Is tissue engineering of patient-specific oral mucosa grafts the future of urethral reconstruction?

A patient has been diagnosedwith a 2 cm long urethral stricture. Acspecific oral mucosa. This can be undertaken by histological examination cording to Hillary et al., 2014 urethral reconstruction or augmentation urethroplasty is suggested, rather than excision and primary anastomosis. In accordance Ram-Liebig et al., 2017 describe in their article a twostep procedure for urethral reconstruction involving some substantial logistical maneuvering. First, a biopsy 0.5 cm in size is taken from the patient's mouth by the urologist (out-patient procedure); the biopsy is then transported to awell-monitored and controlled cell culture facility. In this good-manufacturing-practice (GMP) laboratory oral cells are isolated and expanded. After 3weeks the patient specific oralmucosa graft is ready to be sent back to the urologist. The graft then needs to be implanted to the specific patient within the next 48 h. Currently, a one-step surgical procedure for urethral reconstruction is commonly performed. However, this requires a large piece of healthy donor tissue to be used to reconstruct the urethra. This donor tissue originates mainly from penile skin or buccal mucosa and is associated with donor tissue site morbidity. It has been reported that 10% of patients undergoing one-step urethral reconstruction with oral tissue had moderate to severe oral pain 6 days post-surgery (Dublin and Stewart, 2004). The main advantage of the suggested two-step procedure is that only a small oral biopsy is needed, rather than using a large piece of donor tissue. Only in 1 of the 99 recruited patients oral adverse event has been occurring (Ram-Liebig et al., 2017). The authors agree that their proposed procedure costs more than current methods. However, they argue that the present cost-free alternative has the potential risk of developing complications to the donor site and this could lead to increase healthcare cost for the patient. The first reports using this tissue engineered patient-specific oral mucosa graft triggered a debate among clinician specifically on the cost-effectiveness of this graft and the reliability of the study (Barbagli and Lazzeri, 2015; Osman and Chapple, 2016). Potentially, this article will raise more discussion on these topics, but also will provoke discussion on the efficacy of this two-step procedure with a reported success rate of 67.3% in the 12-month group and 58.2% in the 24-month group,when compared to the conventional one-step oral tissue replacement therapy having a success rate of 90% (Hillary et al., 2014). It can be argued a better understanding is required regarding the most-likely cause of fibrotic events observed with this tissue engineered patient-