|Year : 2021 | Volume
| Issue : 3 | Page : 117-124
Everted Saphenous Vein Graft (eSVG) urethroplasty in long-segment anterior urethral strictures: Medium-term follow-up results
Swatantra Nagendra Rao1, Nikhil Khattar2, Arif Akhtar3, Anuj Varshney3, Hemant Goel3
1 Department of Urology, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Urology Medanta, The Medicity, Gurgaon, Haryana, India
3 PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India
|Date of Submission||03-May-2021|
|Date of Decision||24-Jun-2021|
|Date of Acceptance||08-Jul-2021|
|Date of Web Publication||28-Sep-2021|
Swatantra Nagendra Rao
C-4/4075, Vasant Kunj, New Delhi - 110 070
Source of Support: None, Conflict of Interest: None
Purpose: An everted saphenous vein graft (eSVG) has been used for urethroplasty in men with long segment anterior urethral stricture and chronic tobacco exposed oral mucosa with good initial results. The present study aimed to assess the medium-term outcomes of eSVG urethroplasty (eSVGU) in such patients. Materials and Methods: Prospectively maintained database of 32 patients with chronic tobacco exposed oral mucosa, who underwent an eSVGU for long segment anterior urethral stricture (≥9 cm), was reviewed. Outcomes were assessed with International Prostate Symptom Score (IPSS), uroflowmetry with postvoid residual urine at 1, 3, and 6 months, and thereafter 6 monthly symptomatic assessments. Retrograde urethrogram was done at 3 months and repeated only if there was a recurrence. Successful urethroplasty was defined as satisfactory voiding (maximum flow rate [Qmax] >15 ml/sec) and no need for any auxiliary procedures in follow-up. Patients who lost to follow-up before 3 years were excluded from the final analysis. Data from the patients were recorded on a spreadsheet and expressed as mean and standard deviation wherever feasible. Results: Mean stricture length was 13.75 cm. Two patients were lost to follow-up after 12 months and were excluded from the final analysis. At a mean follow-up of 58 months, 19 patients (63.33%) were voiding successfully with mean IPSS 8.15 and Qmax 23.54 ml/s respectively, while 11 patients (36.67%) required auxiliary procedures and were considered failed. Conclusion: Medium-term results suggest that an eSVG can be considered as a good alternative graft for urethroplasty in patients with long anterior urethral strictures.
Keywords: Auxiliary, stricture length, tobacco-exposed oral mucosa, voided
|How to cite this article:|
Rao SN, Khattar N, Akhtar A, Varshney A, Goel H. Everted Saphenous Vein Graft (eSVG) urethroplasty in long-segment anterior urethral strictures: Medium-term follow-up results. Urol Sci 2021;32:117-24
|How to cite this URL:|
Rao SN, Khattar N, Akhtar A, Varshney A, Goel H. Everted Saphenous Vein Graft (eSVG) urethroplasty in long-segment anterior urethral strictures: Medium-term follow-up results. Urol Sci [serial online] 2021 [cited 2022 Dec 4];32:117-24. Available from: https://www.e-urol-sci.com/text.asp?2021/32/3/117/326936
| Introduction|| |
Urethral stricture disease is relatively common in the Indian population and increasingly common in young- and middle-aged patients. Etiological factors include iatrogenic, inflammatory, trauma-related, congenital, and idiopathic ones. Balanitis xerotica obliterans (BXO) is an inflammatory disease of the anterior urethra that usually affects the glans penis or prepuce, foreskin, meatus, and distal urethra. Substitution urethroplasty is the treatment of choice in these cases, which can be performed by either one- or two-stage urethroplasty utilizing oral mucosal graft.
Oral mucosa graft (OMG) is the graft of choice for all urethral substitutions and has been considered as a gold standard graft. Onlay urethroplasty and multistage repair are commonly used techniques. However, recent literature from India has described poor outcomes of OMG, especially in the population with long-segment urethral strictures and tobacco-exposed oral mucosa., Thus, there is a need to search for alternate grafts for substitution in such a scenario. The saphenous vein appears to be feasible graft material for this subset of patients.
Autologous everted greater saphenous vein graft (eSVG) has continued to give reliable and reproducible results since the 1980s. This technique enhanced surgical techniques and outcomes of vein grafts for urethroplasty, with minimal risks of surgical failure and donor-site complications., However, the grafts have yet to be widely used in clinical practice.
