Dartos Flap Research Articles

Results of urethral plate preservation and use of vascular dartos flap in hypospadias repair

Background: Lower complication rates are observed if urethral plate (UP) is preserved and utilized for reparative surgery of hypospadias.Aim: This study aims to analyze our results of hypospadias repair by UP preservation, and using vascular dartos flap as interposition flap.Materials and Methods: prospective, cohort study of operated cases of hypospadias over 4.5 years' period. Data including age, diagnosis, preoperative testosterone administration, operation, postoperative complications, and assessment of outcome using hypospadias objective scoring evaluation (HOSE) system were collected. We preserved UP as far as possible, for urethral tube construction. We applied meatal advancement and glanuloplasty incorporated (MAGPI) for glanular/coronal hypospadias and tubularized incised plate urethroplasty (TIPU) (Snodgrass) for most other cases. Single dorsal vascular dartos-flap was transposed ventrally as interposition flap in TIPU. Single transurethral catheter 6F/8F size was employed as urethral stent as well as for bladder drainage. At the first review at 2 weeks after getting discharged, all patients underwent urethral calibration and first HOSE-score assessment. Maximum HOSE-score was 16 points and minimum 5.Results: A total of 111 patients with mean (range) age of 34.69 m (11 m– 123 m) were studied. TIPU (n = 49), MAGPI (n = 44), and others (n = 18) were the operations. There were 10 permanent complications; 9 following TIPU (7 (14.3%) single urethrocutaneous fistula (UCF), 1 torsion penis, 1 glans-dehiscence), and 1 following MAGPI (glans-dehiscence). Mean follow-up period was 15 m (range = 3–36 m). HOSE score ≥14 was achieved in 106 (95.5%) cases.Conclusion: The excellent result of MAGPI in our series is due to strict case selection and technical precision. UCF rate of 14.3% in TIPU can be due to the unselected nature of our cases which included small glans diameter and unfavorable UP characteristics.

Comparison of dartos flap and dartos flap plus spongioplasty to prevent fistula in tubularized incised plate urethroplasty

Introduction: Hypospadias is one of the most common congenital anomalies and more than 300 operation techniques have been described for primary hypospadias. The complication rate varies with the complexity of the repair and the surgeon’s experience level. To decrease fistula rate, an additional tissue cover after neourethra reconstruction has been described using various tissues. This technique of spongioplasty with dartos flap interposition allows a better quality of the intermediate layer, with the object of preventing fistula. Aims and Objectives: The aim of our study is to evaluate the role of paraurethral spongial tissue plus dartos flap using an additional tissue cover to prevent fistula formation in patients who underwent urethroplasty with the Snodgrass technique. Materials and Methods: It’s a prospective study, performed on 60 patients aged 15 months to 144 months who underwent mid penile and distal hypospadias repair using the Snodgrass technique. The patients were assigned to one of the two groups. In Group I (30 patients), neourethra was covered with dartos flap, and in Group II (30 patients), the neourethra was covered with dartos flap plus spongioplasty. Results: Urethral fistula were encountered in twelve cases (40%) in Group I, and five cases 16.7%) in Group II (p value 0.045). Conclusions: Considering the results of this study, approximation of the corpus spongiosum along with dartos flap as an intermediate layer in urethral coverage as part of Snodgrass technique reduces the rate of fistula formation. This procedure can be applied easily and effectively to prevent the formation of fistula. Journal of Paediatric Surgeons of Bangladesh (2017) Vol. 8 (1): 5-10

CR03 - Autologous PRP covering urethroplasty versus dartos flap in distal hypospadias repair, a prospective randomized study

CR03 - Autologous PRP covering urethroplasty versus dartos flap in distal hypospadias repair, a prospective randomized study

Median raphe deviation, association with hypospadias and clinical significance: A case report and literature review

Here, we present a case of hypospadias and median raphe deviation with literature review. A 4-yearold patient presented with subcoronal hypospadias and treated by using tubularized incised plate urethroplasty technique. Additionally, a longitudinal dorsal dartos flap was harvested and transposed to the ventral side by the buttonhole maneuver. The ventral view of the patient penis showed a 15 degree deviation to the right side of the center.

