Proximal Hypospadias Surgery Research Articles

Common complications and their managements after penoscrotal hypospadias repairs: comparison of one-stage and staged repairs

Objectives: Surgical repair of hypospadias is challenging and the risk of complications is high, even for the most experienced specialists. In this study, we aim to present our experience with the management of the most common postoperative complications in patients who underwent proximal hypospadias repair. Methods: We retrospectively reviewed the data of patients underwent proximal hypospadias surgery between December 2011 and February 2021. Patients who were repaired with single and staged methods were divided into two groups. Treatment methods of postoperative complications including wound dehiscence, fistula, stricture and diverticulum were examined and the results were noted and statistically compared. Results: Forty-four patients, with a mean age of 34 months at the first surgery were reviewed, 17 of whom underwent a single-stage repair and 27 of whom staged. Except for a patient who underwent Onlay island flap urethroplasty, long TIPU was used in all single-session repairs, and Byar's and Bracka methods in 19 and 8 patients of the staged group, respectively. The overall complication rate was 34% at a mean follow-up of 41 months, and 18% in single-stage repair, and 44% in staged. Glans dehiscence, urethrocutaneous fistula, urethral stricture, and diverticula were seen 2 (4%), 4 (9%), and 4 (9%), respectively. All glans dehiscence and two fistulae along with distal stricture treated with Mathieu urethroplasty. Two proximal short strictures were relieved by single session dilation. Diverticula were repaired by urethroplasty. The complications were successfully treated, and no recurrence developed. Conclusions: The risk of complications is higher due to proximal hypospadias, long urethroplasty and defective penile tissue. Hypoplasic glandular urethra, distal stricture and a neourethra devoid of spongiosum appear to be related for complications. Despite the more encountered, postoperative complications of proximal hypospadias repairs have been shown to be successfully treated with the appropriate techniques.

A Review of Literature on Long-Term Outcomes of Proximal Hypospadias — Urinary, Sexual, and Psychosocial

Proximal hypospadias management involves complex surgical interventions that can lead to the need for long-term specialized care. This review aims to explore the urinary, sexual, and psychosocial outcomes in patients with proximal hypospadias. Patients undergoing surgical correction of proximal hypospadias have generally acceptable urinary flow rates but can still suffer from increased rates of urinary tract infections, voiding difficulties, and leakage as compared to controls. Sexual outcomes of surgical repair closely mimic those of controls. However, a significant proportion of patients report dissatisfaction with their penile appearance after cosmetic surgery. While patients may report hesitancy in approaching sexual or emotional relationships, overall psychosocial outcomes were close to those reports in controls. While still generally very successful, proximal hypospadias surgery has been shown to have more complications in these areas than other milder forms of hypospadias and thus care must be taken to ensure patients are being treated with a holistic mindset throughout their journey.

Parental decision regret in childhood hypospadias surgery: A systematic review.

We conducted a systematic review of the literature to establish the prevalence of and predictive factors for parental decision regret in hypospadias surgery. A search strategy without language restrictions was developed with expert help, and two reviewers undertook independent study selection. Five studies were included in this review (four for quantitative analysis) with a total of 783 participants. The mean overall prevalence of parental decision regret was 65.2% (moderate to severe - 20.3%). Although significant predictors of regret were identified (post-operative complications, small size glans, meatal location, decision conflict between parents, parental educational level and others), they had unexplained discordance between studies. Parental decision regret after proximal hypospadias surgery and refusing surgery was inadequately reported. In conclusion, even though the prevalence of parental decision regret after consenting for the hypospadias repair appears to be high, risk factors associated with it were discordant suggesting imprecision in estimates due to unknown confounders.

Current Trends in Hypospadias Repair. Where are we Standing?

Purpose: Although several surgical approaches are suggested for hypospadias reconstruction but there is not a consensus on the best surgical method of hypospadias repair. This is a survey about technique of choice in treatment of various types of hypospadias. Method and materials: We asked about preferred method of treatment for three different hypospadias scenarios. 170 surgeons completed the questionnaire and enrolled in this study. Results: 51 general urologists, 61 pediatric surgeon, 16 plastic surgeons and 42 pediatric urologists joined the survey. Preferred method of surgery for a distal hypospadias was TIP in 53.5%. TIP was offered by 39.4% , Two stage Urethroplasty in 24.7% and Island On lay Flap in 21.2% to repair a proximal hypospadias without cordee. Two-stage Bracka or Durham Smith were common surgical options in proximal hypospadias surgery with cordee. Conclusion: A growing trend was detected on TIP repair of distal and proximal hypospadias without cordee.

Two simple modifications can potentially change the future of proximal hypospadias surgery. Our series and a review of the literature.

