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Editorial Comment on: Porcine Small Intestinal Submucosa Graft for Repair of Anterior Urethral Strictures
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european urology 51 (2007) 1702–1708
[18] McAninch JW. Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap. J Urol 1993;149: 488–91. [19] Barbagli G, Palminteri E, Bartoletti R. Long-term results of anterior and posterior urethroplasty with actuarial evaluation of the success rates. J Urol 1997;158:1380–2. [20] Lindell O, Borkowski J, Noll F. Urethral stricture repair: results in 179 patients. Scan J Urol Nephrol 1993;27:241–5. [21] Andrich DE, Dunglison N, Greenwell TJ, Mundy AR. The long-term results of urethroplasty. J Urol 2003;170:90–2. [22] Barbagli G, Selli C, Tosto A. Dorsal free graft urethroplasty. J Urol 1996;155:123–6. [23] Wessells H, McAninch JW. Use of free grafts in urethral stricture reconstruction. J Urol 1996;155:1912–5. [24] Pansadoro V, Emiliozzi P. Which urethroplasty for which results? Curr Opin Urol 2002;12:223–7. [25] Elliott SP, Metro MJ, McAninch JW. Long-term follow up of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754–7.
Editorial Comment on: Porcine Small Intestinal Submucosa Graft for Repair of Anterior Urethral Strictures Kenneth W. Angermeier, Section of Prosthetic Surgery and Genitourethral Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation, United States [email protected] The use of buccal mucosa as an onlay graft during substitution urethroplasty revolutionized the field of urethral reconstruction in the early-to-mid 1990s. The next logical progression would seem to be the development of an off-the-shelf material for this purpose to eliminate donor site morbidity as well as constraints on the quantity of graft material available. The authors present the results of the largest study to date using a nonautologous graft for substitution urethroplasty [1]. Commercially available small intestinal submucosa (SIS) grafts were placed ventrally and covered with corpus spongiosum, muscle, or dartos fascia. Although results in previous smaller studies using this material have been mixed [2,3], a 90% success rate was achieved when the grafts were covered with corpus spongiosum in the bulbous urethra. Results in the penile and bulbopenile urethra were not as favorable. This suggests that SIS in its current form requires a highly vascular host bed. Failures occurred very early, but in those in whom the graft did not fail, intermediate-term outcomes were durable. One possibility is that this may represent failure of initial host cell infiltration of the graft leading to
[26] Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M. Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal, or lateral surface of the urethra: are results affected by the surgical technique? J Urol 2005;174:955–8. [27] Barbagli G, De Stefani S, Sighinolfi MC, Annino F, Micali S, Bianchi G. Bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. Eur Urol 2006;50: 467–74. [28] Feil G, Christ-Adler M, Maurer S, et al. Coating with type a collagen fibronectin, or pronectin does not improve adherence of human urothelial cells seeded on small intestine submucosa. Eur Urol Suppl 2005;4(3):242. [29] Andrich DE, Mundy AR. Urethral strictures and their surgical treatment. BJU Int 2000;86:571–80. [30] Kamp S, Knoll T, Osman M, Hacker A, Mihel MS, Alken P. Donor-site morbidity in buccal mucosa urethroplasty: Lower lip or inner cheek? BJU Int 2005;96:619–23.
recurrent stricture. Although these results need to be confirmed by others, it is encouraging to have some support for this option whenever buccal mucosa is not available or the patient wishes to avoid graft harvest. Dorsal SIS graft placement has been described [3]; however, it remains to be seen how SIS may function as a dorsal graft in larger numbers of patients. In addition, given the fact that cell infiltration into SIS grafts has been shown to occur from the periphery toward the center [4], it might be reasonable to try using two grafts of lesser width, one placed dorsally and the other ventrally to see if results might be improved.
References [1] Fiala R, Vidlar A, Vrtal R, Belej K, Student V. Porcine small intestinal submucosa graft for repair of anterior urethral strictures. Eur Urol 2007;51:1702–8. [2] Mantovani F, Trinchieri A, Mangiarotti B, et al. Reconstructive urethroplasty using porcine acellular matrix: preliminary results. Arch Ital Urol Androl 2002;74:127–8. [3] Hauser S, Bastian PJ, Fechner G, Muller SC. Small intestine submucosa in urethral stricture repair in a consecutive series. Urology 2006;68:263–6. [4] Pope JC, Davis MM, Smith Jr ER, et al. The ontogeny of canine small intestinal submucosal regenerated bladder. J Urol 1997;158:1105–10.
