Tratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucal

doi:10.1016/j.acuro.2014.04.001

Actas Urológicas Españolas

Volume 38, Issue 8, October 2014, Pages 544-551

https://doi.org/10.1016/j.acuro.2014.04.001 Get rights and content

Resumen

Introducción

Las uretroplastia con injerto de mucosa bucal es la técnica más popular en el tratamiento de la estenosis de uretra bulbar no traumática; no obstante, los casos con afectación de la porción membranosa suelen tratarse mediante uretroplastia anastomótica perineal progresiva. Se evalúa la viabilidad de llevar a cabo uretroplastia con injerto dorsal (o ventral) en estenosis de uretra bulbar y afectación principalmente membranosa con técnica de Barbagli modificada.

Material y métodos

Estudio prospectivo sobre 14 pacientes con estenosis de uretra bulbomembranosa sometidos a uretroplastia de ampliación con injerto de mucosa bucal entre 2005 y 2013, según la técnica de Barbagli modificada con anclaje proximal del injerto y fijación del mismo sobre la albugínea cavernosa en 12 casos (%) y ventralmente en 2 (%). El tiempo de seguimiento mínimo fue de un año. Se evaluaron resultados subjetivos (satisfacción del paciente) y objetivos (Q_máx y RPM pre y postoperatorios) y complicaciones. Se consideró fracaso la necesidad de cualquier instrumentación postoperatoria.

Resultados

Se intervinieron 14 pacientes, con una mediana de edad de 64 + 13 años. El antecedente principal detectado fue RTU de próstata en 9 casos (64,3%). La mediana de longitud de la estenosis fue 45 + 26,5 mm. Antes de la cirugía el 50% de los pacientes había sido sometido a dilataciones y el 4% a uretrotomía endoscópica. El tiempo quirúrgico fue 177 + 76 min y la estancia hospitalaria 1,5 + 1 d. Q_máx y RPM preoperatorios fueron 4,5 + 4,45 ml/seg y 212,5 + 130 cc, y postoperatorios 15,15 + 7,2 ml/seg y 6 + 21,5 cc (p < 0,01 ambas comparaciones). La cirugía resultó exitosa en 13 casos (92,9%). Ningún paciente presentó complicaciones mayores. Hubo complicaciones menores en uno (7,1%), sin precisar reintervención.

Conclusión

La reparación de estenosis largas de uretra bulbar con afectación membranosa mediante uretroplastia con injerto libre de mucosa bucal supone una alternativa viable en pacientes de etiología no traumática con escasa fibrosis. La ampliación de la luz uretral consigue buenos resultados con mínima tasa de fracaso y escasa probabilidad de complicación. En muchos de estos pacientes la longitud de la estenosis es demasiado larga para realizar técnica anastomótica sin tensión.

Abstract

Introduction

Urethroplasty with oral mucosa grafting is the most popular technique for treating nontraumatic bulbar urethral strictures; however, cases involving the membranous portion are usually treated using progressive perineal anastomotic urethroplasty. We assessed the feasibility of performing dorsal (or ventral) graft urethroplasty on bulbar urethral strictures with mainly membranous involvement using a modified Barbagli technique.

Material and methods

This was a prospective study of 14 patients with bulbomembranous urethral strictures who underwent dilation urethroplasty with oral mucosa graft between 2005 and 2013, performed using a modified technique Barbagli, with proximal anchoring of the graft and securing of the graft to the tunica cavernosa in 12 cases (85.7%) and ventrally in 2 (14.3%). The minimum follow-up time was 1 year. We evaluated the subjective (patient satisfaction) and objective (maximum flow [Qmax] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation.

Results

A total of 14 patients (median age, 64 + 13 years) underwent surgery. The main antecedent of note was transurethral resection of the prostate in 9 cases (64.3%). The median length of the stenosis was 45 + 26.5 mm. Prior to surgery, 50% of the patients had been subjected to dilatations and 4% to endoscopic urethrotomy. The mean surgical time and hospital stay were was 177 + 76 min and 1.5 + 1 day, respectively. The preoperative Qmax and PVRV values were 4.5 + 4.45 mL/sec and 212.5 + 130 cc, respectively. The postoperative values were 15.15 + 7.2 mL/sec and 6 + 21.5 cc, respectively (P < .01 for both comparisons). Surgery was successful in 13 cases (92.9%). None of the patients had major complications. There were minor complications in 1 (7.1%) patient, but reintervention was no required.

