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| Lingual mucosal graft urethroplasty 12 years later: Systematic review and meta-analysis |
Alberto Abratea,Andrea Gregorib,Alchiede Simonatoa,*( )
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aDepartment of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
bDepartment of Urology, ASST Rhodense, G. Salvini Hospital, Garbagnate Milanese, Milan, Italy |
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Abstract Objective: To evaluate the functional results and complications of the lingual mucosal graft (LMG) urethroplasty and to sum up the current state of the art of this surgical technique. Methods: A systematic search of PubMed and Scopus electronic databases was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies involving male patients treated with LMG urethroplasty for urethral stricture were included. Complete protocol is available at http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017080121. A meta-analysis comparing functional and long-term oral complication outcomes of LMG and buccal mucosal graft (BMG) was performed, calculating the odds ratio (OR) and 95% confidence interval (CI). Results: Twenty original articles were included in the qualitative analysis. Strictures of 1.5-16.5 cm have been treated with LMG urethroplasty, due to the improvement of harvesting technique and very low rate of long-term oral complications. Very good functional results have been reported by different authors for LMG urethroplasty, with lower rate of oral complications than BMG. The meta-analysis included six comparative studies involving 187 and 178 patients treated with LMG and BMG urethroplasty, respectively. An OR of 1.65 (95% CI [0.95-2.87], I 2 = 0%) and 0.18 (95% CI [0.03-1.26], I 2 = 68%) were found for LMG vs. BMG urethroplasty, in terms of success and oral complication rate, respectively. Conclusion: LMG urethroplasty can be reasonably considered a first choice technique for urethral stricture with very good results. Oral complications are temporary and minimally disabling, basically less than those for BMG, and depend mainly on the graft extent.
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Received: 29 June 2018
Available online: 09 January 2019
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Corresponding Authors:
Alchiede Simonato
E-mail: alchiede@gmail.com
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Flow of information through the different phases of the systematic review.
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| Author [Ref.] | Type of study | Patients, n (LMG) | Type of graft | Follow-up, month (range) | LE | | Sharma et al., 2013 [17] | Prospective randomized controlled study | 30 (15) | LMG vs. BMG | 15.2 (NA) | 2 | | Chauhan et al., 2016 [20] | Prospective randomized controlled study | 102 (50) | LMG vs. BMG | 25 (12-52) | 2 | | Lumen et al., 2016 [18] | Prospective non-randomised controlled cohort study | 58 (29) | LMG vs. BMG | 30 (NA) | 3 | | Pal et al., 2016 [21] | Prospective non-randomised controlled cohort study | 60 (30) | LMG vs. BMG | 14.1 (7-19) | 3 | | Sharma et al., 2016 [26] | Prospective non-randomised study | 12 (12) | LMG | 11.6 (6-14) | 3 | | Simonato et al., 2006 [8] | Retrospective case series | 8 (8) | LMG | 18 (NA) | 4 | | Kumar et al., 2007 [22] | Retrospective case series | 30 (30) | LMG | 3.8 (NA) | 4 | | Simonato et al., 2008 [11] | Retrospective case series | 29 (27) | LMG or LMG + BMG | 17.7 (6-71) | 4 | | Singh et al., 2008 [12] | Retrospective comparative study | 55 (55) | LMG | 13-22 (NA) | 4 | | Barbagli et al., 2008 [16] | Retrospective case series | 10 (10) | LMG | 5 (3-12) | 4 | | Kumar et al., 2008 [29] | Retrospective case series | 25 (25) | LMG | 4.2 (2.5-7.4) | 4 | | Das et al., 2009 [13] | Retrospective case series | 30 (30) | LMG | 9 (4-12) | 4 | | Xu et al., 2010 [25] | Retrospective case series | 92 (76) | LMG or LMG + foreskin flap or LMG + BMG | 17.2 (3-33) | 4 | | Kumar et al., 2010 [15] | Retrospective comparative study | 79 (41) | LMG vs. BMG | 17.5 (12-26) | 4 | | Xu et al., 2011 [24] | Retrospective case series | 110 (110) | LMG | 22 (6-41) | 4 | | Xu et al., 2014 [14] | Retrospective case series | 36 (22) | LMG vs. BMG vs. LMG + BMG | 38.7 (12-110) | 4 | | Abdelhameed et al., 2015 [27] | Retrospective case series | 23 (23) | LMG | 66 (60-72) | 4 | | Zhang et al., 2016 [28] | Retrospective case series | 101 (101) | LMG | 23 (13-37) | 4 | | Xu et al., 2017 [23] | Retrospective case series | 81 (69) | LMG or LMG + BMG | 41 (15-86) | 4 | | Fu et al., 2017 [19] | Retrospective comparative study | 293 (94) | LMG vs. skin flap | 12 (NA) | 4 |
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Quality assessment of the studies included in the systematic review, ordered by LE.
