Hello and welcome to our webcast, Female Pelvic Reconstruction and the Role of Buckled Mucosal Graft. Thank you for joining us. My name is Gary and I will be the operator for today's presentation. We are joined today by our moderator, Leslie Rickey, and our speaker, Gareth Warren. At this time, I'd like to turn things over to Leslie for opening remarks. Thank you. I would like to welcome all of you to our next installment of our all-virtual forum web-based lecture series. This is a series of presentations by experts in our sub-specialties from across the country, focused on topics based on the FPMRS learning objectives, as well as relevant practice-related topics. The virtual format also provides members the opportunity to interact with the speakers in real time. This presentation will then be captured and made available for view at any time on the AUG's website. Upon completion of this program, you will be given the opportunity to provide some feedback, which we value greatly. For this evening's presentation, it is my pleasure to introduce Dr. Gareth Warren. He is an assistant professor in the Department of Urology with a secondary appointment in obstetrics and gynecology at the University of Rochester Medical Center. He has completed a fellowship in genitourinary reconstruction and his presentation today will be on female pelvic reconstruction and the role of the buckled mucosal graft. Thank you so much, Dr. Warren, for being with us today and I look forward to your presentation. Thank you, Leslie. It was a pleasure to be here and why don't we go ahead and get started. So it's ironic that this falls in line with how your clinical volume because I have just so happen to have a couple of patients who I'm going to be preparing for for treatment with pelvic reconstruction with the need of a buckle graft and I just recently came back from the American Urologic Association, which was also a fairly common topic with videos and poster presentations about this area and female pelvic reconstruction. So let's get started. My outline will be a perspective looking at broad aspects related to oral mucosal grafts, their use, their use within the male patient and then I'll transition to the female patient and I'll give you some perspective related to that. How the actual buckled mucosal graft can be utilized in the urethral reconstruction and other roles in which oral mucosal tissue substitution can be utilized within female pelvic reconstruction. I hope that this talk will give you just a foundation and that you can move forward with additional questions or more additional literature search about more details, but just a broad spectrum related to the topic at hand. I thought it would be wise to start off with a historical timeline. Oral mucosal graft tissue used as tissue substitution has been in existence for quite a long time. The first reported use was in 1873, not enrolled of OBGYN or pelvic reconstruction or male urethral stricture disease, but actually an ophthalmology. Here we have a piece of the mouth going into the eye back in 1873 in Vienna, Austria with use of a lip mucosa to treat conjunctival defects. Here is just an example of a modern-day perspective of how use and harvesting of the lip mucosa and how it was utilized for treatment for defects related to the eye. Transition there a little bit later in 1890 in Ukraine where the first urethralplasty in 1890s was reported again using oral mucosal as a urethral replacement. Here the first time that we have report that actually was utilized for the capacity of the field of urology as it relates to urethral voiding and voiding dysfunction. As we move forward into the 1900s in 1941 in Holmby in the Hospital of Sick Children in London in the UK, hypospadias repair using oral mucosal graft was reported and this was further followed by many decades thereafter out of Cairo, Egypt back in 1993 where we have the first reported case series which reports 20 adult patients which undergone urethral structure repair urethralplasties utilizing oral mucosal. This rich history as it stands is very timely in the sense of just how widespread oral mucosal has been utilized and why it's been such a constant theme related to urethral reconstruction and pelvic reconstruction. And why is that? Well oral mucosal has so many different aspects that are high yield. Number one, everyone has oral mucosal. Everyone has a mouth so it's readily available in all patients both men and women, young and old. It's easily harvested from the cheek or the lip and I'll explain a little bit more detail regarding that. It's a concealed donor site and so the actual harvesting site is not readily apparent from cosmetic purposes. It is hairless. Oftentimes particularly in male urethral structure disease use of an arm or thigh or scrotal skin tissues that were actually hair-bearing were utilized for urethral reconstruction and unfortunately with time those foreign bodies in a urine saturated in urine can develop calcifications and become an itis for infection or more complications. So it's hairless. It's a thick elastin rich epithelium so it's a it's tissue that can take a licking and keep on ticking in a sense that it's highly resistant highly resilient excuse me and it's tough yet easily able to handle. And so these all of these aspects of the reason why oral mucosa and I should also mention it is also used to being in a moist environment how it's an ideal graft to tissue substitution that has been greatly utilized in a wide spectrum. As I look a bit more further back after 1993 when the first case series was reported back in 1996 Alan Mori and Jack McInich out of San Francisco did the first really within the field of urology reported series where they actually defined the technique of harvesting buccal mucosa for urethral reconstruction reporting their outcomes and 11 patients talking about post operative care and complications. One of the key findings in which they highlighted which is still used today is a consideration of a two team approach to harvest having a harvest team as well as a perineal team to be able to reduce operative time and the positioning of the patient which is usually in a high lethotomy position. Retraction and set up being quite