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From January 2010 to May 2012 a sum of 47 patients with long anterior urethral stenosiss were randomized into two groups. The first group included 25 patients who managed by dorsal onlay BMG urethroplasty. The 2nd group included 22 patients who managed by dorsal inlay BMG urethroplasty. Different clinical parametric quantities, postoperative complications and success rate were compared between both groups.

Consequences:

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The overall success rate in dorsal onlay group was 88 % while in dorsal inlay group success rate was 86.4 % during the follow-up period. The average operative clip was significantly longer in the dorsal onlay urethroplasty group ( 205 ± 19.63 proceedingss ) than in the dorsal inlay urethroplasty group ( 128 ± 4.9 proceedingss, p value & A ; lt ; 0.0001 ) . The mean blood loss was significantly higher in the first group ( 228 ± 5.32 milliliters. ) than in the 2nd group ( 105 ± 12.05 milliliter, p value & A ; lt ; 0.0001 ) .

Decisions:

Dorsal onlay technique of Barbagli and dorsal inlay technique of Asopa BMG urethroplasty provide similar success rate. Compared to Barbagli ‘s technique, Asopa ‘ technique is easy to execute and has a shorter operative clip and less blood loss and associated with fewer complications for anterior urethral stenosis fix.

Cardinal words: Dorsal Onlay Urethroplasty, Dorsal Inlay Urethroplasty, Buccal Mucosal Graft, Anterior Urethral Stricture.

Introduction

There are many surgical processs for urethral stenosis fix, such as internal urethrotomy, stent, stenosis deletion and primary re-anastomosis, graft- augmented anastomotic process and spot urethroplasty. Another option is the two staged urethroplasty is indicated in patients with local inauspicious conditions. The pick based on the stenosis length, location, deepness, and denseness of the spongiofibrosis. Substitution urethroplasty is the pillar of intervention for long urethral stenosiss, anterior stenosiss, and multiple urethral stenosiss.

In the past decennary buccal mucosal transplant ( BMG ) has become the favoured tissue for direction of anterior urethral stenosis. Though the first BMG urethroplasty was accomplished in 1941 by Humby, there has been a revival of it after 1990 ( 1 ) . Since so, it has been considered as an ideal transplant stuff for permutation urethroplasty. Buccal transplants have several advantages: it is hair less, rich in blood supply and easy to reap. Furthermore, BMG have a thin lamina propria easing early anastomosis, thick epithelial tissue minimising the opportunity of transplant contracture ( 2 ) , and natural opposition to infection and development of cutaneal diseases such as lichen induration. The unwritten giver site heals rapidly ; unwritten complications of this process are minor and subsided bit by bit within the first twelvemonth ( 3 ) .

A controversial issue has been the location of the transplant on the urethral surface, the ventral onlay transplant technique was described by Morey and McAninch in 1996 ( 4 ) . Although it is a straightforward and easy to execute technique ( 5 ) , ventrally placed transplants are likely to be associated with ballooning and pseudo-diverticulum formation of the ventrally positioned unsupported transplant ( 6 ) . Since Barbagli and associates ( 1996 ) ( 6 ) renewed the construct of the dorsal attack for executing urethroplasty which developed by Monseur, the dorsal onlay transplant technique became the preferable attack for urethroplasty. Dorsal onlay grafting of the urethra let better return of free transplant, as the underlying principals give better mechanical support for the transplant.

Asopa et Al ( 7 ) popularized dorsal inlay technique through a ventral sagittal urethrotomy attack in 2001, and postulated that the process is easier to execute as it does non necessitate urethral mobilisation.

The purpose of our prospective survey is to compare both dorsal onlay technique of Barbagli and dorsal inlay technique of Asopa for direction of long anterior urethral stenosis. To our cognition there is no old comparative survey between the two techniques.

Patients and Methods

Between January 2010 and May 2012 a sum of 47 male patients with long anterior urethral stenosiss necessitating permutation urethroplasty were randomized to two groups. Both groups were managed by either dorsal onlay ( 25 patients ) or dorsal inlay ( 22 patients ) buccal mucosal transplant urethroplasty. The method of randomisation was every surrogate patient with penile, bulbar or panurethral stenosis being assigned to the dorsal onlay ( DO ) and dorsal inlay ( DI ) groups.

Preoperative rating included: clinical history, physical scrutiny, urine civilization, residuary urine measuring, uroflowmetry, retrograde and invalidating cystourethrography.

