[Urethral reconstruction]. / Harnröhrenrekonstruktion.

A urethral stricture is an abnormal narrowing of the urethra due to spongiofibrosis of the urethral mucosa and the underlying corpus spongiosum. The diagnostics include uroflowmetry, sonography and radiology. For penile strictures the success rate of endoscopic treatment is low. Therefore, urethroplasty should always be performed, preferably using oral mucosa. Depending on the complexity, reconstruction must be carried out in one or multiple stages. For short bulbous strictures endoscopic treatment can primarily be carried out. In the case of recurrence urethroplasty should be carried out. The indications for urethral reconstruction are primarily given for long bulbous strictures. Depending on the length and extent of the stricture, a scar resection and end-to-end anastomosis, non-transsecting end-to-end anastomosis or augmentation urethroplasty can be performed. Perineal urethrostomy (the so-called boutonnière procedure) is a treatment option for patients with complex strictures or for patients who want a straightforward solution.

Ureteroplasty with buccal mucosa graft without omental wrap: an effective method to treat ureteral strictures.

PURPOSE: Successful treatment options for ureteral strictures are limited. Surgical options such as ileal interposition and kidney autotransplantation are difficult and associated with morbidity and complications. Techniques such as Boari flap and psoas hitch are limited to distal strictures. Only limited case studies on the success of open buccal mucosa graft (BMG) ureteroplasty exist to this date. The purpose of this study was to evaluate the success of open BMG ureteroplasty without omental wrap. METHODS: In this single-center retrospective study between July 2020 and January 2023, we included 14 consecutive patients with ureteric strictures who were treated with open BMG ureteroplasty without omental wrap. The primary outcome was the success of open BMG ureteroplasty. Further endpoints were complications and hospital readmission. Outcome variables were assessed by clinical examination, kidney sonography, and patient anamnesis. RESULTS: Out of 14 patients, 13 were stricture and ectasia-free without a double-J stent at a median follow-up of 15 months (success rate 93%). No complications were observed at the donor site, and the complication rate overall was low with 3 out of 14 patients (21%) having mild-to-medium complications. CONCLUSIONS: Open BMG ureteroplasty without omental wrap is a successful and feasible technique for ureteric stricture repair.

Comparison of oral morbidity and mid-term efficacy of anterior urethroplasty using an autologous tissue-engineered graft (MukoCell®) versus native oral mucosa graft.

OBJECTIVE: Our study aimed to compare surgical success rate (SR) and oral morbidity of augmentation urethroplasty for anterior urethral strictures using autologous tissue-engineered oral mucosa graft (TEOMG) named MukoCell® versus native oral mucosa graft (NOMG). METHODS: We conducted a single-institution observational study on patients undergoing TEOMG and NOMG urethroplasty for anterior urethral strictures >2 cm in length from January 2016 to July 2020. SR, oral morbidity, and potential risk factors of recurrence were compared between groups were analyzed. A decrease of maximum uroflow rate < 15 mL/s or further instrumentation was considered a failure. RESULTS: Overall, TEOMG (n = 77) and NOMG (n = 76) groups had comparable SR (68.8% vs. 78.9%, p = 0.155) after a median follow-up of 52 (interquartile range [IQR] 45-60) months for TEOMG and 53.5 (IQR 43-58) months for NOMG. Subgroup analysis revealed comparable SR according to surgical technique, stricture localization, and length. Only following repetitive urethral dilatations, TEOMG achieved lower SR (31.3% vs. 81.3%, p = 0.003). Surgical time was significantly shorter by TEOMG use (median 104 vs. 182 min, p < 0.001). Oral morbidity and the associated "burden" in patients' quality of life were significantly less at 3 weeks following the biopsy required for TEOMG manufacture, compared to NOMG harvesting and totally absent at 6 and 12 months postoperatively. CONCLUSIONS: The SR of TEOMG urethroplasty appeared to be comparable to NOMG at a mid-term follow-up but taking into account the uneven distribution of stricture site and the surgical techniques used in both groups. Surgical time was significantly shortened, since no intraoperative mucosa harvesting was required, and oral complications were diminished through the preoperative biopsy for MukoCell® manufacture.

Dorsal oral mucosa graft urethroplasty for female urethral stricture reconstruction: A narrative review.