important. Hydro distention using lidocaine with epi, the preparation of the graft and really highlighted and set the stage for urologists or individuals doing urethral reconstruction on a consistent basis with a concept that buccal mucosal graft was here to stay it was a reliable consistent modality for treatment. A couple of years there later there was a literature review which really highlighted buccal mucosal urethralplasty or tissue substitution using the buccal mucosal graft as being now the gold standard for urethral structures which are not amenable to excision and primary anastomosis which requires some form of tissue substitution or a stage or repair. Here this literature review reviewed several case series related to the use of buccal mucosal graft and the success rate was reported to be roughly 95% with a mean follow-up in three years. Fewer complications compared to skin were discussed and highlighted and really set again the stage related to buccal mucosal graft being used in this manner. And what were we really treating? And these are just some highlighting of some extreme examples of what was being utilized at this time or what we can utilize buccal mucosal graft. Here an example starting in diagram A you can see that this is a young boy who has essentially what we call a hypospadias and his hypospadias is here down on the penile shaft of his urethra and in part B it's delineated as far as opening up to identify the urethral plate in his normal anatomic position which is typically at the glands. And here's an example of how a piece of buccal mucosal graft has been harvested and placed and applied into an exposed open urethral plate up to the tip of the penis to regain normal alignment of the urethra as well as a normal opening of the meatus for urination versus down on the penile shaft that we see in group A. Next here just some imaging that we can see. This is what we see in the urology world related to urethral stricture disease. Long segmented urethral strictures as identified here by the blue arrow not amenable to just excising this area and bringing the tissue together because of the extended length which will need some form of tissue substitution compared to B where you have a short segment of urethral stricture which could be amenable and not necessary needing tissue substitution. And this as we see here on the left are some of the examples on imaging of what we're talking about and the ideal patient who if they need definitive urethral reconstruction will utilize a buccal mucosal graft or for tissue substitution. Garrett, this is Leslie. Can I interrupt you for just a minute? Are you able to go back up two slides to show that buccal graft? Yes. Can you just clarify that's going to be rolled into the urethra, right? So I'll give you some scenarios and more pictures but yes. So there are different ways in which you can be able to utilize the buccal graft once you've harvested. This is an example here of just highlighting how it's initially placed. Once the graft has taken and it has well healed and vascularized we can take up to four to six months after initial placement and then we would do a process of a staged approach that would be stage one and then we will come back at four to six months in a stage two to do the tubularization of this well healed now urethral plate with use of this graft into a tubular structure creating a neo urethra, a new urethra that's an alignment up to the tip of the penis at the meatus. Perfect. Thank you. And next again this is about another example here of a severe urethral structure disease. You see the idea of what is considered to be normal here compared to the stricture portion here. This again is a retrograde urethra gram that is being identified and here significant amount of disease. Ability to be able to excise this area is not an option and so from this area that we see we have to be able to put some form of a tissue substitution and the buccal mucosal graft has been the mainstay and gold standard. Again I approach this as a topic about harvesting in the buccal mucosal graft that Alan Mori presented and we'll go into more detail regarding the use and how do you actually harvest a buccal graft. So before we talk about harvesting we should also look at landmarks of the actual oral mucosal harvest sites. So here are two examples of the oral cavity and we have here on the external and then a portion here on the internal aspect of the inner cheek. Here you have diagrams of the neurovascular bundles, the buccal nerve, the facial artery, the buccinator muscle in which the actual buccal mucosal graft is excised off of and then you have the bony landmarks. You also have the parotid gland which has what we call a Stenson's duct which is a gland or a papillae that is actually within the actual oral mucosa in the inner lining of the cheek that provides secretions that is also well identified. Here you can see the site of a potential excision or harvest graft site in the inner lining of the cheek. We identify this large thickened elastin and epithelium rich layer followed by a lamina propria layer of the actual buccal mucosal graft which is perfect for a graft to be harvested in place for neurovascularization and rejuvenation into actual stable healthy graft site. Here is an example not as widely utilized but I want to highlight this because this was how oral mucosal graft was first reported was here the inner labial harvest site the inner lining of the lower lip is again another example of how tissue can be identified and harvested here in the oral mucosa. Here's a pictorial diagram leading to retraction of the mouth. Here we have a oral retraction where we identify the actual inner lining of the cheek. The actual measurements of the buccal site is identified here. The width is identified as well as the length which is dependent upon how large of a mouth the patient has. We usually identify the Stenson's duct in this situation to be able to prevent its use of being injured in any way and then there are traction sutures on the inner lining of the lip to give you traction as you make your incision here related to, excuse me, as you make your incision here related to your graft site. This is another example of an actual