RECONSTRUCTIVE UROLOGY

Combined buccal mucosa graft and local flap for urethral reconstruction in various forms of hypospadias
Li Q, Li S, Chen W, Xu J, Yang M, Li Y, Wang Y, Zhao Z
Plastic Surgery Hospital, PUMC and CAMS, Beijing, China
J Urol. 2005; 174: 690-2

• Purpose: Hypospadias is one of the most common congenital deformities in the male urogenital system. Although there are more than 250 techniques for treating hypospadias, it is often difficult to repair severe hypospadias using conventional methods.
• Materials and Methods: We combined a buccal mucosa graft with a local onlay flap for urethral reconstruction in cases of severe hypospadias or a failed previous operation. A total of 162 patients with hypospadias (glandular 11, penile 40, penoscrotal 49, scrotal 34 and perineal 28) were treated between July 2000 and November 2003. For patients whose urethral meatus was perineal 2 treatment steps were taken. First, we used the aforementioned method to construct the penile urethra, and then we constructed the scrotal and perineal urethra with a local flap.
• Results: Of the 134 nonperineal cases 127 were managed successfully in 1 stage, and 26 of 28 perineal cases were managed successfully in 2 stages. Most patients had a satisfactory penile appearance. A urethral fistula resulted in 8 cases, of which 4 closed spontaneously within 1 month postoperatively. Meatal stenosis occurred in 1 case.
• Conclusions: This technique is simple, safe and reliable, especially in cases of failed previous operation or for salvage hypospadias repair with deficient local tissue.
  
  
• Editorial Comment
  The reconstruction of the pediatric urethra requires knowledge of the anatomical system, specifically of blood supply of both the native urethra and a pedicled flap as well as other peculiarities of certain flaps e.g. hair growth after puberty, thickness of the basement membrane etc. Whereas buccal mucosa has become a frequent way of urethral reconstruction in circumcised adult patients, its use in pediatric patients is rare for various reasons. The data presented in this paper of more than 160 patients deals with the use of a combination of buccal mucosa with a pedicled flap to resolve different forms of severe or previously unsuccessfully operated hypospadias.
  Various techniques exist both for the simple as well as the complicated cases of urethral malformations. It has been shown like in many other fields of reconstructive surgery that the best results may be obtained with the simplest possible technique and the use of a pedicled instead of a free flap.
  In our experience, the distal hypospadias reconstruction can be performed with an excellent outcome by the MEMO technique (meatus-mobilization technique) (1) with an acceptable surgery time (mean 85 minutes in this series), and no need for a tissue transfer. If necessary a lengthening of the penile shaft is possible in some cases by reconstruction of the penile skin.
  Why do we want to mention this paper then? Not always do we have enough pedicled epithelial tissue for a single stage reconstruction, especially in the previously operated penoscrotal or scrotal hypospadias cases. Although we are not totally convinced that pedicled tissue flaps combined with buccal mucosa may be best solution despite the good results presented here, the recent progress with urothelial cell cultivation (2) may be the future in desperate cases. Instead of harvesting buccal mucosa and transposing it to the urethra, expanded urothelium applied to well vascularized flaps may cause less foreign reaction and less morbidity.
  This paper is a good preparation for applying tissue engineering in combination with pedicled flaps for complicated urethral reconstruction. Such a combination for the time being is probably the best way to successfully introduce tissue engineering into urologic surgery.

References
1. Seibold J, Nagele U, Sievert KD, Stenzl A: Urethral reconstruction in the adult and in infant and young male patients. Urologe A. 2005; 44: 768-73. [in German]
2. Maurer S, Feil G, Stenzl A: Tissue-engineered stratified urothelium and its relevance in reconstructive urology. Urologe A. 2005; 44: 738-42.

Dr. Karl-Dietrich Sievert, Dr. Joerg Seibold,
Dr. M. Praetorius, Dr. Udo Nagele & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany