Barbagli_EU_Genito.qxp 25/2/08 12:53 pm Page 30
Urological Surgery
Current Status of Techniques Using Oral Mucosa in Urethroplasty
a report by
Guido Barbagli
1
and Massimo Lazzeri
2
1. Director, Centre for Reconstructive Urethral Surgery, Arezzo; 2. Urologist, Department of Urology, Santa Chiara-Firenze Hospital, Florence
Currently, oral mucosa is unsurpassed as donor substitute material in The patient is intubated through the nose, leaving the mouth completely
adult anterior urethroplasty.
1
The most common harvest sites of oral free. The patient is draped in two separate parts so that two surgical teams
mucosa are the lower lip and the cheeks.
1
Urological literature uses the can work simultaneously. Each team has its own set of surgical instruments.
term buccal mucosa to include both cheek and lip mucosa. However, One team (usually led by a trainee urologist) harvests and prepares the oral
the term buccal mucosa should be used only to refer to the oral mucosa mucosal graft, while the second team (comprising two urologists) exposes
of the inner cheeks. The term mandibular (lower jaw) alveolar the penile or bulbar urethra. This method saves time and prevents cross-
mucosa should refer to the mucosa of the inner lower lip.
1
Both sites are contamination.
3,4
The patient is placed in a standard supine position for the
collectively known as oral mucosa.
1
Simonato et al. recently described, for penile urethroplasty and in a normal lithotomy position for the bulbar
the first time, using the tongue as an alternative donor site in graft urethroplasty. The patient’s calves are placed in Allen stirrups with sequential
urethroplasty.
2
The aim of this article is to present the current status of inflatable compression sleeves and the lower extremities are then suspended
both one- and two-stage surgical techniques using oral mucosal graft
harvested from the cheek, lip and tongue for application in adult penile
or bulbar urethroplasty.
After careful deflation with
Harvesting Techniques microsurgical instruments, the graft
is tailored according to site, length
Preparation of the Patient
Pre-operative evaluation includes clinical history, physical examination,
and stricture characteristics.
urine culture, residual urine measurement, uroflowmetry, urethral
ultrasound and urethrography. The patient’s clinical history, as well as
stricture aetiology, location and length, are carefully examined to define by placement of the feet within the stirrup boots. Methylene blue is injected
the characteristics required of the oral mucosal graft. The patient and into the urethra to define the diseased urethral mucosa.
anesthesiologist are notified prior to surgery if bilateral graft harvesting
is necessary. Patients who have an ongoing infectious disease affecting Harvesting the Graft from the Cheek
the mouth (such as candida, the varicella virus or the herpes virus) or As stated above, the patient is intubated through the nose, leaving the
who have had previous surgery on the mouth or tongue are informed mouth completely free. By using a mouth retractor, only one assistant is
that genital or extragenital skin will be used for the urethroplasty. A needed to harvest buccal mucosa. The inner mucosal surface of the right
broad-spectrum antibiotic is administered intravenously during the cheek is prepared and disinfected. Stay sutures are placed along the
procedure and for three days after it. For three days before and after external edge of the cheek to keep the buccal mucosa stretched.
surgery the patient uses clorhexidine mouthwash for oral cleansing. The Stensen’s duct (located at the level of the second molar) is identified
and the desired graft measured and marked in an ovoid shape. Lidocaine
hydrochloride (HCL) 1% with epinephrine (1:100,000) is injected along
Guido Barbagli is Director of the Centre for Reconstructive Urethral Surgery in Arezzo, Italy.
He is President of the Society of Genitourinary Reconstructive Surgeons (GURS),
the edges of the graft to enhance haemostasis. The outlined graft is
2008–2010. He has published four books, three book chapters and over 60 journal articles
dissected and removed. The donor site is carefully examined for bleeding
on reconstructive urethral surgery. Dr Barbagli has written articles in peer-reviewed
and then closed with 4-zero polyglactin sutures. If necessary, using the
international journals concerning dorsal onlay graft urethroplasty.
same technique another graft can be harvested from the left cheek. The
graft is stabilised on a silicone board using insulin needles. After careful
Massimo Lazzeri is a Urologist at Santa Chiara-Firenze
Hospital, Florence. Scientific research and clinical
deflation with microsurgical instruments, the graft is tailored according to
investigations have been the prevailing feature of his site, length and stricture characteristics. An ice bag is applied to the cheek
scientific activity since 1992. He has written more than 100
to avoid pain and haematoma formation. The standard graft harvested
articles, 74 of them in international journals. He is a member
of the Editorial Board of European Urology, International
from the cheek is 4cm in length and 2.5cm in width.
Brazil Journal of Urology and Urologia Internationalis and is a
consultant to the Journal of Urology, Urology and the
International Urogynecological Journal. Dr Lazzeri received his
The advantages of taking the graft from the cheek are:
MD from the University of Siena and specialised in urology
at the University of Florence.
• it is readily available from all patients;
E:
lazzeri.m@tiscali.it
• it is possible to harvest two grafts;
30 © TOUCH BRIEFINGS 2007
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