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El-Ghoneimi et al. Plast Aesthet Res 2022;9:39 https://dx.doi.org/10.20517/2347-9264.2021.101 Page 7 of 11

Figure 6. Results of BMG tunneling. (A) A 12-year-old ovotesticular 46XX boy, perineal urethra. (B) The aspect three years after staged
urethroplasty using tunneled BMG, completed by bilateral testicular prothesis later. (C) The glandular meatus showing the deep
anastomosis between a healthy glandular mucosa and the BMG. (D) Flowmeter showing subnormal flow without postvoid residual.
BMG: Bladder mucosa graft.

Redo hypospadias cripples: in one case (Case 2 in Table 1), stenosis of the distal anastomosis needed self-
dilatation with progressive caliber introduced for 3 cm. The frequency was decided according to the interval
of normal voiding stream. This 15-year-old adolescent preferred to keep the self-dilatation for three years.
He also developed graft polyps inside the constructed urethra and stones that were voided after laser
fragmentation.

Localized stenosis of the proximal anastomosis occurred in one perineal hypospadias case, and surgical
treatment with onlay buccal mucosal graft successively treated the stenosis.

In one case of perineal hypospadias, an extended stricture of the graft at the penile level needed a total redo
by staged approach with buccal mucosal graft. A limited prolapse of the mucosa was observed in two cases
with no dysuria, which did not need further surgery.

In the case of extensive penile ischemia after circumcision (Case 10 in Table 1), the adolescent had 12
months of preventive self-dilatation of the meatus to keep good urine stream.

DISCUSSION
In our experience, the use of tunneled BMG to reconstruct the urethra remains a reliable option for a long
urethroplasty in patients with a paucity of skin. Moreover, to reduce the morbidity of long graft retrieval,
the minimal detrusotomy technique seemed to us an attractive solution.

There are many options to reconstruct the urethra after multiple failures of hypospadias reconstruction .
[9]
Today, there is no single technique that can be used for all cases; tailored reconstruction is the optimal
choice according to each case . Salvage hypospadias repair is challenging due to scarring and obliterated
[4]
tissue planes, compromised blood supply, and deficient local tissue. Furthermore, patients with lengthy
strictures or urethral breakdown may require augmentation or replacement of diseased urethral tissue for
true surgical success. In their extensive multicenter series, Barbagli et al. analyzed the data from 1176
patients after failed hypospadias . They showed that a median of five additional procedures is required to
[10]
achieve satisfactory final results. These cases represent two main challenges: skin covering and long segment
urethroplasty.

After multiple hypospadias repairs, the patient is often left with minimal or deficient skin, which
complicates further reconstruction. There are multiple ways of augmenting skin coverage, at times
employing surrounding penile shaft skin with Z-plasties and rotational flaps, but often there is no