Review Article Anterior Urethral Stricture

International Braz J Urol Vol. 33 (4): 461-469, July - August, 2007

Surgical Treatment of Anterior Urethral Stricture Diseases:

Brief Overview

Guido Barbagli, Massimo Lazzeri

Center for Reconstructive Urethral Surgery, Arezzo and Department of Urology, Santa Chiara
Firenze, Florence, Italy

ABSTRACT

We performed an up-to-date review of the surgical techniques suggested for the treatment of anterior urethral strictures.
References for this review were identified by searching PubMed and MEDLINE using the search terms “urethral stricture”
or “urethroplasty” from 1995 to 2006. Descriptive statistics of the articles were provided. Meta-analyses or other multivari-
ate designs were not employed. Out of 327 articles, 50 (15%) were determined to be germane to this review. Eight abstracts
were referenced as the authors of this review attended the meetings where the abstract results were presented, thus it was
possible to collect additional information on such abstracts. Urethrotomy continues to be the most commonly used tech-
nique, but it does have a high failure rate and many patients progress to surgical repair. Buccal mucosa has become the most
popular substitute material in urethroplasty; however, the skin appears to have a longer follow-up. Free grafts have been
making a comeback, with fewer surgeons using genital flaps. Short bulbar strictures are amenable using primary anastomo-
sis, with a high success rate. Longer strictures are repaired using ventral or dorsal graft urethroplasty, with the same success
rate. New tools such as fibrin glue or engineered material will become a standard in future treatment. In reconstructive
urethral surgery, the superiority of one approach over another is not yet clearly defined. The surgeon must be competent in
the use of various techniques to deal with any condition of the urethra presented at the time of surgery.

Key words: urethral stricture; surgical procedures, operative; graft; tissue engineering
Int Braz J Urol. 2007; 33: 461-9

INTRODUCTION urethral strictures remain unknown, but they are prob-

ably the result of a remote unrecognized perineal
Urethral strictures are a frequent source of trauma experienced during childhood (1).
lower urinary tract disorders in adults, such as urinary Surgical treatment of urethral stricture dis-
tract infection, acute urinary retention, high-pressure eases is a continually evolving process, and currently
voiding leading to secondary bladder thickening and there is renewed controversy over the best means of
irritability and even bladder diverticula or perineal fis- reconstructing the urethra. Moreover, the superiority
tulas and abscess (1). Blunt perineal trauma, urethral of one technique over another has not yet been clearly
catheterization or instrumentation, lichen sclerosus and defined. Urologists must be familiar with the use of
sexually transmitted diseases are the most frequent numerous and various surgical techniques to deal with
causes of strictures (1). However, most causes of any condition of the urethra during surgery. This re-

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view aims to provide an update on the reconstructive TREATMENT OF URETHRAL

