Reconstructive Surgery A Comparative Study of Long-Term Results of Buccal Mucosal Graft and Penile Skin Flap Techniques in the Management of Diffuse Anterior Urethral Strictures: First Report in Iran HOSSEINI J, SOLTANZADEH K Department of Urology, Shohada-e-Tajrish Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran ABSTRACT Purpose: To compare Buccal Mucosa Graft with Penile Skin Flap techniques in the management of anterior urethral diffuse strictures longer than 3 cm. Materials and Methods: Thirty seven patients with a mean age of 28.5 (range 5 to 50) years had been treated by these two techniques using the ventral onlay patch from February 1997 to March 2002. Patients' follow-up included physical examination, his- tory taking, retrograde urethrography, cystoscopy and uroflowmetry at the month six, at the end of the first and the second years, and then yearly if required. Results: These techniques were applied for anterior urethral strictures (bulbar and penile) longer than 3 cm. Buccal mucosal graft (BMG) was used in 18 patients and penile skin flap (PSF) in 19. Mean follow-up was 27.5 (range 6 to 50) months. Mean age was 30.8±11.8 years for BMG group and 27.8±15.6 years for PSF group. Urethral stricture etiology, surgery history, and previous endoscopic surgery history were sim- ilar in both groups. The stricture site in BMG group was penile in 2 patients (11.1%), bulbar in 8 patients (44.4%), and penobulbar in 8 patients (44.4%). In PSF group the stricture site was penile in 11 patients (57.9%), bulbar in 5 patients (26.3%) and penob- ulbar in 3 patients (15.8%). Success rate in 6-month follow-up was 93.9% for BUG group and 83% for PSF. By performing dilatation and internal rethrotomy for mild strictures, the success rate with mean follow-up of 27.5 months was 13.8% for BMG group and 78.9% for PSF. Only one patient from BMG developed temporary impotence for about 12 months. Conclusion: BMG and PSF are considered as simple and proper techniques with good long term outcomes in the management of diffuse anterior urethral strictures. These 2 techniques could be applied in patients with history of several surgeries. The results of BMG were better than PSF, still, this difference was not statistically signif- icant. KEY WORDS: urethral strictures, treatment, graft, flap 31 Urology Journal UNRC/IUA Vol. 2, 31-35 Spring 2004 Printed in IRAN Introduction If a patient with urethral stricture needs ure- throcystoplasty, while the excision of stricture and the anastomosis of the ends of urethra are impos- sible or improper, suggesting substitutions would be essential. Using grafts and flaps for augmenta- tion or complete urethral substitution in the form of patch or tube may be applied. Different studies reported that the success rate of flap or graft was generally 85% with no consideration to follow-up duration.(1) In this study the less frequent BMG Accepted for publication in July 2003 A COMPARATIVE STUDY OF LONG-TERM RESULTS OF BUCCAL MUCOSAL GRAFT AND PENILE SKIN FLAP TECHNIQUES IN THE MANAGEMENT OF DIFFUSE ANTERIOR URETHRAL STRICTURES: FIRST REPORT IN IRAN technique was compared to the more familiar tech- nique of PSF. Materials and Methods From February 1997 to March 2002, 37 patients with diffuse anterior urethral (bulbar, penile) stric- ture longer than 3 cm enrolled in this historical cohort study and underwent BMG or PSF. Those patients with associated posterior urethral stric- tures were excluded from the study. Stricture length was determined by urethral retrograde ure- thrography or retrograde urethrography simulta- neously with cystogram. Patients were examined by 14 F rigid or 12 F flexible cystoscopes to deter- mine the length of stricture and to observe ure- thral mucosa. Before urethroplasty, a minimum 6 mounths elapsed from the last urethral surgery. All procedures were performed by one surgeon and by using reconstructive surgical principals. Patients were secured at lithotomy position after general anaesthesia. Corpus spongiosum was freed at the stricture site in ventrum and was vertically opened by ventral incision in a way that normal mucosa at both sides of stricture became visible to a distance of about 5 mm. Cystoscopy was carried out again during the procedure to assure the nor- mality of proximal urethra. According to the length of urethra, one or two grafts of buccal mucosa from the internal surface of cheek or pedi- cled island penile skin were used. Davis ecartor was applied to open the mouth and remove mucosa for grafting. This was done by intranasal or