Full-Thickness Abdominal Skin Graft for Long-Segment Urethral Stricture Reconstruction

Multiple tissue sources have been used for urethral reconstruction in adults. Patients with lichen sclerosis (LS), long segment strictures, or prior oral graft use have less available tissue for urethroplasty. We describe a technique for the use of a full-thickness skin graft of hairless abdominal skin for long segment urethroplasty.


INTRODUCTION
Reconstruction of long-segment adult urethral stricture disease as a result of lichen sclerosis (LS) or available extra-genital skin for grafting (1).Graft tissue has been utilized successfully for urethral reconstruction from various sites including buccal mucosa, genital skin and auricular tissue; however ideal graft source would be extra-genital in origin, hairless, produce minimal postoperative morbidity at the harvest site, be inconspicuous postoperatively and abundant enough in length and width so as to avoid multiple urethral suture lines for men with long segment strictures.In an effort to develop an alternative to available graft sources for complex and long-segment strictures we describe harvest and application of a full-thickness abdominal skin graft for urethral reconstruction.

SURGICAL TECHNIQUE
ated preoperatively with cystoscopy and retrograde vested was demarcated and discussed with the patient preoperatively.Deep venous thrombosis precautions were taken, and all patients achieved a sterile urine culture prior to surgery.
For one or two-staged long segment urethral reconstructive procedures involving the mid or proximal bulbar urethra, the patient was placed in the low lithotomy position.Otherwise, those with bulbar urethra were placed in the supine position.A ventral longitudinal shaft incision is made to expose the penile urethra to the level of the scrotum in men undergoing single-staged repair with a perineal counter-incision to access the bulbar urethra if needed.A bougie-à-boule sound is then used to identify the urethra is incised along its anterolateral edge throughout the length of the stricture with the edges of the urethrotomy is then measured in preparation for graft a two-staged procedure for long segment stricture disease, a grooved director is placed within the urethra and a scalpel is used to open the urethra through mucosa from the proximal urethrotomy site is then sutured to the overlying penile, scrotal, or perineal skin, depending on stricture length, with interrupted 5-0 vicryl sutures.All nonviable corpus spongiosum and urethral mucosa or tissue that is suspicious for lichen sclerosis is excised and sent for pathologic analysis in both single and two staged procedures.
Graft harvest of the abdominal wall involves excision of the skin of the right or left lower quadrant of the abdomen at the level of the anterior superior iliac crest (Figure -1).An area of hairless skin is identi-  For single-stage procedures, the epithelial side of the graft is sutured to the remaining mucosa fascia is accomplished by suturing the graft to the urethral plate medially and the penile skin laterally then completed through the graft, and quilting sutures graft to the underlying dartos and corpora cavernosum limited to the penile urethra and an 18F catheter is placed for strictures extending into the bulbar urethra.
dure had a catheter placed for 5 days postoperatively in conjunction with a moisturized bolster dressing.All other patients undergoing a single procedure for repair had catheter drainage for three weeks postoperatively.

A B
. Six of the ten patients underwent two-staged procedures stage and successful second stage closure in the two men completing both procedures (Figure-3A and Figure -3B).In the other four men, strictures were closed in one stage with a long segment graft.Mean LS developed recurrent stricture formation at a mean two patients in this series with prior urethroplasty utilizing buccal and auricular tissue and involved endoscopically.
All abdominal skin harvest sites healed well patients grew hair from segments of the abdominal skin graft within six months of surgery, one after grafts harvested in this series when areas with hair proved to be unsuccessful in its ability to prevent all future hair growth, and all subsequent grafts were harvested from hairless abdominal regions with no further occurrences of hair growth on the graft.All patients in this series were discharged on postoperative day one and reported minimal pain at the abdominal harvest site.