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| Author [Ref.] | Stricture length, mean (range), cm | Follow-up method | Definition of failure | Success rate, % | Urethral complications, n (%) | | Simonato et al., 2006 [8] | 3.1 (1.5-4.5) | Uroflowmetry 3 and 12 mo
Urethrography 2 weeks, 3 and 12 mo
Urethroscopy 3 and 12 mo | Qmax <15 mL/s
Need for any instrumentation | 87.5 | Stricture recurrence 6 (20.7)
Contrast extravasation, 2 (6.9) | | Simonato et al., 2008 [11] | 3.6 (1.5-9.8) | Uroflowmetry 3 and 12 mo
Urethrography 2 weeks, 3 and 12 mo
Urethroscopy 3 and 12 mo | Inability to void
Post void residual
Need for any instrumentation | 81.5 | NA | | Singh et al., 2008 [12] | 10.2 (3.7-16.5)
9.8 (3.5-12.9) | Uroflowmetry 3, 6 and 12 mo
Urethrography 3, 6 and 12 mo | Need for any instrumentation | 76.6-80 | Meatal narrowing, 8 (14.5)
Stricture recurrence, 7 (12.7)
Contrast extravasation, 3 (5.5)
Wound infection, 3 (5.5)
Penis curvature, 1 (1.8) | | Barbagli et al., 2008 [16] | NA | Uroflowmetry 4, 8 and 12 mo
Urethrography if needed
Urethroscopy if needed
Urethral ultrasound if needed | Need for any instrumentation | 90 | Contrast extravasation, 1 (10)
Stricture recurrence, 1 (10) | | Das et al., 2009 [13] | 10.2 (3.7-16.5) | Uroflowmetry 3 and 6 mo
Urethrography 3 weeks, 3 and 6 mo | Qmax <15 mL/s
Need for any instrumentation | 83.3 | Contrast extravasation, 5 (16.7)
Wound infection, 2 (6.7)
Haematoma, 2 (6.7)
Stricture recurrence, 1 (3.3)
Meatal stenosis, 4 (13.3)
Penis curvature 1 (3.3) | | Xu et al., 2010 [25] | 6.5 (2.5-18.0) | Uroflowmetry 3, 6, 12, 18, 24 and 36 mo
Urethrography if needed
Urethroscopy if needed | Need for any instrumentation | 91.3 | Contrast extravasation, 4 (4.3)
Stricture recurrence, 4 (4.3) | | Kumar et al., 2010 [15] | 8.8 (4.0-16.5) | Uroflowmetry 3, 6 and 12 mo
Urethrography 3, 6 and 12 mo | Qmax <15 mL/s
Need for any instrumentation | 87.8 | Contrast extravasation, 6 (14.6)
Stricture recurrence, 5 (12.2)
Meatal stenosis, 5 (12.2)
Wound infection, 3 (7.3) | | Sharma et al., 2013 [17] | 7.7 (3.2-9.6) | Uroflowmetry 3 weeks, 3, 6, 12 mo
Urethrography 3 mo
Urethroscopy 6 mo | Qmax <10 mL/s
Residual stricture
Need for any instrumentation | 93.3 | NA | | Xu et al., 2014 [14] | 12.5 (6.0-18.0) | Urethrography 4 weeks
Uroflowmetry 3, 6, 12, 24, and 36 mo | Qmax <12 mL/s
Obstructive symptoms
Need for any instrumentation | 90.9 | Meatal stenosis, 2/22 (9.1) LMG
Fistula, 1/9 (11.1) LMG + BMG | | Abdelhameed et al., 2015 [27] | 4.6 (3.0-11.5) | Uroflowmetry 3, 6, 12, 24, 36, 48 and 60 mo
Urethrography 3 and 6 mo | Obstructive symptoms
Residual stricture
Need for any instrumentation | 86.9 | Contrast extravasation, 1 (4.3)
Wound infection, 4 (17.4)
Postvoid dribbling, 3 (13.0) | | Pal et al., 2016 [21] | 9.6 (3.5-15.5) | Uroflowmetry 3 and 6 mo
Urethrography if needed | Qmax <15 mL/s
Significant postvoid residual volume
Need for major instrumentation | 83.3 | Contrast extravasation, 5/30 (16.7)
Stricture recurrence, 2/30 (6.7)
Meatal stenosis, 4/30 (13.3)
Haematoma, 1/30 (3.3) | | Sharma et al., 2016 [26] | 4.7 (3.0-8.5) | Urine analysis 1, 3, 6 and 12 mo
Uroflowmetry 1, 3, 6 and 12 mo
Postvoid residual assessment 1, 3, 6 and 12 mo
Urethrocystoscopy 3 mo | Need for any instrumentation | 91.6 | Stricture recurrence, 1 (8.3) | | Lumen et al., 2016 [18] | 5.0 (1.0-16.0) | Uroflowmetry
Urethrography if needed
Urethroscopy if needed | Stricture recurrence or fistula
Need for any instrumentation | 89.7 | Stricture recurrence, 2/29 (6.9)
Fistula, 1/29 (3.4) | | Chauhan et al., 2016 [20] | 6.7 (3.8-12.2) | Uroflowmetry 1, 3 and 6 mo
Urethrography if needed