techniques currently used to repair anterior urethral STRICTURES
strictures and offer some insight on possible future
strategies. Peterson and Webster suggested that treat-
ment for urethral strictures include numerous op-
tions, such as dilation, urethrotomy, stent and re-
MATERIALS AND METHODS constructive surgical techniques and emphasized
that no one technique is appropriate for all stricture
Inclusion criteria for the literature review were diseases (2).
operationalized before the initial literature search. The
search incorporated original and review articles pre-
senting data regarding all aspects of the surgical re- Internal Urethrotomy vs. Open Urethroplasty
pair of anterior urethral strictures. The exclusion cri- Dilation and urethrotomy continue to be the
teria included articles presenting opinions rather then most commonly used techniques, but they have a high
evidence and articles that were not published in peer failure rate with recurrence in 47.6% of patients and
reviewed journals. The articles reviewed were lim- many patients progress to surgical repair (2,3). More-
ited to English language publications. A review of the over, repeated dilation or urethrotomy exacerbates scar
world literature was performed via the MEDLINE/ formation, thus adding to stricture length and predis-
PubMed databases using the search terms “urethral posing to a more difficult definitive open repair and a
stricture” or “urethroplasty” from January 1995 lower success rate (1-3). Persistent use of dilation or
through August 2006. The bibliographies of all relevant urethrotomy for the treatment of urethral strictures
articles were reviewed for applicable citations that may be the result of unfamiliarity with literature and
might not have appeared upon the database search. inexperience with urethroplasty surgery (3). Surpris-
The authors independently reviewed each abstract ingly, a recent survey of stricture management involv-
identified by the database searches and relevance to ing 424 urologists from the USA showed that only
the topic was ascertained. 21% to 29% indicated that they would refer a patient
with a recurrent urethral stricture to another urologist
for urethroplasty, while 34% elected to continue en-
RESULTS doscopic management despite predictable failure.
Seventy-four percent of urologists believed that lit-
A total of 327 articles were identified in our erature supports the use of urethroplasty only after
search and 50 of these (15%) were determined to be repeated endoscopic failure (4). Greenwell et al. re-
germane to the topic under review. The bibliographies cently developed an algorithm for the management
of all 50 articles were scanned and references that were of urethral strictures based on cost-effectiveness and
not hits in our initial database search were also reviewed. concluded that repeat urethrotomy or dilation are nei-
Four articles were included from the bibliography search ther clinically effective nor cost-effective and can
in the literature review. Eight abstracts were referenced no longer be justified (3). Wright et al. determined,
as the authors of this review were in attendance at the using decision analysis, the cost-effectiveness of dif-
meetings where the abstract results were presented, ferent management strategies for short bulbar ure-
thus it was possible to collect additional information on thral strictures and concluded that the most cost-ef-
the presented abstracts. A meta-analysis or other mul- fective strategy for the management of short bulbar
tivariate designs could not be correctly employed due urethral stricture is to reserve urethroplasty for pa-
to the heterogeneous nature of the data in the articles tients in whom a single endoscopic attempt has failed
reviewed. Reasons for this are that standard diagnosis, (5). Instead, for strictures for which the success rate
success and complication criteria vary among authors. of an urethrotomy is expected to be less than 35%,
Therefore, only descriptive statistics of the articles are applying urethroplasty as the primary therapy is cost-
provided in this review. effective (5).

