Buccal mucosal graft urethroplasty in male cats with traumatic complete urethral rupture

Wanchart Yippaditr Kasetsart University Veterinary Teaching Hospital Hua Hin, Faculty of Veterinary Medicine, Kasetsart University, Prachuap Khiri Khan, Thailand

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Antja Watanangura Veterinary Research and Academic Service, Faculty of Veterinary Medicine, Kasetsart University, Nakhon Pathom, Thailand
Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany

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Disdanai Pencharee Kasetsart University Veterinary Teaching Hospital Hua Hin, Faculty of Veterinary Medicine, Kasetsart University, Prachuap Khiri Khan, Thailand

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Nobuo Sasaki Veterinary Surgery, Graduate School of Agricultural and Life Sciences, University of Tokyo, Tokyo, Japan

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Abstract

OBJECTIVE

To evaluate the feasibility of buccal mucosal graft urethroplasty for repairing complete urethral rupture in cats.

ANIMALS

15 male domestic shorthair cats with traumatic complete urethral rupture.

PROCEDURES

In each cat, a section of buccal mucosa was harvested, sutured, and formed into a tubule by use of an 8F indwelling catheter as support. This tubular graft was connected to both ruptured ends of the urethra to renew the urinary passage. The catheter was left in place until the absence of leakage was confirmed by positive contrast retrograde urethrography. After spontaneous urination was confirmed, cats were discharged from the hospital. Six months later, urethrography was repeated and owners were asked to score their cats’ urinary function and quality of life.

RESULTS

13 cats recovered well following surgery, with no complications in the oral cavity or surgical site and no signs of difficulty or discomfort when urinating. Urethrography 2 weeks and 6 months after surgery revealed no stricture or leakage in the abdominal cavity. The 2 remaining cats developed a urethral stricture and underwent second surgery with a successful outcome. At the 6-month follow-up, 14 cats had only mild urinary signs, and 1 cat had incontinency. Owners indicated they were delighted (n = 14) or pleased (1) with their cats’ quality of life.

CLINICAL RELEVANCE

Buccal mucosa was found to be a good source of graft tissue for performance of urethroplasty in male cats, yielding satisfactory outcomes with few postoperative complications. The described technique may be suitable for severe and complicated cases of urethral rupture in male cats.

Abstract

OBJECTIVE

To evaluate the feasibility of buccal mucosal graft urethroplasty for repairing complete urethral rupture in cats.

ANIMALS

15 male domestic shorthair cats with traumatic complete urethral rupture.

PROCEDURES

In each cat, a section of buccal mucosa was harvested, sutured, and formed into a tubule by use of an 8F indwelling catheter as support. This tubular graft was connected to both ruptured ends of the urethra to renew the urinary passage. The catheter was left in place until the absence of leakage was confirmed by positive contrast retrograde urethrography. After spontaneous urination was confirmed, cats were discharged from the hospital. Six months later, urethrography was repeated and owners were asked to score their cats’ urinary function and quality of life.

RESULTS

13 cats recovered well following surgery, with no complications in the oral cavity or surgical site and no signs of difficulty or discomfort when urinating. Urethrography 2 weeks and 6 months after surgery revealed no stricture or leakage in the abdominal cavity. The 2 remaining cats developed a urethral stricture and underwent second surgery with a successful outcome. At the 6-month follow-up, 14 cats had only mild urinary signs, and 1 cat had incontinency. Owners indicated they were delighted (n = 14) or pleased (1) with their cats’ quality of life.

CLINICAL RELEVANCE

Buccal mucosa was found to be a good source of graft tissue for performance of urethroplasty in male cats, yielding satisfactory outcomes with few postoperative complications. The described technique may be suitable for severe and complicated cases of urethral rupture in male cats.

Introduction

Urethral rupture is common in cats, with reported causes including car accidents, kicks from people, pelvic fractures, bite wounds, gunshot wounds, penetrating injuries, urethral calculi, and iatrogenic injury during urethral catheterization or surgery.1,2,3,4 Traumatic urethral rupture is more common in male cats owing to greater exposure of the urethra to external factors than in female cats.4,5 Urethral rupture may lead to serious conditions and clinical signs such as uroabdomen, azotemia, anuria, inguinal or perineal swelling, necrosis of the surrounding tissue, and loss of hind limb skin, which can be life-threatening.5,6,7,8,9 Additionally, the location, extent, severity, and duration of the injury influence the severity of clinical signs.5,8

Urethral rupture can be treated conservatively or surgically. For minor urethral injuries (eg, contusion and partial laceration), a commonly considered approach is conservative treatment by temporary urinary diversion through urethral catheterization or tube cystostomy while awaiting spontaneous healing. The decision to pursue a surgical approach is generally based on the severity of urethral injury (eg, complete obstruction, large laceration, or rupture).3,5,10 Anastomosis between the 2 ruptured ends of the urethra is generally considered as a primary treatment.11 However, this procedure may be impossible when insufficient urethral length remains and high tension is present at the anastomotic site, resulting in stricture or dehiscence requiring repeated surgical correction.12

