Combined Dorsal and Ventral Onlay Buccal Graft Technique for Large and Complex Penile Strictures

Purpose To present a modified technique of managing extensive penile urethral strictures with dorsal and ventral onlay buccal mucosa grafts. Patients and Methods From October 2014 to January 2016, a total of 12 patients underwent urethroplasty for penile urethral strictures, using dorsal and ventral onlay grafts from buccal mucosa. The mean age was 42.75 (17–71). All patients completed the IPSS and QoL questionnaire, and uroflowmetry was done preoperatively. After surgery, the follow-up included completion of IPSS and QoL questionnaire and measuring of uroflow at 1, 3, 6, and 12 months. Postoperative urethrography was performed in complex cases or in the event of deterioration of voiding symptoms. Results The mean length of the strictures was 5.45 (2, 2–16) cm. Mean Qmax changed from 3.45 ml/sec preoperatively to 18.33 postoperatively, and mean IPS score significantly decreased from 20.1 preoperatively to 8.98 postoperatively. All values were statistically significant (p < 0.001). No intraoperative or immediate postoperative complications were recorded. Overall, at 12 months, 11 out of 12 patients (91.6%) had a marked improvement in quality of life and uroflowmetry parameters. Conclusions In the properly selected patient, the combined use of double graft for penile urethral strictures can be successful with minimal morbidity, at short-term follow-up.


Introduction
Urethroplasty is the treatment of choice for penile and bulbar urethral strictures, o ering the best long-term results [1]. Although anastomotic urethroplasty is widely used for strictures up to 2 cm in length, more extensive strictures usually require some kind of graft augmentation, usually from buccal mucosa [2,3]. Very often, the placement of a single graft, either ventrally or dorsally, is not su cient to achieve adequate urethral caliber. e concurrent use of two grafts, on both the dorsal and ventral urethra (the "Palminteri" technique) has been proposed for extensive bulbar urethral strictures, with very satisfactory results [4]. Up to now, this technique has not been extensively studied for penile urethral strictures. Such strictures usually develop in men as a result of iatrogenic trauma [5]. Before the double graft, guidelines recommended a two-stage urethroplasty to achieve better results and reduce the possibility of graft rejection [6,7]. e use of double graft could be a good alternative, as it could reduce the time to recovery of such patients. e aim of this study is to present the use of a modi ed Palminteri technique for patients with complex and/or extensive penile urethral strictures in a single procedure.

Materials and Methods
From October 2014 until January 2016, 12 patients aged 17-71 years (mean age 42.75 years) underwent urethroplasty with the use and application of free autologous graft on the dorsal and ventral surface of the urethra in one step by the same surgeon.
Preoperatively, all patients, besides the detailed history and physical examination, completed the IPSS questionnaire including the quality of life (QoL) domain and were evaluated with urine ow measurement, urethrogram (retrograde and during urination), and in some cases endoscopy and transabdominal ultrasound, in order to determine the nature and length of the stricture. 4 patients had a suprapubic catheter, while 6 of them had already been treated unsuccessfully for strictures caused by tra c accidents or correction of congenital hypospadias. 4 strictures were posttraumatic, 3 were iatrogenic, 2 were caused by lichen sclerosus (former balanitis xerotica obliterans), 2 were related to congenital hypospadias while 1 case was considered idiopathic. 2 patients had concurrent penile and bulbar urethral strictures.

