Urethroplasty is used to define a class of surgery for the repair of an injury or defect within the walls of the urethra. The bulbar urethra is the most common location for urethral strictures. This portion of the urethra is under the scrotum, an area called the perineum. As the bulbar urethra is not well protected, it is particularly susceptible to straddle trauma during physical exertions. Upon impact, the bulbar urethra is crushed against bone. It is followed up by immediate swelling and blood at the urethral opening at the tip of the penis. Subsequently, the stricture develops slowly over time as the injury heals with a scar that slowly contracts.
End to end urethroplasty for mature bulbar urethral stricture has greater than 95% durable cure rate and low complication rate. The scarred areas are cut out and the remaining urethra is connected. Flaps and grafts are mandatory in patients with longer and complex strictures. Skin graft may be split or full and may be taken from scrotum, bladder mucosa or from other genital sites. Buccal mucosa grafts (BMG) or oral mucosa are reliable and popular substitute for use in urethroplasty as it obviates most of the problems associated with other graft harvesting. Buccal mucosa is resistant to infection, compatible with wet environment and is easy to harvest as well.
Buccal mucosal graft urethroplasty
Buccal mucosa is mucous membrane of the inside of the cheeks. It is continuous with the mucosa of the soft palate, such as the one under surface of tongue and the floor of the mouth and does not contain keratin a kind of protein that makes up outer skin layer and bones etc. Buccal mucosa grafts are usually harvested from the inner cheeks or lower lip portion. The place is prepared by iodine solution and the shape of the graft is marked down using a skin marker. The edges of the graft are incised with a scalpel blade after infiltrating the surgical area suitably. Using scissors the graft is then elevated. Care is taken to prevent any damage to the oral musculature. The graft harvest site is then sutured.
During the urethroplasty, a circumcoronal or circular ringed incision is made through the foreskin and the penis is completely degloved or removed from the underlying tissues. The penile urethra is completely exposed and the stirctured tract is fully opened by a ventral or midline incision near the belly. The urethral mucosal plate is longitudinally incised on the midline. The wings of the urethral mucosal plate are mobilized to create bed for the graft. The buccal mucosa graft is sutured and quilted on to the bed by using interrupted special polyglactin sutures and the urethral plate is augmented. The urethra is closed and is tabularized up to the top by a catheter taking advantages of the mobilized wings of the urethral plate. The glands and penile skin are closed and the catheter is left in place for 2 weeks. Regeneration of the urethral mucosa is facilitated by the graft which works as a roof strip and reduces the time for regeneration.
Ice bags are applied immediately to the mouth and genital region to reduce pain. The patient initially consumes a liquid diet before starting a normal diet. The hospital stay is short for about 3 days only and the catheter is removed 3 weeks after the surgery. In case of infection, the catheter has to be removed immediately. The patient has to void through the new urethra at least twice daily to wash away the pus from it.