We published our initial experience with eSVG in two different cohorts of patients, all with long anterior urethral strictures and tobacco-exposed oral mucosa. In the first cohort, we performed eSVG urethroplasty (eSVGU) in 17 patients with good initial results. Meanwhile, in the second cohort, we performed a prospective non-randomized comparative study using OMG and eSVGU (each group having 15 patients) and the results were comparable. In this article, we report the medium-term follow-up results of eSVGU in patients of both the cohorts.
| Materials and Methods|| |
The records of all 32 patients who underwent eSVGU between November 1, 2014, and January 31, 2017, were prospectively maintained until the latest follow-up. Institutional ethics committee approval was obtained (IEC: 1573, Date: 5-11-2014; and IEC: 9605, Date: December 08, 2015) and all patients were operated on for a long-segment anterior urethral stricture after providing written informed consent. The saphenous vein was used as a substitution material because of poor oral hygiene due to chronic tobacco exposure in all of these patients. Patients with urethral caliber <6 Fr, age >75 years, or a history of urethroplasty, peripheral vascular disease, acute limb ischemia, insufficiency or varicose ulcers, deep-vein thrombosis, and multiple strictures were excluded.
All patients underwent oral cavity examination and assessment of symptoms using International Prostate Symptom Score (IPSS), uroflowmetry for maximum flow rate (Qmax), and postvoided residual urine estimation. Retrograde urethrogram and micturating cystourethrogram were done to delineate the extent and size of stricture segment. Color Doppler ultrasound of both lower limbs was performed in each patient with the aim of determining the degree of patency and competence of the superficial and deep-venous systems.
All urethroplasties were performed under spinal anesthesia in the lithotomy position adapting two team approaches. A midline perineal incision was applied to approach the urethra. Penile invagination in the perineum was performed if required. Kulkarni's one-sided dorsal onlay graft technique was employed from the ventral to beyond midline dorsally, leaving fascia and vascular attachment on the other side intact in all patients.
The urethra was opened via middle dorsal incision and then, the stricture length and caliber of the urethra were measured. The saphenous vein course was marked preoperatively using color Doppler [Figure 1]a. A suitably sized saphenous venous graft was retrieved in the upper thigh using multiple small incisions starting from the saphenofemoral junction in a “no-touch” fashion with a pedicle of surrounding tissue and ligation of even small tributaries avoiding cautery use [Figure 1]b and [Figure 1]c. After harvesting, the vein was submerged in a papaverine solution (30 mg in 100 mL of normal saline solution). The vein was occluded from one end and hydrodistended using the same solution before de-tubularization along its entire length; it was used as an everted graft (endothelium facing outside the lumen) [Figure 1]d, [Figure 1]e, [Figure 1]f.
|Figure 1: (a) Course of saphenous vein premarked with color Doppler (b and c) Long segment of the saphenous vein is retrieved using small incisions (d,e and f) Hydrodistended and detubularized saphenous vein|
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An eSVG was used as a dorsolateral onlay patch. The graft was sutured to the proximal end of the urethra using simple interrupted 4-0 or 7-0 polyglactin 910 braided sutures [Figure 2]a. Thereafter, suturing the edge of the harvested vein graft was performed using continuous sutures [Figure 2]b and [Figure 2]c. A 16 Fr Foley catheter was placed. The graft was spread and fixed using running sutures to the underlying corpora. Meanwhile, the other margin of the graft was sutured to the margin of the spongiosum [Figure 2]d, [Figure 2]e, [Figure 2]f. The wound was closed in layers using interrupted 3/0 polyglactin 910.
|Figure 2: (a) Vein has been placed as a dorsolateral onlay patch and has been sutured to proximal end of the urethra (b and c) Suturing the edge of the harvested vein graft to urethral margin (d,e and f) Suturing the other edge of the graft to the margin of the spongiosum|
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In those patients who had coexisting meatal stenosis or lichen sclerosus involvement of the meatus, a generous dorsal meatotomy was applied and the graft was fixed dorsally using interrupted suture and fed into the meatus to be retrieved from below and was continued as a dorsolateral onlay patch for urethroplasty.
Immediate postoperative wound complications in the perineum and at the donor site were noted. Postoperative antibiotic prophylaxis with third-generation cephalosporine was given for 5 days and changed as required based on any allergies. The catheter was removed at 3 weeks in all patients without performing a periurethral contrast study.
