BERKELEY, CA (UroToday.com) - Complex strictures of the bulbar urethra that are too long to be treated by an end-to-end urethroplasty may be treated with a substitution urethroplasty. Initially, the use of full-thickness free grafts of penile skin had been reported as successful but problems with graft shrinkage and the lack of mechanical support led to problems such as pseudo-diverticuli and a reduced caliber urethra. The use of dartos pedicled flaps has advantages in graft take over free grafts thanks to their own vascularization. Pedicled flaps used ventrally can be subject to sacculation which can lead to post-void dribble and irritative voiding symptoms.

In 1996, Barbagli introduced the concept of the dorsal placement graft urethroplasty where a dorsal urethrotomy is made and the graft is sutured to the corpora cavernosum. This helped to provide mechanical support to the graft and reduced the incidence of sacculation and pseudo-diverticuli formation. The aim of a recent study by M. Raber and F Montorsi and colleagues from Milan, Italy was to prospectively evaluate the outcome of a Barbagli dorsal patch urethroplasty performed with either penile skin or buccal mucosa in order to identify the best substitution material in terms of functional results and to evaluate sexual function after both procedures. The report is published in the December 2005 issue of European Urology.

Over a five-year period, 30 patients with bulbar urethral strictures underwent dorsal onlay urethral reconstruction with either penile skin (n =17) or with a buccal mucosa free graft (n =13). Follow-up was performed at 6, 12 and 18 months postoperatively and annually thereafter. Success was defined as normalization of IPSS and a stable maximum flow rate > 20 ml/sec. Any further instrumentation for stricture recurrence was considered a failure. The International Index of Erectile Function (IIEF) score was also used to assess sexual function. Mean follow-up for the group was 51 months and no patient had less than 20 months follow-up. Pre-operative patient characteristics as defined by questionnaires were similar in both groups.

Analysis of the results showed an overall success rate of 80% (24 patients out of 30). The success rate for the buccal mucosa group was 85% while that of the penile skin group was 76%- this was not statistically different. This raises questions as to whether a buccal graft truly outperforms the penile skin graft as suggested by some authors such as Barbagli who has seen some deterioration over time of his reconstructions done with penile skin. In this study, with a mean follow-up of over 4 years, the authors did not find a significant difference. An interesting finding from the IIEF scores post-operatively is that patient who underwent a penile skin graft rather than a buccal graft reported a significant improvement of the orgasmic function domain. The authors were unable to come up with a reason for this, and I am at a loss also and believe that this is merely a matter of happenstance.

Eur Urol. 2005 Dec; 48(6):1013-17