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
H. Gimbernat, I. Arance, C. Redondo, E. Meilán, G. Andrés, J.C. Angulo
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Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain
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Gimbernat, I. Arance, C. Redondo, E. Meilán, G. Andrés, J.C. Angulo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "H." "apellidos" => "Gimbernat" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Arance" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Redondo" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Meilán" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Andrés" ] 5 => array:4 [ "nombre" => "J.C." "apellidos" => "Angulo" "email" => array:1 [ 0 => "javier.angulo@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 904 "Ancho" => 1750 "Tamanyo" => 297602 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The anastomosis between the graft and the edges of the urethral lumen is completed distally (A). Double row of parallel sutures applied on the cavernous albuginea and the graft, tied without tension on both sides, they give stability to the graft.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0145" class="elsevierStylePara elsevierViewall">Urethral strictures have been traditionally treated with different methods ranging from the more conservative dilations to more complex techniques using grafts and flaps, including endoscopic therapies. The choice of one technique or another depends on the patient's characteristics and, above all, on stenosis length and location.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Etiology plays a key role in strategy planning since, for instance, in the case of strictures of inflammatory origin there is an increased trend toward relapse.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Bulbar urethral or bulbomembranous strictures which require urethroplasty, but are too long for anastomotic techniques, benefit from replacement techniques where the stenotic segment is removed and replaced by a graft which can provide an acceptable urethral calibration so that the patient achieves a good voiding condition.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Urethroplasty with oral mucosal grafts has become a really popular technique over the last decade due to its excellent long-term results, favored by the characteristics of this easily obtained tissue.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Bulbar urethral stenosis with involvement of the membranous portion, especially in cases of post-traumatic origin, has been preferentially treated with transperineal bulboprostatic anastomotic repair, also known as progressive perineal urethroplasty.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> This technique implies a high success rate, depending in a way on the length of the bulbar defect extension to be treated.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Nonetheless, the success of grafting techniques with urethral enlargement has led to an expansion of the indication for urethroplasty with oral mucosal grafts to cases of long strictures with bulbar or membranous involvement, avoiding the separation of the corpora cavernosa and pubectomy, sometimes necessary to perform perineal anastomosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">We present a favorable experience derived from performing replacement urethroplasty with free oral mucosal grafts, ventrally or dorsally placed, in complex strictures of the bulbar urethra with membranous involvement. More studies are needed to clarify the role of elongation and luminal elastic enlargement of the urethra in the success of this kind of surgery, when compared with excision of diseased tissue in anastomotic repair.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0165" class="elsevierStylePara elsevierViewall">Prospective study analyzing the characteristics and results of a series of cases affected by bulbar urethral strictures with membranous involvement and who underwent augmentation urethroplasty with oral mucosal grafts, according to the modified Barbagli technique, at the University Hospital of Getafe. All patients were operated on over the 2005–2013 period. Patients had been contacted by telephone in January 2014. They all showed a minimum follow-up of one year.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The clinical course of the patients was revised, paying special attention to subjective data on patient satisfaction and objective data on bladder voiding, including maximum flow (<span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">max</span>) and post-void residual (PVR), both pre- and postoperative for each case. We also assessed cystourethrography images, both retrograde (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and voiding (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). We registered operative data, duration of the surgical intervention, hospital stay time, and complications according to the Clavien–Dindo scale and EAU recommendations.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> A descriptive statistical analysis was carried out. We used the median and the interquartile range for quantitative variables, and percentages for qualitative variables.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0175" class="elsevierStylePara elsevierViewall">The technique used is a variant of the original Barbagli technique with oral mucosal grafts,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> the main modifications being the following: (a) really proximal graft-anchorage; (b) graft fixation on the albuginea of the corpora cavernosa once urethral enlargement has been performed with stitching of the graft; (c) the use of a hemostatic agent as a sealant of the self-expandable gelatinous matrix and a thrombin base. Additional material is presented with a representative video of this surgery.