Presentation Authors: Shyam Sukumar*, New York, NY, Cooper Benson, New Orleans , LA, Debduth Pijush, Carlos Pagan, Steven Brandes, New York, NY
Introduction: Buccal mucosal grafts (BMGs) are the standard graft material for urethroplasty. Graft take is dependent on a proper host bed and graft. Quality of BMGs can be variable. A leak on post op voiding cystourethrography (VCUG)is believed to be from poor graft take. The effect of BMG histology or oral health or graft take is unknown. The role of oral health or mouth dimensions on postoperative facial morbidity is unknown.
Methods: Prospective review of 10 patients undergoing augmentation urethroplasty with BMG for bulbar strictures. Pre-op and post-op day 1 and 3 wks, patients completed oral health questionnaires: The Kayser-Jones Brief Oral Health Status Exam (BOHSE), McGill Pain Questionnaire (McGill),Oral Health Impact Profile Questionnaire (OHIP 14), and Oral Patient Reported Outcomes Measures(PROMS). Mouth dimensions and measurements were also obtained. Post-op VCUGs were evaluated for leak at 3 weeks. Histology of harvested BMGs were assessed by staff pathologist (CAP) using calibrated eyepiece to measure thickness of each anatomic layer, and grade the graft by a validated oral mucosal inflammation and ulceration index (Oral Mucositis Index).
Results: Mean age 38.7yrs, Q max 6.1 ml/s, IPSS 22, SHIM 17. Types of urethroplasty: Palmintieri double buccal urethroplasty-3, dorsal onlay with ventral inlay-1, combined ventral bulbar BMG with dorsal penile BMG-1, dorsal BMG-2, augmented anastomotic-2, Asopa-1. Mean pre-op oral health scores were low or normal. Mean McGill and Oral PROMS scores at POD 1, 2.1 and 2.0, and at 3 weeks, 17.9 and 17.7, respectively. Mean pre-op mouth dimensions: opening, 4.9 cm (4.5-6.0) and commissure to TMJ length- 4.1 cm(3.5-8). Mean size of BMG harvested = 4.8 x 1.6 cm, and on stretch 5.4 x 2.0 cm; mean delta 9.8% (0-28%)and 18.1%(0-34%),respectively. Patients with the highest pain and oral PROMS scores post op had bilateral BMGs or the smallest mouth opening and shortest length. Mean microscopic thickness of each layer of BMG: epithelium - 692Âµ(500-1200),lamina propria-97Âµ(50-200), and submucosa -1093 Âµ(400-1900). Average mucositis score 2.9(0-11)and BMG friability - 2 (1-3). The patient with a VCUG leak had the highest mucositis index score, lowest SHIM and thickest submucosa.
Conclusions: Harvested BMG vary in quality as to elasticity, thickness, friability and histology. Smaller mouth dimensions appear to be associated with worse post-operative morbidity and pain. Worse BMG histology as to mucositis and submucosa thickness appear to negatively affect graft take. A larger multi-institutional study is currently underway.