New England Section of the American Urological Association

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The History of the Use of Colonic Muscosa in Urethral Reconstruction
Jaime A. Cavallo, MD, MPHS1, Elizabeth J. Pagura, BA2, Leonard N. Zinman, MD1, Alex J. Vanni, MD1
1Lahey Hospital and Medical Center, Burlington, MA, 2Tufts University, Medford, MA

Background:
Oral mucosa graft urethroplasty was first described by the Ukranian surgeon Kirill Sapezhko in 1894. It was his protégé, I. A. Thyrmos, who pioneered substitution urethroplasty with rectal mucosa and published its first use in 1902. We describe the poorly-known evolution of colonic mucosa use in urethral reconstruction to its modern-day resurgence.
Methods:
PubMed and the Journal of Urology archives were both systematically queried for all published literature using the combination of search terms "colonic mucosa" or "rectal mucosa" and "urethroplasty" or "urethral reconstruction". All resulting literature matches were reviewed to describe the chronologic history of colonic mucosa use in urethral reconstruction.
Results:
Thyrmos’ initial description of rectal mucosa substitution urethroplasty in the Eastern scientific literature in 1902 failed to gain the attention of the Western scientific community for the greater part of a century. Brief mention of rectal mucosa as a "feasible but unproven option for urethral reconstruction" in an abstract from the 1918 Urologic Congress in Paris indicates international communication but lack of adoption of the concept. Descriptions of urethroplasty using colonic mucosa grafts did not appear again in the medical literature until Paul Mitofanoff of France published his experimentation with appendicular mucosa grafts in rats beginning in 1994. Between 2002 and 2009, Yue-Min Xu, Chongrui Jin, Rong Chen, Jie-Min Si, and Chao Feng of China applied the concept of colonic mucosa substitution grafts to the dilemma of long-segment complex urethral reconstruction in which oral mucosa grafts would be inadequate in length or unavailable. Their preclinical studies in a dog model and subsequent clinical series achieved colonic mucosa grafts up to 21 cm in length but required concurrent bowel resection. In 2016, Alex Vanni and Leonard Zinman described the first minimally-invasive harvest of rectal mucosa graft up to 15 cm in length for long-segment urethral reconstruction using a transanal endoscopic microsurgical technique. This approach circumvented the need for bowel resection and minimized associated gastrointestinal morbidity. In patients with long-segment urethral stricture or limited availability of oral mucosa for substitution grafting, rectal mucosa remains a viable alternative graft with minimal donor site morbidity to achieve a functional outcome in complex urethral reconstruction.
Conclusions:
The use of colonic mucosa in urethral reconstruction follows a historic trajectory that parallels that of oral mucosa in urethroplasty. In modern reconstructive urology, the advent of minimally-invasive tissue harvest techniques has caused rectal mucosa grafts to re-emerge as a viable alternative to oral mucosa grafts in complex urethral reconstruction.


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