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The patient is placed in lithotomy position. The suprapubic, scrotal, and perineal regions are shaved and disinfected with chlorhexidine. Ureteroscopy is performed by placing a guidance sensor and a 4-Ch ureteral catheter which surpasses the stricture and gains access to the bladder. Immediately thereafter, with the patient in the dorsal lithotomy position, a perineal–scrotal incision is made on the middle line. The dissection of subcutaneous cell tissue and the incision of Colles’ and Gallaudet's fascia allow for the exposure of the bulbospongiosus muscles. Due to the proximal nature of strictures, it is necessary to section the central tendon of the perineum. The bulbospongiosus muscles are cut on the middle line in a cranio-caudal direction and are laterally separated to expose the corpus spongiosum in its full extent. The corpus spongiosum is subsequently released from dorsal attachments to the albuginea of the corpora cavernosa.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Simultaneously, another surgical team proceeds to obtain the buccal mucosa graft (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Demarcation of both Stenon's canal and the selected area is done to get the graft. A saline solution with diluted adrenaline is injected on the edges of the marked area, thus performing hydrodissection of the mucosa, to subsequently section the demarcated area using a cold scalpel. Two traction points on the proximal edge of the graft area make their subsequent dissection easier. Once the graft has been removed, the hemostasis is carefully examined and the edges are approximated with reabsorbable 4-0 suture. The graft is made thinner with some scissors and permanent manual contact. Its extraction is simplified by the administration of topical adrenaline. Identifying the parotid canal is particularly important at the moment of extraction.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The distal edge of the stricture is marked with the help of a Beniqué sound and a dermographic marker. 3 traction points are applied on the urethral spongiosum at different levels. These points keep a precise 180° rotation to make exposure and a comfortable approach to the urethra on its dorsal side easier. A longitudinal incision is made on the dorsal surface of the spongiosum until reaching the cranial limit of the stenotic area (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), with an excellent opening of the urethra being observed and sometimes even the <span class="elsevierStyleItalic">veru montanum</span>.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">This incision enables the visualization of the Beniqué sound and a complete exposure of the urethral lumen through all the stenosed segment. It is advisable to cut 1 more cm, both at the proximal and dorsal levels of the stricture. The affected urethral segment shows a certain degree of fibrosis on the outside, which is removed with scissors, lightening the urethral lumen before proceeding to graft placement. Alternatively, the urethral incision can be made on the ventral side, which implies an easier exposure, though urethral release is equally required. Dorsal positioning implies less graft mobility, which is attached to the base of the crura of the corpora cavernosa and to the trapezoidal space.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The length of the stenotic area is determined with a tape measure and a Foley probe which will serve as a tutor is placed. The proximal part of the graft, which has been previously carved at the bank with reabsorbable 4-0 suture, is fixed. Anastomosis is subsequently completed between the graft and both edges of the urethral lumen in a distal direction, using interrupted stitches of the same suture (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Two parallel lines of reabsorbable suture stitches applied on the cavernous albuginea and the graft on both sides offer stability to it (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Once they have been tied in a distal direction without any tension, the urethral spongiosum is once again fixed to the albuginea of the corpora cavernosa.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">The re-approximation of the bulbospongiosus muscles is performed with a 3-0 reabsorbable braided multifilament suture. Once this muscular structure has been reconstructed, we proceed with a Floseal Hemostatic Matrix injection, 10<span class="elsevierStyleHsp" style=""></span>ml (Baxter Healthcare Corporation, Hayward, CA, USA) on the space located between the spongiosum and the muscular plane. The application of interrupted stitches at a distal level between the spongiosum and the cavernous albuginea further reinforces urethral stability.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Aspiration drainage of the Redon type, which will be kept for approximately 12<span class="elsevierStyleHsp" style=""></span>h after surgery, is placed in the surgical wound. The surgical intervention finishes with the approximation and closure of the planes cut. The endoscopic image at 6 months after surgery showed a perfect integration of the mucous graft, with no residual stenosis areas being observed.