Urethral Reconstructive Surgery - part 9 pot

He used full-thickness skin grafts for urethral reconstruction, hypos-padias, and urethral strictures and also described the first recorded case of buccal mucosal graft urethroplasty.. Q

The Use of Free Grafts for Urethroplasty

D.E Andrich, A.R Mundy

21.1 Introduction – 176

21.2 Grafts Versus Flaps – 176

21.3 The Principles of Grafting – 176

21.1 Introduction

Apart from isolated reports, substitution urethroplasty

really began in the 1940s with Humby [1] He used

full-thickness skin grafts for urethral reconstruction,

hypos-padias, and urethral strictures and also described the first

recorded case of buccal mucosal graft urethroplasty After

him, sporadic cases were reported in the British, European,

and American literature By the mid-1960s grafts were in

regular use for urethral reconstruction for both

hypospa-dias and strictures The foremost proponents were Devine

and Horton from Norfolk, Virginia, USA [2] They and

others continued with graft repairs into the 1970s, but by

then Yaxley [3] and others began developing flap repairs

Most notable were Turner-Warwick [4] and Blandy [5] for

the repair of urethral strictures in adults and Duckett [6]

for the repair of hypospadias in children

The prevailing view seemed to be that a flap was more

reliable because it carried its own blood supply, although

this was never proved Quartey [7] studied the

vascu-lar basis of flap repair and through the 1980s and early

1990s flap repairs dominated genital reconstructive

sur-gery until the Mainz group reintroduced buccal mucosal

free grafts [8] This led to a resurgence of interests in graft

repairs – whatever the material used – so at the beginning

of the 21st century, free grafts have regained their place in

the reconstructive urologists armamentarium

21.2 Grafts Versus Flaps

The flaps used in urethral reconstruction are random

island flaps of penile or scrotal skin carried on a dartos

pedicle – random, because there is no defined artery

sup-plying them and so for the skin paddle to remain viable,

an extensive dartos pedicle must be created The

disad-vantage with a flap repair is that it is time-consuming (and

tedious) to harvest the flap and the dissection is extensive

This produces scarring and loss of the normal contour of

the penis when its dartos layer has been redeployed from

part or all of its circumference

Grafts are inherently less reliable – in theory – because

they have to be revascularized On the other hand, they

are quick and relatively easier to harvest and deploy

There are numerous short- and mid-term follow-up

studies of both grafts and flaps, which essentially show

about the same restricture rates [9] In other words, there

is no real difference between grafts and flaps in terms of

their restricture rate and therefore unless there is a

positi-ve indication or contraindication for one or the other, the

simplicity and speed by which a graft can be harvested

and deployed means that this is the procedure of choice

as far as we are concerned

Positive indications in favor of a flap rather than a

graft include some instances of revision surgery; any

cause of local devascularization such as radiotherapy (or severe peripheral vascular disease); and local infection – all of which interfere with the ability of a graft to take

21.3 The Principles of Grafting

Graft »take« occurs in two phases, each of which lasts about 2 days The first phase is imbibition in which the graft is kept alive by absorbing nutrients from the plasma oozed from the surface of the graft bed The second phase

is inosculation in which the microvasculature of the graft bed links up with the microvasculature exposed on the under surface of the graft Clearly the process leading to inosculation begins during the imbibition phase, but for the viability of the graft itself the two phases are distinct

By the 5th day after grafting, the graft has either taken

or has sloughed off For the graft to take it must be kept

in close contact with the recipient area (and not subject to either undue pressure or hematoma) and free of infection

