Transurethral ventral inlay buccal mucosa graft urethroplasty: technique and intermediate outcomes

Abstract

Link to accompanying video: https://www.dropbox.com/s/lc4q8dmd1ukjzsb/BJU-2022-1023.R1%20Revised%20Video.mp4?dl=0. ObjectiveTo outline our step-by-step surgical technique for a transurethral ventral buccal mucosa graft inlay urethroplasty to treat fossa navicularis and distal urethral strictures. MethodsThe transurethral ventral inlay urethroplasty is accomplished in four steps. First, after obtaining proper exposure the cicatrice is excised via a transurethral ventral urethrotomy until the lumen is at least 24fr. Second, double arm 6-0 polydioxanone suture is used to deliver the triangular buccal mucosal graft to the proximal extent of the urethrotomy and secured externally. Third, the graft is secured to the meatus with 5-0 polyglactin sutures and additional 6-0 double arm polydioxanone sutures are used to quilt the graft for spread fixation. Finally, a 16fr silicone catheter is placed. Patients are discharged the same day and return for void trial after one week. A retrospective, single institution review was conducted to include all patients who underwent this procedure with a minimum of 1 year follow-up. Patients were analyzed for recurrences, and pre-and post-operative urine flow rates, post void residuals, and patient questionnaires were also reviewed. Results44 patients met our inclusion criteria. Median surgical time was 120 minutes. At a mean follow up of 36 months (IQR 22-50) 95% of patients are patent without additional interventions. The 2 patients that did have stricture recurrence were found to have urethral stenosis that extended more proximally, and both were successfully treated with a dorsal onlay buccal urethroplasty. There were significant improvements in urine flow rate, post void residuals, international prostate symptom score and quality of life scores post operatively. There was no difference in post operative sexual function scores. ConclusionThis minimally invasive transurethral ventral urethroplasty has excellent intermediate term outcomes in terms of traditional objective measures of urethroplasty success and patient reported outcomes.

Glans cap-preserving dorsal inlay-free graft augmentation technique for reconstruction of meatal stenosis and fossa navicularis strictures: Analysis of short-term functional outcomes

“…Numerous techniques involve placing the free graft ventrally or dorsally, either as an onlay or inlay, to augment the urethral plate. [ 3 4 5 6 ] In this approach, we opted for a dorsal inlay placement of the free graft because of adequate availability of space on the dorsal aspect and the presence of a vascularized bed for graft support and fixation.…”

“…This can be prevented by applying a tourniquet to the proximal aspect of the penis. [ 3 5 6 ] Occasionally, there may be instances of delayed bleeding in the postoperative period, which are typically self-limiting owing to the splinting effect of the urethral catheter and the application of a compressive dressing. In our study, we encountered one patient who experienced bleeding from the meatus, which was subsequently managed by placing an additional suture to control the bleeding.…”

“…[ 1 2 ] Various surgical techniques have been described for the management of meatal stenosis and FNS, wherein the reconstruction of the urethral lumen is performed with a free graft or local vascularized flap using either inlay or onlay techniques. [ 2 3 4 5 6 ] The most commonly utilized tissues for augmenting the urethral plate include the oral mucosa graft (OMG) and inner preputial free graft (IPG). [ 3 4 6 ] The primary goals of treatment of FNS include alleviating the bothersome symptoms, ensuring unobstructed urine flow, and achieving cosmetically pleasing glans.…”

“…[ 2 3 4 5 6 ] The most commonly utilized tissues for augmenting the urethral plate include the oral mucosa graft (OMG) and inner preputial free graft (IPG). [ 3 4 6 ] The primary goals of treatment of FNS include alleviating the bothersome symptoms, ensuring unobstructed urine flow, and achieving cosmetically pleasing glans. However, the technical challenge lies in enhancing the caliber of the urethral lumen without altering the contour of the glans.…”