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Open urethroplasty is regarded as the gold hairless, has a thick elastin-rich epithelium, which
standard treatment for urethral strictures (1,2). Nev- makes it tough yet easy to handle and a thin and highly
ertheless, urethroplasty is not a routine operation and vascular lamina propria, which facilitates inosculation
a lack of the necessary skills should prompt a referral and imbibition (9). Moreover, the use of buccal mu-
to a specialist skilled in urethroplasty (3). Unfortu- cosa avoids cosmetic disadvantages and consequences
nately, most urologists have little experience with ure- caused by the use of genital skin. Prior to the use of
throplasty surgery and erroneously believe that the buccal mucosa, penile skin was the preferred tissue
use of these complex reconstructive urethral proce- transferred material used for urethroplasty. The ques-
dures are justified only in young, healthy patients, since tion remains: is buccal mucosa really superior to pe-
these treatments are associated to a high rate of com- nile skin? Alsikafi et al. in an effort to answer whether
plications requiring longer patient hospitalization and buccal mucosa is really the best, compared the out-
higher hospital costs. Internal urethrotomy is a less- come of 95 buccal mucosa urethroplasty and 24 pe-
invasive outpatient procedure, providing the obvious nile skin graft urethroplasties (10). The overall suc-
benefits of surgeon/patient convenience and cost con- cess rate of penile skin urethroplasty was 84% (mean
trol. Recent literature, however, shows that urethro- follow-up 201 months), while the success rate of buc-
plasty can also be considered a “minimally” invasive cal urethroplasty was 87% (mean follow-up 48
technique and a more efficient therapy than internal months) and no statistically significant difference was
urethrotomy. Santucci et al. reviewed 70 open ure- found between the two groups (10). Gozzi et al. ret-
throplasties performed on males older than 64 years rospectively evaluated the results on 194 patients
old and concluded that urethroplasty should not be with glanular (20.6%), penile (16%), bulbar (20.1%),
withheld solely on the basis of age, as older men tol- membranous (29.4%) and post-hypospadias repair
erate urethroplasty well and complication rates are (13.9%) urethral strictures (11). All patients were
low (6). MacDonald et al. presented the review of 54 treated by dorsal onlay techniques with genital and
patients who underwent anterior urethroplasty to extra-genital skin grafts and reported excellent re-
evaluate the safety and feasibility of decreasing the sults with a 2% restenosis rate and a mean follow-
impact of urethroplasty by minimizing operative time, up of 31 months (11). We retrospectively reviewed
maximizing adjuvant pain therapy and using anesthetic the outcome of 95 patients who underwent bulbar
agents that decrease the incidence and severity of substitution urethroplasty, 45 receiving penile skin
side effects (7). The authors showed that urethro- grafts (12) and 50 buccal mucosa grafts (13). Thirty-
plasty could be safely performed with less than 24- three of the 45 penile skin urethroplasties were suc-
hours hospital stay and concluded that anterior ure- cessful (73%) and 12 (27%) were failures (12).
throplasty performed as a same-day procedure ap- Forty-two of the 50 buccal mucosal urethroplasty
peared to be safe and well tolerated, without compro- were successful (84%) and 8 (16%) were failures
mising functional outcome, and it costs 40% to 60% (13). The skin graft urethroplasty showed a higher
less than the same procedure performed on in-patients. failure rate (27%) compared to the buccal mucosa
Finally, Rourke & Jordan suggested that treatment for graft (16%), with the penile skin grafts having a
a 2 cm bulbar urethral stricture with primary open longer follow-up (mean 71 months) compared to the
urethroplasty is less costly than endoscopic treatment buccal mucosa grafts (mean 42 months) (12,13). In
with internal urethrotomy (8). conclusion, skin and buccal mucosa are both excel-
lent materials for urethroplasty with a comparable
Urethral Tissue Transferred Material: Penile success rate, though the use of skin appears to have
Skin vs. Buccal Mucosa a longer follow-up than buccal mucosa.
Buccal mucosa has become the most popu-
lar substitute material in the treatment of urethral stric- Penile Urethral Reconstruction
tures, as it is readily available and easily harvested Basically, the surgical technique for penile
from the cheek or lip, allowing for a concealed donor urethral reconstruction is selected according to the
site scar and low oral morbidity (9). Buccal mucosa is etiology of the urethral stricture disease and must also

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be based on the proper anatomic characteristics of One-Stage vs. Two-Stage Repair