In our survey, the urethroplasty was performed by two squad ; one reaping the BMG, and the other squad exposing the stenosis. A contraceptive broad-spectrum antibiotic ( Rocephin ) was administered before surgery and continued 5 yearss postoperatively. The urethroplasty was performed under general endotracheal anaesthesia with transnasal cannulation. In instance of bulbar stenosiss, a midplane perineal scratch was made. In the instance of penile stenosiss, a subcoronal circumferential scratch was made, and the phallus was degloved.

Buccal mucous membrane transplants were harvested from the interior cheeks ( Fig.1 ) with attention to avoid hurt the Stensen ‘s canal, opposite the upper 2nd grinder. The defect of the transplant crop site is closed with chromic goat’s rue suturas. The harvested transplant fat and submucosal beds were removed utilizing scissors for thinning before it is applied as a spot. It is tailored to the form of the scratch. Mouth washes with povidone-iodine unwritten solution were started 2 yearss prior to graft harvest home and continued postoperatively for 3 yearss.

In dorsal onlay, we used the surgical technique which described by Barbagli ( 8 ) . The principal spongiosum was carefully dissected off from the principal cavernosa and rotated. A dorsal urethrostomy was performed with extension of the scratch beyond the strictured section proximally and distally into the normal urethral lms. The transplant was dispersed fixed to the principal cavernosa. After repairing the transplant, several quilting suturas were added to it, and little scratchs along the transplant were made to forestall haematoma or hydrops formation. The purpose of the arrested development and quilting suturas is to make good contact between the transplant and the corporeal bed for procuring the transplant pickings. After debut of a 16 F silicone catheter, the borders of the stricturotomy were so sutured to the transplant every bit good as to the principal cavernosa ( Fig.2 ) .

In dorsal inlay, we used the surgical technique which described by Asopa ( 7 ) . Urethral dissection and rotary motion is non required so blood supply was non affected. A ventral urethrostomy was performed with extension of the scratch beyond the strictured section proximally and distally into the normal urethral lms. The dorsal surface of urethra was incised in the midplane. Using crisp dissection, the borders of the incised dorsal urethra were dissected from the adventitia albuginea, without raising the two borders of the bisected urethra. This dissection consequences in an egg-shaped natural country every bit broad as 1.5-2 centimeter between the bisected borders of the urethra over the tunica albuginea. The harvested BMGs were dispersed fixed over the natural country to cover the defect. After repairing the transplant, several quilting suturas were added to it to forestall dead infinite. The borders of the transplant were attached to the borders of the incised urethra. The ventral urethrostomy was closed by uninterrupted suturas over a 16 F silicone catheter and reinforced with interrupted suturas ( Fig. 3 ) .

Three hebdomads after surgery, a retrograde pericatheter urethrography was performed, and if no extravasation the urethral catheter is removed. Patients were followed up with uroflowmetry and urine civilization every three months. Urethrography and urethroscopy were considered in presence of clogging symptoms the uroflowmetry was less than 15 ml per second. The urothroplasty was considered a failure when postoperative intercession was needed.

Consequences

A sum of 47 patients ( average age 36.6 old ages, range 16 to 59 old ages ) with anterior urethral stenosis underwent BMG urethroplasty by dorsal onlay BMG urethroplasty in 25 patients ( group 1 ) and dorsal inlay BMG urethroplasty in 22 patients ( group2 ) . The etiology of stenosiss was redness in 61.7 % , iatrogenic in 19.1 % , injury in 12.8 % , and idiopathic in 6.4 % . Of the 47 patients, 34 ( 72.3 % ) had a sum of 78 internal urethrotomy processs ( mean 1.7 per patient ) . The stenosis site in both groups is demonstrated in ( Table 1 ) .

