Redo hypospadias surgery: current and novel techniques

Abstract

Failed hypospadias includes patients with multiple attempts at hypospadias surgery. These present as recurrent stricture, urethrocutaneous fistula glans dehiscence, urethral dehiscence, chordee, and glans deformity. Failed hypospadias is a complex and challenging issue. Various surgeries and techniques have been described for hypospadias. We need uniform guidelines for management of failed hypospadias. In this paper, we highlight the current and feasible options in the management of failed hypospadias which would deliver best long-term cosmetic and functional outcomes for the patients.

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REVIEW
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Open Access Full Text Article
http://dx.doi.org/10.2147/RRU.S142989
Redo hypospadias surgery: current and
novel techniques
Sanjay B Kulkarni
Omkar Joglekar
Mohammad H Alkandari
Pankaj M Joshi
Kulkarni Reconstructive Urology
Center, Pune, India
Abstract: Failed hypospadias includes patients with multiple attempts at hypospadias sur-
gery. These present as recurrent stricture, urethrocutaneous fistula glans dehiscence, urethral
dehiscence, chordee, and glans deformity. Failed hypospadias is a complex and challenging
issue. Various surgeries and techniques have been described for hypospadias. We need uniform
guidelines for management of failed hypospadias. In this paper, we highlight the current and
feasible options in the management of failed hypospadias which would deliver best long-term
cosmetic and functional outcomes for the patients.
Keywords: failed hypospadias, hypospadias cripple, penile stricture, glans dehiscence, ure-
throcutaneous fistula, chordee
Introduction
Hypospadias has varying presentations in children.
Anthony Mundy in his editorial review said that it is almost impossible to write a
satisfactory journal article on failed hypospadias repair.1
Hypospadias encompasses a wide range of abnormalities. This includes the abnormal
location of meatus, degree of chordee, the width of urethral plate, and the tilt of glans.
This makes the management of hypospadias a complex issue. There has been controversy
on many issues ranging from the age at which to operate to the technique to be used
as well as the type of procedure to be performed. There are more than 200 mentioned
surgeries for hypospadias. The term failed hypospadias was coined for individuals
with remaining functional complications after multiple failed attempts at hypospadias.
These include recurrent stricture (Figure 1), urethrocutaneous fistula (Figure 2),
glans dehiscence, urethral dehiscence, chordee, and glans deformity. Repeated surgery
increases the likelihood of recurrent fistulation and restructure formation, mainly
because the ventral penile shaft skin is less well vascularized and in turn because of
deficient ventral Dartos tissue.
By and large, a majority of hypospadias cripples would have had more than 3 failed
prior attempts at urethroplasty.2
Failed hypospadias is an important topic for discussion. This is because the best
practices for management of these complications are yet not established. For a young
urologist, we need to lay down guidelines and simplify the management of hypospa-
dias cripple.
Thus, in this paper, we review the management of hypospadias cripple.
Correspondence: Pankaj M Joshi
Kulkarni Reconstructive Urology Center,
3 Rajpath Society, Paud Road, Pune, India
Tel +91 99 2340 6464
Email drpankajmjoshi@gmail.com
Journal name: Research and Reports in Urology
Article Designation: REVIEW
Year: 2018
Volume: 10
Running head verso: Kulkarni et al
Running head recto: Redo hypospadias surgery
DOI: http://dx.doi.org/10.2147/RRU.S142989
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Materials and methods
Ours is a tertiary referral center for management of urethral
stricture. We get referrals from all over the country and the
globe.
From 1995–2018 we have performed 4,368 urethroplas-
ties including 1,171 cases of pelvic fracture urethral injuries.
We have experience in management of hypospadias cripple.
We have performed urethroplasty on more than 200 cases
of hypospadias, including primary and failed. Among the
failed hypospadias, the minimum number of prior surgeries
was 2 and maximum was 17 prior attempts in management
of hypospadias.
We will describe the management of hypospadias cripple
in our center.
Detailed history of all patients is noted. Previous surgical
notes and type of repair performed are thoroughly studied.
On examination, we evaluate the length of penis, shape of
glans, diameter of glans, width of urethral plate, presence of
urethrocutaneous fistula, chordee, and previous scars. The
patient or his parents are specifically asked for details on
penile curvature. Any photographs taken by the patient of
chordee is evaluated. Uroflowmetry is performed. We exam-
ine the patient at voiding to look for the stream of urine and
presence of urethrocutaneous fistula. The cosmetic appear-
ance of the penis is noted. Many patients have been found
to have uncorrected penoscrotal transposition.
Residual urine is evaluated, and ultrasonography
is performed to look for upper tract dilation like
hydrouretero nephrosis.
A surgical plan is made and discussed with the patient
and relatives.
We have standardized the management of failed hypo-
spadias in our unit.
Postoperatively, patient is discharged on day 1. Dressing
is changed on day 5. Per-urethral Foley’s catheter is kept for
7 days in case of Staged repair and 3 weeks in case of single-
stage urethroplasty. Patients receive low-dose antibiotics till
catheter removal. On catheter removal, the patient is exam-
ined at voiding. Any dehiscence or urethrocutaneous fistula
is noted. We maintain a prospective database of all patients
operated in our center. Patients are asked to follow-up at 3
monthly intervals for 1 year and 6 monthly thereafter for a
period of 5 years and then once a year indefinitely.
Many patients are from outside our city. They visit the
referring local urologist who is requested to update us. We
routinely use the internet-based applications like WhatsApp
and e-mail for collecting patient data, flow rates, symptoms,
and the as-required postoperative photographs. Patient con-
fidentially is maintained.
We would like to describe our experience of success rate
under the respective individual headings.
Several factors need to be considered before deciding on
the type of repair to be performed. However, we will simplify
the management of hypospadias cripple.
Figure 1 Complex penile stricture inpatient with multiple hypospadias repair.
Figure 2 Multiple urethrocutaneous stula.