the penile tissues to ensure flap or graft take and sur- Penile urethroplasty should be performed in
vival (14). Furthermore, sexual function can be placed a single-stage whenever possible to avoid patient dis-
at risk by any surgery on the genitalia and dissection comfort and disability that can be caused by the use
must avoid interference with the neurovascular sup- of multi-stage procedures. In patients with urethral
ply to the penis. The use of flaps or grafts, in single or strictures caused by trauma, infection, instrumenta-
multi-stage repair, should not compromise penile length tion or catheter, the penis is generally normal and the
or cause penile chordee, and certainly should not un- penile skin, urethral plate, corpus spongiosum and dar-
towardly affect penile appearance. Penile urethro- tos fascia are suitable for urethral reconstruction. In
plasty could be a simple procedure in patients with a such cases, one-stage urethroplasty is the surgery of
normal penis, but it can be a difficult challenge in men choice. Instead, in patients who have experienced
with strictures associated to genital lichen sclerosus failed hypospadias repair or in whom the penile skin,
or following failed hypospadias repair. Regardless, urethral plate and dartos fascia are not suitable for
penile urethroplasty, be it a single or multi-stage re- urethral reconstruction, two-staged urethroplasty is
pair, is intrinsically prone to complications such as recommended (20,21). In addition, in patients suffer-
edema, hematoma or infection, which in turn can lead ing from genital lichen sclerosus, the use of buccal
to secondary complications, such as fistula or tissue mucosa is mandatory since, as a skin disease, any
necrosis, and it is the procedure most likely to pro- skin that would be used as graft material is already or
duce alterations in sexual functions. may become diseased (22,23). When used in a multi-
stage procedure, the buccal mucosa or skin grafts do
Flaps vs. Grafts not heal in the same way in all patients and numerous
The controversy over the best means of re- revisions of the graft-bed may be necessary to obtain
constructing the penile urethra has been renewed and a satisfactory mucosal bed before the urethral clo-
in recent years, free grafts have been making a come- sure (21). Unfortunately, these repeated surgical re-
back, with fewer surgeons using genital flaps (15-17). visions of the scars could have a tremendous psycho-
Rarely, has the current literature provided us with pro- logical impact on the patient (21).
spective studies comparing the grafts with the flaps,
making it hard to declare a clear favorite (16). At Bulbar Urethral Reconstruction
present, we are uncertain in which patients the use of Basically, the surgical technique used in the
a pedicled flap will have better chances of success repair of the bulbar urethral stricture is selected ac-
than a free graft, as the thin penile corpus spongiosum cording to stricture length (14). Strictures ranging from
and the dartos fascia do not ensure sufficient graft 1 to 2 cm are treated by using end-to-end anastomo-
support in all patients (15,16). Identification and use sis; strictures ranging from 2 to 3 cm are managed
of criteria to more carefully select the appropriate using augmented roof-strip anastomosis; strictures
procedure for the patient might clarify whether the longer than 3 cm are treated using substitution ure-
use of a graft is preferable to the use of a flap ac- throplasty. Finally, in patients with strictures associ-
cording to the characteristics of the vascular and ated to local adverse conditions (fistula, abscess, tu-
mechanical tissues used to support the original ure- mor, stent, or previous failed urethroplasty) multi-stage
thral plate. Different authors recently described a new urethroplasty is mandatory.
one-stage penile urethroplasty that involves a deeply
longitudinal midline incision of the urethral plate and End-to-End Anastomosis
the suturing of buccal mucosal tissue as an inlay graft Short strictures in the bulbar urethra are gen-
into the bed obtained within the urethral plate erally amenable to complete excision with primary
(15,18,19). Unfortunately, the long-term results in a anastomosis via a perineal incision, affording a high
large series of patients treated with this new one-stage success rate of 95%, as reported by Santucci et al.
penile graft urethroplasty are, at the moment, not avail- (24). The surgical technique of end-to-end anastomo-
able in the current literature. sis was recently illustrated step by step by Mundy