It is clearly an advantage if the graft has a dense plexus

on its undersurface, and likewise the opposing surface of the recipient bed, to facilitate inosculation It is an advan-tage if the graft is not too thick, as there is less bulk of tissue to be kept alive during the processes of imbibition and inosculation For both these reasons, split-thickness grafts have an advantage over full-thickness grafts A split-thickness graft is thin and depends for its take on the relatively dense intradermal plexus, which is exposed

on its undersurface, whereas a full-thickness graft is stantially thicker and has to be inosculated through the subdermal plexus, which is much sparser

sub-On the other hand, a split-thickness graft tends to contract because of the relative absence of dermal colla-gen A full-thickness graft, on the other hand, does not contract because the presence of a normal amount of dermal collagen inhibits the contraction process Thus, if

a take can be assured a full-thickness graft is much better than a split-thickness graft because it does not contract and therefore retains its natural characteristics

The exceptions to the rule that full-thickness grafts have a rather sparse subdermal plexus are genital skin and skin from above the jaw line, including buccal mucosa Not only do full-thickness grafts from these areas have

a particularly dense subdermal plexus, but they are also thin when compared with skin from other sites Skin from above the jaw line or from the genitalia therefore does well

as a full-thickness skin graft Few would sacrifice the skin

of the face for urethral reconstruction but the skin from behind the ears (the post auricular Wolfe graft), buccal mucosa (applied as a full-thickness graft), and full-thick-ness grafts of penile and preputial skin are expendable within the limits of the amount usually required

Grafts take best when they are applied as patches to place by the recipient graft bed It is difficult to apply

176 Chapter 21 · The Use of Free Grafts for Urethroplasty

21

a free graft as a tube because it is difficult to provide a

supporting recipient bed equally all around the

circumfe-rence of the tube and therefore ensure take (⊡ Fig 21.1)

Thus at 1–3 years of follow-up, the restricture rate of tube

grafts is three times the restricture rate of patch grafts

[10] A complete circumferential reconstruction of the

urethra is not commonly indicated except in the penile

urethra, but when it is, it is therefore safer to apply the

graft as a patch in the first instance and then to roll it into

a tube as a second stage in order to achieve the lowest

possible long-term restricture rate

21.4 Summary of Principles

In short, there is no significant difference in terms of cure

of the stricture between a graft repair and a flap repair but

a graft repair is generally quicker and easier and so a graft

is best unless there is a positive indication for a flap

Full-thickness grafts contract less and retain their

characteristics better than split-thickness grafts and so

full-thickness grafts should be used whenever possible

The best sources of material for a full-thickness graft

are the postauricular skin, buccal mucosa, and penile and

preputial skin

Patch grafts do better than tube grafts and so when a

circumferential reconstruction of the urethra is required,

it is best to do it in two stages

21.5 Urethroplasty Using Free Grafts

There is little or no place for substitution urethroplasty

in the posterior urethra and this will not be discussed

further

21.6 Bulbar Urethroplasty

The vast majority of bulbar urethral strictures are fairly straightforward strictures in which a one-stage repair is possible These were (and, by some surgeons, still are) commonly repaired with a preputial/penile skin flap These days, a graft of buccal mucosa or full-thickness penile shaft skin is more commonly used Until recently, the bulbar stricture was opened on its ventral aspect and the graft (or flap) was sewn in ventrally to close the defect Recently, Barbagli [11] has introduced the dorsal stricturotomy and patch as the dorsal siting of the graft provides better support, with a better vascular bed and better long-term stricture-free survival as a consequence

A particular problem of a ventral patch was out-pouching

of the patch because of lack of support This in turn led

to postmicturition dribbling, postcoital pooling of semen and a variety or irritative symptoms in addition In this regard, a ventral buccal mucosal graft – being tougher than skin – gives better results than a ventral skin graft With a dorsally placed stricturotomy and patch, there is probably no difference between the two [12]

There are still a few occasions when a two-stage bulbar urethroplasty is indicated: with grossly infected strictures; after excision of tumors; amyloid disease or vascular mal-formations of the urethra; or after excision of a Urolume stent, all of which will leave a defect that will need to be circumferentially reconstructed Such reconstructions, as already argued, are best done in two stages Here a graft can be placed between the two ends of healthy urethra with a scrotal funnel sutured to the margins of the graft and the proximal and distal urethrostomies The graft is then rolled into a tube at a second stage

