Failed Hypospadias Repair Research Articles

Clinical Outcome and Quality of Life Assessment in Patients Treated With Perineal Urethrostomy for Anterior Urethral Stricture Disease

We performed a quality of life assessment for patients treated with perineal urethrostomy for anterior urethral stricture disease. We retrospectively reviewed 173 patients (median age 55 years) who underwent perineal urethrostomy (from 1978 to 2007) as part of a plan for a staged urethroplasty repair for a complex anterior urethral stricture. The perineostomy was made using flap urethroplasty. The clinical outcome was considered a failure when postoperative instrumentation was needed. A questionnaire was used to evaluate patient quality of life and satisfaction. Stricture etiology was unknown in 50.3% of the cases, lichen sclerosus in 17.3%, catheter in 13.3%, instrumentation in 8.7%, failed hypospadias repair in 4.6%, trauma in 4.1% and infection in 1.7%. Stricture length was 1 to less than 2 cm in 1.2% of cases, 2 to less than 3 cm in 3.5%, 3 to less than 4 cm in 12.1%, 4 to less than 5 cm in 13.8%, 5 to less than 6 cm in 7.5%, greater than 6 cm in 4.1% and panurethral in 57.8%. Of 173 patients 91 (52.6%) underwent prior urethroplasty. Median followup length was 62 months (range 12 to 361). Of 173 cases 121 (70%) were successful and 52 (30%) were failures, requiring revision of the perineostomy. Of 173 patients 135 (78%) were satisfied with the results obtained with surgery, 33 (19.1%) were very satisfied, 127 (73.4%) with a median age of 57 years (range 23 to 85) refused to do the second stage of urethroplasty and 46 (26.6%) with a median age of 47.5 years (range 27 to 72) are currently on a waiting list for the second stage of urethroplasty. Perineostomy is a necessary procedure for patients with complex urethral pathology and satisfaction rates are high.

Staged Reconstruction of Long Segment Urethral Strictures in Men With Previous Pediatric Hypospadias Repair

Reconstruction of long segment urethral stricture disease in adults with a history of pediatric hypospadias repair remains complex secondary to poor urethral blood supply, extensive penile scarring and the need for significant amounts of graft or flap tissue. We describe our experience with staged urethroplasty in this cohort of men. A total of 15 males underwent staged urethroplasty for urethral stricture disease following previous hypospadias repair in childhood. All men underwent 2-stage repair with a minimum of 6 months separating each operation. Bulbar urethral stricture disease due to previous dilation was seen in 2 of the 15 men (14%). Graft sources included buccal mucosa in 12 cases, full-thickness hairless abdominal wall skin in 2, penile skin in 1 and posterior auricular tissue in 1. Median patient followup was 22 months (range 5 to 62) after stage 2 closure. Median patient age at presentation was 31 years (range 19 to 57). Mean stricture length was 8 cm (range 5 to 14) and mean graft area was 22 cm(2) (range 10 to 38). There was no clinical evidence of stricture recurrence, fistula or wound dehiscence at last followup in 13 of the 15 men (86%). Two men with a congenital hypoplastic glans were left with distal hypospadias. Minor voiding symptoms were described in 3 of the 15 men (21%) with resolution in all by 6 months postoperatively. We describe outcomes after staged reconstruction for extensive urethral stricture disease in men after previous pediatric hypospadias repair in childhood. At intermediate followup staged urethroplasty provided acceptable outcomes.

Preserved urethral plate urethroplasty for failed hypospadias repair: report of 249 cases

Preserved urethral plate urethroplasty for failed hypospadias repair: report of 249 cases

Long-Term Efficacy of Distal Penile Circular Fasciocutaneous Flaps for Single Stage Reconstruction of Complex Anterior Urethral Stricture Disease