oral intubation. The width of graft or flap was about 1.5 cm and its length was based on the length of urethral stricture. During the removal of buccal mucosa, we were careful not to hurt parotid gland duct. Then the graft was fairly thinned and the site of its removal left unsutured. The graft or flap was interruptedly sutured over a 18F sili- courethral catheter in the adult or appropriately in children with a distance of 2 mm in the form of ventral onlay with 4.0 vicryl. If stricture site was bulbar, spongioplasty would have been per- formed as well, but if the site of stricture was penile a vascular flap from dartus or tunica vagi- nalis was applied as a flap or graft. Cystostomy was carried out in all patients. Patients were at complete bed rest for 5 days and received IV antibiotics for one week and oral antibiotics for another one week after the removal of catheter. Retrograde urethrography along foley catheter was conducted at the end of the third week. If extravasation of contrast media was not seen, foley catheter would be removed, otherwise, it would be remained for another week. If the patient urinated properly 48 hours after the removal of foley catheter, cystostomy would have been also removed. Patients were followed up at the end of the week 4, months 3, 6, 12, 18, and 24, and then annually for examination and history taking. Retrograde urethrography, uroflowmetry and cystoscopy were conducted at the months 6, 12, and 24. Any ure- thral stricture in cystoscopy was considered as a failure. SPSS software was used for statistical analysis. Descriptive statistical indicators included mean standard deviation and median and analytic statis- tical indicators consisted of independent t test, Mann-Whitney U test, X2 test, Fisher's exact test, and Gehan's test. A P value of lower than 0.05 was regarded as significant difference or correlation. Minimum follow-up of patients was 6 months and patients were followed up for a mean of 27.5 (range 6 to 50) months. Eighteen out of 37 patients underwent BMG and 19 underwent PSF. Their mean age was 28.5 (range 5 to 50) years. Mean age for BMG was 30.8±11.8 years and for PSF was 27.8±15.6. (t=0.64, df = 35, p=0.52) The length of strictures was between 3 and 12 cm. The site of stricture in the cases of BMG was penile in 2 patients (11.1%), bulbar in 8(44.4%), and penobulbar in 8 (44.4%). While in the cases of PSF, it was penile in 11 patients (57.9%), bulbar in 5(26.3%), and penobulbar in 3 (15.8%) (table 1). The etiology of stricture was catheterization in 6 patients, TURP in 1, trauma in 10, extrophy in 1, hypospadiasis in 8 , urethritis in 4, and unknown in 7 (table 2). In BMG, 9 patients (50%) had a history of surgi- cal urethroplasty and in PSF 10 patients (52.6%) had the same history. (X2=0.02, df =1, p=0.87). The episodes of endoscopic surgeries (dilatation and internal urethrotomy) in BMG were 1.3±1.9 and in PSF were 0.8±1.1 (MWU=157, p=0.64). 32 TABLE 1. Frequency distribution of sites of urethral strictures BMG = buccal mucosal graft PSF = Penile skin flap Site of stricture Technique of surgery Penile Bulbar Penobulbar Total BMG 2(11.1%) 8(44.4%) 8(44.4%) 18(100%) PSF 11(57.9%) 5(26.3%) 3(15.8%) 19(100%) Total 13(35.1%) 13(35.1%) 11(29.7%) 37(100%) A COMPARATIVE STUDY OF LONG-TERM RESULTS OF BUCCAL MUCOSAL GRAFT AND PENILE SKIN FLAP TECHNIQUES IN THE MANAGEMENT OF DIFFUSE ANTERIOR URETHRAL STRICTURES: FIRST REPORT IN IRAN Results The mean length of BMG was 2.3±7 cm and of PSF was 6.4±2.7 cm (t=0.62, df =35, p = 0 . 5 3 ) . Patients who underwent urethroplasty with buccal mucosa of mouth did not develop any problem dur- ing hospitalization. Besides, they were able to uri- nate after the removal of foley catheter. In 6- month follow-0up, urethral stricture was observed through cystoscopy in one out of 18 patients (6- month success rate was 93.6%). In 12-month fol- low-up of 14 patients, 86% developed no stricture. In 18-month follow-up of 11 patients, the same suc- cess rate was seen. In PSF, 2 patients developed wound infection and fistula and one developed dehiscence of suture during hospitalization. Primary surgical success rate was 83.3%. In 6- month follow-up of 19 patients no urethral stric- ture was reported and the success rate was 83.3%. No stricture was seen in 12-month follow-up of 13 patients (77.3%) (table 3). These results statistical- ly had no significant difference (Overall compari- son statistics=0.7, df =1, p=0.37). In general, 4 patients in BMG developed ure- thral stricture and consequently underwent inter- nal