vascularity to the anastomosis. In addition, we emphasized dilatation of the glans segment of the tunnel in a manner that prevents meatal stenosis as well as a proximal fistula or diverticulum. The limitations of this study include its small size, short followup and retrospective nature. It is possible that longer followup would reveal further complications. Changes in our practice during the years have been the result of observation rather than of randomized, controlled trials. We have not yet had the benefit of evaluating our patients as adults. However, the literature suggests that despite a high complication rate early in the postoperative course the successful buccal graft is stable


and functions well as patients transition into puberty.24

CONCLUSIONS TBMTG is a good alternative technique for urethral substitution in children with proximal hypospadias. The main benefit is eliminating the risk of significant complications such as breakdown of the repair. Optimizing the penile shaft before TBMTG allows for a tube graft to be tunneled, which protects its integrity. This may enhance the odds of a successful outcome by simplifying the urethroplasty portion of the repair.

REFERENCES 1. Lee OT, Durbin-Johnson B and Kurzrock EA: Predictors of secondary surgery after hypospadias repair: a population based analysis of 5,000 patients. J Urol 2013; 190: 251. 2. Powell CR, McAleer I, Alagiri M et al: Comparison of flaps versus grafts in proximal hypospadias surgery. J Urol 2000; 163: 1286. 3. Cilento BG Jr and Atala A: Proximal hypospadias. Urol Clin North Am 2002; 29: 311, vi. 4. Filipas D, Fisch M, Fichtner J et al: The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine. BJU Int 1999; 84: 108. 5. Mokhless IA, Kader MA, Fahmy N et al: The multistage use of buccal mucosa grafts for complex hypospadias: histological changes. J Urol 2007; 177: 1496. 6. Baskin LS and Duckett JW: Buccal mucosa grafts in hypospadias surgery. Br J Urol, suppl., 1995; 76: 23. 7. Markiewicz MR, DeSantis JL, Margarone JE 3rd et al: Morbidity associated with oral mucosa harvest for urological reconstruction: an overview. J Oral Maxillofac Surg 2008; 66: 739. 8. Markiewicz MR, Lukose MA, Margarone JE 3rd et al: The oral mucosa graft: a systematic review. J Urol 2007; 178: 387.

9. Humby G: A one-stage operation for hypospadias. Br J Surg 1941; 29: 84. 10. Webster GD, Brown MW, Koefoot RB Jr et al: Suboptimal results in full thickness skin graft urethroplasty using an extrapenile skin donor site. J Urol 1984; 131: 1082.

17. Hensle TW, Kearney MC and Bingham JB: Buccal mucosa grafts for hypospadias surgery: long-term results. J Urol 2002; 168: 1734. 18. Nelson CP, Bloom DA, Kinast R et al: Long-term patient reported outcome and satisfaction after oral mucosa graft urethroplasty for hypospadias. J Urol 2005; 174: 1075.

11. Kinkead TM, Borzi PA, Duffy PG et al: Long-term followup of bladder mucosa graft for male urethral reconstruction. J Urol 1994; 151: 1056.

19. Zhao M, Li Y, Tang Y et al: Two-stage repair with buccal mucosa for severe and complicated hypospadias in adults. Int J Urol 2011; 18: 155.

12. Burger RA, Muller SC, el-Damanhoury H et al: The buccal mucosal graft for urethral reconstruction: a preliminary report. J Urol 1992; 147: 662.

20. Leslie B, Lorenzo AJ, Figueroa V et al: Critical outcome analysis of staged buccal mucosa graft urethroplasty for prior failed hypospadias repair in children. J Urol 2011; 185: 1077.

13. Dessanti A, Rigamonti W, Merulla V et al: Autologous buccal mucosa graft for hypospadias repair: an initial report. J Urol 1992; 147: 1081.

21. Snodgrass W and Elmore J: Initial experience with staged buccal graft (Bracka) hypospadias reoperations. J Urol 2004; 172: 1720.

14. Brock JW 3rd: Autologous buccal mucosal graft for urethral reconstruction. Urology 1994; 44: 753.

22. Perera M, Jones B, O’Brien M et al: Long-term urethral function measured by uroflowmetry after hypospadias surgery: comparison with an age matched control. J Urol 2012; 188: 1457.

15. Duckett JW, Coplen D, Ewalt D et al: Buccal mucosal urethral replacement. J Urol 1995; 153: 1660. 16. Metro MJ, Wu HY, Snyder HM 3rd et al: Buccal mucosal grafts: lessons learned from an 8-year experience. J Urol 2001; 166: 1459.

23. Bracka A: Buccal mucosa: good but not perfect. J Urol 2011; 185: 777. 24. Goyal A, Singh MV and Dickson AP: Oral mucosa graft for repair of hypospadias: outcomes at puberty. J Urol 2010; 184: 2504.

EDITORIAL COMMENT The authors provide another piece of evidence that oral mucosa grafts are an ideal substitute for the penile urethra in cases of severe hypospadias. However, the technique does not represent a 1-stage approach. This fact seems important since others

have noted well beforehand that 1-stage oral mucosa grafts are prone to complications and failure (references 16 and 17 in article). In contrast to dorsal inlay staged repair, the graft is primarily tubularized and put in a tunneled graft bed



reaching the tip of the glans. The penile shaft is reconstructed in a prior step, providing a healthy graft bed. This novel approach is innovative and easy to perceive. Results are comparable to those of other series and the cosmetic outcome is appealing. I only wonder whether a primary tube to the glans tip would allow for the creation of a slit-like meatus, which is important for a directed stream of urine.

This aspect has always been considered important for the functional outcome with voiding at least as important as cosmesis. Christian Schwentner

Department of Urology University of Tu¨bingen Tu¨bingen, Germany

REPLY BY AUTHOR We agree that an attempt to reconstruct proximal hypospadias in a single stage runs an unacceptably high risk of failure, particularly in the setting of secondary repairs. Although our complication rate is similar to that in published series, the type of complications that we encountered was more benign. We did not treat any case of urethroplasty

dehiscence or complex fistulas, which were common in prior experiences using buccal tissue. Attaining a slit-like meatus is indeed important functionally and cosmetically. It is successfully achieved with the TBMTG technique by the vertical incision and dilatation of the glans when tunneling the buccal tube.

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