We determined the overall efficacy and predictors of success of the distal penile circular fasciocutaneous flap in the management of complex anterior urethral stricture disease not due to lichen sclerosus. We performed a retrospective review of all patients undergoing reconstruction of complex anterior urethral strictures without lichen sclerosus repaired from 1985 to 2006. Primary and overall stricture-free survival curves were estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to identify univariate and multivariate predictors of flap success. A total of 124 patients met the inclusion and exclusion criteria. Median patient age was 48 years (range 16 to 83). Median followup was 7.3 years (range 1 month to 19.5 years). Median stricture length was 8.2 cm (range 0.5 to 24). At 1, 3, 5 and 10 years the overall estimated stricture-free survival rates were 95%, 89%, 84% and 79%, respectively. On multivariate analysis smoking (HR 4.0, 95% CI 1.2-12.9, p = 0.02), history of hypospadias repair (HR 4.4, 95% CI 1.3-14.6, p = 0.01) and stricture length 7 to 10 cm (HR 7.0, 95% CI 1.4-34.7, p = 0.02) were predictive of failure. Fasciocutaneous flap urethroplasty has good and durable success rates in the treatment of complex anterior urethral strictures. Predictors of failure included smoking, history of hypospadias repair and longer stricture length.

Lingual Mucosal Graft Urethroplasty for Anterior Urethral Reconstruction

ObjectiveEvaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. MethodsFrom January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. ResultsMean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8–100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. ConclusionsThe mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.

VID-05.07: Combined buccal mucosa graft and penile flap for urethral reconstruction in failed hypospadias repair

Hypospadias is one of the most common congenital deformities in the male urogenital system. Although there are more than 200 techniques for treating hypospadias, it is often difficult to repair severe forms using conventional methods. We present a method of combining buccal mucosa and fasciocutaneous penile flap for urethral reconstruction.

The Multistage Use of Buccal Mucosa Grafts for Complex Hypospadias: Histological Changes

We report our experience using buccal mucosa in the multistage repair of complex hypospadias, and the observed histological changes. We evaluated 31 patients (14 adults and 17 children). A total of 19 patients presented after failed hypospadias repair with deficient ventral skin, 5 presented with scrotal hypospadias and 7 presented with perineal hypospadias. Patients who had previously undergone hypospadias repair had 3 to 7 failed trials. Two stage buccal mucosa graft was performed using the Bracka technique. In the first stage residual fibrosis was released, the glans was split and the buccal mucosa graft was sutured to the ventral surface of the penis to form a future urethral plate. Second stage reconstruction was performed after 6 months with interposed scrotal dartos tissue. Buccal mucosa was histologically studied before grafting, and at 6 months after graft uptake and exposure to the air. Buccal mucosa free graft showed excellent uptake within 5 days in all cases. At 6 months the buccal mucosa was well vascularized and pliable. Minute fistulas occurred in 3 cases (9.7%), which were closed at a later stage. Histological analysis of buccal mucosa tissues before and after graft and prolonged exposure to the air (more than 6 months) was conducted. The buccal mucosa displayed epithelial hyperplasia with mild and focal keratinization. The lamina propria was slightly edematous and minimally infiltrated by mononuclear inflammatory cells. The lamina propria papillae were elongated, extending to 75% of the mucosal thickness compared to the normal buccal mucosa. The buccal mucosal graft displayed good vascularization, similar to that of the normal mucosa. Multistage repair using buccal mucosa is an excellent option for urethral reconstruction. It guarantees excellent graft uptake and good vasculature, which improves success. It also provides supple tissue for glanular and urethral reconstruction in cases of severe complex hypospadias.

Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients

To determine the key points for a successful redo hypospadias procedure using tubularized incised plate urethroplasty operation. A retrospective chart review of a cohort of 100 patients (Mean age: 4.5 years, range: 2-12) who had undergone a redo tubularized incised plate urethroplasty operation was performed. Fischer exact and Chi square tests were used for statistical analysis. The incidence of complications of tubularized incised plate urethroplasty reoperation after failed repairs of meatal advancement and glanuloplasty procedure (n: 14), meatal based flap (n: 36), and tubularized incised plate urethroplasty (n: 50) were 29% (n: 4), 22% (n: 8) and, 28% (n: 14) respectively (P > 0.05). The overall complication rate was 26% (n: 26). Eighteen patients (18%) had fistula, five had meatal stenosis (5%), two had dehiscence (2%) and one had neourethral stenosis (1%). Postoperatively, fistula was closed in 18 patients and 5 underwent meatoplasty. Two patients with dehiscence and one with neourethral stenosis underwent an unsuccessful third redo tubularized incised plate urethroplasty reoperation and they were candidates for a complex hypospadias repair (3%). The ultimate success rate of tubularized incised plate urethroplasty reoperation after treatment of complications was 97%. Tubularized incised plate urethroplasty is a safe and efficacious alternative procedure for hypospadias reoperations if the urethral plate has no scars and outcome is favourable if the first failed hypospadias repair is a meatal based flap procedure. The complication rate increases if the urethral plate has been previously incised in the midline and a redo third redo must be avoided.

