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Bulbar Urethroplasty with Dorsal Onlay Buccal Mucosal Graft and Fibrin Glue
european urology 50 (2006) 467–474
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
Bulbar Urethroplasty with Dorsal Onlay Buccal Mucosal Graft and Fibrin Glue Guido Barbagli a,*, Stefano De Stefani b, Maria Chiara Sighinolfi b, Filippo Annino b, Salvatore Micali b, Giampaolo Bianchi b a b
Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy Department of Urology, University of Modena-Reggio Emilia, Modena, Italy
Article info
Abstract
Article history: Accepted May 11, 2006 Published online ahead of print on June 5, 2006
Objectives: We describe a new surgical technique with the use of fibrin glue for bulbar urethra reconstruction using a dorsal buccal mucosal onlay graft. Methods: Six patients with a mean age of 43 yr underwent bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. The urethra was mobilised from the corpora cavernosa and opened along its dorsal surface. The buccal mucosal graft was applied on the corpora cavernosa using 2 ml of fibrin glue. Two interrupted polyglactin 5-0 sutures were used to fix the apices of the graft to the underlying albuginea of the corpora cavernosa. The urethra was rotated back to cover the graft and an adjunctive fibrin glue was injected over the urethra. Results: The mean operative time was 100 min (range, 90–120 min). No intraoperative or postoperative complications were observed. Voiding cystourethrography was performed when the catheter was removed 2 wk after surgery. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Mean follow-up was 16 mo (range, 12–24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients 6 and 12 mo after surgery. Conclusions: The use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction.
Keywords: Buccal mucosa Bulbar urethra Graft Fibrin glue Urethral stricture Urethroplasty
# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Tel. +39 0575 403412; Fax: +39 0575 27056. E-mail address: [email protected] (G. Barbagli).
1.
Introduction
Numerous surgical techniques have been described to repair bulbar urethral strictures according to stricture length, including end-to-end anastomosis,
augmented roof strip anastomotic urethroplasty, onlay repair using flap, or graft and multistaged procedures [1]. Short bulbar stricture, ranging from 1 to 2 cm, is generally managed by primary end-toend anastomosis [2] and augmented anastomotic
0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.05.018
468
european urology 50 (2006) 467–474
urethroplasty is suggested for strictures 2–3 cm in length [1,3–5]. Strictures longer than 3 cm are generally managed using tissue (skin or buccal mucosa) transfer procedures accomplished in a variety of ways including dorsal or ventral onlay graft urethroplasty [6–12]. Finally, in patients with strictures longer than 6 cm involving both penile and bulbar urethra or associated with local adverse conditions, multistage urethroplasty or mesh graft urethroplasty is mandatory [13,14]. Buccal mucosal onlay graft urethroplasty is one of the most widely used methods for the repair of the strictures in the bulbar urethra and provides excellent results [6–12,15,16]. Stricture recurrences can, however, occur despite using an adequate surgical technique and substitution material may deteriorate over time [15–17]. In our experience, stricture recurrences after bulbar substitution onlay urethroplasty show two different features, namely, extensive fibrous tissue involving the entire grafted area or a short fibrous ring stricture at the distal or proximal anastomotic sites where the apices of the graft are sutured to the apices of the urethral plate [18–20]. We investigated the prevalence, location, and etiology of these postoperative anastomotic ring strictures, which can affect any type of substitution bulbar urethroplasty [20]. Moreover, substitution urethroplasty using free graft requires a long catheterisation time and postoperative urinary leakage at the anastomotic site during the first postoperative radiologic investigation may also require a more prolonged catheterisation time [6,9], causing a negative psychological impact on the patient. Recently, the use of fibrin sealant was suggested to decrease immediate urinary leakage following prostatectomy [21] or to reduce the catheterisation time following penile urethroplasty [22]. We suggest here the use of fibrin glue in a new technique of dorsal onlay buccal mucosal graft urethroplasty to reduce the time of postoperative catheterisation, the risk of postoperative urinary leakage, and the incidence of postoperative anastomotic rings at the apices of the sutures between the graft and the mucosal urethral plate. 2.
disease) were not included in the study. In all patients, the bulbar strictures were managed using a dorsal urethral opening described by Barbagli et al. in 1996 [6]. The buccal mucosal graft was applied over the albuginea of the corpora cavernosa using fibrin glue and the urethra was rotated back to cover the graft.
2.1.
Preoperative evaluation
Each patient’s clinical history and chart were reviewed to evaluate the presence of previous perineal blunt trauma or previous repeated urethrotomy or urethroplasty failure and the genitalia were inspected to exclude the presence of lichen sclerosus disease. Preoperative tests included urine culture, residual urine measurement, retrograde and voiding cystourethrography, sonourethrography, and urethroscopy. The etiology of the stricture and its location and length were carefully examined to better define the characteristics needed in the buccal mucosal graft. Finally, patients who currently had an infectious disease affecting the mouth (such as candida, varicella virus, or herpes virus) or who had previous surgery in the mandibular arch that prevented the mouth from being opened wide, or who played a wind instrument were informed that genital or extra genital skin would be used for the urethroplasty. Patients were fully informed that bulbar urethroplasty is a safe procedure as far as sexual function is concerned.
2.2.
Surgical technique
2.2.1.