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Redo hypospadias surgery
The main factors determining the type of urethroplasty
to be performed depends on the following:
1. Scarring of urethral plate
2. Width of urethral plate
3. Width of glans
4. Degree of chordee
5. Ventral skin
We will discuss the above factor in specific urethroplasty.
Surgical techniques
Single-stage dorsal inlay urethroplasty
In patients with urethral stricture, we incise the urethra
ventrally (Figure 3).3,4 This incision is extended proximally
till the normal urethra with good healthy spongiosum. We
then measure the width of urethral plate. If the urethral plate
is more than 8 mm in width, then decision to perform a
single-stage dorsal inlay augmentation urethroplasty is made
(Figures 4 and 5). We make a midline incision into the dorsal
urethral plate, about 1.5 cm in width. These are multiple
parallel incisions and not a single deep midline incision.
A buccal graft is harvested by a second team. The graft is
inserted as dorsal inlay and quilted to the underlying corpora
with 3 rows of continuous quilting sutures. Occasionally,
multiple interrupted quilting sutures are made (Figure 6).
Periurethral incisions are made and the urethra tubularized
using subcuticular sutures over a silicone catheter. Wide
glans wings are essential for creating a vertically slit meatus.
Glansplasty is done. The second layer of Dartos fascia is
sutured to cover. Skin is closed with subcuticular sutures. A
suprapubic catheter is inserted.
In case the urethral plate is narrow, we perform our novel
2-stage urethroplasty which is also described here.
We have performed this repair in 59 patients with a suc-
cess rate of 94.91%. Two patients had glans dehiscence and
1 had urethrocutaneous fistula. Both were repaired subse-
quently after a 6 months interval.
Staged buccal graft urethroplasty
We classify patients into 2 main categories, patients with
salvageable urethral plate and patients with scarred penis
with no urethral plate.
Figure 3 Ventral urethrostomy inpatient with complex penile stricture after failed
hypospadias.
Figure 4 Width of urethral plate more than 8 mm – single-stage dorsal inlay
augmentation.
Figure 5 Incision till wide proximal good caliber urethra.