Failed Hypospadias Repair Presenting in Adults

Failed Hypospadias Repair Presenting in Adults

TUBULARIZED INCISED PLATE URETHROPLASTY (SNODGRASS) FOR HYPOSPADIAS REOPERATION

TUBULARIZED INCISED PLATE URETHROPLASTY (SNODGRASS) FOR HYPOSPADIAS REOPERATION Hazim R Akal FICMS(Urol), Lecturer, Dept.of surgery, Medical College, Thiqar University Abstract Reoperation for failed hypospadias has been considered to be seriously bothersome because abundant penile skin doesn’t tend to remain for urethroplasty or for penile shaft skin coverage. in this study, the tubularization of incised urethral plate was employed for those who had no excessive penile skin after failure of hypospadias repair. Between June 2003 and February 2006, 18 boys, (4.5-18) years old, underwent tubularized Incised-Plate (TIP) for previously failed hypospadias repair. The hypospadias defects included 9 (50%) distal (coronal or subcoronal), 5 (27.5%) distal penile and 4 (22.2%) mid shaft defects (three of them have residual chordee),13 patients had one operation and 5 had two operation previously. all patients did not have foreskin because of the previous surgery. There was not apparent scarring of the plate. The operation was successful in eleven out of 13 (84.5%) patients who had undergo one operation before and 3 out of 5 (60%) of patients with 2 operation previously as well have sufficient outcome. Complication was observed in 4 patient. The absence of preputial skin in reoperative cases makes tubularized incised-plate urethroplasty the ideal operation. In addition, this procedure can give excellent functional and cosmetic results however the patients require revisional hypospadias surgery. The technique has few complications as well as proved success and versatility that continue to expand its applicability and popularity.

Anastomotic Fibrous Ring as Cause of Stricture Recurrence After Bulbar Onlay Graft Urethroplasty

We retrospectively reviewed patterns of failure after bulbar substitution urethroplasty. In particular we investigated the prevalence and location of anastomotic fibrous ring strictures occurring at the apical anastomoses between the graft and urethral plate after 3 types of onlay graft techniques. We reviewed the records of 107 patients who underwent bulbar urethroplasty between 1994 and 2004. Mean patient age was 44 years. Patients with lichen sclerosus, failed hypospadias repair or urethroplasty and panurethral strictures were excluded. A total of 45 patients underwent dorsal onlay skin graft urethroplasty, 50 underwent buccal mucosa onlay graft urethroplasty and 12 underwent augmented end-to-end urethroplasty. The clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 74 months (range 12 to 130). Of 107 cases 85 (80%) were successful and 22 (20%) failed. Failure in 12 patients (11%) involved the whole grafted area and in 10 (9%) it involved the anastomotic site, which was distal and proximal in 5 each. Urethrography, urethral ultrasound and urethroscopy were fundamental for determining the difference between full-length and focal extension of re-stricture. Failures were treated with multistage urethroplasty in 12 cases, urethrotomy in 7 and 1-stage urethroplasty in 3. Of the patients 16 had a satisfactory final outcome and 6 underwent definitive perineal urinary diversion. The prevalence and location of anastomotic ring strictures after bulbar urethroplasty were uniformly distributed in after 3 surgical techniques using skin or buccal mucosa. Further studies are necessary to clarify the etiology of these fibrous ring strictures.