The mean stenosis length, harmonizing to retrograde and invalidating cystourethrography, in the dorsal onlay urethroplasty group was 4.9 centimeter ( run 4 to 15 ) and in the dorsal inlay urethroplasty group 4.4 centimeter ( run 4 to 12 ) . The average operative clip was significantly longer in the dorsal onlay urethroplasty group ( 205 ± 19.63 proceedingss ) than in the dorsal inlay urethroplasty group ( 128 ± 4.9 proceedingss, p value & A ; lt ; 0.0001 ) . The mean follow up in both groups was 22.6 and 24.2 months, severally. The mean blood loss was significantly higher in the first group ( 228 ± 5.32 milliliters. ) than in the 2nd group ( 105 ± 12.05 milliliter, p value & A ; lt ; 0.0001 ) . Merely one patient in the dorsal onlay urethroplasty group required postoperative blood transfusion. Hospitalization in the first and 2nd groups averaged 4.3 yearss ( run 4 to 6 yearss ) and 3.2 yearss ( run 2 to 6 ) , severally. Three patients in first group and four patients in 2nd group had postoperative lesion infection, all are managed successfully with alteration in antibiotics harmonizing to civilization sensitiveness trial utilizing lesion swab. One patient in the dorsal inlay urethroplasty group showed extravasation of contrast medium on pericatheter urethrogram after 3 hebdomads of operation, he was managed successfully by two hebdomads of extra catheterisation. In the dorsal onlay group, 2 patients developed important chordee after surgery, which was managed by dorsal fold. Four patients in first group suffered from annoying post-void dribble, while merely one patient in 2nd group developed annoying post-void dribble.

Three patients ( 12.8 % ) in each group developed stenosis at 3, 6, 12, and 18 month followup. Patients with perennial stenosis presented with weak urinary watercourse, diminished urinary flow ( peak urinary flow & A ; lt ; 15 ml/s ) , dysuria, and perennial UTI. Four of the failure instances who developed a distal anastomotic stenosis, and one who had two stenosed rings at the distal and proximal site of anastmosis, all of them respond good to internal urethrotomy. Another patient ( group2 ) developed long section stenosis and required unfastened surgery. Five of the patients with perennial stenosis had undergone multiple endoscopic processs with attendant periurethral fibrosis and pronounced spongiofibrosis. The six stenosiss, which recurred in our survey harmonizing to the preoperative site of the stenosis, were one penile, two bulbar, and three panurethral. It is good cognize that panurethral stenosis fix is hard job to work out and the success rate is lower when compared to simple penile or bulbar stenosis fix.

Peak urinary flow rates improved in the first group from an norm of 8.2 ml/sec preoperatively to 23.4 ml/sec postoperatively. In the 2nd group the maximal urinary flow increased from an norm of 9.1 ml/sec preoperatively to 24.5 ml/sec postoperatively. AUA symptom score decreased from a mean of 22.4 preoperatively to 4.8 postoperatively in the first group. Besides AUA symptom score decreased from a mean of 23.5 preoperatively to 5.1 postoperatively in the 2nd group.

The giver sites were all to the full epithelialised by 6 hebdomads No long-run complications as respect the giver site. Four patients suffered from trouble opening the oral cavity, and a salivary flow job up to 3 months after surgery but subsequently they overcame the disablement.

BMG urethroplasty was considered successful if no intercession in the signifier of distension or OU was needed, and the maximal flow rate was & A ; gt ; 15 ml/s during the follow-up period. The overall success rate in dorsal onlay group was 88 % while in dorsal inlay group success rate was 86.4 % during the follow-up period.

Discussion

Urethral Reconstruction with stenosis deletion and end-to-end inosculation remains the gilded criterion technique for covering with short urethral stenosiss of ? 2 centimeter, with good long term results. Patients with longer or complex stenosiss, require permutation urethroplasty ( 9 ) . The ideal tissue for permutation urethroplasty remains controversial. Candidate tissues that have been used for urethral Reconstruction are split and full-thickness tegument transplants, vesica mucous membrane, and unwritten mucosal ( 2 ) .

Several surveies reported that permutation urethroplasty utilizing Full-thickness skin transplants or vesica mucous membrane, are associated with high complication rate, particularly during long-run follow-up. These informations have led to the current enthusiasm for buccal mucous membrane grafting in rehabilitative surgery of both hypospadias and stenosis fix ( 10 ) .

Buccal mucosal transplants ( BMGs ) are considered as the best stuff for urethroplasty due to different factors including: rich in blood supply, easy handiness, opposition to infection, in add-on to a thick epithelial tissue and a thin lamina propria easing early anastomosis ( 1, 3 ) .

