Introduction
Urethral stricture disease is a disorder that affects 400 of every 100,000 males. Its surgical therapeutic treatment can pose a challenge. A urethral stricture is a condition that involves scarring of the urethral issue. This narrows the tube (urethra) that passes urine out of the body. A urethral stricture restricts the urine flow from the urinary bladder. This can lead to a variety of medical issues in the urinary tract, including inflammatory conditions or urinary tract infections.
Buccal mucosa graft (BMG) was first recommended for urethral stricture treatment and reconstruction by Humby in the year 1941. Since then, it has become an ideal therapeutic approach because of its ease of availability, easy handling characteristics, hairlessness, the biocompatibility of the buccal mucosa in a wet environment, speedy ingrowth, and early graft survival.
What Is Urethroplasty?
Urethroplasty is a surgical procedure where the urethra is reconstructed to treat conditions like urethral strictures. Most surgeons consider it the treatment of choice in urethral strictures treatment.
What Is BMG Urethroplasty?
It is called buccal mucosal graft (BMG) urethroplasty. Earlier, urethral reconstruction with grafts was performed by mostly using genital mucosal flaps and grafts of extragenital tissue. But with these grafts, the surgical procedure was more difficult, with increased complications and failure rates. The buccal graft is currently considered ideal because of its easy attainability, easy surgical handling characteristics, hairlessness, compatibility to survive in a wet environment, rapid in-growth and graft survival, and infection resilience.
What Are the Indications of BMG Urethroplasty?
The indications of BMG urethroplasty include treating urethral strictures in men with urethral reconstruction and women with various trauma and congenital conditions such as hypospadias (a birth defect in boys where the opening of the penis is on the underside rather than the tip).
What Is the Surgical Technique for BMG Urethroplasty?
The surgical procedure is as follows:
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The buccal graft harvest is obtained from the inner cheek. The inner cheek site is prepped, and the graft is outlined using a marker. After the administration of local anesthesia, the graft is then incised. It is dissected off of the buccinator muscle. Caution is taken to avoid Stensen’s duct. The incised buccal graft is placed in saline till the time of implantation. The inner cheek site is usually left open to heal on its own.
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The urethroplasty procedure is performed in the high lithotomy position (a supine position with legs flexed and separated). It is important to ensure that the patient is properly secured and padded. Meanwhile, the perineum of the patient is prepped and covered in a normal sterile manner. To delineate the urethral contour, a French catheter is used. The exact position of the distal portion of the stricture is identified. After urethral exposure, the urethra over the urethral catheter is incised using a scalpel blade, and the urethral stricture is completely opened.
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After identifying the location of the stricture, it is either removed or that particular section of the urethra is reconstructed depending on the length and location of the stricture.
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A BMG urethroplasty is implemented if the blockage is longer or located in the penile urethra. The incision is then closed, and a small drain is usually placed for a day or so. A catheter is placed to allow the urethra to heal while urine can still pass through the body. Resorbable stitches are placed to suture the muscles and skin.
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Medications are usually prescribed for overcoming urinary bladder spasms and bladder pain.
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A special mouthwash is recommended for the oral rinse to prevent oral infections at the graft site.
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Follow-up after two to three weeks is required, and imaging scans should be done to check the healing process.
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The patient is usually advised to avoid sexual contact, masturbation, any sort of physical activity, or lifting heavy weights for upto a minimum of four to six weeks. Medicines are given to prevent penile erection.
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Regular walking is recommended to the patient.
What Are the Complications of BMG Urethroplasty?
Post-operative complications can occur at two sites- either at the harvest site or the site of stricture reconstruction. However, the complications are the least with buccal grafts. The buccal harvest site complications might include bleeding, pain, infection, facial swelling, damage to Stensen’s duct (salivary excretory duct of the parotid gland), loss of sensitivity of the lower lip, and restricted mouth opening. However, these complications are self-limiting and resolve within a period of a few weeks to months.
The immediate complications at the site of urethral stricture reconstruction are quite rare. Wound infections, scrotal swelling, scrotal ecchymosis (testicular bruises), hematomas (a pool of clotted blood in a body space), skin paresthesia, and urinary urgency are some of the minor complications that might occur after the surgery.
Other rare risks include nerve injury to legs, feet, elbows, or fingers due to the position of the patient during the surgery. Nerve damage symptoms will improve with time. Erectile dysfunction may also occur, but this problem is temporary.
What Are the Benefits of BMG Urethroplasty?
Research indicates that BMG urethroplasty is currently the best reliable option to cure urethral strictures. The success rate is good, and the recurrence rate is minimal. The urine can flow freely from the bladder due to this surgical procedure. The healing process is speedy, and the patient is usually discharged in the next 24 to 48 hours. The success rate of this surgery is over 80%, with consistent follow-ups. In a few cases, the success rate is effectively higher than 90% depending on the location and length of the urethral stricture.
Conclusion
BCG urethroplasty is a type of surgery to repair the urethral stricture. The prognosis of this technique is quite good, with regular follow-ups. However, for the treatment, a complete team of surgical doctors is required to carry out the procedure because it is technique-sensitive. Also, the healthcare provider should guide the patient about the complications and risk factors associated with the surgery. Buccal grafts to repair urethral strictures have gained popularity because of their ease of technical accessibility, high-end performance, reliability, and overall good success rate with minimal recurrences. It has now become the treatment of choice, even for shorter urethral strictures. It has substituted genital flaps and other extragenital tissues.
