Outcomes of Double-face Augmentation Urethroplasty Using Buccal Mucosal Graft in Near-obliterative Bulbar Urethral Stricture
Phase: NA
Conditions: Urethral Stricture, Anterior, Urethral Stricture Disease
Sponsor: Menoufia University

Outcomes of double-face augmentation urethroplasty
using buccal mucosal graft for near-obliterative
bulbar urethral stricture.
27/01/2025

Outcomes of double-face augmentation urethroplasty
using buccal mucosal graft for near-obliterative
bulbar urethral stricture.
Introduction 
Urethral stricture is a pathology that is often complex and difficult to
manage. Various techniques have been developed to treat it, ranging
from  primary  anastomosis  to  tissue  flaps  and  grafts.  Currently,  the
preferred tissue for grafts is the oral mucosa due to its excellent physical
characteristics  and  because  harvesting  is  simple,  with  low  rates  of
morbidity.(1)
 Traditionally,  short  segment  obliterative  traumatic  bulbar  urethral
strictures (<2 cm) are managed by excision and end-to-end anastomotic
urethroplasty (EEA). However, non-traumatic bulbar urethral strictures
(>2 cm) that are not amenable to EEA can be managed by augmentation
urethroplasty. The current trend in the management of bulbar urethral
strictures  is  non-transection,  minimal  urethral  mobilization,  and
augmentation of the urethra. Augmentation bulbar urethroplasty can be
performed using a dorsal or ventral approach, depending on the length,
extent, and caliber of the stricture. Various techniques for bulbar urethral
reconstruction  with  favorable  outcomes  have  been  described  in  the
available literature.(2)

Combined  dorsal  and  ventral  onlay  augmentation  urethroplasty
technique  was  described  by  Palminteri  et  al.(3) for  bulbar  urethral
reconstruction. 
Nontraumatic near-obliterative bulbar urethral strictures (BUS) of <2 cm
in  length  can  be  managed  with  non-transecting  anastomotic  bulbar
urethroplasty or augmented anastomotic urethroplasty. However, if the
obliterative stricture segment is >2 cm and the urethral caliber is <6F,
augmentation with a single graft may not be sufficient. In these cases,
double-face augmentation urethroplasty (DFAU) is indicated. DFAU can
be performed using either a dorsal (dorsal onlay and ventral inlay) or
ventral (ventral onlay and dorsal inlay) approach. (4)
In dorsal approach, the urethra was mobilized on the left side. Dorsal
urethrotomy was performed at the level of the stricture. A free graft was
harvested and fixed to the apex of the proximal urethral margin using
interrupted  sutures  (sutured  to  the  medial  urethral  margin  and  the
underlying corpora cavernosa). Ventral inlay augmentation with a free
graft was at the level of the narrowed urethral plate (<6 mm) and the
urethra was closed over a 16F catheter.(5) 

Aim of the study
 We present our initial experience with the double-face augmentation
urethroplasty technique using buccal mucosal graft for near-obliterative
bulbar urethral strictures through ventral or one-sided dorsal perineal
approach and the analysis of the short-term outcomes of this technique.

Patients and Methods:
Study type: a prospective non-controlled interventional study.
Sampling: hospital-based sample.
Masking: open label.
Intervention Model:  all patients with long segment more than 2 cm
near-obliterative  bulbar  urethral  stricture  underwent  the  double-face
augmentation urethroplasty technique through one-sided dorsal perineal
approach. 
Sample size: all candidates patients for the next 2 years.
Study  Location:  El-Hussein,  Sayed  Galal,  Al-Azhar  University
Hospitals, Cairo, and Menoufia university hospital, Cairo, Egypt. 
Study Population
Inclusion criteria
The  study  will  include  patients  with  long  segment  bulbar
urethral stricture (>2 cm).
Urethral lumen size less than 6 Fr.

