BUCCAL MUCOSA GRAFT AUGMENTED ANASTOMOTIC URETHROPLASTY FOR THE TREATMENT OF BULBAR URETHRAL STRICTURES

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1 General Urology Arch. Esp. Urol. 215; 68 (1): BUCCAL MUCOSA GRAFT AUGMENTED ANASTOMOTIC URETHROPLASTY FOR THE TREATMENT OF BULBAR URETHRAL STRICTURES Ramón Virasoro 1,2,3, Oscar Alfonso Storme 3, Leandro Capiel 1,2, Diego Andrés Ghisini 2 and Agustín Rovegno 1. 1 Centro de Educación Médica e Investigaciones Clínicas Dr. Norberto Quirno (CEMIC), Buenos Aires, Argentina. 2 Obra Social de los Empleados de Comercio y Actividades Civiles (OSECAC), Buenos Aires, Argentina. 3 Eastern Virginia Medical School, Norfolk, Virginia, USA. Summary.- OBJECTIVE: To report our outcomes with the use of buccal mucosal graft anastomotic urethroplasty to reconstruct complex anterior urethral strictures. METHODS: Between October 27 and January 211 we conducted a retrospective review of a series of 65 patients from 2 different centers. We analyzed demographic data, surgical outcomes and complications. RESULTS: Patient mean age was 5.9 years (range: 25 to 75), mean stricture length was 3.95 cm (range: 3 to 7 cm) and mean follow-up months (range: 12.7 to 52.77). Eighty percent of patients had prior treatments, mainly direct visual internal urethrotomy (DVIU) and urethral dilatation. Most frequent etiologies were iatrogenic in 46.15% of patients and idiopathic in 35.38% of patients. Success rate was achieved in 96.92% of patients; only 2 patients presented recurrence and were treated successfully with one DVIU. Clavien Dindo I-II complications were found in 59% of patients. No patient had chronic sequels. CONCLUSION: Augmented anastomotic urethroplasty using dorsal onlay buccal mucosa graft enables correction, in one time, of long segment urethral strictures with severe spongiofibrosis and/or obliterated lumen. Our outcomes are comparable with those of previously reported in international series. Keywords: Urethral stricture. Anterior urethra. Augmented anastomotic urethroplasty. Buccal mucosa Ramón Virasoro Department of Urology Eastern Virginia Medical School 225 Clearfield Ave. Virginia (USA) rvirasor@evms.edu CORRESPONDENCE Accepted for publication: November 4 th, 215 Resumen.- OBJETIVO: Reportar nuestros resultados con la utilización de la anastomosis ampliada con injerto de mucosa yugal para el manejo de la estrechez compleja de la uretra bulbar. MÉTODOS: Análisis retrospectivo de 65 pacientes operados en 2 Centros Hospitalarios independientes de cirugía reconstructiva, entre octubre de 27 y enero de 211. Se analizaron datos demográficos, resultados y complicaciones. RESULTADOS: La edad promedio de los pacientes fue de 5,9 años (rango: 25 a 75), siendo la longitud media de la estrechez de 3,95 cm (rango: 3 a 7) y un

2 731 R. Virasoro, O. A. Storme, L. Capiel, et al. seguimiento promedio de 33,13 meses (rango: 12,7 a 52,77). El 8% de los pacientes había sido tratado previamente con múltiples uretrotomías internas y dilataciones. Las etiologías más frecuentes fueron instrumental (46,15%) e idiopática (35,38%). La tasa de éxito fue del 96,92%, recidivando en 2 pacientes, que fueron exitosamente tratados con uretrotomía interna. Las complicaciones fueron menores, Clavien Dindo I-II, ocurriendo en el 39,92% de los pacientes, y ninguna de ellas dejó secuelas incapacitantes a largo plazo. CONCLUSIÓN: La anastomosis ampliada permite corregir en un tiempo extensos procesos cicatrizales de la uretra y con gran compromiso de la luz uretral. Los resultados obtenidos en