Open surgical urethroplasty with a free graft from the oral mucosa represents another treatment option for urethral strictures. The success rate of this intervention is much higher compared to the previously mentioned procedures. Plastic reconstruction is mainly used in cases of long bulbar and all penile strictures, as well as after frustrating multiple urethrotomies or bougienage.1,2 However, the removal of the mucosa from the patient’s oral cavity leads to postoperative complications.3
In urethroplasty, the urethra is opened longitudinally over the narrowed area and dilated with a graft from the oral mucosa. Depending on the length of the stricture, the size of the graft taken also varies. Oral mucosa can be harvested from the cheek, as well as from the patient’s tongue or lip.4.
According to Tritschler et al,5 urethroplasty with oral mucosa is recommended when slitting has not been successful or the stricture has an extension of more than 2.5 cm in length. It should be emphasized that preinterventional performance of two or more urethrotomies causes an increased risk of failure of urethroplasty.6 This procedure should therefore be used early, especially in younger patients and in multiple and high-grade, long-stretch strictures.7.
In individual cases, high success rates have been achieved with this method.8 However, only data from individual clinics from retrospective studies are available. The American Urological Association guideline for the treatment of urethral strictures in men also confirms the lack of evidence for this accepted procedure. Thus, at the current time, only studies with evidence class C, based on reports and opinions of experts and clinical trials by recognized authorities, respectively, are available.
The removal of the oral mucosa is also associated with side effects in some cases. The size of the graft also increases the risk of long-lasting sequelae. The larger the graft needed and the larger the oral defect caused, the more likely local complications will occur at the harvest site. Thus, the studies by Dublin and Stewart9 and by Wood et al.10 demonstrate the ongoing health consequences that developed from the side effects of oral surgery. In addition, scarring changes develop in the patients’ mouths, which pose an increased risk of cancer because of the constant irritation and risk of infection.11.
The results of the study by Piemonte et al, which included a total of 406 patients, showed that in 75.56% of patients suffering from oral cancer, chronic injury to the oral mucosa had preceded the disease (p < 0.0001). These findings are similarly supported by Perry et al.12. Furthermore, especially strictures with a length ≥ 5 cm pose an increased risk for sequelae and the formation of a recurrence.13
|1||Andrich and Mundy. What is the best technique for urethroplasty? European Urology. 2008; 54(5):1031-1041.|
|2||Zugor et al. Offene urethrale Rekonstruktion bei Harnröhrenstrikturen. Urologie. 2014(1): 76-78|
|3||Dublin and Stewart. Oral complications after buccal mucosal graft harvest for urethroplasty. BJU International. 2004; 94(6):867-869.|
|4||Anger JT, Buckley JC, Santucci RA, Elliott SP, Saigal CS. Trends in stricture management among male Medicare beneficiaries: underuse of urethroplasty? Urology 2011; 77(2): 481–485.|
|5||Tritschler et al. Harnröhrenstrikturen – Ursachen, Diagnose und Therapien. Deutsche Ärzteblatt International. 2013; 110(13):220-226.|
|6||Kessler et al. Long-term results of surgery for urethral stricture: a statistical analysis. J Urol. 2003 Sep;170(3):840-4.|
|7||Leyh. Urethrotomia interna. Urol 2014; 45(03): 233-241.|
|8||Barbagli G, Guazzoni G, Lazzeri M: One-stage bulbar urethroplasty: retrospective analysis of the results in 375 patients. Eur Urol 2008; 53: 828–33.|
|9||Dublin and Stewart. Oral complications after buccal mucosal graft harvest for urethroplasty. BJU International. 2004; 94(6):867-869.|
|10||Wood et al. The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain. The Journal of Urology. 2004; 172(2):580-583.|
|11||Perry BJ et al. Sites of Origin of Oral Cavity Cancer in Nonsmokers vs Smokers Possible Evidence of Dental Trauma Carcinogenesis and Its Importance Compared With Human Papillomavirus. JAMA Otolaryngol Head Neck Surg. 2015;141(1):5-11.|
|12||Perry BJ; Zammit AP,Lewandowski AW, Bashford JJ, Dragovic AS, Perry EJ, Hayatbakhsh R, Perry CFL. Sites of Origin of Oral Cavity Cancer in Nonsmokers vs Smokers Possible Evidence of Dental Trauma Carcinogenesis and Its Importance Compared With Human Papillomavirus. JAMA Otolaryngol Head Neck Surg. 2015;141(1):5-11.|
|13||Kinnaird et al. Stricture length and etiology as preoperative independent predictors of recurrence after urethroplasty: A multivariate analysis of 604 urethroplasties. Can Urol Assoc J 2014;8(5-6)|