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Kulkarni et al
We usually see patients with penile stricture and fistulas.
When the urethral plate is scarred, we tend to excise all the
scarred tissue (Figure 7). We check the chordee and correct
it with multiple ventral transverse corporotomies. In case the
curvature still remains, we perform corporal plication on the
dorsal side or lateral side as the situation demands.
We prefer using buccal graft for urethroplasty.5,6–9 Buccal
mucosal graft is harvested by a separate team simultaneously.
We use cheek grafts and do not prefer using lip grafts. Lip
grafts, though mentioned in the literature as being supple,
leave behind scarring of the donor site which can be a
cosmetic issue. Dartos is mobilized and sutured in the mid-
line. The graft is then placed above the Dartos and quilted
with multiple stitches usually as wide as the native urethra
( Figures 8 and 9). Placement of the graft on the Dartos helps
in tubularization at second stage. It also improves the blood
supply to the graft. Literature has mentioned the use of tunica
vaginalis flap on the graft bed. We give a tie over dressing on
the graft. Parents are taught to keep wetting the dressing by
Normal Saline irrigation, which is removed on day 2.
The catheter is removed on day 7. Patient/parents are
instructed to keep the graft moist by pouring water at regular
intervals in the day time and by application of moisturizer.
No medications are given to suppress erections.
Usually, the graft contracts by 15%–20%; hence the
reason behind a wide 3 cm graft being inserted in an adult.
There remains a controversy regarding the excision of exist-
ing urethral plate. We do not believe in excising any existent
plate unless it is extremely scarred. Each and every millimeter
of native urethra is helpful for reconstructing a wide urethra.
A buccal graft can be split and inserted around the ure-
thral plate if necessary rather than excision of the plate. One
important step of staged urethroplasty is to quilt the graft
adequately to the underlying tissue with absorbable sutures.
The patient is evaluated at intervals of 3 months. There
is usually some amount of graft contraction that takes place.
At 6 months, the graft is supple, and so the second stage of
the procedure is performed.
Figure 6 Dorsal inlay augmentation.
Figure 7 Scarred urethral plate after multiple failed hypospadias urethroplasty. Figure 8 Bracka urethroplasty – insertion of buccal graft.

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In the second stage, periurethral incisions are made and
the neourethra is constructed. This incision is made as lat-
eral as possible. The edges of the graft should be mobilized
to the minimum. In case there is scarring of urethral plate,
another small graft can be inserted as dorsal inlay augmenta-
tion. Dartos is used to cover the urethral repair. Wide glans
wings are created. This is essential to avoid meatal stenosis.
All the suture lines lie ventrally in hypospadias surgery. A
per-urethral Foley’s catheter can put a strain on the suture line
and cause dehiscence. Therefore, we usually prefer inserting
a suprapubic catheter for all our patients.
The aim is to create a vertical slit meatus which is wide.
All this works provided the graft remains supple and has
no contracture.
In our unit, this type of urethroplasty was performed from
1995 until 2010 when we changed our protocol. This has
been highlighted in the next section. We have performed this
staged urethroplasty in 29 patients. Whenever we have done
a staged buccal graft repair, our graft contraction rate was
33%, needing graft revision and redo surgery. Similarly in
various high-volume units, the graft contraction (Figure 10)
after a Bracka repair is as high as 39%. Mundy1 published
interesting work at the American Urology Association.
When the Bracka procedure was assessed in the UK, the
graft contraction rate was 3%, but when the same procedure
was done in Middle East, a graft contraction rate of 39%
was observed.10–12
This proves the effect of climacteric and ethnic factors in
the healing process. We have faced a graft contraction rate
of 34%. In such patients, our initial approach was to insert
another graft and wait for 6 months. This has also failed
in some attempts. We now insert a graft and tubularize the
urethra at the same time (Figure 11).
Since necessity is the mother of invention, this graft
contracture made us review our technique.
We recently published a novel composite 2-stage
urethroplasty for penile urethral strictures, mainly failed
hypospadias.
Two stage surgery – novel approach
First stage: Johanson’s
Having assessed the patient clinically in the outpatient depart-
ment, patients were admitted a day before surgery.12 Patients
were requested to apply Betadine scrub solution to genitalia
a day before surgery. A single dose of intravenous antibiotic
was administered. The patient is placed in supine position.
Urethroscopy was performed with a narrow endoscope such
as 6 or 4.5 Fr ureteroscope and length of stricture assessed.
The urethra was longitudinally opened along its ventral sur-
face and the spongiosum tissue is sutured (Figure 12). The
penile skin margins are sutured to the margins of the urethral
plate, and the new urinary meatus was located in the healthy
urethral mucosa 2 cm proximally to the stricture, leaving a
wide open meatus proximally to void through. A 14-Fr Foley
Figure 9 Quilting the graft in Bracka urethroplasty.
Figure 10 Graft contraction.