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0215" class="elsevierStylePara elsevierViewall">A total of 14 patients are described, 12 of whom had stenosis at the level of the bulbar and membranous urethra and 2 at the level of the membranous urethra exclusively. The median age was 64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13 years. In 9 patients (64.3%) the etiology was secondary to prostate transurethral resection performed over a period greater than 5 years before, in one (7.1%) secondary to traumatic bladder catheterization, in another one (7.1%) secondary to closed ureteral traumatism, and in the remaining 3 cases (21.4%) it was idiopathic. In one case (7.1%) the length of the stenosis was 2–3<span class="elsevierStyleHsp" style=""></span>cm, in 5 (35.7%) 3–4<span class="elsevierStyleHsp" style=""></span>cm, in 4 (28.6%) 4–6<span class="elsevierStyleHsp" style=""></span>cm, and in 4 (28.6%) it exceeded 6<span class="elsevierStyleHsp" style=""></span>cm. The median length of the stenosis was 45<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>26.5<span class="elsevierStyleHsp" style=""></span>mm.</p><p id="par0220" class="elsevierStylePara elsevierViewall">A total of 7 patients (50%) had a history of previous urethral dilation and 4 (28.6%) of previous endoscopic urethrotomy. None of them showed genital lichen sclerosus or had previously undergone circumcision. Two patients (14.3%) showed previous incontinence and 3 (21.4%) recurrent infections of the urinary tract. 3 cases (21.4%) showed multiple stenosis and one patient (7.1%) showed involvement of the penile urethra. The graft used for urethroplasty was oral mucosa in all cases. In 2 patients (14.3%) it was ventrally placed and in 12 (85.7%) dorsally. In 3 cases (21.4%) a double flap was obtained, one from each cheek. In these cases, nasal intubation hugely favors graft extraction.</p><p id="par0225" class="elsevierStylePara elsevierViewall">The median surgical time was 177<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>76<span class="elsevierStyleHsp" style=""></span>min (range 95–240) and the median hospital stay was 1.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1 days (range 1–6). At the time of discharge only one patient (7.1%) had a cystostomy catheter and the median time of bladder catheter was 23<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.5 days (range 14–49). The median preoperative <span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">max</span> value was 4.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.45<span class="elsevierStyleHsp" style=""></span>ml/min (range 1.7–9.7) and the median PVR 212.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>cc (range 0–420). <span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">max</span> and PVR values at 3 months after surgery were 15.15<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.2<span class="elsevierStyleHsp" style=""></span>ml/min (range 9.6–29.6) and 6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>ml (range 0–97), respectively. Improvement in both parameters was statistically significant (signed range test, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0002; respectively) (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">No patient within this series showed major complications. One patient (7.1%) showed a minor complication in the first postoperative month, consisting of a urinary fistula which was resolved with bladder catheterization. No case developed incontinence after surgery. There were no complications associated with the extraction of the free graft from the oral mucosa. Throughout follow-up, 3 patients (21.4%) showed endoscopic or radiologic data suggestive of partial stenosis, though with clinical improvement in all cases. One case required dilation maneuvers 4 years after surgery, thus being considered a failure. All the other patients confirmed good voiding function and showed objective data (PVR and <span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">max</span>) of improvement in bladder voiding without instrumentation. Therefore, with a median follow-up of 54.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23.7 months, we can consider that the procedure was successful in 92.9% of patients.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0235" class="elsevierStylePara elsevierViewall">The bulbar urethra is surrounded by the thickest portion of the corpus spongiosum and is eccentrically positioned, so that the dorsal side of the surrounding tissues looks thin, whereas it is ventrally thicker. As it moves distally, the urethra adopts a more central position within the corpus spongiosum.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Stenosis length is a prognostic factor as well as a factor used to decide on the type of urethroplasty<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a> and, consequently, it may be a source of confusion when analyzing the healing power of each technique.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the case of bulbar or membranous urethral strictures, termino-terminal urethroplasty is considered to have better results than augmentation urethroplasty, though this fact could be biased by the own definition of its indication.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> That is why, in the case of strictures smaller than 2<span class="elsevierStyleHsp" style=""></span>cm in length, termino-terminal anastomosis is considered the technique of choice. However, for strictures greater than 2<span class="elsevierStyleHsp" style=""></span>cm, when the urethral lumen is well preserved and the area of spongiofibrosis is small, augmentation urethroplasty with grafting in the dorsal or ventral position is the ideal technique, with long-term success rates up to 90%.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–16</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">We can use grafts or flaps for augmentation techniques. There is a historical controversy on which of the 2 is the most appropriate one, though nowadays it is clearly established that the recurrence rate of stenosis is 14–15.7%, with no apparent differences between grafts and flaps.