21.7 Penile Urethroplasty

Simple strictures of the penile urethra are probably best treated by a one-stage flap procedure such as the Orandi flap [13]

Unfortunately, simple strictures of the penile urethra are not that common Many are caused by either previous hypospadias repair or to lichen sclerosus (balanitis xerotica obliterans, BXO) which will usually require excision of the urethra [14] In lichen sclerosus, this is almost always the case In hypospadias retrieval surgery, it is less commonly necessary and indeed if the natural urethral plate is still present and can be preserved, then it should be preserved.Lichen sclerosus is a disease of genital skin and there-fore repairs using genital skin almost always lead to restricturing Nongenital skin is less affected and so, for example, a postauricular Wolfe graft is much less likely

to lead to restricturing but still occurs in approximately 30%–40% of cases Buccal mucosa rarely suffers lichen sclerosus and so a buccal mucosal free graft should pro-

⊡ Fig 21.1 This illustrates the problems of providing vascular support

for a tubular free graft Dorsally and ventrally (hatched areas) are well

supported but laterally on each side (X) support is poor

178 Chapter 21 · The Use of Free Grafts for Urethroplasty

21 bably be used as the material of choice for the reconstruc-tion of the urethra after excision for this disease.

Reconstruction of a previously failed hypospadias

repair is not subject to this proviso The only requirement

is for sufficient skin for the repairs If this can be

harves-ted locally, all is well and good, otherwise a postauricular

Wolfe graft provides the best material

21.8 Points of Technique

Quilt the graft in position This ensures fixation; provides

drainage holes for any hematoma or seroma; and

guaran-tees take at the site of each quilting stitch (and therefore

of the whole graft)

In staged reconstructions, quilt the graft directly on to

the tunic albuginea in the mid-line and 0.5 cm or so on

either side More laterally on each side, incorporate some

dartos with the quilting stitch (⊡ Fig 21.2) This will make

the edges of the graft easier to mobilize at the second stage

(⊡ Fig 21.3)

At the second stage, don’t over-mobilise the two edges

of the graft Aim to produce an oval urethra rather than a

circular tube This is less likely to interfere with the

vascu-larity of the neourethral tube (⊡ Fig 21.4)

At the second stage, close the neourethral tube with

stitches through the dermis rather than the epidermis to

reduce the risk of fistulation (⊡ Fig 21.5)

⊡ Fig 21.3 To show how incorporating the dartos on each lateral

aspect facilitates mobilization of the graft at the second stage of a two-stage procedure

⊡ Fig 21.4 To illustrate how closing the neourethra as an oval in the

second stage of a two-stage procedure requires less mobilization and therefore less risk of ischemia