Failed Hypospadias Repair Presenting in Adults

ObjectivesTo evaluate the results of one-stage and multistage urethroplasty in adults with complications following multiple failed hypospadias repairs. MethodsSixty adults underwent reconstructive surgery of the following complications after hypospadias repair: stricture (34), residual hypospadias (26), fistula (18), meatal stenosis (11), penile curvature (9), hair (4), diverticula (2), and stone (1). A total of 36% of the patients had one complication and 64% had two or more complications. Twenty-nine patients underwent one-stage repair with buccal or skin grafts or direct repair, and 31 underwent multistage repairs with buccal or skin grafts. ResultsMean follow-up was 33.8 mo. Of the 60 cases, 45 (75%) had a final successful outcome and 15 (25%) failed. One-stage repair provided 24 (82.7%) successes and 5 (17.3%) failures. Multistage repair provided 21 (67.7%) successes and 10 (32.3%) failures. Buccal mucosa grafts provided 81% of success in one-stage procedures and 82.3% in multistage procedures. Penile skin grafts provided 80% of success in one-stage procedures and 50% in multistage procedures. ConclusionsAdults with complications following childhood hypospadias repair are still a difficult population to treat with a high failure rate for reoperative surgery.

The midterm success rates of tubularized incised plate urethroplasty in reoperative patients with distal or midpenile hypospadias

To review the midterm results of tubularized incised plate (TIP) urethroplasty (Snodgrass method) in reoperative patients with distal or midpenile hypospadias. The results of TIP urethroplasty in 37 patients who had previously failed hypospadias repair were reviewed. Of the patients, 21 (56.8%) had coronal, 11 (29.7%) had subcoronal, and 5 (13.5%) had midpenile hypospadias. The mean age was 4.1 (2-16) years. Twenty-three patients had one operation and 14 patients had two operations previously. Of all the patients, 14 did not have a foreskin because of circumcision. The urethral plate had been disturbed in 6 patients, but there was not apparent scarring of the plate. Postoperative follow-up was 2.3 years with a range of 1.1-3.9 years. Genital examination, urethral calibration, and uroflowmetry were performed in control. Satisfaction of the families about the function and appearance of penis was also evaluated. Successful functional and cosmetic results were achieved in 29 patients (78.4%). All the families were happy with penile aesthetic appearance. The urethral plate seemed healthy at the operation in nine patients who had undergone TIP urethroplasty before and the outcomes were successful in eight of them. The operation was successful in 19/23 (82.6%) patients who had undergone one operation before and in 10/14 (71.4%) patients with two operations as well (P < 0.05). In addition, sufficient outcomes were obtained in also 11 of the 14 patients with circumcision. The success rate was higher in patients <5 years (P < 0.05). The rate was also higher during the recent period (2001-2003) since the experience we had increased (P < 0.05). TIP urethroplasty was unsatisfied in four of the six patients who had had disturbed urethral plate before and in five of eight patients who did not have sufficient amount of dartos tissue for flap to cover neourethra. Complication was observed in eight patients (21.6%): four had a pinpoint fistula, two had wound dehiscence, one had meatal stenosis, and one had mild meatal regression and a short neourethral stricture. All of these complications were repaired successfully at a later date. The mean hospital stay was 4.6 days. TIP urethroplasty provides good functional and cosmetic midterm outcomes in most of the reoperative patients with distal or midpenile hypospadias unless contraindicated by previous resection or gross scarring of the urethral plate. This procedure seems not to disturb the urethral plate and, therefore, it can be applied on reoperative patients who had undergone TIP urethroplasty before. It can also be used in a circumcised patient when there is a lack of foreskin.

