Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure

Objective:Secondary pyeloplasty for recurrent ureteropelvic junction obstructions may be a safe and feasible surgical option for patients.This study aimed to demonstrate outcomes of utilizing a non-transecting buccal mucosa graft ureteroplasty for management of recurrent ureteropelvic junction obstruction after prior failed pyeloplasty.Methods:We performed a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery database for all consecutive patients who underwent buccal mucosa graft ureteroplasty between April 2012 and June 2022 for management of recurrent ureteropelvic junction obstructions after prior failed pyeloplasty.The primary outcome included surgical success which was defined as the absence of flank pain and no obstruction on imaging.Results:Overall,ten patients were included in our analysis.The median stricture length was 2.5(interquartile range[IQR]1.8-4.0)cm.The median operative time was 230.5(IQR 199.5-287.0)min and median estimated blood loss was 50.0(IQR 28.8-102.5)mL.At a median follow-up of 10.3(IQR 6.2-14.8)months,80%of patients were surgically successful and there were no major(ClavieneDindo Grade>2)complications.Conclusion:Buccal mucosa graft ureteroplasty is a valuable non-transecting surgical option for patients with recurrent ureteropelvic junction obstructions who failed prior pyeloplasty and has comparable outcomes to the literature regarding standard transecting techniques.

Current trends in urethral stricture management

The recent International Consultation on Urological Disease(ICUD)panel 2010 confirmed that a urethral stricture is defined as a narrowing of the urethra consequent upon ischaemic spongiofibrosis,as distinct from sphincter stenoses and a urethral disruption injury.Whenever possible,an anastomotic urethroplasty should be performed because of the higher success rate as compared to augmentation urethroplasty.There is some debate currently regarding the critical stricture length at which an anastomotic procedure can be used,but clearly the extent of the spongiofibrosis and individual anatomical factors(the length of the penis and urethra)are important,the limitation for this being extension of dissection beyond the peno-scrotal junction and the subsequent production of chordee.More recently,there has been interest in whether to excise and anastomose or to carry out a stricturotomy and reanastomosis using a Heineke-Miculicz technique.Augmentation urethroplasty has evolved towards the more extensive use of oral mucosa grafts as compared to penile skin flaps,as both flaps and grafts have similar efficacy and certainly the use of either dorsal or ventral positioning seems to provide comparable results.It is important that the reconstructive surgeon is well versed in the full range of available repair techniques,as no single method is suitable for all cases and will enable the management of any unexpected anatomical findings discovered intra-operatively.

How and when of eyelid reconstruction using autologous transplantation

Reconstructive surgery of the eyelid after tumor excision,trauma or other causes can be challenging,especially due to the complexities of the anatomic structures and to the necessity of both functional and aesthetic successful outcomes.The aim of this minireview was to investigate the use of tissue transplantation in eyelid reconstruction.Surgical procedures are various,based on the use of both flaps,pedicled or free,and grafts,in order to guarantee adequate tissue reconstruction and blood supply,which are necessary for correct healing.Common techniques normally include the use of local tissues,combining non-vascularized grafts with a vascularized flap for the two lamellae repair,to attempt a reconstruction similar to the original anatomy.When defects are too wide,vast,deep,and complex or when no adjacent healthy tissues are available,distant area tissues need to be recruited as free flaps or grafts and paired with mucosal layer reconstruction.With regards to the anterior lamella,full thickness skin grafts are commonly preferred.With regards to the reconstruction of posterior lamella,there are different graft options,which include conjunctival or tarsoconjunctival,mucosal or palatal or cartilaginous grafts usually combined with local flaps.Free flap transplantation,normally reserved for rare select cases,include the use of the radial forearm and anterolateral flaps combined with mucosal grafts,which are surgical options currently reported in the literature.

One-stage dorsal lingual mucosal graft urethroplasty for the treatment of failed hypospadias repair

The aim of this study was to retrospectively investigate the outcomes of patients who underwent one-stage onlay or inlay urethroplasty using a lingual mucosal graft （LMG） after failed hypospadias repairs. Inclusion criteria included a history of failed hypospadias repair, insufficiency of the local skin that made a reoperation with skin flaps difficult, and necessity of an oral mucosal graft urethroplasty. Patients were excluded if they had undergone a failed hypospadias repair using the foreskin or a multistage repair urethroplasty. Between January 2008 and December 2012, 110 patients with failed hypospadias repairs were treated in our center. Of these patients, 56 underwent a one-stage onlay or inlay urethroplasty using LMG. The median age was 21.8 years （range： 4-45 years）. Of the 56 patients, one-stage onlay LMG urethroplasty was performed in 42 patients （group 1）, and a modified Snodgrass technique using one-stage inlay LMG urethroplasty was performed in 14 （group 2）. The median LMG urethroplasty length was 5.6 ± 1.6 cm （range： 4-13 cm）. The mean follow-up was 34.7 months （range： 10-58 months）, and complications developed in 12 of 56 patients （21.4%）, including urethrocutaneous fistulas in 7 （6 in group 1, 1 in group 2） and neourethral strictures in 5 （4 in group 1, 1 in group 2）. The total success rate was 78.6%. Our survey suggests that one-stage onlay or inlay urethroplasty with LMG may be an effective option to treat the patients with less available skin after failed hypospadias repairs; LMG harvesting is easy and safe, irrespective of the patient＇s age.

Tunneled tubularized bladder mucosal graft for long urethral reconstruction:is it a reliable option in selected complex cases in children and adolescents?

Aim:We analyzed the use of tubularized tunneled bladder mucosa graft(TBMG)and its application as a salvage procedure or as primary surgery for long urethroplasty in children and adolescents.Specific attention was given to a new method to harvest a long bladder mucosa graft through a minimal detrusotomy.Methods:We analyzed the files of 10 patients who underwent TBMG urethroplasty at median age of 105 months(range 20-195 months).The indications were perineal hypospadias cripple in two,masculinizing genitoplasty for ovotesticular Ovotesticular Disorder of Sex Development(DSD)in two,perineal hypospadias in four,duplicated urethra in one,and complications of circumcision in one.Staged reconstruction was performed in all patients.The first stage was removal of all fibrous tissues and efficient treatment of curvature and skin coverage.After a minimal delay of one year,a free bladder mucosa graft was harvested through a minimal detrusotomy and tubularized.Tunneling of the graft was proceeded from the perineal urethrostomy to the glans.Results:The graft was successfully harvested through the minimal detrusotomy approach for variable lengths of urethroplasty;the median length was 10.5 cm(range 8-16 cm).The median follow up was 61.7 months(range 18-160 months).TBMG was the last surgery with no redo in five cases(50%).Long stricture occurred in one case of primary perineal hypospadias and needed a redo staged surgery.Two patients performed self-dilatation for distal stenosis.Conclusion:The tunneled bladder mucosa tube graft technique represents a good alternative for a long urethroplasty in patients with a paucity of healthy skin.The minimal detrusotomy technique for graft retrieval may reduce graft harvesting morbidity.

Epispadias:recent techniques

Aim:This paper presents the latest surgical approaches for epispadias treatment in the pediatric population,as well as those for adolescent and adult populations after initial failed repair in childhood.Methods:The retrospective study was conducted between March 2005 and May 2020 and included 18 patients with the mean age of 21 months(range 11-48 months)(Group A),who underwent primary epispadias repair and 15 patients with the mean age of 18 years(range 13-29 years)(Group B),who underwent redo surgery after failed epispadias repair in childhood.In Group A,the surgery was performed as a one-stage procedure using complete penile disassembly technique,while,in Group B,the surgery was done as a two-stage procedure and included complete straightening and lengthening of the penis,followed by urethral reconstruction.Penile straightening and lengthening were achieved by tunica albuginea incision and grafting.In Group A,the urethral plate was mobilized,transposed ventrally,and tubularized and augmented with vascularized preputial skin flap where needed.In Group B,the urethra was reconstructed either using the buccal mucosa graft and genital skin flaps or with tubularization of genital skin flaps.Successful treatment was defined as a functional and esthetically acceptable penis without complications.Results:The mean follow-up was 88 months(range 15-197 months).Satisfactory results were achieved in 26/33 patients.Urethral fistula occurred in 4/18 patients from Group A and in 3/15 patients in Group B and was surgically repaired after four months.Skin dehiscence occurred in eight patients,five from Group A and three from Group B.Recurrent penile curvature was observed in 2/18 patients from Group A and required surgical correction and in 2/15 patients from Group B and was mild and did not need surgical repair.Eleven patients from Group B who filled out the International Index for Erectile Function reported satisfying erectile function,sexual desire,intercourse,and overall satisfaction.Conclusion:Primary or redo epispadias repair is challenging even for experienced reconstructive urologists.Only radical surgical approach can lead to complete correction of all deformities and provide successful outcome.

Urethroplasty in a post irradiation urethral stricture-a review

Radiotherapy-induced urethral strictures(RIUS)decrease quality of life and present a great challenge for surgical reconstruction,especially due to proximal location,compromised vascular supply,and poor wound healing.It is unclear whether urethroplasty is an option in cases with stricture resulting from exposure to pelvic radiation.We review the pathophysiology,diagnostic workup,and disease-specific aspects of RIUS.Furthermore,we discuss several management alternatives such as excision and primary anastomosis,as well as techniques for open reconstruction with flaps.The most extensive techniques in the treatment of strictures include,for example,those using gracilis muscle flaps,as they can involve periurethral tissue to provide sufficient vascularity for excellent post-surgery urethral healing.In brief,RIUS represent a significant challenge.In carefully chosen patients,urethroplasty should be considered as a feasible and durable treatment.However,medical practitioners should always take into consideration that the results of urethroplasty in RIUS are not comparable to urethroplasties without a radiation background.