Alternatively, urethrostomy with or without cystostomy should be performed only in cats with intrapelvic or prepubic urethral rupture in which neither urethral catheterization nor primary repair is possible. These techniques may result in various complications, such as subcutaneous infiltration of urine, stricture of urethra and urethral stoma, bleeding of the urethral mucosa, recurrent upper and lower urinary tract infection, urinary incontinence, dermatitis due to urine scalding, bladder mucosal prolapse due to severe cystitis, and permanent loss of bladder contour.11,13,14,15,16,17 As a result, the quality of life of affected cats deteriorates, ending in euthanasia for some.18 Alternative procedures therefore become necessary, which are also not without complications. For example, genital and extragenital skin grafts have been used, with complications including fistulas, hair growth, stone formation, and graft contraction.19,20,21 Bladder mucosal grafts can lead to secondary meatal stenosis and urinary obstruction owing to glandular protrusion of bladder epithelium.19,22,23 Alternative sources of graft tissue such as intestinal submucosa grafts, peritoneal grafts, vascularized tunica vaginalis flaps, colonic mucosal graft, fascia lata autografts, and arterial and venous grafts have also been reported.19,24,25,26,27,28,29,30

In human medicine, several studies31,32,33 involving buccal mucosal grafts have yielded high success rates with fewer complications than other graft types. The purpose of the study reported here was to determine the feasibility of repairing urethral defects in cats with traumatic urethral rupture by means of buccal mucosal graft urethroplasty. Given the aforementioned successful results in humans, we anticipated that a buccal mucosal graft could also be used to repair urethral defects with satisfactory outcomes in cats.

Materials and Methods

Case selection

Fifteen male domestic shorthair cats (8 neutered and 7 sexually intact) admitted to the Kasetsart University Veterinary Teaching Hospital Hua Hin, Thailand, for treatment of traumatic complete urethral rupture were included in this study. Informed consent was obtained from all cat owners. The Institutional Animal Care and Use Committee of Kasetsart University approved the study intervention (approval No. ACKU62-VET-028).

Preoperative evaluation and surgical preparation

All cats had been referred to the hospital between 3 to 5 days after the incident that had caused the urethral rupture. All received a complete physical examination and clinicopathologic tests that included a CBC, measurement of BUN and serum creatinine concentrations and alanine aminotransferase activity, and blood gas and electrolyte analysis.

Complete urethral rupture was diagnosed by ultrasonography, followed by retrograde urethrography with iohexol (Omnipaque; Figure 1). To medically stabilize the cats prior to surgery, temporary urinary diversion with a cystostomy tube (Buster 8F silicone foley catheter; Kruuse) was performed by means of laparotomy and a collection bag was connected to the tube. Clinical signs, vital parameters (heart rate, respiratory rate, mucous membrane characteristics, capillary refill time, and rectal temperature), and urine output were regularly monitored. All cats became stable within 1 week after hospital admission. The CBC parameters and BUN and serum creatinine concentrations were reevaluated before surgery.

Figure 1
Figure 1

Lateral positive contrast retrograde urethrography image of a neutered male cat with urethral trauma showing leakage of contrast medium from the urethra, confirming complete urethral rupture.

Citation: Journal of the American Veterinary Medical Association 260, 1; 10.2460/javma.20.09.0540

Once cats were stable, morphine (0.2 mg/kg), alfaxalone (2 mg/kg), and cephalexin (22 mg/kg) were administered for analgesia, anesthetic induction, and antimicrobial prophylaxis, respectively, prior to surgery. Anesthesia was maintained with isoflurane throughout the surgery. Each cat was positioned in dorsal recumbency.

A ventral midline incision was made through the caudal aspect of the abdominal wall and elongated if necessary over the pubis. Stay sutures were placed in the apex of the urinary bladder and retracted cranially. A pelvic osteotomy was performed to approach the membranous urethra, then the proximal end of the ruptured urethra was examined and debrided. Thereafter, an indwelling 1.0 × 130-mm catheter (Buster; Kruuse) was inserted in a retrograde direction from the external urethral orifice to the distal end of the ruptured urethra, which was subsequently debrided.

Graft harvest and application

In preparation for graft harvesting, the oral cavity was rinsed with 1% chlorhexidine solution. A 1 × 2-cm rectangular portion of buccal tissue was harvested from the inside of the upper lip near the molar teeth and parallel to the dental arch by use of a scalpel and sharp scissors (Figure 2). The excised tissue section was trimmed with scissors to remove the fat and muscle from beneath the mucosal layer. Then, the resulting graft was soaked in saline (0.9% NaCl) solution. The site of tissue excision was not sutured but was compressed with gauze until the bleeding stopped.

Figure 2
Figure 2

Photograph of a 1 × 2-cm rectangular portion of buccal mucosa harvested from the inside of the upper lip of a cat near the molar teeth and parallel to the dental arch to serve as a graft for urethroplasty. The graft was prepared by removing the attached muscle and underlying fat from beneath the mucosal layer.