COMMENTS
Urethral reconstruction in patients with long segment stricture disease remains a complicated surgical problem especially in men with previous hypospadias surgery and those with LS as an etiology.segment strictures of varied etiology has been reported stricture disease after previous hypospadias repair has Men with long-segment stricture disease secondary to LS appear to have a higher recurrence rate secondary to One of the critical events for urethral reconstruction of long-segment strictures involves obtaining the appropriate tissue for urethral defect substitution.Harvest of tissue from the surrounding penile skin is defects, some authors have used composite repairs tion with buccal or penile skin grafts.Berglund and Angermeir described the use of a combined penile or these authors were able to obtain good results from these techniques for long-segment strictures some of the potential drawbacks include the need to harvest graft tissue from multiple sites, the risk of suture line ischemia secondary to incorporation of multiple grafts into the anastomosis, the risk of hair growth on genital may predispose to an LS related stricture recurrence.
Buccal mucosa alone has been demonstrated to be a good choice for extra-genital graft tissue with in long segment stricture reconstruction involves the

A B
requires harvest from both cheeks and potentially the lower lip.Complications reported with oral harvest from just one site include neurosensory deficits, the buccal mucosa graft harvest postoperatively with harvest site morbidity and limited patient complaints related to the abdominal wall harvest for long-segment previously been described in several smaller series for urethral reconstruction with reported success been related, in part, to the widespread use of tubegrafts for reconstruction at this time, and the choice of single versus two-staged repair for complicated skin for long-segment stricture reconstruction has not tissue are that it provides extra-genital tissue origin, and the limited graft site morbidity observed in this series.Furthermore, the abundant length and width of the abdominal skin graft allows for harvest of a single graft segment as compared to buccal mucosa or penile skin grafts which require multiple harvest sites and suture lines between grafts within an anastomosis for long-segment stricture defects.While abdominal skin until long-term outcomes are known, the availability of this tissue offers the reconstructive surgeon an additional option for substitution urethroplasty of long-segment strictures.

CONCLUSION
We describe a technique for full-thickness abdominal skin graft use in long-segment urethral stricture reconstruction.When harvested from hairless regions, these grafts have acceptable success rates with few complications at early follow-up.Selective use of abdominal skin grafts may be well suited for patients with long-segment urethral strictures in one or two stages when other graft sources are not available or feasible.

EDITORIAL COMMENT
ness abdominal skin graft for urethral strictures as an description focusing mainly in the procedure itself with a limited number of patients treated (10) and the present knowledge in urethroplasty.Since the popularization of mucosal grafts in urethral structure and hypospadias repair, there is a consensus that mucosal grafts are more appropriate and recently tunica vaginalis is also being studied as a valid option.Skin grafts have been extensively studied in the past with success and reported in the literature also with long term follow-up.Bracka has shown long-term clinical data in over 1000 patients with skin grafts and later buccal mucosa grafts including the second-stage suggested donor area is attractive should be based on clinical results in a larger series and not only on surgical technique descriptions.
In summary, I would like to encourage the authors to resubmit their experience later with more patients and a longer follow-up.

Federal University of Sao Paulo
Sao Paulo, SP, Brazil E-mail: amcdjr@uol.com.br

REPLY BY THE AUTHORS
In this surgical technique manuscript, we describe the procedure to harvest, prepare and place a full-thickness skin graft for men with long segment urethral strictures.While long segment urethral reconstruction is relatively rare, the most tissue source for urethral reconstruction.Many have described the use of genital skin, non-genital skin and buccal mucosa as graft sources; these with prior urethroplasty or pediatric hypospadias repair, as several men in our study were.In our potential graft sources include composite grafts of multiple buccal grafts with the possible addition we describe is not meant to replace standard techniques of buccal or genital skin grafts, but is a supplemental technique to consider when approaching a complicated patient with few ideal graft sources.As the editor mentions, more data will be forthcoming.

Figure 1 -
Figure 1 -Harvest of a full-thickness abdominal skin.A)-Region of the abdominal skin is marked that is hairless on a region and is covered by the patient's belt.B) and C)-A full thickness skin graft is harvested.D)-The graft site is closed with deep dermal and subcutiticular sutures.
the patient's belt line will eventually conceal the wound (Figure-1A).A full thickness skin graft is harvested to the level of the subcutaneous tissue (Figure-1B and Figure-1C).Once the graft is sharply excised, the deep dermal tissue of the harvest site is closed with interrupted 3-0 vicryl sutures fol--

Figure 2 -
Figure 2 -Processing and placement of full-thickness abdominal skin graft.A)-The harvested abdominal wall graft is thinned to transparency.B)-The graft is sewn into place around the urethral plate.The graft is then pie crusted and quilting sutures are placed.

Table 1 -
Clinical demographics of patients undergoing abdominal wall skin graft.