NOT

⊡ Fig 21.5 To show how closing the dermal layer rather than the

epidermal layer at the second stage of a two-stage procedure reduces

NOT

⊡ Fig 21.2 To illustrate the incorporation of the dartos layer on the

Always overclose suture lines with a layer of dartos,

particularly at the corona, which is the most vulnerable

area

If a hematoma develops in the wound after the second

stage, drain it Hematomas and seromas are a common

cause of fistulation because of secondary infection

5 Blandy JP (1980) Urethral stricture Postgrad Med J 56:383–418

6 Duckett JW Jr (1980) Transverse preputial island flap technique for

repair of severe hypospadias Urol Clin North Am 7:423–431

7 Quartey JKM (1985) One-stage penile/preputial island flap

ureth-roplasty for urethral stricture J Urol 134:474–487

8 Burger R, Muller SC, Hohenfellner R (1992) Buccal mucosal graft: a

preliminary report J Urol 147:662–664

9 Wessells H, McAninch JW (1998) Current controversies in

ante-rior urethral stricture repair: free-graft versus pedicle skin-flap

reconstruction World J Urol 16:175–180

10 Greenwell TJ, Venn SN, Mundy AR (1998) Changing practice in

anterior urethroplasty BJU Int 83:631–635

11 Barbagli G, Selli C, di Cello V, Mottola A (1996) A one-stage dorsal

free-graft urethroplasty for bulbar urethral strictures B J Urol

78:929–932

12 Andrich DE, Mundy AR (2001) The Barbagli procedure gives the

best results for patch urethroplasty of the bulbar urethra BJU Int

88:385–389

13 Orandi A (1968) One-stage urethroplasty B J Urol 40:77

14 Venn SN, Mundy AR (1998) Urethroplasty for balanitis xerotica

Repair of Bulbar Urethra Using

the Barbagli Technique

G Barbagli, M Lazzeri

22.1 Introduction and Historical Background – 182

22.2 Anatomical Remarks – 182

22.3 Step-by-Step Surgical Details – 183

22.3.1 Preparation of the Bulbar Urethra – 183

22.3.2 Preparation and Suture of the Graft (Skin or Buccal Mucosa) – 184

22.3.3 Preparation and Suture of the Flap – 186

22.3.4 Postoperative Course – 187

22.3.5 Intraoperative, Perioperative, and Postoperative Complications – 187

22.4 Long-Term Results and Attrition Rate

of the Barbagli Procedures – 187

22.5 Conclusions – 187

References – 187

22.1 Introduction and Historical

Background

The dorsal onlay graft urethroplasty, also named

Bar-bagli technique, builds on previous steps in the urethral

surgery:

▬ The principles of the buried skin strip as suggested by

Denis Browne [1]

▬ The experimental and clinical studies on urethral

re-generation according to Weaver, Schulte, and Moore

[2–4]

▬ Urethral reconstruction using a free full-thickness

skin graft as popularized by Devine [5]

▬ The dorsal approach to urethral lumen as suggested

by Monseur [6]

22.2 Anatomical Remarks

In the bulbar urethra, the relationship between the

spongi-osum tissue and the mucosal membrane are quite different

from penile tract (⊡ Fig 22.1A): the corpus spongiosum is thick in the ventral urethral surface, and thin in the dorsal urethral surface (⊡ Fig 22.1B) Furthermore, the urethral lumen is located dorsally and not centrally (⊡ Fig 22.1B) The bulbar urethra is easily freed from the underlying corpora cavernosa (⊡ Fig 22.2D, E), and the lumen may be opened along its dorsal surface (⊡ Fig 22.2F) In patients who have undergone repeated and deep internal ureth-rotomies at 12 o’clock, the urethral lumen is adherent and firmly fixed to the tunica albuginea, because the longitudinal internal cut involve the urethral mucosa, spongiosum tissue, and the tunica albuginea The healing

of this kind of urethrotomy and the urinary extravasation cause a scar that joins together the urethral mucosa and the tunica albuginea Also, in patients with an indwelling urethral stent in place, it may be difficult to approach and

to free the dorsal urethral lumen In obese patient, its may

be difficult to free the urethra from the corpora

caverno-sa, because these patients have a deep and flat perineum

In all these patients, a ventral or lateral approach to the urethral lumen for urethroplasty could be advisable

182 Chapter 22 · Repair of Bulbar Urethra Using the Barbagli Technique

22

⊡ Fig 22.1A, B Anatomy of penile (A) and bulbar urethra (B) [12, 13]

22.3 Step-by-Step Surgical Details

22.3.1 Preparation of the Bulbar Urethra

The patient is placed in simple lithotomy position, and

a midline perineoscrotal incision is made overlying the

stricture site (⊡ Fig 22.2A) The bulbocavernous

mus-cles are separated in the midline, and, in patients with

proximal bulbar urethral stricture, the central tendon of

perineum is dissected (⊡ Fig 22.2B) The bulbar urethra

is free from the bulbocavernous muscles for its entire

length, and the muscles are fixed to a retractor using four

stitches (⊡ Fig 22.2C) The bulbar urethra is dissected

from the corpora cavernosa, starting from 2 cm distally

(not proximally) to the stricture (⊡ Fig 22.2D) In this tract (⊡ Fig 22.2D), it is easier to free the urethra from the corpora cavernosa, because the urethra is thinner and not involved in the disease Using a loop, the urethra is com-pletely mobilized from the corpora cavernosa and rotated

