Combining Preputial Flap with Buccal Mucosa Graft (BMG) for Rescue Urethroplasty in Long Segments of Urethral Loss
SIU Academy®. Joshi P. 11/12/21; 342767; MVP-01.08 Topic: Strictures
Dr. Pankaj Joshi
Dr. Pankaj Joshi
Contributions Biography
Abstract
Combining Preputial Flap with Buccal Mucosa Graft (BMG) for Rescue Urethroplasty in Long Segments of Urethral Loss

Topic: Reconstruction

Applicant 1: Pankaj, Applicant 2: Marco, Applicant 3: Amey, Applicant 4: Sandeep, Applicant 5: Vipin, Applicant 6: Shreeranga, Applicant 7: Shreyas, Applicant 8: Guido, Applicant 9: Francesco, Applicant 10: Sanjay

Applicant 1: Joshi, Applicant 2: Bandini, Applicant 3: Patil, Applicant 4: Bafna, Applicant 5: Sharma, Applicant 6: Yatam, Applicant 7: Bhadranavar, Applicant 8: Barbagli, Applicant 9: Montorsi, Applicant 10: Kulkarni

Applicant 1: Kulkarni Endosurgery Institute, Applicant 2: Vita-Salute San Raffaele, Applicant 3: Kulkarni Endosurgery Institute, Applicant 4: Kulkarni Endosurgery Institute, Applicant 5: Kulkarni Endosurgery Institute, Applicant 6: Kulkarni Endosurgery Institute, Applicant 7: Kulkarni Endosurgery Institute, Applicant 8: Centro Chirurgico Toscano, Applicant 9: Vita-Salute San Raffaele Hospital, Applicant 10: Kulkarni Endosurgery Institute

Applicant 1: India, Applicant 2: Italy, Applicant 3: India, Applicant 4: India, Applicant 5: India, Applicant 6: India, Applicant 7: India, Applicant 8: Italy, Applicant 9: Italy, Applicant 10: India

Applicant 1: Presenting Author, Applicant 2: Author/Co-Author, Applicant 3: Author/Co-Author, Applicant 4: Author/Co-Author, Applicant 5: Author/Co-Author, Applicant 6: Author/Co-Author, Applicant 7: Author/Co-Author, Applicant 8: Author/Co-Author, Applicant 9: Author/Co-Author, Applicant 10: Author/Co-Author

Introduction and Objectives:

When extensive segments of urethra are missing, urethroplasty becomes extremely challenging or even impossible. Indeed, augmented techniques require the native urethra, even if narrow, to allocate the graft beside. However, some patients may present with no urethral plate left. We developed an advanced technique of urethral reconstruction, which may represent a rescue solution in those patients with long and obliterative segments of urethra.

Materials and Methods:

Between 2014 and 2021, seventeen patients required our flap plus graft urethroplasty. BXO was a criterion for exclusion. After perineal incision, the peno-bulbar urethra was exposed using the Kulkarni\'s of one-side dissection and penile invagination techniques. BMG was harvested matching the total length of the urethral loss. BMG was quilted to the corpora. Secondly, a circumferential incision was taken on the preputial penile skin, 2.5 cm from the distal margin. From this incision, a superficial degloving was carried, which included only the skin, leaving the underline dartos in place. The distal preputial skin ring was detached from the inner prepuce with a circumcoronal incision. Here, a full thick degloving was carried disconnecting the penile skin with its dartos from the underlying Buck\'s fascia. Following these steps, we harvested a ring-shaped flap of penile skin with its dartos. The ring was then opened ventrally to create a flap and then transposed to the perineum. The new urethra was created covering the BMG with the preputial flap over a 14 ch catheter. Proximal and distal anastomoses with the native urethra completed the procedure. Failure after urethroplasty was defined as any postoperative instrumentation.

Results:

The median length of the urethral gap was 6.5 cm. The median age at diagnosis was 37 years. The median operation time was 137 minutes. Postoperative complications included one penile hematoma and one penile skin dehiscence. After a median follow-up of 32 months, 16 patients were free from failure and 76% had postmicturition dribbling.