Citation: Journal of the American Veterinary Medical Association 260, 1; 10.2460/javma.20.09.0540

Urethroplasty

A surgical loupe (Heine Optotechnik GMBH & Co) was used to help visualize the urethroplasty procedure. The inserted indwelling catheter was used as a supporting structure. The buccal mucosal graft tissue was rolled to wrap around the catheter. Each end of the graft was sutured along its edge with 5-0 polydioxanone (PDS II; Ethicon LLC) in a simple interrupted pattern forming a tube, and a stay suture was placed in each end of the graft tube to stretch the graft cranially and caudally. Then, a simple continuous suture pattern was used to appose the longitudinal edges of the graft to form a tube surrounding the catheter (Figure 3). The graft tube was connected to the distal urethral end by means of end-to-end anastomosis with 5-0 polydioxanone in a simple interrupted pattern. Afterward, the catheter was inserted further into the proximal urethral end and urinary bladder. The same anastomosis method was used to connect proximal urethra to the graft tube (Figure 4).

Figure 3
Figure 3

Photograph showing the creation of an artificial urethral segment by suturing the longitudinal edges of the graft of Figure 2 over an indwelling catheter (which served as a supporting structure) with 5-0 polydioxanone in a simple continuous pattern.

Citation: Journal of the American Veterinary Medical Association 260, 1; 10.2460/javma.20.09.0540

Figure 4
Figure 4

Photograph of the graft tube being sutured to the proximal and distal ends of the remaining ruptured urethra with 5-0 polydioxanone in a simple interrupted pattern.

Citation: Journal of the American Veterinary Medical Association 260, 1; 10.2460/javma.20.09.0540

Thereafter, the omentum was used to cover around the graft tube and both anastomotic ends to increase vascular perfusion. The temporary cystotomy tube was removed, and the urinary bladder was sutured with 5-0 polydioxanone in a simple interrupted pattern. The osteotomy site was closed with a 0.6-mm-diameter piece of orthopedic wire. Abdominal lavage was performed with warm sterile saline (0.9% NaCl) solution and suction. The muscle layer was sutured with 4-0 polydioxanone (PDS II; Ethicon LLC) in a simple continuous pattern, and the subcutaneous layer was sutured similarly. The skin was closed with 4-0 polyamide monofilament nonabsorbable suture (Dafilon; B. Braun Medical Inc) in a cross-mattress pattern. The indwelling catheter was affixed to the prepuce with polyamide monofilament nonabsorbable suture and left in place for 2 weeks to ensure urethral patency and prevent anastomotic sites from urine irritation, which, in the authors’ experience, can cause urine leakage and urethral stricture. The catheter was connected to a urine collection bag to monitor urine output.

Postoperative management and follow-up

Immediately after cats recovered from anesthesia, an Elizabethan collar was applied to deter self-mutilation. Urine output from the catheter was monitored daily for 2 weeks. Amoxicillin–clavulanic acid (15 mg/kg, PO) was administered every 12 hours after surgery for 2 weeks. Morphine (0.2 mg/kg, SC) was administered every 4 to 6 hours for 3 consecutive days, and tolfenamic acid (4 mg/kg, PO) was given every 24 hours for the following 3 days for analgesia.

For each cat, the previously administered clinicopathologic tests were repeated 3 days after surgery. During the first 2 weeks after surgery, clinical signs and vital parameters of each cat were monitored and urine output was measured every 4 hours. Healing of oral mucosa was observed daily by oral examination. Two weeks after surgery, positive contrast retrograde urethrography was again performed to confirm the absence of leakage along the urethra. If no leakage was detected, the catheter was removed. After catheter removal, spontaneous urination and urinary bladder distension were monitored every 6 hours by observation for signs of tenesmus or urination on bedding and in the litter box, palpation of the urinary bladder, and ultrasonography of the abdomen. All cats were discharged from the hospital 2 to 3 days after the catheter was removed, and spontaneous urination was confirmed.

For 6 months after surgery, all cats were followed up for detection of any complications, difficulty, or discomfort. At 6 months, physical examination and retrograde urethrography were repeated. In addition, 2 instruments were used to interview owners about their cats’ status. The first was a modified version of the American Urological Association symptom index questionnaire,34 whereby frequencies of urination again < 2 hours after completion of urination, stopping and starting urination again several times (intermittency), incontinency, a weak urine stream, and pushing or straining to begin urination were scored on a scale from 0 (not at all) to 5 (almost always). The total scores for each of these 5 variables were determined, with a total score of 1 to 7 interpreted as excellent, 8 to 19 as good, and 20 to 35 as poor. The second instrument was a modified International Prostate Symptom Score quality-of-life questionnaire35 that asked owners, “How would you feel if your cat had to live with a urinary condition the way it is now, no better, no worse, for the rest of his life?” Possible scores ranged from 0 (delighted) to 5 (unhappy).