All patients with a minimum of 3 years of follow-up were included from both cohorts. Outcomes were assessed with the IPSS, uroflowmetry with postvoid residual urine volume, and donor and recipient site complications at 1, 3, and 6 months, and then at 6 monthly symptomatic assessments. Retrograde urethrogram and micturating cystourethrogram were obtained at 3 months in every patient and repeated only in cases of recurrence of bothersome lower urinary tract symptoms and uroflowmetry with a maximum flow rate of (Qmax) < 15 mL/s). Urethroscopy was performed, especially in cases of recurrence. Endoscopic urethral dilatation was performed for flimsy narrowing, whereas direct vision internal urethrotomy (DVIU) was performed if a dense stricture was found. A staged urethroplasty was performed for complete re-stricture and a redo urethroplasty was performed for repeated failure of endoscopic management. Patients who were lost to follow-up (minimum 3 years) were excluded from the final analysis. Successful urethroplasty was defined as a Qmax >15 mL/s on uroflowmetry and no need for endoscopic dilatation or DVIU on follow-up.
Data from the patients were recorded on a spreadsheet (MS Excel), analyzed using Statistical Package for Social Sciences version 22.0, and expressed as mean and standard deviation wherever feasible.
| Results|| |
A total of 32 patients with chronic tobacco-exposed oral mucosa who underwent an eSVGU for long-segment anterior urethral stricture (≥9 cm) were included in this study. In this study, the most common etiological factor for urethral stricture was idiopathic. All 32 patients who underwent eSVGU had intraoperative stricture length of 9 cm or more (mean stricture length: 13.75 cm). Fourteen patients had narrow meatus, requiring simultaneous meatoplasty. The demographics, preoperative characteristics, etiology, and intraoperative details of eSVGU are summarized in [Table 1].
|Table 1: Demographic, preoperative, etiological, and intraoperative characteristics|
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Postoperatively, three patients developed infection of the wound at the site of perineal incision with serous discharge, who were managed conservatively with antibiotics without any further sequelae and voided successfully until their last follow-up. Five patients developed wound infections at the saphenous vein graft harvesting incision site; they were also managed conservatively without any further sequelae and incision site wound healed by the secondary intention of wound healing. None of the patients had postoperative penile curvature. The mean duration of follow-up was 58.0 (7.53) months (range: 46 to 72 months). The details of postoperative follow-up are summarized in [Table 2].
|Table 2: Postoperative follow-up details of everted saphenous vein graft urethroplasty|
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Out of the 32 patients, two patients developed bothersome lower urinary tract symptoms within the 1st month and were voiding with Qmax 12.2 and 6.3 mL/s. Retrograde and micturating cystourethrogram at 3 months showed diffuse narrowing involving the whole of the anterior urethra in both of these patients and they underwent staged urethroplasty. Three patients developed similar complaints at 3 months and were voiding with Qmax < 15 mL/s. In addition, narrowing was demonstrated on retrograde and micturating cystourethrogram. On urethroscopy of these three patients, two had a short section of flimsy narrowing and required endodilatation, while one patient has a short area of dense narrowing and required DVIU. Between 3 and 12 months, four more patients developed symptomatic recurrences requiring auxiliary procedures in the form of DVIU or staged urethroplasty. Two patients were lost to follow-up after 12 months, who were voiding with Qmax of 22.6 and 18.4 mL/s at their last follow-up and were excluded from the final analysis. Two patients developed delayed short segment recurrences at 30 months, both of whom required DVIU. A total of 11 patients required auxiliary procedures, which were considered to have failed, while the remaining 19 patients were voiding successfully until their last follow-up. Pre- and postoperative follow-up details of all failed eSVGU from both cohorts (S.No. 1 to 7 from the first cohort and 8 to 11 from the second cohort) are shown in [Table 3].
|Table 3: Pre- and postoperative follow-up details of failed everted saphenous vein graft urethroplasty from both cohorts|
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Three patients who underwent staged urethroplasty were further managed by second staged urethroplasty after 6 months. Out of six patients who were treated with DVIU, four presented with stricture recurrences on further follow-up, one patient who had lichen sclerosus underwent staged urethroplasty, and three patients were managed by ventral onlay augmentation urethroplasty using a local penile skin graft, while two patients who underwent DVIU at 30 months of follow-up were put on self-intermittent calibration. Two patients who were treated with endodilatation were managed by DVIU for stricture recurrence and were put on self-intermittent calibration. All of these patients were voiding well until their latest follow-up.
Out of 32 patients who underwent eSVGU, 11 patients requiring auxiliary procedure were considered as failed. The mean stricture length in failed patients was 14.45 ± 2.16 cm (range: 11-18 cm). Of the 11 patients who failed eSVGU, 7 patients (63.36%) underwent meatoplasty due to meatal narrowing and 4 patients (36.36%) had BXO. Comparing these variables in 19 successful patients, BXO was present in five patients (26.32%), meatoplasty was required in seven patients (36.84%), and the mean stricture length was 12.32 ± 2.24 cm (range: 10.0–17.0 cm). Two patients who were lost to follow-up had an idiopathic urethral stricture and their intraoperative stricture lengths were 9.0 and 15.0 cm.