Preparation of the bulbar urethra
The patient is placed in a simple low lithotomy position. The patient’s calves are carefully placed in Allen stirrups with sequential inflatable compression sleeves and the lower extremities are then suspended by the patient’s feet within the boots of the stirrups. Proper positioning ensures that there is no pressure on any aspect of the calf muscles and no inward boot rotation to avoid peroneal nerve injury. The skin of the suprapubic region, scrotum, and perineum is shaved and this region is prepared and draped appropriately.
Methods
Between January 2003 and December 2004, six patients with a mean age of 42 yr (range, 26–64 yr) underwent bulbar urethroplasty using buccal mucosal graft and fibrin glue. The stricture etiology was instrumentation in four patients and unknown in two. Five patients had undergone previous urethrotomy or dilation. The average stricture length was 4.5 cm (range, 3–6 cm). Patients with lichen sclerosus, failed hypospadias repair, previously failed urethroplasty, and a stricture extending into the penile urethra (pan-urethral
Fig. 1 – The midline perineal incision is underlined.
european urology 50 (2006) 467–474
469
Fig. 4 – The urethra is dissected from the corpora cavernosa. Fig. 2 – The bulbocavernous muscles are separated on the midline.
Methylene blue is injected into the urethra to better define the urethral mucosa involved in the disease. A midline perineal incision is made overlying the stricture site (Fig. 1). The bulbocavernous muscles are separated in the midline (Fig. 2) and, in patients with proximal urethral stricture, the central tendon of the perineum is dissected. The urethra is freed from the bulbocavernous muscles for its entire length and the muscles are fixed to a retractor using four stitches (Fig. 3). The bulbar urethra is dissected from the corpora cavernosa (Fig. 4). The urethra is rotated 1808 and the distal extent of the stenosis is identified by gently inserting a 16F
Fig. 3 – The bulbar urethra is completely freed from the bulbocavernous muscles and the muscles are fixed to retractor.
catheter with a soft round tip until it meets resistance (Fig. 5). The dorsal urethral surface is incised in the midline until the catheter tip and urethral lumen are exposed. The stricture is then incised along its entire length by extending the urethrotomy distally and proximally (Fig. 6). Once the entire stricture has been incised, the length and width of the remaining urethral plate is measured. Proximal and distal calibration of the urethra with modified nasal speculum is critical for identifying any residual narrowing. The buccal mucosal graft is trimmed to an appropriate size according to the length and width of the urethrotomy.
Fig. 5 – The urethra is rotated of 1808 using a loop. The catheter is inserted and the incision on the dorsal urethral surface is underlined.
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european urology 50 (2006) 467–474
Fig. 6 – The stenosis is fully opened.
2.2.2.
Fig. 7 – The buccal mucosal graft is fixed over the albuginea of corpora cavernosa using fibrin glue.
Cheek harvesting technique
Recently, we fully described our current surgical technique for harvesting buccal mucosal graft from the inner cheek, including postoperative complications and patient discomfort [23]. The patient is intubated through the nose, allowing the mouth to be completely free. The patient is draped in two separated parts and two surgical teams work simultaneously. Each team has its own set of surgical instruments, including suction and bipolar cautery. By using a mouth retractor that has its own light, only one assistant is needed to harvest the buccal mucosa. The inner mucosal surface of the right cheek is prepared and disinfected, and stay sutures are placed along the external edge of cheek to keep the buccal mucosa stretched. The Stensen duct, located at the level of the second molar, is identified and the desired graft size is measured and marked in an ovoid shape. Lidocaine HCl 1% with epinephrine (1:100,000) is injected along the edges of the graft to enhance hemostasis. The outlined graft is sharply dissected and removed. The donor site is carefully examined for bleeding and is closed with 4-0 polyglactin sutures. The graft is stabilised on a silicone board using insulin needles. After careful deflation with microsurgical instruments, the graft is tailored according to site, length, and stricture characteristics. An ice bag is applied to the cheek to reduce edema, pain and haematoma.
stabilise the urethral margins to the corpora cavernosa over the graft (Fig. 10). At the end of the procedure the graft is completely covered by the urethra and fibrin glue (2 ml) is injected over the urethra to prevent urinary leakage. The bulbocavernous muscles are sutured over the spongiosum tissue (Fig. 11). Colles fascia, the perineal fat, and the skin are closed with interrupted absorbable sutures (Fig. 12). A suction drain is left in place for 1 d. The catheter is left in place for 2 wk.
2.2.4.
Postoperative care
The patient consumes a clear liquid diet and ice cream before advancing to a soft, then regular diet. The patient ambulates on the first postoperative day and is discharged from the
2.2.3. Sticking the graft to the albuginea of the corpora using fibrin glue The bulbar urethra is moved to the right side and fibrin glue (2 ml) is injected over the albuginea of the corpora cavernosa. The buccal mucosal graft is spread fixed over the fibrin glue bed (Fig. 7). The two apices of the graft are sutured to the proximal and distal apices of the urethrotomy (Fig. 8). A Foley 16F grooved silicone catheter is inserted. The bulbar urethra is rotated to its original position over the graft (Fig. 9). Three interrupted 4-0 polyglactin sutures for each side are used to
Fig. 8 – The apices of graft are fixed to the albuginea and to the apices of urethrotomy.
european urology 50 (2006) 467–474
471
Fig. 11 – The bulbocavernous muscles are closed over the urethra. Fig. 9 – The urethra is rotated back to its original position to cover the graft.
hospital 3 d after surgery. All patients receive postoperative broad-spectrum antibiotics and are maintained on oral antibiotics until the catheter is removed. Two weeks after surgery the bladder is filled with contrast medium, the Foley catheter is removed, and voiding cystourethrography is obtained.