ONE STAGE CORRECTION OF CONGENITAL COMPLEX PENILE CURVATURE BY COMBINED MODIFIED NESBIT'S PROCEDURE WITH DORSAL DARTOS FLAP

Background: Congenital complex penile curvature (CCPC) is a rare deformity that arises from asymmetry of the corpora cavernosa. Congenital complex penile curvature has two abnormality components: torsion and curvature of the penis either ventral or dorsal. Objectives: Evaluation of one stage correction of CCPC by combination of modified Nesbit's procedure with dorsal dartos flap. Patients and Methods: This prospective study was conducted at Al-Azhar University Hospital in Damietta. Twenty eight patients with CCPC were evaluated and corrected during the period from October 2014 to September 2017. Their mean age was 5.5±2.1years (range 2–9.5 y). The direction of mal-rotation was anticlockwise in 23 patients and clockwise in 5 patients. Fifteen cases have ventral curvature; 8cases have dorsal curvature, while 5 cases have lateral curvature. All cases were treated firstly by modified Nesbit's procedure for correction of chordee, and then dorsal dartos flap was used for correction of penile mal-rotation in one stage. Results: All patients were corrected with high success rate. There were no more than 10° of residual mal-rotation or binding in all patients. One patient (3.57%) had penile hematoma that treated conservatively. All patients and their parents were satisfied with wonderful cosmetic and functional outcomes with no recurrent mal-rotation or binding. All cases were followed up for a mean follow up period of 9 ± 1.7 months (range 6 - 12 m.). Conclusion: Congenital complex penile curvature can be treated in one-stage surgery with excellent cosmetic and functional outcomes by combination of modified Nesbit's procedure with dorsal dartos flap.

Use of fibrin sealant and tunica vaginalis flap in the repair of urethro-cutaneous fistulas: experience in a tertiary care centre

Background: Urethro-cutaneous (UC) fistulas are one of the most common complications after hypospadias surgery. To repair a UC fistula, an experienced surgeon with vast knowledge in the field of hypospadias is essential. Various techniques of UC fistula repair have been described. We share our experience in the use of fibrin sealant and tunica vaginalis flap as intermediate cover in UC fistula repairs.Methods: Our objective was to evaluate the efficacy of fibrin sealant and tunica vaginalis flap in urethro-cutaneous fistula repair in those patients where dartos flap is not available. Total 40 patients were retrospectively evaluated and segregated into the fibrin sealant group and the tunica vaginalis flap group. All repairs had been done by the same surgeon with 6-0 polyglactin suture at least 6 months from the primary repair. The re-fistulation rate was noted in both the groups.Results: Re-fistulation rate was 20% for tunica vaginalis flap and 70% for fibrin sealant. The general re-fistulation rate with the use of dartos flap is 20-30% at our institute.Conclusions: We concluded that tunica vaginalis flap as intermediate cover gives good results in urethro-cutaneous fistula repair.

Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience

Fistulas are a common complication of hypospadias surgery; they are more frequent after mid-shaft and posterior hypospadias repair. Surgical treatment of fistula still remains challenging with a significant failure rate. The basic principle is to add layers between skin and neourethra in order to decrease the incidence of recurrent urethrocutaneous fistula (UCF). We report our experience of UCF repair using a vascularized tunica vaginalis flap (TVF) after posterior and mid-shaft hypospadias surgery. A retrospective review of all patients operated on using TVF for UCF in our institution between December 2005 and July 2017 was performed. Among 36 cases, TVF was used at a first attempt in 22 patients; 14 children had a prior attempt to close the fistula, and four of them had two surgeries before TVF repair. UCF was respectively penoscrotal (n=3, 8%), posterior (n=19, 53%), midshaft (n=9, 25%) and anterior (n=5, 14%). The size of the fistula was more than 5mm in 26 patients. The UCF was treated successfully in every case after one single procedure. In the three children with two fistulas, both fistulas were successfully treated by the same TVF. After an average follow-up time of 45 months there was no recurrence of the initial UCF. In four cases of undescended testis, it was possible to dissect the flap through an inguinal incision and perform an orchydopexy in the same time. One patient presented a testicular atrophy after undescended testis surgery. Area review of published series shows excellent results in UCF repair including recurrent fistula (Table). TVF can aspire to some advantages with regard to a dartos flap (DF). First of all, a nearly 2.5-fold lower incidence of fistula after fistula repair with TVF than with DF (5.1% vs. 12.2%) has been shown. Secondly, TVF allows treating multiple fistulas, and can also be brought to the anterior part of the penis until the balano preputial furrow, allowing curing anterior fistula. Furthermore, it doesn't lead to aesthetic complications such as penile rotation or distal skin necrosis, which can occur during DF procedures. TVF is a simple and reproductive technique for UCF repair, with a high success rate. The risk of testicular atrophy has to be considered in case of associated undescended testis surgery, and careful attention must be given to the TVF dissection. This technique should be considered as first choice treatment for any UCF.

