Open Journal of Urology, 2011, 1, 4-7
doi:10.4236/oju.2011.11002 Published Online February 2011 (http://www.SciRP.org/journal/oju)
A Two-Stage Buccal M u c osal Graft (BMG) for
Managing Recurrent Proximal Penile Hypospadias in
Pediatric & Adolescent Populations
M. G. Elsheikh, A. Fayad
Cairo University, Cairo, Egypt
Received December 31, 2010; revised February 13, 2011; accepted February 20, 2011
Abstract
Introductio n: The presence of a recur rent proxim al penile hypos padius represents a surgical challenge to the urologist due
to the presence of e xcessive scarring an d fibrosis of the ti ssues. This problem is more pronounced in ci rcumcised patien ts,
in whom there is no enough skin for one stage procedures. Buccal mucosal grafts represent a good surgical option. The
aim of this study was to evaluate the results of two stages buccal mucosal urethroplasty in pediatric & adolescent patients,
presenting with recurrent proximal penile hypospadias who are circumcised. Methods: Thirty seven pediatric & adoles-
cent patients underwent two stages buccal mucosal urethroplasty for recurrent proximal penile hypospad ius. In all cases
the buccal graft was place d dorsally followed by the second stage closure after 6 m onths. Results: The mean age was 17.7
(14-20) years. With a mean follow-up of 28.3 m onths, 33 patients (89.2%) ha d a final success ful outc om e. Of the 4 c ases
that were co nsidered as fai lure, 3 patie nts (8.1%) deve loped uret hra-cutaneous fistula that required closu re after 3 m onths.
The remaining patient developed meatal stenosis. Conclusion: Although buccal mucosal urethroplasty is a two staged
procedure, i t is feasi ble opti on fo r pediatr ic & adol escent pat ients p resentin g with recurren t proxim al peni le hypos padius ,
who had n o skin available for p e n i l e fl a ps, with a success rate approaching 89.2%.
Keywords: Buccal Graft Urethroplasty, Hypospadias
1. Introduction
Hypospadias is a congenital abnormality occurring in 1 of
300 live births (1). Nowadays, most cases of hypospadias
can be successfully repaired with a one-stage procedure in
the first year of life with a success rate approaching 90%
(2). The penile skin with the underlying dartos fascia
provides together with the prepuce in uncircumcised
children good tissue for primary repair together with
managing any encountered complications.
Unfortunately, the repeated attempts at surgical repair
in recurrent failures after hypospadias repair wou ld result
in densely scarred, immobile, hypovascular, or signifi-
cantly shortened penis (3).
The repair of these penile hypospadias represents a
challenge for the urologists, the tissues being fibrosed,
hypovascular and immobile. Furthermore, there is no
enough healthy penile skin for r epair.
2. Patients and Methods
This is a prospective study carried out between February
2006 and A pril 2009 on 37 pediatric & adolescent patients
presenting with recurrent proximal penile hypospadias.
The age of p atients range d between 14 and 20 years (mean
17.7). All patients had undergone a variety of primary
hypospadias correctio ns in the past while 10 patients h ad
two trials of previous repair. All patients were found to be
circumcised at time of presentations. Thirty patients had
penile chordee.
The main complaint was proximal pen ile hypospadias,
with ventral chordee in 30 pat ients. T he urethral plate was
found to be fibrosed and scarred. All patients included in
the study were found to be circumcised.
Preoperatively, all patients underwent physical ex-
amination to exclude BXO, urine analysis and culture. All
our patients and their relatives were informed about the
procedure and signed an appropriate consent.
All of the patients were managed by 2 stages buccal
mucosal urethroplasty. At the first stage, we performed a
urethroscopy under general anesthesia to assess the ure-
thra, then while the patient in the lithotomy position, all
the scarred urethral plate was completely removed
through a two para-urethral incision that extends to the tip

M. G. ELSHEIKH ET AL.5
of the penis splitting the glans into two wings. Proximally
the incisions surround the meatus. All the scarred tissues
are excised to straighten the penis. The meatus was ac-
cordingly transferred to a more proximal po s ition.
The defect was accurately measured. The defect length
ranged between 3.5 cm to 7.5cm with a mean of 5.2cm.
