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Biomedical subjects

Guido Barbagli

Publications and source records attributed to Guido Barbagli.

17 recordsLinked to original sources
PubMed2006

Bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue.

OBJECTIVES: We describe a new surgical technique with the use of fibrin glue for bulbar urethra reconstruction using a dorsal buccal mucosal onlay graft. METHODS: Six patients with a mean age of 43 yr underwent bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. The urethra was mobilised from the corpora cavernosa and opened along its dorsal surface. The buccal mucosal graft was applied on the corpora cavernosa using 2 ml of fibrin glue. Two interrupted polyglactin 5-0 sutures were used to fix the apices of the graft to the underlying albuginea of the corpora cavernosa. The urethra was rotated back to cover the graft and an adjunctive fibrin glue was injected over the urethra. RESULTS: The mean operative time was 100 min (range, 90-120 min). No intraoperative or postoperative complications were observed. Voiding cystourethrography was performed when the catheter was removed 2 wk after surgery. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Mean follow-up was 16 mo (range, 12-24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients 6 and 12 mo after surgery. CONCLUSIONS: The use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction.

Adult↗
PubMed2006

Failed hypospadias repair presenting in adults.

OBJECTIVES: To evaluate the results of one-stage and multistage urethroplasty in adults with complications following multiple failed hypospadias repairs. METHODS: Sixty adults underwent reconstructive surgery of the following complications after hypospadias repair: stricture (34), residual hypospadias (26), fistula (18), meatal stenosis (11), penile curvature (9), hair (4), diverticula (2), and stone (1). A total of 36% of the patients had one complication and 64% had two or more complications. Twenty-nine patients underwent one-stage repair with buccal or skin grafts or direct repair, and 31 underwent multistage repairs with buccal or skin grafts. RESULTS: Mean follow-up was 33.8 mo. Of the 60 cases, 45 (75%) had a final successful outcome and 15 (25%) failed. One-stage repair provided 24 (82.7%) successes and 5 (17.3%) failures. Multistage repair provided 21 (67.7%) successes and 10 (32.3%) failures. Buccal mucosa grafts provided 81% of success in one-stage procedures and 82.3% in multistage procedures. Penile skin grafts provided 80% of success in one-stage procedures and 50% in multistage procedures. CONCLUSIONS: Adults with complications following childhood hypospadias repair are still a difficult population to treat with a high failure rate for reoperative surgery.

Adult↗
PubMed2006

Anastomotic fibrous ring as cause of stricture recurrence after bulbar onlay graft urethroplasty.

PURPOSE: We retrospectively reviewed patterns of failure after bulbar substitution urethroplasty. In particular we investigated the prevalence and location of anastomotic fibrous ring strictures occurring at the apical anastomoses between the graft and urethral plate after 3 types of onlay graft techniques. MATERIALS AND METHODS: We reviewed the records of 107 patients who underwent bulbar urethroplasty between 1994 and 2004. Mean patient age was 44 years. Patients with lichen sclerosus, failed hypospadias repair or urethroplasty and panurethral strictures were excluded. A total of 45 patients underwent dorsal onlay skin graft urethroplasty, 50 underwent buccal mucosa onlay graft urethroplasty and 12 underwent augmented end-to-end urethroplasty. The clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 74 months (range 12 to 130). RESULTS: Of 107 cases 85 (80%) were successful and 22 (20%) failed. Failure in 12 patients (11%) involved the whole grafted area and in 10 (9%) it involved the anastomotic site, which was distal and proximal in 5 each. Urethrography, urethral ultrasound and urethroscopy were fundamental for determining the difference between full-length and focal extension of re-stricture. Failures were treated with multistage urethroplasty in 12 cases, urethrotomy in 7 and 1-stage urethroplasty in 3. Of the patients 16 had a satisfactory final outcome and 6 underwent definitive perineal urinary diversion. CONCLUSIONS: The prevalence and location of anastomotic ring strictures after bulbar urethroplasty were uniformly distributed in after 3 surgical techniques using skin or buccal mucosa. Further studies are necessary to clarify the etiology of these fibrous ring strictures.

Adolescent↗
PubMed2006

Dorsal buccal mucosa graft urethroplasty for female urethral strictures.