Urethroscopy if needed | Obstructive symptoms
Need for any instrumentation | 80 | NA | | Zhang et al., 2016 [28] | 7.0 (2.0-16.0) | Uroflowmetry 4 weeks, 3, 6, 12, 24 and 36 mo
Urethrography 4 weeks, 3, 6, 12, 24 and 36 mo | Stricture recurrence
Fistula | 81.2 | Stricture recurrence, 17 (16.8)
Fistula, 2 (2.0) | | Xu et al., 2017 [23] | 12.1 (8.0-20.0) | Urethrography 4 weeks
Uroflowmetry 3, 6, 12, 18 and 24 mo
Urethrography if needed
Urethroscopy if needed | Qmax <12 mL/s
Obstructive symptoms
Need for any instrumentation | 82.7 | Stricture recurrence, 10 (12.3)
Fistula, 4 (4.9) | | Fu et al., 2017 [19] | 4.9 (1.5-12.0) | Uroflowmetry 3 weeks, 3 and 12 mo | Qmax <12 mL/s
Fistula or diverticulum
Obstructive symptoms
Need for any instrumentation | 85.1 | NA |
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Functional results and urethral complications of LMG urethroplasty.
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| Author [Ref.] | Graft length, mean (range), cm | Immediate complications, n (%) | Long-term complications, n (%) | | Simonato et al., 2006 [8] | 3.3 (3.0-7.0) | Oral discomfort, all (100) | None | | Kumar et al., 2007 [22] | 8.5 (4.2-16.2) | Pain, 28 (93.3)
Slurring speech, 6 (20) | None | | Kumar et al., 2008 [29] | 6.5 (3.5-16.4) | Pain, 23 (92)
Slurring speech, 6 (24) | None | | Simonato et al., 2008 [11] | NA | Oral discomfort, all (100)
Slurring speech, all (100)
Difficulty in mouth opening, 2 (100) LMG + BMG
Reduced slivatory flow, 1 (50) LMG + BMG
Neurosensory deficit, 2 (100) LMG + BMG | None | | Das et al., 2009 [13] | 10.7 (3.9-17.0) | Pain, all (100)
Slurring speech, all (100) | None | | Xu et al., 2010 [25] | NA (4.0-14.0) | Oral discomfort, all (100)
Difficulty in moving the tongue, all (100) | Numbness, 10 (13.2) | | Kumar et al., 2010 [15] | 9.2 (4.5-17.0) | Pain, 38 (92.7)
Slurring speech, 9 (21.9)
Numbness, 2 (4.9)
Salivatory disturbance, 1 (2.4)
Delayed feeding, 1 (2.4) | None | | Xu et al., 2011 [24] | 5.2 (3.0-7.0)
11.5 (7.5-14.5) | Pain, 105 (95.4)
Delayed feeding, 8 (17.6) bilateral graft
Difficulty in moving the tongue, 14 (48.3) bilateral graft
Numbness, 35 (31.8)
Parageusia, 12 (10.9)
Slurring speech, 38 (34.5) | Numbness, 7 (6.4)
Parageusia, 3 (2.7)
Slurring speech, 3 (2.7) | | Sharma et al., 2013 [17] | NA | Bleeding, 1 (6.7)
Pain, all (100)
Swelling of the tongue, 2 (13.3)
Difficulty in opening the mouth, 2 (13.3)
Difficulty in tongue protrusion, all (100)
Swallowing, all (100)
Difficulty in chewing, all (100)
Speech difficulty, all (100)
Numbness, 6 (40) | Difficulty in tongue protrusion, 2 (13.3)
Speech difficulty, 3 (20) | | Xu et al., 2014 [14] | NA (7.0-15.0) | Pain, all (100)
Difficulty in moving the tongue, all (100) | None | | Abdelhameed et al., 2015 [27] | 5.6 (4.0-12.0) | Oral discomfort, all (100)
Difficulty in moving the tongue, all (100)
Speech difficulty, all (100)
Numbness, 9 (39.1) | None | | Pal et al., 2016 [21] | 10.1 (4.8-16.2) | Pain, 27 (90)
Difficulty in moving the tongue, 11 (36.7)
Slurring speech, 11 (36.7) | None | | Chauhan et al., 2016 [20] | NA | Pain, 20 (40)
Bleeding, 8 (16)
Difficulty in chewing, 24 (48)
Swelling of the tongue, 13 (26)
Difficulty in articulation, 22 (44)
Difficulty in opening the mouth, 19 (38)
Dry mouth, 7 (14)
Sensitivity disorders, 23 (46) | Difficulty in articulation, 1 (2) | | Lumen et al., 2016 [18] | 5.0 (1.0-20.0) | Pain, 17 (58.6)
Difficulty in eating, 18 (62.1)
Sensitivity disorders, 21 (72.4)
Speech difficulty, 27 (93.1)
Dysgeusia, 14 (48.3) | Difficulty in eating solids, 1 (3.4)
Oral tightness, 1 (3.4)
Sensitivity disorders, 9 (31)
Salivary changes, 2 (6.9)
Speech difficulty, 4 (13.8)
