The fact that over 200 technical of urethroplasties were published, highlights the difficulty of reconstructive surgery of the urethra, which exposes to many complications and functional and cosmetic results unsatisfactory often see ill.
Free flap of oral mucosa are used for over a hundred years for reconstructive plastic surgery, and since 1941 for surgery of the urethra, but the use of the oral mucosa in this indication only really developed as from 1986, and especially over the last 20 years, particularly with the experience of BARBAGLI.
Currently, the use of free flap oral mucosa appears to be the best option in reconstructive surgery of the urethra with tissue transfer.
There are many surgical procedures using this technique, and which differ in particular in function of the location of the stenosis, in the bulb of the urethra, or the external portion of the urethra.
1) Penile urethroplasties
The choice of the surgical technique to be adopted to repair stenosis of the penile portion of the urethra is carried out according to the origin of the shrinkage.
BARBAGLI noted among more than 400 patients he operated on 80% of cases corresponded equally to cure hypospadias failures and to atrophic lichen sclerosus, and the remaining 20% post-traumatic stenosis or developed following endoscopic maneuvers, or bladder indwelling catheter or choking after reconnaissance attacks, infectious or post, or other rarer causes.
In patients whose stenosis is cause post traumatic or occurred following endoscopic maneuvers or indwelling catheter or infectious post, the penis is normal and the repair is feasible by a dorsal urethroplasty in a time with free flap mucosa mouth.
Ches patients with urethral stenosis is related to a curing failure of hypospadias or lichen, the penis is not normal and surgical treatment most often appeal to urethroplasties technique several times using scraps of oral mucosa.
In the 2000s, S. KULKARNY described a new technique pan urethroplasty in one time with several free flaps of mouth (usually two) for processing extended strictures of all the penile urethra and the bulbar urethra developed in cases of lichen sclerosus atrophic.
2) Urethroplasties bulbar
Surgical technique where the urethral stricture seat in the bulbar urethra, is a function of the length of the constriction.
The alternative is to place the free flap of oral mucosa:
- the ventral side of the urethra, which is indicated in the stenosis in the most proximal portion of the urethral bulb.
This intervention will be described in detail in an article which will be published shortly.
- on the dorsal surface of the urethra, which is indicated in stenosis of the distal-most portion of the urethral bulb.
In some cases, it may be necessary to place two free flaps of oral mucosa, one in a prone position, the other in the dorsal position.
The free flap oral mucosa can also be used as input in tissue resection – suture of the urethra to ensure the conditions for success are:
- complete excision of fibrosis surrounding the stenosis,
- spatulation extensive urethral ends,
- a wide anastomosis without tension.
In the reconstructive surgery of the urethra, one encounters very different pathological situations making each patient a particular case.
Surgical techniques are also numerous.
The surgeon must integrate before treating urethral stricture a certain number of parameters concerning the seat of stricture, its length, its etiology and anatomy as well as patient characteristics.
He must master several techniques enabling it to cope with a variety of situations that present themselves to him.
Some bibliographical references:
1) Barbagli G, Selli C, Tosto A, Palminteri E
Dorsal free graft urethroplasty.
J Urol 1996; 155: 123.
2) Kulkarni SB, Kulkarni JS, Kirpekar DV
A new technique of urethroplasty for balanitis xerotica obliterans.
J Urol 2000; 163: 352.
3) Barbagli G, De Stefani S, Annino F et al.
Muscle and nerve sparing bulbar urethroplasty: a new technique.
Eur Urol 2008; 54: 335.
4) Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques
Mahmoud Mustafa1, Dina Abugaber2, Sacit Nurigorgel3, Ertugrul Sefik3, Ozan Horsanali3 and Wael Sadaqah2
5) Palminteri E, Manzoni G, Berdondini E, et al. Combined dorsal plus ventral double buccal mu- cosa graft in bulbar urethral reconstruction. Eur Urol 2008 53 (1): 81-90.
6) Guralnick ML, Webster GD; The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol; 2001; 165: 1496-1501.
7) Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A. Two-sided Bulbar Ure- throplasty Using Dorsal Plus Ventral Oral Graft: Urinary and Sexual Outcomes of a New Techni- que. J Urol 2011 185 (5) :1766-71.