nuestra serie se comparan con aquellos de las series internacionales ya reportados. Palabras clave: Estrechez uretral. Uretroplastía aumentada. Injerto de mucosa yugal. Uretra anterior. INTRODUCTION Currently, there is no doubt that Excision and Primary Anastomosis (EPA) with stricture excision and 3 French caliber is the most efficacious and durable technique for simple and less than 2 cm bulbar urethral strictures. In expert hands, this technique has a success rate of 9 al 98% (1-5). Nevertheless, complex urethral strictures continue to be challenging for the novel reconstructive surgeon, as the election of the surgical technique and the adequate substitution tissue are decisive for best outcomes. In the field of urethral reconstruction it is paramount to be familiar with every alternative techniques, and tailor it to the patient s need (6). Skin flaps, popular in the second half of last century, were replaced for grafts, as this last imply less effort to harvest and render similar results (7). Furthermore, the chronic passage of urine through a substituted urethral segment with skin has shown poor long-term results (8). Since first reported in 1992 (9), Buccal Mucosa Graft (BMG) has became the first choice to replace long urethral strictures, in one or multiple stages (3). Currently, for long and irregular caliber urethral strictures, onestage reconstruction alternatives are dorsal or ventral patch with graft/skin, and Augmented Anastomosis Urethroplasty (AAU). First described by Turner- Warwick in 1993 (1), and popularized by Guralnick and Webster (11) in 21, this technique combines anastomotic with tissue replacement techniques. The narrowest segment of the stricture and the adjacent spongiofibrosis are excised, typically up to 2 cm in length. The urethra is then spatulated dorsally both proximally and distally, up to the point of normal caliber and normal epithelium. A partial urethral anastomosis is done (dorsal or ventral) and finally the urethrotomy is covered with the graft. The main advantage of this combined technique is the opportunity to reconstruct, in a single stage, severe and narrow urethral segments that otherwise would have required multiple stages, as tubed urethral reconstruction has shown poor mid-term outcomes. The purpose of the study is to report our experience with Buccal Mucosal Graft Augmented Anastomosis Urethroplasty (BMG-AAU) to treat complex bulbar urethra strictures. METHODS We retrospectively reviewed all clinical records of patients that underwent urethroplasty in two independent centers, between October 27 and January 211. We included patients with bulbar urethral stricture >2 cm that underwent BMG-AAU and had at least 6 months follow-up. We excluded patients who had simultaneous repair in other urethral segment and/or had less than 6 months follow-up. We analyzed patients demographic, stricture length, complications and recurrence rates. Patients were studied preoperatively with history and physical examination, urethroscopy, retrograde and voiding cystourethrograms to define stricture s site and length (Figure 1). To avoid stricture under staging due to high voiding pressure changes proximal to the stricture, a 16 french suprapubic tube was placed on those patients who did not have one on presentation, and these were staged 3 months later. All patients had preoperative evaluation with urine culture and sensitivity. Patients with negative cultures received Figure 1. Proximal bulbar stricture, 3 cm in length with a normal segment between two severe strictures.