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However, the complication rate is higher in the donor area when flaps are used. These complications include penile hematoma, skin necrosis, fistula formation, and a higher risk of urethral diverticulum formation.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Regarding graft origin, there is currently an increasing trend to use oral mucosa as donor tissue, although historically the preferred tissue has been preputial mucosa or penile skin due to their easier extraction and their histological characteristics. With regard to the use of preputial skin or oral mucosal grafts, the literature shows mixed results. Whereas Alkisafi et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> found no differences among them, Barbagli et al. detected a higher failure rate with preputial mucosa.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Our experience is favorable to the use of oral mucosa in all cases. Oral mucosal grafts are resistant and easy to obtain and to handle. They have a thick epithelium with their own thin layer and a dense panlaminar vascular plexus. It is a moist tissue resistant to skin conditions, such as lichen sclerosus. Oral mucosa also has a privileged immunology, having shown in preclinical studies a large number of fibroblasts which reduce fibrosis. In those patients who require the extraction of several free grafts, labial and/or lingual mucosa can also be used, though these tissues are thinner than buccal mucosa.</p><p id="par0255" class="elsevierStylePara elsevierViewall">The development of urethroplasty with oral mucosal grafts in the dorsal position implies an evolution of the techniques used for the treatment of urethral stenosis. In 1979, Devine et al. made the use of genital and extragenital grafts popular for urethral reconstruction.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Monseur described in 1980 a new technique where the dorsal surface of the urethra was opened and fixed to the underlying corpora cavernosa, leaving the urethral catheter in place for a long period of time until the regeneration of the oral mucosa.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In 1996 Barbagli et al. combined both concepts, thus developing a new treatment paradigm for urethral stenosis based on the placement of a free oral mucosal graft on the dorsal side of the urethra, either with augmented anastomosis or with dorsal onlay grafting without urethral sectioning.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The latter technique has become the most commonly used one due to its good, long-lasting results,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and it has inspired the experience we present. Most recently, Barbagli et al. have also shown their wide experience with the use of ventral onlay grafting in long strictures of the proximal urethra with a non-traumatic etiology,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> quite similar to the cases presented here where the graft was ventrally placed.</p><p id="par0260" class="elsevierStylePara elsevierViewall">In short, dorsal urethroplasty with free buccal mucosa graft is a technique which achieves satisfactory results in the repair of long complex strictures of the bulbar urethra with involvement of the membranous urethra. It is a substitute alternative to transperineal bulboprostatic anastomotic repair, traditionally recommended in those cases secondary to urethral trauma which show extensive fibrosis. The aim of the non-anastomotic technique we describe is to enlarge the urethral lumen without causing any shortening. Its results are satisfactory, particularly in patients with limited fibrosis, but with urethral lumen retraction due to thermal injuries, which are possibly secondary to a pervious transurethral resection with poor isolation quality. The probability of success is very high and the number of complications is limited. Patients also benefit from early discharge from hospital.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres372194" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec351314" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres372193" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec351315" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0050" "titulo" => "Materials and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Surgical technique" ] ] ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack94285" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-03-25" "fechaAceptado" => "2014-04-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec351314" "palabras" => array:6 [ 0 => "Urethroplasty" 1 => "Urethral stricture" 2 => "Bulbar urethra" 3 => "Membranous urethra" 4 => "Oral mucosa graft" 5 => "Reconstructive surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec351315" "palabras" => array:6 [ 0 => "Uretroplastia" 1 => "Estenosis uretral" 2 => "Uretra bulbar" 3 => "Uretra membranosa" 4 => "Injerto de mucosa oral" 5 => "Cirugía reconstructiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">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.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">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 [<span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">max</span>] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 14 patients (median age, 64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>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<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>26.5<span class="elsevierStyleHsp" style=""></span>mm. 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<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>76<span class="elsevierStyleHsp" style=""></span>min and 1.