real person who's having the incision here of this graft site. Here you can see the well delineated buccal mucosal graft. His mouth is on retraction. His tongue is moved laterally to the side. It's completely fine to use an actual endotracheal tube. This is not a situation where you use an LMA where you can be able to move depending upon the side that you want to prepare your graft or provide a graft and again Stenson's duct is identified. Stenson's duct is identified. The length of the actual structure of the harvest site is appreciated with a marking stitch. Next, lidocaine and epi is generally utilized to be able to provide some control of hemostasis as well as hydro dissection of your graft site. Here you can see an example of that being done where you infiltrate usually on the lateral borders of your graft site to be able to allow for better dissection and release of the actual buccal mucosal graft off of the buccinator muscle. Here is a picture here. There are tags, sutures that are placed on the tip of your actual graft site and they begin to incise. You usually take a 15 blade or some scalpel and you make an incision along your marking along identifying the again buccal mucosal graft and in this next slide you can see how you're releasing the buccinator muscle applying tension and counter tension on the actual graft harvest graft site to be able to release this done sharply generally with scissors or actually 15 blade where you actually release this buccinator muscle off of the buccal excuse me release the buccal mucosal graft off of the buccinator muscle to be able to identify your graft site. Once you have removed based upon the measurement that you feel is appropriate or how much tissue you can be able to get in one's mouth keep in mind that this can be done bilaterally if need be based upon how length of the actual structure and the amount of tissue substitution that is needed. It has to be carefully prepared and defatted so once you have released the actual buccal mucosal graft you can take it to the back table when you actually defat it sharply removing any residual buccinator muscle or any fat creating a thin again highly resilient buccinator a buccal mucosal graft that is ideal for actually graft placement. This just showed you an example of a prepared ready to utilize buccal mucosal graft. Here we stretch it out thin to be able to identify and see it. We mark it for measurement of how much we're actually utilizing to compare our graft site and this is ready to go for actually placement. And these are just some examples of again how this is utilized. My examples that I'm demonstrating here are examples of how we're going to do as Leslie kind of clarified. This is a staged approach so here this urethral structure extends from the glands of the penis all the way down past the penoscorum junction into the perineum. Here in this situation likely buccal mucosal graft was used from both cheeks both left and right in which it was laid down along the native urethral plate which is right here. It is sutured to the skin and the graft bed tissue. It is quilted as far as puncture sites to allow for any resolution of any hematoma and it's placed after this is placed to dressing is placed over this and it's allowed the time to heal. Four to six months after the graft has taken as well healed then you begin the process of tubularization of the actual buccal mucosal graft to recreate what is now a new urethra or a final stage of your urethralplasty. This buccal mucosal graft can also be used although I don't have a specific picture of it per se in a one stage approach where you have a shorter segment of structure that can be used as almost like a patch graft onto an area of the urethra and then closed primarily thereafter. Again another example of tissue being utilized. This is now four to six months out afterwards and you can see again on the right the native tissue of the native urethral plate and then you see the additional site of the graft, this hyperemic area which is consistent with use of graft tissue of a donor site where you can see has been placed here and is nicely healed and can be ready for the next stage. Again this just highlights again what Leslie was mentioning about this first and second stage approach. Here in 3A it is well healed ready for tubularization. 3B you can see that this area is now involuted and tubularized into a luminal structure, a Foley catheter is going to be placed here and then you can see finally in 3C that the actual skin and surrounding connective tissue is placed around and the actual urethral plate is enclosed as well as the whole entire penile shaft the skin is closed over a Foley catheter and this is the completion of a stage urethroplasty using buccal mucosal graft. Post-operatively there are a few complications and I'll go over a little bit of that related to harvesting a buccal mucosal graft. This is obviously three to four weeks out after having a buccal mucosal graft harvested from its inner lining of left cheek. Here is well healed. There are times where you can be able to close it primarily using absorbable suture or there are times where you can't due to risk of traction or scarring and there you leave it open just as if you would cut the inside lining of your mouth with food intake or something in your mouth it is well healed it heals very quickly high cell turnover and this heals on its own even if you don't close it. Again the success rate related to this is 96% with a mean follow-up at 36 months with fewer complications compared to use of penile skin or a thigh or labial or back skin related to urethral structure repair. Some of the complications that have been reported although are extremely rare are oral paresthesia any innervation or damage to that nerve area there can be a level of numbness in the inner lining of cheek which often resolves over the next 6 to 12 months. Scar contracture there are often times I've only in my experience not in my training where I've actually seen a scar form after a buccal mucosal graft harvest site with limitation of the oral opening. Usually we refer those patients to ENT to ear nose and throat and steroid therapy may be utilized to be able to loosen up that scar and with