Outcome of standard tabularized incised plate urethroplasty repair using dartos flap and tunica vaginalis flap in of hypospadias cases

Background: Hypospadias, with prevalence of 1 per 300 live births, is a congenital malformation caused by incomplete fusion of urethral folds, in which the meatal orifice opens on the inferior surface of the penis. The commonest complication of hypospadias surgery is fistula formation which requires re-operation. Several techniques of providing vascularised soft tissue cover to neourethra have been described. They include de-epithelized skin, corpus spongiosum, dartos fascia and tunica vaginalis. The purpose of our study was to compare outcomes of standard tubularised incised plate urethroplasty (TIP) repair using dartos flap and TVF in of hypospadias cases.Methods: This study was carried out in the Department of Surgery (Paediatric Surgery Division) of Pt. JNM Medical College and associated Dr. BRAM Hospital, Raipur in patients diagnosed to had distal, mid penile and proximal penile type of hypospadias. The study was carried out during the period from February 2016 to September 2017. Total no of cases studied was 55. All admitted patients for primary Snodgrass repair were randomized into two groups by Simple Random method to avoid selection bias. Group A of 27 patients were prospectively selected for repair using TVF for soft tissue cover. Group B of 28 Patients, comparable in age and type of hypospadias, who underwent TIP repair using dartos flap as soft tissue cover. Descriptive statistics were employed to characterize the data.Results: Patients were from 1 year to 13 years of age at time of surgery for hypospadias. Mean age being 4.69+3.15. There was almost equal number of patients in both groups of flap. Both groups were comparable in terms of age and type of hypospadias. Overall, dartos flap group had significantly higher rate of urethrocutaneous fistula formation than tunica vaginalis flap. In TVF group only one patient (3.7%) developed skin necrosis while in Dartos group 5 patients (17.86%) developed skin necrosis. Both TVF group and Dartos group had one patient with residual torsion.Conclusions: In present study we have noted higher rate of fistula formation and skin necrosis in dartos flap group as compared to tunica vaginalis. Tunica vaginalis flap definitely have an edge over preputial dartos flap and we would recommend its use as waterproofing second layer in hypospadias cases.

Outcome of Snodgrass urethroplasty by modifying tubularization and dartos layer in Erbil

Background and objective: Snodgrass first described the tubularized, incised plate (TIP) urethroplasty for distal hypospadias repair in 1994. This study aimed to find out whether there is any difference in the fistula rate with single versus double layer tubularization, and the use of ventral versus dorsal dartos layer. Methods: Between May 2009 and July 2014, tubularized incised plate urethroplasty was performed for correction of hypospadias in Erbil for 112 patients with age ranging from 1-32 years. Five patients were excluded from the study because of lack of adequate follow up. Data were analyzed using the statistical package for the social sciences. Results: Urethral fistula occurred in seven cases (6.5%).The use of an additional reinforcing second layer for the tubularization had a significant effect on decreasing the fistula formation (P = 0.05). The fistula rate was slightly lower with dorsal dartos flap (5.4%) than ventral dartos flap (7.8%). Conclusion: The urethral plate, when dissected, should be thick enough to allow for tubularizationin two layers. Both dorsal and ventral dartos flaps are effective in preventing urethral fistula.

