Page 81 - Read Online

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

complication rate needing redo surgery was 46%. Stricture at the proximal anastomosis occurred in 30% of
cases, and multiple surgeries were needed in 30% of patients.

In our limited experience using TBMG in severe primary hypospadias repair in four cases, one patient had
major complications (long stricture) that needed a complex two-stage redo surgery. This category of
hypospadias remains challenging even as a primary case, and there is no evidence in the literature of
[17]
superiority of one technique of the others . Our current practice now is to proceed with one-stage repair
using double-face preputial flap whenever the skin is available to reconstruct the urethra and there is a well-
[18]
vascularized skin coverage . We keep the option of free graft only in the case of a paucity of skin, a
condition that occurrs rarely in our experience.

The other category of patient in our series is the masculinizing genitoplasty for ovotesticular 46XX DSD.
These patients had their surgery at a later age than the usual age for hypospadias reconstruction. The
available foreskin was deficient, and the penile corpora needed cavernotomy to correct a significant
curvature. TBMG allowed a long urethral segment reconstruction (12 and 14 cm) with apical meatus. Both
patients had perineal fistula that occurred early after surgery and was closed by local surgery one year later
without recurrence. Prolapses of the mucosa occurred in one case, and at last follow-up, nine years later, the
patient was asymptomatic and no surgery was done for a minimal bladder mucosa prolapse.

In the case of hypospadias cripples, our two patients had multiples surgeries which left them with a scarring
unhealthy skin coverage. After the first stage, removal of all fibrosed reconstructed urethra and treatment of
significant residual curvature, the patients were left with a perineal urethrostomy at the level of their initial
normal urethra. TBMG was a reliable salvage option, and none experienced skin breakdown. One of the
patients, covered initially by a full-thickness free skin graft, needed self-dilatation for three years to treat
distal stenosis, and then he progressively stopped the dilatation. This stenosis is probably secondary to
poorly vascularized glans after multiple surgical procedures. In the other patient, who underwent seven
failed surgeries, TBMG was successful without any complications, and the patient did not need any
dilatation.

In some rare cases such as urethral duplication, TBMG seemed to us a good option, as the graft remains
totally in the deep tissues and the distal and proximal anastomosis are well covered by vascularized local
flaps. The same experience was reported by Mouttalib et al., who successfully reconstructed long congenital
[15]
urethral stenosis in two children .
We used the same technique in a teenager with a major complication of circumcision at 15 years old. He
had an ischemic sloughing of all the penile shaft skin, urethra, corpus cavernosum, and glans. He was
treated somewhere else by total skin graft to cover the penis, leaving the meatus at a distance of 16 cm from
the tip of the penis. TBMG as a salvage procedure was a successful option to reconstruct a 16 cm urethra
without penile skin disruption. For this case, we opted to do preventive self-dilatation of the meatus for one
year, and no distal stenosis was observed.

Morbidity related to bladder mucosa retrieval is one of the disadvantages of the bladder mucosa graft. The
long detrusotomy is logically a source of postoperative bladder pain, hematuria, and dysfunction . In our
[19]
series, we used an innovative method to retrieve the bladder mucosa graft through a minimal length of
detrusotomy (2 cm). We could reach a length of 16 cm graft using this method. This approach may reduce
the morbidity related to graft retrieval.