Onlay Island Flap Technique Research Articles

Evaluation of double faced transverse preputial (onlay) island flap for hypospadias repair in pediatrics: a randomized controlled study

BackgroundThe preputial onlay island flap technique has been popularized for hypospadias repair as a result of offering a consistent combination of acceptable functional and cosmetic results. Like other techniques, urethrocutaneous fistulae and stricture continues to be the most common complications, in addition to other complications, which could be attributed to the compromise in flaps vascularity. Some authors describe a technique that resolves some of these problems by combining the unique benefits of the double faced preputial flaps. The aim of this study:- to evaluate double faced preputial onlay island flap technique for complications rate, outcomes of surgical procedure, and cosmetic results in comparison to transverse inner preputial flap technique.Patients and methodsThis was a prospective randomized controlled study that included 68 patients with anterior, mid-penile, and posterior penile hypospadias, with shallow and narrow urethral plate of size less than 6 mm, who underwent single-stage repair using preputial flaps, conducted at the department of pediatric surgery (Al-Azhar University, Cairo, Egypt), between May 2019 and October 2021, to evaluate double faced transverse preputial onlay island flap technique. Thirty-four patients underwent double faced transverse preputial onlay island flap (group A) and another 34 patients underwent inner transverse preputial onlay island flap (control group) (group B). The follow-up period ranged from 12 to 26 months.ResultsThe overall complication rate was 20.5% (14 of 68 children). Complications developed in 5 cases (14.7%) in group A who underwent double face onlay island flap (2 glannular dehiscence, 1 penile rotation, 1 fistula, and 1 diverticulum), as opposed to 9 patients in group B (26.4%) who underwent transverse inner preputial flap (3 developed glannular dehiscence, 2 skin flap necrosis, 3 fistulae, and 1 diverticulum). After management of the complications, all patients had good surgical outcomes with satisfactory cosmetic results.ConclusionDouble faced transverse preputial onlay island flap is an alternative option to reconstruct narrow urethral plate hypospadias. So that double faced transverse preputial onlay island flap technique appears to achieve satisfactory surgical outcomes with lower complication rate.

Urethroplasty for chordee with a paper-thin hypoplastic urethra: A long-term study.

ObjectivesTo establish a standard surgical procedure for children with chordee with a paper‐thin hypoplastic urethra, which was based on the degree of curvature and urethral plate quality. To guidelines for the management of this disorder.MethodsWe reviewed 58 cases of chordee with a paper‐thin hypoplastic urethra, managed between March 2006 and September 2020. The age of the patients ranged from 23 to 89 months. Operative details and postoperative complications were analyzed.ResultsMild‐moderate chordee with a paper‐thin hypoplastic urethra correction was performed using a tubularized incised plate (13 cases) or onlay island flap (five cases) technique after penile degloving. Severe chordee with a paper‐thin hypoplastic urethra required transection of the urethra and underwent a Duckett (11 cases) or staged (29 cases) urethroplasty. Complications in the tubularized incised plate and onlay island flap groups were 7.7% and 20%, respectively. The overall complication rate was 10.3% in the staged group and 27.3% in the Duckett group.ConclusionsReconstruction of the entire hypoplastic urethra should be recommended in the management of chordee with a paper‐thin hypoplastic urethra. We propose an algorithm based on the degree of curvature and urethral plate quality. The tubularized incised plate or onlay island flap technique can be used for mild to moderate chordee with a paper‐thin hypoplastic urethra, and the outcome of the tubularized incised plate technique tends to be better than that of the onlay island flap technique. Duckett or staged urethroplasty is suitable for severe chordee with a paper‐thin hypoplastic urethra, and the staged technique can improve the overall success rate.