Lingual mucosal graft two-stage Bracka technique for redo hypospadias repair

ObjectivesTo report our initial experience in redo hypospadias repair with a lingual mucosal graft (LMG) using a two-stage Bracka technique. Patients and methodsThis study was prospectively conducted and included 26 patients with hypospadias with failed previous repairs. All the patients had a LMG using a two-stage Bracka technique. In the first stage, the harvested LMG, from the ventro-lateral surface of the tongue, was implanted in a well-prepared vascularised bed in the ventral aspect of the penis. After 6months, tubularisation of the well-taken graft was completed. Tunica vaginalis or a dartos flap was used as second-layer coverage of the neourethra. Success was defined as acceptable aesthetic and functional outcomes without any additional surgical interventions. ResultsThe mean (SD) patient age was 5.15 (1.6)years. The mean (SD) LMG length was 3.82 (0.9)cm and the width was 1.5 (0.5)cm. The mean (SD) number of previous repairs was 2.76 (1.1). The mean (SD) follow-up was 12 (2)months. Donor-site complications included: pain in all patients, with a pain score of >3 on the visual analogue pain scale (0–10) in 10 (38%); and speech problems in 19 (73%). First-stage complications were graft loss (n=2) and contracture (n=1). The second stage was completed in 23 patients resulting in the following significant complications: meatal stenosis plus fistula (n=2), breakdown (n=1). Successful hypospadias repair was achieved in 77% (20/26) of the patients. ConclusionLingual mucosa is a reliable and versatile graft material in the armamentarium of two-stage Bracka hypospadias repair with the merits of easy harvesting and minor donor-site complications.

The Fisher Technique for Correction of Penile Torsion in Children: Who Are the Candidates?

To report our experience in the treatment of penile torsion with a special reference to the Fisher technique. We reviewed 30 cases of congenital penile torsion treated from 2009 to 2015 in a single center. Sixteen patients presented a moderate rotation of 45°-90° and 14 had a severe rotation with an angle greater than 90°. Chordee was present in 17 cases and distal glanular hypospadias in 15 cases. Median age at surgery was 10 months. In 14 cases, degloving along with skin realignment, alone, allowed correction of the torsion. In 16 cases, the Dartos flap (Fisher technique) was used. Out of the 30 patients, 29 had a good result, with a complete correction of the torsion. Only 1 patient had a residual torsion of 30°. Complications were minor and consisted of skin excess in 11 patients; 1 single case needed to be reoperated for that skin complication. The need for the Dartos flap procedure was significantly correlated to the degree of torsion (P = .001): it was used in 4 out of 16 patients (25%) with a torsion of less than 90°, and in 12 out of 14 patients (86%) with a torsion of 90° or more. Most of penile rotations less than 90° can be corrected by skin degloving and realignment. The Fisher technique is a simple and safe procedure for correction of persistent rotation after skin degloving; such cases have usually a penile rotation greater than 90°.

Tubularized incised plate urethroplasty with dorsal dartos flap cover and asymmetrical prepucial flaps: A valuable option in hypospadias repair?

Background: Snodgrass or tabularized incised plate (TIP) repair is the most common technique for distal penile hypospadias cases. However different variations of this procedure have been tried in attempts to reduce the complications. The variations reported are for the cover of the neourethra and creations of prepucial flaps In this study the authors report another variation devised by them in which there is dorsal prepuce is divided into two unequal parts. Patients and Methods: We have managed 35 patients of distal hypospadias without chordee with hypospadias were managed wherein the neourethra was created by incised urethral plate and it was covered by a dorsal dartos flap taken from 1/3rd portion of asymmetrically divided prepuce after discarding its outer layer and rest 2/3rd of the two layered prepuce used to cover the penile shaft. Results: Three (8.57 %) patients developed a fistula at the coronal level, of which one closed spontaneously within three months of repair while two healed after a surgical repair. There was retraction of the meatus in one patient. All the remaining patients had acceptable cosmetic and functional outcome. Conclusion: The tubularized incised plate repair with suggested modification of asymmetrical division of dorsal prepuce and use of dartos flap to cover the neourethrais a good option in select patients of hypospadias without chordee. The advantage is that there is no overlapping of suture lines of the neourethra and skin and it takes care of glanular tilt. However the cosmesis is not as good as in cases where there is symmetrical division of prepucial flaps.