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1 day, respectively. The preoperative <span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">max</span> and PVRV values were 4.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.45<span class="elsevierStyleHsp" style=""></span>ml/s and 212.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>cc, respectively. The postoperative values were 15.15<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.2<span class="elsevierStyleHsp" style=""></span>ml/s and 6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>21.5<span class="elsevierStyleHsp" style=""></span>cc, respectively (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>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.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">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.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">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 (Q<span class="elsevierStyleInf">máx</span> y RPM pre y postoperatorios) y complicaciones. Se consideró fracaso la necesidad de cualquier instrumentación postoperatoria.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se intervinieron 14 pacientes, con una mediana de edad de 64<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>13 años. El antecedente principal detectado fue RTU de próstata en 9 casos (64,3%). La mediana de longitud de la estenosis fue 45<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>26,5<span class="elsevierStyleHsp" style=""></span>mm. 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<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>76<span class="elsevierStyleHsp" style=""></span>min y la estancia hospitalaria 1,5<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>d. Q<span class="elsevierStyleInf">máx</span> y RPM preoperatorios fueron 4,5<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>4,45<span class="elsevierStyleHsp" style=""></span>ml/seg y 212,5<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>cc, y postoperatorios 15,15<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>7,2<span class="elsevierStyleHsp" style=""></span>ml/seg y 6<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>21,5<span class="elsevierStyleHsp" style=""></span>cc (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>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.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gimbernat H, Arance I, Redondo C, Meilán E, Andrés G, Angulo JC. Tratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucal. Actas Urol Esp. 2014;38:544–551.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0280" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0080" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 897 "Ancho" => 1800 "Tamanyo" => 118549 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pre (A) and postoperative (B) retrograde cystourethrography in one of the patients in the series.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 890 "Ancho" => 1751 "Tamanyo" => 126421 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pre (A) and postoperative (B) voiding cystourethrography in one of the patients in the series.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 515 "Ancho" => 997 "Tamanyo" => 89327 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Obtaining of the oral mucosa graft. Hydro-dissection of the mucosa and section of the demarcated area provided by traction sutures is conducted.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 899 "Ancho" => 1750 "Tamanyo" => 306364 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Longitudinal incision over the dorsal surface of the spongiosum including the stenotic region (A). The oral mucosa graft adapts to the defect (B). Traction sutures are applied on the spongiosum at a different level to maintain 180° rotation that facilitates exposure of the dorsal aspect of the urethra.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 904 "Ancho" => 1750 "Tamanyo" => 297602 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The anastomosis between the graft and the edges of the urethral lumen is completed distally (A). Double row of parallel sutures applied on the cavernous albuginea and the graft, tied without tension on both sides, they give stability to the graft.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1609 "Ancho" => 2928 "Tamanyo" => 99959 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Changes in (A) maximum flow (<span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">max</span>; ml/s) and (B) in post-void residual (PVR; cc) according to the signed rank test with the difference between the end point and baseline (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0002; respectively).</p>" ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 67163673 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis de los factores implicados en el fracaso de la uretroplastia en el varón" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Gimbernat" 1 => "I. Arance" 2 => "C. Redondo" 3 => "E. Meilan" 4 => "F. Ramón de Fata" 5 => "J.C. Angulo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2013.07.003" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2014" "volumen" => "38" "paginaInicial" => "96" "paginaFinal" => "102" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24051326" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.E. Andrich" 1 => "C.J. Leach" 2 => "A.R. Mundy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "BJU Int" "fecha" => "2001" "volumen" => "88" "paginaInicial" => "385" "paginaFinal" => "389" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11564027" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dorsal versus ventral oral mucosal graft urethroplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Hosseini" 1 => "A. Kaviani" 2 => "M. Hosseini" 3 => "M.M. Mazloomfard" 4 => "A. Razi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Urol J" "fecha" => "2011" "volumen" => "8" "paginaInicial" => "48" "paginaFinal" => "53" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21404203" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prostomembranous urethral injuries; a review of the literature and a rational approach to their management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.D. Webster" 1 => "G.L. Mathes" 2 => "C. Selli" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "1983" "volumen" => "130" "paginaInicial" => "898" "paginaFinal" => "902" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6355512" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transperineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect and role of ancillary maneuver: a retrospective study in 172 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.K. Singh" 1 => "D.S. Pawar" 2 => "A.K. Khandelwal" 3 => "Jagmohan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0974-7796.65104" "Revista" => array:6 [ "tituloSerie" => "Urol Ann" "fecha" => "2010" "volumen" => "2" "paginaInicial" => "53" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20882154" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gapometry and anterior urethrometry in the repair of posterior urethral defects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.M. Koraitim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.juro.2008.01.041" "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "2008" "volumen" => "179" "paginaInicial" => "1879" "paginaFinal" => "1881" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18353388" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Defining the case for anastomotic or substitution urethroplasty in complex urethral stricture with membranous involvement: analysis of a personal prospective series # 846" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. González" 1 => "E. Mateo" 2 => "F. Lista" 3 => "G. Andrés" 4 => "J.C. Angulo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:3 [ "titulo" => "26th annual EAU congress" "conferencia" => "Vienna" "serieFecha" => "2011" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification of surgical complications: a new proposal in evaluation in a cohort of 6,336 patients and results of a survey" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Dindo" 1 => "N. Demartines" 2 => "P.A. Clavien" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "2004" "volumen" => "240" "paginaInicial" => "205" "paginaFinal" => "213" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15273542" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Notificación y clasificación de comlicaciones después de procedimientos quirúrgicos urológicos: una evaluación y recomendaciones del panel de guías clínicas de la EAU" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D. Mitropulos" 1 => "W. Artibani" 2 => "M. Grefen" 3 => "M. Remzi" 4 => "M. Roupret" 5 => "M. Truss" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2012.02.002" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2013" "volumen" => "37" "paginaInicial" => "1" "paginaFinal" => "11" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22824080" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Barbagli" 1 => "S. de Stefani" 2 => "M.C. Sighinolfi" 3 => "F. Annino" 4 => "S. Micali" 5 => "G. Bianchi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2006.05.018" "Revista" => array:6 [ "tituloSerie" => "Eur Urol" "fecha" => "2006" "volumen" => "50" "paginaInicial" => "467" "paginaFinal" => "474" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16806665" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Opciones de tratamiento quirúrgico en la estenosis de uretra bulbar" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.C. Regueiro" 1 => "J.C. Carrasco" 2 => "J. Álvarez" 3 => "R. Prieto" 4 => "M.E. Leva" 5 => "M.J. Requena" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2012.03.006" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2013" "volumen" => "37" "paginaInicial" => "167" "paginaFinal" => "173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22710090" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Male urethral stricture disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.A. Santucci" 1 => "J.F. Joyce" 2 => "M. Wise" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.juro.2007.01.041" "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "2007" "volumen" => "177" "paginaInicial" => "1667" "paginaFinal" => "1674" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17437780" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manejo racional y selectivo de los pacientes con estenosis de uretra anterior" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Gómez" 1 => "P. Marchetti" 2 => "O.A. Castillo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2010.09.008" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2011" "volumen" => "35" "paginaInicial" => "159" "paginaFinal" => "166" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21339014" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dorsal onlay skin graft bulbar urethroplasty: long term follow up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Barbagli" 1 => "G. Morgia" 2 => "M. Lazzeri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2007.08.019" "Revista" => array:6 [ "tituloSerie" => "Eur Urol" "fecha" => "2008" "volumen" => "53" "paginaInicial" => "628" "paginaFinal" => "634" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17728049" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long term follow up of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.P. Elliot" 