The aim of this study was to investigate oral morbidity and patient satisfaction in a homogeneous group of patients who underwent OM harvesting.
Design, setting, and participants
This study is a prospective analysis of 350 patients who underwent OM harvesting from a single cheek.
Intervention
The graft was harvested in an ovoid shape with closure of the wound. Standard graft size was 4 cm in length and 2.5 cm in width.
Measurements
Self-administered, nonvalidated semiquantitative (0, absence of complications or symptoms; 3, the worst complication or symptom) questionnaire consisting of six questions was used to investigate early complications, with 13 questions designed to investigate late complications and patient satisfaction.
Results and limitations
Early complications included bleeding, which occurred in 15 patients (4.3%); two patients required immediate surgical revision of the harvesting site. The majority of patients (85.2%) showed no pain, and only 3.7% of patients required use of anti-inflammatory drugs. The majority of patients (65.8%) showed slight or moderate swelling. With respect to late complications, most of the patients (73.4%) reported oral numbness for 1 wk, 22.9% for 1 mo, and 3.77% for 3 mo. Numbness resulting from scarring was absent or slight in most of patients. Changes in oral sensitivity occurred in 2.3% of patients. No difficulties opening the mouth or smiling was found in 98.3% and 99.7% of patients, respectively. Slight or moderate dry mouth was found in 97.1% of patients. In response to the question, “Would you undergo oral mucosa graft harvesting using this technique again,” 343 patients (98%) replied “yes,” and 7 patients (2%) replied “no.”
Conclusions
The harvesting of an OM ovoid graft from a cheek with closure of the wound is a safe procedure with a high patient satisfaction rate.
Introduction
Congenital or acquired defects of the male urethra can be repaired using various substitute materials, including genital or extragenital skin and oral mucosa (OM) [1]. At the present time, the use of OM has been the most reliable and popular substitute for urethral reconstructive surgery [1]. A systematic review analysed 1353 cases involving OM-based urethroplasty for repair of urethral stricture or hypospadias/epispadias, reporting success in 418 (66.5%) and 553 (76.4%) cases, respectively [1]. The success of using OM for urethral surgery can be partially attributed to the tissue’s biologic properties [2]: OM is easy to harvest and obviates most of the problems associated with other graft harvesting, providing simple accessibility and a concealed donor site scar [1], [2]. The two most common sites of OM harvesting found in the literature are the mucosa from the inner cheek and the mandibular (lower jaw) labial alveolar region [1]. Simonato et al first reported a preliminary experience with the use of lingual mucosal graft for urethral surgery [3].
Nevertheless, in a few studies, OM harvesting was associated with oral complications, such as numbness, tightness of the mouth, and motor deficits [4], [5], [6], [7]. An overview reported an overall rate of donor site complications finding not statistically different between two donor sites (cheek or lip), with a morbidity rate of 3% to 4% for both sites [7]. Complications such as scarring and contracture were found to be more frequent in patients undergoing harvest from the cheek than patients undergoing labial harvest [7]. However, the labial harvest can impinge on the mental nerve, causing perioral numbness or other complications [2].
There is an absence of consensus within the urologic community on the best way to report surgical complications after oral graft harvesting, and this absence has hampered proper evaluation of the reconstructive urologist’s work and possibly progress in the reconstructive urethral surgery field. For a valuable quality assessment, relevant data on complications must be obtained in a standardised and reproducible manner to allow comparison between the different centres, between different techniques, and within a single centre over time.
The aim of this study was to investigate oral morbidity and patient satisfaction in a homogeneous group of patients who underwent OM harvesting from a single cheek using the same standardised technique.
Section snippets
Study design
The study is a prospective analysis of 350 patients (median age: 42 yr; range: 14–78 yr) who underwent OM graft harvesting for urethral reconstruction from a single cheek. Patients who underwent OM harvesting from both cheeks or from the lip or from both cheek and lip were excluded from the study. The primary outcome measure was the incidence of early and late complications, as was recorded using an internal self-administered, semiquantitative, nonvalidated questionnaire (Appendix). The
Early complications
Early postoperative complications are summarised in Table 1 and included bleeding from the harvesting site, which occurred within 3 d after surgery in 15 patients (4.3%). However, only two patients at the beginning of our learning curve required immediate surgical revision of the harvesting site to stop bleeding. The majority of patients (85.2%) showed no pain (49.2%) or slight pain (36%) in the immediate postoperative course, and only 3.7% of patients required use of anti-inflammatory drugs
Discussion
Patient-reported outcomes (PROs), such as a health-related quality of life (HRQoL) questionnaire, have been used to investigate the general outcome of a surgical procedure, but recently there has been interest in using PROs to aid management of individual patients. In medicine, PROs have been used in clinical practice in various ways. Instruments like one-time screening questionnaires for conditions such as depression or cancer provide feedback to patients’ clinicians on communication, clinical
Conclusions
Harvesting oral graft from a cheek with wound closure is a safe procedure with a high patient satisfaction rate. To avoid postoperative complications, it is mandatory to harvest the graft in an ovoid-shaped fashion, and the size of the graft should not exceed 4 cm in length and 2.5 cm in width.