THE RELATION OF HYPOSPADIAS TYPES, AGES, AND SURGICAL TECHNIQUES FOR URETHROCUTANEOUS FISTULA COMPLICATION IN CHILD HYPOSPADIAS CASES

Objective: To find correlation between hypospadias type, age, and surgical technique for urethrocutaneous fistula in child hypospadias cases. Material & Method: This research was an observational analytic research with cross sectional approach. It was conducted at Bina Sehat Jember Hospital, Paru Jember Hospital, and Bhayangkara Bondowoso Hospital. The research samples were hypospadias patients who had done hypospadias repair with susceptible age from 0 months until 16 years. Result: In this study, was found correlation between type of hypospadias with urethrocutaneous fistula (p=0.03 and r=0.43). And the other hand, this research did not find relationship between age at hypospadias surgery with urethrocutaneous fistula complication (p=0.34 and r=0.3). The results of this study indicate that the incidence of urethrocutanoeus fistula complications in the surgery using TIP technique was greater than Onlay Island Flap technique, but in this study, there was no association between hypospadias surgery technique used with complications of uretrocutanoeus fistula (p=0.3 and r=0.22). Conclusion: In this study, there was a significant relationship between hypospadias type with urethrocutaneous fistula complication with statistically moderate strength and positive correlation direction. This study did not show any significant relationship between age and hypospadias surgery technique with complications of urethrocutanoeous fistula.

Evaluation of Onlay Island Flap Technique in Shallow Urethral Plate Hypospadiasis.

Background:Hypospadias is one of the most common congenital genital anomalies in males that necessitates to be operated early in infancy (when 6 to 9 months old). On the other hand, hypospadias is a challenging field of pediatric urology with multiple reconstruction techniques. A perfect hypospadias repair is supposed to return urethral continuity with sufficient caliber, eradicate phallus curvature, and supply an acceptable appearance with low complications.Objectives:This study aimed to evaluate the outcomes of using onlay island flap technique in the repair of hypospadias with shallow urethral plate.Patients and Methods:In this prospective study within June 2012 to December 2013, we performed onlay island flap procedure to repair hypospadias with shallow urethral plate measuring less than 6 millimeter. This technique was selected for all types of hypospadiasis except subcoronal type. Nesbit’s dorsal plication procedure was established for chordee. In cases with very small glans, urethroplasty was performed without glansplasty.Results:Twenty three patients with mean age of 30 (range 10 - 60) months underwent onlay island flap repair; all had a shallow urethral plate < 6 mm, 3 had a very small glans, and 18 had chordee. Meatus was located in distal shaft in 5 cases, mid shaft in 8, proximal in 6 and penoscrotal type in 4 patients. Chordee was corrected with Nesbit’s dorsal plication in 16 cases. Complications were: meatal stenosis in 2 cases and urethrocutaneous fistula in 2 patients, all of which were repaired surgically. Mean follow up time was 13 (3 - 20) months. All cases that had glansplasty have excellent esthetic appearance.Conclusions:This technique offers acceptable results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.

One-Stage repair of hypospadias using the modified prepucial island flap technique: Experience with 200 cases

Background: Surgical repair of hypospadias has taxed the skills of surgeons the world over. One-stage repair is preferable because it decreases operative trauma, allows use of virgin unscarred tissue, decreases number of hospitalizations, and hence is more economical than two-stage repairs. During the last 7 years, the author has managed 200 cases of hypospadias and their complications in a tertiary care service hospital. This study aimed to evaluate the outcomes of using modified onlay island flap technique in the repair of hypospadias with a narrow urethral plate. Patients and Methods: In this prospective study conducted between June 2008 and June 2015, we performed modified onlay island flap procedure for the repair of hypospadias with a narrow urethral plate – less than 7 mm. This technique was used for all types of hypospadias with minimal or no chordee except penoscrotal. We did not require any tunica plication in our study. Results: Two hundred patients with age ranging from 3 years to 10 years (average 5 years) underwent modified onlay island flap repair; all had a narrow urethral plate of less than 7 mm; 30 (15%) had mild chordee. Meatus was located in coronal in 10 (5%) cases, subcoronal in 120 (60%), midpenile in 50 (25%), and proximal penile in 20 (10%) patients. Chordee was corrected with degloving only in 30 (15%) patients. Complications were meatal stenosis in none and urethrocutaneous fistula in 10 (5%) patients. Mean follow-up duration was 12 months. Conclusion: This technique offers acceptable results regarding meatal stenosis, urethrocutaneous fistula, along with good aesthetic outcome.

