Tips and Techniques in Oral Mucosa Harvest for Urological Reconstruction

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To the Editor: Urethral defects can be attributed to an array of etiologies, the most prevalent being stricture and hypospadias.1 Defects larger than 2 cm are usually not repairable by end-to-end anastomosis of urethral margins and may require a flap procedure graft to treat.2 When considering free tissue grafts in the reconstruction of urethral defects, several tissues have been considered. These include bladder mucosa and free skin grafts. These treatment modalities have been reported to be associated with a high failure rate and often require repeated operations.3
An increasingly common tissue being used for the repair of urethral defects is oral mucosa.
The donor site is easily accessible and most oral and maxillofacial surgeons possess the surgical expertise required for harvesting the graft. The technique was first described by Humby in 1941.4
The most common sites of tissue harvest in the oral cavity for urologic reconstruction are the buccal mucosa and the labial mucosa of the lower lip.1,5,6
Between May 2010 and January 2015, 41 buccal mucosal grafts have been used for urethral reconstruction in 37 patients who suffered from recurrent urethral strictures at the Città della Scienza e della Salute Hospital, University of Turin, Turin.
All operations were performed in a 2-team approach under general anesthesia and rhino-tracheal intubation. The urologist began the operation with preparing the urethral recipient region. As soon as he could estimate the defect size, the maxillofacial surgeon started harvesting the buccal mucosal graft.
For mucosal cheek defect of 3 cm2 or less, the wound was closed primarily.
For larger defect, the wound was closed with the aid of a resorbable membrane (Tutopatch) to guide the secondary healing and absorbable interrupted sutures.
All patients underwent a simple protocol of manual cheek stretching after an initial period of healing. This treatment protocol also eliminated contracture of the buccinators muscle.
The most common complication occurring at the buccal donor site was scarring and contracture that occurred in 7 patients of our series.
No intraoperative complications were observed in our series.
No patients reported intraoral pain at 6-month follow-up. One patient reported numbness of the buccal region. Salivary flow was normal in all patients. The ability to eat and drink was the same of prior surgery for all the patients.
Swallow and speech functions were not affected by the operation.
Of the patients, 78% would agree to have the same operation done again.
In this way, the surgeon preserve the inner part of the lower lip, the area near the Stenon duct and take a safety margin from the vermilion.
Figure 1 shows the donor site, the mucosa graft, and the suggested harvesting area.
We suggest primarily closure only when the defects are of 3 cm2 or less. In the other patients, we suggest to close by secondary intention with the aid of a resorbable membrane to guide the healing and to protect the muscle.
Following oral mucosa graft harvest, patients should expect to ingest fluids orally within 24 hours postoperatively without much discomfort. Most patients will be able to eat solid foods within 2 days postoperatively and should expect to return to a normal diet within 5 to 7 days.
To conclude, urethral reconstruction with free buccal mucosal grafts is a simple and secure method in the interdisciplinary approach for the treatment of urethral strictures.
The strength and adaptability of buccal mucosa tissue has been unsurpassed by others contributing to the ever-growing popularity of the tissue's use.

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