followup. An enlarged meatal design and temporary postop-erative meatal dilation have improved the outcome in pa-tients who received a graft in the last 5 years. Buccal mucosaremains a good choice in those who require extragenital skinfor urethral reconstruction.

REFERENCES

1. Duckett, J. W., Coplen, D., Ewalt, D. et al: Buccal mucosalurethral replacement. J Urol, 153: 1660, 1995

2. Baskin, L. S. and Duckett, J. W.: Buccal mucosa grafts in hypo-spadias surgery. Br J Urol, suppl., 76: 23, 1995

3. Brock, J. W., III: Autologous buccal mucosal graft for urethralreconstruction. Urology, 44: 753, 1994

4. Burger, R. A., Muller, S. C., el-Damanhoury, H. et al: The buccalmucosal graft for urethral reconstruction: a preliminary re-port. J Urol, 147: 662, 1992

5. Dessanti, A., Rigamonti, W., Merulla, V. et al: Autologous buccalmucosa graft for hypospadias repair: an initial report. J Urol,147: 1081, 1992

6. Gonzalvez Pinera, J., Perez Martinez, A., Andujar Cairo, M. etal: Buccal mucosa free graft for severe hypospadias repair. CirPediatr, 7: 48, 1994

7. Humby, G.: A one-stage operation for hypospadias. Br J Urol, 29:84, 1941

8. Caldamone, A. A., Edstrom, L. E., Koyle, M. A. et al: Buccalmucosal grafts for urethral reconstruction. Urology, suppl., 51:15, 1998

9. Fichtner, J., Fisch, M., Filipas, D. et al: Refinements in buccalmucosal grafts urethroplasty for hypospadias repair. WorldJ Urol, 16: 192, 1998

10. Fichtner, J., Filipas, D., Fisch, M. et al: Long-term follow-up ofbuccal mucosa onlay urethral reconstruction: when and wheredo complications occur? Presented at meeting of AmericanAcademy of Pediatrics, Section on Urology, San Francisco,California, abstract 66, October 17–19, 1998

11. Martinez-Pineiro, J. A., Martinez-Pineiro, L. and Tabernero, A.:Substitution urethroplasties with free graft buccal mucosa.Arch Esp Urol, 51: 645, 1998

12. Riccabona, M.: Reconstruction or substitution of the pediatricurethra with buccal mucosa: indications, technical aspects,and results. Tech Urol, 5: 133, 1999

13. Yerkes, E. B., Adams, M. C., Miller, D. A. et al: Coronal cuff: a

problem site for buccal mucosal grafts. J Urol, 162: 1442, 199914. Kraemer, K. H.: Heritable diseases with increased sensitivity to

cellular injury. In: Dermatology in General Medicine, 3rd ed.Edited by T. B. Fitzpatrick. New York: McGraw-Hill, 1987

15. Wessells, H. and McAninch, J. W.: Use of free grafts in urethralstricture reconstruction. J Urol, 155: 1912, 1996

16. Hensle, T. W., Tennenbaum, S. Y., Reiley, E. A. et al: Hypospa-dias repair in adults: adventures and misadventures. J Urol,165: 77, 2001

EDITORIAL COMMENT

After reporting an initial 39% complication rate of buccal mucosagrafts for urethral reconstruction these authors now conclude thatwith longer followup even in the hands of experienced surgeonsanother 50% of patients have complications (57%). The major sur-prises in this series are that patient age had no effect on outcome andtube grafts led to a more successful outcome compared with onlays.As noted, these parameters are distinctly the opposite of what hasbeen reported previously by others (references 9 and 16 in article).Meatal stenosis is a major cause of hypospadias repair failure. It isimportant to ensure that urethra caliber increases as it progressesdistal and a circular anastomosis is avoided proximal and distal. Thelatter principle would decrease the formation of a linear scar, whichheals from end to end and, thus, is prone to contracture. As proposedby the authors, the tennis racquet design avoids this circular config-uration and may be the primary factor, rather than the combinationwith dilation, that has decreased their meatal stenosis rate.

The authors reporting on a difficult group of patients who requirelong-term followup because of an inherently high and increasingcomplication rate with time. Whether meatal dilation is necessarywith a large caliber distal glanular neourethral anastomosis can onlybe answered by assessing reconstruction alone in their next cohort ofpatients requiring complex buccal mucosal graft reconstruction.

Martin A. KoyleDepartment of Pediatric UrologyChildren’s Hospital and University of Colorado School of

MedicineDenver, Colorado

1. Horton, C. E., Jr. and Horton, C. E.: Complications of hypospa-dias surgery. Clin Plast Surg, 15: 371, 1988

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