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Buccal Grafts for Urethroplasty in Pre-pubertal Boys: What Happens to the Neourethra After Puberty?
Victor H. Figueroa, Pediatric Urologist, Rodrigo L. Romao, Pediatric Urologist, Walid A. Farhat, Pediatric Urologist, Martin A. Koyle, Pediatric Urologist, Darius J. Bagli, Pediatric Urologist, Armando J. Lorenzo, Pediatric Urologist, Joao L. Pippi Salle, Pediatric Urologist.
The Hospital for Sick Children, Toronto, ON, Canada.

BACKGROUND: Buccal mucosa grafts (BMG) are often used in complex urethral reconstructions when preputial skin is not available or it is inadequate to address large defects during hypospadias repair. Although it has been routinely used in pre-pubertal boys there are concerns that the neo-urethra may not grow proportionally to the phallus following endogenous androgen stimulation (EAS). To address the paucity of data on the topic, we report our experience on pre-pubertal BMG urethroplasties (BMGU) following the onset of puberty.
METHODS: The medical records of all patients who underwent BMGU between 2000 and 2010 at a single institution referral center were retrospectively reviewed. Boys in whom the 1st stage BMGU was performed before the age of 12 years and the last follow up was recorded after puberty were further analyzed. Demographic information, initial meatal location, quality of graft before tubularization, flow rate parameters (FRP) and complications were captured.
RESULTS: During the 10-year study period 137 patients underwent staged BMGU. Of these 10 cases satisfied the inclusion criteria. Mean patient age at time of first stage BMGU was 8 years (range 5-11). The mean follow-up was 40.6 months (9-66). Five patients underwent required BMGU due to complications after tubularized incised urethroplasty done at our institution and 5 for problems after repairs done elsewhere. The buccal grafts were harvested from the cheek and lower lip in 7 and 3 cases respectively. Ventral penile curvature was present in 3 cases, corrected at the time of first stage of BMGU with ventral relaxing corporotomies and midline dorsal plication in 2 and 1 cases, respectively. One patient was re-grafted due to contraction of the original buccal graft. The interval between the 1st and 2nd stage BMGU was 15.8 months (6-87). Second layer coverage was possible in 5 cases, 3 with dartos and 2 tunica vaginalis flaps. No recurrence of ventral curvature (VC) was present at the time of 2nd stage BMGU. Complications included one urethro-cutaneous fistula and 2 glanular dehiscences (both with cheek mucosa graft). The final position of the meatus was glanular in 9 boys, and coronal in one. Importantly, none developed post-pubertal recurrence of VC during follow-up. The average maximum flow was 25.7 ml/s, adequate for the age in all patients.
CONCLUSIONS: BMGs appear to grow proportionally with the phallus during EAS at puberty, as no recurrence of VC or inadequate FRP were observed in this series. Despite the small number of subjects, our results are reassuring and support continued use of BMG in the pediatric pre-pubertal population.


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