At that stage, we shifted to the oral cavity for harvesting
the buccal graf t. A buccal mucosal graft of a relatively the
same length and the largest possible width was properly
measured and then harvested from the inner side of the
cheek taking care to avoid the opening of the parotid duct
opposite to the upper 2nd molar. We needed to shift to the
other cheek in 5 patients to harvest an additional length.
The use of nasal endotracheal tube made the exposure of
the oral cavity easier giving a wider space for working.
We used to inject diluted epinephrine (1:200,000) sub-
mucosally as this made the harvesting of the graft easier
and less bloody. The graft was then transferred to a side
table where complete de-fating was carried out. T he donor
site was left without approximating sutures; any bleeding
was controll ed with diathermy.
The graft was then transferred to the penis and fixed to
the underlying corpora as a dorsal graft with 5-0 vicryl
sutures. Multiple sutures were used to properly anchor the
graft to the underlying corpora. The edges of the graft
were sutured to the dartos fascia and not only th e skin to
facilitate the later mobilization of the edges for later clo-
sure at th e tim e of the second s tage. The widt h of t he gr aft
harvested should no t be less than 1.5 cm.
A 16 F silicon catheter was used in 22 patients, while a
14 F catheter was used in the remaining 15 patients who
were of younger ag e. The catheter was left for one week.
The dressi ng w as rem ov ed a ft er 3 days a nd d ai ly dressi ng
with antiseptic solution was carried out 3 times daily. The
donor site was cleansed with antiseptic mouth wash and
topical anesthetics for the first 3 days.
The second stage was performed after 6 months, to
ensure proper vascularisation of the graft. Preoperative
urine analysis and culture were performed to ensure ster-
ile urine and prophylactic antibiotics were started preop-
eratively. Two vertical Para-m ucosal incisions were made
that allowed the free mobilization of the graft edges to be
approximated in the midline without tension. Vicryl su-
tures (5-0) were used for the closure of the neo-urethra
around the silicone catheter. We used 16 F silicone
catheter in 20 patients while 14 F catheter was used in the
remaining 17 cases. The idea of selecting the catheter
caliber was to close the graft without any tension. The
catheter was left indwelling for 3 weeks.
The mean follow up was 28.3 (12-50) months. Success
was defined as having a functioning urethra without fis-
tula, meatal stenosis, stricture or residual chordee and
having a cosmetically acceptable glandular meatus. The
Figure 1
Figure 2
necessity of meatal or urethral dilatation and the presence
of complications or a poor aesthetic result requiring revi-
sion were considered as failures.
3. Results
Our study was carried out on 37 pediatric & adolescent
patients, the mean age was 17.7 (14-20) years. As regard
the previous attempts at repair: Snod Grass was tried in 32
cases while transverse preprutial island flap was tried in
three cases and longitudinal ventral penile skin flap in the
remaining 2 cases. All the ten cases with two trials of
repair had Snod Grass being the second procedure.
As regard the first stage; the overall operative time
ranged between 125min and 210min with a mean of 147.
Mean time for harvesting buccal graft was 17min. The
hospital stay ra nge d betwee n 3-5 d ays wi th a mean of 3.4.
The dressing was removed on the 3rd post-operative day.
5 of our p ati ents ha d t hei r gra f t bein g i nfecte d a nd ne ede d
swabs from the graft for culture and sensitivity. The an-
tibiotic was prescribed for a week. None of our patients
showed graft loss after their first stage.
As regard the 2nd stage; the overall operative time
ranged between 105min and 180min with a mean of 135.
The hospital stay ranged bet ween 2-4 days w ith a mean of

M. G. ELSHEIKH ET AL. 6
3.16.
Of the 37 cases included in the study, 33 (89.2%) were
classified as successes and 4 cases (10.8%) as failures.
The failures were due to urethro-cutaneous fistula in 3
cases (8.1%) and meatal stenosis in one case (2.7%).
The fistula developed immediately after removal of
urethral catheter after the second stage. The patient was
considered as failure and underwent closure of the fistula
successfully 3 months later. Meatal stenosis was the other
cause of failure; the patient was 18 years old, and pre-
sented with gradual decrease in the urinary flow after
removal of the uret hral catheter after successful 2nd stage.