EVALUATION OF THE USE OF DORSAL DARTOS FLAP FOR THE PREVENTION OF FISTULA AFTER SNODGRASS REPAIR OF HYPOSPADIAS

The Snodgrass technique or the tubularized incised plate (TIP) repair is considered as excellent option for treatment of distal and mid-shaft hypospadias. Urethro-cutaneous fistula remains the most frustrating complication of hypospadias repair. After performing a tubularized incised plate (TIP) repair, the incidence of fistulae is reported to be up to 17% of cases. This study aimed to evaluate the use of dorsal dartos flap for the prevention of fistula formation after Snodgrass repair for distal hypospadias. The current study included 35 patients aged 2-6 years during the period between February 2013 to January 2016. All the patients had distal hypospadias and underwent Snodgrass or TIP repair. The neo-urethra was covered by dorsal preputial interpositional flap transposed ventrally via a button hole maneuver as a method to prevent fistula formation. Patients were followed up and their complications were assessed based on the patients’ medical records. The procedure was completed successfully in all patients, with no intraoperative complications. All patients had good functional results with straight penis and vertical slit shaped meatus at the tip of the glans. Thirty four (97.14%) patients had no evidence of fistula development. One patient only (2.8%) developed fistula. Meatal stenosis occurred in 3 patients (8.5%). In conclusion, the neo-urethral covering with well-vascularized dartos flap, harvested dorsally and button holed at its base for ventral transposition, represents a good choice for fistula prevention after Snodgrass repair.

Tubularized parameatal based dartos-spongiosum flap urethroplasty in distal hypospadias with flat glans, shallow meatal groove, and severe glans tilt

Objective: To report the technique and results of single stage tubularized parameatal based dartos-spongiosum flap urethroplasty for distal hypospadias with flat glans, shallow meatal groove, and severe glans tilt. Materials and Methods: The study was conducted over a period of 2-year from October 2013 to October 2015, and 19 patients with distal hypospadias were included in the study with flat glans, poor urethral groove, and severe glans tilt, who otherwise would have been subjected to transection of urethral plate and a two-stage procedure. In this technique, bilateral flaps were fashioned along the preputial edge beginning from the hypospadiac meatus with intact dartos, keeping the base of the flaps attached to the bifurcated spongiosum. The urethral plate was transected. Glans was split wide open. Bilateral flaps joined at ventral midline creating new urethral plate which was tubularized with the creation of slit like wide meatus at the tip of glans. Neourethral coverage was provided with double dartos flap. Complications and aesthetic appearance on a score of 1-10 were outcome measures. Results: There was no urethral stricture, residual chordee, penile rotation, or asymmetrical penis. The average aesthetic score was 8.5. Meatus was at the tip of glans with adequate caliber in all patients. Two (10.5%) out of 19 patients developed subcoronal fistula that required surgical closure. Conclusion: Tubularized parameatal-based dartos-spongiosum flap urethroplasty is viable and easy to reproduce option for management of a specific group of patients with distal hypospadias (with flat glans, poor urethral plate, and glans tilt) and is associated with very low complication rate.

Grafted tubularised incised-plate urethroplasty: An objective assessment of outcome with lessons learnt from surgical experience with 263 cases

