [8,10]. The usual practice was to place this graft on the ventral aspect of the urethra [11]. In 1998, Barbagli et al. introduced dorsally placed grafts for the first time and postulated that dorsal placement is
Correspondence: M. Soliman, Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt. Tel: +20 181369517. Fax: +20 403400881. E-mail: [email protected]
(Received 21 August 2013; revised 28 November 2013; accepted 23 January 2014) ISSN 2168-1805 print/ISSN 2168-1813 online 2014 Informa Healthcare DOI: 10.3109/21681805.2014.888474
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Anterior urethral stricture repair advantageous because the underlying corpora gives better mechanical support to the graft as well as the blood supply [8]. However, the best means of substitution urethroplasty remains controversial, and the superiority of one technique over another has not yet been clearly defined [12]. This is attributed to a lack of prospective randomized and other well-conducted trials on the management of urethral stricture disease [13]. As a consequence, the level of evidence on the surgical treatment of urethral strictures and the guidelines on which technique to use in each particular circumstance is low [14]. The aim of this study was to compare the outcomes of dorsal onlay urethroplasty using buccal mucosa graft (BMG) or PSF in the repair of long anterior urethral stricture, in order to identify the best substitution material for this challenging problem on a prospective, randomized basis. Material and methods This prospective, randomized study was performed in the Urology Department, Tanta University, Egypt, and was approved by the institutional ethics review board. All patients provided written consent before enrolment. The study included patients aged at least 18 years with long anterior urethral stricture (>2 cm) not amenable to anastomotic urethroplasty in whom the aetiology was considered to be inflammatory, idiopathic or postinstrumentation (catheter or endoscopy). In total, 37 patients were subjected to substitution urethroplasty and were randomized to receive either dorsal onlay BMG or PSF. The randomization list was concealed from the investigators during the study to avoid selection bias as subjects were enrolled. Patients with balanitis xerotica obliterans, unhealthy penile skin or oral mucosal pathology, and recurrent cases who had undergone more than one previous internal urethrotomy or dilatation, or had a history of urethroplasty were excluded from the study. All patients were evaluated preoperatively with complete history taking including International Prostate Symptom Score (IPSS), sexual function, physical examination, urine analysis, urinary tract ultrasound with postvoid residual urine estimation, uroflowmetry, retrograde urethrography (RUG) and voiding cystourethrography (VCUG).
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et al. [15]. The urethra was completely mobilized from the corpora cavernosa and rotated 180 degrees (Figure 1). The strictured tract was opened along its dorsal surface, extending the incision for about 1 cm both proximally and distally into the normal urethral lumen. The urethra was calibrated proximal and distal to the strictured segment and a BMG or PSF was applied as a dorsal onlay over 16 Fr silicone catheter using 5-0 polyglactin sutures (Figures 2 and 3). In the PSF group, either a circumpenile or a longitudinal vascular skin flap was harvested, according to the stricture site. In the other group, the BMG was harvested from one cheek or from one cheek and the lower lip, depending on stricture length, and the procedure was achieved by a two-team approach (the perineal team exposes the stricture, while the other simultaneously harvests the graft from the mouth). A prophylactic broad-spectrum antibiotic (cefotax) was administered 2 h before surgery and continued for 5 days postoperatively. In the BMG group, mouth washes with povidone–iodine oral solution were started 2 days before graft harvesting and continued postoperatively for 2 days. The catheter was removed 3 weeks postoperatively when no extravasation was detected on voiding cystourethrography; otherwise, the catheter was kept for another 2 weeks. Follow-up consisted of careful history taking including IPSS, sexual function and uroflowmetry at 3, 6, 12 and 18 months and every year subsequently. An RUG was ordered to rule out recurrence of the stricture if the patient had obstructive symptoms on IPSS and the peak urinary flow rate (Qmax) was found to be less than 15 ml/s on uroflowmetry. Clinical outcome was considered a success when
Technique The surgical technique used for dorsal onlay urethroplasty was the one previously described by Barbagli
Figure 1. Complete mobilization and exposure of the urethra. Inset: Rotation of the urethra and line of incision along the dorsal surface of the bulbopendulous urethra.
