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Current Status of Techniques Using Oral Mucosa in Urethroplasty
consequences. The standard graft harvested from the lip is 4cm long
• the donor site scar is concealed; and and 1.5cm wide. In some patients, the lip was so thin that the graft
was less than 1.5cm wide.
• it has a thick, elastin-rich epithelium, which makes it tough yet easy
to handle. The advantages of harvesting the graft from the lip are:
In our experience, buccal mucosa harvest from the cheek (with closure • it is readily available from all patients;
of the donor site) is a safe procedure with a high level of patient
satisfaction and early-onset complications that do not develop into • the harvesting procedure is quick and easy and does not require nasal
permanent late-onset sequelae.
4
Other authors have suggested leaving intubation or a special retractor; and
the harvest site open.
5
• the graft harvested from the lip is ideal for any urethroplasty requiring
The size of the graft harvested from the cheek must be tailored a single small, thin graft.
according to the physiognomy of the patient’s face and mouth
opening, with the standard graft measuring 4cm in length and 2.5cm The graft is ideal for paediatric cases (hypospadias) or for one-stage
in width. In some patients it is possible to harvest longer and wider dorsal inlay graft penile or bulbar urethroplasty.
12–14
The urethra is
fully exposed and the strictured tract is opened by a ventral midline
incision. The urethral plate is longitudinally incised on the dorsal
midline down to the corpora and the wings of the urethral plate are
The graft is tailored into an ovoid shape
laterally mobilised. The graft is sutured and quilted onto the bed of the
to close the edges of the donor site dorsal urethral incision with interrupted 6-zero sutures and
without tension, avoiding difficulties in
augmentation of the urethral plate is obtained. The urethra is closed
and tubularised, taking advantage of the mobilised wings of the
opening the mouth post-operatively.
urethral plate. A Foley Charriere (CH) 14 silicone catheter is left in
place for three weeks. For this kind of urethroplasty, the required graft
should be narrow (not more than 1.5cm wide) to avoid the margins of
grafts. The graft is tailored into an ovoid shape to close the edges of the graft overlapping the thin margins of the urethral plate incision.
the donor site without tension, avoiding difficulties in opening the For this reason, the ideal graft for this kind of urethroplasty should be
mouth post-operatively. It is likely that surgeons who leave the harvest harvested from the lip or tongue.
site open take a larger graft. In such cases, closure of the site may
produce post-operative consequences. We prefer to take smaller grafts Harvesting the Graft from the Tongue
from both cheeks instead of one larger graft from a single cheek. Graft harvesting from the tongue can be performed by a young urologist
Grafts harvested from the cheeks are ideal for any urethroplasty assisted by an oral surgeon. A standard mouth opener is put into place.
requiring large and resistant grafts. The apex of the tongue is passed through via a stitch for traction outside
the mouth, and the ventral surface of the tongue is fully exposed. It is not
In patients with lichen sclerosus or failed hypospadias repair requiring necessary to infiltrate the graft site with lidocaine, epinephrine or any
two-stage substitution urethroplasty to circumferentially replace the other kind of solution. The opening of the submandibular Wharton’s duct
entire original diseased urethral plate, the long and wide graft is identified. The site of the route of the underlying lingual nerve is
harvested from the cheek is an ideal substitute material.
6–9
In patients carefully identified. The required graft is measured and marked on the
with bulbar urethral stricture requiring a one-stage ventral/dorsal onlay
procedure, the graft should be not less than 4cm long and 2.5cm
wide, and should be resistant to mechanical weakness. Thus, for these
Although this procedure is quick and
reasons, cheek grafts are the preferred substitute material.
10,11
simple, we rarely harvest tissue from
Harvesting the Graft from the Lip the lip because some patients
It is quick and easy to harvest tissue from the lip with a standard
experience lower lip retraction or
orotracheal tube. Three stay sutures are placed along the external
edge of the lower lip to keep the buccal mucosa stretched while the eversion of the lip vermilion border.
desired graft is measured and marked. Lidocaine HCL 1% with
epinephrine (1:100,000) is injected along the edges of the graft to
enhance haemostasis. The graft is delicately dissected and removed. right ventral surface of the tongue. The graft edges are incised using a
The donor site is carefully examined for bleeding and left open (to heal scalpel and the graft is removed using sharp scissors. The graft bed is
by secondary intention). An ice bag is immediately applied to the lip to carefully examined for bleeding. The donor site is closed using 4-zero
reduce oedema and to avoid pain and haematoma formation. polyglactin interrupted sutures. Graft de-fatting is necessary to remove
Although this procedure is quick and simple, we rarely harvest tissue the underlying fibrovascular tissue. The standard graft harvested from the
from the lip because some patients experience lower lip retraction or tongue is 4cm long and 2.5cm wide. In patients requiring double graft
eversion of the lip vermilion border.
4
Using a graft no greater than 4cm harvesting, the same procedure is repeated on the left ventral surface of
long and 1.5cm wide reduces the risk of these adverse aesthetic the tongue. At the end of the procedure, the dorsal surface of the tongue
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