Boomerang Technique, The Buccal Mucosal Grafting Harvesting Model for Long Urethral Stricture Urethroplasty; A Case Series
Vol. 17 No. 3 (2020),
16 May 2020
Purpose: Currently, three methods are implicated in cases of long urethral stricture including harvesting buccal mucosa of inner cheeks, harvesting lip mucosa and finally lingual mucosal graft. This study evaluated the feasibility, safety and morbidity of our “Boomerang shape” technique used for graft retrieval from the inner cheeks to repair long urethral defect cases which are usually 12-15 cm in length and 2.5 cm in width.
Materials and Methods: The Kilner-Doughty mouth retractor is inserted to give access to the donor site. Initially, the internal surface of the right/left cheek is cleaned with a solution containing 10% povidone-iodine. Then, Stensen’s duct, located at the level of the second molar is identified and the desired size of the graft is measured and marked in a boomerang shape, 1.5 cm from the Stensen’s duct and 1.5 cm from the edge of the cheek. To decrease submucosal bleeding from the harvest site, 1% lidocaine combined with a 1:100,000 epinephrine solution is injected using a 25-gauge long needle. The outlines of the graft are drawn by using a scalpel through the mucosa. Then, the outlined graft is sharply dissected and removed, leaving the muscle intact. A 5-0 polyglactin continuous suture is used for the closure of the harvest site. The standard graft harvested from the cheek should be 12-15 cm in length and 2.5 cm in width.
Results: Between 2017-2019, five adults have had their mucosal grafts harvested by the “Boomerang shape” technique in our center. No donor site complications were observed. Moreover, no urethral strictures or diverticulum occurred and the functional outcomes were satisfactory in all patients.
Conclusion: Our routine technique of harvesting the buccal mucosa from the cheek is secure and easily performable by any surgeon. It has minimal incidence of intra and post-operative complications.
- Urethral stricture
- Urethral reconstruction
- Buccal mucosa graft
- Boomerang technique
Fallahkarkan M, Razzaghi MR, Karami H, Ghiasy S, Tayyebiazar A, Javanmard B. Experience of 138 Transurethral Urethrotomy With Holmium: YAG Laser. J Lasers Med Sci.. 2019;10:104-7.
Razzaghi MR, Karkan MF, Ghiasy S, Javanmard B. Laser application in iran urology: a narrative review. J Lasers Med Sci.. 2018;9:1.
Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol.. 2007;177:1667-74.
Fallah-Karkan M, Hosseini MA, Azad BK, Heidarzadeh A, Hosseini J. Persian version of Patient-Reported Outcome Measure for Urethral Stricture Surgery (USS-PROM) Questionnaire, Validation and Adaptation Study. Urol J. 2020;17: 61-7.
Hosseini J, Kaviani A, Mohammadhosseini M, Rezaei A, Rezaei I, Javanmard B. Fistula repair after hypospadias surgery using buccal mucosal graft. Urol J. 2009;6:19-22.
Hosseini J, Kaviani A, Hosseini M, Mazloomfard MM, Razi A. Dorsal versus ventral oral mucosal graft urethroplasty. Urol J. 2011;8:48-53.
Wessells H, McAninch JW. Use of free grafts in urethral stricture reconstruction. J Urol. 1996;155:1912-15.
Korneyev I, Ilyin D, Schultheiss D, Chapple C. The first oral mucosal graft urethroplasty was carried out in the 19th century: the pioneering experience of Kirill Sapezhko (1857–1928). Eur Urol. 2012;62:624-7.
El-Kasaby A, Fath-Alla M, Noweir A, El-Halaby M, Zakaria W, El-Beialy M. The use of buccal mucosa patch graft in the management of anterior urethral strictures. J Urol.. 1993;149:276-8.
Barbagli G, Balo S, Montorsi F, Sansalone S, Lazzeri M. History and evolution of the use of oral mucosa for urethral reconstruction. Asian J Urol. 2017;4:96-101.
Morey AF, McAninch JW. Technique of harvesting buccal mucosa for urethral reconstruction. J Urol. 1996;155:1696-7.
Barbagli G, Fossati N, Sansalone S, et al. Prediction of early and late complications after oral mucosal graft harvesting: multivariable analysis from a cohort of 553 consecutive patients. J Urol. 2014;191:688-93.
Maarouf A, Elsayed E, Ragab A, et al. Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair. J Pediatr Urol. 2013;9:754-8.
Dublin N, Stewart LH. Oral complications after buccal mucosal graft harvest for urethroplasty. BJU Int. 2004;94:867-9.