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Strictured segment opened
Figure 2. Opening of the strictured segment.
there were no obstructive symptoms on IPSS, with Qmax of 15 ml/s or higher. Failure was reported in patients with obstructive symptoms, Qmax less than 15 ml/s and evidence of recurring stricture on RUG with any subsequent postoperative instrumentation, including dilatation. Statistical analysis Differences between the two groups were analysed statistically with the SPSS program, version 11.0. Demographic data were analysed by the Student’s
Catheter
t test. Categorical variable were analysed by the chisquared test. Two-tailed p values less than 0.05 were considered statistically significant. Results In total, 37 patients (19 patients in the BMG group and 18 patients in the PSF group) were included in this study. The preoperative parameters were comparable between the two groups. The causes of stricture in this series were: postinstrumentation in six and five patients, postinflammatory in five and six
Flab or graft
Figure 3. Suture of the graft or flap to the urethra.
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Anterior urethral stricture repair patients, and idiopathic in eight and six patients in the BMG and PSF groups, respectively. The site of stricture was pendulous, bulbar and bulbopendulous strictures in nine, 13 and 15 patients, respectively. The mean age of the patients was 37 years (range 18– 52 years) and 36.2 years (21–50 years) in the BMG and PSF groups, respectively. Mean stricture length in the BMG group was 5.6 cm (range 3.5–12.5 cm) and in the PSF group 5.4 cm (4–12 cm), with no statistically significant difference between the two groups (p > 0.05) (Table I). Mean follow-up was 24.2 months (range 12– 50 months) and 25.1 months (range 14–61 months) in the BMG and PSF groups, respectively. All patients completed at least 1 year of follow-up (Table II). In the BMG group, mucosa used for substitution urethroplasty was obtained from a single cheek in 11 patients and from a single cheek and the lower lip in eight patients. In the PSF group, the technique used was a circumferential flap in 14 cases and longitudinal in four cases. The mean operative time was significantly shorter in the BMG group (155 ± 6.2 min) than in the PSF group (218.5 ± 15.1 min) (p < 0.001). The mean hospital stay was 4.5 days (range 4–6 days) in the BMG group and 5 days (4–7 days) in the PSF group, with no statistically significant difference (p > 0.05) (Table II). The Qmax was improved in the BMG group from an average of 8.6 ml/s preoperatively to 22.3 ml/s postoperatively, while in the PSF group the Qmax increased from an average of 9.3 ml/s preoperatively to 23.3 ml/s postoperatively. However, IPSS decreased from a mean of 22.8 preoperatively to 4.2 postoperatively in Table I. Preoperative parameters in the buccal mucosa graft (BMG) and penile skin flap (PSF) groups. BMG
PSF
p
No. of patients
19
Mean age (years)
37 (18–52)
18 36.2 (20–51)
NS
Mean stricture length (cm)
5.6 (3.5–12.5)
5.4 (4–12)
NS
Mean IPSS
22.8
23.2
NS
Mean Qmax (ml/s)
8.6
9.3
Cause of stricture
NS NS
Postinstrumentation
6
5
Postinflammatory
5
6
Idiopathic
8
6
Pendulous
5
4
Bulbous
6
7
Bulbopendulous
8
7
Site of stricture
NS
IPSS = International Prostate Symptom Score; Qmax = peak urinary flow rate; NS = not significant (p > 0.05).
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Table II. Outcomes in the buccal mucosa graft (BMG) and penile skin flap (PSF) groups.
Mean operative time (min)
BMG
PSF
p
155 ± 6.2
218.5 ± 15.1
< 0.001
Mean hospital stay (days)
4.5 (4–6)
5 (4–7)
NS
Mean follow-up (months)
24.2 (12–50)
25.1 (14–61)
NS
Success rate
17 (89.5%)
15 (83.3%)
NS
Mean IPSS
4.2
5.3
NS
Mean Qmax (ml/s)
22.3
23.3
NS
Preference by patient
16 (84.2%)
12 (66.7%)
< 0.05
Early postoperative complications
NS
Haematoma
1 (5.3%)
1 (5.5%)
Wound infection
1 (5.3%)
1 (5.5%) 3 (33.3%)
Penile skin problems Superficial necrosis
0
Skin loss
0
1 (5.5%)
Penile torsion
0
2 (11%)
Perioral numbness
3 (15.8%)
0
Increased salivation
3 (15.8%)
0
Troublesome postvoid dribbling
3 (15.8%)
6 (33.3%)
Oral morbidity
< 0.05
IPSS = International Prostate Symptom Score; Qmax = peak urinary flow rate; NS = not significant (p > 0.05).
