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Inicio Actas Urológicas Españolas (English Edition) Treatment for long bulbar urethral strictures with membranous involvement using ...
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Vol. 38. Issue 8.
Pages 544-551 (October 2014)
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Vol. 38. Issue 8.
Pages 544-551 (October 2014)
Surgical Technique
Treatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graft
Tratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucal
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H. Gimbernat, I. Arance, C. Redondo, E. Meilán, G. Andrés, J.C. Angulo
Corresponding author
javier.angulo@salud.madrid.org

Corresponding author.
Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain
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Abstract
Introduction

Urethroplasty with oral mucosa grafting is the most popular technique for treating nontraumatic bulbar urethral strictures; however, cases involving the membranous portion are usually treated using progressive perineal anastomotic urethroplasty. We assessed the feasibility of performing dorsal (or ventral) graft urethroplasty on bulbar urethral strictures with mainly membranous involvement using a modified Barbagli technique.

Materials and methods

This was a prospective study of 14 patients with bulbomembranous urethral strictures who underwent dilation urethroplasty with oral mucosa graft between 2005 and 2013, performed using a modified technique Barbagli, with proximal anchoring of the graft and securing of the graft to the tunica cavernosa in 12 cases (85.7%) and ventrally in 2 (14.3%). The minimum follow-up time was 1 year. We evaluated the subjective (patient satisfaction) and objective (maximum flow [Qmax] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation.

Results

A total of 14 patients (median age, 64±13 years) underwent surgery. The main antecedent of note was transurethral resection of the prostate in 9 cases (64.3%). The median length of the stenosis was 45±26.5mm. Prior to surgery, 50% of the patients had been subjected to dilatations and 4% to endoscopic urethrotomy. The mean surgical time and hospital stay were 177±76min and 1.5±1 day, respectively. The preoperative Qmax and PVRV values were 4.5±4.45ml/s and 212.5±130cc, respectively. The postoperative values were 15.15±7.2ml/s and 6±21.5cc, respectively (p<0.01 for both comparisons). Surgery was successful in 13 cases (92.9%). None of the patients had major complications. There were minor complications in 1 (7.1%) patient, but reintervention was not required.

Conclusion

The repair of long bulbar urethral strictures with membranous involvement using urethroplasty with free oral mucosa grafts represents a viable alternative for patients with nontraumatic etiology and little fibrosis. The dilation of the urethral lumen achieves good results with minimum failure rates and little probability of complications. For many of these patients, the length of the stricture is too long to perform the tension-free anastomosis technique.

Keywords:
Urethroplasty
Urethral stricture
Bulbar urethra
Membranous urethra
Oral mucosa graft
Reconstructive surgery
Resumen
Introducción

Las uretroplastia con injerto de mucosa bucal es la técnica más popular en el tratamiento de la estenosis de uretra bulbar no traumática; no obstante, los casos con afectación de la porción membranosa suelen tratarse mediante uretroplastia anastomótica perineal progresiva. Se evalúa la viabilidad de llevar a cabo uretroplastia con injerto dorsal (o ventral) en estenosis de uretra bulbar y afectación principalmente membranosa con técnica de Barbagli modificada.

Material y métodos

Estudio prospectivo sobre 14 pacientes con estenosis de uretra bulbomembranosa sometidos a uretroplastia de ampliación con injerto de mucosa bucal entre 2005 y 2013, según la técnica de Barbagli modificada con anclaje proximal del injerto y fijación del mismo sobre la albugínea cavernosa en 12 casos (%) y ventralmente en 2 (%). El tiempo de seguimiento mínimo fue de un año. Se evaluaron resultados subjetivos (satisfacción del paciente) y objetivos (Qmáx y RPM pre y postoperatorios) y complicaciones. Se consideró fracaso la necesidad de cualquier instrumentación postoperatoria.

Resultados

Se intervinieron 14 pacientes, con una mediana de edad de 64+13 años. El antecedente principal detectado fue RTU de próstata en 9 casos (64,3%). La mediana de longitud de la estenosis fue 45+26,5mm. Antes de la cirugía el 50% de los pacientes había sido sometido a dilataciones y el 4% a uretrotomía endoscópica. El tiempo quirúrgico fue 177+76min y la estancia hospitalaria 1,5+1d. Qmáx y RPM preoperatorios fueron 4,5+4,45ml/seg y 212,5+130cc, y postoperatorios 15,15+7,2ml/seg y 6+21,5cc (p<0,01 ambas comparaciones). La cirugía resultó exitosa en 13 casos (92,9%). Ningún paciente presentó complicaciones mayores. Hubo complicaciones menores en uno (7,1%), sin precisar reintervención.

Conclusión

La reparación de estenosis largas de uretra bulbar con afectación membranosa mediante uretroplastia con injerto libre de mucosa bucal supone una alternativa viable en pacientes de etiología no traumática con escasa fibrosis. La ampliación de la luz uretral consigue buenos resultados con mínima tasa de fracaso y escasa probabilidad de complicación. En muchos de estos pacientes la longitud de la estenosis es demasiado larga para realizar técnica anastomótica sin tensión.

Palabras clave:
Uretroplastia
Estenosis uretral
Uretra bulbar
Uretra membranosa
Injerto de mucosa oral
Cirugía reconstructiva

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