urethrotomy or dilatation, of which one patient had no stricture in follow-up cystoscopy; however, no judgment could have been done for the 3 other patients because of insufficient follow- up duration. Thus, they were considered finally as failed cases. PSF was failed in 7 patients due to fistula or tis- sue dehiscence, therefore, repeated surgery was decided. Internal urethrotomy was carried out for the other 4 patients with recurrent stricture reported by cystoscopy, in 3 of whom the stricture improved without any procedure, while surgery was required for the other one. Regarding the results of internal urethrotomies due to postoperative strictures with a mean follow- up of 27.5 months in BMG, 15 out of 18 patients (83.8%) improved, while in PSF 15 out of 19 (78.9%) improved with no need of repeated sur- gery. The difference was statistically significant. (table 4) (Fisher's exact test p=0.53). Potency was studied in 29 patients; temporary impotency occurred for 12 months in just one patient of BMG who had bulbar stricture. Discussion In this study the success rate of BMG was com- pared to PSF. Total success rate of flaps and grafts was 85%.(1) Six months success rate of the two groups of BMG and PSF was respectively 93.9% and 83.3%, which were comparable to the success rate of other studies. In 2002, a study was performed by Andrich and Mundy(2) in which 14 patients underwent patch urethroplasty with buccal mucosa and 4 patients underwent PSF. Recurrence of disease occurred in one patient (success rate was 93%). Our results were comparable to those of this study. In a study conducted by Meneghini and Cucuola,(3) published in 2001, 20 patients with a mean stricture length of 3.6 cm underwent BMG; their mean follow-up was 13 months with a success rate of 80% which was comparable to our BMG study with 12-month 33 TABLE 2. Frequency distribution of preoperative eti- ology of urethral stricture BMG = buccal mucosal graft PSF = Penile skin flap Technique of surgery Etiology BMG PSF Total Catheterization 5(27.8%) 1(5.3%) 6(16.4%) TURP 0(0%) 1(5.3%) 1(2.7%) Trauma 5(27.8%) 5(26.3%) 10(27%) Bladder extrophy 0(0%) 1(5.3%) 1(2.7%) Hypospadiasis 4(22.2%) 4(21.1%) 8(21.6%) Urethritis 1(5.6%) 3(15.8%) 4(10.8%) Unknown 3(16.7%) 4(21.1%) 7(18.9%) Total 18(100%) 19(100%) 37(100%) TABLE 3. The rate of success in different follow up time BMG = buccal mucosal graft PSF = Penile skin flap Success survival of treatment based on surgical technique Postoperative time BMG PSF O 100% 83.3% 6-Month 93.9% 83.3% 12-Month 86.7% 77.3% 18-Month 86.7% 77.3% TABLE 4. Frequency distribution of final success of treatment excluding follow-up period in BMG and PSF groups Final success Technique of surgery Yes No Total BMG 15 83.3% 3 16.7% 18 100% PSF 15 78.9% 4 21.1% 19 100% Total 30 81.8% 7 18.9% 37 100% A COMPARATIVE STUDY OF LONG-TERM RESULTS OF BUCCAL MUCOSAL GRAFT AND PENILE SKIN FLAP TECHNIQUES IN THE MANAGEMENT OF DIFFUSE ANTERIOR URETHRAL STRICTURES: FIRST REPORT IN IRAN follow-up and success rate of 86.7%, considering that the stricture length was longer in our study. In 2001 a study was published by Andrich and Mundy(4) in which 129 patients underwent BMG in the form of onlay or tube graft. Success rate of onlay graft was 89% and the results were similar to our study. The manifestation of clinical symp- toms was described as the recurrence of disease in their study. Another survey was carried out by Webster and Islelin(5) in 1999, in which, 29 patients were studied. The skin of penile shaft was used in 20 patients, prepuce in 7 and the buccal mucosa in 2. The success rate was 97% in 19- month follow-up. These results were better than ours, however, success rate in the mentioned study was reported according to patients' symptoms and those strictures which were observed in RUG or cystoscopy and the patients had not any symptom, were regarded as the success of treatment. Barbagli et al(6) studies 37 patients; in whom the scrotum was used in 31 patients and the buccal mucosa in 6. Mean follow-up was 21 months and success rate was 92% which was better than our study. However, in this study the mean length of flaps was 4.7 cm and the mean length of graft was 4 cm which indicated shorter strictures and less complicated patients. In a review article, McAninch and Wessells1 studied diffuse anterior urethral strictures in which end to end anastomosis could not be done. They found out that the success rate of free graft was 84% and flap was 85%. This was also similar to the results of our study. The same authors(7) performed