Background/ObjectiveTo draw a hint towards two simple modifications that could potentially decrease the complication rate.Patients and MethodsIt was a single center, single operator and retrospective study. All patients with severe hypospadias operated according to koyanagi with or without modifications were presented. The surgical technique was described. Complications like fistula, stenosis, dehiscence and urethral diverticulum were studied.Results and LimitationsNineteen patients were included and presented in a chronological manner. The first four patients were operated according to the original koyanagi technique. The next 15 patients were operated according to koyanagi and the urethroplasty was covered by a tunica vaginalis flap. In 10 of them, glanduloplasty was done primarily and in the last 5 patients, glanduloplasty was done as a secondary procedure. The complication rates were 100% in the original koyanagi group, and 0% in the subset were glanduoplasty was deferred.ConclusionsSystematically covering the urethroplasty with a tunica vaginalis flap and deferring the glanuloplasty might ameliorate the results of the koyanagi technique.

Challenges in managing proximal hypospadias: A 17-year single-center experience

BackgroundThere are only a few publications in the medical literature reporting on complication rates in proximal hypospadias surgery, particularly with regard to long-term follow-up. MethodsOver a 17.5-year period, we operated 100 patients with penoscrotal, scrotal and perineal hypospadias. Sixty-four had a single-stage repair, including 15 who received a buccal mucosa inlay “Snodgraft” repair. Thirty-six had a two-stage Bracka repair of which 19 received buccal or lower lip grafts and 17 had preputial grafts. Overall, 34 patients received buccal grafts. The median follow-up was eight years (range 1–16 years). Three patients were operated for residual chordee years later. ResultsUrethral fistulae occurred in a total of 26/100 (26.0%) cases, meatal stenosis in 16/100 (16.0%), wound breakdown in six (6.0%) and graft failure in one (1.0%). The fistula rate after the single-stage approach was 15/64 (23.4%), whereas it was 11/36 (30.6%) following two-stage repair (P = 0.4811). ConclusionsProximal hypospadias remains a challenging condition to treat. It is possible to perform a single-stage repair in 64.0% of cases. This brings down the median number of operations to only two. Lower lip grafts were used in 34.0% but are now used in redo-surgeries only. Our fistula rate was 26.0% but has decreased significantly in recent years. Level of evidenceLevel III.

Commentary to “Hypospadias: Are we as good as we think when we correct proximal hypospadias?”

The authors should be congratulated for bringing to the spotlight something aboutwhich most experienced surgeons are discreet. The manuscript openly discusses the bad results of proximal hypospadias surgery. When the alarm is raised by one of the most experienced institutions in hypospadias surgery, a thorough look at practice and knowledge is needed. The definition of proximal hypospadias is far from being clear, and heterogeneity in reporting the initial description is one of the main factors for underestimation of bad results on posterior hypospadias surgery. Multifactorial perioperative factors may influence the outcome in proximal hypospadias. Most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined [1]. The authors reviewed many suggestions and hypotheses explaining why correction of proximal hypospadias is more difficult than that of distal. I was eager to know more about the inherited factors of the tissues that may aggravate the prognosis of proximal hypospadias. However, the authors limited their explanation on the physical factors (length and diameter of the tube to construct). We have to admit that the challenge in hypospadias surgery is not only to obtain an acceptable urine flow but also to get a functional size of the penis as well as the absence of significant curvature at puberty. We have been surprised by our own results of adolescents operated in childhood for proximal hypospadias. The majority (74%) had impaired testicular function requiring testosterone treatment for the initial or secondary induction of puberty. Most of them had a significantly short penis (-2DS) [2]. Persistent significant penile curvature is one of the most disappointing results of hypospadias surgery. The authors have reported honestly their unpublished data on the high frequency of redo hypospadias for persistent chordee, even if the surgery was done at their expert center.

Long-term functional outcomes after penoscrotal hypospadias repair: A retrospective comparative study of proximal TIP, Onlay, and Duckett

A variety of techniques are available for proximal hypospadias repair. Onlay, proximal tubularized incised plate (TIP), and Duckett are among the popular choices because they can be performed as a one-step procedure. However, the decision to select a procedure often comes down to the surgeon's preference rather than that supported by evidence-based data. In particular, there is a paucity of literature on the long-term urinary outcomes after proximal hypospadias repair. The aim of this study was to evaluate the evolution of long-term uroflowmetry parameters after proximal hypospadias surgery over a long-term follow-up including the adolescent period. Files from patients who underwent primary proximal hypospadias repair at our institution between 1997 and 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (pTIP vs. Onlay vs. Duckett) was performed according to the following postoperative time interval endpoints: 0-1 years, 1-2, >2-4, >4-6, >6-10, >10-12, and >12 years. Maximal urinary flow rate (Qmax) in relation to voiding volume (VV) adjusted for age or body surface area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques. Fifty-two patients met the inclusion criteria with a median follow-up of 10 years: 25 (59.6%) TIP, 18 (34/6%) Onlay, and nine (17.3%) Duckett. Overall, Qmax increased progressively according to time and age in particular during the period covering adolescence. At follow-up 12 years postoperatively, median Qmax values were 18.5mL/second, 13.8mL/second and 16.6mL/second for TIP, Onlay, and Duckett, respectively, with no significant differenced detected between groups (p=0.5) see figure). Compared with normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax<25th percentile of nomograms was more prevalent in patients aged 3-7 years old at 83.8% but decreased to less than 21.2% in patients aged >13 years for all procedures (see figure). These results are consistent with previous work showing frequently reduced Qmax after hypospadias surgery with great potential for improvement at puberty. These results suggest that the obstructive urinary flow pattern observed in patients early on is a frequent finding after proximal hypospadias surgery. However, because of the remarkable improvement observed at puberty a watchful waiting approach is proposed in order to avoid unnecessary intervention.