Female urethral stricture is currently a challenging situation. In general, urethra dilatation can be selected for treatment, but the complications and high recurrence rate urge doctors to consider other treatments. Recently, dorsal oral mucosa graft urethroplasty is concerned by more and more surgeons, but there are not enough reports so far. A comprehensive search of dorsal oral mucosa graft urethroplasty was performed. According to the existing literature, there are applications of buccal mucosa and lingual mucosa, and compared with other kinds of grafts, the success rate is higher. However, there is a lack of multicenter, large sample and long follow-up studies. And there is still no enough comparative study between different types of oral mucosa. In summary, dorsal oral mucosa graft urethroplasty is an effective option for the management of female urethral stricture. More multicenter and large sample studies with long-term follow-up data are needed.

Factors to Consider in Augmentation Urethroplasty with Oral Mucosa Graft or Penile Skin Flap for Anterior Urethral Stricture: A Systematic Review and Meta-analysis.

Context: Oral mucosa graft (OMG) and penile skin flap (PSF) are common substitutions in urethroplasty; however, the recommended substitution for anterior urethral strictures remains uncertain. Objective: To compare the efficacy of OMG and PSF in anterior urethral strictures in terms of success rate and prevalence of postvoid dribbling based on current studies. Evidence acquisition: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and registered at PROSPERO (ID: CRD42022313879). All publications until March 1, 2022, were searched in the PubMed, EMBASE, and Cochrane Library databases without any restriction. Studies that focused on patients with anterior urethral strictures undergoing single-stage augmentation urethroplasty with OMG and PSF, and reported comparable success rates between the two substitutions were included. Evidence synthesis: Thirteen studies involving a total of 1216 patients were included in the screening procedures, and 12 studies were eventually included in the meta-analysis. No significant difference in success rates was identified between OMG and PSF (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 0.96-2.07, p = 0.08). No significant difference was observed in the comparison of success rates in penile urethral strictures (OR: 0.95, 95% CI: 0.53-1.70, p = 0.86) and in the comparison of postvoid dribbling (OR: 0.59, 95% CI: 0.31-1.11, p = 0.10). However, a subgroup analysis suggested that OMG had a higher success rate than PSF in studies with the top 50% sample size (six studies, OR: 1.678, 95% CI: 1.055-2.668, p = 0.029) and the top 50% follow-up period (five studies, OR: 2.279, 95% CI: 1.193-4.352, p = 0.013). Conclusions: OMG provides the same success rate and postvoid dribbling as PSF. However, based on the existing evidence, OMG is more likely to perform better in a cohort with long-term follow-up and a relatively large sample size. More studies on the two substitutions are necessary to evaluate the factors of urethroplasty success rate, performance of substitutions in penile urethral strictures, and indicators of quality of life. Patient summary: In this research, we compared the outcomes of oral mucosa graft (OMG) and penile skin flap for urethroplasty in anterior urethral stricture patients in 13 studies. We found that these were similar in terms of success rate and postvoid dribbling. However, OMG could probably provide a higher success rate when the studies had more patients or a longer follow-up period.

A Sandwich-Like Oral Mucosa Graft-Conjunctiva In Situ-Dermis-Fat Graft for Reconstruction of the Anophthalmic Socket with Ocular Infection History.

INTRODUCTION: A novel technique of using a sandwich-like structure, namely, an oral mucosa graft (OMG)-conjunctiva in situ-dermis-fat graft (DFG) (OMG-C-DFG), to reconstruct a contracted and low-capacity anophthalmic socket for a patient with ocular infection history was evaluated. METHODS: This was retrospective case study of four patients (cases) who underwent anophthalmic socket reconstruction surgery in which the OMG-C-DFG technique was applied. The procedures were performed in the Department of Ophthalmology at the Ninth People's Hospital, Shanghai JiaoTong University School of Medicine (Shanghai, China). Postoperative cosmetic appearance, graft outcome, the ability to wear an ocular prosthesis, and postoperative complications were evaluated. RESULTS: The median (± standard deviation) age of patients was 41.5 ± 22.1 (range 10-60) years. All patients suffered from contracted and low-capacity anophthalmic sockets. Three patients had a history of orbital implant infection and one patient had a history of enucleation due to exogenous endophthalmitis after globe rupture. The DFG and OMG were harvested from the abdominal region and lower lip, respectively. All four patients achieved a good postoperative appearance, with dermal surfaces appearing pink and smooth, the orbital areas showing good fullness, the ocular prosthesis showing good wearability, and no narrowing of the sockets. There was no lipid secretion, fat lysate outflow, or infection in the graft bed. There were only small amounts of scars and no infection of the donor site. CONCLUSION: The sandwich-like structure can be effectively used to reconstruct the contracted and low-capacity anophthalmic socket with a history of orbital infection in one stage.

What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review.

PURPOSE: The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given. MATERIALS AND METHODS: To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed. RESULTS: Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL. CONCLUSIONS: The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.

Uretroplasty with oral mucosal graft in patients with anterior urethral stenosis. Comparative study with conventional treatment.

ANTECEDENTES: El manejo con uretroplastía de la estenosis uretral es una opción quirúrgica fundamental, y comparar la uretroplastía con injerto de mucosa oral con la uretroplastía término-terminal tiene trascendencia para conocer la diferencia entre ambas técnicas. OBJETIVO: Comparar la uretroplastía con injerto de mucosa oral con la uretroplastía término-terminal en pacientes con estenosis uretral tipo Jordan C, D y E. MÉTODO: Cuasiexperimento realizado en pacientes con estenosis uretral anterior operados de uretroplastía con anastomosis término-terminal o con injerto de mucosa bucal. RESULTADOS: Veintinueve pacientes con una media de edad de 50.7 años, 6 diabéticos, 9 hipertensos, longitud media de la estenosis de 3.6 cm, 19 operados con uretroplastía termino-terminal (grupo 1) y uretroplastía con mucosa bucal (grupo 2). El Índice Internacional de Síntomas Prostáticos promedio preoperatorio fue grave en la mayoría de los pacientes (93%). Hubo mejoría significativa en el posoperatorio en ambos grupos (p = 0.0001 y p = 0.0011), así como en los resultados uroflujométricos (p = 0.0046 y p = 0.00062). CONCLUSIONES: Ambos procedimientos lograron mejorías significativas en la sintomatología urinaria a los 6 meses en comparación con los valores preoperatorios. BACKGROUND: Urethroplasty management of urethral stricture is a fundamental surgical option, and comparing urethroplasty with oral mucosal graft with end-to-end urethroplasty is important to know the difference between both techniques. OBJECTIVE: To compare urethroplasty with oral mucosal graft with end-to-end urethroplasty in patients with urethral stricture type Jordan C, D and E. METHOD: Quasi-experiment performed in patients with anterior urethral stricture operated with urethroplasty with end-to-end anastomosis or with oral mucosal graft. RESULTS: Twenty-nine patients with a mean age of 50.7 years, 6 diabetic, 9 hypertensive, mean stenosis length of 3.6 cm, 10 with end-to-end urethroplasty (group 1) and 19 operated with urethroplasty with buccal mucosa (group 2). The average preoperative International Prostatic Symptom Index was severe in most patients (93%). There was significant improvement postoperatively in both groups (p = 0.0001 and p = 0.0011), as well as in uroflowmetric results (p = 0.0046 and p = 0.00062). CONCLUSIONS: Both procedures achieved significant improvements in urinary symptomatology at 6 months compared to preoperative values.

Patient-reported outcomes for typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting: a single-center analysis of more than 800 patients.

PURPOSE: The optimal harvesting site for oral grafting in patients with urethral strictures remain controversial, with no study investigating morbidity on large scale. We aimed to compare typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting in terms of complications and patient-reported outcomes. METHODS: Within 827 patients treated at our referral center with oral graft urethroplasty, we compared typical vs atypical harvesting techniques. A self-administered, semiquantitative, non-validated questionnaire assessed early (10 days) and late (4 months) postoperative complications and patient-reported outcomes. A semiquantitative score was calculated according to patient responses, and it was used to assess early (6 questions) and late (13 questions) patient dissatisfaction status. Patients were defined early and/or late dissatisfied when they scored ≥ 7 and ≥ 10 at the early or late questionnaires, respectively. RESULTS: Between 1998 and 2019, our patients predominantly received typical single cheek harvesting (89% vs 11%), with + 1.5% increase rate per year (p < 0.001). Early and late dissatisfied patients were, respectively, 170 (23%) vs 39 (44%) and 59 (8%) vs 16 (18%) in the typical vs atypical groups. Atypical harvesting was associated with higher rates of early (Odds ratio [OR]: 2.34; 95% Confidence interval [CI] 1.44-3.75; p = 0.001) and late (OR: 2.37; 95%CI 1.22-4.42; p = 0.008) postoperative dissatisfaction. CONCLUSIONS: Typical single cheek harvesting was the preferred surgical option at our center and it was associated with negligible early and late rates of complications and patient's dissatisfaction. Conversely, atypical lingual, labial or bilateral cheeks harvesting was associated with higher complications and frequent patient dissatisfaction.