Can a slit‐like meatus be achieved with the V‐incision sutured meatoplasty for onlay island flap hypospadias repair?

To evaluate whether the V-incision sutured meatoplasty (VSM) is useful for configuring the constructed meatus after the onlay flap and the Mathieu flip-flap repair for hypospadias, as the transverse preputial onlay island urethroplasty is excellent for repairing anterior hypospadias with no chordee, and a slit-like normal meatus cannot be constructed in many patients who had the original onlay island-flap repair The configuration of the meatus which was repaired by the onlay island flap technique with VSM (group 2) was evaluated and compared with that of the original onlay technique (group 1). Group 1 consisted of 30 patients treated with only the classic onlay procedure as primary hypospadias repair (1999-2001). Group 2 consisted of 22 patients treated using the onlay procedure with VSM as primary hypospadias repair (2002-2004). There were complications after surgery in four (18%) of 22 patients in group 1 and in five (17%) of 30 in group 2, with no significant difference. A slit-like meatus was achieved in eight (27%) of 30 in group 1 and in 12 (55%) of 22 in group 2. There was a significant difference between the groups in meatal configuration (P = 0.04). The VSM is a useful technique to make a slit-like meatus for onlay island flap urethroplasty and flip-flap hypospadias repair, although the technique cannot always achieve the intended result.

Outcomes of one-stage techniques for proximal hypospadias repair

Objectives. To evaluate the success of three preputial flap techniques in the one-stage correction of proximal hypospadias. Methods. From 1993 to 1999, 43 children underwent one-stage proximal hypospadias repair using preputial flaps, which were performed by a single surgeon. Of the 43 patients, 21 (48.8%), 10 (23.2%), and 12 (27.9%) underwent tubularized island flap urethroplasty, double-faced tubularized island flap urethroplasty, and onlay island flap urethroplasty, respectively. The age range of the patients at surgery was 18 months to 14 years (mean 3.4). Dorsal plication was required for chordee repair in 12 patients (3 in tubularized island flaps, 3 in double-faced tubularized island flaps, and 6 in onlay island flaps). In addition to the dorsal plication, posterior dissection of the urethral plate without division was performed on 3 of the 6 patients with mild to severe chordee in the onlay island flap group. The incidence of complications requiring repeated surgery was evaluated for each group. Results. The follow-up was 8 months to 7 years (mean 4.1 years). The overall complication rate was 90% for the double-faced tubularized island flap repair, 38% for the tubularized island flap repair, and 33% for the onlay island flap repair. Recurrent chordee was observed in 2 (66.6%) of the 3 patients who underwent onlay island flap repair with urethral plate dissection. Conclusions. The use of a tubularized island flap is suggested for one-stage repair of proximal hypospadias, especially in the patients with severe chordee. Because of the high complication rates, the double-faced tubularized island flap technique is not advocated. The onlay island flap may also be used for proximal hypospadias repair if mild chordee is present. Because of the high recurrent chordee rate, dissection of the urethral plate without division is not suggested in the onlay island flap technique.

