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Paper text:
a 58-year - old african american gentleman presented with a history of idiopathic bulbar urethral stricture disease .
he had been managed with multiple transurethral dilation and incision procedures for over a decade .
urodynamics testing had been performed previously and demonstrated a high - pressure , low - flow pattern with normal bladder capacity .
his additional medical history included sarcoidosis , anemia of chronic disease , gout , and hypertension .
urinalysis , prostate - specific antigen levels , and testosterone levels were within normal limits .
after extensive counseling , the patient was taken to the operating room for definitive management of his stricture with substitution urethroplasty .
four 4 - 0 vicryl stay stitches were placed in the urethra to allow for 180 degrees of rotation , providing excellent access to the dorsal urethra .
the dorsal aspect of the urethra was opened sharply at the 12 o'clock position between the stay sutures ( fig .
the length of the urethrotomy was extended until the distal and proximal urethral segments easily accommodated 26-fr and 30-fr calibration , respectively ( fig .
the stricture ultimately measured 7 cm in length , and the urethral plate measured 1.2 cm in width .
a buccal mucosal graft measuring 2.2 cm in width was harvested from the inner left cheek in standard fashion .
, the ventral urethral plate was sharply incised in the midline without significant violation of the spongiosum .
the wings of the opened plate were mobilized with sharp dissection to allow for an elliptical defect .
the graft was sewn into place by using two separate 5 - 0 pds sutures in running fashion ( fig .
a lubricated 16-fr silicone foley catheter was then placed under vision across the repaired area ( fig .
the patient 's postoperative imaging 3 weeks after the procedure demonstrated a patent , wide - caliber urethra ( fig .
3 ) . after 3 years of follow - up , he was voiding with a strong stream and with minimal pvr ( < 10 ml ) at every visit .
historically , numerous surgical approaches have been used to treat these lesions . depending on the length and location of the stricture as well as the experience and preference of the surgeon
, strictures in the bulbar urethra may be approached in an excisional manner or with tissue substitution .
although excision with primary anastomosis can be applied to extensive proximal strictures , this is controversial and challenging for most practicing urologists . for longer or more complicated strictures , substitution techniques utilizing grafts or flaps
substituted tissue is transferred into the urethra as either an onlay or inlay . in onlay procedures , the urethra and its overlying spongiosium
the graft material is then either substituted in place of both the mucosa and sponge together ( dorsal onlay ) or in place of the mucosa only with the transected sponge being closed over the repair ( ventral onlay ) . in contrast , in inlay procedures , only the mucosa of interest is opened throughout the length of the stricture , with the corresponding sponge remaining largely undisturbed .
the mucosal edges are then usually undermined to some degree , and the graft material is then sewn to the edges of the mucosa . in general , bulbar strictures in excess of 2 cm are most commonly treated with ventral onlay of buccal mucosa .
although this is a fairly straightforward procedure anatomically , it does require disruption of the ventral spongiosum .
it is important to recognize that this vascular tissue bed becomes much more concentrated ventrally as one moves from the distal to the proximal urethra .
division of this network of vessels can contribute to intraoperative blood loss that may limit visualization .
additionally , there is a theoretical benefit in terms of graft support if more of this vascular tissue could be spared .
furthermore , suture reapproximation of the spongiosum after a ventral onlay could create a furled lie of the graft , although this has not been established to the author 's knowledge .
this work builds on the concept of a " stricturoplasty " that takes advantage of the heineke - mikulicz principle .
this was previously described by james pierce in 1962 and was resurrected by lumen et al .   in 2010 .
andrich and mundy   wisely point out that some patients may already have impaired retrograde blood flow ( e.g. , prior hypospadias repair ) , and preservation of vascularity seems prudent .
the ventral inlay technique that we have described here is designed to minimize disruption of the spongiosum while providing a well - vascularized bed for the graft . whereas this may not be well suited to every patient with stricture disease ( i.e. , patients with full thickness spongiofibrosis ) , for well - selected patients
additionally , patients presenting for definitive repair of urethral stricture may require further urethral procedures for other reasons later in life .
for example , many patients will go on to be screened and possibly treated for prostate cancer . despite improvements in delivery of radiation and technical performance of radical prostatectomy ,
a subset of these men may require placement of an artificial urinary sphincter for treatment of incontinence .
it is logical to assume that maximizing the potential of the urethra to resist compression - induced erosion would , therefore , be beneficial .
this concept has been reinforced by utilizing surgical maneuvers to preserve the bulbar arteries at the time of anastomotic urethroplasty .
additionally , andrich and mundy   point out that minimizing spongiosal trauma may also be of benefit to patients who require a subsequent urethroplasty .
thus , in the era of minimally invasive surgery , it seems prudent to preserve as much blood flow as possible as long as this does not compromise the treatment of the patient .
since this is the first description of an approach to bulbar stricture disease and a solitary case , it does not serve to establish superiority over ventral onlay substitution .
however , our report demonstrates the feasibility of substitution urethroplasty for bulbar strictures with minimal disruption to the ventral spongiosum .
one may argue that ventral onlay is often done in the proximal bulb , because this technique obviates the disruption associated with circumferential urethral mobilization .
alternatively , dorsal onlay could be performed as suggested by andrich and mundy . however , a few key points deserve consideration .
reviewed ventral , dorsal , and lateral graft onlays for bulbar strictures and showed no difference in overall success .
more recently , figler et al .   also reviewed the impact of graft position and once again showed no appreciable differences between dorsal and ventral placement .
however , what if the ventral onlay technique only failed to show superiority owing to division of the spongiosum ?
barbagli 's group suggested that " ventral placement of the graft is more efficacious in the proximal part of the bulbar urethra , where the spongiosum tissue is thicker and better vascularized . "
additionally , they felt that graft failure may stem from poor inosculation from insufficient vascularity of the graft bed , which would seem more likely when the graft is placed on the thinner dorsal spongiosum or on a divided ventral spongiosum .
the approach described here takes advantage of having a graft in direct contact with an undisturbed bed of spongiosum at its thickest location . to the authors ' knowledge
, this represents the first description of a ventral inlay in the treatment of urethral stricture disease .
although further study will be required to determine the role of this type of repair in the reconstructive urologist 's armamentarium , feasibility has been established and a logical rationale exists for considering this type of approach .
to describe the novel technique of ventral inlay substitution urethroplasty for the management of male anterior urethral stricture disease . a 58-year - old gentleman with multifocal bulbar stricture disease measuring 7 cm in length 
 was treated using a ventral inlay substitution urethroplasty . 
 a dorsal urethrotomy was created , and the ventral urethral plated was incised . 
 the edges of the urethral plate were mobilized without violation of the ventral corpus spongiosum . a buccal mucosa graft was harvested and affixed as a ventral inlay to augment the caliber of the urethra . 
 the dorsal urethrotomy was closed over a foley catheter . 
 no intraoperative or postoperative complications occurred . 
 postoperative imaging demonstrated a widely patent urethra . 
 after three years of follow - up , the patient continues to do well with no voiding complaints and low postvoid residuals . 
 ventral inlay substitution urethroplasty appears to be a safe and feasible technique for the management of bulbar urethral strictures .