Conclusion

The repair of long bulbar urethral strictures with membranous involvement using urethroplasty with free oral mucosa grafts represents a viable alternative for patients with nontraumatic etiology and little fibrosis. The dilation of the urethral lumen achieves good results with minimum failure rates and little probability of complications. For many of these patients, the length of the stricture is too long to perform the tension-free anastomosis technique.

Section snippets

Introducción

La estenosis de uretra ha sido tratada históricamente mediante diferentes métodos que van desde las más conservadoras dilataciones hasta las técnicas más complejas con injertos y colgajos, pasando por tratamientos endoscópicos. La elección de una u otra técnica depende de las características del paciente y, sobre todo, de la longitud y localización de la estenosis¹. La etiología desempeña un papel fundamental en la planificación de la estrategia a adoptar dado que, por ejemplo, en el caso de

Material y métodos

Estudio prospectivo que analiza las características y resultados de una serie de casos afectos de estenosis de uretra bulbar con afectación membranosa sometidos a uretroplastia de ampliación con injerto de mucosa bucal, según la técnica de Barbagli modificada, en el Hospital Universitario de Getafe. Todos los pacientes fueron intervenidos en el periodo 2005-2013. Los pacientes han sido contactados telefónicamente en enero de 2014. Todos presentan un seguimiento mínimo de un año.

Se revisó la

Resultados

Se describen un total de 14 pacientes, de los cuales 12 tenían estenosis a nivel de la uretra bulbar y membranosa y 2 a nivel de la uretra membranosa exclusivamente. La mediana de edad fue 64 + 13 años. En 9 pacientes (64,3%) la etiología fue secundaria a resección transuretral de próstata realizada en un plazo mayor a 5 años antes, en uno (7,1%) secundaria a sondaje vesical traumático, en otro (7,1%) secundaria a traumatismo uretral cerrado y en los 3 casos restantes (21,4%) idiopática. En un

Discusión

La uretra bulbar está rodeada por la porción más gruesa del cuerpo esponjoso y se posiciona excéntricamente, de manera que el aspecto dorsal de los tejidos circundantes es fino, mientras que ventralmente es más grueso. A medida que avanza distalmente la uretra adopta una posición más centrada en el interior del cuerpo esponjoso.

La longitud de la estenosis es factor pronóstico a la vez que factor empleado para decidir el tipo de uretroplastia11, 12, 13 y, en consecuencia, puede resultar un

Conflicto de intereses

Los autores declaran que no tienen ningún conflicto de intereses.

Agradecimientos

A Juan Dorado (Pértica) por su ayuda en el análisis estadístico. A José Domínguez (documentación médica) por su trabajo en la obtención de iconografía.

Bibliografía (23)

H. Gimbernat et al.
Análisis de los factores implicados en el fracaso de la uretroplastia en el varón
Actas Urol Esp
(2014)
G.D. Webster et al.
Prostomembranous urethral injuries; a review of the literature and a rational approach to their management
J Urol
(1983)
M.M. Koraitim
Gapometry and anterior urethrometry in the repair of posterior urethral defects
J Urol
(2008)
G. Barbagli et al.
Bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue
Eur Urol
(2006)
J.C. Regueiro et al.
Opciones de tratamiento quirúrgico en la estenosis de uretra bulbar
Actas Urol Esp
(2013)
R.A. Santucci et al.
Male urethral stricture disease
J Urol
(2007)
R. Gómez et al.
Manejo racional y selectivo de los pacientes con estenosis de uretra anterior
Actas Urol Esp
(2011)
G. Barbagli et al.
Dorsal onlay skin graft bulbar urethroplasty; long term follow up
Eur Urol
(2008)
D.S. Kellner et al.
Ventral onlay buccal mucosal grafts for anterior urethral strictures: Long-term follow up
J Urol
(2004)
C. Chapple et al.
SIU/ICUD consultation on urethral strictures: The management of anterior urethral stricture disease using substitution urethroplasty
Urology
(2014)

P.C. Devine et al.