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silicone catheter is left in place for 7 days. A soft dressing is
applied. The dressing is removed on day 2, and patient was
discharged from the hospital. Catheter was removed on day
7, and uroflowmetry is performed.
Second-stage urethroplasty using oral mucosal graft inlay:
Asopa dorsal inlay Buccal mucosal graft (BMG)
Six months after the first stage, the patients are evalu-
ated clinically for closure of the urethra by second-stage
urethroplasty. Uroflowmetry and urine culture were assessed.
Three days before surgery patients were requested to apply
Betadine scrub to genitalia twice a day and do Chlorhexi-
dine gargles twice a day. On the day of surgery, intravenous
broad-spectrum antibiotics are administered. The patients
are intubated through the nose, allowing the mouth to be
completely free. The patients are operated by 2 surgical
teams who work simultaneously, each having its own set
of surgical instruments. The oral mucosa graft is harvested
from the cheek according to our standard technique used on
more than 553 patients. The graft is tailored as per individual
case. The patient is placed in supine position. A stay suture
is taken at glans and penis stretched. The new meatus after
1 stage is calibrated with the progressive insertion of 10, 12,
14, 16 Fr Nelaton catheters. This gave us the size of proximal
normal urethra. The lateral skin incisions of the urethral
plate are outlined depicting the narrow urethral plate. The
lateral margins of the urethral plate are dissected from the
penile skin. A midline dorsal longitudinal mucosal incision
of the urethral plate is outlined from the existing meatus to
where the neomeatus at glans would be. The urethral plate
is incised longitudinally and opened. This is deepened until
corpora. Any scarred tissue from previously failed surgeries is
excised. A wide bed for the graft is created. The buccal graft
harvested is then applied as dorsal inlay (Figure 13). Multiple
quilting sutures are done with 6-0 polyglactin. The concept
is to make a wide urethral plate using a dorsal inlay buccal
graft. This should be as wide as the native proximal urethra.
A suprapubic catheter is inserted. A 8-Fr soft tube was used
as urethral stent. Urethra is tubularized with subcuticular
sutures of polydioxanone (Figures 14 and 15). Glansplasty
is performed to create wide vertical slit-like meatus. Meatal
reconstruction is most important technically as meatal ste-
nosis will lead to fistula formation.
Local Dartos is mobilized and used to cover the suture
line. A narrow strip of Dartos may be inserted in between
the urethra and glans. The penile skin is meticulously closed.
A soft dressing is applied. The soft tube used as a urethral
stent is kept just across the constructed urethra. Dressing is
removed on day 4, and the patients were discharged. They
are requested to follow-up on day 21. After clinical assess-
ment, the urethral stent is removed, and suprapubic tube is
clamped. After successful voiding per urethra, the suprapu-
bic tube is removed. Uroflowmetry is recorded. Patients are
asked to regularly follow-up every 3 months for 1 year and
then annually.
The advantage of this technique is that the buccal graft
is not inserted in Stage I. So, graft contraction may be less,
and if it happens, it is hidden. Once the graft is inserted in
Figure 11 Dorsal inlay augmentation in a contracted graft.
Figure 12 Stage I Johanson’s urethroplasty.

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Figure 13 Dorsal inlay buccal graft augmentation.
Stage II, the urethra is tubularized. This keeps the graft moist
and reduces the risk of graft contraction.
We started performing this technique in 2010. Since then,
we have moved away from inserting buccal graft in Stage I
(Bracka) unless there are no options. We have performed this
type of staged urethroplasty in 53 patients since 2010. Three
patients had partial glans dehiscence, 2 developed urinary
tract infection (UTI), and 2 had urethrocutaneous fistula.
The 2 patients with UTI needed intravenous antibiotics. In
1 patient, the UTI kept recurring, and this was probably due
to the presence of previous skin-lined urethra. He has been
maintained on low-dose antibiotics. In patients with glans
dehiscence and urethrocutaneous fistula, redo surgery was
done after an interval of 6 months.
Pedicled preputial ap/tube
Usually, hypospadias cripple has deficient local ventral skin,
and circumcision already been done in previous surgeries.
In case the prepuce is intact, it can be used as a flap to make
the ventral wall of the urethra or it can be tubularized like a
preputial tube.13 However, compared to grafts, this is used
Figure 14 Periurethral incision.
as last resort. Use of penile/preputial flaps/tubes has high
risk of diverticulum formation and should be avoided. The
technique of pedicled penile or preputial flap is standard, and
it has been described by Asopa et al.13
Figure 15 Urethral tubularization.

