Buccal Mucosal Onlay Graft of The Ventral Urethra
In this single stage procedure the urethra will be visualized (in the area of the defect), and the incision will be started at its mid-line (usually) using a bovie knife to dissect the dermal and sub-dermal layers until the associated musculature, corpus cavernosum, corpus spongiosum, and ventral urethral aspects are exposed. (a) Particular care is used during the dissection to prevent damage to nerves and blood vessels (which could result in erectile dysfunction or loss of tactile sensation of the penis). The area of the defect is evaluated and marked laterally mid-line, and (marked) positioning sutures are positioned (one, each) at the proximal and distal ends of the area of urethra closest to border of the defective area. Simultaneously, a urological surgeon who is specifically trained in buccal mucosal harvesting techniques will begin harvest and repair of a section of the inside cheek of the patient, corresponding to the dimension/shape calculated and requested by the surgeon performing the urethral aspect of the procedure. When available, an oral/maxillofacial surgeon or ENT specialist will harvest the buccal mucosa in accordance with those requested specifications. Upon retrieval, the buccal graft is presented to the urethral surgeon, who will then prepare the graft by trimming and removal of extraneous tissue.
The surgeon will create an incised opening laterally between the known outer borders of the defect, retract the incised opening to the desired diameter, and position the graft to cover the incision. This will form a tunnel, or diversion through the stricture which is 10 mm (optimally) in estimated diameter, to allow for the flow of urine. Using micro surgical techniques, the buccal graft will be sutured in place and fibrin glue applied to the suture line to prevent leakage and formation of a fistula. At this time an appropriately sized (a) Foley catheter will be inserted through the repair and into the bladder (and connected to a urinary drainage system), and the incision closed (layer by layer). Some surgeons will inject a local anesthetic such as 2% plain lidocaine or 0.5% bupivicaine into the areas to allow the patient an additional period of relief from discomfort.
Micro-doppler circulatory measurement of the penile vasculature is performed at way points throughout the procedure, and a final assessment is taken and recorded. The incision is inspected and dressed, and the patient is discharged to recovery.
(a) At this time, some surgeons prefer to insert a safety guide (as used in urethrotomy) from the urinary meatus, through the stricture, and into the bladder for purposes of maintaining positioning.
(b) some surgeons prefer the use of a suprapubic catheter, as they believe insertion of an in-dwelling urethral catheter may damage the surgically repaired area
University of Kansas, Department of Urology video of the procedure
Expected average success rate: The success rate for this procedure is between 87 and 98%, buccal mucosal onlay urethroplasty is considered the best of repair options for strictures greater than 2 cm in length. Within recent years, surgeons have been applying the onlay to the dorsal aspect of the urethra with great success. Buccal mucosa best approximates the tissue which composes the urethra.
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