time that scarring will loosen up. There can be issues related to bleeding often while we are actually placing the buccal mucosal graft I actually place that lidocaine epinephrine soaked sponge in the oral cavity again to help with hemostasis and I try to close my site and there can always be concerns related to infection. Post-operatively regarding a buccal mucosal graft I resume a regular diet at the onset on post-op day one. A cold compress can be used over the mouth to help for swelling because it can be some level of swelling. We often provide patients with oral lidocaine and antiseptic mouthwash to be able to use at their leisure again to be able to help with any oral pain that they may have in addition to the narcotic medication that is often prescribed after having undergone a urethralplasty. And again this all set the stage of how we look at tissue substitution in modern day how the graft technique has been kind of applied with very little changes since 1996 and how we can be able to utilize it and move forward to deal with complex urethral pelvic reconstruction. So I would promise you the people who are listening here that although I've talked much about male urethral reconstruction and the goal here is to talk about female pelvic reconstruction, I wanted to make this a point of how we're laying down the foundation of much of the work, the literature, the data, the technique has been based off of male urethral reconstruction and it's easily been transferable to female pelvic reconstruction particularly relates to female urethral stricture disease. So next let's go on to the discussion now with that historical and baseline foundation about pelvic female reconstruction and the role of buccal mucosal graft. Female urethral stricture disease, number one, it's a rare occurrence. There's a lack of consensus regarding the diagnosis and treatment because very few women actually have the diagnosis or disease or need treatment. It is often overlooked and under-diagnosed primarily because the presenting symptoms are variable and nonspecific and so therefore the management of patients particularly females with urethral stricture disease can be quite challenging. Urethral stricture disease overall is a very rare entity. Roughly up to 8% of all women with lower urinary tract symptoms will be diagnosed with bladder outlet obstruction or BOO. Within that group 4 to 13% of these women will demonstrate that they have an actual urethral stricture with a diagnosis and so roughly that develops to an incidence about 0.1 to 1% of women with lower urinary tract symptoms actually have a urethral stricture disease that has been documented. The symptoms related to female urethral stricture or disease are broad and often are symptoms that come across in the women or the patients that we see every day in clinic for a variety of different reasons related to avoiding dysfunction. Weak stream or poor urine flow, urine dribbling, recurrent urinary tract infections, urinary urgency and frequency or even urge incontinence, dysuria or urethral pain or even pelvic pain, actually acute urinary retention and these are all very nonspecific and variable as far as their severity and symptoms of how they present. And I bring this picture up because I can tell a story about each one of these young ladies that are here today. Urethral stricture disease and the presentation can happen in anyone. It could be a 78 year old female grandmother who is battling cervical cancer and ovarian cancer possibly and has had radiation therapy for example. It could be a 45 year old mother of three who has had a sling placed and has had complications with mesh erosion of some issue. It could be idiopathic or a situation where a patient has had surgery or a trauma, a young girl in a motor vehicle crash that has had catheterizations in the past and has developed inflammation or scarring or trauma iatrogenically related to urethra therefore developing these symptoms. This is what makes urethral stricture disease in females so challenging because it has a broad spectrum of how it can impact patients and the symptoms are quite varied. If you look, let's take a step back and look at the etiology of bladder outlet obstruction or BOO, it's related to prior surgery, pelvic organ prolapse, primary bladder neck obstruction, chronic voiding dysfunction, districter dyssynergia, diverticulum, malignancy and also urethral stricture. And so when evaluating patients as you all know related to outlet obstruction or weak stream, it can be a combination of different disease processes that could be contributing to their presentation. Here's a schematic from the Journal of Urology in 2016 as a systematic review that was looking at female urethral reconstruction out of Rutgers in New Brunswick, New Jersey. And I like this diagram because it sets the stage looking at urethral stricture disease, talking about the etiology of the actual disease process, looking at preoperative patient evaluation, the diagnosis and then talking about surgical options. And I will focus them specifically during this talk related to buccal mucosal graft urethroplasty. Here you can see that the etiology is broad as I explained. It can be traumatic from obstetrical or pelvic fracture or iatrogenic injury related to a catheter. It could be related to vaginal surgery, urethral surgery or urethral catheterization or radiation or issues related to a urethral sling. And very rarely do we see issues in women related to infection other than something such as Lyklin sclerosis or cancer in the urethra. The diagnosis of the female urethral stricture also brings another conundrum related to the management. What truly is the normal parameter for female urethral calibration? There is no no data or set benchmark that we identify what is an actual normal parameter for female urethral calibration. In the journal Urology in 2006 there was a quote that I like to emphasize is that the caliber of the female urethra at which pathological conditions may arise is undefined. At what point do women present and you identify based upon the caliber of the urethra that is deemed to be pathologic and is deemed to be a problem? All of this sets the tone of having no set guidelines or algorithm