2.2.5.
Postoperative complications
A possible early minor complication is urethrorrhagia due to nocturnal erections. Possible later minor complications are temporary numbness, dysesthesia to the perineum, and scrotal swelling.
3.
was needed, including dilation. The mean operative time was 100 min (range, 90–120 min). No intraoperative or postoperative complications were observed. In all patients, postoperative voiding cystourethrography was performed 2 wk after surgery and no urinary leakage was present. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Average follow-up was 16 mo (range, 12–24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients at 6 and 12 mo after surgery.
Results
Clinical outcome was considered a success or a failure at the time that any postoperative procedure
Fig. 10 – The urethra is fixed to the corpora cavernosa.
Fig. 12 – Suction drain and Foley catheter are left in place.
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4.
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Discussion
Buccal mucosal onlay graft urethroplasty represents one of the most widely methods for the repair of strictures in the bulbar urethra because of its thick and highly vascular spongiosum tissue. Location of the graft has recently become a contentious issue [8] since the time we described our original techniques of dorsal onlay graft urethroplasty [6]. The design rationale for this new approach was based on the concept that the corpora cavernosa remains a healthy host for receiving free buccal mucosal graft [6,8]. Moreover, graft fixation by suture onto a defined surface may decrease graft shrinkage and sacculation [6,8]. Success with buccal mucosal grafts for repairing bulbar urethral strictures has generally been high with dorsal or ventral onlay grafts [6– 12,15–17,19]. The application of fibrin glue in urology mainly relates to its sealing power; it has been shown to be a beneficial adjunct to sutures for closing wounds and promoting healing because it increases tissue plane adherence, accelerates revascularization, reduces haemorrhage, prevents seroma formation, and decreases inflammation [21,22,24,25]. Recently, Morris et al. reported the outcome of graft take and wound healing in a series of patients in whom fibrin sealant was used as tissue glue in the reconstruction of complex genital skin loss [26]. The fibrin glue used in our series of patients contained two solutions of human products, one consisting of fibrinogen, factor XII, plasmafibronectin, plasminogen dissolved with an aprotinin solution (bovine), and another of an activate thrombin component (human) mixed with a calcium chloride solution. When combined, a dense gelatinous clot is quickly formed at the point of application. Because this fibrin sealant is not synthetic and, therefore, biocompatible with the natural fibrinolytic mechanism, healing is promoted without inflammation and fibrosis formation [21,25]. Bach et al. have shown that, in a rat animal model, cultured and in vitro expanded urothelial cells can be successfully reimplanted onto a prefabricated tubelike structure using fibrin glue as a delivery matrix and native cell expansion vehicle [27]. To determine the effectiveness of fibrin glue as a transplanted delivery vehicle, in an animal model, Schoeller et al. cultured cells onto a prefabricate capsule created by a silicon block [28]. These authors showed that the used delivery vehicle of fibrin glue, which mainly contains fibronectin, is clearly the structural constituent and regulator of cell behaviour in urothelial culture reimplantation [28]. Moreover, fibronectin not only helps attach the transplanted cells to the recipient bed but also enhances migration of growth factors
and is itself a nutrient [28]. These properties are essential and might be the key to bridge the gap in which the reimplanted cell is nourished by the diffusion of extracellular fluid until revascularisation and definite incorporation occur [28]. In 2001, Currie et al. reviewed the advantages and disadvantages of using fibrin glue with skin graft and tissue-engineered skin substitutes and concluded that it has a haemostatic effect, increases the percentage of graft take, and may have a protective effect against infection [29]. Fibrin sealant has been widely used in Europe, Japan, and the United States [24]. Discussion of the safety of fibrin glue is important because this sealant is composed of human products [24]. Donors are initially screened and retested after 3 mo for human immunodeficiency virus, Epstein-Barr virus, cytomegalovirus, and hepatitis A, B, and C before plasma processing, and a large study on sealant use showed no seroconversion to any of these diseases [24]. Moreover, the plasma is then thermally treated to ensure further viral safety [24]. The use of fibrin glue in bulbar urethroplasty using buccal mucosa shortens the graft revascularisation time because it helps attach the transplanted cells to the recipient bed and enhances migration of growth factors and is itself a nutrient [28]. Moreover, the use of fibrin glue avoids the necessity of numerous interrupted stitches to fix the graft to the albuginea of the corpora cavernosa, which represents a tedious and time-consuming step in onlay urethroplasty. Apposition of the graft and its adhesion to the corpora cavernosa can be simplified by using fibrin glue, which allows ideal fixation of the graft to its vascular bed and thus better revascularization of the transplanted tissue. Secure adhesion of the graft keeps it wide open reducing the risk of sacculation and shrinkage, allowing the surgeon to perform an easier anastomosis between the graft and the urethral margins. At the end of our surgical procedure, the grafted area was covered by fibrin glue to avoid urinary leakage. The catheter was removed 2 wk after the urethroplasty and the occurrence of postoperative leakage seems to have been reduced in this small series of patients. We recently reported our preliminary experience with the use of fibrin glue in bulbar urethral reconstruction in six patients who underwent augmented anastomotic repair [30]. The short-term results on this limited series of patients were satisfactory and, consequently, we also extended the use of fibrin glue to an adjunctive series of six patients who underwent dorsal onlay graft urethroplasty. Further comparative studies are necessary to
european urology 50 (2006) 467–474
confirm that the use fibrin glue is really beneficial compared to using quilting with sutures to stabilise the graft to the corpora cavernosa bed [30]. Moreover, additional studies are necessary to evaluate whether its use reduces the restricture rate at the anastomotic sites [30]. These anastomotic fibrous rings still represent the most important cause of restricture following any kind of substitution bulbar onlay graft urethroplasty and we are still engaged in improving our surgical techniques to reduce failure rate [20].