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with the use of nicely executed color drawings and recently illustrated step by step by Mundy, who also
excellent commentary (25). Recently, the stricture included an excellent commentary (29). In 2004,
length ideal for the application of end-to-end anasto- Delvecchio et al. suggested that the use of augmented
mosis has become a contentious issue. Guralnick & roof-strip anastomotic urethroplasty incorporating the
Webster suggested that end-to-end anastomosis is graft onlay into the receiving urethral plate is less suc-
appropriate only for a bulbar stricture of 1 cm or less cessful, either because of the inherent deterioration
as excision of a 1 cm urethral segment with opposing of transferred tissues exposed to urine or to the fact
1 cm proximal and distal spatulation results in a 2 cm that the onlay is performed in an area of dense
urethral shortening, which may be adequately accom- spongiofibrosis, generally at the site the stricture dis-
modated by the elasticity of the mobilized bulbar ure- ease originated, which is unsuitable for simple onlay
thra without chordee (26). The authors emphasized grafting (30). These authors proposed always excis-
that excision of a longer urethral segment risks penile ing this area, followed by direct reanastomosis of the
shortening or chordee, even if lengthening maneuvers floor strip and onlay of the adjacent “better” stricture,
are applied (26). On the contrary, Morey & Kizer re- whatever its length (30). The authors showed that this
ported 22 patients with proximal bulbar urethral stric- technique had only a 5.2% failure rate in 38 patients,
tures greater that 2.5 cm long (range 2.6 to 5 cm) that compared with a 9% failure rate in 11 patients who
were managed using an extended anastomotic ap- underwent a simple augmented graft urethroplasty
proach, suggesting that the possibility of reconstruct- without excision of the strictured tract. They concluded
ing the urethra is proportional to the length and elas- that excision of the worst stricture segment avoids a
ticity of the distal urethral segment (27). They reported long onlay in a poor urethral bed where failure often
a 91% success rate with a mean follow-up of 22.1 occurs at the location of even the smallest stricture
months, and with no increase in erectile complaints caliber (30). Augmented roof strip anastomotic repair
compared to shorter strictures (27). Finally, Al-Qudah may be arranged using ventral or dorsal graft loca-
& Santucci suggested that the use of end-to-end anas- tion. In 2005, Abouassaly & Angermeier reported the
tomosis is also controversial in the treatment of short results of 36 patients undergoing augmented anasto-
and medium length urethral strictures (range 0.5 to motic repair with ventral onlay grafts and 4 patients
3.0 cm) (28). They presented 47 short urethral stric- undergoing augmented anastomotic repair with dor-
tures treated with end-to-end anastomosis or buccal sal onlay grafts and concluded that ventral or dorsal
mucosal onlay graft urethroplasty and compared early onlay seems to offer comparable results (31). In 2006,
and intermediate outcomes to determine which was Abouassaly and Angermeier recommended complete
the best technique (28). The recurrence rate was 7% excision of the stricture and use of an augmented roof-
in those patients who underwent end-to-end anasto- strip anastomotic repair for strictures that cover a
mosis and 0% in patients who underwent buccal mu- particularly narrow area of 1-2 cm in length (32). Out
cosal graft urethroplasty. Early and late major com- of 69 patients, 63 were successful (91%) with a mean
plications occurred in 18% of the patients after anas- follow-up of 34 months (32).
tomotic repair, including penile chordee and erectile
dysfunction (28). In conclusion, buccal mucosal onlay Substitution Urethroplasty Using Buccal
graft urethroplasty is suggested as the operation of Mucosal Graft
choice even for short urethral strictures (28). Buccal mucosal urethroplasty represents the
most widespread method for the repair of strictures
Augmented Roof Strip Anastomosis in the bulbar urethra, due to its highly vascular tissue.
In 1998, Iselin and Webster modified our origi- Location of the graft on the urethra surface has be-
nal technique of dorsal onlay urethroplasty (29). In come a contentious issue (33), dating from the time
this procedure, the worst section of the stricture is we described dorsal onlay graft urethroplasty tech-
removed and the urethra is re-anastomosed and dor- niques (34). Wessells & Armenakas suggested a list
sally augmented with a free graft (29). The surgical of the technical advantages of ventral onlay urethro-
technique of augmented roof-strip anastomosis was plasty: complete circumferential mobilization of the

