A supero-medial thigh flap for urethral reconstruction in epispadias and hypospadias

Abstract

A reliable axial flap from the adductor region has been used for many years to repair a series of urethral defects formerly regarded as difficult problems. In particular the flap has proved invaluable in the treatment of epispadias “cripples”. Suggestions are also made for correcting the reverse chordee deformity due to the shortage of skin on the dorsum which, if untreated, spoils the functional result. The use of a supero-medial thigh flap was reported by Hirshowitz et al. (1980, 1982) for repair of the scrotum and vulva. The same flap had been discovered independently in 1978 in this department and used for the repair of epispadias and hypospadias “cripples”. Its reliability was soon recognised and the presence of axial vessels from the medial femoral circumflex artery and vein were demonstrated by transillumination at the time of surgery and by study in the post-mortem room. Some patients with epispadias are referred at puberty with an unrepaired scarred penis and a reverse chordee deformity. The defect cannot be repaired with local tissue alone and the same difficulty is encountered with some hypospadias “cripples”. Occasionally untreated cases of perineal hypospadias are seen with a marked shortage of local tissue. In our experience scrotal flaps may fail to heal and orthodox groin flaps may have difficulty in reaching the target. Although the superomedial thigh flap will require at least two stages it is a reliable technique and it provides a generous amount of tissue with which to solve what may at first sight seem to be an insuperable problem. It is easy to underestimate the total tissue defect in these cases before correcting the chordee or reverse chordee deformity: for instance the repair of epispadias and ectopia vesicae in an adult may need flaps up to 20 cm in length (Fig. 1).