5.
Conclusions
Reconstructive urethral surgery requires technical refinement and the use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction using dorsal buccal mucosal graft. Longer follow-up on a larger series of patients is necessary to confirm our satisfactory preliminary reports using fibrin sealant glue. We are still gathering data.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.eururo.2006.05.018 and via www.europeanurology. com. Subscribers to the printed journal will find the supplementary data attached (DVD).
References [1] Barbagli G, Palminteri E, Lazzeri M, Guazzoni G. Anterior urethral strictures. BJU Int 2003;92:497–505. [2] Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol 2002;167:1715–9. [3] Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture. J Urol 1999;161:815– 8. [4] Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol 2001;165:1496–501. [5] Delvecchio FC, Anger JT, Webster GD. A proposal that whenever possible stricture excision be a part of all bulbar urethroplasties: a progressive approach to patient selection. J Urol 2004;171:17, abstract 66. [6] Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty. J Urol 1996;155:123–6. [7] Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol 1998;160:1307–9.
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[8] Andrich DE, Leach CJ, Mundy AR. The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra. BJU Int 2001;88:385–9. [9] Barbagli G, Palminteri E, Balo` S, Picinotti A, Lazzeri M. Dorsal onlay graft urethroplasty. Current technique stepby-step. Contemp Urol 2002;14:18–32. [10] Rosestein DI, Jordan GH. Dorsal onlay graft urethroplasty using buccal mucosa graft in bulbous urethral reconstruction. J Urol 2002;167:16, abstract 63. [11] Barbagli G, Palminteri E, Lazzeri M. Dorsal onlay techniques for urethroplasty. Urol Clin N Am 2002;29:389–95. [12] Kane CJ, Tarman GJ, Summerton DJ, et al. Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction. J Urol 2002; 167:1314–7. [13] Schreiter F. The two-stage mesh-graft urethroplasty using split-thickness skin. Atlas Urol Clin N Am 1997;5:75–90. [14] Carr LK, Macdiarmid SA, Webster GD. Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty. J Urol 1997;157:104–8. [15] Armenakas NA. Long-term outcome of ventral buccal mucosal grafts for anterior urethral strictures. AUA News 2004;9:17–8. [16] Elliot SP, Metro MJ, McAninch JW. Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754–7. [17] Andrich DE, Dunglison N, Greenwell TJ, Mundy AR. The long-term results of urethroplasty. J Urol 2003;170:90–2. [18] Barbagli G, Palminteri E, Lazzeri M, Turini D. Interim outcomes of dorsal skin graft bulbar urethroplasty. J Urol 2004;172:1365–7. [19] 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. [20] Barbagli G, Palminteri E, Guazzoni G, Turini D, Lazzeri M. Anastomotic fibrous rings as cause of stricture recurrence after bulbar onlay graft urethroplasty: an open issue. J Urol 2006;175:104, abstract 314. [21] Diner EK, Patel SV, Kwart AM. Does fibrin sealant decrease immediate urinary leakage following radical retropubic prostatectomy? J Urol 2005;173:1147–9. [22] Hick EJ, Morey AF. Initial experience with fibrin sealant in pendulous urethral reconstruction. Is early catheter removal possible? J Urol 2004;171:1547–9. [23] Barbagli G, Palminteri E, De Stefani S, Lazzeri M. Harvsting buccal mucosal grafts. Keys to success. Contemp Urol 2006;18:16–24. [24] Morey AF, McDonough RC, Kizer WS, Foley JP. Drain-free simple retropubic prostatectomy with fibrin sealant. J Urol 2002;168:627–9. [25] Evans LA, Ferguson KH, Foley JP, Rozanski TA, Morey AF. Fibrin sealant for the management of genitourinary injuries, fistulas and surgical complications. J Urol 2003;169: 1360–2. [26] Morris MS, Morey AF, Stackhouse DA, Santucci RA. Fibrin sealant as tissue glue: preliminary experience in complex genital reconstructive surgery. Urology 2006;67:688–91.
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[27] Bach AD, Bannasch H, Galla TJ, Bittner KM, Stark GB. Fibrin glue as matrix for cultured autologous urothelial cells in urethral reconstruction. Tissue Eng 2001;7:45–53. [28] Schoeller T, Neumeister MW, Huemer GH, et al. Capsule induction technique in a rat model for bladder wall replacement: an overview. Biomaterials 2004;25:1663–73.