3 BUCCAL MUCOSA GRAFT AUGMENTED ANASTOMOTIC URETHROPLASTY FOR THE TREATMENT OF BULBAR URETHRAL STRICTURES 732 Amoxicillin/Clavulanic acid and Ciprofloxacin as preoperative prophylaxis, and patients with positives cultures were treated according to sensitivity 48 hours previous to surgery; if intravenous antibiotic treatment was required, patients were hospitalized and started treatment one day before surgery. Urethral reconstructions were performed by 2 surgeons, using homogeneous technique. Magnification with 2.5 x lenses was used. BMG was harvested using previously described technique (12). Generally we harvested one side and left it open to heal by secondary intention. We used a perineal approach with the patients in lithotomy position, for which we used Allen stirrups; extreme precautions were taken to avoid complications related to positioning. An inverted Y perineal incision was used, followed by midline division of the isquiocavernosus muscle; then the corpus spongiosum was identified and freed both proximally and distally. A Scott s retractor was utilized in all surgeries. The narrowest urethral segment was identified with intraoperative urethroscopy and we transected the corpus spongiosum at that point. We excised up to 2 cm of urethral stricture. A dorsal urethrotomy was performed both proximally and distally until normal appearance and 3 Fr. caliber urethra were found (Figure 2). In all patients we performed a proximal urethroscopy to evaluate relationship to striated sphincter. In the majority of patients stricture advanced up to the sphincter but not beyond. Figure 2. Excision of the narrowest urethral segment, then a dorsal urethrotomy was performed both proximally and distally until normal appearance and 3 French caliber of urethra were found. removed. After 3 weeks a voiding cystourethrography was performed to evaluate surgical results; the suprapubic tube was removed 2 days later. Patients had a urethroscopy at 6 and 12 months after surgery. Failure was considered as the requirement of any further instrumentation. (Dilatation, DVIU or Urethroplasty). Buck s fascia was excised extensively to improve elasticity of corpus spongiosum and allow urethral mobilization. The floor-strip partial anastomosis was done in two layers: mucosa with 5/ Vicryl and adventitia with 4/ PDS. The BMG was sutured to the dorsal bed with 6/ Vicryl and to the urethra with 4/ Vicryl (Figure 3). A 14 french silicone Foley catheter was used as urethral stent in all patients. Two surgical drains were placed, one at the reconstruction plane and the other at the subcutaneous plane. Oral intake started 12 hours after surgery, progressing to general diet depending on patient s tolerance. Oral swishes with chlorhexidine.12%, every 6 hours were encouraged. Patients continued with IV amoxicillin/clavulanic acid and ciprofloxacin 48 after surgery, and were discharged on ciprofloxacin to complete 5 days. First postoperative control was 48 hours after discharge, then weekly until Foley catheter was Figure 3. Bucal mucosa graft sutured to corpus cavernosum. Both proximal and distal urethra have normal appearance and excellent caliber.

4 733 R. Virasoro, O. A. Storme, L. Capiel, et al. RESULTS Between October 27 and June 211 a total of 147 urethroplasties were performed at both centers, Sixty eight patients received a BMG-AAU, of whom 3 were excluded: one patient that had simultaneous meatoplasty and 2 patients that had less than 6 months follow-up. A total of 65 patients were included in the present study. Patient mean age was 5.9 years (R: 25-75). Urethral stricture etiologies were Iatrogenic in 3 patients (46.15%), Idiopathic in 23 patients (35.38%), Infection in 6 patients (9.2%) and blunt trauma in 6 patients (9.2%). Mean stricture length was 3.95 cm. (R: 3-7), all of them located at the bulbar urethra (Table I). Eighty percent of the patients (52/65) had been previously treated with multiple urethrotomies and dilatations. No patient had undergone previous urethral reconstruction (Table II). Buccal mucosa graft was used in all patients and in all cases the donor site was left open. Only 2 patients (3%) required bilateral grafts, as they had lengthy urethral