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urethra is not necessary, thus preserving arterial and this fibrin sealant is non-synthetic and, therefore
venous connections to the corpora cavernosa; stric- biocompatible with the natural fibrinolytic mechanism,
ture is easily seen; performance of a urethrotomy al- healing is promoted without inflammation and fibrosis
lows the lumen to be clearly delineated, thus allowing formation (38). Several studies emphasized the use
the surgeon to identify mucosal edges, measure the of fibrin glue in tissue-engineered procedures (39,40).
size of the plate, carry out a watertight anastomosis The use of fibrin sealant is widely published in the
and, if necessary, excise portion of the stricture and literature. Since this sealant is composed of human
perform dorsal re-anastomosis (35,36). products, the plasma is screened, tested and thermally
Success with bulbar buccal mucosal grafts treated to ensure viral safety (41).
has been high with dorsal (13,33) or ventral graft The application of fibrin glue in surgery
location (35,36) and the different graft positions have mainly relates to its sealing power. It has been shown
shown no difference in success rate (13,31). Re- to be a beneficial adjunct to sutures for closing
cently, Abouassaly and Angermeier reported the in- wounds and promoting healing since it increases tis-
termediate term results on 100 patients with penile sue plane adherence, accelerates revascularization,
(21%), bulbar (82%) and bulbomembranous (17%) reduces hemorrhage, prevents seroma formation and
urethral strictures undergoing anterior and posterior decreases inflammation. The published urological lit-
buccal mucosal graft urethroplasty using different erature has recently contained an increasing num-
graft locations (ventral or dorsal) (31). These pa- ber of studies suggesting the use of fibrin glue in
tients had a final success rate of 92% (mean follow- reconstructive genital and urethral procedures. In
up 29.5 months) (31). In our experience, the place- 2002, DeCastro & Morey described the use of fibrin
ment of the grafts on the ventral, dorsal or lateral tissue adhesive in genital skin loss due to Fournier’s
surface of the bulbar urethra provided the same suc- gangrene (42). In 2003, Evans et al. reported the
cess rates (83% to 85%) and stricture recurrence use of fibrin sealant to manage iatrogenic urinary
was uniformly distributed in all patients (13). Recently, tract injuries, urinary fistulas and surgical complica-
we reviewed the patterns of failure following bulbar tions (38). In 2004, Hick and Morey assessed
substitution urethroplasty and investigated the preva- whether fibrin sealant promotes early catheter re-
lence and location of anastomotic fibrous ring stric- moval after urethral reconstruction (43). In 2006,
tures occurring at the apical anastomosis between Morris et al. reported the use of fibrin glue in the
the graft and urethral plate (37). Out of 107 patients, reconstruction of genital skin loss (44). We recently
85 (80%) were successful and 22 (20%) failured. reported our experience with the use of fibrin glue in
Failure in 12 patients (11%) involved the entire bulbar urethral reconstruction in a series of patients
grafted area and in 10 patients (9%) it involved the who underwent augmented anastomotic repair (45)
anastomotic site (5 distal, 5 proximal). The preva- or dorsal onlay graft urethroplasty (46). However,
lence and location of these anastomotic ring stric- further comparative studies are necessary to con-
tures were uniformly distributed among the three firm that the use of fibrin glue is really beneficial and
different surgical techniques, using either skin or to evaluate whether its use reduces restenosis rate
buccal mucosal grafts (37). Others authors found following substitution urethroplasty (45,46).
these anastomotic fibrous ring strictures after sub-
stitution onlay urethroplasty (37). Tissue Engineering Urethroplasty
McAninch recently emphasized that urethral
Use of Fibrin Glue in Urethral Reconstruction reconstruction can require some of the most challenging
Fibrin glue contains fibrinogen, Factor XII, techniques in urological surgery and excellent results
plasmafibronectina and plasminogen dissolved in an can be obtained with today’s techniques, but it would
aprotin solution (bovine) with an activate thrombin be a significant advantage to have tissue-engineered
component (human) mixed with a calcium chloride products for urethroplasty (47). Carson suggested that
solution. When combined, a dense gelatinous clot is urethroplasty represents a model of international
quickly formed at the point of application. Because progress in urology and the field of urethral stricture