[29] Currie LJ, Scarpe JR, Martin R. The use of fibrin glue in skin grafts and tissue-engineered skin replacement: a review. Plast Reconstr Surg 2001;108:1713–26. [30] Barbagli G, De Stefani S, Sighinolfi MC, et al. Experience with fibrin glue in bulbar urethral reconstruction using dorsal buccal mucosa graft. Urology 2006;67:830–2.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
Bulbar Urethroplasty with Dorsal Onlay Buccal Mucosal Graft and Fibrin Glue Guido Barbagli a,*, Stefano De Stefani b, Maria Chiara Sighinolfi b, Filippo Annino b, Salvatore Micali b, Giampaolo Bianchi b a b
Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy Department of Urology, University of Modena-Reggio Emilia, Modena, Italy
Article info
Abstract
Article history: Accepted May 11, 2006 Published online ahead of print on June 5, 2006
Objectives: We describe a new surgical technique with the use of fibrin glue for bulbar urethra reconstruction using a dorsal buccal mucosal onlay graft. Methods: Six patients with a mean age of 43 yr underwent bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. The urethra was mobilised from the corpora cavernosa and opened along its dorsal surface. The buccal mucosal graft was applied on the corpora cavernosa using 2 ml of fibrin glue. Two interrupted polyglactin 5-0 sutures were used to fix the apices of the graft to the underlying albuginea of the corpora cavernosa. The urethra was rotated back to cover the graft and an adjunctive fibrin glue was injected over the urethra. Results: The mean operative time was 100 min (range, 90–120 min). No intraoperative or postoperative complications were observed. Voiding cystourethrography was performed when the catheter was removed 2 wk after surgery. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Mean follow-up was 16 mo (range, 12–24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients 6 and 12 mo after surgery. Conclusions: The use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction.
Keywords: Buccal mucosa Bulbar urethra Graft Fibrin glue Urethral stricture Urethroplasty
# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Tel. +39 0575 403412; Fax: +39 0575 27056. E-mail address: [email protected] (G. Barbagli).
1.
Introduction
Numerous surgical techniques have been described to repair bulbar urethral strictures according to stricture length, including end-to-end anastomosis,
augmented roof strip anastomotic urethroplasty, onlay repair using flap, or graft and multistaged procedures [1]. Short bulbar stricture, ranging from 1 to 2 cm, is generally managed by primary end-toend anastomosis [2] and augmented anastomotic
0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.05.018
468
european urology 50 (2006) 467–474
urethroplasty is suggested for strictures 2–3 cm in length [1,3–5]. Strictures longer than 3 cm are generally managed using tissue (skin or buccal mucosa) transfer procedures accomplished in a variety of ways including dorsal or ventral onlay graft urethroplasty [6–12]. Finally, in patients with strictures longer than 6 cm involving both penile and bulbar urethra or associated with local adverse conditions, multistage urethroplasty or mesh graft urethroplasty is mandatory [13,14]. Buccal mucosal onlay graft urethroplasty is one of the most widely used methods for the repair of the strictures in the bulbar urethra and provides excellent results [6–12,15,16]. Stricture recurrences can, however, occur despite using an adequate surgical technique and substitution material may deteriorate over time [15–17]. In our experience, stricture recurrences after bulbar substitution onlay urethroplasty show two different features, namely, extensive fibrous tissue involving the entire grafted area or a short fibrous ring stricture at the distal or proximal anastomotic sites where the apices of the graft are sutured to the apices of the urethral plate [18–20]. We investigated the prevalence, location, and etiology of these postoperative anastomotic ring strictures, which can affect any type of substitution bulbar urethroplasty [20]. Moreover, substitution urethroplasty using free graft requires a long catheterisation time and postoperative urinary leakage at the anastomotic site during the first postoperative radiologic investigation may also require a more prolonged catheterisation time [6,9], causing a negative psychological impact on the patient. Recently, the use of fibrin sealant was suggested to decrease immediate urinary leakage following prostatectomy [21] or to reduce the catheterisation time following penile urethroplasty [22]. We suggest here the use of fibrin glue in a new technique of dorsal onlay buccal mucosal graft urethroplasty to reduce the time of postoperative catheterisation, the risk of postoperative urinary leakage, and the incidence of postoperative anastomotic rings at the apices of the sutures between the graft and the mucosal urethral plate. 2.
disease) were not included in the study. In all patients, the bulbar strictures were managed using a dorsal urethral opening described by Barbagli et al. in 1996 [6]. The buccal mucosal graft was applied over the albuginea of the corpora cavernosa using fibrin glue and the urethra was rotated back to cover the graft.
2.1.
Preoperative evaluation
Each patient’s clinical history and chart were reviewed to evaluate the presence of previous perineal blunt trauma or previous repeated urethrotomy or urethroplasty failure and the genitalia were inspected to exclude the presence of lichen sclerosus disease. Preoperative tests included urine culture, residual urine measurement, retrograde and voiding cystourethrography, sonourethrography, and urethroscopy. The etiology of the stricture and its location and length were carefully examined to better define the characteristics needed in the buccal mucosal graft. Finally, patients who currently had an infectious disease affecting the mouth (such as candida, varicella virus, or herpes virus) or who had previous surgery in the mandibular arch that prevented the mouth from being opened wide, or who played a wind instrument were informed that genital or extra genital skin would be used for the urethroplasty. Patients were fully informed that bulbar urethroplasty is a safe procedure as far as sexual function is concerned.
2.2.
Surgical technique
2.2.1.