the BMG group and decreased from a mean of 23.3 preoperatively to 5.3 postoperatively in the PSF group (Table II). At 12 months’ follow-up, the mean Qmax was 20.8 ml/s and 21.5 ml/s, while the mean IPSS was 5.4 and 6.1 in the BMG and PSF groups, respectively. The overall success rate was 86.5% (32 patients out of 37), including 17 patients in the BMG group (89.5%) (Figure 4A,B) and 15 patients in the PSF group (83.3%) (Figure 5A,B). The difference between the two groups was not statistically significant (p > 0.05). In both pendulous and bulbopendulous stricture, success was achieved in 11 out of 13 cases (84.6%) and in nine out of 11 cases (81.8%) in the BMG and PSF groups, respectively, with no significant difference (p > 0.05). In bulbous stricture, success was achieved in all cases of BMG and in six out of seven cases of PSF (85.7%), with no significant difference (p > 0.05) (Table II). With regard to early postoperative complications, the rates of both haematoma and minor wound infection were similar in the two groups (Table II). With the exception of one case of extensive skin loss that required a split-thickness skin graft, all complications specific to the PSF group were minor with no
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A
B
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Figure 4. Retrograde urethrography: (A) preoperatively; (B) 6 months later, after buccal mucosa graft technique.
subsequent problems (three cases with superficial skin necrosis that healed within 1 month postoperatively and two cases with minor penile torsion that did not interfere with sexual intercourse) (Table II). Only 24 out of 37 patients who were sexually potent preoperatively reported no significant negative effects on erectile function postoperatively. In the BMG group, six patients (31.6%) had minor oral complications: three cases complained of perioral numbness and another three had increased salivation. All of the patients were recovered within 1 month postoperatively (Table II). Nine patients developed some degree of postvoid dribbling postoperatively. This symptom was considered bothersome if patients needed manual urethral compression after voiding to empty residual urine. The rate of incidence of troublesome postvoid urine dribbling was significantly higher in the PSF than in the BMG group (three vs six cases, p < 0.05) (Table II). Postoperative recurrence was reported in five patients (13.5%), comprising two in the BMG group (one with a history of pendulous and another with bulbopendulous stricture) and three in the PSF group (one with a history of pendulous, one with bulbopendulous and one with bulbous urethral stricture). All the recurrent cases were reported during the first
A
12 months postoperatively. Also, they all had a ring stricture that was managed successfully with internal urethrotomy, except for one patient with long segment stricture in the PSF group who was managed with ventral onlay BMG urethroplasty. After 6 months of urethroplasty, 16 patients (84.2%) in the BMG group were satisfied and said that they would recommend this procedure to another patient, as opposed to only 12 patients (66.7%) in the PSF group. The difference between groups was statistically significant (p < 0.05). Discussion Open urethroplasty is considered the gold standard for anterior urethral stricture repair [16]. However, there is still controversy about the superiority of different surgical techniques [1,17,18]. For anterior urethral stricture, the recommended surgical technique for repair should be selected according to stricture length. Primary end-to-end anastomosis is suggested for stricture less than 2 cm as it has the highest chance of success (>90%) [12,19]. However, with longer stricture, the impact of urethral shortening on penile curvature during erection becomes a major concern and so it becomes necessary to carry out a substitution technique [10].
B
Figure 5. Retrograde urethrography: (A) preoperatively; (B) 6 months later, after penile skin flap technique.