Surgical Technique.
Patients were advised to start mouth washouts with hexetidine solution 5 days before the operation. Preoperative antibiotics were usually used in the form of a uoroquinolone 1 hour before the operation. Skin shaving of the scrotum and perineum was performed in the operating theater to reduce infection risk. General anesthesia was administered. Mouth exposure was achieved with the use of the Kilner-Doughty retractor, and the harvesting of the graft was always performed rst. We prefer to use a single wide graft (from 6 to 10 centimeters long and 1.5 centimeters wide) which we then divide in two longitudinal halves, instead of harvesting from both cheeks. Oral mucosa was closed with a running 3-0 monocryl suture. e rest of the procedure was usually performed with the patient in the supine position. A longitudinal penile skin incision was used to access the urethra, which was then mobilized with careful dissection through the dartos and Buck's fascia. A 16 or 18 Fr Nelaton catheter helped to identify the distal margin of the stricture. A longitudinal incision was then performed over the stenotic part of the ventral penile urethra and was extended up to the proximal margin of the stricture. A second incision was also performed on the dorsal surface of the urethral plate, involving the strictured area at its full length. Half strip of buccal graft was then sutured in dorsal inlay according to Asopa technique while the other half strip of the graft was placed as a ventral onlay (Figure 1). e corpus spongiosum, subcutaneous tissue, and skin were then closed with interrupted sutures. Care was taken to develop at least three subcutaneous layers without suture lines overlapping in order to minimize the risk of stula formation. e use of antibiotics was resumed immediately following the operation; patients were advised to have cold drinks and/or ice cream, as well as to follow a soft diet. Patients usually stayed in hospital for 48-72 hours. ey completed a 10-day antibiotics course or continued taking antibiotics until the removal of the catheter, which was planned in 3 weeks postoperatively.
Follow-up included uro owmetry at 1, 3, 6, and 12 months and urethrogram (when recurrence was suspected) and completion of the IPSS questionnaire. Surgical correction was considered successful when there was statistically signi cant improvement in Qmax, IPSS, and QoL score. e study also recorded operative time, catheterization period, and duration of hospitalization.
Statistical analysis was performed with the Stata MP

Discussion
e use of double buccal mucosa grafts on the ventral and dorsal bulbar urethra, rst described by Palminteri in 2008, since then had been applied only in small series to penile urethral strictures [4]. Our department has used the Palminteri technique with slight modi cations (mainly as regarding the graft thickness) for penile urethral strictures. EAU Guidelines recommend a two-stage urethroplasty for better long-term results [6,7]. We used not only buccal mucosa grafts but preputial grafts as well, in a single procedure. Although this is a retrospective study with few patients and a short follow-up, the technique looks very promising as it can provide adequate width of the urethra, and it can reduce the recurrence rate to minimum, even in complicated cases. e single patient who developed a recurrence had the longest stricture length, involving the largest part of the urethra, which was the result of a previous transurethral prostatectomy. e recurrence occurred in the area of the anastomosis of the graft with the membranous but not with the penile urethra.
One of our major concerns was the meticulous dissection through the scrotal layers of dartos and Buck's fascia so as to prevent the formation of urethrocutaneous stula [9]. As a result, we did not experience any stulae in our patients.
We regard the urinary tract infections that two patients developed as a result of the previously indwelling suprapubic catheters and the many courses of antibiotics that they had taken.
e high success rate of our series and the statistically signi cant improvement of uro owmetry and IPS score are in concordance with the improvement in their quality of life scores, even in the patient who developed the restricture and eventually had to self-dilate every second week. is was not unexpected, given that this patient (who was the eldest in our series) had a long-term suprapubic catheter before the operation.
In conclusion, the concurrent use of double buccal mucosa from a single graft or preputial grafts in complex penile urethral strictures is a new technique, with excellent results as regards voiding parameters and quality of life. It can also reduce the recurrence and stula formation rates common to older techniques. e outcome from its use in penile urethral strictures is encouraging but more extensive, prospective studies with larger series of patients and longer follow-up are needed. Disclosure e present study was awarded with second video prize at the 23rd Panhellenic Congress held in Rhodes, 2016.

Conflicts of Interest
None of the authors declare con icts of interest.

Authors' Contributions
Nikolaos Mertziotis was responsible for the concept, the design, and the data analysis of the study. He was the supervisor and gave the approval of the nal version of the manuscript. Andreas Konandreas was involved in the retrieval of the data and writing of the manuscript. Christos Kyratsas was involved in the writing of the manuscript, analysis of the data, and performed grammar and spelling modi cations of the manuscript. All authors have read and approved the nal version of the manuscript and agree with the order of presentation of the authors.