Preparation of the bulbar urethra
The patient is placed in a simple low lithotomy position. The patient’s calves are carefully placed in Allen stirrups with sequential inflatable compression sleeves and the lower extremities are then suspended by the patient’s feet within the boots of the stirrups. Proper positioning ensures that there is no pressure on any aspect of the calf muscles and no inward boot rotation to avoid peroneal nerve injury. The skin of the suprapubic region, scrotum, and perineum is shaved and this region is prepared and draped appropriately.
Methods
Between January 2003 and December 2004, six patients with a mean age of 42 yr (range, 26–64 yr) underwent bulbar urethroplasty using buccal mucosal graft and fibrin glue. The stricture etiology was instrumentation in four patients and unknown in two. Five patients had undergone previous urethrotomy or dilation. The average stricture length was 4.5 cm (range, 3–6 cm). Patients with lichen sclerosus, failed hypospadias repair, previously failed urethroplasty, and a stricture extending into the penile urethra (pan-urethral
Fig. 1 – The midline perineal incision is underlined.
european urology 50 (2006) 467–474
469
Fig. 4 – The urethra is dissected from the corpora cavernosa. Fig. 2 – The bulbocavernous muscles are separated on the midline.
Methylene blue is injected into the urethra to better define the urethral mucosa involved in the disease. A midline perineal incision is made overlying the stricture site (Fig. 1). The bulbocavernous muscles are separated in the midline (Fig. 2) and, in patients with proximal urethral stricture, the central tendon of the perineum is dissected. The urethra is freed from the bulbocavernous muscles for its entire length and the muscles are fixed to a retractor using four stitches (Fig. 3). The bulbar urethra is dissected from the corpora cavernosa (Fig. 4). The urethra is rotated 1808 and the distal extent of the stenosis is identified by gently inserting a 16F
Fig. 3 – The bulbar urethra is completely freed from the bulbocavernous muscles and the muscles are fixed to retractor.
catheter with a soft round tip until it meets resistance (Fig. 5). The dorsal urethral surface is incised in the midline until the catheter tip and urethral lumen are exposed. The stricture is then incised along its entire length by extending the urethrotomy distally and proximally (Fig. 6). Once the entire stricture has been incised, the length and width of the remaining urethral plate is measured. Proximal and distal calibration of the urethra with modified nasal speculum is critical for identifying any residual narrowing. The buccal mucosal graft is trimmed to an appropriate size according to the length and width of the urethrotomy.
Fig. 5 – The urethra is rotated of 1808 using a loop. The catheter is inserted and the incision on the dorsal urethral surface is underlined.
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Fig. 6 – The stenosis is fully opened.
2.2.2.
Fig. 7 – The buccal mucosal graft is fixed over the albuginea of corpora cavernosa using fibrin glue.
Cheek harvesting technique
Recently, we fully described our current surgical technique for harvesting buccal mucosal graft from the inner cheek, including postoperative complications and patient discomfort [23]. The patient is intubated through the nose, allowing the mouth to be completely free. The patient is draped in two separated parts and two surgical teams work simultaneously. Each team has its own set of surgical instruments, including suction and bipolar cautery. By using a mouth retractor that has its own light, only one assistant is needed to harvest the buccal mucosa. The inner mucosal surface of the right cheek is prepared and disinfected, and stay sutures are placed along the external edge of cheek to keep the buccal mucosa stretched. The Stensen duct, located at the level of the second molar, is identified and the desired graft size is measured and marked in an ovoid shape. Lidocaine HCl 1% with epinephrine (1:100,000) is injected along the edges of the graft to enhance hemostasis. The outlined graft is sharply dissected and removed. The donor site is carefully examined for bleeding and is closed with 4-0 polyglactin sutures. The graft is stabilised on a silicone board using insulin needles. After careful deflation with microsurgical instruments, the graft is tailored according to site, length, and stricture characteristics. An ice bag is applied to the cheek to reduce edema, pain and haematoma.
stabilise the urethral margins to the corpora cavernosa over the graft (Fig. 10). At the end of the procedure the graft is completely covered by the urethra and fibrin glue (2 ml) is injected over the urethra to prevent urinary leakage. The bulbocavernous muscles are sutured over the spongiosum tissue (Fig. 11). Colles fascia, the perineal fat, and the skin are closed with interrupted absorbable sutures (Fig. 12). A suction drain is left in place for 1 d. The catheter is left in place for 2 wk.
2.2.4.
Postoperative care
The patient consumes a clear liquid diet and ice cream before advancing to a soft, then regular diet. The patient ambulates on the first postoperative day and is discharged from the
2.2.3. Sticking the graft to the albuginea of the corpora using fibrin glue The bulbar urethra is moved to the right side and fibrin glue (2 ml) is injected over the albuginea of the corpora cavernosa. The buccal mucosal graft is spread fixed over the fibrin glue bed (Fig. 7). The two apices of the graft are sutured to the proximal and distal apices of the urethrotomy (Fig. 8). A Foley 16F grooved silicone catheter is inserted. The bulbar urethra is rotated to its original position over the graft (Fig. 9). Three interrupted 4-0 polyglactin sutures for each side are used to
Fig. 8 – The apices of graft are fixed to the albuginea and to the apices of urethrotomy.
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Fig. 11 – The bulbocavernous muscles are closed over the urethra. Fig. 9 – The urethra is rotated back to its original position to cover the graft.
hospital 3 d after surgery. All patients receive postoperative broad-spectrum antibiotics and are maintained on oral antibiotics until the catheter is removed. Two weeks after surgery the bladder is filled with contrast medium, the Foley catheter is removed, and voiding cystourethrography is obtained.
