Evaluation of the Extent of Primary Buccal Mucosal Graft Contracture in Augmentation Urethroplasty for Stricture Urethra: A Prospective Observational Study at a Tertiary Healthcare Centre

Introduction. Buccal mucosal graft (BMG) urethroplasty is considered as gold standard in the treatment of urethral stricture disease. The successful outcome after BMG urethroplasty varies between 66 and 99%. One of the possible causes for failure is BMG contracture. Primary BMG contracture rate is poorly understood and unreported. The present study aimed to evaluate the extent of contracture of buccal mucosa immediately after harvesting. Materials and Methods. This was a prospective observational study conducted in the Department of Urology at our institute between January 2016 and December 2019. All patients with urethral stricture disease undergoing BMG urethroplasty for the first time were enrolled in the study after obtaining informed consent. Demographic and patient clinical profile was noted. Based on the intraoperative urethral stricture size, the preharvest graft was marked on the buccal mucosa and the size was calculated. Postharvest unstretched size of the graft was measured immediately after graft removal from the oral cavity. Alteration in BMG size was analysed using paired t-test. Results. Forty-four patients were included in the study. Mean age of the patient was 53.6 years. Mean stricture length was 7.45 cm (range 4–12 cm). Mean pre- and postharvest BMG size was 8.3 × 1.5 cm and 7.6 × 1.3 cm, respectively. There was a 8.4% decrease in length and 9.5% decrease in width of the buccal mucosal graft. Conclusion. Primary buccal mucosal graft contracture is around 8.4% in length and 9.5% in width. It would be better to mark wider than necessary while harvesting buccal mucosa so that tension-free anastomosis is performed.

Delayed postoperative interface keratitis due to Enterococcus faecalis after Descemet membrane endothelial keratoplasty

To report the clinical course and management of interface keratitis due to Enterococcus faecalis after Descemet membrane endothelial keratoplasty (DMEK). A 64-year-old man underwent DMEK, with unevenful immediate postoperative course, with a visual recovery of 20/30 at 2 weeks. At 3 months of clinical visit, interface keratitis was noted. DMEK graft removal with stromal bed scrapings was performed. A diagnosis of E. faecalis interface keratitis was made. The patient responded favourably to antibiotic susceptibility-guided intensive treatment with vancomycin 5% with complete resolution of infection. After 2 months of graft removal, Descemet stripping endothelial keratoplasty (DSEK) was performed. The corneal clarity was restored and the best corrected visual acuity was 20/40 at last follow-up of 1 year. E. faecalis should be kept as a differential in delayed onset interface keratitis after DMEK. After microbiological cure with antibiotic therapy, visual rehabilitation with DSEK restores corneal clarity and results in favourable visual outcome.

Long-term Outcomes and Survivorship of Fresh-Frozen Meniscal Allograft Transplant With Soft Tissue Fixation: Minimum 10-Year Follow-up Study

Background: Meniscal allograft transplant (MAT) is considered an effective procedure for reducing pain and improving knee function. Nevertheless, the current knowledge regarding the results of MAT is limited to short- to mid-term follow-up studies, especially for arthroscopic techniques. Purpose: To evaluate the long-term clinical outcomes, reoperations, and failures with a minimum follow-up of 10 years after fresh-frozen MAT performed arthroscopically with soft tissue fixation. Study Design: Case series; Level of evidence, 4. Methods: A total of 46 patients (age, 36.6 ± 10.6 years; 36 male, 10 female) who underwent medial MAT (n = 27) or lateral MAT (n = 19) with a minimum 10-year follow-up were evaluated with the Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale for pain, and Tegner score. Surgical failure was defined as the need for partial or total graft removal (meniscectomy or knee replacement), and clinical failure was defined as the need for partial or total graft removal in addition to a poor Lysholm score (<65 points) at final follow-up. Survival analysis was performed with Kaplan-Meier curve, and clinical scores were analyzed based on the Patient Acceptable Symptom State (PASS) for MAT. Results: 10-year survival and clinical data were available for 38 patients. Because 6 meniscectomies were required, the rate of survival free from surgical failure was 91% at 5 years and 86% at 10 years. Lower survival was reported in lateral MAT (73%) compared with medial MAT (96%). Because a further 4 patients had poor Lysholm scores, the rate of survival free from surgical and clinical failure was 87% at 5 years and 70% at 10 years. The average Lysholm score at final follow-up was 82 ± 20, and 60% to 82% of patients achieved PASS of the various KOOS subscales. The Tegner score and the KOOS Sport score significantly decreased from mid-term to long-term evaluation ( P < .001 and P < .05, respectively). Other KOOS subscales and the Lysholm score remained stable at long-term evaluation. No significant differences were found between isolated MAT or combined MAT regarding subjective scores, surgical failures, or clinical failures. Conclusion: Up to 10 years after surgery, 86% of fresh-frozen MATs with soft tissue fixation were still in situ, and satisfactory clinical results were present for about 70% of patients. Decline of clinical outcomes from midterm to long term was noted only in sports-related scores. A higher number of overall reoperations was noted in female patients, whereas a higher risk of failure was present in the patients with lateral MAT.

