Flap vs graft final

2. GRAFTS OR FLAPS…......................
Ahmed Eliwa
MD Urology , Zagazig University

5. Grafts
Flaps
Technique
Outcomes
Disadvantages
Technique
outcomes
Advantages

6. • In 1993, El-Kasaby et al. first suggested the use of
oral mucosal graft from the lip in the management of
penile and bulbar urethral strictures.
• From 1966 to 2006, a total of 1,267 studies were
reported in the literature on the use of oral mucosa
in reconstructive surgery

7. Technical aspects
• Advantages of grafts especially oral mucosa
• Reliability and reproducibility
• Multiple sources

8. Technical
outcomes
Why grafts are good
Buccal mucosa offers the advantages of being
• accustomed to a wet environment
• good vascularity
• Hairless
• easy to harvest
• thick epithelium making it easy to handle
• less chance of graft contracture
• thin lamina propria allowing early inosculation,
reduced rate of pseudodiverticulum formation
Bhargava S, Chapple CR: Buccal mucosal urethroplasty: is it the new
gold standard? BJU Int. 2004; 93: 1191-3.

9. Easier
• GRAFTS are quick and relatively easier to
harvest and deploy.
Technical
outcomes

10. Technical
outcomes

11. Technical
outcomes
“The simplicity and speed by which a graft
can be harvested and deployed means that
this is the procedure of choice as far as we
are concerned.”
Easier

12. Technical
outcomes
Multiple Sources
TEMS instruments. TEMS, transanal ndoscopic
micro-surgical technique.
Transanal endoscopic micro-surgical technique
(TEMS) in salvage urethroplasty
Xu YM, Qiao Y, Sa YL, et al. Urethral reconstruction using
colonic mucosa graft for complex strictures. J Urol
2009;182:1040-3

13. ON THE OTHER HAND………

14. • The flaps used in urethral reconstruction are
random island flaps of penile or scrotal skin
carried on a dartos pedicle
random, because there is no
defined artery supplying them
and so for the skin paddle to
remain viable, an extensive
dartos pedicle must be created

15. • The use of genital skin pedicle flap is a difficult
procedure
• Requiring extensive penile and scrotal
dissection to mobilize the flap to the deep
perineum
• time-consuming (and tedious)
• associated to postoperative torsion and penile
scarring .
• Loss of the normal contour of the penis
Morey AF, McAninch JW: When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology. 1996; 48:
194-8.
Greenwell TJ, Venn SN, Mundy AR: Changing practice in anterior urethroplasty. BJU Int. 1999; 83: 631-5.

16. Technical limitations
• Lichen Sclerosis
• previous hypospadias repair
• recurrent balanitis/balanoposthitis with
scarring
• Cicumcision

17. Outcome

18. • The results of buccal mucosa grafts for
urethral stricture reconstruction have been
excellent (90±100%)
• El-Kasaby AW, Fath-Alla M, Noweir AM, El-Halaby MR, Zakaria W, El-Beialy MH (1993) The use of buccal mucosa
patch graft in the management of anterior urethral strictures. J Urol 149: 276±278
• Lopez JA, Valle J, Timon A, Blasco B, Ambroj C, Murillo C, Valdivia JG (1996) Use of autologous buccal mucosa graft
for urethral surgery in males. Eur Urol 29: 227±230
• Morey AF, McAninch JW (1996) When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology
48: 194± 198

19. The buccal mucosa graft has been enthusiastically
adopted for the repair of anterior urethral
strictures, with early results being excellent, and
may open up a new chapter in urethral
reconstructive surgery
• Burger RA, Muller SC, El-Damanhoury H, Tschakalo€A,Riedmiller H, Hohenfellner R (1992) The buccal mucosa graft for urethral
reconstruction: a preliminary report. J Urol 147:662±664
• El-Kasaby AW, Fath-Alla M, Noweir AM, El-Halaby MR, Zakaria W, El-Beialy MH (1993) The use of buccal mucosa patch graft in the
management of anterior urethral strictures. J Urol 149: 276±278

20. BMG has been used successfully for treating
all types of strictures, with medium-term
outcomes comparable to using skin
Because of its inherent advantages buccal
mucosa has become the recommended
source for tissue substitution

21. • [diverticulum formation, hair growth,
dermatitis of the inlay, and restenosis].
Rogers HS, McNicholas TA, Blandy JP (1992)
Long term re-sults of one stage scrotal patch
urethroplasty. Br J Urol 69: 621±628

22. • penile skin flaps are tedious to develop and
mobilize and have not been uniformly
successful in adult stricture disease
De La Rosette JJMCH, De Vries JDM, Lock MTWT, Debruyne FMJ
(1991) Urethroplasty using the pedicled island Flap technique in
complicated urethral strictures. J Urol 146: 40±42

23. • Extragenital skin flap is associated to higher
complication rates,
7. Webster GD, Brown MW, Koefoot RB Jr, Sihelnick S: Suboptimal results in full thickness
skin graft urethroplasty using an extrapenile skin donor site. J Urol. 1984; 131: 1082-3.

25. now clearly established from a review of the
literature that the stricture recurrence rate is 14.5%-
15.7% using a flap or a graft
A randomized controlled trial confirmed that the efficacy of
grafts and flaps was identical, but there was a much higher
morbidity with penile skin flaps, which were also technically
more complex and were thus less likely to be preferred by
patients
In the bulbar urethra, the current standard of
care is to use a graft in most cases, because
the efficacy of grafts and flaps appears to be
virtually identical.

26. • The real controversy in modern stricture
reconstruction is the following:
• should one choose a free graft or a distal
penile skin flap to reconstruct long strictures
in the face of a compromised graft bed?