2.2.5.
Postoperative complications
A possible early minor complication is urethrorrhagia due to nocturnal erections. Possible later minor complications are temporary numbness, dysesthesia to the perineum, and scrotal swelling.
3.
was needed, including dilation. The mean operative time was 100 min (range, 90–120 min). No intraoperative or postoperative complications were observed. In all patients, postoperative voiding cystourethrography was performed 2 wk after surgery and no urinary leakage was present. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Average follow-up was 16 mo (range, 12–24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients at 6 and 12 mo after surgery.
Results
Clinical outcome was considered a success or a failure at the time that any postoperative procedure
Fig. 10 – The urethra is fixed to the corpora cavernosa.
Fig. 12 – Suction drain and Foley catheter are left in place.
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Discussion
Buccal mucosal onlay graft urethroplasty represents one of the most widely methods for the repair of strictures in the bulbar urethra because of its thick and highly vascular spongiosum tissue. Location of the graft has recently become a contentious issue [8] since the time we described our original techniques of dorsal onlay graft urethroplasty [6]. The design rationale for this new approach was based on the concept that the corpora cavernosa remains a healthy host for receiving free buccal mucosal graft [6,8]. Moreover, graft fixation by suture onto a defined surface may decrease graft shrinkage and sacculation [6,8]. Success with buccal mucosal grafts for repairing bulbar urethral strictures has generally been high with dorsal or ventral onlay grafts [6– 12,15–17,19]. The application of fibrin glue in urology mainly relates to its sealing power; it has been shown to be a beneficial adjunct to sutures for closing wounds and promoting healing because it increases tissue plane adherence, accelerates revascularization, reduces haemorrhage, prevents seroma formation, and decreases inflammation [21,22,24,25]. Recently, Morris et al. reported the outcome of graft take and wound healing in a series of patients in whom fibrin sealant was used as tissue glue in the reconstruction of complex genital skin loss [26]. The fibrin glue used in our series of patients contained two solutions of human products, one consisting of fibrinogen, factor XII, plasmafibronectin, plasminogen dissolved with an aprotinin solution (bovine), and another of an activate thrombin component (human) mixed with a calcium chloride solution. When combined, a dense gelatinous clot is quickly formed at the point of application. Because this fibrin sealant is not synthetic and, therefore, biocompatible with the natural fibrinolytic mechanism, healing is promoted without inflammation and fibrosis formation [21,25]. Bach et al. have shown that, in a rat animal model, cultured and in vitro expanded urothelial cells can be successfully reimplanted onto a prefabricated tubelike structure using fibrin glue as a delivery matrix and native cell expansion vehicle [27]. To determine the effectiveness of fibrin glue as a transplanted delivery vehicle, in an animal model, Schoeller et al. cultured cells onto a prefabricate capsule created by a silicon block [28]. These authors showed that the used delivery vehicle of fibrin glue, which mainly contains fibronectin, is clearly the structural constituent and regulator of cell behaviour in urothelial culture reimplantation [28]. Moreover, fibronectin not only helps attach the transplanted cells to the recipient bed but also enhances migration of growth factors
and is itself a nutrient [28]. These properties are essential and might be the key to bridge the gap in which the reimplanted cell is nourished by the diffusion of extracellular fluid until revascularisation and definite incorporation occur [28]. In 2001, Currie et al. reviewed the advantages and disadvantages of using fibrin glue with skin graft and tissue-engineered skin substitutes and concluded that it has a haemostatic effect, increases the percentage of graft take, and may have a protective effect against infection [29]. Fibrin sealant has been widely used in Europe, Japan, and the United States [24]. Discussion of the safety of fibrin glue is important because this sealant is composed of human products [24]. Donors are initially screened and retested after 3 mo for human immunodeficiency virus, Epstein-Barr virus, cytomegalovirus, and hepatitis A, B, and C before plasma processing, and a large study on sealant use showed no seroconversion to any of these diseases [24]. Moreover, the plasma is then thermally treated to ensure further viral safety [24]. The use of fibrin glue in bulbar urethroplasty using buccal mucosa shortens the graft revascularisation time because it helps attach the transplanted cells to the recipient bed and enhances migration of growth factors and is itself a nutrient [28]. Moreover, the use of fibrin glue avoids the necessity of numerous interrupted stitches to fix the graft to the albuginea of the corpora cavernosa, which represents a tedious and time-consuming step in onlay urethroplasty. Apposition of the graft and its adhesion to the corpora cavernosa can be simplified by using fibrin glue, which allows ideal fixation of the graft to its vascular bed and thus better revascularization of the transplanted tissue. Secure adhesion of the graft keeps it wide open reducing the risk of sacculation and shrinkage, allowing the surgeon to perform an easier anastomosis between the graft and the urethral margins. At the end of our surgical procedure, the grafted area was covered by fibrin glue to avoid urinary leakage. The catheter was removed 2 wk after the urethroplasty and the occurrence of postoperative leakage seems to have been reduced in this small series of patients. We recently reported our preliminary experience with the use of fibrin glue in bulbar urethral reconstruction in six patients who underwent augmented anastomotic repair [30]. The short-term results on this limited series of patients were satisfactory and, consequently, we also extended the use of fibrin glue to an adjunctive series of six patients who underwent dorsal onlay graft urethroplasty. Further comparative studies are necessary to
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confirm that the use fibrin glue is really beneficial compared to using quilting with sutures to stabilise the graft to the corpora cavernosa bed [30]. Moreover, additional studies are necessary to evaluate whether its use reduces the restricture rate at the anastomotic sites [30]. These anastomotic fibrous rings still represent the most important cause of restricture following any kind of substitution bulbar onlay graft urethroplasty and we are still engaged in improving our surgical techniques to reduce failure rate [20].