Free full thickness skin graft urethroplsaty: Current technique

J Urol

(1979)

Cited by (11)

Double-face urethroplasty in patients with obliterative bulbar strictures post-transurethral resection of the prostate mid-term outcomes in high-volume referral center
2023, Asian Journal of Urology
Citation Excerpt :
Dorsal approach would involve a full thickness urethrotomy and this would possibly cause incontinence as the stricture is close to membranous urethra. Gimbernat et al. [25] reported a continence rate of around 93% in a study of 14 patients. The novelty introduced by us is the fixation of the dorsal inlay graft with Vicryl® tacker first described by Joshi PM [18], since in very proximal strictures the quilting of the graft becomes challenging.
Incidences of post-transurethral resection of the prostate (post-TURP) strictures are between 2.2% and 9.8%. Stricture commonly occurs within the first 6 months. Our objective was to assess the outcomes of patients with obliterative strictures post-TURP that underwent a double-face urethroplasty.
This is a single-center prospective study of 17 patients with obliterative proximal bulbar stricture post-TURP who underwent double-face graft urethroplasty by two surgeons between January 2014 and January 2020. We defined post-TURP obliterative strictures as those patients who presented with complete or almost complete obstruction of the urethral lumen and who have had a history of acute urine retention. We have excluded patients with bladder neck contracture. Primary outcome was treatment success, defined as the no need for further treatments. Secondary outcome was post-urethroplasty continent rate.
Seventeen patients were included in the study with median age of 66 (interquartile range 40–77) years; median time of follow-up was 24 (interquartile range 12–84) months; median stricture length was 4 (interquartile range 2–6) cm. Of the 17 patients, 15 (88.2%) were successful. All patients were continent after urethroplasty.
With mid-term follow-up, treatment of obliterative proximal bulbar strictures with double-face buccal mucosa graft is a safe and effective procedure. Obliterative proximal bulbar strictures merit double-face urethroplasty with high-rate success and functional outcomes.
Bulbomembranous Urethral Strictures Repair After Surgical Treatment of Benign Prostatic Hyperplasia. Experience From a Latin American Referral Centre
2021, Urology
To evaluate stricture recurrence and urinary incontinence (UI) rates in patients who underwent bulbomembranous anastomosis for management of short (≤ 2cm) bulbomembranous urethral stricture (BMS) after benign prostatic hyperplasia (BPH) surgical treatment. In addition, we studied if there was any relation between post urethroplasty UI and the method employed for BPH surgical treatment.
A retrospective study was conducted between January 2011 and October 2019. We included all patients who developed BMS after undergoing Transurethral Resection of the Prostate, Holmium Laser Enucleation of the Prostate or Open Simple Prostatectomy (OSP). We excluded patients with UI after BPH surgical treatment as well as patients who underwent a dorsal or ventral onlay oral graft urethroplasty for longer proximal bulbar strictures, and also patients with associated bladder neck contracture or other strictures locations. We defined failure as the need for any intervention to restore the urethral caliber.
Overall, 77 patients were included in the study with mean age 70 years (sd 8). Median BMS length was 1.5 cm (IQR 1-2). Median follow-up was 53 months (IQR 24 to 82). Of the patients, 74/77 (96.1%) were classified as success and 3/77 (3.9%), as failure. Out of the 6/77 (7.8%) patients who had postoperative UI, 5 of them had been treated for their BPH with OSP (p 0.001).
Bulbomembranous anastomosis is a suitable reconstructive option for short proximal bulbar urethral strictures after BPH surgical treatment. OSP was associated with postoperative UI more frequently than endoscopic treatments modalities.
Treatment of long anterior urethral stricture associated to lichen sclerosus
2017, Actas Urologicas Espanolas
La estenosis panuretral asociada a liquen escleroso supone un reto terapéutico. Presentamos el análisis de nuestros resultados empleando 2 técnicas de uretroplastia basadas en injerto de mucosa oral.
Estudio retrospectivo en pacientes con estenosis larga de uretra anterior (> 8 cm) asociada a liquen escleroso. Los pacientes recibieron uretroplastia con injerto de mucosa oral según técnica de Kulkarni (n = 25) o uretroplastia en 2 tiempos tipo Bracka-Johanson (n = 15). Se evalúan datos demográficos, tiempo operatorio, complicaciones (Clavien-Dindo), estancia hospitalaria, EAV de dolor postoperatorio, tasa de fracaso, necesidad de retratamiento y datos funcionales que incluyen IPSS, CdV y Qmáx, residuo posmiccional (RPM).