Hypospadias: a critical analysis of cosmetic outcomes using photography

To analyse the cosmetic outcome of hypospadias surgery using photography, rather than the classical assessment by reoperation rate secondary to fistula, diverticulum, stenosis and residual penile curvature. The study included 181 consecutive patients with hypospadias who underwent surgery between 1997 and 1999. Distal hypospadias (47) was repaired using either the 'meatal advancement and glanuloplasty' or the glans approximation procedure. Proximal hypospadias (68) was repaired using the onlay island-flap technique with preservation of the urethral plate. Penile curvature when present was corrected by dorsal plication ( approximately 20%). Two patients with perineal hypospadias required a two-stage repair. Complex repeat repairs (36) were defined as those patients who had undergone previous surgery 1-7 times and required a new urethroplasty by a secondary onlay island-flap technique. The follow-up ranged from 6 months to 3 years. Photographs of the penis were taken before, immediately and 3-12 months after surgery; these were assessed to document objectively the cosmetic outcome. The final photographs were evaluated for overall appearance, a mucosal collar, the location and configuration of the meatus. The standard was to create a penis that would pass cosmetically as a normal circumcised penis. The patients who had chordee without hypospadias (15) and fistula repair (13) did not undergo glanuloplasty and therefore were not included in the final photographic analysis; this left 153 patients with follow-up photographs. There were five cases of urethral fistula (7%) and one of meatal stenosis (1%) in the proximal group, and three of fistula (8%) and two meatal stenosis (6%) in the complex group. The distal group had one complication (haematoma) and the two-stage group had no complications. Analysis of the photographs showed that most patients had the appearance of a normal circumcised penis. Not unexpectedly, the patients who had undergone previous surgery had the least satisfactory results (60% appearing normal) compared with the proximal and distal groups (76% and 82% appearing normal, respectively). Hypospadias can be repaired safely with few complications in a single stage in most patients. Classical complications such as fistula and stenosis occur in < 10% of patients, including those undergoing complex revisions. Cosmetic outcomes are generally good and photography is an objective means to document the appearance.

Preservation of urethral plate spongiosum: technique to reduce hypospadias fistulas

Objectives. Fistula remains the most common complication of hypospadias repair. Buried and well-vascularized suture lines reduce the incidence of fistula. We review the results of routine preservation and incorporation of the abortive spongiosum to prevent fistulas with the onlay island flap technique of hypospadias repair. Methods. Thirty-six consecutive boys underwent hypospadias repair with an onlay island flap during a 2-year period, with preservation and incorporation of the abortive spongiosum. The technique of using the abortive spongiosum in these children was reviewed. The age at surgery, preoperative meatal position, chordee presence, and neourethral length was noted. Results. The average age at surgery was 13.1 ± 18.5 months, with an average follow-up of 15.4 ± 6.7 months. The preoperative meatal position was midshaft in 15 boys, more proximal in 14, and more distal in 7 boys. Four boys required dorsal plication because of persistent chordee after skin takedown. The average neourethral length created with the onlay flap was 16.8 ± 7.6 mm. Complications occurred in 5 patients and included three diverticulae, one urinary tract infection, and one glanular adhesion. No fistula occurred in any patient. Conclusions. The abortive spongiosum is routinely obtainable with careful penile degloving. This technique provides a vascular tissue for coverage of the suture lines and reduces fistula formation.

Treatment of proximal hypospadias with a tubularized island flap urethroplasty and the onlay technique: A comparative study

Background/Purpose: The onlay island flap urethroplasty was first described in the repair of mid and distal penile hypospadias. Since then, this technique has been increasingly used in more severe cases of hypospadias, because of the complications of tubularized flaps, mainly megaurethra and proximal anastomotic strictures. The aim of this study was to compare the morbidity of these 2 techniques. Methods: Between April 1994 and December 1998, 80 patients underwent surgical treatment for hypospadias. A tubularized island flap (Duckett technique) was performed in 42 cases, and the onlay island flap technique was used in 38 patients. The authors retrospectively compared the complication rate and type of these 2 procedures. Results: Altogether, fistula was the most frequent complication without any significant difference between the 2 groups (21.4% for Duckett technique and 18.4% for onlay repair; P >.05). However, the anastomotic stricture was much more common in the tubularized flap group (7.14% v 2.63%; P <.05). Moreover, a megaurethra was found only in the Duckett technique group (4.7%). There was no case of chordee recurrence, but 6 patients (15.7%) treated with the onlay technique required urethrolysis including dissection of the chord behind the urethral plate, and in the other 3 patients of the same group (7.9%), a dorsal Nesbit plication also was necessary. In all these cases, the urethroplasty included an island cutaneous flap to provide ventral coverage to the neourethra. Conclusions: The authors conclude that both techniques present similar complications. However, proximal strictures and megaurethra are more common after the Duckett technique. This procedure is of choice in patients with scrotal hypospadias. Conversely, the onlay repair should be completed with other procedures (urethrolysis, dorsal Nesbit plication) to obtain good results in patients with severe degree of chordee. J Pediatr Surg 35:1453-1455. Copyright © 2000 by W.B. Saunders Company.