strictures (>7 cm). Mean follow-up was months (R: 12.7 to 52.77). Success rate was achieved in 96.92% of the patients. Two patients presented obstructive symptoms at follow-up. Both patients presented a proximal recurrence as evidenced on urethroscopy and urethrography, and were treated successfully with one DVIU. Mild complications (Clavien-Dindo I-II) occurred in 59% of patients (table III), with no invaliding sequel. Urinary infections were mainly treated with oral antibiotics; only 2 patients required intravenous antibiotics due to multi-resistant germs. One patient with epididymitis was treated with oral antibiotics, local treatment and analgesics Dribbling, was more common in patients with long strictures. No diverticulum was found by urethrography. Oral pain longer than 1 week occurred in 4 patients, and no one had pain after one month. Partial perineal wound dehiscence occurred in 3 patients; no further procedures were required and they closed by secondary intention. Postoperative de novo erectile dysfunction was observed in 3 patients; all had effective response to sildenafil and had resolved by 12 months from surgery. One patient had neuropathic perineal pain, with effective response to Pregabalin. DISCUSSION Urethral stricture disease creates physical and psychological distress in personal, family and work aspects of the patients. One stage urethral reconstruction technique is the best alternative to reconstruct urethral defects, and allows faster social and work insertion for patient. The first procedure, in a naïve patient, could be the only one able to cure the stricture, therefore a correct surgical technique choice is so important. BMG-AAU can correct long urethral strictures with irregular and narrow lumen (11,13-14). In bulbar urethra is especially helpful, due to its intrinsic elasticity and motility. BMG is the chosen tissue in the majority of the international centers (15-21), and has been helpful in many reconstructive techniques, especially AAU. In the majority of cases, the decision to perform an AAU is based on intraoperative findings and surgeon s choice. It should be considered on Table I. Urethral stricture etiologies in previous and current Augmented Anastomosis Urethroplasty studies. Etiology Webster (%) Angermeier (%) El-Kassaby (%) Hoy (%) Current series (%) Idiopatic Iatrogenic Trauma Infection/ Inflammatory Radiation Other 1.8

5 BUCCAL MUCOSA GRAFT AUGMENTED ANASTOMOTIC URETHROPLASTY FOR THE TREATMENT OF BULBAR URETHRAL STRICTURES 734 Table II. Patient urethral surgery history before Buccal Mucosal Graft Augmented Anastomosis Urethroplasty. catheter for 3 months is advised, to place the urethra at rest and let the stricture declare for itself. Previous treatment Dilatations (repeated) DVIU 3 DVIU Dilatations + 1 DVIU Dilatations + 2 DVIU Dilatations + 3 DVIU N (%) 6 (33.3) 2 (11.1) 1 (5.5) 4 (22.2) 3 (16.6) 2 (11.1) After this period, patients are re-stratified with urethrograms. In our series success rate was similar to other published previously, although our follow-up term is shorter; longer follow-up is necessary. Mean age, stricture length, location and etiology on this series are similar to other series already published. The largest series, reported by El-Kassaby et al. (24), included 223 patients who had AAU, all with BMG as ventral onlay. Stricture length was 4.2 cm. The success rate was 93.7%, and as in other series (25), most (12/14) were diagnosed in the first year postoperatively. Forty percent noted post void dribbling. lengthy strictures, not amenable for EPA, with the imposed risk of penile curvature due to urethral shortening (13). On staging the stricture one must consider clinic-radiological discrepancies due to intrinsic anatomic variables. Radiologic techniques could potentially understage degree of spongiofibrosis, and here ultrasound may be beneficial (22). Moreover, in patients without suprapubic diversion on initial evaluation, hidrodistension proximal to the stricture may underestimate the stricture, hence a suprapubic Table III. Postoperative complications. Complication Urinary Tract Infection N (%) 5 (22.72) More recently, Hoy et al. (26) presented their series from Alberta, Canada, including 