Results

Animals

Fourteen cats had complete membranous urethral rupture, whereas the remaining cat had complete prostatic urethra rupture, following external trauma. Case characteristics were summarized (Supplementary Table S1). Initial clinical signs included dysuria, abdominal distension, and inappetence or decreased appetite. On physical examination, severe abdominal pain was observed in all cats, a palpable abdominal fluid wave in 11 cats, and bruising of the inguinal region or abdomen in 3 cats.

Results of the first CBC revealed leukocytosis in 11 cats, with a mean ± SD WBC count among those cats of 21,000 ± 2,557 cells/μL (range, 19,500 to 25,000 cells/μL; reference interval, 5,500 to 19,500 cells/μL). Mean BUN and serum creatinine concentrations in all 15 cats were 58.2 ± 21.28 mg/dL (range, 35 to 120 mg/dL; reference interval, 16 to 36 mg/dL) and 6.6 ± 1.53 mg/dL (range, 4.39 to 8.02 mg/dL; reference interval, 0.8 to 2.4 mg/dL), respectively. Eight cats had hyperkalemia, with a mean blood potassium concentration among those cats of 7.29 ± 1.02 mEq/L (range, 6.2 to 8.38 mEq/L; reference interval, 3.5 to 5.5 mEq/L). Results of postoperative clinicopathologic tests were unremarkable. The length of the urethral rupture in all cats was approximately 1 cm.

Urethral reconstruction and outcome

The harvested buccal mucosal graft was difficult to roll and suture because of the small size and thinness of the tissue. The interrupted sutures and stay sutures at both ends of the graft were useful to stretch the graft and made it more stable for suturing along the tube.

Physical examination after surgery showed all cats to be healthy, with good wound healing and with no wound dehiscence, complications at the surgical site, or bruising of inguinal or abdominal region. All cats were able to eat normally within 1 day after surgery. A CBC performed 3 days after surgery revealed leukocytosis in 5 cats (mean, 20,600 ± 1,515 cells/μL; range, 19,200 to 23,000 cells/μL). Mean BUN concentration for all 15 cats was 19.4 ± 6.9 mg/dL (range, 11 to 30 mg/dL), and mean serum creatinine concentration was 1.6 ± 0.5 mg/dL (range, 1.0 to 2.6 mg/dL). Results of blood gas and electrolyte analysis were unremarkable.

Within 1 week after surgery, the wound created when harvesting the buccal mucosal graft had healed properly in all cats, with no complications. Urine output of all cats was between 1.31 and 1.85 mL/kg/h (reference interval, 1 to 2 mL/kg/h). Skin sutures in all cats were removed 10 days after surgery.

Positive contrast urethrography 2 weeks after surgery revealed no urine leakage along the area of the tubular graft. At this stage, the urethral catheter was removed. Thirteen of the 15 cats were able to urinate normally after the catheter had been removed and had no apparent complications, difficulty, or discomfort, including dysuria and stranguria, during urination. Nevertheless, the 2 remaining cats developed urethral stricture 3 days after the catheter had been removed. This stricture was diagnosed by reinsertion of a catheter, which resisted passage through the anastomotic area, resulting in the need for repeated surgery. During second surgery, the urethral stricture at buccal mucosal graft segment was identified and excised. The proximal and distal urethral ends created by this excision were debrided, and the same procedure as previously described was performed again with a longer buccal mucosal graft (1 × 2.5 cm) to minimize the tension. The cats were subsequently treated as they were following the previous surgery, with successful outcomes.

Six months after surgery, all cats were able to urinate without any difficulty. Positive contrast retrograde urethrography revealed no leakage, stricture, or urethral abnormality. The diameter of graft tube was compared with that of adjacent urethral segments, revealing minimal differences (Figure 5). The median percentage difference in diameter of the graft tube from the diameter of the adjacent segments was 21.4%. In owner responses to the American Urological Association symptom index questionnaire, 11 cats were scored as having no urinary signs (ie, total score of 0), and 2 cats were scored as stopping and starting urinating several times (intermittency) and having a weak urine stream approximately 1 time in 5 urinations. One cat had a total score of 5 (always) for incontinency, and another cat had a total score of 12 attributable to a score of 5 (always) for intermittency, 2 (approx 1 time in 3 urinations) for incontinency, and 5 (always) for a weak stream. Owners of 14 cats were delighted with their cats’ quality of life, and the remaining owner was pleased.

Figure 5
Figure 5

Lateral positive contrast retrograde urethrography image of a neutered male cat 6 months after buccal mucosal graft urethroplasty, revealing no leakage between the urinary bladder and the prepuce. The diameter of urethral segment created from the buccal mucosal graft was 2.17 mm (arrowhead), compared with the 2.82-mm diameter of adjacent native urethral segment (arrow).

Citation: Journal of the American Veterinary Medical Association 260, 1; 10.2460/javma.20.09.0540

Discussion

In the present study, buccal mucosal grafts were successfully used to repair complete urethral rupture in male cats. Clinical and radiographic findings confirmed that this urethroplasty technique resulted in minimal postoperative complications and satisfactory urethral function.