Exclusion criteria 
Urethro-cutaneous fistula, urethral abscess or diverticulum.
A scarred and unsalvageable urethral plate or scarred perineum.
Lichen sclerosis (Balanitis xerotica obliterans).
Unhealthy/unavailable buccal mucosa. 
Pre-operative evaluation:
    Medical and surgical history
 
  including age, cause of stricture,
presence of medical diseases like diabetes mellitus, and history of
previous urethral procedures.
The following questionnaires will be used for assessment of LUTS,
sexual function and satisfaction, and oral health:
IPSS (international prostate symptom score).(7)
IIEF-5 Score (international index of erectile function).(8)
MSHQEJD  (male  sexual  health  and  ejaculatory
dysfunction questionnaire).(9)
BMG  questionnaire  for  brief  oral  health  status
examination (BOHSE).(10)

    Physical examination
 
  including BMI, oral, abdominal and penile
examination and presence of supra-pubic catheter.
    Laboratory  investigations
 
  (urine  analysis,  urine  culture  and
sensitivity,  complete  blood  count,  bleeding  profile  and  serum
creatinine levels).
    Uroflowmetry (UFM)
 
 .
    Radiologic investigations: 
 
 
# Retrograde urethrography (RGU) and micturating cystourethrography
(MCU). 
# Renal and bladder ultrasound with estimation of pre and post voiding
residual urine.
An informed consent will be signed by each patient.
surgical technique:
The patient will be put in lithotomy position then a midline perineal
incision will be made & buccal mucosal graft will be harvested. 
Buccal graft harvest Using a marking pen, the graft well be outlined 2.5
cm wide and as long as is required. Bupivacaine 0.5% with epinephrine
will  be  injected  underneath  the  graft  for  good  analgesia  and
intraoperative hemostasis. The graft will be then incised and dissected of
the buccinator muscle, while avoiding Stensen's duct. The defect will be
left open to close by secondary intention, as it is less painful. The graft

will be pinned out and defatted/thinned on the back table. It will be kept
in saline until the time of implantation.(11)
The patient is placed in an exaggerated lithotomy position. A 16Fr
urinary catheter is inserted, identifying the distal end of the segment
affected by stenosis, and methylene blue is injected. A longitudinal
incision is made in the perineum. The left and dorsal surfaces of the
urethra  are  dissected,  with  the  right  border  maintained.(12) A
longitudinal incision is made along the midline of the dorsal wall of the
urethra affected by stenosis, extending up to 1cm beyond the area of
stenosis, preserving
the spongy tissue (Figure-1A). The defect created in the urethra acquires
an elliptical form and the oral mucosa will be placed as an inlay graft
onto  this  segment  (Figure-1B).  The  incision  in  the  urethra  should
proceed until the maximum degree of relaxation is achieved, preserving
the corpus spongiosum. The graft is secured to the corpus spongiosum,
as  is  usual  with  these  grafts,  using  separate  oral  mucosa/corpus
spongiosum
sutures with 4-0 vicryl. Next, the edge of the graft is fixed to the edge of
the urethra using continuous sutures with 5-0 vicryl. The remaining
portion of oral mucosa is fixed onto the corpus cavernosum, as described
by Barbagli et al.(12) The edges of the urethra are then sutured to the
dorsal oral mucosa using 4-0 vicryl suture (Figure-1C). A schematic

drawing is provided to further illustrate the placement of the mucosal
grafts.(1)
Figure 1 - (A) Longitudinal incision in the dorsal surface of the urethra, with rotation of
180°, (B) Oral mucosa dorsal onlay and ventral inlay graft, (C) Suturing of the edges of the
urethra, (D) Schematic drawing showing placement of the mucosal grafts.(1)

The complications will be graded using the modified Clavien-Dindo
classification system.(13)

FOLLOW UP:   The follow up period will be at least 6 months
The patients will be treated with broad spectrum IV antibiotics for 48–72
h, which will be followed by oral antibiotics until catheter removal. The
patients will be also treated with analgesics, bladder antispasmodics,
stool softener, and diazepam to help prevent erections.
The patients will be discharged after the drain is removed, if it was put,
usually within 2–3 days after surgery. 
They  will  be  followed  up  at  the  clinic  after  1  week  for  wound
assessment. Another visit will be scheduled 30 days after surgery where
the urethral catheter will be removed, and a voiding urethrogram will be
taken. 
A 3 monthly follow-up visits thereafter will be scheduled for assessment
of LUTS with performing simple uroflowmetry, treatment satisfaction
and sexual function.
The  follow-up  will  rely  mainly  on  patient  symptoms  (subjective
diminished  force-of-stream,  UTI,  urinary  retention,  etc.),  while
diagnostic  procedures  such  as  urethroscopy  and/or  retrograde
urethrogram will be done selectively.