Tubularized incised plate (TIP) in previously operated (redo) hypospadias

Objective We report our experience of using the tubularized incised plate (TIP) technique for repair of hypospadias in patients who had undergone one or more failed attempts at repair. Methods A total of 30 children (age range 2–10 years; mean 4.3 years) with hypospadias presented to our unit for redo hypospadias. The number of prior repairs was as follows: one in 17 patients, two in eight patients and three in five patients. The meatus was at the distal shaft in 19 cases, mid shaft in eight cases, and proximal shaft in three cases. Preoperatively 13 patients had fistulae, and none had residual chordee. The urethral plates were judged to be surgically altered in 11 patients and unaltered in 19 patients. The neourethra was then reconstructed using the Snodgrass TIP technique. Follow-up urethral calibration was performed to assess the results. All patients were discharged same day postoperatively. All patients were followed up at 1 week, 3 weeks, 6 weeks, 3 months, 6 months and 1 year. Patients were contacted in June/July 2005 and brought back for re-evaluation of the results. Results The cosmetic and functional results were satisfactory as judged by the parents. Overall complications were encountered in 7 patients (23%). Complications included six fistulae, five were associated with meatal stenosis and one with infection. Stand alone meatal stenosis occurred in three other cases of which only one required intervention. Fistula repair was successfully performed 6 months later in five patients with associated meatoplasty. One case had a revised repair. One case required meatotomy. Conclusion The TIP procedure is a viable option with satisfactory cosmetic and functional results for the correction of a previously failed hypospadias repair.

Salvage Mathieu urethroplasty: Reuse of local tissue in failed hypospadias repair

Objectives To report our experience with Mathieu urethroplasty for revision of hypospadias repairs. Mathieu perimeatal-based flap urethroplasty remains a popular technique more than seven decades after its description for single-stage hypospadias repair. The excellent results of primary distal hypospadias repair are well documented, but reports of the results using the technique as a salvage procedure are sparse. The reuse of local tissue may be hampered by the presence of scar tissue and reduced vascularity. Methods A total of 40 patients underwent salvage urethral reconstruction. Of the 40 patients, 34 (mean age 70 months, range 11 to 216) underwent salvage Mathieu urethroplasty. All patients underwent surgery at least 6 months after the previous surgery. One, two, and three or more prior procedures had been performed in 22, 6, and 6 patients, respectively. The mean follow-up period was 29 months (range 1 to 84). In 6 patients, local tissue was scarred and immobile, and they underwent the procedure using buccal mucosal grafts. Results Satisfactory functional and cosmetic results after the initial procedure were achieved in 25 patients (74%). Two patients underwent reoperation for repair of meatal stenosis, and 5 (15%) underwent simple repair of fistula without the need for urethral reconstruction. Two patients underwent reoperation at other medical centers and were lost to follow-up. Overall, cure was achieved in 32 (94%) of the 34 patients. Conclusions Mathieu urethroplasty is an efficient technique for salvage hypospadias repair. Patient selection is the key to successful repair. Despite the effects of previous surgery, local tissue of adequate quality to facilitate repair exists in most patients.

SPLIT ONLAY SKIN FLAP FOR THE SALVAGE HYPOSPADIAS REPAIR

Following failed hypospadias repair absence of the penile foreskin, a shortage of ventral skin and residual chordee may all contribute to poor long-term results. We describe a technique called the split onlay skin (SOS) flap that has improved our surgical outcomes in boys requiring salvage hypospadias repair. The SOS flap uses a transverse island of penile shaft skin that is mobilized on its vascular pedicle and rotated into position to the ventrum of the penis at the site of the urethral defect. The flap is transected transversely, and half of the flap is used as an onlay to repair the urethra and the other half is used for additional skin coverage where needed on the penile shaft. We treated 11 boys 30 to 124 months old (mean age 60.3 months) who had a mean of 2 previous failed hypospadias repairs. All 11 boys presented with complex combinations of urethrocutaneous fistulas, stricture or urethral diverticula. Of the 11 patients 6 (54.5%) had development of postoperative fistulas. Five of these fistulas were surgically closed with no further complications. One penoscrotal fistula closed spontaneously after 7 months. Mild chordee from contraction of the flap and a urethral diverticulum developed in 1 boy. At a mean followup of 24.5 months all patients, including those who underwent closure of the secondary fistula, were voiding well with excellent appearance. In cases where little local tissue is present the SOS flap procedure is an excellent way to transfer healthy dorsal tissue to the ventrum for an onlay salvage urethroplasty while providing additional coverage of the urethral defect and a tension-free skin closure. Despite the high fistula rate we encountered following the initial SOS procedure, we endorse this technique because the transferred dartos provides additional tissue, which facilitates subsequent fistula repair. These boys can achieve a successful cosmetic result without incorporation of scrotal tissue or a free graft, which we believe leads to more predictable results.