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Kulkarni et al
In multiple failed cases, we use the dorsal penile skin
as a pedicled flap and transpose it to the ventral side, using
as a onlay cover over the native plate. Two incisions are
made on the dorsum of penis, 1.5 cm apart. The incisions
are deepened till the level of Buck’s fascia. The skin island
is then mobilized on the Dartos pedicle. The mobilization
is done till the root of the penis. A button hole is made, and
the skin island is transposed ventrally in such a way that the
skin overlies as ventral cover for the native urethral plate.
An all-silicone catheter is then inserted, and the edges of
penile flap are sutured to the native urethral plate. Overlying
Dartos acts as a second layer of cover. We have performed
this in 5 patients.
It may be challenging to cover the skin on the neoure-
thra. The incision on the dorsal aspect of penis may not be
sutured, leaving it to heal by epithelization. This is similar
to the concept of penile relaxing incisions which were used
for Stage II closure in Johanson’s urethroplasty.
Closure of urethrocutaneous stula
There may be 1 or many fistulas which are connected between
the ventral skin and the urethra. This is as a result of distal
meatal stenosis or ischemia of the ventral skin. The manage-
ment depends on the size of meatus and concomitant stricture.
In case meatus is narrow, there is urethral stricture, the urethra
is incised ventrally till a good caliber urethra is seen. If the
width of urethra is more than 8 mm, then Asopa single-stage
dorsal inlay buccal graft augmentation urethroplasty is per-
formed. If the width is <8 mm, then the urethra is kept open
and our novel 2-stage approach is used to close the urethra.
If the urethra is normal caliber, then urethrocutaneous
fistula can be closed locally.
We use 3 approaches here:
1. If the fistula is more than 5 mm in width, peri-fistula inci-
sion is made (Figure 16). We use an ophthalmic scalpel as
it helps in fine dissection. The fistula tract is cored down
till the level of the underlying urethra. Excess fistula tract
is excised, and polydioxanone is used to close the fistula
(Figure 17). Second-layer closure is done with Dartos
tissue. The overlying ventral skin is closed (Figure 18).
We usually keep the catheter for 2 weeks. We have done
this in 31 patients, which include 5 of our own fistulas.
All except 1 were successful.
2. If the fistula is narrow, after dissection a suture is passed
through the fistula. A small Mosquito forceps is passed
through the glans and brought out through the fistula.
It grabs the suture and pulls it inside the urethra. This
helps in inverting the fistula tract. The direction of the
fistula tract is now toward the meatus, and catheter can be
removed early. We have used this technique in 14 patients
and none required revision.
Figure 17 Coring the stula tract till the underlying urethra.
Figure 16 Peri-stula incision in a case of urethrocutaneous stula after hypospadias
repair.
Figure 18 Closure of urethrocutaneous stula.