OUTCOME
Anatomic (Objective): Urethral patency will be evaluated by 
Uroflowmetry, and
Urethrography.
Functional  (Subjective): LUTS,  sexual  function,  and  satisfaction.
Through:
IPSS (international prostate symptom score).(7)
IIEF-5 Score (international index of erectile function). (9)
MSHQEJD  (male  sexual  health  and  ejaculatory  dysfunction
questionnaire). (9)
USS-PROM (patient reported outcome for urethral stricture surgery).
(14)

References 
1.
Barroso Jr U, Prado F. A new double graft technique in urethroplasty for
complex  urethral  stenosis:  preliminary  findings.  International  braz  j  urol.
2021;47(4):856-60.
2.
Enganti B, Reddy MS, Chiruvella M, Bendigeri MT, Ragoori D, Ghouse
SM, et al. Double-face augmentation urethroplasty for bulbar urethral strictures:
Analysis of short-term outcomes. Turkish Journal of Urology. 2020;46(5):383.
3.
Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, et
al. Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral
reconstruction. european urology. 2008;53(1):81-90.
4.
Enganti B, Chiruvella M, Bendigeri MT, Ragoori D, Ghouse SM, Pandya S,
et al. Double-face Augmentation Urethroplasty for Bulbar Urethral Strictures:
Technical  Implications and Short-term Outcomes for a Dorsal  Versus Ventral
Approach. European Urology Open Science. 2021;26:10-3.
5.
Kulkarni  S,  Barbagli  G,  Sansalone  S,  Lazzeri  M.  One‐sided  anterior
urethroplasty:  a  new  dorsal  onlay  graft  technique.  BJU  international.
2009;104(8):1150-5.
6.
Gelman J, Siegel JA. Ventral and dorsal buccal grafting for 1-stage repair of
complex anterior urethral strictures. Urology. 2014;83(6):1418-22.
7.
Cockett A, Aso Y, Chatelain C. The international consultation on benign
prostatic hyperplasia. World Health Organization: Paris, France. 1991.
8.
Rosen RC, Cappelleri J, Smith M, Lipsky J, Pena B. Development and
evaluation of an abridged, 5-item version of the International Index of Erectile

Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International journal
of impotence research. 1999;11(6):319-26.
9.
Rosen RC, Catania JA, Althof SE, Pollack LM, O’Leary M, Seftel AD, et al.
Development  and  validation  of  four-item  version  of  Male  Sexual  Health
Questionnaire to assess ejaculatory dysfunction. Urology. 2007;69(5):805-9.
10.
Kayser-Jones J, Bird WF, Paul SM, Long L, Schell ES. An instrument to
assess  the  oral  health  status  of  nursing  home  residents.  The  gerontologist.
1995;35(6):814-24.
11.
Zimmerman  WB,  Santucci  RA.  Buccal  mucosa  urethroplasty  for  adult
urethral strictures. Indian Journal of Urology. 2011;27(3):364-70.
12.
BARBAGLI  G,  PALMINTERI  E,  RIZZO  M.  Dorsal  onlay  graft
urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures.
The Journal of urology. 1998;160(4):1307-9.
13.
Dindo  D,  Demartines  N,  Clavien  P-A.  Classification  of  surgical
complications: a new proposal with evaluation in a cohort of 6336 patients and
results of a survey. Annals of surgery. 2004;240(2):205-13.
14.
Jackson MJ, Sciberras J, Mangera A, Brett A, Watkin N, N'dow JM, et al.
Defining  a  patient-reported  outcome  measure  for  urethral  stricture  surgery.
European Urology. 2011;60(1):60-8.