PURPOSE: We describe the feasibility and complications of dorsal buccal mucosa graft urethroplasty in female patients with urethral stenosis. MATERIALS AND METHODS: From April 2005 to July 2005, 3 women 45 to 65 years old (average age 53.7) with urethral stricture disease underwent urethral reconstruction using a dorsal buccal mucosa graft. Stricture etiology was unknown in 1 patient, ischemic in 1 and iatrogenic in 1. Buccal mucosa graft length was 5 to 6 cm and width was 2 to 3 cm. The urethra was freed dorsally until the bladder neck and then opened on the roof. The buccal mucosa patch was sutured to the margins of the opened urethra and the new roof of the augmented urethra was quilted to the clitoris corpora. RESULTS: In all cases voiding urethrogram after catheter removal showed a good urethral shape with absent urinary leakage. No urinary incontinence was evident postoperatively. On urodynamic investigation all patients showed an unobstructed Blaivas-Groutz nomogram. Two patients complained about irritative voiding symptoms at catheter removal, which subsided completely and spontaneously after a week. CONCLUSIONS: The dorsal approach with buccal mucosa graft allowed us to reconstruct an adequate urethra in females, decreasing the risks of incontinence and fistula.

Aged↗
PubMed2006

Urethral reconstruction.

PURPOSE OF REVIEW: To present an up-to-date review on the main surgical techniques used to treat urethral strictures. RECENT FINDINGS: Anterior urethroplasty can be treated in outpatient surgical settings, thus decreasing the impact of urethroplasty. To improve outcome in adult patients, reconstructive surgeons have learned to apply the principles of hypospadias surgery, such as delicate tissue handling, avoidance of overlapping suture lines, tissue and the development of preputial skin flaps, to adult urethral surgery. Penile skin has been used as a free graft or harvested as a flap for some time, thanks to its location, hairless skin and durability. Since the early 1990s the use of buccal mucosa was introduced in genital reconstructive surgery and has become popular for complex urethral reconstructions. The use of fibrin glue was recently suggested to fix the buccal mucosal graft in a better way and to cover the anastomosis between the graft and urethral plate. SUMMARY: Urethral reconstructive surgery is changing rapidly and this change has posed problems for surgeons who see the principles that previously defined their profession becoming obsolete or unworkable. New techniques, new tools, such as fibrin glue, and new engineered material are a part of our future.

Fibrin Tissue Adhesive↗
PubMed2005

Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique?

PURPOSE: The use of buccal mucosa graft onlay urethroplasty represents the most widespread method of bulbar urethral stricture repair. The graft may be placed on the ventral or dorsal urethral surface according to surgeon experience and preference. We investigated whether the results are affected by the surgical technique by comparing the outcome of 3 types of bulbar urethroplasty using buccal mucosa graft. MATERIAL AND METHODS: We repaired 50 bulbar urethral strictures with buccal mucosa grafts from 1997 to 2002. Mean patient age was 42 years. The etiology of stricture was ischemia in 12 cases, trauma in 6, instrumentation in 4 and unknown in 28. Patients with lichen sclerosus, failed hypospadias or urethroplasty and stricture extending into the penile urethra were not included. A total of 47 patients (94%) had undergone previous urethrotomy or dilation. The buccal mucosa graft was always harvested from the cheek using a 2 team approach. Mean graft length was 4.2 cm. The graft was placed on the ventral, dorsal and lateral bulbar urethral surface in 17, 27 and 6 cases, respectively. Clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 42 months (range 12 to 76). RESULTS: Of 50 cases 42 (84%) were successful and 8 (16%) failed. The 17 ventral grafts provided success in 14 cases (83%) and failure in 3 (17%). The 27 dorsal grafts provided success in 23 cases (85%) and failure in 4 (15%). The 6 lateral grafts provided success in 5 cases (83%) and failure in 1 (17%). No surgical complications were observed. Failures involved the anastomotic site (distal in 2 and proximal in 3) and the whole grafted area in 3 cases. They were treated with urethrotomy in 5 cases and 2-stage urethroplasty in 3. CONCLUSIONS: In our experience the placement of buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success rates (83% to 85%) and the outcome was not affected by the surgical technique. Moreover, stricture recurrence was uniformly distributed in all patients.

