In the first stage the penis was straightened, if required the urethral plate is replaced with graft of any genital or extragenital origin.

  • The treatment starts by removing fibrous tissue which is on ventral aspect of the penis. In secondary cases, any poor quality distal urethra was removed too, whereas the urethral plate is first spared in primary cases. Glans wings were developed by performing a deep cut in the midline and lifting glanular tissue off the top of the penile corpora laterally.

  • An erection test was done at the end of this step. If curvature persists, then generally perform a dorsal plication. Then, they completely de-glove the penis, detach the dorsal neurovascular bundle and plicate the tunica albuginea in the midline by creating multiple small transversal cut in the portion we plicate.

  • This is the point at which in primary cases, it was essential to need to decide as to transect the urethral plate or to conserve it.

  • Next a proximal urethrostomy is done. If the meatus is perineal, we generally try to progress it to the level of the penoscrotal junction. The spatulated meatus was anchored to the corpora cavernosa and nearby skin.

  • The gap was formed in the ventral aspect of the penis that needs to be filled in the first stage generally with a free graft. The latter it can be of extragenital or genital origin. The main genital harvesting site is the prepuce.

  • The main extragenital harvesting site was instead the mouth. Oral mucosa graft can be harvested from the inner cheek or lower lip or from the tongue. It can be noted, however, that according to normal and established dental terminology, the term buccal mucosa refers to the oral mucosa lying the inner cheek of oral cavity. An alternative extragenital harvesting site is the retroauricular region.

  • The inner preputial layer whenever still accessible is in our opinion, the graft of choice, it is not obtainable in most redo cases, may be quite hypoplastic in some primary cases with severe hypospadias and must be avoided in all BXO cases.

  • The oral mucosa is thus the graft most commonly used in staged reconstructions. We generally wish to harvest the graft starting the inner cheek, as the mucosa is more solid and thick. The area to harvest must be outlined initially with mandatory detection of Stensen’s duct and then infiltrated with 1:100,000 epinephrine with bupivacaine. Infiltration make successive dissection easy in order to minimize the quantity of fat left on the under-surface and to avoid dissection into the muscles. We generally shut the donor site in the inner cheek by the help of intermittent reabsorbable sutures. Fibrin glue was used as an option. If the graft was harvested starting the lower lip, the donor site was always left open.

  • The under-surface of the graft is additional defatted by positioned the graft spread above a finger and remove the fat by sharp dissection with a scissor. Multiple passages in antibiotic solution are done.

  • The graft was then protected to the ventral aspect of the corpora. The perimeter is sewn initially and then multiple quilting stitches are done through the graft by multiple parallel rows to to reduce the complications of a hematoma and graft loss.

  • A catheter was placed from the urethrostomy and set with a glandular stitch. Folded petroleum jelly gauze was positioned in between the graft and catheter to keep the latter in place and to support its healing process. A compressive dressing was performed while others wish to use a tie-over dressing, comprises of a roll of petroleum jelly gauze held in that place by sutures all along the graft margins.

  • Postoperatively, bed rest was necessary for 3-5 days based on the level of the graft and the patient’s age. Parenteral, large spectrum antibiotic coverage is done for 3-5 days. The catheter is generally taken out after 5-7 days.