End-to-end anastomosis is the primary treatment used for repairing intrapelvic urethral rupture in male cats, when indwelling catheterization and secondary healing is not possible. This technique mainly requires suture cohesion, resulting in high tension at the anastomotic sites.36 Because of a lack of mucosal continuity, stricture formation occurs from fibrous tissue proliferation in the gap between 2 urethral segments, leading to urethral obstruction.5 The length of the urethral rupture should be also considered. In a previous study37 involving male cat cadavers, experimentally induced defects as long as 20% to 30% of the urethral length were able to be apposed without tension. In all cats of the present study, the urethral defects were approximately 1 cm long or approximately 16% of the median length of pelvic urethra (6 cm).37 However, anastomosis of the ruptured ends of the urethra was not possible because of the timing of surgery after the traumatic incident (approx 2 weeks) and tissue contraction, fibrosis, need for debridement, and pressure from pelvic fractures in some cats. A common alternative treatment for cats with urethral stricture or those in which primary treatment cannot be performed is urethrostomy.

Several techniques have been evaluated to overcome the aforementioned challenges that prevent primary treatment for urethral rupture. Crural release and ischial osteotomy can be used to reduce tension on the urethra during repair of large segmental urethral defects in male cats.35 Nevertheless, this technique requires a wide incision and causes bone and soft tissue trauma. Moreover, the cranial ischial displacement needs to be well stabilized to prevent reversion, which causes high tension at anastomotic site.37 Options in human medicine for correction of hypospadias and urethral stenosis of traumatic origin include the use of grafts or flaps of various tissue sources.20,21,22,23,26,38,39 These procedures have moderate success rates, but are not without complications.19

In the present study, a buccal mucosal graft was chosen because of its excellent characteristics. Histologic studies31,33 have shown that the buccal mucosa is composed of thick epithelium, together with thin and highly vascularized lamina propria, facilitating imbibition, inosculation, and angiogenesis of the graft. The thick epithelium and rich elastin also make buccal mucosal grafts easy to handle and durable.40 Another beneficial aspect of buccal mucosal grafts is that they are easily harvested, hairless, accustomed to a wet environment, and resistant to infection and have an abundant blood supply.33,41 Research on dogs has shown that among the graft materials that could be used to repair refractory urethral strictures such as skin, bladder mucosa, and buccal mucosa, buccal mucosa is optimal because of its lower stricture rate and graft shrinkage.42 The success rate for the use of buccal mucosal grafts in human urethroplasty patients is also higher than that of the skin grafts.43 At the harvest site, the remaining buccal mucosa should be left unsutured to avoid the postoperative pain that suturing would cause. There is also no difference in long-term morbidity between closed and open harvest sites.44 Furthermore, the use of buccal mucosal grafts yields good results, particularly in complicated cases of urethral reconstruction.29,32 Because buccal mucosa and the urethra are similar in tissue composition, buccal mucosal grafts can be easily attached to the urethral bed.33

Postoperative complications attributable to buccal mucosa harvest in humans include postoperative pain and swelling at the harvest site, mouth tightness, oral numbness, oral discomfort, salivary changes, difficulty opening the mouth, damage to the parotid duct with symptoms of salivary obstruction, and injury to the long buccal and mental nerves.32,45,46,47,48 Nevertheless, the cats of the present study showed no signs of pain or discomfort and were able to eat shortly after surgery. The harvest site healed without any signs of infection or degenerative reaction.

In humans with extensive ureteral stricture, buccal mucosal tubal grafts have been successfully used for ureteral reconstruction.49 The usefulness of peritoneal free grafts has been studied in rabbits.27 These 2 techniques involve the use of free buccal mucosa or peritoneal tissue to form a tube for repairing ureters and urethras. In the present study, we modified these single procedure techniques for use in cats with complete urethral rupture. Our technique was different from onlay free-graft urethroplasty, which is a common approach for humans with hypospadia, epispadia, and stricture, which may require 1- or 2-stage procedures.49,50,51,52 Onlay grafts in such cases appear to have better outcomes than tubular grafts because of the greater blood supply.22,24,34 Given the potential for inadequate vascularization of the tubular graft, we used an omentum wrap, which has a rich blood supply, in the present study to increase graft integration.49 The rectus abdominis muscle, with its microvascular blood supply, can also be used as a pedicle flap or free flap to repair urethral defects.53,54,55 That technique might be a good option to use with the buccal mucosal graft to increase blood supply and graft survivability. Whether the grafts survived in the present study was not established because no postoperative histologic examination was indicated for the included clinical patients.