Adolescent↗
PubMed2004

Heroic measures may not always be justified in extensive urethral stricture due to lichen sclerosus (balanitis xerotica obliterans).

OBJECTIVES: Strictures due to lichen sclerosus (LS) may affect the urethra as far proximally as the mid-bulb. For such strictures, a staged full-length repair is required and should use a nonpenile graft source such as buccal mucosa. Many cases occur in a population already accustomed to seated voiding, leading us to re-evaluate this approach and, in some circumstances, recommend definitive perineal urethrostomy alone. METHODS: We reviewed the medical records and retrograde urethrograms of all patients undergoing surgery for LS at our facilities between January 1991 and June 2002. RESULTS: A total of 63 patients, with an average age of 54.2 years, underwent surgery for LS stricture with an average follow-up of 38.5 months (range 4 to 117). Of the 63 patients, 19 underwent grafting in preparation for future reconstruction. Of these, 11 completed the second-stage repair, and 8 patients elected not to undergo the second stage of the repair, leaving a functional perineal urethrostomy. This led us to look more critically at definitive perineal urethrostomy alone for some patients. Parallel with the staged repairs, and subsequent to them, 44 patients underwent perineal urethrostomy alone. CONCLUSIONS: The often extensive nature of LS, the prevailing philosophy that urethroplasty must use nonpenile skin, the limited availability of such sources, and the acceptance of many patients for seated voiding makes definitive perineal urethrostomy alone a viable treatment option. In all our cases, this satisfied patients' quality of life concerns, leaving the anterior urethra dry and amenable to future repair. Younger men desirous of penile voiding should still be considered for staged repair using current techniques.

Adult↗
PubMed2004

Lichen sclerosus of the male genitalia and urethral stricture diseases.

INTRODUCTION: The true incidence of urethral involvement in patients with genital lichen sclerosus (LS) is unknown. We review the epidemiology and discuss the pathogenesis of LS and urethral stricture diseases. MATERIALS AND METHODS: During the period 1991-2002, of 925 patients who underwent urethroplasty for anterior urethral stricture, 130 patients (14%) received the diagnosis of LS. In all patients with LS the histology was re-examined to confirm the clinical diagnosis. Retrograde and voiding urethrography was used to establish urethral involvement in the disease. RESULTS: In 106 patients (82%) the histology provided the classical features of LS, and 24 patients (18%) showed some histological variations. In 49 patients (37%) the LS involved the pendolous urethra (meatus-navicularis-penile), and in 53 cases (41%) a panurethral stricture was evident. CONCLUSIONS: LS urethral involvement appears to be a much more common and extensive disease than previously reported, and requires particular care in its early diagnosis.

Adolescent↗
PubMed2003

One-stage circumferential buccal mucosa graft urethroplasty for bulbous stricture repair.

A one-stage onlay urethroplasty, using a buccal mucosa graft, is presented for patients with bulbous strictures in whom the urethral mucosa is seriously involved in the disease. Of 40 patients who underwent a dorsal buccal mucosa graft urethroplasty for bulbous urethral strictures, 5 required complete removal of the urethral mucosa and its replacement by a buccal mucosa graft. All these patients had undergone previous urethrotomy with a false passage inside the bulbous urethra and had a suprapubic tube in place. The goal of removal and replacement of the urethral mucosa in each case was to create a new, wide urethral mucosal bed to promote successful one-stage reconstruction. All patients voided spontaneously without problems after removal of the catheter. After 4 months, the mean peak flow was 21 mL/s. After 6 months, urethroscopy did not show any stricture recurrence. None of the patients required instrumentation or dilation. In patients with bulbous urethral strictures and false passage into the mucosa and spongiosum tissues, the complete removal and replacement of the urethral mucosa using a circumferential buccal mucosa graft promotes successful one-stage urethral reconstruction.

Follow-Up Studies↗
PubMed2003

Penile urethral reconstruction: concepts and concerns.