En todos los casos hubo afectación glandular y peneana y en el 75% de uretra bulbar. En el 22,5% se empleó un solo injerto, en el 72,5% 2 y en el 5% 3. Los pacientes tratados en un solo tiempo fueron más jóvenes (p = 0,007). A pesar de que la longitud de la estenosis fue equivalente en ambas técnicas (p = 0,96), la tasa de recidiva y de complicaciones fue superior en 2 tiempos (p = 0,05 y p = 0,03; respectivamente), así como el tiempo operatorio (p < 0,0001) y la estancia global (p = 0,0002). No hubo diferencias en IPSS, CdV, Qmáx o RPM preoperatorios, ni tampoco en los valores postoperatorios de IPSS o Qmáx; pero sí en CdV (p = 0,006) y RPM (p = 0,03) a favor de uretroplastia en un tiempo. La EAV de dolor en el 1.^er día postoperatorio fue también menor en la uretroplastia de Kulkarni que en el primer tiempo de Johanson-Bracka (p < 0,0001).
En pacientes con liquen escleroso y estenosis larga de uretra anterior la uretroplastia de Kulkarni proporciona resultados operatorios más eficientes y mejor valorados por el paciente que la uretroplastia de Johanson-Bracka. Además, evita el deterioro temporal cosmético, sexual y miccional inherente a la cirugía en 2 tiempos.
Panurethral stricture associated with lichen sclerosus is a therapeutic challenge. We present the analysis of our results using two urethroplasty techniques based on oral mucosa graft.
Retrospective study in patients with long anterior urethral stricture (> 8 cm) associated with lichen sclerosus. Patients received urethroplasty with oral mucosa graft technique according Kulkarni (n = 25) or two-step Johanson-Bracka urethroplasty (n = 15). Demographics, operative time, complications (Clavien-Dindo), hospital stay, days with catheter, EAV postoperative pain, failure rate, need for retreatment and functional data including IPSS, QoL, Qmax, post void residual (PVR) are evaluated.
In all cases there was involvement of glandular and penile urethra, and in 75% of bulbar urethra. A single graft was used in 22.5%, two in 72.5% and three in 5%. Patients treated at a single step were younger (P = .007). Although the length of the stenosis was equivalent in both techniques (P = .96), relapse and complication rates were higher in two-step surgery (P = .05 and P = .03; respectively) and so was operative time (P < .0001) and overall stay (P = .0002). There were no differences in preoperative IPSS, QoL, Qmax or PVR, neither in postoperative values of IPSS or Qmax; but there was a difference in QoL (P = .006) and PVR (P = .03) favouring single-step urethroplasty. VAS pain on postoperative day 1 was also lower in Kulkarni urethroplasty than in the first step of Johanson-Bracka technique (P < .0001).
In patients with lichen sclerosus and long anterior urethral stricture Kulkarni urethroplasty provides more efficient and better patient reported outcomes than Johanson-Bracka urethroplasty. It also prevents cosmetic, sexual and voiding temporary deterioration inherent to 2-step surgery.
Nontraumatic posterior urethral stenosis
2017, Actas Urologicas Espanolas
La enfermedad estenótica de la uretra posterior es una complicación no menor de los tratamientos aplicados en la hipertrofia benigna de próstata, cáncer de próstata (CaP) y tras neovejigas ortotópicas, pudiendo comprometer el resultado funcional miccional.
Identificar los factores etiológicos de la enfermedad estenótica de causa no traumática de la uretra posterior, su prevención y su tratamiento.
Se han revisado los artículos indexados en PubMed en idiomas inglés y español de las secuelas estenóticas de la uretra posterior tras los tratamientos aplicados en el cáncer de próstata, en la cirugía de la hipertrofia benigna de próstata y de las neovejigas ortotópicas. Se han incluido estudios de cohortes, revisiones de artículos y estudios prospectivos y retrospectivos, con el mayor número de casos.
La evidencia obtenida en la bibliografía es que la frecuencia de aparición de dichas estenosis no es despreciable, que su morbilidad puede ser importante y que debe sospecharse tras la pérdida de la calidad miccional. Su prevención empieza con una apropiada técnica quirúrgica y/o radioterápica. Aunque el tratamiento endoscópico es el preferido inicialmente, en ocasiones se requieren uretroplastias complejas abiertas, siendo la incontinencia urinaria la secuela más importante, pudiendo requerir implantes de esfínteres artificiales.
