BACKGROUND: The hypospadias cripple has undergone one or more hypospadias repairs with a poor result. There is no redundant penile skin for local flap creation. The buccal mucosal graft inlay urethroplasty is helpful in these difficult cases. We report our experience with the buccal mucosal graft inlay urethroplasty in the repair of the hypospadias cripple in children.
METHODS: Six boys (mean age 6 years, range 2-13 years) were referred with a poor hypospadias repair result. A mean of 4 hypospadias surgeries had left them all with residual hypospadias and scarring, 5 with stenosis or stricture, 4 with poor cosmesis and chordee, and 3 with urethrocutaneous fistulae. Nasotracheal intubation was done to facilitate graft harvest from the inner lip and/or cheek. All patients underwent cystoscopy at the time of their reconstruction to evaluate their urethra. All donor sites were closed with running absorbable suture.
RESULTS: All patients had inlay urethroplasties with dorsal relaxation of the urethral plate. All the donor sites healed uneventfully. At a mean follow-up of 2 years, all patients had mid to distal glanular meatuses, none had chordee, and cosmesis had improved considerably in all cases. Complications were 1 urethrocutaneous fistula and 1 episode of cystitis. There were no strictures.
CONCLUSION: The buccal mucosal graft inlay urethroplasty is a good salvage procedure for the hypospadias cripple with no local skin for flap creation. Donor site morbidity is impressively low, and success rate is high for this difficult population of patients. We recommend it for use as an inlay to allow a generous relaxing incision into the dorsal urethral plate, which allows for a tension free closure of the whole urethra.

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