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Anterior urethral stricture repair When considering the substitution urethroplasty, there are two main issues in the current controversy: the use of oral mucosa versus penile skin and the use of dorsal versus ventral placement of the graft or flap [20]. For pendulous urethral stricture repair, PSFs were preferred in the era when grafts were exclusively applied on the ventral aspect. It was believed that because of the relative deficiency of covering tissues in the penile urethra and poor vascularity of this segment, there was reduced potential for the survival of ventrally applied free grafts, with subsequent poor outcomes [21]. Later, Barbagli et al. described the dorsal onlay graft for augmentation urethroplasty where graft was dorsally sutured to the corpora cavernosa [22]. This allows better acquisition of a richer blood supply, with better graft survival and better outcome. Following Barbagli’s series, several authors described the use of buccal mucosa placed in a dorsal onlay fashion and reported good outcomes [6,23,24]. Dubey et al. reported a series of 43 patients undergoing dorsal onlay BMG urethroplasty for pendulous strictures, 28 of which were single-stage operations and 15 two-stage procedures, with respective success rates of 85.7% and 86.7% [23]. In another study comparing dorsal onlay BMG and penile skin graft (PSG) for pendulous stricture, Barbagli et al. found a higher rate of success (82% vs 78%) when using BMG compared with PSG [25]. Similarly, in patients with pendulous and bulbopendulous strictures in the present study, success was achieved in 84.6% and 81.8% in the BMG and PSF groups, respectively. In a similar study by Dubey et al. on repair of strictures involving the pendulous urethra, BMG and PSF urethroplasty provided comparable outcomes [6]. The bulbar urethra is well known to be the most reliable portion of the urethra as an ideal graft bed owing to its rich vascularity, and hence oral mucosa graft urethroplasty represents the most widespread method for the repair of its stricture [20,26]. Barbagli et al. showed that placement of the grafts on the ventral and dorsal surface of the bulbar urethra provided comparable success rates (83% and 85%, respectively) [27]. Other articles described the use of buccal mucosa placed in a dorsal onlay fashion and reported up to 100% success rates [28]. Various success rates have been achieved with the previous technique and include 75%, 87% and 98% success in studies by Xu et al., Dubey et al. and Pansadoro et al., respectively [29–31]. In a large retrospective study of 375 patients comparing dorsal onlay BMG and PSG for bulbar stricture, the authors reported a higher rate of success
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(82.8% vs 59.6%) when using BMG compared with PSG [32]. Raber et al. [4] reported 85% success in BMG versus 76% in PSG in a series that included 30 patients (13 had dorsal onlay BMG and 17 had PSG). However, no statistically significant differences were found between the two arms. Similarly, in patients with bulbar stricture in this study, success was achieved in all cases of BMG and in six out of seven cases of PSF (85.7%), but again with no significant difference (p > 0.05). Several other series reported that both penile skin and oral mucosa are excellent materials for substitution urethroplasty of the anterior urethra stricture repair, with a comparable success rate [6,33]. In 2005, Alsikafi et al. reported 84% success rate with PSG versus 87% with BMG urethroplasty [33]. Similarly, in a randomized controlled trial, Dubey et al. reported comparable success rates for the two techniques (85.8% for PSF vs 89.9% for BMG) [6]. These results are in complete agreement with the present results (83.3% for PSF vs 89.5% for BMG). From the technical point of view, in the study by Dubey et al., BMG urethroplasty was reported to be technically easier and to require significantly less operative time. The mean operative time in the BMG group was significantly less than in the PSF group (162 vs 224 min) [6]. Similarly, in the present series, the mean operative time was significantly shorter in the BMG (155 min) than in the PSF group (218.5 min) (p < 0.001). In Dubey’s series, the hospital stay was shorter in the BMG than in the PSF group [6]. Similarly, in this series, the mean hospital stay was 4.5 days in the BMG versus 5 days in the PSF group, but with no statistically significant difference (p > 0.05). With regard to short-term complications following the two procedures, it was reported that postoperative morbidity is higher in patients managed with PSF urethroplasty than in those with BMG urethroplasty [6]. The reported incidence of superficial penile necrosis following PSF urethroplasty in various studies varies between 4% and 27% [6,34]. Dubey et al. reported an incidence of superficial penile skin necrosis of 27.2% following PSF urethroplasty, which healed with conservative measures within 6 weeks of surgery and with only one patient having extensive skin loss. Similarly, in the present series, three patients (33.3%) had superficial skin necrosis and only one patient had extensive skin loss that required a split-thickness skin graft. Penile torsion was reported in two patients in Dubey’s series after PSF urethroplasty [6]. This is in agreement with the present series, where penile torsion was also reported in two cases. All of the cases
