Long-term followup of bladder mucosa graft for male urethral reconstruction

Autologous bladder mucosa was used as a free graft for complex urethral reconstruction in 95 male patients, ranging in age from 1 to 21 years. Primary indications for surgery include previous failed hypospadias repair in 68 cases, primary hypospadias in 11, bladder exstrophy/epispadias complex in 10 and others in 6. Patients were divided into 3 groups based on the configuration of the bladder mucosa replacement. Group 1 (37 patients) underwent complete urethral replacement to the tip of the glans. Group 2 (16 patients) underwent placement of a bladder mucosa onlay patch graft. Group 3 (42 patients) underwent a combined repair using tubularized bladder mucosa proximally and either a pedicled preputial tube (6), free preputial or penile skin tube (13), local glandular skin flaps (15), or intact glandular urethra or tubularized urethral plate (8) distally to avoid a terminal segment of bladder mucosa. All patients were followed for a mean of 3.4 years (range 6 months to 8 years). An overall good functional and cosmetic result was eventually achieved in 81 patients (85%). However, 63 patients (66%) required between 1 and 9 (mean 2.7) additional procedures to treat complications before achieving a good result. The most common complications were meatal stenosis and/or prolapse. Meatal problems were significantly more common in group 1 (68%) than in those who underwent a patch or combined procedure (12 and 36%, respectively). Although bladder mucosa provides an excellent and readily available material for urethral substitution in these challenging cases, the urologist should be aware of the significant incidence of postoperative problems and their management. The high incidence of meatal problems suggests that bladder mucosa should not be incorporated as a circumferential terminal urethral segment.