Overall, 19 patients (63.33%) were voiding successfully with mean IPSS and Qmax of 8.15 and 23.54 mL/s, respectively, while 11 patients (36.67%) who have flimsy or dense narrowing and segment-level recurrence, requiring auxiliary procedures such as DVIU and staged urethroplasty were considered failed. A mean follow-up period was 58.0 (7.53) months (range: 46 to 72 months). [Figure 3] presents a flowchart showing successful and failed eSVGU.
|Figure 3: Flowchart showing successful and failed eSVGU. DVIU: Direct vision internal urethrotomy, eSVGU: Everted saphenous vein graft|
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| Discussion|| |
We conducted studies on our initial experience using saphenous vein graft for urethroplasty in long anterior urethral strictures in two different cohorts of patients and published the results. In the first cohort study, we used eSVG for urethroplasty in 17 men with long anterior urethral strictures. The initial results were good (82.35%) at a mean follow-up of 17.64 months; we also confirmed uroepithelium ingrowth by taking a biopsy from grafted mucosa at 3 months. In a second cohort study, we conducted a prospective non-randomized comparative study using OMG and eSVGU (each group having 15 patients) for long anterior urethral strictures. The results were comparable with success rates of 69.20% and 78.50%, respectively, at a mean follow-up of 23.13 months. In the present study, we prospectively followed up and maintained records of all 32 patients from both cohorts who underwent eSVGU for long anterior urethral strictures (mean length 13.03 cm) and at a mean follow-up of 58 months (range: 46 to 72 months); overall, 19 patients (63.33%) were voiding successfully. The two patients who were lost to follow-up after 12 months were voiding well until the last visit. The patients with voiding failure had a slightly longer mean stricture length (14.45 cm) than those who were voiding successfully (12.32 cm). There were more failures from the first cohort (7/17; 41.1%) than from the second cohort (4/15; 26.66%), which could reflect the learning curve with the handling of a vein as a graft and the shorter mean follow-up of the second cohort (64.29 months vs. 51.53 months). Most of the failures (9/11; 81.8%) occurred within the first 12 months.
Unlike an oral graft, which maintains its original tissue characteristics and becomes integrated with the urethral epithelium, a vein graft does not “take.” Instead, it disintegrates completely, leaving only a matrix for uroepithelium to grow over. An everted vein was first shown to yield better results in an experimental study on rabbits where both non-everted and everted jugular veins were used as a tube for an excised urethral segment. The results were better for the everted group, wherein the graft lasted longer. Later experiments with an everted saphenous vein showed successful results even at 1 year.
These studies form the basis of our work and the initial results were promising. The intermediate results also held promise and the outcomes of the second cohort are better than those of the first. The important factor behind the improved results in the second cohort is the use of a “no-touch technique” of handling the saphenous vein during the dissection and omission of the side with a vein size of less than 3 mm at the saphenofemoral junction on Doppler study. (This was not mentioned as a selection criterion for the side of the vein graft in any of the previous studies. The realization of the importance of this came later during the first cohort where we ended up retrieving a relatively thin vein in one patient.)
Oral mucosal graft has been the preferred substitution tissue for single-stage reconstruction of long anterior strictures, but there have been very few prospectively reported long-term outcomes and there is a clear need to search for alternatives. Most long-term data are retrospective low-level evidence, either from high-volume single-institution or tertiary-level multi-institutional series, where failure in patients outside of a study protocol does not generally get reported. Oral mucosa harbors human papillomaviruses such as HPV16 and 18, so using such mucosa as a graft potentially increases the risk of HPV transmission and is associated with a risk of malignancy. Oral mucosa chronically exposed to tobacco becomes unhealthy due to fibrosis and retrieval of a graft is associated with higher donor-site morbidity and poor stricture outcomes if such grafts are used for urethral reconstruction. Moreover, scrotal malignancy after the use of chronic tobacco-exposed mucosa has also been reported, the risk of which has to be studied further. Stricture length is an essential factor in determining the prognostic results and standard surgical techniques. Chen et al. treated 40 patients by dorsal onlay OMG urethroplasty and reported an 82% success rate for stricture length >4 cm and 76% for stricture length ≥6 cm. Similarly, Yalcinkaya et al. reported success rates of 88.0% and 40.0% for men with average stricture lengths of ≤7 cm and >7 cm, respectively, by using a buccal mucosal graft. Multiple oral mucosal grafts are required for urethroplasty in patients with long anterior urethral stricture. These grafts require multiple joining suture lines to achieve the desired length for urethroplasty, which is a source for focal narrowing and failure of surgery. In view of the poor results in long and pan-urethral strictures, even a definitive permanent urethrostomy has been suggested as a viable option. Various techniques have been developed for use of local penile tissue grafts for urethroplasty such as penile skin graft, inner preputial free graft, and penile skin flap, but the results are poor in patients with lichen sclerosus involvement, while in non-lichen sclerosus patients graft length can sometimes not be achieved adequately when the stricture segment is very long. Bladder, rectal, or enteral mucosa can also be used as graft material, but the retrieval in such cases is quite invasive. This background explains why researchers are seeking new ideas for other substitution materials and why vein graft has been extensively researched in animal studies along with 1-year histological studies in rabbits.,, Studies have also shown successful results with the use of a saphenous vein as a graft in complicated hypospadias repair.,, These studies prompted us to use a saphenous vein in men with long urethral stricture and tobacco-exposed oral mucosa.