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of penile torsion in both series were mild and did not interfere with sexual intercourse. Short-term complications after BMG urethroplasty are generally temporary and not bothersome [35]. In the BMG group in the study reported here, six patients (31.6%) had minor oral complications: three complained of perioral numbness and another three had increased salivation. All patients recovered within 1 month. Similarly, Dubey et al. reported that 25.7% in the BMG group had minor oral morbidity [6]. However, in the present series, the rates of both haematoma and minor wound infection were similar in the PSF and BMG groups (two cases in each group), in agreement with findings reported by Dubey et al. [6]. Postvoid dribbling represent the most common long-term complication, owing to various grades of sacculation of the patch [24]. Dubey et al. reported bothersome postvoid dribbling following both techniques; however, it was significantly lower in the BMG urethroplasty group than in patients with PSFs (14.8% vs 32.14%, p < 0.001) [6]. This is similar to the present results, where the incidence rate of troublesome postvoid urine dribbling was significantly higher in the PSF than in the BMG group (33.3% vs 15.8%, p < 0.05). In another study, bothersome postvoid dribbling was reported in 8% and 7% in patients with BMG and PSF urethroplasty, respectively, with no significant difference [4]. Whether sexual function is affected by urethroplasty is still a matter of controversy. Erickson et al. reported that no statistically significant difference was seen in patient erectile function before and after anterior urethroplasty [36]. Similarly, Feng et al., in their systemic review and meta-analysis, conclude that for anterior urethroplasty, only bulbar anastomosis has a higher incidence of erectile dysfunction postoperatively [37]. The present results are in accordance with these results, in that no significant effect on patient erectile function was reported postoperatively. In this series, after 6 months of urethroplasty, 16 patients (84.2%) in the BMG group were satisfied and said that they would recommend this procedure to other patients, as opposed to only 12 patients (66.7%) in the PSF group, with a statistically significant difference (p < 0.05). These results are in agreement with those reported by Dubey et al., where the degree of patient satisfaction was significantly higher in those undergoing BMG urethroplasty [6]. In conclusion, BMG and PSF dorsal onlay urethroplasty have similar success rates. However, BMG is technically easier, takes less operative time and has a potential advantage in reducing postoperative morbidity, therefore leading to satisfaction in most of the patients.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References [1] Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol 2008;54:1031–41. [2] Hosseini J, Kaviani A, Hosseini M, Mazloomfard MM, Razi A. Dorsal versus ventral oral mucosal graft urethroplasty. Urol J 2011;8:48–53. [3] Mundy AR. The long-term results of skin inlay urethroplasty. Br J Urol 1995;75:59–61. [4] Raber M, Naspro R, Scapaticci E, Salonia A, Scattoni V, Mazzoccoli B, et al. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa for repair of bulbar urethral stricture: results of a prospective single center study. Eur Urol 2005;48:1013–17. [5] Mundy AR, Stephenson TP. Pedicled preputial patch urethroplasty. Br J Urol 1988;61:48–52. [6] Dubey D, Vijjan V, Kapoor R, Srivastava A, Mandhani A, Kumar A, et al. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol 2007;178:2466–9. [7] Venn SN, Mundy AR. Early experience with the use of buccal mucosa for substitution urethroplasty. Br J Urol 1998;81:738–40. [8] Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol 1998;160:1307–9. [9] Pansadoro V, Emiliozzi P, Gaffi M, Scarpone P. Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures. J Urol 1999;161:1501–3. [10] Kane CJ, Tarman GJ, Summerton DJ, Buchmann CE, Ward JF, O’Reilly KJ, et al. Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction. J Urol 2002;167:1314–17. [11] Wessells H. Ventral onlay graft techniques for urethroplasty. Urol Clin North Am 2002;29:381–7; vii. [12] Peterson AC, Webster GD. Management of urethral stricture disease: developing options for surgical intervention. BJU Int 2004;94:971–6. [13] Barbagli G, Lazzeri M. Can reconstructive urethral surgery proceed without randomised controlled trials? Eur Urol 2008;54:709–11. [14] Lumen N, Hoebeke P, Oosterlinck W. Urethroplasty for urethral strictures: quality assessment of an in-home algorithm. Int J Urol 2010;17:167–74. [15] Barbagli G, Selli C, di Cello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol 1996;78:929–32. [16] Morey A. Urethral stricture is now an open surgical disease. J Urol 2009;181:953–4. [17] Mundy AR, Andrich DE. Urethral strictures. BJU Int 2011; 107:6–26. [18] Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol 2011;59:797–814. [19] Barbagli G, Palminteri E, Lazzeri M, Guazzoni G. Anterior urethral strictures. BJU Int 2003;92:497–505. [20] Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. Current controversies in reconstructive surgery of the anterior urethra: a clinical overview. Int Braz J Urol 2012; 38:307–16; discussion 316.
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