Graft substances, such as skin and bladder mucosa, have been previously used for urethral replacement when local epithelial tissue was not available. However, these substances have been associated with meatal prolapse, stricture and fistula formation. We have used buccal mucosa as a tissue for urethral substitution in these situations during the last 8 years. We review our clinical experience in 18 urethral reconstructions performed for urethral replacement in 4 cases of exstrophy/epispadias, 12 complex hypospadias repairs and 2 cases of complex bulbar urethral strictures. There have been 5 cases of meatal stenosis (2 requiring operative revision) but none of meatal eversion. There has also been 1 urethrocutaneous fistula and 1 mid graft stricture. Mean followup was 27 months and minimum followup was 6 months. Histological examination of the buccal mucosal graft compared to grafts of skin showed that the full thickness of the dermis or lamina propria is thinnest while the native vascular supply is greatest in the buccal mucosa. These 2 factors are associated with improved graft take and may explain the encouraging clinical results.