Dorsal Onlay Grafts Meet With Success
Taken from the buccal mucosa, these grafts could help salvage fasciocutaneous flap repair failures
The technique, which can be performed successfully as part of a single- or multiple-stage approach, may help “salvage” patients who have failed prior attempts at fasciocutaneous flap repair.
“Genital fasciocutaneous ventral onlay flaps remain the most common technique for repairing pendulous urethral strictures,” said Daniel Rosenstein, MD, director of urologic trauma at Santa Clara Valley Medical Center and clinical instructor in urology at Stanford University Medical Center in Palo Alto, Calif. “Although frequently successful, these flaps have inherent limitations, including lack of spongy support and consequent sacculation post-void dribbling as well as local complications such as penile torsion and ischemic skin necrosis.”
In cases of stricture secondary to complex hypospadias, no local skin is available for reconstruction, he continued. With lichen sclerosis involving the genital skin as well as the urethra, the use of local flaps lead to rapid restructure. Because of these concerns, Dr. Rosenstein's team has used a different approach for stricture repair that involves selective use of a dorsal onlay graft of buccal mucosa as part of a single- or multiple-stage procedure.
At the Société Internationale d'Urologie 29th Congress here, Dr. Rosenstein presented results in seven patients with complex pendulous strictures in whom he performed dorsal buccal graft onlay reconstruction as a single- or multiple-stage repair over a recent 36-month period. Stricture etiology was multifactoral. All patients had failed attempts at endoscopic management elsewhere, and three of them had failed prior fasciocutaneous flap repair, Dr. Rosenstein reported.
Three patients underwent single-stage repair with a single dorsal buccal mucosal graft onlay, and three underwent two-stage repair. One patient with pan-urethral lichen sclerosis underwent a proximal single-stage repair with a distal staged buccal and mesh graft repair and is awaiting the second-stage repair. The mean stricture length was 7 cm.
At a mean follow-up of 12.7 months, the mean maximum flow rate had increased from 7.7 cc/sec before repair to 22.3 cc/sec afterwards. No patient showed evidence of a recurrent stricture although one patient reported bothersome ventral chordae in the early postoperative period, the researchers reported. At the last assessment, six patients (86%) are voiding without complaint, and one patent is catheterizing his reconstructed urethra without any complications.
“Pendulous urethral strictures may present a particular challenge for the reconstructive urologist,” Dr. Rosenstein said. He added that he is encouraged by the early results and that longer term follow-up in a larger number of patients is needed to confirm the durability and reproducibility of the early findings.