related to the use of identification to diagnose as a urethral stricture disease. Here, Joe Buckley and Casey Kovalok at a Leahy Clinic looked at their intermediate outcomes of female urethral reconstruction graft versus harvest. They identified the inability to pass a 70 French flexible cystoscope defines the definition of a stricture or concern or suggestion of a stricture. Here in another article with Wormley, Elizabeth, and Journal of Urology in 2006, it said the inability to place a catheter greater than 12 French is suggestive of a stricture. And then lastly, you can look at urodynamic diagnosis. Urodynamic studies suggest female bladder outlet obstruction with a PDET with a max greater than 25 centimeters of water with a flow rate of less than 12 suggest that there might be concern that that might be a urethral obstruction. And so when we look at the preoperative patient evaluation of diagnosis, patient history and physical examination definitely is important with all mainstays. Urinalysis is also important. But if you look at key imaging or procedures that we can do to delineate if it's actually a true urethral stricture, cystoscopy with direct visualization of the urethra is key. Avoiding systoleurethrogram or DCUG is an option. And I put down in a highlighted endovaginal MRI is often not a primary or mainstay for patient evaluation of diagnosis, but can be utilized particularly if there's a concern for actually malignancy. Indications for surgery are urethral loss or urethral stricture. And that urethral loss and stricture and the timing of surgery is key if you have free of infection inflammation and this is the ability for the tissue to be ready to prepare to accept a graft or septum type of urethral reconstruction. Here's just an example of an imaging study done on a woman who had a concern for urethral stricture disease. Here you can actually see on a video systoleurethra, video scoped systoleurethrogram that her bladder is filled and then just proximal to a stricture in her urethra, there's bologna and dilation in this proximal aspect of the female urethra. Cystoscopy which is what we often identify actually looking at a direct scope where you actually look into the actual urethra and urethral lumen and you can see scarring and narrowing here. This is normal tissue of the urethral lumen and then we get our scarring and narrowing here consistent with a stricture. Oftentimes, unamenable to be able to advance a scope but even can advance maybe a pediatric scope or a small scope or a small catheter but not amenable to be able to advance a larger scope, therefore causing symptoms, therefore pathologically identified as a stricture concerning for repair. Again, I highlight how hard or more challenging it is to be able to identify due to female anatomy of the urethra about how we identify what is truly a urethral stricture compared to in men where the anatomy allows for a little bit greater delineation of what is actually a narrowed segment of the urethra and which is identified as a urethral stricture. This falls in line with a couple of things. Number one, the proximal urethra, excuse me, the female urethra just in general is quite short. It's a short segment, roughly on average about four centimeters in length compared to a male urethra including internal and external length of the urethra can extend up to 20 centimeters in length with the varied areas of segment that can be injured. The area and the concern related to incontinence as you talk about urethral stricture disease in females is often a concern as it relates to you have a little bit more greater availability and leeway with concern with related to incontinence after having a repair on the male side. So next we're going to highlight and talk about the actual treatment options. I'm going to focus my talk specifically on the buccal mucosal graft urethroplasty. Here we identify several different treatment options. The most commonly utilized primary form of option for urethral stricture disease when someone has been defined as having one is a minimally invasive approach and that minimally invasive approach can include urethral dilation as well as optical urethrotomy. Essentially what that entails is actually incision or cutting of the urethral stricture to open up an area releasing that scar within the urethra. These are all procedures that we often utilize in male urethral stricture disease, but there's even higher rates of recurrence and low success rates in women as we see here based upon this literature review that I'm referring to in the Journal of Urology in 2016 looking at 40% related to high rates of recurrence with urethral dilation. If we look at the buccal mucosal graft urethroplasty, the overall success rate is 94% looking at a total of 32 different case series and reports looking at the literature specifically looking at buccal mucosal graft urethroplasty as it relates to female urethral stricture disease. When we set the stage related to a buccal mucosal graft, what approach can we take related to the female urethra? Similar to a male urethra, there's a ventral and dorsal aspect and they can be placed either, but that can also be the same related to the female, the ventral or dorsal approach. There are pluses and disadvantages related to either one. On the ventral approach side, you avoid potential damage to the clitoral structure, so you're away from any decrease in sensation related to the clitoral structures, generally decrease in bleeding because there's less or more of a manipulation of the actual urethra itself, decreased risk of stress urinary recontinence, and you avoid any dorsal mobilization of the urethra, again, reducing the risk of bleeding, incontinence, and damage. However, on the dorsal approach, there's a strong mechanical support, there's local vascularization of the graft due to the clitoral involvement in the clitoral cavernous tissue. You avoid disruption of potential sling placement. Oftentimes, if patients have concomitant incontinence or developed incontinence, that you have a virgin plane on the ventral approach of the urethra to be able to place a sling versus placing your graft on the dorsal approach. And then lastly, it provides more of a physiologic or