1 => "M.J. Metro" 2 => "J.W. McAninch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.ju.0000057800.61876.9b" "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "2003" "volumen" => "169" "paginaInicial" => "1754" "paginaFinal" => "1757" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12686826" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventral onlay buccal mucosal grafts for anterior urethral strictures: long-term follow up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.S. Kellner" 1 => "J.A. Fracchia" 2 => "N.A. Armenakas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.ju.0000103500.21743.89" "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "2004" "volumen" => "171" "paginaInicial" => "726" "paginaFinal" => "729" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14713797" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current controversies in anterior urethral stricture repair: free-graft versus pedicle skin-flap reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H. Wessells" 1 => "J.W. McAninch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "World J Urol" "fecha" => "1998" "volumen" => "16" "paginaInicial" => "175" "paginaFinal" => "180" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9666540" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SIU/ICUD consultation on urethral strictures: the management of anterior urethral stricture disease using substitution urethroplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Chapple" 1 => "D. Andrich" 2 => "A. Atala" 3 => "G. Barbagli" 4 => "A. Calvalcanti" 5 => "S. Kulkami" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urology.2013.09.012" "Revista" => array:7 [ "tituloSerie" => "Urology" "fecha" => "2014" "volumen" => "83" "paginaInicial" => "S31" "paginaFinal" => "S47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24411214" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0210569108709446" "estado" => "S300" "issn" => "02105691" ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long term outcomes of penile skin grafts versus buccal mucosal graft for substitution urethroplasty of the anterior urethra" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N.F. Alsikafi" 1 => "M. Eisenberg" 2 => "J.W. McAninch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Urol" "fecha" => "2005" "volumen" => "174" "paginaInicial" => "173" "paginaFinal" => "187" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Free full thickness skin graft urethroplsaty: current technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.C. Devine" 1 => "J.R. Wendelken" 2 => "C.J. Devine" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "1979" "volumen" => "121" "paginaInicial" => "282" "paginaFinal" => "285" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/372564" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "L’élargissement de l’urètre au moyen du plan sus uretral" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Monseur" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Urol (Paris)" "fecha" => "1980" "volumen" => "86" "paginaInicial" => "439" "paginaFinal" => "449" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dorsal free graft urethroplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Barbagli" 1 => "C. Selli" 2 => "A. Tosto" 3 => "E. Palminteri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "1996" "volumen" => "155" "paginaInicial" => "123" "paginaFinal" => "126" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7490808" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventral oral mucosal onlay graft urethroplasty in nontraumatic bulbar urethral strictures: surgical technique and multivariable analysis of results in 214 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Barbagli" 1 => "F. Montorsi" 2 => "G. Guazzoni" 3 => "A. Larcher" 4 => "N. Fossti" 5 => "S. Sansalone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2013.05.046" "Revista" => array:6 [ "tituloSerie" => "Eur Urol" "fecha" => "2013" "volumen" => "64" "paginaInicial" => "440" "paginaFinal" => "447" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23759258" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack94285" "titulo" => "Acknowledgements" "texto" => "<p id="par0270" class="elsevierStylePara elsevierViewall">To Juan Dorado (Pértica) for his help in the statistical analysis. To José Domínguez (medical records) for his work in iconography obtaining.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000003800000008/v1_201409260028/S2173578614001310/v1_201409260028/en/main.assets" "Apartado" => array:4 [ "identificador" => "6292" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Surgical technique" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000003800000008/v1_201409260028/S2173578614001310/v1_201409260028/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578614001310?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
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| 2017 September | 27 | 6 | 33 |
| 2017 August | 30 | 3 | 33 |
| 2017 July | 21 | 10 | 31 |
| 2017 June | 36 | 21 | 57 |
| 2017 May | 56 | 12 | 68 |
| 2017 April | 48 | 2 | 50 |
| 2017 March | 35 | 19 | 54 |
| 2017 February | 19 | 6 | 25 |
| 2017 January | 11 | 10 | 21 |
| 2016 December | 31 | 10 | 41 |
| 2016 November | 26 | 6 | 32 |
| 2016 October | 33 | 10 | 43 |
| 2016 September | 0 | 5 | 5 |
| 2016 August | 0 | 2 | 2 |
| 2016 July | 0 | 1 | 1 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 0 | 11 | 11 |
| 2016 April | 0 | 12 | 12 |
| 2016 March | 0 | 9 | 9 |
| 2016 February | 0 | 6 | 6 |
| 2016 January | 0 | 2 | 2 |
| 2015 December | 0 | 3 | 3 |
| 2015 September | 0 | 1 | 1 |
| 2015 July | 0 | 1 | 1 |
| 2015 June | 0 | 1 | 1 |
| 2014 November | 0 | 2 | 2 |
| 2014 October | 1 | 0 | 1 |
Show all