180 degrees (⊡ Fig 22.2E) The stricture portion is incised dorsally, starting over the urethral catheter (⊡ Fig 22.2E), and extending the stricturotomy for 2 cm into the healthy urethra proximal and distal to the stricture The strictured tract is dorsally opened for all its length (⊡ Fig 22.2F)

⊡ Fig 22.2A–F Preparation of the bulbar urethra [12, 13]

C

22.3.2 Preparation and Suture of the Graft

(Skin or Buccal Mucosa)

In patients with stricture shorter than 4 cm, an ovoid

strip of ventral penile skin is outlined for harvesting

(⊡ Fig 22.2A) In patients with stricture longer than 4 cm,

a double circumferential subcoronal incision is made for

harvesting a longer preputial skin strip When local

epi-thelial foreskin is unavailable or the patient does not agree

to harvesting from the prepuce, the buccal mucosa is

preferred to other various types of extragenital free grafts,

because of its qualities [7] We chose the inner check over

the inner lip as a donor site, because the width of the lip

limits the size of the graft [7] Moreover, the buccal

muco-sa is thicker and resistant in the cheek when compared

with the buccal mucosa from the lip The buccal mucosa harvesting increases the operative time by 1 h

Thus, a two-team approach may be used in which a perineal team exposes and calibrates the strictured tract, while another simultaneously harvests the graft from the mouth This procedure also increases the sterilization of the surgical act The reduced operative time has remar-kable advantages and may prevent troublesome complica-tions from prolonged lithotomy position [7]

The fenestrated ovoid preputial free skin or buccal mucosa graft is spread-fixed and quilted to the overlying tunica albuginea of the corporal bodies (⊡ Fig 22.3A).The right mucosal margin of the opened urethra is sutured to the right side of the patch graft, spreading open the strictured tract to the new roof, which is the flat,

184 Chapter 22 · Repair of Bulbar Urethra Using the Barbagli Technique

22

⊡ Fig 22.3A–E Dorsal onlay urethroplasty using skin or buccal mucosa graft: standard technique [12, 13]

fixed graft (⊡ Fig 22.3B) The urethra is rotated back to its

original position (⊡ Fig 22.3B) The left urethral margin

is sutured to the left side of the patch graft and corporal

bodies, and the grafted area is entirely covered by the

ure-thral plate (⊡ Fig 22.3C) The bulbocavernous muscles

are approximated over the grafted area (⊡ Fig 22.3D) A

small suction drain is placed in the region of the repair,

and an indwelling 16-Fr silicone Foley catheter is left in

place (⊡ Fig 22.3E) The suprapubic cystostomy is

unne-cessary

In patients with stricture who require a complete

removal of the strictured tract, the urethra is

comple-tely transected below the tip of the urethral catheter

(⊡ Fig 22.4A) The urethral scar or disease is removed,

and the distal and proximal urethral edges are mobilized

from the underlying corpora cavernosa, using a gentle traction on the stitch fixed to the spongiosum tissue (⊡ Fig 22.4B) The proximal mucosal edge is spatulated and spread over the corpora cavernosa, and the mobilized distal urethra is widely opened along its dorsal surface (⊡ Fig 22.4C) The free skin or buccal mucosa graft is spread-fixed and quilted to the underlying corpora, and its lower margin is sutured to the proximal mucosal edge

of the urethra (⊡ Fig 22.4D) The left mucosal margin of the opened distal urethra is sutured to the left side of the graft (⊡ Fig 22.4E) The urethra is rotated back over the grafted area and sutured to proximal mucosal edge and to the right corpora cavernosa (⊡ Fig 22.4F) The bulboca-vernous muscles are sutured over the bulbar urethra, and the perineal closure is made as previously described

⊡ Fig 22.4A–F Augmented roof strip anastomotic urethroplasty [12, 13]