another study in which 40 patients were treated by penile skin, prepuce and the buc- cal mucosa. Thirty (86%) out of 33 patients with proper follow-up had successful results. These suc- cess rates had no relation to the site of used graft, previous intervention and the cause of stricture and generally agree to that of ours. In this study 37 patients with diffuse anterior urethral stricture were studied, of whom18 were treated by the buccal mucosa and 19 by the penile skin. Mean patients' follow-up was 27.5 months. All patients were followed up for at least 6 months and both groups were similar in age, etiology of stricture; length of stricture, episodes of previous urethrotomies and history of previous surgery, however, no complete similarity was seen in the site of stricture which was due to the higher num- ber of cases with penile stricture in PSF. The PSF of 3 patients ended in failure during hospitaliza- tion, 2 of whom developed urethral fistula to skin due to wound infection and one with bladder extrophy and multiple pervious urethroplasties, developed dehiscence. In this study, contrary to some of the above mentioned studies, strictures which were observed in follow-up cystoscopy without patients' symptom were also considered in final results. In 6-month follow-up, success rates of BMG and PSF were respectively 93.9% and 83.8% which were decreased with time, as they became 86.7% and 77.3% in 18-month follow-up, respectively. The results of urethrotomy and dilatation of postoper- ative strictures were not taken into account. Regarding the outcome of secondary treatment, 15 out of 14 patients (78.9%) in PSF and 15 out of 18 patients (83.8%) in BMG with a mean follow up of 27.5 months improved. Although BMG's primary outcome of treatment and its follow-up were better than PSF, this differ- ence was not statistically significant (p=0.53). In comparison with failed treatment group with successful treatment group, no significant differ- ence was seen in the length of stricture and previ- ous urethroplasty (stricture length of 6.7±2.1 cm vs 6.6±3.2 cm and history of urethroplasty in 36.4% vs 57.7%) (p=0.88, df=35, t=-0.14 for length of stricture and p=0.23, df=1, X2=1.4 for history of surgery). Subjective potency was studied in 29 out of 37 patients. This analysis was not carried out in 8 patients due to lower age or mental retardation. All of the patients were potent preoperatively. Only a 40-year-old patient in BMG with bulbar stricture developed postoperative temporary impo- tency which lasted for about one year. In most studies, potency was not considered in the out- come of treatment. In a survey published by Webster and Islein5 in 1999, 5 out of 29 patients (14%) developed temporary impotency which last- ed for about 3-6 months. Patients' mean age in this study was ≥41 years. Mean age of impotent patients was 50 years. Conclusion Both BMG and PSF are simple and proper tech- niques with approximately similar and good long term results in the management of diffuse anteri- or urethral strictures. Regarding cosmetic aspect and the scar of genital site BMG is better than PSF; however, no difference is seen in the cure rate. The results of treatment have no clear relation- ship with surgical history and the length of stric- 34 A COMPARATIVE STUDY OF LONG-TERM RESULTS OF BUCCAL MUCOSAL GRAFT AND PENILE SKIN FLAP TECHNIQUES IN THE MANAGEMENT OF DIFFUSE ANTERIOR URETHRAL STRICTURES: FIRST REPORT IN IRAN ture. The mentioned techniques have no effect on patients' potency. References 1. Wessells H, McAninch JW. Current controversies in anteri- or urethral stricture repair: free graft versus pedicled skin flap reconstruction. World J Urol 1998; 16(3): 175-180. 2. Joseph JV, Andrich DE, Mundy AR. Urethroplasty for refractory anterior urethral stricture. J Urol 2002 Jan; 167(1): 127-129. 3. Meneghini A, Cacciola A, Cavarretta L, et al. Bulbar Urethral stricture repair with buccal mucosa graft urethro- plasty. Eur Urol 2001 Mar; 39(3): 264-267. 4. Andrich DE, Mundy AR. Substitution urethroplasty with buccal mucosa free grafts. J Urol 2001 Apr; 165(4): 1131- 1133. 5. Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for bulbar urethral stricture. J Urol 1999 Mar; 161(3): 815-818. 6. Barbagl., G., Palminteri, E., Rizzo, M., Dorsal onlay graft urethroplasty susing penile skin or buccal mucosa in adult bulbo-urethral strictures, J.Urol., (1998) Oct, 160(4), 1307- 1309. 7. Wessells H, McAnrich JW. Use of free grafts in urethral stricture reconstruction.. J Urol 1996 Jun; 155(6): 1912- 1915. 35