Treatment of panurethral strictures using one side dissection dorsal onlay buccal mucosal graft urethroplasty

The management of panurethral stricture was still challenging and controversial. We presented a case of pan urethral strictures management by using a one-sided dissection of dorsal onlay buccal mucosal graft (BMG) urethroplasty (Kulkarni technique). A 53-years old man admitted with panurethral stricture who had previously undergone several procedures. Bipolar micturition cystourethrography procedure revealed 17 cm stricture length. One-sided dissection dorsal onlay buccal mucosal graft urethroplasty was performed. No drain was placed. The Foley catheter was removed four weeks after surgery, and the results of the micturition were favourable. No fistulae were found at a straight erection and meatus at a normal position. The postoperative flow rate (Qmax) was 24.9 ml/second. As a conclusion Kulkarni technique urethroplasty gained good outcome for panurethral stricture in our case.


Introduction
Management of panurethral stricture has changed over time. Earlier the two stages of urethroplasty were introduced by Johanson in 1953. However, that technique relied on the genital skin to build the urethra as it may increase the risk of secondary recurrence to the integration of infected skin to the reconstructed site. 1 The treatment of urethral strictures using urethral reconstruction remains a challenge and varies by the site, length, depth, and thickness of the strictures. Especially for stricture with a length of more than 2 centimetres needs higher modalities and more challenging. [2][3][4] Panurethral stricture gives high morbidity rates and affecting patient's quality of life due to challenging management approach. A better understanding in patient care, may give important role for patient's quality of life in the future. [1][2][3] In this study, we describe our experience with one side dissection dorsal onlay buccal mucosal graft (BMG) urethroplasty technique for repairing long anterior urethral strictures.

Case Report
A 53-year-old male was admitted due to urinary retention. The patient started to complain about urinary retention after a prolonged and several attempts for indwelling urethral catheterization.  General anaesthesia was selected for the surgery, and the patient was positioned in a lithotomy position. The first approach was the urethral procedure, and the second was taking the graft from the buccal mucosa. Using a perineal approach by a midline incision, penile degloving was performed to free the penis from dartos and exposed it to the corpus spongiosum of the anterior urethra. Then using a onesided dissection, the bulbar urethra was separated from corpora cavernosa to prevent the artery from facing more damages. The penile urethra was then dissected to the coronal sulcus. Further, around 17 cm length narrowed segment of the urethra was identified and incised in the middle part along with the stricture area ( Figure 2). The next step was harvesting the graft from the buccal mucosa; an adequate length of the graft was gathered from the inner cheek area below the Stensen's duct (Figure 3). The graft was harvested mainly from the inner cheek and extended to the lower lip if a more

Discussion
The urethral stricture was defined as the narrowing of the calibre of the urethra due to the formation of scar tissues surrounding the urethra. 5,6 Meanwhile, a panurethral stricture is a urethral stricture involving the entire urethra from the meatus until the proximal bulbar. 4 Most panurethral strictures in developing countries were caused by lichen sclerosis and iatrogenic factors, such as urethral catheterisation, cystourethroscopy, transurethral resection, and previous urethral surgeries. 4,5 Other reports found trauma and sexually transmitted diseases are the most common factors. 7 The urethral substitution was priorly done by using flap and grafts from the genital area. However, genital skin pedicle flaps were required advanced penoscrotal dissection for flap mobilisation to the deep perineum and associated it with penile scarring and postoperative torsion. A higher complication rate was associated with the extragenital skin flap, but better results were reported using full-thickness retro auricular skin grafts. Buccal mucosa was emerging as a choice for flap in urethral reconstruction. Buccal mucosa graft offers some advantages due to its wet environment, good vascularity, hairless, easy handling, and harvesting compared to bladder mucosa.
Moreover, it had less possibility of graft contracture and less risk of pseudodiverticulum formation. It has become popular only after 1990. Even though, Humby has already described buccal mucosa for urethral substitution in 1941. 8,9 We presented one side dorsal onlay BMG urethroplasty,

Conclusion
Kulkarni technique urethroplasty gained good outcome for panurethral stricture in our case.