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repair has matured greatly with a growing number of 2. Peterson AC, Webster GD: Management of urethral
single-stage repairs being performed with continued stricture disease: developing options for surgical in-
improvements in patient outcome (48). Moreover, the tervention. BJU Int. 2004; 94: 971-6.
use of tissue engineering to optimize graft material 3. Greenwell TJ, Castle C, Andrich DE, MacDonald JT,
may allow us to combine the most refined surgical Nicol DL, Mundy AR: Repeat urethrotomy and dila-
tion for the treatment of urethral stricture are neither
techniques with the best graft material, to archive even
clinically effective nor cost-effective. J Urol. 2004; 172:
more reliable results (48).
275-7.
Ribero-Filho et al. recently presented a new 4. Brandes SB, Smith J, Virgo K, Johnson FE: Adult ante-
urethroplasty technique that uses human cadaveric rior urethral strictures: a national practice patterns sur-
urethral acellular matrix (49). After having been har- vey. J Urol. 2001; 165: 13.
vested from a cadaveric donor the urethral mucosa 5. Wright JL, Wessells H, Nathens AB, Hollingworth W:
and spongiosum tissue were enzymatically converted What is the most cost-effective treatment for 1 to 2-cm
into a urethral acellular matrix graft (49). The graft bulbar urethral strictures: societal approach using de-
was applied onto the urethra as a ventral onlay patch. cision analysis. Urology. 2006; 67: 889-93.
No immunosuppressors were necessary, there were 6. Santucci RA, McAninch JW, Mario LA, Rajpurkar A,
no postoperative complications and the final outcome Chopra AK, Miller KS, et al.: Urethroplasty in patients
was satisfactory (49). Could it be that we have older than 65 years: indications, results, outcomes and
reached the limit of this veteran workhorse of substi- suggested treatment modifications. J Urol. 2004; 172:
201-3.
tution urethroplasty? (50). The time has arrived to look
7. MacDonald MF, Al-Qudah HS, Santucci RA: Minimal
beyond buccal mucosa to the development of other
impact urethroplasty allows same-day surgery in most
forms of substitution material, incorporating tissue patients. Urology. 2005; 66: 850-3.
engineered materials or stem cells into our quest for 8. Rourke KF, Jordan GH: Primary urethral reconstruc-
the Holy Grail of urethral substitution (50). tion: the cost minimized approach to the bulbous ure-
thral stricture. J Urol. 2005; 173: 1206-10.
9. Barbagli G, Palminteri E, De Stefani S, Lazzeri M: Har-
CONCLUSION vesting buccal mucosal grafts. Keys to success.
Contemp Urol. 2006; 18: 17-24.
Reconstructive urethral surgery must bet- 10. Alsikafi NF, Eisenberg M, McAninch JW: Long-term
ter adapt to the characteristics of the disease if the outcomes of penile skin graft versus buccal mucosal
features defining its professionalism are to be graft for substitution urethroplasty of the anterior ure-
strengthened: control over setting standards, im- thra. J Urol. 2005; 173:87.
provement of minimally invasive procedures, re- 11. Gozzi C, Pelzer AE, Bartsch G, Rehder P: Genital free
skin grafts as dorsal onlay for urethral reconstruction.
search and translation of the basic scientific results
J Urol. 2006; 175: 38.
into daily clinical practice, and imposing the respon-
12. Barbagli G, Palminteri E, Lazzeri M, Turini D: Interim
sibility for organizing, appraising and maintaining outcomes of dorsal skin graft bulbar urethroplasty. J
quality patient care. Urol. 2004; 172: 1365-7.
13. Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini
D, Lazzeri M: Bulbar urethroplasty using buccal mu-
CONFLICT OF INTEREST cosa grafts placed on the ventral, dorsal or lateral sur-
face of the urethra: are results affected by the surgical
None declared. technique? J Urol. 2005; 174: 955-7.
14. Barbagli G, Palminteri E, Lazzeri M, Guazzoni G: Ante-
rior urethral strictures. BJU Int. 2003; 92: 497-505.
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Received: January 2, 2007

Accepted: March 5, 2007

Correspondence address:
Dr. Massimo Lazzeri
Department of Urology, Santa Chiara-Firenze
Piazza Indipendenza, 11
Florence, 50129, Italy
E-mail: [email protected]

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