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3. Occasionally, when fistula is large and meatus normal
we insert a small graft as dorsal inlay through the fistula
tract and tubularize the urethra. We have done this in 7
patients, and this has worked well.
Chordee correction
Chordee in hypospadias is usually due to scarred tissue, short
ventral urethra, and disproportionate length of the corporal
tissues.
Occasionally, the chordee is corrected by skin dissection
or transecting the urethral plate. Majority of the times, there
is corporal disproportion which needs to be addressed.
There are 2 options possible: to make the long side short,
to make the short side long.
Penile length in hypospadias is precious. Hence, we defer
from using penile plication technique for chordee correction.
However, if needed, it can be done using the Lue multiple
dot technique.
For lengthening the short side, we prefer making several
transverse corporotomies, which usually lead to correction.
If grafting is needed for chordee correction,then single stage
urethroplasty is not recommended. Chordee assessment and
correction is done in each individual case.
Discussion
Hypospadias cripple should be managed in specialized high-
volume centers. Having multiple surgeries makes each further
surgical procedure challenging. Usually, hypospadias cripple
merit 2-staged urethroplasty.
Traditionally 2-staged urethroplasty involves the appli-
cation of buccal mucosa in the first stage for subsequent
tubularization after 6 months. In our previous study, involving
data of 2 high-volume centers, we found that the use of oral
mucosa in the first stage showed a high incidence of scar-
ring and retraction, requiring multiple revisions, with high
surgeon and patient disappointment.11 Andrich and Mundy10
presented similar results of staged BMG. The contraction
rate of BMG in first stage was 4% in the UK as compared to
33% in Saudi Arabia. Overall, the contraction rate of BMG
when placed in the first stage varies between 20% and 38%
across all high-volume centers. This contraction rate leads
often to revision surgeries.
Oral mucosa is normally in a moist environment in the
oral cavity. Application as a staged graft exposes it to dry air
and friction with clothes. In our experience, marsupialization
of the urethra at the first stage without using any substitution
of oral graft appears to be more suitable for an anatomical
reconstruction at the second stage using an oral graft as dorsal
inlay.4 The oral mucosa is deeply closed inside the urethra,
which is a humid canal like the oral cavity, thus reinstating
the original environment of the oral mucosa. Based on these
reasons, we believed that our composite 2-stage urethroplasty
might improve the success rate of complex penile urethro-
plasty, avoiding the traps of scarring and retraction of the
transplanted oral graft.
Conclusion
Hypospadias complication is a challenging reconstructive
urology issue. There are no clear guidelines for the man-
agement of these types of patients. Traditionally, 2-stage
urethroplasty has been used with grafting in first stage
leading to revision and graft contraction. Our novel tech-
nique of using a graft in the second stage avoids the issue
of revision and graft contraction. Patients should be warned
of the need for additionally surgery. Mundy1 observed that
it takes a surgical lifetime to learn how to deal with all
these various problems of hypospadias, and even still it is
difficult to categorize satisfactorily the treatment plan for
such patients.
In this review, we have simplified the approach and advo-
cate dorsal inlay augmentation for successful management
of hypospadias cripple. The idea is still to individualize each
case, take down the previous repair, correct the abnormalities
and the urethral plate, and reconstruct the urethra and penis
to its normal shape and function.
Disclosure
The authors report no conflicts of interest in this work.
References
1. Mundy AR. Failed hypospadias repair presenting in adults. Eur Urol.
2006;49(5):774–776.
2. Craig JR, Wallis C, Brant WO, Hotaling JM, Myers JB. Management
of adults with prior failed hypospadias surgery. Transl Androl Urol.
2014;3(2):196–204
3. Hayes MC, Malone PS. The use of a dorsal buccal mucosal graft with
urethral plate incision (Snodgrass) for hypospadias salvage. BJU Int.
1999;83(4):508–509.
4. Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A. Dorsal
free graft urethroplasty for urethral stricture by ventral sagittal ure-
throtomy approach. Urology. 2001;58(5):657–659.
5. Bracka A. The role of two-stage repair in modern hypospadiology.
Indian J Urol. 2008;24(2):210–218.
6. Myers JB, McAninch JW, Erickson BA, Breyer BN. Treatment of
adults with complications from previous hypospadias surgery. J Urol.
2012;188(2):459–463.
7. Barbagli G, Perovic S, Djinovic R, Sansalone S, Lazzeri M. Retrospec-
tive descriptive analysis of 1,176 patients with failed hypospadias repair.
J Urol. 2010;183(1):207–211.
8. Leslie B, Lorenzo AJ, Figueroa V, et al. Critical outcome analysis of
staged buccal mucosa graft urethroplasty for prior failed hypospadias
repair in children. J Urol. 2011;185(3):1077–1082.

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9. Kozinn SI, Harty NJ, Zinman L, Buckley JC. Management of complex
anterior urethral strictures with multistage buccal mucosa graft recon-
struction. Urology. 2013;82(3):718–722.
10. Andrich DE, Mundy AR. Climate – a potential cause of primary graft fail-
ure in buccal mucosal graft urethroplasty. J Urol. 2009;181(Suppl 4):15.
11. Barbagli G, De Angelis M, Palminteri E, Lazzeri M. Failed hypospadias
repair presenting in adults. Eur Urol. 2006;49(5):887–894
12. Joshi PM, Barbagli G, Batra V, et al. A novel composite two-stage
urethroplasty for complex penile strictures: a multicenter experience.
Indian J Urol. 2017;33(2):155–158.
13. Asopa HS, Elhence IP, Atri SP, Bansal NK. One stage correction of
penile hypospadias using a foreskin tube. A preliminary report. Int
Surg. 1971;55(6):435–40.