title: Small intestinal submucosa as a urethral coverage layer.
abstract: OBJECTIVE
  Urethrocutaneous fistula is the most common complication of hypospadias surgery. Numerous techniques have been used to decrease the incidence of this complication and the use of biocompatible materials in surgery has expanded the options in difficult situations. We hypothesized that porcine small intestinal submucosa may be used as a coverage layer after urethral surgery. We evaluated the histological changes associated with small intestinal submucosa when used as a coverage layer over the urethra in a rabbit model.
  
  
  METHODS
  We performed urethral surgery in 16 New Zealand White rabbits divided into 4 animals each in groups 1-sham operation with penile degloving only, 2-penile degloving and small intestinal submucosa patch placement, 3-urethrotomy without a patch and 4-urethrotomy with a small intestinal submucosa patch. The graft edges were marked with permanent suture at surgery for later identification. All rabbits were maintained for 6 weeks before sacrifice. The urethra of each animal was then serially sectioned and examined histologically.
  
  
  RESULTS
  Histological examination of animals with an small intestinal submucosa patch revealed a foreign body tissue reaction with an infiltrate of histiocytes, giant cells and lymphocytes in the area of graft placement. There was no histological evidence of remaining small intestinal submucosa patch in any sections. The urethral mucosa healed normally in all cases in which it was disrupted. There was no evidence of acute or chronic inflammation in any group 1 or 2 nonsmall intestinal submucosa animals and none in the animals with a small intestinal submucosa graft in areas other than the former graft site. There were also no urethrocutaneous fistulas in any of the 8 rabbits that underwent urethrotomy.
  
  
  CONCLUSIONS
  Small intestine submucosa provides an adequate coverage layer in the rabbit penis after urethrotomy. Histologically the foreign material did not alter normal healing of the urethral mucosa, although it did appear to cause an infiltration of histiocytes, giant cells and lymphocytes. Small intestinal submucosa has previously been studied as a scaffold on which tissue may be remodeled or may regenerate. Our study shows that small intestinal submucosa did not interfere with normal tissue healing in this animal model. When used as a urethral coverage layer, it appears to provide extra tissue between the urethra and skin. Small intestinal submucosa may potentially decrease the incidence of urethrocutaneous fistula after urethral surgery.
authors.affiliation: Division of Pediatric Urology and Department of Pathology, Vanderbilt Children's Hospital and Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: D J
authors.initials: DJ
authors.lastname: Grossklaus
authors.forename: S B
authors.initials: SB
authors.lastname: Shappell
authors.forename: M C
authors.initials: MC
authors.lastname: Adams
authors.forename: J W
authors.initials: JW
authors.lastname: Brock
authors.forename: J C
authors.initials: JC
authors.lastname: Pope
mesh_terms: D000818:Animals; D017577:Cutaneous Fistula / Q000517:prevention & control; D005549:Foreign-Body Reaction; D007021:Hypospadias / Q000601:surgery; D007413:Intestinal Mucosa; D007421:Intestine, Small; D008297:Male; D023421:Models, Animal; D010413:Penis / Q000601:surgery; D011817:Rabbits; D014521:Urethra / Q000601:surgery*; D014522:Urethral Diseases / Q000517:prevention & control; D014548:Urinary Fistula / Q000517:prevention & control