Urethral reconstruction in cases with re-do and/or primary severe urethral defects: the use of local skin flaps and buccal mucosa

Abstract

Introduction: The difficulties of urethral reconstruction in adults with re-do and/or circumcised peno- scrotal hypospadias with chordee are well known by all urologists. For this reason, our aim was to discuss urethral reconstruction techniques used in our operations and the difficulties we encountered. Materials and Methods: Thirty-two of 126 patients who applied urology clinics because of their urethral defects between the years 1994 and 2007 were adults with re-do and/or circumcised severe proximal hypospadias with chordee. For urethral reconstruction, we used local skin in 20 cases, buccal mucosa in 10, and local skin combined with buccal mucosa in 2. Mean follow up was 23 months (3-96 months). Results: In the local skin group, urethral fistula occurred in 4 (4/20) patients. In the buccal mucosa group, 6 (6/10) patients developed anastomotic stenosis and 5 of them developed small fistulas. After internal urethrotomy and fistula repair, functional urethras with desired lengths and diameters were obtained. One (1/2) fistula developed in local skin combined with buccal mucosa group. Conclusion: In order to provide a good penile orthoplasty and stricture prophylaxis, it is essential that the urethral bed is cleared of all of fibrotic tissues, and that the proximal urethral end be excised up to the level of best perfusion. Circular penile fasciocutaneous flaps rather than scrotal skin flaps should be used for anterior urethral reconstruction. The urethral plate should be secured as far as possible, and patch flaps rather than tube flaps should be used. Buccal mucosa may be a good choice in re-do and/or circumcised primary adult cases with severe proximal hypospadias with chordee that do not have adequate local skin.