Augmented perineal urethrostomy using a dorsal buccal mucosal graft, bi-institutional study.

PURPOSE: To present our technique and outcomes for perineal urethrostomy augmented with a dorsal onlay buccal mucosa graft (BMG). Results from initial series and collaboration from an international center are included. METHODS: A retrospective chart review of all adult patients who underwent urethral reconstruction with perineal urethrostomy utilizing a buccal mucosal graft between January 1, 2002 and January 1, 2013 was performed. All surgeries were performed by three surgeons using the same technique (GHJ, KAM, and RV). Success was defined as no need for additional treatment following definitive surgery. RESULTS: A total of 44 patients met inclusion criteria. Mean patient age was 60 (range 44-81) years. All strictures were pananterior. Etiologies included unknown in 16 (36%), failed hypospadias repair in six (14%), lichen sclerosus in ten (23%), iatrogenic in seven (16%), Fournier's in three (7%), urethral cancer in one (2%) and penile cancer in one (2%). Mean follow-up was 45 (range 6-136) months. Overall success was 80%. Nine patients recurred, of which four had a successful revision, two are awaiting potential revision, and three are being managed with periodic dilations. CONCLUSIONS: BMG perineal urethrostomy is a valid alternative for complex urethral strictures due to lichen sclerosus, previous failed reconstructions or hypospadias cripples. Midterm results are encouraging for this novel technique.

Regulatory challenges for autologous tissue engineered products on their way from bench to bedside in Europe.

Since the late eighties of last century the high potential of tissue engineered products (TEP)s has been shown for the treatment of various diseases and many scientific publications appeared in this field. However, only few products reached the market since. Development of TEPs is a promising but owing to its novelty a very challenging task that requires experts in this still developing field as well as ample financial resources. This paper summarises relevant regulatory challenges during quality, preclinical and clinical development of autologous TEPs in Europe. Selected strategies on how to manage major issues are presented, together with some examples from the development of an autologous TEP for urethroplasty. Considering these aspects may help other investigators with potential strategies during the development of novel TEPs.

Treatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graft.

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. MATERIAL 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+26.5mm. 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 was 177+76min and 1.5+1 day, respectively. The preoperative Qmax and PVRV values were 4.5+4.45mL/sec and 212.5+130 cc, respectively. The postoperative values were 15.15+7.2mL/sec and 6+21.5cc, respectively (P<.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 no 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.

Histological and immunohistochemical changes in the rat oral mucosa used as an autologous urethral graft.

PURPOSE: The purpose of this study was to determine the histological and functional (immunohistochemical) changes that take place in oral mucosa grafts implanted in the rat urethra. METHODS: Urethroplasty was performed in 26 male Wistar rats weighing 250 g. All animals received autologous oral mucosa urethra grafting under general anesthesia. Samples were analyzed 10, 20, 30, 40, 50, 60, 90, and 120 days after surgery using light and scanning electron microscopy and immunofluorescence for the determination of the expression of epithelial markers (pancytokeratin, cytokeratin 1, 4, 13, and filaggrin). RESULTS: Grafted oral mucosa tissues were subjected to significant histological changes from the beginning with the formation of a well-developed epithelium whose structure was comparable to the native urethra from day 60 of the surgical implant. The immunofluorescence analysis demonstrated that the cytokeratin expression profile tended to mimic the pattern of the native urethra. These data suggest that the oral mucosa is able to efficiently transdifferentiate to the urethral environment. CONCLUSIONS: The efficient transdifferentiation process of the grafted oral mucosa at both the histological and immunofluorescence levels, and the absence of local complications confirm the clinical usefulness of this type of tissues for the repair of the urethra.