
 urethral stricture is a chronic and common urological problem and difficult to manage fraught with high patient morbidity and stricture recurrence [ 1 , 2 ] . since the resurgence in the use of buccal mucosa grafts ( bmg ) in substitution urethroplasty in the late 1980s ,
there has been controversy over which surgical technique is the most appropriate for its application . in experienced hands
the results of the ventral and dorsal onlay of bmg for bulbar urethroplasty are the same .
bmg has become an ideal urethral substitute because of ease of harvest , surgical handling characteristics , hairlessness , and compatibility in a wet environment and it is early in growth and graft survival ; because of these unique characteristics , buccal mucosa has gained popularity in the realm of reconstructive urology .
standard bulbar urethroplasties using bmg should have a lifetime success rate approaching 92% [ 3 , 4 ] .
there is paucity of data on this subject in sub - saharan africa ; the purpose of this study was to compare ventral and dorsal onlays for bulbar urethroplasty in a low resource setting .
it is performed at a tertiary referral hospital at mulago over a two - year duration ( 20102012 ) .
consecutive patients presenting with difficulty in passing urine ( weak stream , incomplete emptying , and frequency ) due to a penile urethra stricture were recruited in two phases : over a 12-month period for dorsal onlay grafting and the subsequent 12 months another set was recruited for ventral onlay grafting .
we collected data using a questionnaire ; data were extracted from the patients files and entered in an excel spread sheet and then exported to spss version 17 and analysis was done using descriptive statistics .
a urethral stricture was diagnosed through history taking and physical examination and confirmed on performing a cystourethrogram ( ascending and micturating urethrogram ) .
recurrence ( failure ) was defined as a need for additional surgical procedure or filiform bougienage within the follow - up period .
variables studies included level of client satisfaction ; patients were asked if they were satisfied or not with the ease of voiding urine , erectile dysfunction ( ed ) , and postvoid dribbing .
ed was considered if it was of sudden onset and did not exist prior to surgery .
the question asked was if at any time after surgery erections were insufficient for intercourse in comparison to before surgery .
postvoid dribbling was defined as a dribble or urine leak a few minutes after voiding .
the success of urethroplasty was from the patient self - reports of improved urine stream , complete emptying , and reduced frequency .
the perineal dissection team laid the stricture open to determine its length before the graft harvest team proceeded .
all the patients received intraoperative antibiotics ( ceftriaxone and metronidazole ) intravenously before the oral mucosa was excised .
the face and cheek were prepped with 0.5% chlorhexidine and draped in the usual sterile manner with sterile linen .
three 3/0 silk sutures are placed through the lip to provide traction . a mouth gag and a retractor
0.5% of bupivacaine with epinephrine were injected underneath the graft for preemptive analgesia and intraoperative haemostasis .
the graft was incised and dissected off of the buccinators muscle , while avoiding stensen 's duct .
the oral pack is removed in the evening and the patient is asked to rinse his mouth with cold water and dilute mouthwash .
the cavity was inspected for any bleeding and the patient asked to start cold oral liquids in the evening . in a day or two the patient was advised to shift to semisolid , nonspicy diet and can consume normal diet as soon as he can tolerate it . patient was placed a high lithotomy position , properly padded and secured . subsequently the patient 's perineum was prepped with 0.5% of chlorhexidine and draped in normal sterile fashion .
a 22f catheter was used to delineate the urethral contour and to determine the exact location of the distal portion of structure ; a number 15 blade scalpel was used to incise the urethra over the urethral catheter and the urethral stricture is opened completely .
the lumen of the structure was intubated with either an 8f - feeding tube or with a small ( < 8  mm ) guide wire , and the stricture was incised until normal urethra was identified .
both proximal and distal urethral stumps were bougied to ensure they are wide open to 30f .
the buccal mucosa was then sewn onto the ventral defect using a running and interlocking 5/0 vicryl suture , for a good seal .
the tunic of the spongiosum is closed over the graft for a well vascularized bed .
the bulbospongiosus muscle was closed with a running 3/0 vicryl and the skin was closed with multiple vertical mattress stitches using 2/0 vicryl rapide .
the technique employed was similar to the one outlined by barbagli et al , 2006 .
for the follow - up period , the catheters were removed on the 21st day after the operation was done .

 table 1 shows the demographic , clinical characteristics and the outcomes of the buccal graft procedures .
the mean age was 55 years , the age range was 1086 years , and the recurrence rates were 1620% .