ObjectiveSnodgrass urethroplasty remains the preferred technique in primary distal hypospadias but development of meatal stenosis often limits distal extension of the midline incision of the urethral plate (MIUP), which remains a limiting factor in reconstructing an apical neomeatus (NM). We here-in assess the cosmetic and functional outcome with distal extension of the MIUP in grafted tubularised incised-plate urethroplasty (G-TIP) repair. Patients and methodsThis prospective study included the surgical experience of 263 cases of primary hypospadias operated upon between 2012 and 2015. The G-TIP technique included standard steps of Snodgrass urethroplasty, including degloving and harvesting of glans wings, followed by MIUP that was extended distally beyond the margins of the urethral plate (UP) into the glans. The incised bed was grafted with a free preputial skin graft and fixed to the bed with polydioxanone 7-0 suture. The UP was tubularised and the suture line reinforced with a Dartos flap. The urethral catheter was removed at 7–10days after the repair and the outcome was assessed at follow-up using the Hypospadias Objective Scoring Evaluation (HOSE) system. ResultsAn apical NM was achieved in 96% of the patients with a 3.7% incidence of urethrocutaneous fistula. The presence of suture tracks and graft at the margins of the NM were seen in the initial 4% and 5% of cases, respectively. Acceptable cosmetic results, with objective HOSE scores of >14, were achieved in 96% of cases. ConclusionThe G-TIP repair is a straightforward and feasible technique facilitating reconstruction of an apical NM, with an optimum outcome based on HOSE scoring. However, multicentre data are needed for undertaking comparative analysis and to assess the universal applicability of this technique in primary hypospadias.

Is the double cross flap technique the panacea for avoiding fistula formation in hypospadias surgery?

Objective The aim of this study was to analyze retrospectively the 9-year experience of a single institution in the use of the double cross flap technique to interpose a double dartos flap to protect the neourethra with the aim of preventing fistula formation. Patients and methods Between October 2005 and September 2014 a total of 127 children with distal and midshaft primary hypospadias underwent tubularized incised plate urethroplasty by means of a double dartos flap obtained with a double cross flap to protect the neourethra. A Foley catheter was left in situ for 7 days. Success was defined as no incidence of complications requiring reintervention, along with good cosmetic result. A questionnaire was administered to estimate parental satisfaction. Parents were asked to evaluate the cosmetic appearance of the penis as good, acceptable, bad, or indifferent. Results The patient age at the time of surgery ranged from 12 months to 10 years (median 39 months). Three patients exhibited fistula at follow-up (2.3%). In two patients a glandular dehiscence of the urethroplasty occurred (1.5%). Mild stenosis of the neomeatus occurred in three patients (2.3%). No penile iatrogenic rotation occurred. A ‘good’ cosmetic result was reported by 68.5% of parents, acceptable by 22.8%, bad by 3.9% and indifferent by 4.7% of parents as per the parental questionnaire. Conclusion The double cross flap technique is not the panacea to prevent fistula formation in hypospadias surgery. Nevertheless, it offers an unquestionable advantage in terms of avoidance of fistula formation. The experience and skills of the surgeon performing urethroplasty remain the mainstay for best results.

Vascularized dorsal dartos flap to prevent fistula in tubularized incised plate urethroplasty for primary distal and mid shaft hypospadias

The aim of the present study was to evaluate the importance of neourethral covering using vascularized dorsal flap for preventing fistula in Tabularized incised plate (TIP) urethroplasty. The study included 52 children (aged 2-10 years) who had hypospadias repaired including 44 with distal and 8 with mid shaft hypospadias. In all children, a standard tabularized incised plate urethroplasty was followed by reconstruction of new surrounding urethral tissue. A longitudinal dartos flap was harvested from excessive dorsal preputial and penile hypospadiac skin and transposed to ventral side by a buttonhole maneuver. It was sutured to the glans wings and the neomeatus and to the corpora covernosa over the neo-urethra. Thus the new urethra was completely covered with well-vascularzed subcutaneous tissue. At a mean follow-up of 18 months, the result was successful with no fistula or urethral stenosis, except 2 of the mid penile hypospadias. All patients had good functional and cosmetic results with straight penis and vertical slit shaped meatus at the tip of the penis. The 2 patients developed tiny fistula, which were closed spontaneously after meatal dilatation. In conclusion, urethral covering should be part of TIP urethroplasty. A dorsal well-vascularized dartos flap, button holed ventrally is a good choice for preventing fistula for distal and mid shaft hypospadias.

Surgical Repair of Mid-shaft Hypospadias Using a Transverse Preputial Island Flap and Pedicled Dartos Flap Around Urethral Orifice.

