Coronal cuff: A problem site for buccal mucosal grafts

Purpose: Urethral reconstruction of complex hypospadias or epispadias continues to present a significant challenge. Buccal mucosa as an onlay or tube graft is an excellent option when faced with paucity of penile skin. We identified the factors that lead to success or failure in these repairs. Materials and Methods: During 6 years we placed 34 buccal mucosal grafts in 31 patients to repair complex hypospadias and epispadias. Penile skin was preferentially used for urethroplasty but a free buccal mucosal graft was used for reconstruction due to lack of adequate penile skin. The cases were complicated with an average of 5 previous unsuccessful repairs each in 16. Grafts ranged from 1.5 to 10 cm. and 10 patients required pieced grafts. We created 1 combination, 16 onlay and 17 full tube grafts. Buccal mucosa was used with a Thiersch-Duplay urethroplasty in 8 patients. Results: Anastomotic stricture in 5 patients was proximal in 4. Fistula was a complication in 13 grafts that generally developed on the distal shaft, particularly at the coronal cuff. Of the 7 patients who underwent proximal Thiersch-Duplay urethroplaSty with a distal buccal graft 6 had a coronal fistula. Fistula was more common with tube and pieced than with onlay grafts. Conclusions: Fistula is overwhelmingly the most common complication after buccal mucosal graft urethroplasty. Most fistulas develop at the coronal cuff, and we suspect that skin coverage and potential blood supply have not been good in that region. Anticipation of this problem during stage 1 of hypospadias repair would allow more advantageous distribution of the existing penile skin. Good distal skin coverage cannot be compromised in these complex cases.