anatomic reconstruction placing on the dorsal approach. Typically, in my experience, I tend to utilize the dorsal approach when need be, purely for those purposes of, again, a strong mechanical support with good vascularization of the clitoral cavernous tissue, and you avoid the disruption for any potential need for a sling placement further down the line. So next will be, and I apologize in advance, the plan for a video did not work out as planned, but I have snippets of highlighted segments of how to prepare a patient in regards to a placement of a buccal mucosal graft after it's been properly harvested, as I explained previously in the presentation, here in a dorsal approach with a female patient here with urethral stricture. So just of note, this Foley catheter is roughly about a 14 French, defined to be that based upon her symptoms, she was significant in having a low voiding stream, with a low uroflow, with significant lower urinary tract symptoms and was defined to have scarring consistent with her stricture. We had delineated the actual urethral with placement of the Foley catheter. From there, we used similar same concepts, used hydro dissection for marking with injection around the dorsal aspect of a superior portion of the urethral meatus. From there, we did a dissection of the dorsal aspect of the urethra going to the 3 and 9 o'clock position sharply. Retractions are utilized to extend the labia and to identify the vaginal mucosa to be able to do this. Further dissection sharply, and this gets into concern about disruption of the clitoral cavernous tissue, where you have to do deep dissection to be able to release that bladder, excuse me, to release that urethra on the dorsal aspect up to generally almost the bladder neck. Again, the urethra is a short segment to be able to get access to the site of where the urethral stricture is. Once you have palpated the actual bladder neck, you have good mobilization of the dorsal aspect of the urethra for your dissection. Next, you actually do a urethrotomy. You incise the urethra on the dorsal aspect along the midline, opening up the urethral plate, incising the actual urethral stricture. That is a concern. Here, next, an actual bougie sound is placed that delineates this actual stricture where we can be able to incise over this and open up the urethra and to identify the urethral plate. From there, once you have harvested the buccal mucosal graft, and I should make note that many institutions and centers utilize a two-team approach that was initially discussed back in 1996 with Alan Morey in regards of identifying either a urologist or an ENT or plastic surgeon who is amenable to harvesting a graft while there's a separate team that is down in the perineum dealing with the dissection to prepare the graft for placement. It does cut down on operative time, cuts down on patient positioning and high lithotomy during this time period and is a widely utilized practice of having this two-team approach. Here in this situation, we have our buccal mucosal graft that's been harvested. We have some pre-placed stitches here in the apical, the most proximal portion of our urethrotomy. Again, utilizing this graft to be placed as a patch over our urethrotomy over the site of our stricture. Here, there are several absorbable sutures that are placed and on a running fashion on the lateral aspects of the urethral plate to replace our graft. Key point to have the mucosa of the graft facing in the actual lumen of the urethra and creating the neo-urethra, and you can see how that is done here. We continue on with placement of our buccal mucosal graft here in this positioning here. Now, continue suturing coming from proximally more distally as we approach the actual urethral meatus or the neo-created urethral meatus. Gary, this is Leslie. Can I interrupt for one minute? Yes. Can you orient either on this slide or the previous one? Was the urethrotomy made all the way through the meatus? So there's just a posterior plate there? Sure. So let me go back to a couple of slides here. And so here is an example of, again, this is the clitoris here, this is the vaginal cavity, and here we are making an incision right on the dorsal aspect of which we've already dissected out. You've mobilized this dorsal aspect of the urethra. You're incising the aspect of the urethra, creating a urethrotomy. With that urethrotomy, you actually open and you can identify the actual urethral lumen incising and releasing that urethral stricture, opening up that scar tissue. So now you have almost like we've described, it's almost like a hot dog bun that's been split open. That is a conduit and a graft that you can be able to use, a harvest site that you can be able to place a graft down. So there's basically a posterior plate from the length of the, well, at least with the stricture distal. Correct. That's absolutely correct. Yep. And this is not completely through and through. This is, again, just the dorsal aspect. And so the, if you look at it from a superior aspect of the urethra versus inferior aspect of the urethra, you're not going completely through and through. You're just releasing the scar on the dorsal aspect of the actual urethra, not the ventral aspect of the urethra, opening up, getting access into the actual true urethral lumen. Once that actual stricture site has been opened and incised, you can have good access within the actual complete urethra at this point. And now you have to put it back together. You have to reconstruct that area that has been opened due to your urethrodomy, which was the site of your stricture. Utilizing this graft tissue, you place the most proximal portion of your graft site onto the most apical or most proximal portion of your urethrodomy. And with the zorobral sutures, you follow that graft tissue again on, let me get my pointer over here, you follow that tissue and you incise it again using that urethral, the lateral borders of your urethral plate that you've opened up until you get to the most distal tip where you have your defined meatus at that point. Here again is an example of the actual buccal mucosal graft that has been placed, again suturing on the lateral borders with some additional redundant tissue that is