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Page 8 of 11 El-Ghoneimi et al. Plast Aesthet Res 2022;9:39 https://dx.doi.org/10.20517/2347-9264.2021.101

redundant skin available for these patients. Many of these options leave extensive scarring, or, when direct
transfer of scrotal skin is used, there is a large area of hair-bearing skin that will become evident after
puberty, leaving the patient with a poor cosmetic result. Updates of older techniques such as the Cecil Culp
[11]
technique were modified and reported by Weiss et al. . In their 39-patient series using a Cecil Culp-
modified technique (three stages), the final complication rate remained high with 21% having long-term
complications including skin breakdown.

To avoid the major complication of skin breakdown, tunneling of a tubularized graft seemed to us a good
alternative in such cases with a paucity of skin and scarring covering tissues.

In our experience, none of our patients had skin breakdown. Tunneling was also, in our opinion, beneficial
in preventing urethral fistula. In our experience, fistulas occurred in two patients and were treated by local
closure. The easiness and efficiency of the closure was due to the position of the fistula deep in the perineum
at the proximal anastomosis that allowed multiple well-vascularized available layers, in contrast with penile
fistula. Positioning of the suture line of tubularization against the corpus cavernosum in a closed space
created by tunneling is probably the reason for the absence of fistula in the penile shaft.

Fine et al. reported their experience with tunneled buccal mucosal graft in 34 children with proximal
hypospadias (75% primary) . The mean length of the urethral construction was 5.3 cm (range 3-9 cm).
[12]
Their overall complication rate with more than one year of follow-up was 32%, including fistula in five
patients, proximal stricture in four, and meatal stenosis in two. No patients experienced skin breakdown.
The rate of stricture might be underestimated with relatively short follow-up compared to other series.

Zhao et al. presented a series of 57 adults with failed hypospadias repair, in whom they performed
tubularized buccal graft urethroplasty, which was tunneled as an initial stage and anastomosed 6-12 months
[7]
later .
Recently, Kim et al. reported their experience with tunneled buccal mucosal graft after failed hypospadias
[8]
surgery in 48 cases . Only 14.7% of patients were complication free, and all others required at least one redo
surgery. In their experience, the mean length of the graft was relatively short at 3.7 cm. Only 22.9% of
patients were stricture free after six years, while none of their patients had skin breakdown.

In our opinion, the use of tubularized tunneled buccal mucosal graft has its limits in the length of urethral
reconstruction; the extensive length needed in our cases (median 10.5 cm and maximum 16 cm) exceeded
the maximal length used in the reported cases. Moreover, the morbidity of buccal mucosal graft harvesting
is not negligeable. Among the paucity of reports on morbidity of buccal graft harvesting, Wood et al.
reported postoperative significant pain in 83% of patients, and the main long-term complications were
persistent perioral numbness (26%) .
[13]

[5]
Bladder mucosa tube graft was initially published in 1947 by Memmelaar . Modifications of the initial
technique to reduce the complications were more or less successful. Ransley et al. combined bladder mucosa
[6]
with preputial skin grafts to reduce the incidence of distal prolapses .

Tunneling of the bladder mucosal graft has been rarely reported for primary hypospadias or redo for long
[14]
posterior urethral stricture . Recently, Lanciotti et al. reported a large series of 50 children with severe
[15]
hypospadias, operated by a staged bladder mucosal graft . The graft was tunneled during the second stage.
[16]
The mean graft length was 5.7 cm (range 35-85 mm). At a mean follow-up of five years, the total