40 dorsal grafts provided success in 32 ( 8 failed cases ) and 32 ventral grafts provided success in 27 ( 5 failed cases ) .
we found that dorsal and ventral onlay grafts offer the same performance ; the recurrence rates were 1620% , comparable with data from elsewhere [ 1 , 2 , 913 ] .
the procedures were fairly easy to perform ; the mean operating time was 2 hours .
the etiology of these strictures was postinflammatory ( infection ) for the most part ( 97% ) as is common in low resource settings where urethritis due to sexually transmitted diseases is prevalent .
for the most part , the outcome for both dorsal onlay grafts and ventral onlay grafts in bulbar urethroplasty is similar .
the findings in this study affirm that the ventral onlay technique is , however , less cumbersome and therefore more suitable for surgeons new to the practice of urethroplasty .
the complications associated with ventral onlay techniques can be minimized by meticulous surgical technique , but in series with longer followup , complications still tend to be more prevalent . in urethroplasty ,
two - stage dorsal onlay of bmg ( after complete excision of the scarred urethra ) still provides the best results , although in certain circumstances a one - stage dorsal onlay procedure is possible . in general ,
tube graft procedures in the management of bulbar urethral strictures are associated with much higher rates of recurrence and should therefore be avoided .
the most common graft materials in use today are buccal mucosa ( bm ) , preputial skin ( when available ) , and penile and preputial skin flaps with their own blood supply .
the most appropriate use of these materials has long been the subject of controversy , especially in terms of which type of tissue and whether as a graft or flap and at which site along the urethra [ 813 ] .
the use of bm in urethral surgery was first described in 1941   but not reported again until the late 1980s . since then
, it has proved to be a versatile graft material well suited to repair the urethra [ 10 , 1517 ] because it is a wet epithelium , which is easily harvested and amenable to surgical manipulation , has a privileged immunity rendering it less prone to infection , and is more resistant to stricture recurrence than skin particularly in the presence of lichen sclerosus , previously known as balanitis xerotica obliterans . in this study
, we experienced 10% ( 7 patients ) stricture recurrence and the three had perineal wound infections .
bm also has a dense submucosa with a dense capillary network that facilitates the early imbibition of nutrients from the wound bed as well as early inosculation of neovasculature [ 10 , 1518 ] .
the graft is harvested either from the inner aspect of one or both cheeks , from the posterior lower lip , or in cases where extensive substitution is necessary , from all three sites .
several papers have looked at the morbidity associated with harvesting the bm graft , and all conclude that morbidity is lower with inner cheek harvest than lower lip , because these patients tend to have a lesser degree of discomfort and a lower rate of paraesthesia ( secondary to mental or lingual nerve injury ) postoperatively [ 19 , 20 ] .
we however technically preferred the lower lip approach and had no adverse events . when substitution procedures are necessary , historically various tissues have been used including genital ( penile and scrotal ) skin , extragenital skin , bladder mucosa , and buccal mucosa .
these tissues have been used as either pedicled flaps with their own blood supply or as free tissue grafts . the use of colonic mucosa has also been reported , but this is not validated yet and seems to involve a significantly greater degree of morbidity for graft harvest than any of the other methods mentioned .
there was no difference between dorsal and ventral onlay buccal graft outcomes for bulbar urethral strictures .
the success rate was 80 to 84% after an average follow up period of one year .
this was a single - site study and by one operator experienced in dealing with urethral strictures .
cug ( cystourethrogram ) was only done for those experiencing difficulties in passing urine ; no follow - up cystoscopies were done ( for any patient ) .
poor oral hygiene and the use of tobacco were not factored in as potential confounders ; these factors are known to influence the outcome of the bmg .
the mean follow - up period of one year was short to draw definite conclusions , though a general sense is given for ease of performing the procedure and short term outcomes especially of urethral patency .
 
 purpose . 
 although the use of buccal mucosa in substitution urethroplasty has been practiced for some years , it has not been free of controversy over which surgical technique is the most appropriate to use . 
 there is paucity of data in sub - saharan africa about its success ; this study presents the outcomes of dorsal and ventral buccal graft urethroplasty at a sub - saharan tertiary hospital . methods . 
 this is a prospective study in which buccal mucosa was used for ventral and dorsal grafts ; followup was up to two years . 
 all patients provided informed written consent for the procedures . results . 
 seventy - two patients with bulbar urethral strictures underwent buccal graft one - stage urethroplasty . 
 mean age was 55 years ; etiology of the strictures was postinflammatory due to urethritis from sexually transmitted infections 97% ( 70/72 ) and trauma 3% ( 2/72 ) . 
 buccal mucosa grafts were harvested from the cheek using a two - team approach . 
 grafts were placed on the ventral and dorsal urethral surfaces in 32 and 40 cases , respectively ; the success rate was 84 and 80% , respectively . 
 repeated urethroplasty was successfully done among 10% ( 7/72 ) and patients reported resolution of symptoms in the follow - up period . conclusion . 
 there was no difference between dorsal and ventral onlay buccal graft outcomes for bulbar urethral strictures . 
 the success rate was 80 to 84% . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion
Limitations