Uretroplastica con innesto ventrale di mucosa orale

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L’intervento denominato “uretroplastica con innesto di mucosa orale” consiste nell’aprire completamente l’uretra nel punto in cui è presente la stenosi ed allargare il canale con un innesto di mucosa orale.

Figura 1

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Figura 4

Fondamentalmente, esistono quattro tipi di uretroplastica con innesto di mucosa orale:

  • Uretroplastica con innesto ventrale di mucosa orale. In questa procedura, la mucosa orale viene suturata nella faccia ventrale del canale uretrale (figure 1,2).
  • Uretroplastica con innesto dorsale di cute o mucosa orale. In questa procedura, la cute o la mucosa orale vengono suturate nella faccia dorsale del canale uretrale (figure 3,4).
  • Uretroplastica con innesto laterale di mucosa orale. In questa procedura, la mucosa orale viene suturata nella faccia laterale del canale uretrale.
  • Uretroplastica con sostituzione completa di mucosa orale. In questa procedura, la mucosa uretrale viene sostituita completamente con la mucosa orale.

 

L’intervento chirurgico denominato Uretroplastica con innesto di cute o mucosa orale è indicato fondamentalmente nei pazienti con stenosi, non traumatica, dell’uretra bulbare di lunghezza superiore a 2 cm.

Articolo n° 1

Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M.
Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique?
J Urol. 2005 Sep;174(3):955-7

Purpose: The use of buccal mucosa graft onlay urethroplasty represents the most widespread method of bulbar urethral stricture repair. The graft may be placed on the ventral or dorsal urethral surface according to surgeon experience and preference. We investigated whether the results are affected by the surgical technique by comparing the outcome of 3 types of bulbar urethroplasty using buccal mucosa graft.
Material and Methods: We repaired 50 bulbar urethral strictures with buccal mucosa grafts from 1997 to 2002. Mean patient age was 42 years. The etiology of stricture was ischemia in 12 cases, trauma in 6, instrumentation in 4 and unknown in 28. Patients with lichen sclerosus, failed hypospadias or urethroplasty and stricture extending into the penile urethra were not included. A total of 47 patients (94%) had undergone previous urethrotomy or dilation. The buccal mucosa graft was always harvested from the cheek using a 2 team approach. Mean graft length was 4.2 cm. The graft was placed on the ventral, dorsal and lateral bulbar urethral surface in 17, 27 and 6 cases, respectively. Clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 42 months (range 12 to 76).
Results: Of 50 cases 42 (84%) were successful and 8 (16%) failed. The 17 ventral grafts provided success in 14 cases (83%) and failure in 3 (17%). The 27 dorsal grafts provided success in 23 cases (85%) and failure in 4 (15%). The 6 lateral grafts provided success in 5 cases (83%) and failure in 1 (17%). No surgical complications were observed. Failures involved the anastomotic site (distal in 2 and proximal in 3) and the whole grafted area in 3 cases. They were treated with urethrotomy in 5 cases and 2-stage urethroplasty in 3.
Conclusions: In our experience the placement of buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success rates (83% to 85%) and the outcome was not affected by the surgical technique. Moreover, stricture recurrence was uniformly distributed in all patients.

Articolo n° 2
Barbagli G., Guazzoni G., Lazzeri M.
One-Stage bulbar urethroplasty: Retrospective analisys of the results in 375 patients
Eur Urol 2008; 53:828-33

Objective: To review the outcome of bulbar urethroplasty using one-stage surgical techniques.
Methods: Of 375 patients, who underwent one-stage bulbar urethroplasties, 165 patients (44%) underwent anastomotic repair (AR), 40 (10.7%) underwent augmented anastomotic repair (AAR) using penile skin grafts (PSGs) or oral mucosal grafts (OMGs), and 170 (45.3%) underwent onlay grafting techniques (OGTs) using PSGs or OMGs. Clinical outcome was considered a failure when any postoperative instrumentation was needed. The chi(2) and Fisher’s exact test for categorical data were used. The sample size of 375 patients provides a statistical power (1-beta) of 99% at alpha=0.05; p<0.05 was set as significant.
Results: The average follow-up was 53 mo. Of 375 cases, 313 (83.5%) were successful and 62 (16.5%) failures. Of 165 ARs, 150 (90.9%) were successful and 15 (9.1%) failures. Of 40 AARs, 24 (60%) were successful and 16 (40%) failures. Of 170 OGTs, 139 (81.8%) were successful and 31 (18.2%) failures. The AR showed statistically significant higher success rate compared to OGT (p=0.023) and AAR (p=0.0001). Of 47 PSGs, 28 (59.6%) were successful and 19 (40.4%) failures. Of 163 OMGs, 135 (82.8%) were successful and 28 (17.2%) failures. This difference was statistically significant (p=0.002).
Conclusions: One-stage bulbar urethroplasties showed an overall 83.5% success rate. The AR showed the higher success rate compared to the OGT or AAR. OMGs (82.8% success rate) perform statistically better than PSGs (59.6% success rate).