Las estenosis no traumáticas de la uretra posterior son complicaciones que pueden ser importantes, llegando a comprometer el éxito del tratamiento inicial de la enfermedad de base y requiriendo en ocasiones de cirugías complejas que pueden llevar a la incontinencia.
Posterior urethral stenoses and contractures are complications after treatment of benign prostatic hyperplasia (BPH), localised prostate cancer (PCa), and orthotopic neobladder formation, compromising prognosis and functional outcomes.
To identify factors related to aetiology, prevention and treatment of non-traumatic posterior urethral stenosis and contractures.
Review of the published evidence related to posterior urethral stenosis and contractures after PCa treatment, BPH therapies and orthotopic neobladder formation. PubMed database search with English and Spanish papers considered. Cohort studies, case series, prospective and retrospective studies and review papers were included.
Posterior urethral stenoses and contractures are common, leading to significant morbidity. A worsening on voiding quality should rise some concerns. Careful surgical and/or radiotherapic techniques prevent their development. Endoscopic therapies are the initial approach, with complex urethroplasties often required. Subsequent urinary incontinence, the most important sequelae, may need artificial sphincters.
Non-traumatic posterior urethral stenoses could be important complications, potentially compromising the outcomes of initial therapy. They could require complex surgeries leading to urinary incontinence.
Dorsal onlay urethroplasty for membranous urethral strictures: Urinary and erectile functional outcomes
2016, Journal of Urology
Citation Excerpt :
Experience with radiation induced bulbomembranous urethral strictures has been reported9–11 but these patients typically have poorer preoperative erectile function as in our study. Gimbernat et al noted a 1-year patency rate of greater than 90% using various augmentation techniques for strictures involving the membranous urethra.4 They did not evaluate continence or erectile function following urethroplasty.
We evaluated urinary and erectile functional outcomes after dorsal onlay urethroplasty for bulbomembranous urethral strictures. Our aim was to understand the functional implications of dissection of the posterior urethra.
We report on men who underwent membranous urethral stricture repair by buccal mucosal graft dorsal onlay substitution urethroplasty. Continence and erectile function were assessed preoperatively and postoperatively. Tissue routinely excised from the intercrural space during dissection of the dorsal aspect of the membranous urethra was evaluated for scar, striated muscle and nerves.
A total of 16 consecutive men with a mean age of 48.3 years (range 26 to 72) who had strictures with a mean length of 56 mm (range 15 to 170) involving the membranous urethra were included in analysis. Of the 16 men 15 were continent preoperatively and remained continent postoperatively. Three of 10 men (30%) with a preoperative SHIM (Sexual Health Inventory for Men) score of 17 to 25 had a decrease after urethroplasty. All 16 men had an improved maximum urinary flow rate with a mean improvement of 22 ml per second. I-PSS (International Prostate Symptom Score) improved from a median of 23 to 4 postoperatively with a median bother score improvement of 5 to 0. Histopathological assessment identified striated muscle and nerves in 6 (46%) and 9 (69%) of 13 specimens. Overall nerves and muscle comprised an average of less than 15% of the specimen.
The dorsal onlay technique with a buccal mucosal graft for membranous urethral stricture repair does not compromise continence or erectile function in most patients. Dissection at the level of the membranous urethra should be limited because striated muscle and cavernous nerves are present.
Buccal mucosa for use in urethral reconstruction: evolution of use over the last 30 years
2023, Frontiers in Urology

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Técnica quirúrgicaTratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucalTreatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graft

Resumen

Introducción

Material y métodos

Resultados

Conclusión

Abstract

Introduction

Material and methods

Results

Conclusion

Section snippets

Introducción

Material y métodos

Resultados

Discusión

Conflicto de intereses

Agradecimientos

Actas Urol Esp

J Urol

J Urol

Eur Urol

Actas Urol Esp

J Urol

Actas Urol Esp

Eur Urol

J Urol

Urology

J Urol

Técnica quirúrgica
Tratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucalTreatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graft