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Page 2 of 11 El-Ghoneimi et al. Plast Aesthet Res 2022;9:39 https://dx.doi.org/10.20517/2347-9264.2021.101

Results: The graft was successfully harvested through the minimal detrusotomy approach for variable lengths of
urethroplasty; the median length was 10.5 cm (range 8-16 cm). The median follow up was 61.7 months (range 18-
160 months). TBMG was the last surgery with no redo in five cases (50%). Long stricture occurred in one case of
primary perineal hypospadias and needed a redo staged surgery. Two patients performed self-dilatation for distal
stenosis.

Conclusion: The tunneled bladder mucosa tube graft technique represents a good alternative for a long
urethroplasty in patients with a paucity of healthy skin. The minimal detrusotomy technique for graft retrieval may
reduce graft harvesting morbidity.

Keywords: Hypospadias, bladder mucosa graft, hypospadias cripples, urethra reconstruction

INTRODUCTION
[1]
Redo surgery for proximal hypospadias remains a challenging procedure with inconsistent results . The
[2,3]
majority of cases need staged reconstruction . Unfortunately, in some cases, the multiplicity of failed
reconstruction ends with hypospadias cripples with multiple unhealthy scars, residual curvature, and
inefficient urethroplasty.

It takes a surgical lifetime to learn how to deal with all of these various problems, but, even so, it is very
difficult to satisfactorily categorize the treatment of such patients . In such cases, the lack of healthy skin to
[4]
cover the penile shaft is challenging. The classical staged free grafts (buccal or bladder mucosa) requires,
after the second stage, healthy well-vascularized skin to cover the tubularized flap.

Bladder mucosa tube graft was initially published in 1947 by Memmelaar . Its use was frequently criticized
[5]
because of the high complications rate including mucosal prolapsus, proximal anastomosis stricture, and
[6]
morbidity related to long detrusotomy .

The tunneling approach of a tubularized free graft has been developed to minimize the rate of skin
[7,8]
breakdown after redo surgery . The hypothesis was that the first stage of reconstruction, including
correction of curvature, would leave an interval for revascularization of the tissues and skin coverage.
Tunneling would not interrupt the vascularization of the surrounding tissues with no risk for skin
dehiscence and less risk for graft necrosis.

Our aim was to analyze our cases where we used the tubularized tunneled bladder mucosa graft (TBMG)
technique and its application as a salvage procedure (multiple failed reconstructions with no healthy skin or
severe loss of skin) or as primary surgery for long urethroplasty (perineal hypospadias or masculinizing
genitoplasty).

METHODS
We reviewed the medical files of 10 patients who underwent TBMG urethroplasty. The indications were
redo perineal hypospadias in two, masculinizing genitoplasty for ovotesticular DSD in two, perineal
hypospadias in four, duplicated urethra in one, and complications of circumcision in one (the detailed data
are shown in Table 1).

Steps of surgery
First surgical procedure
Efficient treatment of curvature with specific procedures adapted was performed. All of our hypospadias