Conclusion:

Our flap plus graft substitution urethroplasty appeared to be a valid alternative to perineostomy for patients with long segments of urethral loss. In our hands, the procedure was safe and effective. However, it requires advanced knowledge of graft and flap harvesting and it should be performed only by very experienced reconstructive surgeons.

Combining Preputial Flap with Buccal Mucosa Graft (BMG) for Rescue Urethroplasty in Long Segments of Urethral Loss

Topic: Reconstruction

Applicant 1: Pankaj, Applicant 2: Marco, Applicant 3: Amey, Applicant 4: Sandeep, Applicant 5: Vipin, Applicant 6: Shreeranga, Applicant 7: Shreyas, Applicant 8: Guido, Applicant 9: Francesco, Applicant 10: Sanjay

Applicant 1: Joshi, Applicant 2: Bandini, Applicant 3: Patil, Applicant 4: Bafna, Applicant 5: Sharma, Applicant 6: Yatam, Applicant 7: Bhadranavar, Applicant 8: Barbagli, Applicant 9: Montorsi, Applicant 10: Kulkarni

Applicant 1: Kulkarni Endosurgery Institute, Applicant 2: Vita-Salute San Raffaele, Applicant 3: Kulkarni Endosurgery Institute, Applicant 4: Kulkarni Endosurgery Institute, Applicant 5: Kulkarni Endosurgery Institute, Applicant 6: Kulkarni Endosurgery Institute, Applicant 7: Kulkarni Endosurgery Institute, Applicant 8: Centro Chirurgico Toscano, Applicant 9: Vita-Salute San Raffaele Hospital, Applicant 10: Kulkarni Endosurgery Institute

Applicant 1: India, Applicant 2: Italy, Applicant 3: India, Applicant 4: India, Applicant 5: India, Applicant 6: India, Applicant 7: India, Applicant 8: Italy, Applicant 9: Italy, Applicant 10: India

Applicant 1: Presenting Author, Applicant 2: Author/Co-Author, Applicant 3: Author/Co-Author, Applicant 4: Author/Co-Author, Applicant 5: Author/Co-Author, Applicant 6: Author/Co-Author, Applicant 7: Author/Co-Author, Applicant 8: Author/Co-Author, Applicant 9: Author/Co-Author, Applicant 10: Author/Co-Author

Introduction and Objectives:

When extensive segments of urethra are missing, urethroplasty becomes extremely challenging or even impossible. Indeed, augmented techniques require the native urethra, even if narrow, to allocate the graft beside. However, some patients may present with no urethral plate left. We developed an advanced technique of urethral reconstruction, which may represent a rescue solution in those patients with long and obliterative segments of urethra.

Materials and Methods:

Between 2014 and 2021, seventeen patients required our flap plus graft urethroplasty. BXO was a criterion for exclusion. After perineal incision, the peno-bulbar urethra was exposed using the Kulkarni\'s of one-side dissection and penile invagination techniques. BMG was harvested matching the total length of the urethral loss. BMG was quilted to the corpora. Secondly, a circumferential incision was taken on the preputial penile skin, 2.5 cm from the distal margin. From this incision, a superficial degloving was carried, which included only the skin, leaving the underline dartos in place. The distal preputial skin ring was detached from the inner prepuce with a circumcoronal incision. Here, a full thick degloving was carried disconnecting the penile skin with its dartos from the underlying Buck\'s fascia. Following these steps, we harvested a ring-shaped flap of penile skin with its dartos. The ring was then opened ventrally to create a flap and then transposed to the perineum. The new urethra was created covering the BMG with the preputial flap over a 14 ch catheter. Proximal and distal anastomoses with the native urethra completed the procedure. Failure after urethroplasty was defined as any postoperative instrumentation.

Results:

The median length of the urethral gap was 6.5 cm. The median age at diagnosis was 37 years. The median operation time was 137 minutes. Postoperative complications included one penile hematoma and one penile skin dehiscence. After a median follow-up of 32 months, 16 patients were free from failure and 76% had postmicturition dribbling.

Conclusion:

Our flap plus graft substitution urethroplasty appeared to be a valid alternative to perineostomy for patients with long segments of urethral loss. In our hands, the procedure was safe and effective. However, it requires advanced knowledge of graft and flap harvesting and it should be performed only by very experienced reconstructive surgeons.

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