Historically upper genitourinary tract reconstruction has included endoscopic and surgical management techniques. Ongoing innovation in technique including increasing use of flaps and grafts in reconstructive surgery have altered the current landscape. In the past 20 years the use of oral mucosal grafts has been increasingly described for its use in genitourinary reconstruction1.
Kirill Mikhailovich Sapezhko
Russian surgeon Kirill Sapezhko is noted to have pioneered the use of oral mucosal graft and published his experience treating four patients with urethral stricture using both lingual and buccal mucosal grafts towards the end of the 19th century2. However, despite the early description of use, techniques did not become more common until towards the end of the 20th century. In the late 1990s, oral mucosa became more promising as its use in urethral reconstruction became more widespread3. The AUA 2016 urethral stricture guidelines specify buccal mucosa as the first choice graft for urethroplasty. Given its success in urethral reconstruction, the application of buccal mucosa graft has recently expanded to ureteral reconstruction.
Prior to the use of oral mucosal grafts in upper tract reconstruction, management of ureteral strictures was composed of ureteroureterostomy, ureteroneocystostomy with or without the addition of a boari flap or psoas hitch, downward nephropexy, and ileal and appendiceal reconstruction. The use of the appendix for ureteral reconstruction was first described in 19123. However, these techniques are associated with various morbidity and mortality including alterations in bladder capacity and mucus production.
Oral mucosa is suitable for incorporation into the urinary tract as it is hairless, easy to access and harvest, and viable in a urinary environment. The initial experiment describing use of buccal mucosa graft in ureteral reconstruction was first described by Naude in 19994. He described his work with five complex patients with ureteral strictures who underwent buccal mucosa patch grafts with an omental wrap; all five patients had maintained long term ureteral patency and drainage. The use of the strictured ureter to provide a “ureteral plate” with intact blood supply has led to advancement in the onlay repair technique commonly used with oral mucosal grafts which allows for the narrow ureteral segment to be sufficiently expanded for urine to flow through1,5.
In 2015, Li et al. published their first case of laparoscopic ventral onlay lingual mucosal graft ureteroplasty for a patient with 3 cm proximal stricture; although the follow up was limited, they reported resolution of hydronephrosis at 12 weeks post operatively6. Cheng et al. have also reported their data on laparoscopic lingual mucosal graft ureteroplasty with success rate of 100% at mean 15.5 month follow up time.6
Since then, technique has continued to become more refined with more recent literature describing the use of robotic surgery to perform ureteral reconstruction using oral mucosa grafts demonstrating similar long-term outcomes and success rates as previous management. In a recent study of 19 patients undergoing robotic buccal ureteroplasty, the overall success rate was 90% at 26 months7. Continued evolution in technique allows urologists to continue to offer upper tract reconstruction without the associated morbidity and mortality of prior management techniques including ileal interposition and renal autotransplantation.
- Xiong S, Wang J, Zhu W, Yang K, Ding G, Li X, Eun DD. Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review. Biomed Res Int. 2020 Jul 27;2020:6178286. doi: 10.1155/2020/6178286. PMID: 32775430; PMCID: PMC7407031.
- Korneyev I, Ilyin D, Schultheiss D, Chapple C. The first oral mucosal graft urethroplasty was carried out in the 19th century: the pioneering experience of Kirill Sapezhko (1857-1928). Eur Urol. 2012 Oct;62(4):624-7. doi: 10.1016/j.eururo.2012.06.035. Epub 2012 Jun 27. PMID: 22749735.
- Barbagli G, Balò S, Montorsi F, Sansalone S, Lazzeri M. History and evolution of the use of oral mucosa for urethral reconstruction. Asian J Urol. 2017 Apr;4(2):96-101. doi: 10.1016/j.ajur.2016.05.006. Epub 2016 Jun 26. PMID: 29264212; PMCID: PMC5717976.
- Naude JH. Buccal mucosal grafts in the treatment of ureteric lesions. BJU Int. 1999;83:751. doi: 10.1046/j.1464-410x.1999.00019.x
- Gonzalez AN, Mishra K, Zhao LC. Buccal Mucosal Ureteroplasty for the Management of Ureteral Strictures: Patient Selection and Considerations. Res Rep Urol. 2022 Apr 9;14:135-140. doi: 10.2147/RRU.S291950. PMID: 35433528; PMCID: PMC9007613.
- Yang K, Fan S, Li Z, Guan H, Zhang P, Li X, Zhou L. Lingual mucosa graft ureteroplasty for ureteral stricture: a narrative review of the current literature. Ann Palliat Med. 2021 Apr;10(4):4840-4845. doi: 10.21037/apm-20-2339. Epub 2021 Mar 23. PMID: 33832320.
- Zhao LC, Weinberg AC, Lee Z, Ferretti MJ, Koo HP, Metro MJ, Eun DD, Stifelman MD. Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience. Eur Urol. 2018 Mar;73(3):419-426. doi: 10.1016/j.eururo.2017.11.015. Epub 2017 Nov 26. PMID: 29239749.
Tina Lulla, MD