Kulkarni Dorso-lateral Graft Urethroplasty: a mid-term follow-up study

Enzo Palminteri1, Giovanni Battista Di Pierro2, Elisa Berdondini1, Giuseppina Cucchiarale1, Francesco Valentino1, Gianluca Milan1, Pietro Grande2, Cristiano Cristini2, Ugo Ferrando1
  • 1 Centro di Chirurgia Uretrale, Clinica Cellini, Humanitas (Torino)
  • 2 Università "La Sapeinza" Dipartimento di Ostetricia, Ginecologia e Urologia (Roma)

Objective

To report mid-term outcomes of Kulkarni dorso-lateral graft urethroplasty for anterior urethral strictures.

Materials and Methods

Between 2009 and 2013, 69 men(mean age 50 years) with anterior urethral strictures underwent dorso-lateral graft urethroplasty.
The stricture site was penile in 34(49.2%%), bulbar in 11(15.9%) and peno-bulbar in 24(34.9%). The cause of stricture was iatrogenic in 18 cases(26.2%), unknown in 22(31.8%), trauma in 2(2.9%), catheter in 19(27.5%) and lichen sclerosus in 8(11.6%). Of 69 patients, 5(7.3%) men had previously undergone dilatation, 9(13.1%) urethrotomy, 5(7.3%) urethroplasty and 38(55.1%) multiple treatments.
Mean stricture length was 5 cm(range: 1-17).
The urethra was dissected from the corpora cavernosa only along the left side, starting from the distal tract of the strictured urethra. Along the right side, the urethra remained attached to the corpora cavernosa for its full length, thus preserving its lateral vascular blood supply. The distal extent of the stenosis was identified, the dorso-lateral urethral surface was incised along the midline and the urethral lumen was exposed. The stricture was then incised along its entire length by extending the urethrotomy 1 cm both distally and proximally in the healty urethra. The urethra augmentation was performed by preputial skin(PS) and/or buccal mucosa(BM) grafts, that were previously harvested and trimmed to an appropriate size, then fixed over the tunica albuginea with quilting 5/0 polyglactin sutures. The right margin of the graft was sutured to the left margin of the urethral mucosa plate with interrupted 5/0 sutures on a 18-Fr catheter. The urethra was rotated to its original position over the graft.
Voiding cysto-urethrography was performed upon catheter removal, 3 weeks after surgery.
Follow-up assessment included uroflowmetry and urine culture every 4 months in the first year and annually thereafter. Urethrography and urethroscopy were performed in patients presenting any new/residual obstructive symptoms or peak flow rate(Qmax) < 14 mL/s.
Clinical outcome was considered a failure when any postoperative procedure was needed, including dilatation.

Results

Employed grafts were BM in 29 (42.1%) patients, PS in 38 (55.1%) and BM + PS in 2 (2.8%).
The BM graft harvesting was monolateral in 25 (80.6%) patients and bilateral in 6 (19.4%), respectively. Mean graft length was 6.1 cm (range: 2.5-17).
Mean follow-up was 30 months (range: 12-51). There were no postoperative complications such as wound infections, hematomas or bleeding. At voiding urethrography following catheter removal at 3 weeks, in 7 (10.1%) cases a mild leakage at the graft anastomosis was observed. However, this resolved spontaneously with a 12-Fr catheter for 3-4 additional weeks.
Of 69 patients, 61 (88.4%) were successful. The 8 (11.6%) failures were treated by perineostomy in 5 cases with long recurrences and urethrotomy in 3 patients with stenotic rings.

Discussions

In 1996, Barbagli introduced the use of the dorsal grafting by the dorsal urethrotomy underlining two advantages: the corpora gives good mechanical and vascular support for the graft; furthermore, it preserved the integrity of the spongiosum on its abundant ventral side. However, in the original dorsal graft technique the urethra needs to be completely freed from the corpora. This step might be difficult in scarred urethras which are often firmly attached to the corpora; furthermore, especially in long or recurrent ischemic strictures, the extensive urethral mobilisation from the corpora with the interruption of the lateral blood supply (circumferential arteries) may even more compromise the vascularization of a diseased urethra.
In this context, to avoid the excessive circumferential mobilisation of the urethra and preserve its controlateral vascular supply, Kulkarny proposed a less aggressive dorso-lateral approach. This technique is part of the new trend to reduce the surgical trauma of a technique and subsequent recurrences and complications.
Our study with a mid-term follow-up confirms that the dorso-lateral grafting represents an effective and minimally invasive reconstructive approach for anterior urethral strictures.

Conclusion

In the last two decades, patch grafting procedures have spread rapidly and the dorsal or ventral graft placement using dorsal or ventral urethrotomy approaches has become a contentious issue.
In this context, Kulkarni has recently proposed a less invasive one-sided dorso-lateral graft urethroplasty to avoid the full circumferential mobilisation of the urethra and to preserve its controlateral vascular supply. He described the technique with the use of oral mucosa and as a valid alternative to a staged procedure.
Our study with a mid-term follow-up confirms that the dorso-lateral grafting represents an efficient and less invasive reconstructive approach for anterior urethral strictures.

References

1. Andrich DE and Mundy AR.
What is the best echnique for urethroplasty?
Eur Urol 2008; 54:1031.
2. Patterson JM and Chapple CR.
Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures.
Eur Urol 2008; 53: 1162.
3. Presman D, Greenfield DL.
Reconstruction of the perineal urethra with a free full-thickness skin graft of the prepuce. J Urol 1953; 69: 677-80
4. Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology 1996; 48: 194-8.
5. Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty. J Urol 1996; 155: 123-6.
6. Kulkarni S, Barbagli G, Sinsilone S, Lizzeri M. One-sided anterior urethroplasty: a new dorsal onlay graft technique. BJU Int, 2009; 104: 1150-55.

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