To evaluate the effects, particularly the incidence of anastomotic fistula, of a pedicled dartos flap around the urethral orifice in the treatment of urethroplasty of mid-shaft hypospadias. A total of 46 cases of congenital mid-shaft hypospadias were included in this study. The patients ranged in age from 0.7 to 25.4years and the average was 5.8years. The patients received penis chordee correction. A transverse preputial island flap was developed for urethral reconstruction. The proximal dartos of the urethral orifice was used to develop a pedicled dartos flap, which was transposed to cover and strengthen neourethral anastomosis. The ventral penile skin defect was repaired by another flap. The 46 patients were examined during follow-up visits for 6months to 3years. An anastomotic fistula was observed in one case (2.2%). Scar healing without fistula was observed in another patient due to poor blood supply to part of the ventral penile skin. No other incidences of fistula, urethral rupture, flap necrosis, wound infections, urinary tract (meatal) stenosis, or urethral diverticulum were observed in the patients. A pedicled dartos flap around the urethral orifice can take advantage of well-vascularized local tissue to add a protective layer to the proximal aspect of the neourethral anastomosis for reducing the incidence of anastomotic fistula in mid-shaft hypospadias repair using a transverse preputial island flap. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Penile degloving and dorsal dartos flap rotation approach for the management of isolated penile torsion.

Penile torsion is a counterclockwise rotational anomaly of the penile shaft or glans. We aimed to evaluate the outcomes of penile degloving and dorsal dartos flap rotation used for the repair of isolated penil torsion. During evaluation of the patients admitted to our polyclinic for circumcision between January 2013-December 2014, 5 cases of isolated penile torsion were determined. Following the circumcision procedure performed with bipolar cautery, patients undergoing penile degloving were checked whether penile torsion was relieved or not. In case of insufficient improvement, torsion was corrected with application of dorsal dartos flap. Penile torsion was corrected with dartos flap in 2, and penile degloving in 3 cases. The mean age of the patients was 5.6 years (4-7), and the mean operative time 12 minutes (7-20), respectively. The mean operation time was 17.5 (15-20) minutes and 8.3 (7-10) minutes in the dorsal dartos flap and penile degloving groups, respectively. The preoperative mean degree of penile torsion was 50° (30°-70°). The mean degree of torsion was 65° and 40° in the dorsal dartos and penile degloving groups, respectively. During the postoperative follow up, 1 case of residual torsion (<10°) was observed in the dorsal dartos flap group. Residual torsion was not observed in other patients. Exploration for isolated cases of penile torsion during the circumcision procedure should not be overlooked. Successful results can be obtained with penile degloving and dartos flap rotation in cases with low and moderate torsion.

A modified method of dartos flap coverage of neourethra in the repair of hypospadias and urethrocutaneous fistula

Background: Hypospadias is a common congenital anomaly and its repair has been characterised by constant evolution. Urethrocutaneous fistula (UCF) formation remained the most common complication of hypospadias repair the occurrence of which precludes one of the goals of hypospadias surgery. Aim: To assess the modification of interposing layer of dartos flap coverage in hypospadias and UCF repairs in the prevention of UCF. Materials and Methods: In this retrospective review, 11 cases of hypospadias and UCF were repaired with our modification of dartos flap interposition from January 2010 to December 2013. The medical records were retrospectively reviewed to determine the clinical presentation, the age at surgery, the position of meatus and UCF, history of previous repair and the surgical outcomes. Results: The ages range from 1 to 25 years with a mean age of 8.36 years. Eight patients had repair of hypospadias, two patients had repair of post-circumcision UCF and a patient had repair of congenital UCF (CUCF). All the patients with hypospadias had tabularised incised plate urethroplasty except two of them who had staged repair with buccal mucosa graft reconstruction. Those with post-circumcision UCF and CUCF had incised plate plus simple closure. All the patients had our modified interposing layer of dartos flap incorporated. The outcomes were satisfactory in nine patients, one patient had glanular dehiscence and another one had complete dehiscence of the wound. Conclusion: This modification of dartos flap interposition can be added to the various surgical armamentariums in the management of these patients.