5.
Conclusions
Reconstructive urethral surgery requires technical refinement and the use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction using dorsal buccal mucosal graft. Longer follow-up on a larger series of patients is necessary to confirm our satisfactory preliminary reports using fibrin sealant glue. We are still gathering data.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.eururo.2006.05.018 and via www.europeanurology. com. Subscribers to the printed journal will find the supplementary data attached (DVD).
References [1] Barbagli G, Palminteri E, Lazzeri M, Guazzoni G. Anterior urethral strictures. BJU Int 2003;92:497–505. [2] Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol 2002;167:1715–9. [3] Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture. J Urol 1999;161:815– 8. [4] Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol 2001;165:1496–501. [5] Delvecchio FC, Anger JT, Webster GD. A proposal that whenever possible stricture excision be a part of all bulbar urethroplasties: a progressive approach to patient selection. J Urol 2004;171:17, abstract 66. [6] Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty. J Urol 1996;155:123–6. [7] Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol 1998;160:1307–9.
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[8] Andrich DE, Leach CJ, Mundy AR. The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra. BJU Int 2001;88:385–9. [9] Barbagli G, Palminteri E, Balo` S, Picinotti A, Lazzeri M. Dorsal onlay graft urethroplasty. Current technique stepby-step. Contemp Urol 2002;14:18–32. [10] Rosestein DI, Jordan GH. Dorsal onlay graft urethroplasty using buccal mucosa graft in bulbous urethral reconstruction. J Urol 2002;167:16, abstract 63. [11] Barbagli G, Palminteri E, Lazzeri M. Dorsal onlay techniques for urethroplasty. Urol Clin N Am 2002;29:389–95. [12] Kane CJ, Tarman GJ, Summerton DJ, et al. Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction. J Urol 2002; 167:1314–7. [13] Schreiter F. The two-stage mesh-graft urethroplasty using split-thickness skin. Atlas Urol Clin N Am 1997;5:75–90. [14] Carr LK, Macdiarmid SA, Webster GD. Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty. J Urol 1997;157:104–8. [15] Armenakas NA. Long-term outcome of ventral buccal mucosal grafts for anterior urethral strictures. AUA News 2004;9:17–8. [16] Elliot SP, Metro MJ, McAninch JW. Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754–7. [17] Andrich DE, Dunglison N, Greenwell TJ, Mundy AR. The long-term results of urethroplasty. J Urol 2003;170:90–2. [18] Barbagli G, Palminteri E, Lazzeri M, Turini D. Interim outcomes of dorsal skin graft bulbar urethroplasty. J Urol 2004;172:1365–7. [19] 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. [20] Barbagli G, Palminteri E, Guazzoni G, Turini D, Lazzeri M. Anastomotic fibrous rings as cause of stricture recurrence after bulbar onlay graft urethroplasty: an open issue. J Urol 2006;175:104, abstract 314. [21] Diner EK, Patel SV, Kwart AM. Does fibrin sealant decrease immediate urinary leakage following radical retropubic prostatectomy? J Urol 2005;173:1147–9. [22] Hick EJ, Morey AF. Initial experience with fibrin sealant in pendulous urethral reconstruction. Is early catheter removal possible? J Urol 2004;171:1547–9. [23] Barbagli G, Palminteri E, De Stefani S, Lazzeri M. Harvsting buccal mucosal grafts. Keys to success. Contemp Urol 2006;18:16–24. [24] Morey AF, McDonough RC, Kizer WS, Foley JP. Drain-free simple retropubic prostatectomy with fibrin sealant. J Urol 2002;168:627–9. [25] Evans LA, Ferguson KH, Foley JP, Rozanski TA, Morey AF. Fibrin sealant for the management of genitourinary injuries, fistulas and surgical complications. J Urol 2003;169: 1360–2. [26] Morris MS, Morey AF, Stackhouse DA, Santucci RA. Fibrin sealant as tissue glue: preliminary experience in complex genital reconstructive surgery. Urology 2006;67:688–91.
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european urology 50 (2006) 467–474
[27] Bach AD, Bannasch H, Galla TJ, Bittner KM, Stark GB. Fibrin glue as matrix for cultured autologous urothelial cells in urethral reconstruction. Tissue Eng 2001;7:45–53. [28] Schoeller T, Neumeister MW, Huemer GH, et al. Capsule induction technique in a rat model for bladder wall replacement: an overview. Biomaterials 2004;25:1663–73.
[29] Currie LJ, Scarpe JR, Martin R. The use of fibrin glue in skin grafts and tissue-engineered skin replacement: a review. Plast Reconstr Surg 2001;108:1713–26. [30] Barbagli G, De Stefani S, Sighinolfi MC, et al. Experience with fibrin glue in bulbar urethral reconstruction using dorsal buccal mucosa graft. Urology 2006;67:830–2.