Not merely the type of transplant tissue but besides the site for transplant placing is important, as the blood supply of the recipient country and the transplant support are both indispensable in transplant consumption ( 7,11,12,13 ) . The tendency of dorsal onlay over ventral transplant spot arrangement was popularized by Barbagli et Al in 1998 ( 14 ) . It was established that dorsally placed BMG transplant technique has better mechanical support and an abundant blood supply. Furthermore, dorsally placed BMG transplant avoids pseudodiverticulum formation and sacculation of the transplant sometimes observed undermentioned ventral onlay, because it is supported by bodily organic structures ( 6 ) . The Barbagli dorsal onlay technique involves dissection of the urethra from the principal cavernosa and its rotary motion of 180 grade. In instance of old repeated dilations or internal urethrotomies, the urethral withdrawal from the principal is trouble due to the fibrotic adhesions ; moreover, this attack may damage erectile map and the bulbar arterias when really proximal dissection from the principal is required ( 15, 16 ) .

Asopa popularized ( 2001 ) the dorsal inlay technique ( 7 ) by ventral sagittal urethrotomy attack. In the Asopa process the urethra is non mobilized or dissected, which non merely preserves the urethral blood supply coming through circumflex and perforating vass but besides simplifies the process.

The purpose of this prospective survey is to compare the consequences of dorsal onlay ( Barbagli ) technique and dorsal inlay ( Asopa ) technique in direction of long anterior urethral stenosis. To our cognition before our work there were no old surveies comparing the two techniques. A randomised survey on urethroplasty techniques is hard as different factors like stenosis length, site, old intercession and grade of spongiofibrosis affect process consequences. The patients with different variables were good balanced in both groups. The merely uncontrolled variable was the grade of spongiofibrosis. Urethral echography is undependable in foretelling the deepness of spongiofibrosis when compared with histopathological correlativity ( 17 ) .

In this survey BMG dorsal onlay urethroplasty and BMG dorsal Inlay urethroplasty provided comparable results for anterior urethral stenosiss fix. We reported success rate in dorsal onlay group 88 % while in dorsal inlay group success rate was 86.4 % . The overall success rate of both groups is comparable with those in other series of BMG urethroplasty ( Table 2 ) utilizing Barbagli technique or Asopa technique for anterior urethral stenosis fix

Using Asopa ‘ technique no mobilisation of the urethra is required, which non merely preserves the urethral blood supply coming through circumflex and perforating vass but besides simplifies the process, as no urethral dissection is required to put the transplant dorsally. In our survey the average operative clip with Asopa ‘ technique was significantly shorter ( 128 ± 4.89 proceedingss ) than the average operative clip in Barbagli ‘s technique ( 205 ± 19.63 proceedingss, p value & A ; lt ; 0.0001 ) . The other distinguishable advantage of Asopa ‘ technique is that the stenosis site is straight seen, and the BMG can be tailored to the dorsal urethrotomy defect ; in Barbagli ‘s technique, visual image is rendered hard by the rotary motion necessary for urethral scratch dorsally. Asopa ‘ technique may besides be more suited when the urethra is adherent to underlying corpora cavernosa as a effect of repeated OUs and in corpulent patients where a dorsal attack may be peculiarly hard ( 18 ) . In this survey, the mean blood loss in the first group was significantly more than in the 2nd group ( 228 ± 5.32 Vs. 105 ± 12.05, p value & A ; lt ; 0.0001 ) which could be attributed to urethral dissection and rotary motion in Barbagli ‘s technique. However in Asopa ‘ technique, The hemorrhage from the borders of the spongious urethra at the ventral urethrotomy site is more than in the dorsal onlay technique but can normally be controlled efficaciously with diathermy or suturas.

In this survey, there are minor complications. There was no postoperative diverticulum formation, urinary incontinency or de novo erectile disfunction, but wound infection was present in three patients in first group and four patients in 2nd group, and could be managed cautiously by antibiotics. Four patients in first group and merely one patient in 2nd group suffered from annoying post-voiding dribble, while merely one patient in 2nd group developed annoying post-voiding dribble, and could be managed cautiously by manual urethral compaction. . In the dorsal onlay group, two patients developed important chordee after surgery, which was managed by dorsal fold. The re-stricture rate was low three patients in each group ; all of them were managed by internal urethrotomy. Merely one patient required unfastened surgery. No long-run morbidity was observed as respect the giver site.

Decisions:

Dorsal onlay technique of Barbagli and dorsal inlay technique of Asopa BMG urethroplasty provide similar success rate. Compared to Barbagli ‘s technique, Asopa ‘ technique is easy to execute and has a shorter operative clip and less blood loss and associated with fewer complications for anterior urethral stenosis fix.

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