322: One-Stage and Multi-Stage Penile Urethroplasty in 60 Adult Patients after Failed Hypospadias Repair: Comparison Between Penile Skin and Buccal Mucosa Grafts

322: One-Stage and Multi-Stage Penile Urethroplasty in 60 Adult Patients after Failed Hypospadias Repair: Comparison Between Penile Skin and Buccal Mucosa Grafts

Reoperative urethroplasty after failed hypospadias repair

Reoperative urethroplasty after failed hypospadias repair is a significant challenge in reconstructive urology. These reoperations comprise a spectrum ranging from surgical failures in which apparently supple tissues remain to cases with limited or scarred genital tissues that are not suitable for urethroplasty. Decision making involves identification of all persisting complications, including persistent curvature, fistulas, strictures, diverticulum, and hair within the urethra, and careful assessment of the availability and vascularity of remaining tissues to correct them. The fact that complication rates after reoperation are greater than those after primary repair implies that previously operated tissues have reduced blood supply and that even experienced surgeons may overestimate the residual vascularity.

Enlargement and Sculpturing of a Small and Deformed Glans

We present 2 techniques of enhancement and sculpturing of a small and/or deformed glans. The small glans in primary or re-do hypospadias repair was enhanced by longitudinal double-faced island flaps incorporated onto the ventral side of the glans between the glans wings. The deformed glans, of small or normal size (with normal urethra or well functioning neourethra), was enlarged and sculptured by injection of hydrogel. Between May 1997 and March 2002, 27 patients underwent glans enhancement and sculpturing. Small deformed glans occurred after failed hypospadias repair in 10 patients, penile trauma in 3, hemangioma sclerozation in 2, primary hypospadias in 8 and normally developed penile body in 4. A double-faced island flap was performed in 14 patients, glans was enhanced by hydrogel injection in 9 and both procedures were performed in 4. Mean followup was 34 months for the double-faced flap technique 17 months for hydrogel injection. Satisfactory enlargement and esthetic appearance were achieved in 13 of the 14 patients who underwent the double-faced flap technique and 1 required surgical correction. Of the 9 patients who underwent either single or multistage hydrogel injection 8 had good results and 1 required partial removal of hydrogel after hypercorrection. The combination of these 2 techniques provided satisfactory results in all 4 cases. Enlargement and sculpturing of a small deformed glans are challenging and difficult. A double-faced island flap and/or injection of hydrogel resolves this problem satisfactorily.

Successful Use of Tunica Vaginalis Grafts for Treatment of Severe Penile Chordee in Children

Prior reports have suggested that tunica vaginalis free grafts for the treatment of chordee are associated with a high failure rate and residual curvature. We reviewed our experience with tunica vaginalis free grafts for the treatment of severe chordee associated with scrotal and perineal hypospadias. The records of 25 children with scrotal or perineal hypospadias associated with severe ventral chordee requiring a corporal graft to straighten the phallus treated from 1996 to 2001 were reviewed. Of the cases 5 were reoperative due to prior failed urethroplasty and residual chordee. All patients undergoing primary surgery received testosterone treatment preoperatively. Dermis was used in 3 patients, small intestinal submucosa in 3 and a free graft of tunica vaginalis in the remaining 19. One child had 2 tunica grafts placed at the same setting to correct the chordee. Patient age ranged from 5 months to 16 years (median 8 months). All patients have been followed for a minimum of 1 year and a maximum of 5 years. All patients completed stage 2 repair of the hypospadias at which artificial erection was performed to detect residual ventral curvature. In only 1 patient with a prior failed hypospadias repair was there evidence of recurrent chordee after tunica vaginalis graft placement. This patient was treated with a dorsal plication at the time of urethroplasty. No other patient had evidence of residual or recurrent chordee. In our hands, tunica vaginalis grafting of the corpora has produced excellent results. It is a readily available material and easy to harvest in patients who require extensive perineal dissection at the first operation. Long-term followup of these children as they progress through puberty is needed.