Reconstruction of the penile urethra is a challenging exercise, and for many surgeons an ungratifying experience. The past three decades have seen us move from predominantly 2-staged surgery, through foreskin grafts, and then single stage flap reconstructions, and now in the 3rd millennium, for some situations 2-stage repair has again become the favoured option. Satisfying short-term solutions have sometimes resulted in poor long-term outcomes when reviewed 10 years later. Clearly there are still problems to be resolved, hence the need for continuing evolution in our surgical management. Lessons have been learned from the treatment of Lichen Sclerosus, from strictures following hypospadias repair, and strictures associated with severe spongiofibrosis. Management of these problems has traditionally been associated with not only a high incidence of restricture and fistula formation, but also with poor cosmetic results, something that men today find increasingly difficult to accept. Several considerations are fundamental to achieving the best functional and aesthetic results. These include the presence or absence of Lichen Sclerosus, the extent of urethral disease and its grade (i.e. mucosal disease or with accompanying spongiofibrosis); furthermore the use of non-genital grafts for urethral reconstruction when the local penile tissues are deficient or unhealthy. In arriving at our present strategy, a collaborative approach that integrates established urological practice with the different perspectives of a plastic surgeon (A.B.) has proved constructive and beneficial.

Humans↗
PubMed2002

Dorsal onlay techniques for urethroplasty.

Dorsal onlay graft urethroplasty is a versatile procedure which may be combined with various substitute materials such as preputial skin, buccal mucosa grafts or pedicled flaps. Others substitute materials such as human urethral mucosa from corpses or collagen matrix will be possible in future. The long-term results of a wide series of patients showed a final success rate from 92% to 97%. Any kind of substitution urethroplasty deteriorate over time, and in our series of patients with an extended follow-up from 21.5 to 43 months the success rate of dorsal onlay graft urethroplasty decreased from 92% to 85%. With regard to substitute material concerns (buccal mucosa versus preputial skin) a long-term follow-up is mandatory to establish if buccal mucosa is superior to foreskin as urethral substitute material. At present, the authors currently use both according to patient preference, status of the genital tissues or strictures characteristics.

Catheterization↗
PubMed2002

Tachykinin NK1 and NK2 receptors mediate inhibitory vs excitatory motor responses in human isolated corpus cavernosum and spongiosum.

Motor effects produced by tachykinins were studied in human isolated corpus spongiosum and cavernosum. In quiescent preparations neurokinin A caused potent contractions (pD(2)=8.3 - 7.9 respectively) prevented by the NK(2) receptor-selective antagonist nepadutant, whereas [Sar(9)]SP sulfone and senktide (NK(1) and NK(3) receptor-selective agonists) produced no effect or spare contractions. In KCl-precontracted corpus spongiosum septide (pD(2)=7.1) and [Sar(9)]SP sulfone (pD(2)=7.7) produced tetrodotoxin-resistant relaxations, abolished by the tachykinin NK(1) receptor-selective antagonist SR 140333. [Sar(9)]SP sulfone (1 microM) produced similar relaxations in precontracted corpus cavernosum. Electrical field stimulation (EFS) elicited tetrodotoxin-sensitive relaxations, which were additive to those produced by [Sar(9)]SP sulfone. N(omega)-nitro-L-arginine (L-NOARG) totally prevented both [Sar(9)]SP sulfone- and EFS-induced relaxations. These results show that tachykinin NK(1) and NK(2) receptors mediate opposite motor effects in human penile tissues, suggesting a possible modulatory role of tachykinins on smooth muscle tone in these organs.

Adult↗
PubMed2002

Vestibular flap urethroplasty for strictures of the female urethra. Impact on symptoms and flow patterns.