163 patients who underwent BMG AAU in a dorsal onlay fashion. Median stricture length was 4.5 cm (range 2-12 cm), and most patients had previous procedures. After a median follow-up of 31 months, authors presented a 96.9% success rate. Of all 6 recurrences, 5 were managed with DVIU and one required a new open repair. Table IV summarizes the current and previous series that included AAU. Lastly, by transecting the urethra transversely, vascularity is interrupted, and one must consider this when planning re do urethroplasty on recurrent strictures. Jordan and others have proposed to preserve the proximal vasculature of the urethra. (27,28). Current literature lacks of scientific evidence to support this principle (29,3). Dribbling Oral Paresthesias Erectile Dysfunction Wound Breakdown Perineal Paresthesias Chronic Perineal Pain Epididymitis Oral Pain 5 (22.72) 3 (13.63) 3 (13.63) 3 (13.63) 2 (9.9) 1 (4.54) 1 (4.54) 1 (4.54) CONCLUSION Augmented Anastomotic Urethroplasty using buccal mucosa graft dorsal onlay allows correction, in a single stage, of long urethral strictures with severe spongiofibrosis and/or obliterated lumen. Our outcomes are compatible with international reported series. A long-term study must be considered to evaluate real efficacy of this procedure. ABBREVIATION RUG: Retrograde Urethrography DVIU: Direct Vision Internal Urethrotomy

6 735 R. Virasoro, O. A. Storme, L. Capiel, et al. Table IV. Previous and current studies of Augmented Anastomosis Urethroplasty. Reference Guralnick and Webster, 21 (11) Abouassaly and Angermeier, 27 (14) El-Kassaby et al, 27 (24) Welk and Kodama, 212 (25) Hoy et al, 213 (26) Current series N. patients Mean Age Stricture (cm) 1.5 (RUG) 4.5 (Graft size) 4.2 (RUG) 5.5 (graft size) 4.2 (RUG) 4.7 (Graft size) 4.5 (Graft size) 4.5 (RUG) 3.95 (RUG) Previous treatments, % Dorsal/ Ventral graft 2/9 11/58 /234 21/ 163/ 65/ Follow-up (months) Success rate,% REFERENCES AND RECOMMENDED READINGS (*of special interest, **of outstanding interest) *3. *4. * Santucci R, Mario L, Mc Aninch J: Anastomotic urethroplasty for bulbar urethral strictures: analysis of 168 patients. J Urol, 22; 167: Micheli E, Ranieri A, Peracchia G, Lembo A: End to end urethroplasty: long-term results. BJU, 22; 9: Andrich D, Dunglison N, Greenwell T, Mundy A: The long-term results of urethroplasty. J Urol, 23;17(1): 9-2. Eltahawy E, Virasoro R, Schlossberg S, Mc Cammon K, Jordan G: Long-term follow-up for excision and primary anastomosis for anterior urethral strictures. J Urol, 27; 177: Barbagli G, De Angelis M, Romano G, Lazzeri M: Long-term follow-up of bulbar end-to-end anastomosis: A retrospective analysis of 153 patients in a single center experience. J Urol, 27; 178: Barbagli G, Palminteri E, Bartoletti R, Selli C., Rizzo M: Long-term results of anterior and posterior urethroplasty with actuarial evaluation of the success rates. J Urol, 1997;158(4): Wood D, Andrich D, Greenwell T, Mundy A: Standing the test of time: the long-term results of urethroplasty. World J Urol, 26; 24(3): ** **14. **15. Devine PC, Horton C, Devine CJ Sr, Devine CJ Jr, Crawford H, Adamson J. Use of full thickness skin grafts in repair of urethral strictures. J Urol, 1963; 9: Burger R, Muller S, El-Damanhoury H, Tschakaloff A, Riedmiller H, Hohenfellner R. The Buccal mucosal graft for urethral reconstruction: A preliminary report. J Urol, 1992; 147: Turner-Warwick R. Principles of urethral reconstruction. in: G. Webster, R. Kirby, L. King, (Eds.) Reconstructive Urology. vol. 2. Blackwell Scientific, BOSTON; 1993: 69 (chapter 46) Guralnick M, Webster G: The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol, 21; 165: Morey A, McAninch J: Technique of harvesting buccal mucosa for urethral reconstruction. J Urol, 1996; 155: Morey A, Kizer W. Proximal bulbar urethroplasty via extended anastomotic approach-what are the limits?. J Urol, 26;175: Abouassaly R, Angermeier KW. Augmented anastomotic urethroplasty. J Urol, 27;177: El-Kasaby A, Fath-Alla M, Noweir A, El-Halaby M, Zakaria W, El-Beialy M. The use of buccal mucosa patch graft in the management of anterior urethral strictures. J Urol, 1993; 149:

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