Our graft technique was successfully used in primary anastomosis of complete urethral rupture because the tubular grafts were able to reduce the tension between both anastomosed ends of the ruptured urethra. This method caused a small, clinically unappreciable reduction in urethral diameter. Only 2 of 15 cats developed urethral stricture after the first urethroplasty procedure. However, this problem was solved by performing the same procedure once more, with no recurrent stricture or other complications noted 2 weeks and 6 months after the second surgery. Indeed, no degenerative changes, stricture, or fistula formation were observed in 13 cats 2 weeks and 6 months after the first and only urethroplasty procedure. In the cats that required 2 surgeries, the first surgery may have failed from tension at the anastomotic site because of the insufficient graft length. Retraction of the urothelium could prevent mucosa apposition and ultimately could lead to stricture formation.50

In summary, buccal mucosa tissue was found to be a good source of graft material for cats undergoing urethroplasty due to complete urethral rupture, providing a successful outcome with excellent quality of life. We would recommend that the tubular graft be connected to the distal end of the remaining urethra before the proximal end owing to the lower mobility of the distal end. The tissue appeared to be incorporated well into the urethral defects, with few complications. Therefore, buccal mucosal graft urethroplasty should be considered for clinical use in male cats with severe and complicated urethral rupture.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org

Acknowledgments

The authors thank all colleagues at Kasetsart University Veterinary Teaching Hospital Hua Hin for their support. We also express our gratitude to the cats, cat owners, and referring veterinarians who made it possible to successfully complete this study.

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    Powers MY, Campbell BG, Weisse C. Porcine small intestinal submucosa augmentation urethroplasty and balloon dilatation of a urethral stricture secondary to inadvertent prostatectomy in a dog. J Am Anim Hosp Assoc. 2010;46(5):358365.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Khoury AE, Olson ME, McLorie GA, Churchill BM. Urethral replacement with tunica vaginalis: a pilot study. J Urol. 1989;142(2 pt 2):628630.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Shaul DB, Xie HW, Diaz JF, Mahnovski V, Hardy BE. Use of tubularized peritoneal free grafts as urethral substitutes in the rabbit. J Pediatr Surg. 1996;31(2):225228.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Lebret T, Gobet F, Dallaserra M, Mitrofanoff P. Use of a digestive mucosal graft in urethroplasty. Eur Urol. 1995;27(1):5861.

  • 29.

    Frang D, Furka I, Köves S. Urethral replacement with autologous venous graft: an experimental study in the dog. Urol Res. 1982;10(3):145147.

  • 30.

    Paulo NM, Fischer P, Matos MP, et al. Experimental substitution urethroplasty in dogs using homologous segments of carotid artery maintained in glycerol. Ciȇnc Anim Bras. 2000;1(1):6571.

    • Search Google Scholar
    • Export Citation
  • 31.

    Dubey D, Kumar A, Mandhani A, Srivastava A, Kapoor R, Bhandari M. Buccal mucosal urethroplasty: a versatile technique for all urethral segments. BJU Int. 2005;95(4):625629.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    Maarouf AM, Elsayed ER, Ragab A, et al. Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair. J Pediatr Urol. 2013;9(6 pt A):754758.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Bhargava S, Chapple CR. Buccal mucosal urethroplasty: is it the new gold standard? BJU Int. 2004;93(9):11911193.

  • 34.

    Barry MJ, Fowler FJ Jr, O'Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992;148(5):15491557.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35.

    Cockett ATK, Aso Y, Denis L. Recommendations of the International Consensus Committee concerning Prostate Symptom Score (IPSS) and Quality of Life Assessment. In: Proceedings of the 2nd International Consultation on Benign Prostatic Hyperplasia (BPH). International Consensus Committee; 1993:553555.

    • Search Google Scholar
    • Export Citation
  • 36.

    Stone EA, Barsanti JA. Urologic surgery of the dog and cat. In: Surgical Therapy for Urethral Obstruction in Dogs. Lea & Febiger; 1992:149156.

    • Search Google Scholar
    • Export Citation
  • 37.

    Zemer O, Benzioni H, Kaplan R, et al. Evaluation of crural release and ischial osteotomy for relief of tension in the repair of large segmental urethral defects in male cats. Vet Surg. 2013;42(8):971978.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Gearhart JP, Peppas DS, Jeffs RD. Complications of paraexstrophy skin flaps in the reconstruction of classical bladder exstrophy. J Urol. 1993;150(2 pt 2):627630.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39.

    Li LC, Zhang X, Zhou SW, Zhou XC, Yang WM, Zhang YS. Experience with repair of hypospadias using bladder mucosa in adolescents and adults. J Urol. 1995;153(4):11171119.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40.

    Mehrsai A, Djaladat H, Sina A, Salem S, Pourmand G. Buccal mucosal graft in repeat urethroplasty. Urol J. 2005;2(4):206210.

  • 41.

    Elkassaby A, Kotb M. Management of anterior urethral strictures with buccal mucosa: our pioneering experience. Afr J Urol. 2016;22(1):2432.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42.

    El-Sherbiny MT, Abol-Enein H, Dawaba MS, Ghoneim MA. Treatment of urethral defects: skin, buccal or bladder mucosa, tube or patch? An experimental study in dogs. J Urol. 2002;167(5):22252228.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 43.

    Pansadoro V, Emiliozzi P. Which urethroplasty for which results? Curr Opin Urol. 2002;12(3):223227.

  • 44.