INTRODUCTION: To assess the impact on subjective symptoms and flow patterns of a new surgical technique designed to correct strictures of the female distal urethra and urethral meatus. MATERIALS AND METHODS: Seventeen patients (mean age 41.2 years) with symptomatic strictures of either the distal urethra or the urethral meatus entered the study. Patients reporting an AUA score >20, a diagnosis of bladder outlet obstruction according to the Abrams-Griffiths nomogram and the Schaefer linPURR diagram, urethral calibration <20 F and radiologic evidence of the stricture, were considered eligible for surgery. A pedicled flap isolated from the vaginal vestibule was anastomosed with two longitudinal running sutures along the two edges of an opened urethra. RESULTS: In all cases, diffuse fibrosis of the urethral wall was demonstrated at histological examination. Mean (+/- SE) preoperative and 12-month follow-up results were as follows: AUA score 25.2 +/- 2.1 vs. 8.4 +/- 1.2 (p < 0.0001); peak flow rate (ml/s) 13.2 +/- 1.2 vs. 36 +/- 1.5 (p < 0.0001); detrusor pressure at Q(max) (cm H(2)O) 45 +/- 5 vs. 17 +/- 3; residual urine volume (ml) 120 +/- 5 vs. 20 +/- 5 (p < 0.0001). Fifteen patients (88%) showed an unobstructed Abrams-Griffiths nomogram and a Schaefer linPURR diagram postoperatively. All but 2 cases (88%) could be calibrated at 28 F postoperatively and showed a normal urethral lumen at voiding cystourethrography. Complications were never noted. CONCLUSIONS: Female patients with symptomatic strictures of the distal urethra or urethral meatus may be treated efficaciously and safely with vestibular flap urethroplasty. Although this technique must be performed under optical magnification it is easy to perform and is not associated with complications.

Adolescent↗
PubMed2002

New 2-stage buccal mucosal graft urethroplasty.

PURPOSE: Previously buccal mucosal grafts used for repairing adult bulbourethral stricture with the 1-stage dorsal technique has provided a satisfactory outcome in our experience. We present the wider use of buccal mucosal grafts for 2-stage urethroplasty. MATERIALS AND METHODS: A total of 24 men 25 to 60 years old (median age 45) with a complex bulbar stricture underwent 2-stage urethroplasty using a buccal mucosal graft to repair the perineostomy. The primary etiology of stricture was traumatic in 4 cases, inflammatory in 16 and unknown in 4. The 2 x 6 cm. graft was harvested from the inner cheek and sutured to the left margin of the urethral mucosal plate with running 6-zero polyglactin suture. Patients were discharged from the hospital within 3 days with a 14Fr silicone urethral catheter in place. Radiological studies and urethroscopy were done 1 year after closure. RESULTS: A final successful outcome with no recurrent stricture was achieved in 23 of 24 men (92.8%) at a median followup of 18 months (range 13 to 32). In 1 case a urethrocutaneous fistula at the initial radiological assessment closed spontaneously after 14 days of catheterization. No urethral diverticula developed. The mean postoperative peak flow rate is 22 ml. per second (range 18 to 25). CONCLUSIONS: Our new 2-stage buccal mucosal graft urethroplasty may be an excellent technique for complex bulbar urethral stricture disease. Our suggestions may increase usefulness of the 2-stage technique for repairing complex strictures due to the avoidance of classic complications.

Adult↗
PubMedDate not supplied

Bulbar urethroplasty using the dorsal approach: current techniques.

INTRODUCTION: The use of flaps or grafts is mandatory in patients with longer and complex strictures. In 1995-96 we described a new dorsal onlay graft urethroplasty. Over time, our original technique was better defined and changed. Now this procedure (also named Barbagli technique) has been greeted with a fair amount of enthusiasm in Europe and in the United States. SURGICAL TECHNIQUE: The patient is placed in normal lithotomy position, and a midline perineo-scrotal incision is made. The bulbar urethra is then free from the bulbo-cavernous muscles, and is dissected from the corpora cavernosa. The urethra is completely mobilized from the corpora cavernosa, it is rotated 180 degrees, and is incised along its dorsal surface. The graft (preputial skin or buccal mucosa) or the flap is fixed and quilted to the tunica albuginea of the corporal bodies. The right mucosal margin of the opened urethra is sutured to the right side of the patch-graft. The urethra is rotated back into its original position. The left urethral margin is sutured to the left side of the patch graft and to the corporal bodies, and the grafted area is entirely covered by the urethral plate. The bulbo-cavernous muscles are approximated over the grafted area. A 16F silicone Foley catheter is left in place. COMMENTS: Dorsal onlay graft urethroplasty is a versatile procedure that may be combined with various substitute materials like preputial skin, buccal mucosa grafts or pedicled flaps.

Journal Article↗