He needed meatal d ilatation for 2 weeks ther eafter. None
of the patients who were considered as success needed
any further intervention during the follow-up. Further-
more, none of our patients experienced any degree of
penile chordee. Also, no one complained from any oral
problems during the follow-up.
4. Discussion
The management of complications in pediatric and ado-
lescent age groups, in whom multiple attempts of hypo-
spadias repair had failed, is a surgical challenge and still
represents a complex problem for reconstructive urolo-
gists. This is attribute d to the fact that repeated attem pts at
repair would result in tissues that are fibrosed, hypovas-
cular and immobile. The deficiency of enough unscarred
penile skin, being used for previous attempt at repair, adds
another difficulty.
Historically, various tissues have been used to repair
the damaged urethra including genital (penile and scrotal)
skin, extra-genital skin, bladder mucosa and buccal mu-
cosa. These tissues have been used as either pedicled flaps
with their own blood supply or as free tissue grafts. The
most common graft materials in use today are buccal
mucosa, preputial skin (when available) and penile and
preputial skin flaps with their own blood supply.
The use of buc cal mucosa (B M) in urethral surgery was
first describ ed by Humby in 1941, (4) however, it was not
reported again until the late 1980s.
The main reported advantages of the buccal mucosa
that favors its use in substitution urethroplasty is it’s na-
ture being wet epithelium, it is readily harvested, it has
been shown to be resistant to recurrence of strictures
(especially in the presence of balanitis xerotica obliterans,
BXO). The presence of a dense submucosa with a dense
capillary network facilitates early imbibition and early
inosculation (5).
It was not until 1992 when Burger et al. reported the
first use of BM for repair of complications following
childhood hypospadias surgery (6).
In 1995, Bracka conducted his study on managing
complications after hypospadias repair and he concluded
that a two-stage repair by splitting the glans and lining it
with penile skin or BM grafts was extremely adaptable
and successful (7).
In studying the outcomes of buccal mucosa (BM)
penile urethroplasty, most of the studies reported a high
success rate (8).
In 1998 Mundy et al reported a success rate of 100% on
8 cases, as 2 stages buccal mucosal urethroplasty due to
penile stricture caused by BXO (9). Three years later, he
published his results on 39 cases underwent 2 stages
procedures and followed –up for at least 2 years and re-
ported a success of 83% (5).
Dubey et al reported a series of 43 patients undergoing
dorsal-onlay BM urethroplasty for penile strictures. 28 of
their patients h ad a one -st a ge procedure, while 15 of their
patients required two-stages. The mean follow-up was
shorter for two-stage reconstruction (24.2 months) com-
pared to one-st age proce dures (34 m onths). They reporte d
success rate of 86.7% for two-stage procedures, with the
majority of recurrences being managed successfully with
DVIU (10). The same authors reported the outcomes of
the 2 stage procedure on 14 cases with strictures due to
BXO, after a mean follow-up of 32.5 months, they re-
ported a success rate of 78.6% (11).
Our success rate was 89.2%, a result which is compa-
rable to that publi shed by Mundy et al (5) and Dubey et al
in his first series (10) but much better than that reported by
the same author in his second series (11).This might be
attributed to the fact that most published series on two
stages buccal urethroplasty was done for BXO, this is not
the case in our study as no ne o f o ur pat i e nt s had BXO.
In our study, none of our patients developed contracture
of the initial graft, and none of the succeeded cases required
more than the two previously planned surgeries. That’s
why we do not agree with Shukla et al. in 2004 (12) , who
concluded his study that a 2-stage repair is actually a mis-
nomer and that about 70% of cases required at least one
additional procedure (a mean of extra 1.6 pro cedures).
5. Conclusion
Although, there is no single technique that can fit for all
situations, the use of 2 stage buccal mucosal uret hroplasty
appears to be a successful and feasible option for man-
agement of patients with recurrent proximal penile hy-
pospadias in the absence of sufficient penile skin with a
success rate approaching 89.2%. Although most of our
patients have been follow ed up for more th an 2 year s yet,
longer follow-u p is still required.
6. References
[1] L. S. Baskin, “Hypospadias and Urethral Development”,

M. G. ELSHEIKH ET AL. 7
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