Surgical Technique
Treatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graftTratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucal

https://doi.org/10.1016/j.acuroe.2014.07.006Get rights and content

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.

Materials 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 177 ± 76 min and 1.5 ± 1 day, respectively. The preoperative Qmax and PVRV values were 4.5 ± 4.45 ml/s and 212.5 ± 130 cc, respectively. The postoperative values were 15.15 ± 7.2 ml/s and 6 ± 21.5 cc, respectively (p < 0.01 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 not 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.

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 (Qmáx 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. Qmáx 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.

Introduction

Urethral strictures have been traditionally treated with different methods ranging from the more conservative dilations to more complex techniques using grafts and flaps, including endoscopic therapies. The choice of one technique or another depends on the patient's characteristics and, above all, on stenosis length and location.1 Etiology plays a key role in strategy planning since, for instance, in the case of strictures of inflammatory origin there is an increased trend toward relapse.

Bulbar urethral or bulbomembranous strictures which require urethroplasty, but are too long for anastomotic techniques, benefit from replacement techniques where the stenotic segment is removed and replaced by a graft which can provide an acceptable urethral calibration so that the patient achieves a good voiding condition.2 Urethroplasty with oral mucosal grafts has become a really popular technique over the last decade due to its excellent long-term results, favored by the characteristics of this easily obtained tissue.3

Bulbar urethral stenosis with involvement of the membranous portion, especially in cases of post-traumatic origin, has been preferentially treated with transperineal bulboprostatic anastomotic repair, also known as progressive perineal urethroplasty.4, 5 This technique implies a high success rate, depending in a way on the length of the bulbar defect extension to be treated.6 Nonetheless, the success of grafting techniques with urethral enlargement has led to an expansion of the indication for urethroplasty with oral mucosal grafts to cases of long strictures with bulbar or membranous involvement, avoiding the separation of the corpora cavernosa and pubectomy, sometimes necessary to perform perineal anastomosis.7

We present a favorable experience derived from performing replacement urethroplasty with free oral mucosal grafts, ventrally or dorsally placed, in complex strictures of the bulbar urethra with membranous involvement. More studies are needed to clarify the role of elongation and luminal elastic enlargement of the urethra in the success of this kind of surgery, when compared with excision of diseased tissue in anastomotic repair.

Section snippets

Materials and methods

Prospective study analyzing the characteristics and results of a series of cases affected by bulbar urethral strictures with membranous involvement and who underwent augmentation urethroplasty with oral mucosal grafts, according to the modified Barbagli technique, at the University Hospital of Getafe. All patients were operated on over the 2005–2013 period. Patients had been contacted by telephone in January 2014. They all showed a minimum follow-up of one year.

The clinical course of the

Results

A total of 14 patients are described, 12 of whom had stenosis at the level of the bulbar and membranous urethra and 2 at the level of the membranous urethra exclusively. The median age was 64 ± 13 years. In 9 patients (64.3%) the etiology was secondary to prostate transurethral resection performed over a period greater than 5 years before, in one (7.1%) secondary to traumatic bladder catheterization, in another one (7.1%) secondary to closed ureteral traumatism, and in the remaining 3 cases

Discussion

The bulbar urethra is surrounded by the thickest portion of the corpus spongiosum and is eccentrically positioned, so that the dorsal side of the surrounding tissues looks thin, whereas it is ventrally thicker. As it moves distally, the urethra adopts a more central position within the corpus spongiosum.

Stenosis length is a prognostic factor as well as a factor used to decide on the type of urethroplasty11, 12, 13 and, consequently, it may be a source of confusion when analyzing the healing

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgements

To Juan Dorado (Pértica) for his help in the statistical analysis. To José Domínguez (medical records) for his work in iconography obtaining.

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Please cite this article as: Gimbernat H, Arance I, Redondo C, Meilán E, Andrés G, Angulo JC. Tratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucal. Actas Urol Esp. 2014;38:544–551.

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