SVG arose as an alternative because of its sufficient length and easy availability. It can be regarded as a first-line treatment approach in patients with long-segment anterior urethral stricture due to the offered advantages including single-sided providing adequate length and caliber, better elasticity, and rapid blood supply, with minimal side effects such as graft necrosis, stricture recurrence, and chance of fistula formation due to its thin wall. This is supported by a previous clinical study by Rao et al. demonstrating the safety and effectiveness of eSVG over OMG. Similarly, an observational study by Akhtar et al. noted that eSVG is feasible graft material for a subset of patients with poor oral hygiene due to chronic exposure to tobacco. In addition, eSVG does not need multiple sutures in the case of long-segment strictures.
In the present study, the graft was placed dorsolaterally by Kulkarni's technique so that the urethra is circumferentially mobilized from the corpora cavernosa to its dorsal surface, keeping the central tendon of the perineum intact. Furthermore, it was observed that preserving the urethral vasculature dorsally mainly improves graft uptake and minimizes the risk of developing urethral diverticula. Similar findings were observed in a study by Barbagli et al., who reported a higher success rate with minimal complications with the dorsal urethral surface approach.
We showed extreme caution as is due according to the IDEAL methodology of accepting new surgical procedures and the initial, as well as medium-term results, though inferior to reported results for OMG, are still encouraging for eSVG use. The saphenous vein provides sufficient length, a large caliber matching that of the urethra, easy availability, and greater adaptability to stretched penile length. Chronic smoking can cause injury to vascular endothelium, but when it is used as a graft, it disintegrates completely, leaving only a matrix for the uroepithelium to grow over, unlike OMG., Therefore, the saphenous vein should be further explored for shorter strictures wherever oral mucosal graft use is not feasible, as in cases of chronic tobacco exposure and in patients with severe pulmonary comorbidities, for whom general anesthesia is not possible for taking an oral graft. In addition, the ease with which saphenous vein can be retrieved from the thigh means that it should be considered as an alternative before rectal or enteral mucosa in such scenarios.
Postoperatively, three and five patients developed wound infections at the perineum and donor sites, respectively, which were successfully managed by antibiotics. The infection rates were 9.4%, and 15.6%, respectively. Similarly, Rao et al. noted wound infection in the perineum and donor sites in 26.0% of patients from the eSVG group. In contrast to this, in the literature on cardiovascular surgery, it is described that eSVG was associated with limb complications. Belczak et al. detected limb complications such as wound infection (25%), erysipelas (9.1%), lymphorrhea (4.5%), edema (52,3%), paresthesia (29.5%), and deep-vein thrombosis (2.3%) in patients undergoing SVG for cardiovascular surgery.
The limitations of this study are selection bias, small sample size, and that this study was performed at a single institution. Therefore, to obtain definitive findings, there is a need for further multi-institutional study with a larger sample size. Extensive studies have been conducted on oral grafts techniques for shorter bulbar strictures. Therefore, future comparative studies will be necessary to compare the results with saphenous vein in patients with shorter bulbar strictures. However, the real-world applicability will be established upon the use of this approach by other researchers with reproducible results.
| Conclusion|| |
eSVG has acceptable medium-term follow-up outcomes and can thus be used as a viable alternative graft for dorsolateral onlay urethroplasty in patients with long-segment anterior urethral stricture with chronic tobacco-exposed oral mucosa.
I thank my patients for participating and co-operating in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]