High Potential of Bacterial Adhesion on Block Bone Graft Materials

Bone graft infections represent a challenge in daily clinics, resulting in increased patient discomfort and graft removal. The aim of this study was to investigate the initial adhesion of five representative pathogens on three different block bone graft materials (xenogeneic, alloplastic and allogeneic) and to assess if chlorhexidine (CHX) can effectively control the initial bacterial adhesion. Three different block bone grafting materials (Tutobone®, Endobon® and human spongiosa) were incubated with Escherichia coli, Staphylococcus aureus, Streptococcus mutans, Enterococcus faecalis and Pseudomonas aeruginosa in the presence or absence of 0.2% CHX solution. Bacterial adhesion was assessed by the direct counting of the colony-forming units (CFUs) and visualized by scanning electron microscopy (SEM). Overall, the selected bacterial species adhered successfully to all tested bone replacement scaffolds, which showed similar bacterial counts. The lg CFU values ranged from 5.29 ± 0.14 to 5.48 ± 0.72 for E. coli, from 4.37 ± 0.62 to 5.02 ± 0.48 for S. aureus, from 4.92 ± 0.34 to 4.95 ± 0.21 for S. mutans, from 4.97 ± 0.40 to 5.22 ± 0.13 for E. faecalis and from 4.23 ± 0.54 to 4.58 ± 0.26 for P. aeruginosa. CHX did not interfere with initial microbial adhesion, and yet it killed all adhered bacterial cells. Thus, CHX can be used to prevent subsequent biofilm infections.

To What Extent Buccal Mucosal Graft Can Shrink Immediately after Harvesting during Substitutional Urethroplasty for Stricture Urethra?

Introduction: Long segment stricture urethra is a difficult urological disease to treat. Substitutional urethroplasty utilising the Buccal Mucosal Graft (BMG) has shown promising results. Still up to one fourth of the patients can develop recurrence in the long term. Shrinkage of BMG immediately after harvesting, is a less studied phenomenon. It may compromise the tension free placement of BMG over the urethral defect, especially in long strictures. This may ultimately affect the final outcome. Aim: To study postharvest shrinkage of the BMG in patients undergoing substitutional urethroplasty. Materials and Methods: A prospective observational study was conducted during the study period from 2018 to 2020. All 18 patients of substitutional urethroplasty with BMG were enrolled. The baseline clinical profile was noted. Preharvest size of BMG was calculated and marked over the Buccal Mucosa (BM). Postharvest size was measured immediately after graft removal from the oral cavity. Changes in the donor area were also assessed. Alteration in BMG size and donor site area was analysed using paired t-test. Alterations in tobacco and non-tobacco users were compared using an unpaired t-test. Descriptive data were presented in the form of mean, range, percentage and standard deviation. Statistical analysis was completed using SPSS software, version 21.0 (IBM Corp, NY, USA). Statistical significance was kept below 0.05. Results: There were 18 cases which were finally available for analysis. Mean age was 32.9±14.2 years. Balanitis Xerotica Obliterans (BXO) was the most common aetiology. Pan-anterior stricture was found in 9/18 of cases. Mean pre and postharvest BMG size was 7.7×1.8 and 6.9×1.6 cm, respectively. An 8.8% decrease in length (p<0.001**) and 10.8% decrease in width of BMG (p<0.001**) occurred after harvesting, which were statistically significant. A significant Increase in the donor site area was also seen (18.5%, p<0.001**). Conclusion: A shrinkage of around 9% in the length and 11% of the width was seen in BMG after harvesting. The study suggests taking an extra 10% of measured size of BMG, in order to compensate for the expected shrinkage. The donor site area also increases and can be left open to heal by itself.