Urethral conditions affect children and adults, increasing the risk of urinary tract infections, voiding and sexual dysfunction, and renal failure. Current tissue replacements differ from healthy urethral tissues in structural and mechanical characteristics, causing high risk of postoperative complications. 3D bioprinting can overcome these limitations through the creation of complex, layered architectures using materials with location-specific biomechanical properties. This review highlights prior research and describes the potential for these emerging technologies to address ongoing challenges in urethral tissue engineering, including biomechanical and structural mismatch, lack of individualized repair solutions, and inadequate wound healing and vascularization. In the future, the integration of 3D bioprinting technology with advanced biomaterials, computational modeling, and 3D imaging could transform personalized urethral surgical procedures.
The advent and success of buccal mucosal grafts as a substitution material in the urinary tract has changed the landscape of reconstructive urology. Due to its ease to harvest, low morbidity, and advantageous properties, there has been a growing number of applications for buccal mucosal grafts in upper and lower urinary tract reconstruction as well as genital reconstruction. In this article, we review the historical application and the evolution of buccal mucosal grafts and provide an up-to-date review on its utilization in urologic procedures.
At present, excision and primary anastomosis (EPA) urethroplasty is a highly reliable method of reconstruction for short bulbar urethral strictures. Longer strictures are often managed with grafting techniques to ensure a tension-free repair. Here we report our initial experience with a new, extended anastomotic technique for long bulbar strictures that incorporates plication of the ventral corporal bodies to reduce the distance between the urethral ends and obviates the need for grafting.
We reviewed records for all urethroplasties performed by a single surgeon at our institution between January 2018 and February 2020. We identified a cohort of older patients with complex strictures who underwent Extended Primary Anastomosis with Penile Plication (EPAPP). Patient demographics, stricture characteristics, perioperative 75 parameters, and postoperative outcomes were evaluated.
Of 346 urethroplasty records reviewed, 10 patients (2.9%) underwent EPAPP. Mean stricture length was 3.75 ± 1.4 cm. EPAPP patients were older than those repaired by other techniques (mean age 66.6 vs 55.6, P = .024), and most were not sexually active preoperatively. Postoperative voiding cystourethrogram confirmed urethral patency without extravasation in all patients. At a median follow up of 9.7 months (IQR 8.5-11.5) 8 patients remained asymptomatic after EPAPP alone and 2 patients required a single balloon dilation for stricture recurrence.
EPAPP is a promising alternative option for the management of long bulbar strictures among appropriately selected patients.
To assess efficacy and safety of liposomal bupivacaine (LB) infiltration of the buccal mucosal graft (BMG) harvest site in alleviating pain by evaluating the postoperative narcotic usage, pain score, and morbidities.
Single-blinded randomized controlled trial of 43 adult patients for BMG substitution urethroplasty between January 2015 to June 2017 (Clinicaltrials.gov: NCT03720223). A computer-generated allocation scheme randomized patients to control group (n = 22) no further local anesthetic infiltration aside from that of used in the hydrodissection for BMG harvest, and to intervention group with additional infiltration of LB to BMG harvest site (n = 21). We assessed postoperative cumulative narcotic use on post-op day 1 and 2 (24- and 48-hour total intravenous [IV] morphine equivalents in milligrams). A self-reported 10-point numeric rating scale survey was administered to assess postprocedural oral pain, oral conditions, and morbidity on days 1-3, and at 1-month follow-up. Fisher's exact test and independent T test were performed to assess differences between treatment groups. Linear regression was used to determine adjusted effect estimates of intervention.
Compared to controls, a significantly lower narcotic use was noticed among the LB treatment group on post-op day 1 (IV morphine equivalent mean difference 8.58 mg; 95% confidence interval 1.59, 15.56, P =.017), while no significant difference was noticed on post-op day 2. There was no significant difference between treatment groups with regards to postprocedural oral pain score or oral morbidities.
Our study showed that LB infiltration of the BMG harvest site is safe and associated with lower 24-hour narcotic use only at post-op day 1.
To compare the postprocedural oral pain scale and other patient reported oral morbidities for nonclosure vs closure of buccal mucosal graft (BMG) harvest sites through systematic review and meta-analysis of comparative studies.
A systematic literature search was performed in September 2018. Nonrandomized comparative studies were summarized and randomized controlled trials were evaluated according to the Cochrane Collaboration recommendations. The outcomes assessed were: pain, perioral numbness, mouth opening tightness, and impairment of oral intake. Standardized mean difference, and relative risk with corresponding 95% confidence intervals were extrapolated. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed according to the shape of the BMG harvested. PROSPERO registry (CRD42016043502).
A total of 269 patients from 4 randomized controlled trials were included for meta-analysis. Overall pooled effect estimates on the reported pain score assessed on postprocedural day 1, day 3-7 and 6 months, have shown no significant difference between the closure and nonclosure treatment groups. Subgroup analysis showed that rectangular shaped BMG harvest sites that were not closed had lower pain scores (standardized mean difference−0.90, 95% confidence interval −1.70, −0.10) on postoperative day 1. No reported short or long-term oral morbidities required further surgical intervention in either treatment group.
The evidence suggests that at 6-month follow-up, there is no overall significant difference between nonclosure and closure of BMG harvest sites. However, among rectangular shaped BMG, not closing the harvest site may lead to less immediate postoperative pain when compared to closure of the harvest site.