    Muruganandam K, Dubey D, Gulia AK, et al. Closure versus nonclosure of buccal mucosal graft harvest site: a prospective randomized study on post operative morbidity. Indian J Urol. 2009;25(1):7275.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45.

    Fabbroni G, Loukota RA, Eardley I. Buccal mucosal grafts for urethroplasty: surgical technique and morbidity. Br J Oral Maxillofac Surg. 2005;43(4):320323.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 46.

    Kamp S, Knoll T, Osman M, Häcker A, Michel MS, Alken P. Donor-site morbidity in buccal mucosa urethroplasty: lower lip or inner cheek? BJU Int. 2005;96(4):619623.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 47.

    Jang TL, Erickson B, Medendorp A, Gonzalez CM. Comparison of donor site intraoral morbidity after mucosal graft harvesting for urethral reconstruction. Urology. 2005;66(4):716720.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 48.

    Tolstunov L, Pogrel MA, McAninch JW. Intraoral morbidity following free buccal mucosal graft harvesting for urethroplasty. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;84(5):480482.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 49.

    Badawy AA, Abolyosr A, Saleem MD, Abuzeid AM. Buccal mucosa graft for ureteral stricture substitution: initial experience. Urology. 2010;76(4):971975.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 50.

    Andrich D, Mundy A. Surgery for urethral stricture disease. Contemp Urol. 2001;13:3240.

  • 51.

    Andrich DE, Greenwell TJ, Mundy AR. The problems of penile urethroplasty with particular reference to 2-stage reconstructions. J Urol. 2003;170(1):8789.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 52.

    Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol. 2008;54(5):10311041.

  • 53.

    Calfee EF III, Lanz OI, Degner DA, et al. Microvascular free tissue transfer of the rectus abdominis muscle in dogs. Vet Surg. 2002;31(1):3243.

  • 54.

    Degner DA, Walshaw R, Arnoczky SP, et al. Evaluation of the cranial rectus abdominus muscle pedicle flap as a blood supply for the caudal superficial epigastric skin flap in dogs. Vet Surg. 1996;25(4):292299.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 55.

    Miller JM, Lanz OI, Degner DA. Rectus abdominis free muscle flap for reconstruction in nine dogs. Vet Surg. 2007;36(3):259265.

Supplementary Materials

  • Figure 1

    Lateral positive contrast retrograde urethrography image of a neutered male cat with urethral trauma showing leakage of contrast medium from the urethra, confirming complete urethral rupture.

  • Figure 2

    Photograph of a 1 × 2-cm rectangular portion of buccal mucosa harvested from the inside of the upper lip of a cat near the molar teeth and parallel to the dental arch to serve as a graft for urethroplasty. The graft was prepared by removing the attached muscle and underlying fat from beneath the mucosal layer.

  • Figure 3

    Photograph showing the creation of an artificial urethral segment by suturing the longitudinal edges of the graft of Figure 2 over an indwelling catheter (which served as a supporting structure) with 5-0 polydioxanone in a simple continuous pattern.

  • Figure 4

    Photograph of the graft tube being sutured to the proximal and distal ends of the remaining ruptured urethra with 5-0 polydioxanone in a simple interrupted pattern.

  • Figure 5

    Lateral positive contrast retrograde urethrography image of a neutered male cat 6 months after buccal mucosal graft urethroplasty, revealing no leakage between the urinary bladder and the prepuce. The diameter of urethral segment created from the buccal mucosal graft was 2.17 mm (arrowhead), compared with the 2.82-mm diameter of adjacent native urethral segment (arrow).

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    Kinkead TM, Borzi PA, Duffy PG, Ransley PG. Long-term followup of bladder mucosa graft for male urethral reconstruction. J Urol. 1994;151(4):10561058.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Kropp BP, Ludlow JK, Spicer D, et al. Rabbit urethral regeneration using small intestinal submucosa onlay grafts. Urology. 1998;52(1):138142.

  • 25.

    Powers MY, Campbell BG, Weisse C. Porcine small intestinal submucosa augmentation urethroplasty and balloon dilatation of a urethral stricture secondary to inadvertent prostatectomy in a dog. J Am Anim Hosp Assoc. 2010;46(5):358365.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Khoury AE, Olson ME, McLorie GA, Churchill BM. Urethral replacement with tunica vaginalis: a pilot study. J Urol. 1989;142(2 pt 2):628630.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Shaul DB, Xie HW, Diaz JF, Mahnovski V, Hardy BE. Use of tubularized peritoneal free grafts as urethral substitutes in the rabbit. J Pediatr Surg. 1996;31(2):225228.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Lebret T, Gobet F, Dallaserra M, Mitrofanoff P. Use of a digestive mucosal graft in urethroplasty. Eur Urol. 1995;27(1):5861.

  • 29.

    Frang D, Furka I, Köves S. Urethral replacement with autologous venous graft: an experimental study in the dog. Urol Res. 1982;10(3):145147.

  • 30.

    Paulo NM, Fischer P, Matos MP, et al. Experimental substitution urethroplasty in dogs using homologous segments of carotid artery maintained in glycerol. Ciȇnc Anim Bras. 2000;1(1):6571.