Articolo n° 3
Guido Barbagli , Salvatore Sansalone , Giuseppe Romano and Massimo Lazzeri
Ventral onlay oral mucosal graft bulbar urethroplasty
BJU Int 2011; 108: 1218-1231

The current surgical approach to the uncomplicated bulbar urethral stricture began in 1993 when El-Kasaby et al . described the repair of anterior urethral strictures using an oral mucosa graft, including eight patients who underwent bulbar urethroplasty. In 1996, Morey and McAninch first described ventral onlay oral mucosa urethroplasty, suggesting suturing of the oral graft in the ventral surface of the urethra. In 1996, Barbagli et al . described the dorsal free-graft urethroplasty, suggesting suturing the graft in the dorsal surface of the urethra, over the albuginea of the underlying corpora cavernosa. The location of the graft on the ventral or dorsal urethral surface has become a contentious issue, dating from the time these two techniques were described. Success with bulbar oral mucosal grafts has been high with dorsal or ventral graft location and the different graft positions have shown no differences in success rates. Recently, we developed a new muscle and nerve-sparing bulbar urethroplasty, avoiding fully opening the bulbo-spongiosum muscle, thus better preserving ejaculatory function. The selection of a surgical technique for bulbar urethra reconstruction, in addition to respecting the status of the genitalia tissue and components, must also be based on the proper anatomical characteristics of the bulbar urethra, to ensure graft take and survival. Further, sexual function can be placed at risk by any surgery on the genitalia, and dissection must avoid interference with the neurovascular supply to the penis and genitalia. Bulbar urethroplasty using grafts should not compromise penile length or cause penile chordee, and certainly should not untowardly affect penile and genitalia appearance.
1. Domanda: L’intervento può essere effettuato in regime di convenzione con il Sistema Sanitario Nazionale?
Risposta: L’intervento chirurgico può essere effettuato in regime di convenzione con il Sistema Sanitario Nazionale, senza alcuna spesa per il paziente.


2. Domanda: Per questo tipo di intervento quale tipo di anestesia è previsto?
Risposta: Anestesia generale con intubazione nasale.


3. Domanda: Quante ore dura l’intervento?
Risposta:Circa due ore


4. Domanda: Ci sono rischi per l’erezione, la fertilità e la continenza urinaria, dopo l’intervento?
Risposta: No


5. Domanda: Quanti sono i giorni di degenza in ospedale previsti per questo intervento?
Risposta: In genere il ricovero ospedaliero varia da 5 a 7 giorni.


6. Domanda: Per quanto tempo dovrò portare il catetere dopo l’intervento?
Risposta: Il catetere deve rimanere in sede per quattro settimane dopo l’intervento. Fino a quando non verrà effettuata la prima radiografia di controllo postoperatoria.


7. Domanda: Quali particolari limitazioni sono suggerite durante la convalescenza?
Risposta: Durante la convalescenza è suggerito l’uso di un antibiotico per via orale fino a che non viene rimosso il catetere. È suggerito di non effettuare lungi viaggi in auto, lavori pesanti, attività sessuale e sportiva.


8. Domanda: Quanto tempo dopo l’intervento potrò riprendere la mia attività lavorativa, sportiva e sessuale?
Risposta: Le attività lavorativa, sportiva e sessuale possono essere riprese gradualmente dopo circa 30 giorni dalla rimozione del catetere.


9. Domanda: Dopo l’intervento posso usare la bicicletta od il motorino?
Risposta: L’uso di bicicletta, motorino, cavallo, mezzi a sella in palestra sono sconsigliati.


10. Domanda: Quali cibi e bevande devo evitare dopo l’intervento?
Risposta: L’uso di birra, vini spumanti e gassati sono controindicati. Un uso esagerato di cioccolata, cacao, frutta secca, crostacei non è consigliato.