not needed creating the now meatus. This is an example here of the actual residual or excess graft tissue that is not needed, is trimmed, now creating a new meatus here with an actual urethral lumen. This is excess graft tissue that is cut at the distal end of your urethra. A Foley catheter has been placed here in this new created urethral lumen that you see here into the bladder and now you close, again closure of that graft bed utilizing that clitoral cavernous tissue as a bed. You're re-approximating now our wound from the clitoral cavernous tissue to the actual buccal mucosal graft along the dorsal aspect. From there, the actual vaginal wound is enclosed and re-approximated. Again, this area is brought together in a fashion coming from 9 o'clock to 3 o'clock positioning, re-approximating the tissues here around the opening of our new created urethral meatus with a Foley catheter in place. And another example of vaginal wound closure, again, along the dorsal aspect of our initial incision as we were trying to mobilize and identify the dorsal aspect of our urethra. So when I go back and I talk about buccal mucosal graft, and that was just one example of time points of critical steps related to a buccal mucosal graft and a dorsal approach for urethral restriction of female, the success rates remain as high just as they are in females, or excuse me, just as they are in males with a 94% success rate with this fashion compared to repeated minimally invasive approaches who have low, high rate of recurrence and low overall success rate with urethral dilation or optical urethronomy. And again, this is a situation that can impact any woman at any stage, and you have to be vigilant and think about this, particularly based upon their history, if they had previous radiation surgery, if they've had previous trauma, or they've had previous iatrogenic surgeries or hospitalizations requiring catheterization, as to whether or not they could true and truly have a urethral stricture. In conclusion, when I talk about urethral oral mucosal graft, although not widely utilized at all, during my research, I found several different articles, and I put these all on one slide to show that there are, just as it is the creativity and the art of science is key in any form of reconstructive surgery, buccal mucosal graft has been utilized in various different aspects. Here we see buccal mucosal graft at the top portion here, utilized as an article during in-physician treatment of recurrent vesicle vaginal fistula here. There's also another one that looks at a buccal mucosal graft repair for recurrent rectovaginal fistula. Here there's an autologous buccal mucosal graft augmentation for a foreshortened vagina. So there are various different ways in which physicians have utilized buccal mucosal graft for a very wide range of female pelvic reconstruction. The most well-defined and well-studied is the female urethral stricture, but there's a wide variety that potentially can be utilized. I highlighted this last article, Is Vaginal Mucosal Graft an Excellent Substitute Material for Urethral Construction in Female to Male Transsexuals? Dealing with Gender Disorder in the Transgender Patient Population, this is an interesting, and I'm sure that there have been case reports or series looking at the use of buccal mucosal graft as a tissue substitute dealing with reconstruction as it relates to the transgender patient. In conclusion, buccal mucosal graft is a well-established tissue substitute for urethral reconstruction, whether it be female or male, with excellent outcome data. Although the history of buccal and oral mucosal graft has been based primarily in the male patient with male urethral stricture disease, it is clearly evident that it can be utilized also as well in female patients. Graft technique is simple, reliable, and with minimal complications. The graft technique has been identified, well-established since 1996, and here you can see there's been very little changes, I have to say, and it's something that is reliable, simple, with minimal complication, and well-tolerated by the patient. Female urethroplasty with buccal mucosal graft is a feasible, safe, and effective form of treatment for urethral stricture disease, and as highlighted, there are also venues of use of buccal mucosal graft for fistula repair, for shortened vagina due to reconstructive surgery, or vaginal tissue loss, and I presume even in the exploration of reconstructive procedure operations related to the transgender patient population. Thank you very much for your time. Thank you, Dr. Warren. That was a really great presentation. I actually, you know, there is certainly, I think it's something for all of us to keep in mind when it comes to reconstruction, especially with the kind of non-hair-bearing nature and the mucosal nature of the buccal graft, it's hard to find that tissue that's easily accessible in the body, and I think especially some of the potential uses, whether it has to do with vaginal shortening or if you need some extra tissue, it is, if you're aware of it and have, you know, people in the hospital that can harvest the tissue for you, it is an accessible tissue source to use, so I think it's really wonderful that you're able to highlight that, and I think it's something we should all keep in mind. You know, one of the things I've seen at urology meetings, and I'm not quite sure why, because I have very few idiopathic female strictures in my practice, but I feel like there does seem to be a growing body of literature around female strictures and how to best treat them, and so I'm just wondering, I know if you were to measure a procedure such as the one that you showed versus dilation, I mean, if you measured from the point of treatment out, I don't know, a year, there might be greater success rates, but certainly the procedure does have some potential morbidity with it, so what would you say to someone showing up with a new stricture? So, excellent point, because I just had this discussion just a couple of weeks ago. I read off of the patient and what their situation is and what they feel most comfortable with. Typically, if you're going to have a recurrence and it's similar related to a male versus female