DOI: 10.1016/j.eururo.2007.01.100 DOI of original article: 10.1016/j.eururo.2007.01.099
european urology 51 (2007) 1702–1708
[18] McAninch JW. Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap. J Urol 1993;149: 488–91. [19] Barbagli G, Palminteri E, Bartoletti R. Long-term results of anterior and posterior urethroplasty with actuarial evaluation of the success rates. J Urol 1997;158:1380–2. [20] Lindell O, Borkowski J, Noll F. Urethral stricture repair: results in 179 patients. Scan J Urol Nephrol 1993;27:241–5. [21] Andrich DE, Dunglison N, Greenwell TJ, Mundy AR. The long-term results of urethroplasty. J Urol 2003;170:90–2. [22] Barbagli G, Selli C, Tosto A. Dorsal free graft urethroplasty. J Urol 1996;155:123–6. [23] Wessells H, McAninch JW. Use of free grafts in urethral stricture reconstruction. J Urol 1996;155:1912–5. [24] Pansadoro V, Emiliozzi P. Which urethroplasty for which results? Curr Opin Urol 2002;12:223–7. [25] Elliott SP, Metro MJ, McAninch JW. Long-term follow up of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754–7.
Editorial Comment on: Porcine Small Intestinal Submucosa Graft for Repair of Anterior Urethral Strictures Kenneth W. Angermeier, Section of Prosthetic Surgery and Genitourethral Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation, United States [email protected] The use of buccal mucosa as an onlay graft during substitution urethroplasty revolutionized the field of urethral reconstruction in the early-to-mid 1990s. The next logical progression would seem to be the development of an off-the-shelf material for this purpose to eliminate donor site morbidity as well as constraints on the quantity of graft material available. The authors present the results of the largest study to date using a nonautologous graft for substitution urethroplasty [1]. Commercially available small intestinal submucosa (SIS) grafts were placed ventrally and covered with corpus spongiosum, muscle, or dartos fascia. Although results in previous smaller studies using this material have been mixed [2,3], a 90% success rate was achieved when the grafts were covered with corpus spongiosum in the bulbous urethra. Results in the penile and bulbopenile urethra were not as favorable. This suggests that SIS in its current form requires a highly vascular host bed. Failures occurred very early, but in those in whom the graft did not fail, intermediate-term outcomes were durable. One possibility is that this may represent failure of initial host cell infiltration of the graft leading to
[26] Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M. Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal, or lateral surface of the urethra: are results affected by the surgical technique? J Urol 2005;174:955–8. [27] Barbagli G, De Stefani S, Sighinolfi MC, Annino F, Micali S, Bianchi G. Bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. Eur Urol 2006;50: 467–74. [28] Feil G, Christ-Adler M, Maurer S, et al. Coating with type a collagen fibronectin, or pronectin does not improve adherence of human urothelial cells seeded on small intestine submucosa. Eur Urol Suppl 2005;4(3):242. [29] Andrich DE, Mundy AR. Urethral strictures and their surgical treatment. BJU Int 2000;86:571–80. [30] Kamp S, Knoll T, Osman M, Hacker A, Mihel MS, Alken P. Donor-site morbidity in buccal mucosa urethroplasty: Lower lip or inner cheek? BJU Int 2005;96:619–23.
recurrent stricture. Although these results need to be confirmed by others, it is encouraging to have some support for this option whenever buccal mucosa is not available or the patient wishes to avoid graft harvest. Dorsal SIS graft placement has been described [3]; however, it remains to be seen how SIS may function as a dorsal graft in larger numbers of patients. In addition, given the fact that cell infiltration into SIS grafts has been shown to occur from the periphery toward the center [4], it might be reasonable to try using two grafts of lesser width, one placed dorsally and the other ventrally to see if results might be improved.
References [1] Fiala R, Vidlar A, Vrtal R, Belej K, Student V. Porcine small intestinal submucosa graft for repair of anterior urethral strictures. Eur Urol 2007;51:1702–8. [2] Mantovani F, Trinchieri A, Mangiarotti B, et al. Reconstructive urethroplasty using porcine acellular matrix: preliminary results. Arch Ital Urol Androl 2002;74:127–8. [3] Hauser S, Bastian PJ, Fechner G, Muller SC. Small intestine submucosa in urethral stricture repair in a consecutive series. Urology 2006;68:263–6. [4] Pope JC, Davis MM, Smith Jr ER, et al. The ontogeny of canine small intestinal submucosal regenerated bladder. J Urol 1997;158:1105–10.
DOI: 10.1016/j.eururo.2007.01.100 DOI of original article: 10.1016/j.eururo.2007.01.099