Dysgeusia, 1 (3.4) | | Zhang et al., 2016 [28] | 7.2 (2.5-16.0) | Pain, all (100)
Numbness, 25 (24.7) | Numbness, 5 (5.5)
Slurring speech, 5 (5.5)
Swallowing dysfunction, 5 (5.5)
Parageusia, 3 (3.3) | | Xu et al., 2017 [23] | NA (9.0-17.0) | Pain, all (100)
Difficulty in moving the tongue, all (100) | Numbness, 4 (4.9)
Slurring speech, 2 (2.5)
Difficulty in moving the tongue, 5 (6.2) |
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Donor site complications after lingual mucosa harvesting: Post-operative and 1 year after surgery (or at the end of the follow-up period).
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Fundamental steps of the surgical technique for LMG urethroplasty. (A) Patient is placed in lithotomy position under general anesthesia with naso-tracheal intubation. Urethra is probed with a catheter to detect the stricture. (B) The stenotic urethra is completely mobilized from the corpora cavernosa after a complete degloving of the penis (in case of long penile urethroplasty) or a perineoscrotal incision (in case of bulbar urethroplasty). The strictured tract is fully opened by a ventral midline incision and carefully measured. The urethral plate is longitudinally incised on the dorsal midline down to the corpora and the wings of the urethral plate are laterally mobilized. (C) LMG harvesting can be started during the latter part of the urethral mobilization or at the same time by two teams. A silicone bite block prop—mouth opener—is placed. (D) Direct traction is applied with two Babcock clamps to expose the ventrolateral surface of the tongue. A surgical pen is used to mark the required graft after identification of the opening of the Warton duct. (E) The graft edges are incised with a scalpel and a full-thickness mucosal graft is harvested using sharp scissors. Although a graft of 7-8 cm can be easily harvested from one half of the tongue, it should be at least 2 cm longer than the measured stricture length and 15-25 mm wide. Thus for long strictures the procedure can be repeated on the contralateral side. After the lingual mucosa is harvested, the wound is closed with interrupted polyglactin 4-0 sutures, without excessive tension. (F) Lingual mucosa is then prepared completely removing the underlying fibrovascular tissue. (G) The LMG is sutured and quilted on the bed of the dorsal urethral incision with tension free, interrupted, absorbable and at least 4-0 sutures, and an augmentation of the urethral plate is obtained. (H) The urethra is closed and tubularized over an indwelling 14Ch silicone catheter. A dartos fascial flap is obtained to cover the urethral suture. (I) The glans and penile skin are closed with interrupted 3-0 absorbable sutures. A Foley 14Ch silicone catheter should be left in place for at least 3 weeks. LMG, lingual mucosal graft.
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Forest plot of OR (95% CI) for success rate (A) and long-term oral complications (B) of LMG (Experimental) vs. BMG (Control) urethroplasty. The center of each square represents the OR, the area of the square is the number of samples and thus the weight used in the meta-analysis and the horizontal line indicates the 95% CI. LMG, lingual mucosal graft; BMG, buccal mucosal graft; OR, odds ratio; CI, confidence interval.
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Funnel plots for publication bias. (A) Six studies analyzing success rate of LMG vs. BMG urethroplasty; (B) Five studies analyzing long-term oral complication rate of LMG vs. BMG urethroplasty. LMG, lingual mucosal graft; BMG, buccal mucosal graft.
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