Neourethral Reconstruction With Folded Buccal Mucosa

Urethral strictures – narrowings of the urethra – present a significant challenge in reconstructive urology. These can arise from trauma, inflammation, infection, or prior surgical interventions, leading to bothersome urinary symptoms like weak stream, incomplete emptying, and recurrent infections. While various techniques exist for urethral repair, complex or long-segment strictures often require neourethral reconstruction, the creation of a completely new urethra using alternative tissue sources. Historically, options were limited by graft availability and success rates. However, in recent decades, buccal mucosa – the lining of the inner cheek – has emerged as a highly reliable and versatile material for this purpose, especially when utilizing a folded technique to maximize urethral caliber and minimize complications.

The beauty of using buccal mucosa lies not only in its histological similarity to the urethra but also in its ready accessibility and relatively non-inflammatory nature. Unlike skin grafts which tend to contract and epithelialise poorly within the urinary tract, buccal mucosa offers excellent long-term results with a lower risk of stenosis (re-narrowing). The ‘folded’ technique specifically enhances these benefits by essentially doubling the mucosal surface area available for urethral lining, creating a wider and more compliant neourethra. This approach has become a gold standard for many urologists treating extensive urethral loss or complex stricture disease, providing patients with improved urinary function and quality of life. It’s important to understand that this is a sophisticated surgical procedure reserved for cases where simpler repair methods are unlikely to succeed.

Indications and Preoperative Assessment

The decision to proceed with neourethral reconstruction using folded buccal mucosa isn’t taken lightly. Careful patient selection and thorough preoperative assessment are paramount to success. Primarily, the technique is indicated in patients with:

Long-segment urethral strictures (typically >2cm)
Strictures secondary to trauma or prior failed repairs
Panurethral strictures – involving the entire urethra
Urethral loss due to cancer resection or extensive injury

However, certain contraindications exist. Active urinary tract infection must be ruled out and treated preoperatively. Significant comorbidities like uncontrolled diabetes or severe cardiovascular disease should be optimized before surgery. Patients with a history of lichen sclerosus in the oral cavity may not be ideal candidates, as this can impact the quality of the buccal mucosa graft. A comprehensive assessment includes:

Detailed medical history focusing on previous urological interventions and systemic conditions.
Physical examination including evaluation for associated pelvic floor dysfunction.
Urodynamic studies to assess bladder function and identify any underlying voiding disorders.
Imaging studies – retrograde urethrogram, cystoscopy, or MRI – to define the extent and location of the stricture/loss and plan surgical approach. This imaging is critical for determining the length of buccal mucosa required.
Thorough oral examination to assess the health of the buccal mucosa itself, ensuring it’s free from lesions or inflammation.

Patient counseling is crucial, explaining the procedure’s complexity, potential risks (including graft contraction, fistula formation, and need for further interventions), and expected outcomes. Realistic expectations are key to patient satisfaction. The goal is always functional improvement – complete restoration of normal voiding isn’t always achievable, but significant symptom relief is often possible.

Surgical Technique: Harvesting and Preparation

The surgical technique itself involves several distinct phases, beginning with the careful harvesting of buccal mucosa. Typically, an ellipse of mucosa is marked inside the patient’s cheek, avoiding areas with prominent blood vessels or salivary gland ducts. The size of this ellipse dictates the length of the neourethra created; meticulous planning based on preoperative imaging is essential to ensure sufficient graft material. Once harvested, the buccal mucosa undergoes a crucial preparation step: folding. This is usually achieved by creating parallel incisions along the mucosal surface, effectively doubling its width without compromising its tensile strength. The resulting folded mucosa resembles a ‘tube’ ready for anastomosis – connection – with the remaining urethral segments or skin grafts if necessary.

This folding process isn’t merely about increasing caliber; it also creates a more compliant and adaptable graft. The folds allow for better stretch and conformability within the urinary tract, reducing the risk of contracture over time. Some surgeons prefer to perform the folding in situ – directly in the mouth – while others may choose to fold it on a back table under sterile conditions. Regardless of the method, precise technique is vital to avoid tears or damage to the mucosal surface. The prepared buccal mucosa graft is then ready for implantation during the reconstructive phase of the surgery.

Anastomosis and Postoperative Care

The actual reconstruction involves creating a connection between the harvested and folded buccal mucosa graft and the existing urethral segments, or if there’s complete urethral loss, to skin grafts at both ends. This anastomosis requires meticulous surgical skill and attention to detail. The technique employed varies depending on the location and extent of the stricture/loss – end-to-end anastomosis is used for connecting two urethral segments, while flap reconstruction may be necessary in cases of extensive tissue loss. Suprapubic catheter drainage is typically placed immediately postoperatively to divert urine and allow the neourethra to heal without pressure or contamination.

Postoperative care is critical for maximizing success rates. Patients will require several weeks with a suprapubic catheter, during which regular follow-up appointments are scheduled to monitor for complications like infection, fistula formation, or stricture recurrence. Gradual catheter removal – typically in stages – allows the neourethra to adapt and function properly. Long-term monitoring is also essential, as late stenosis can occur even years after successful reconstruction. Patients are instructed on pelvic floor exercises to strengthen urethral support and optimize voiding function. The overall success of this technique relies heavily on a multidisciplinary approach involving careful preoperative planning, meticulous surgical execution, and diligent postoperative management.

Long-Term Outcomes and Considerations

Long-term outcomes with folded buccal mucosa neourethral reconstruction are generally excellent, demonstrating significantly improved urinary function in appropriately selected patients. Studies report patency rates (the percentage of patients remaining free from stricture recurrence) ranging from 70% to 90% at five years or more, which is substantially higher than historical results achieved with other techniques. However, it’s important to acknowledge that this isn’t a one-size-fits-all solution and complications can occur. Potential long-term issues include:

Stricture recurrence – despite high patency rates, some patients will experience re-narrowing of the neourethra requiring further intervention
Fistula formation – an abnormal connection between the neourethra and surrounding tissues
Graft contraction – leading to decreased urethral caliber and flow
Urinary incontinence – though less common, can occur due to altered urethral support

Regular follow-up is essential for early detection and management of these complications. Patient education on self-monitoring for urinary symptoms is also vital. Furthermore, the aesthetic impact of buccal mucosa harvesting should be discussed with patients preoperatively. While generally minimal, some degree of cheek asymmetry or discomfort can occur. In conclusion, neourethral reconstruction with folded buccal mucosa represents a significant advancement in reconstructive urology, offering a reliable and durable solution for complex urethral stricture disease and loss. It requires careful patient selection, meticulous surgical technique, and dedicated postoperative care to achieve optimal outcomes.