urethral stricture, it's going to happen within that year, six months to a year. Patients who have never undergone surgery before or have had any treatment and just being identified as having a urethral stricture, by all means, I offer them a potential option for a minimally invasive technique. I explained to them the risks and benefits related to it, the outcomes related to it compared to a definitive surgery. It sets the stage, I think, for two-fold to be able to at least identify that that is a stricture that was opening up resolution of some of their urinary symptoms so you can associate the stricture to their lower urinary tract symptoms or voiding dysfunction and it gives them some time. Oftentimes, in those situations, again, with failures, I've never had a success story where someone has had a urethral stricture and they've done fine and not needed any additional therapy. But it sets the stage for someone, particularly a woman, who may not necessarily be prepared for a major reconstructive surgery, that they know and they understand the disease process. They understand where their urinary symptoms are coming from and that in the future, they do have a viable option such as a buccal mucosal graft. So, again, I often will recommend or offer, I should say, the option. I explain both of them and their risks and benefits and then have them make a decision. I've also had a patient who was older in age who, for a variety of reasons, who just felt that due to the risk of morbidity and the complexity of doing the definitive surgery, has opted to undergo dilation. And so she is on a regular, consistent dilation regimen in which she's able to cath herself or even come in to get dilated and that suits her fine. So I also meet the needs of the patient and what works with them the best. So also, Leslie, you brought up a very good point and I forgot to highlight that there's no expectation that anyone or should or can just immediately go right out and just start harvesting their own buccal grafts. And even if that has not necessarily been something that is standard or utilizing your residency training or training in your career, by all means, developing a relationship with someone, whether it be ENT or urology, to be able to harvest that graft, I think it's important. And you're right that there can be situations where you don't think you're going to need additional tissue. You should always have that in the back of the head that that is an option, even if you don't know how to harvest it, there's someone that's in the hospital that does. And one last question, since you may collectively have in your practice more than, you know, 10 of us put together, do you have any sense of the etiology of some of these strictures in women? Because they are relatively uncommon. Correct. The times that I have seen patients, the most common has been history of, well, three things, history of radiation therapy in the past due to for a gynecological, gynecologic surgery, as well as iatrogenic related to difficulty, Foley catheterization or trauma in some fashion related to the urethra. And then lastly, urethral loss. And that's been to complications related to a mesh or not usually mesh, but mesh urethral sling in which has been either erosion or infection that has brewed and has resulted in destruction of the actual urethra itself. And in all of those situations, eventually inflammatory process comes into play, scarring develops, and you develop these lower urinary tract symptoms, and they define that they have a structure. But I do have to say, and I agree with you, as I was quite surprised about the amount of submitted abstracts and presentations at my annual meeting that we both attended just this past week, that it finds that is in more common play than we least expect. And in talking to some of my other reconstructive colleagues, I think it's one of those situations where it has often been in the background where you may get one or two patients per year or one every other year, and you never know what to do. And there's not any algorithm or diagnostic testing or setup or pathway to be able to execute for these patients. Oftentimes, it's blurred by recurrent urinary tract infections or pelvic organ prolapse or history of incontinence status post sling. So, really teasing out what is that underlying etiology makes it a challenging diagnosis. But here, we have the armamentarium and the skill set to be able to treat it, and just as if we treat male patients in our practice for reconstructive disease or have a suspicion for it using buccal, we can be able to do it here with good results and safely and effectively. Good. I think those are great points, and I just want to wrap things up. I think that was perfect. I think it's a great intersection about how when it comes to FPMRS urology, traditional urology and gynecology lines become very blurred, and there's a way that we can all be learning and sharing information. I think this is one of those places, especially with more and more of the population aging, they're going to be getting slings, and sometimes there can be some ureteral trauma or side effects down the line that could benefit from this therapy. I really do want to give a big thank you to Dr. Gareth Warren for that fantastic presentation. I also want to thank all of our participants for carving out time in your day to participate. I do just want to let everybody know our next program is June 14th with Dr. Susan Krauss talking about neurogenic lower urinary tract dysfunction just in time for the FPMRS boards a few weeks later. I know that's always an area everybody's always interested to learn about. Again, thank you to everybody. Thank you to Dr. Warren, our participants, and our host. Until then, be well, and we'll see you next time. Thank you very much. Thank you, Dr. Warren and Leslie. On behalf of AUGS, I'd also like to thank everyone else for your participation in today's event. This concludes today's program. Again, we thank you, and have a great night.

female pelvic reconstruction

buckled mucosal graft

urethral reconstruction

oral mucosal grafts

female urethral strictures

cystoscopy

buccal mucosal graft urethroplasty

fistula repair

vaginal tissue augmentation