Skin graft for 2-stage treatment of severe hypospadias: back to the future?

Abstract

Despite the introduction of more refined surgical techniques, the optimal treatment of the most severe forms of hypospadias remains to be determined. Single stage procedures, whether with the use of flaps or grafts, have long been regarded as the best approach, although the complication rate is nonnegligible with all procedures. We report the use of a 2-stage repair with preputial graft interposition and subsequent tubularization of the urethral plate applied it to all severe cases of hypospadias with significant chordee or small glans. Both stages of the procedure were completed in 34 patients. Complications in 8 cases (23.5%) included 4 glans disruption in 4, coronal grove fistula in 2, urethral diverticulum in 1 and urethral stenosis due to balanitis xerotica obliterans in 1. Two pinhole fistulas also occurred which closed spontaneously. No complete disruptions or postoperative hematomas/bleeding was noted. Cosmetic and functional outcome after a minimum followup of 1 month was optimal in all cases with a normally located "slit" meatus and straight penile shaft. Although the controversy between use of grafts and flaps will probably continue forever, we believe that our 2-stage approach should be considered as a valid alternative for the most severe forms of hypospadias. Long-term results appear to outnumber the necessity of a learning curve for appropriate graft manipulation.