Eppley BL, Keating M, Rink R. A buccal mucosal harvesting technique for urethral reconstruction. J Urol. 1997;157:1268-70.
Castagnetti M, Ghirardo V, Capizzi A, Andretta M, Rigamonti W. Donor site outcome after oral mucosa harvest for urethroplasty in children and adults. J Urol. 2008;180:2624-8.
Kumar A, Goyal NK, Das SK, Trivedi S, Dwivedi US, Singh PB. Oral complications after lingual mucosal graft harvest for urethroplasty. ANZ J Surg. 2007;77:970-73.
Xu YM, Xu QK, Fu Q, et al. Oral complications after lingual mucosal graft harvesting for urethroplasty in 110 cases. BJU Int. 2011;108:140-5.
Markiewicz MR, Margarone III JE, Barbagli G, Scannapieco FA. Oral mucosa harvest: an overview of anatomic and biologic considerations. EAU-EBU update series. 2007;5:179-87.
Hosseini J, Soltanzadeh K. A comparative study of long-term results of Buccal Mucosal Graft and Penile Skin Flap techniques in the management of diffuse anterior urethral strictures: first report in Iran. Urol J. 2009;1:94-8.
Mirzazadeh M, Fallahkarkan M, Hosseini J. Penile fracture epidemiology, diagnosis and management in Iran: a narrative review. Transl Androl Urol. 2017;6:158.
Hosseini J, Fallah-Karkan M, Rahavian A, et al. Feasibility, complication and long-term follow-up of the newly nelaton based urethral dilation method, retrospective study. Am J Clin Exp Urol. 2019;7:378-83.
Andrich D, Mundy A. Substitution urethroplasty with buccal mucosal-free grafts. J Urol. 2001;165:1131-4.
Markiewicz MR, Lukose MA, Margarone JE, Barbagli G, Miller KS, Chuang S-K. The oral mucosa graft: a systematic review. J Urol. 2007;178:387-94.
Markiewicz MR, DeSantis JL, Margarone III JE, Pogrel MA, Chuang S-K. Morbidity associated with oral mucosa harvest for urological reconstruction: an overview. J Oral Maxillofac Surg. 2008;66:739-44.
Jang TL, Erickson B, Medendorp A, Gonzalez CM. Comparison of donor site intraoral morbidity after mucosal graft harvesting for urethral reconstruction. Urology. 2005;66:716-20.
Barbagli G, Vallasciani S, Romano G, Fabbri F, Guazzoni G, Lazzeri M. Morbidity of oral mucosa graft harvesting from a single cheek. Eur Urol.2010;58:33-41.
Bhargava S, Chapple C, Bullock A, Layton C, MacNeil S. Tissue‐engineered buccal mucosa for substitution urethroplasty. BJU Int.2004;93:807-11.
Morey AF. Tissue-engineered buccal mucosa for substitution urethroplasty. J Urol. 2005;174:1858.
Bhargava S, Patterson JM, Inman RD, MacNeil S, Chapple CR. Tissue-engineered buccal mucosa urethroplasty—clinical outcomes. Eur Urol. 2008;53:1263-71.
Orabi H, Safwat AS, Shahat A, Hammouda HM. The use of small intestinal submucosa graft for hypospadias repair: Pilot study. Arab J Urol. 2013;11:415-20.
Barbagli G, De Angelis M, Romano G, Ciabatti PG, Lazzeri M. The use of lingual mucosal graft in adult anterior urethroplasty: surgical steps and short-term outcome. Eur Urol.2008;54:671-6.
Xu Y-M, Sa Y-L, Fu Q, Zhang J, Si J-M, Liu Z-S. Oral mucosal grafts urethroplasty for the treatment of long segmented anterior urethral strictures. World J Urol. 2009;27:565-71.
Singh O, Gupta SS, Arvind NK. Anterior urethral strictures: a brief review of the current surgical treatment. Urol Int. 2011;86:1-10.
Wessells H, Morey AF, McAninch JW. Single stage reconstruction of complex anterior urethral strictures: combined tissue transfer techniques. J Urol. 1997;157:1271-4.
Elliott SP, Metro MJ, McANINCH JW. Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol. 2003;169(5):1754-7.
Berglund RK, Angermeier KW. Combined buccal mucosa graft and genital skin flap for reconstruction of extensive anterior urethral strictures. Urology. 2006;68:707-10.
- Abstract Viewed: 287 times
- pdf/5534 Downloaded: 97 times