Ventral versus Dorsal Buccal Urethroplasty: Advantages and Disadvantages
Both ventral and dorsal buccal mucosal graft urethroplasty approaches yield similar success rates (83-85%) with no statistically significant difference in outcomes, though the ventral approach may offer technical advantages including shorter operative time and preservation of urethral blood supply. 1
Buccal Mucosal Graft Selection
- Oral mucosa should be used as the first choice when using grafts for urethroplasty (Expert Opinion) 2
- Buccal mucosa is preferred with reported success rates of 92% in multiple studies 3
- Either buccal or lingual mucosal grafts can be used as equivalent alternatives (Strong Recommendation; Evidence Level: Grade A) 2
- Lingual mucosa is thinner than buccal mucosa, potentially providing an advantage in reconstructive procedures of the distal urethra and meatus 2
Dorsal Approach (Barbagli Technique)
Advantages:
- Provides a more stable graft bed with robust support from the tunica albuginea of the corporal bodies
- May reduce the risk of urethral diverticulum formation
- Potentially better vascular bed for graft take
Disadvantages:
- Technically more challenging
- Requires complete mobilization of the urethra
- Longer operative time
- Potential risk to urethral blood supply during circumferential dissection
Ventral Approach
Advantages:
- Technically easier and quicker to perform 4, 5
- Preserves the dorsal urethral blood supply
- Better exposure of the strictured segment
- Simpler surgical approach, especially for long anterior urethral strictures 5
- Less urethral mobilization required
Disadvantages:
- Potential risk of urethral diverticulum formation
- Concerns about adequate graft support
- Possible higher risk of sacculation
Ventral Sagittal Urethrotomy Approach (Asopa Technique)
This technique allows dorsal placement of the buccal mucosal graft through a ventral urethrotomy approach, combining advantages of both approaches:
- Allows dorsal graft placement without complete urethral mobilization
- Preserves urethral blood supply
- Technically easier than traditional dorsal approach
- Particularly useful for long anterior urethral strictures 5
- Medium-term results comparable to traditional dorsal approach (87% success rate) 5
Comparative Outcomes
- A comparative study showed no statistically significant difference in outcomes between dorsal and ventral approaches 6
- Success rates are similar (83-85%) regardless of whether the graft is placed on the ventral, dorsal, or lateral surface of the bulbar urethra 1
- Ventral group had mean maximum flow rate of 18.8 mL/min and residual urine of 32 mL, while dorsal group had mean maximum flow rate of 19.6 mL/min and residual urine of 27 mL 6
Decision-Making Algorithm
For short bulbar strictures (<2 cm):
- Consider excision and end-to-end anastomosis as first-line approach
For longer strictures (≥2 cm):
Approach selection factors:
- Surgeon experience and preference
- Stricture location and length
- Previous interventions
- For long anterior urethral strictures: consider ventral sagittal urethrotomy approach (Asopa technique)
- For complex strictures with compromised vascularity: consider dorsal approach
Pitfalls and Caveats
- Avoid tubularized urethroplasty in a single stage due to high risk of restenosis 2, 3
- Do not use hair-bearing skin for substitution urethroplasty (Clinical Principle) 2
- Avoid synthetic materials, allografts, or xenografts except under experimental protocols (Expert Opinion) 2
- Recognize that recurrence typically involves the anastomotic site rather than the grafted area 1
- Regular follow-up is essential to monitor for recurrent strictures
In conclusion, both ventral and dorsal approaches provide similar outcomes, and the choice between them should be based primarily on the specific characteristics of the stricture and surgeon expertise rather than perceived superiority of one technique over the other.