Surgical TechniqueTreatment 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☆
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.
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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.