Initial experience with staged buccal graft (Bracka) hypospadias reoperations

We report outcomes from staged buccal graft urethroplasty after failed hypospadias surgery.

When the urethral plate had been excised or was visibly scarred after prior surgery patients underwent staged buccal graft repair. In the first operation persistent penile curvature was corrected, a proximal cutaneous urethrostomy was created, scarred tissues distally were excised and buccal graft was quilted into place for subsequent urethroplasty. At least 6 months later the now revascularized buccal strip was tubularized and covered with a dartos or tunica vaginalis flap.

A total of 25 patients underwent stage 1 repair following an average of 4.4 prior hypospadias surgeries. Complete graft take occurred in 22 (88%) cases while the remaining 3 had focal scar or graft contracture that was successfully patched before tubularization. To date 20 patients have undergone the stage 2. There were no cases of meatal stenosis, neourethral stricture or diverticulum. A fistula occurred in 1 (5%) of 18 cases in which a flap barrier layer was used. Partial glans dehiscence occurred in 4 prepubertal boys with graft obtained from the cheek, and they have undergone successful reoperative glansplasty. All patients completing surgery have a vertical slit neomeatus.

Staged buccal graft reoperation reliably creates a well vascularized substitute urethral plate for tubularization with low complication rates and good cosmetic outcomes. Inner lip, which is thinner than cheek, may be a better source of graft for the glanular urethra.