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Urethroplasty - Augmented Urethroplasty (Barbagli)

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Guido Barbagli from Arezzo, Italy published his innovative technique of dorsal onlay free graft urethroplasty in the journal of urology in 1996. His technique of urethroplasty has revolutionized the management of urethral strictures world over. We introduced his technique in Pune, India in 1997. Barbagli initially used free prepucial skin graft as a dorsal onlay. Later on he started using buccal mucosa graft.

Indications

The indications are as follows:

  1. long bulbar stricture
  2. short bulbar stricture of non traumatic origin
  3. post TURP stricture.  

Investigations

The required investigation is the ascending urethrogram to demonstrate the site and length of the stricture.

Procedure

The patient is placed in lithotomy position after spinal anesthesia. Dilute Methylene Blue dye is injected through the meatus into the urethra. The penis and perineum are massaged to push the dye proximally. I apply a 6 F feeding tube as a tourniquet to lightly compress the urethra below the glance penis. A midline perineal incision is made the bulbar urethra is dissected from corpora cavernosa. I place two stay sutures ventrally at 6 O’ Clock position on the facia over corpora spongiosa. These stay sutures allow me to rotate the bulbar urethra to open the urethra exactly at 12 O’ Clock (dorsal) position over a dilator distal to the stricture. The urethra is spatulated through the stricture proximally into normal urethra minimum to a distance of 1.5 cm.

Buccal mucosa graft harvesting : the graft can be taken under general or local anesthesia. A retractor is placed to wide open the jaws. A roller gauze is packed into the pharynx to block aspiration of blood during dissection. The Stensons Duct opening opposite the second upper molar tooth is marked with Methylene Blue. Injury to the duct opening is avoided by making an incision from the angle of mouth towards the lower jaw. Xylocaine with 2%  Adrenaline is injected with a fine needle from the angle of mouth to anterior tonsiler pillar below the buccal mucosa. A stay suture is taken at the angle of mouth just inside the vermilion border. Two parallel incisions 1.5 cm apart are made from the angle of mouth to the anterior tonsil pillar. The buccal mucosa graft is harvested. Any injury to the Buccinator muscle is avoided. Bleeders if any are coagulated with bipolar diathermy. Initially I use to close the defect in the buccal mucosa at 3 – 0 chromic catgut continues sutures. Now for last five years, I have rarely closed the wound. The buccal mucosa graft is kept in a bowl of saline to which Gentamycin injection is added. The graft defatting of the graft is performed. Some surgeons perform aggressive defatting to make the graft very thin and transparent. Moderate defatting is sufficient in my opinion. Some surgeons pin down the graft with multiple needles on a silicon block to facilitate defatting. The buccal mucosa graft is transferred to the perineal surgeon. The graft is placed over the corpora cavernosa with mucosa facing towards the lumen. The graft is spread and fixed to the corpora cavernosa. Quilting sutures with absorbable material allow the graft to be fixed to the underlying structures. This prevents collection of seroma below the graft and tiny holes created with the suture material allow the serous fluid to drain. Some surgeons make multiple incisions in the graft similar to skin graft.  It allows narrow a graft to cover wider area.  I personally do not use it. The edge of the corpora spongiosa is sutured to the buccal mucosa with continuous sutures to the right side. A 14 F silastic catheter is inserted into the bladder. Then the left edge of corpora spongiosa is sutured to the buccal mucosa with continuous sutures. Each stitch incorporates the underlying corpora cavernosa, the buccal mucosa and the corpora spongiosa (three in one stitch). Care must be taken while suturing to avoid inadvertent needle entry into the periurethral catheter.

The success of dorsal onlay buccal mucosa graft urethroplasty depends upon the width of the urethral plate. If the stricture is tight and long, the urethral plate will be too narrow.  With a narrow urethral plate (less than 5mm)  we can not suture edge of the urethral mucosa to the BMG. If we do this the effective lumen will be 20F. So edge of the corpora spongiosa is sutured to the BMG leaving strips of exposed spongiosa on both sides of the urethral plate. This violates the principle of primary healing and it will heal by secondary intention and may lead to restricture formation.

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