    • Search Google Scholar
    • Export Citation
  • 31.

    Dubey D, Kumar A, Mandhani A, Srivastava A, Kapoor R, Bhandari M. Buccal mucosal urethroplasty: a versatile technique for all urethral segments. BJU Int. 2005;95(4):625629.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    Maarouf AM, Elsayed ER, Ragab A, et al. Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair. J Pediatr Urol. 2013;9(6 pt A):754758.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Bhargava S, Chapple CR. Buccal mucosal urethroplasty: is it the new gold standard? BJU Int. 2004;93(9):11911193.

  • 34.

    Barry MJ, Fowler FJ Jr, O'Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992;148(5):15491557.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35.

    Cockett ATK, Aso Y, Denis L. Recommendations of the International Consensus Committee concerning Prostate Symptom Score (IPSS) and Quality of Life Assessment. In: Proceedings of the 2nd International Consultation on Benign Prostatic Hyperplasia (BPH). International Consensus Committee; 1993:553555.

    • Search Google Scholar
    • Export Citation
  • 36.

    Stone EA, Barsanti JA. Urologic surgery of the dog and cat. In: Surgical Therapy for Urethral Obstruction in Dogs. Lea & Febiger; 1992:149156.

    • Search Google Scholar
    • Export Citation
  • 37.

    Zemer O, Benzioni H, Kaplan R, et al. Evaluation of crural release and ischial osteotomy for relief of tension in the repair of large segmental urethral defects in male cats. Vet Surg. 2013;42(8):971978.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Gearhart JP, Peppas DS, Jeffs RD. Complications of paraexstrophy skin flaps in the reconstruction of classical bladder exstrophy. J Urol. 1993;150(2 pt 2):627630.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39.

    Li LC, Zhang X, Zhou SW, Zhou XC, Yang WM, Zhang YS. Experience with repair of hypospadias using bladder mucosa in adolescents and adults. J Urol. 1995;153(4):11171119.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40.

    Mehrsai A, Djaladat H, Sina A, Salem S, Pourmand G. Buccal mucosal graft in repeat urethroplasty. Urol J. 2005;2(4):206210.

  • 41.

    Elkassaby A, Kotb M. Management of anterior urethral strictures with buccal mucosa: our pioneering experience. Afr J Urol. 2016;22(1):2432.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42.

    El-Sherbiny MT, Abol-Enein H, Dawaba MS, Ghoneim MA. Treatment of urethral defects: skin, buccal or bladder mucosa, tube or patch? An experimental study in dogs. J Urol. 2002;167(5):22252228.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 43.

    Pansadoro V, Emiliozzi P. Which urethroplasty for which results? Curr Opin Urol. 2002;12(3):223227.

  • 44.

    Muruganandam K, Dubey D, Gulia AK, et al. Closure versus nonclosure of buccal mucosal graft harvest site: a prospective randomized study on post operative morbidity. Indian J Urol. 2009;25(1):7275.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45.

    Fabbroni G, Loukota RA, Eardley I. Buccal mucosal grafts for urethroplasty: surgical technique and morbidity. Br J Oral Maxillofac Surg. 2005;43(4):320323.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 46.

    Kamp S, Knoll T, Osman M, Häcker A, Michel MS, Alken P. Donor-site morbidity in buccal mucosa urethroplasty: lower lip or inner cheek? BJU Int. 2005;96(4):619623.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 47.

    Jang TL, Erickson B, Medendorp A, Gonzalez CM. Comparison of donor site intraoral morbidity after mucosal graft harvesting for urethral reconstruction. Urology. 2005;66(4):716720.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 48.

    Tolstunov L, Pogrel MA, McAninch JW. Intraoral morbidity following free buccal mucosal graft harvesting for urethroplasty. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;84(5):480482.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 49.

    Badawy AA, Abolyosr A, Saleem MD, Abuzeid AM. Buccal mucosa graft for ureteral stricture substitution: initial experience. Urology. 2010;76(4):971975.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 50.

    Andrich D, Mundy A. Surgery for urethral stricture disease. Contemp Urol. 2001;13:3240.

  • 51.

    Andrich DE, Greenwell TJ, Mundy AR. The problems of penile urethroplasty with particular reference to 2-stage reconstructions. J Urol. 2003;170(1):8789.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 52.

    Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol. 2008;54(5):10311041.

  • 53.

    Calfee EF III, Lanz OI, Degner DA, et al. Microvascular free tissue transfer of the rectus abdominis muscle in dogs. Vet Surg. 2002;31(1):3243.

  • 54.

    Degner DA, Walshaw R, Arnoczky SP, et al. Evaluation of the cranial rectus abdominus muscle pedicle flap as a blood supply for the caudal superficial epigastric skin flap in dogs. Vet Surg. 1996;25(4):292299.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 55.

    Miller JM, Lanz OI, Degner DA. Rectus abdominis free muscle flap for reconstruction in nine dogs. Vet Surg. 2007;36(3):259265.

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