Two-stage complex hypospadias repair when urethral plate has to be divided: Ventral corporoplasty using a tunica vaginalis flap

ObjectiveTo demonstrate ventral corporoplasty, with tunica vaginalis flap to reconstruct the corpora cavernosa, in a two-stage strategy for proximal hypospadias surgery. MethodsAssessment of residual curvature after complete urethral plate division and transverse superficial cuts in albuginea. Ventral incision of tunica albuginea to elongate the ventral surface of the penis and use of a tunica vaginalis flap to reconstruct the defect in corpora cavernosa. Dorsal preputial island flap was used to cover the penile ventral surface, to be tubularized in a second stage, together with the original urethral plate. ResultsPatient had an uneventful follow-up. Penile aspect was very satisfactory with no residual curvature. ConclusionTunica vaginalis is an attractive alternative for ventral corporoplasty in hypospadia repair and has the advantages of prompt disposability, autologous use, and does not represent an extra cost for treatment.

V575 TWO STAGE COMPLEX HYPOSPADIA REPAIR WHEN URETHRAL PLATE HAS TO BE DIVIDED: VENTRAL CORPOROPLASTY USING A TUNICA VAGINALIS FLAP

Abstract Objective To demonstrate ventral corporoplasty, with tunica vaginalis flap to reconstruct the corpora cavernosa, in a two-stage strategy for proximal hypospadias surgery. Methods Assessment of residual curvature after complete urethral plate division and transverse superficial cuts in albuginea. Ventral incision of tunica albuginea to elongate the ventral surface of the penis and use of a tunica vaginalis flap to reconstruct the defect in corpora cavernosa. Dorsal preputial island flap was used to cover the penile ventral surface, to be tubularized in a second stage, together with the original urethral plate. Results Patient had an uneventful follow-up. Penile aspect was very satisfactory with no residual curvature. Conclusion Tunica vaginalis is an attractive alternative for ventral corporoplasty in hypospadia repair and has the advantages of prompt disposability, autologous use, and does not represent an extra cost for treatment.

Proximal hypospadias repair with principles of progressive perineal urethroplasty

Background: Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct. Significant variability exists for preferred approaches of repair. Often combinations of procedures are required in staged manner. Here, we have combined steps of pelvic fracture urethral distraction defects (PFUDD) repair with tubularized incised plate procedure in a single stage. Materials and Methods: A total of 8 patients consisting of 5 adults (mean age 20 years) and 3 children less than 3 years old that presented with proximal hyposphadias were included. All patients underwent degloving and progressive perineal approach as described by Webster for repair of PFUDD including mobilization of the entire bulbar urethra from the neomeatus to the membranous urethra with division of lateral attachments, division of attachment from perineal body and corporal separation. Mobilization of the urethral plate from the corpora cavernosa to the glans was carried out. The urethral plate was tubularized with a dorsal incision. Results: The neomeatus was advanced by a distance of 2.5-3.8 cm in all eight patients. Dartos fascia was used in 5 adults and 1 child for cover. Two patients required a tunica vaginalis flap as dartos was tethered during the harvesting. Catheter drainage was 18 days on an average (14-21 days). Fistula (pinpoint) occurred in one adult, which healed with further catheter drainage. All the patients were voiding normally and satisfied in terms of cosmetic appearance. None of the patients had wound infection or total disruption, residual chordee, meatal stenosis or any erectile difficulties. Conclusion: The steps of progressive perineal approach for repair of posterior urethral distraction defects if followed aids in achieving the goals of proximal hypospadias surgery in a single stage.

Primary Severe Hypospadias: Comparison of Reoperation Rates and Parental Perception of Urinary Symptoms and Cosmetic Outcomes Among 4 Repairs

We compared complication rates, urinary symptoms and cosmetic outcomes as perceived by parents of patients undergoing 1 of 4 repairs for proximal hypospadias associated with ventral curvature. A total of 93 patients underwent hypospadias repair between 2004 and 2010. In patients requiring no urethral plate transection the repair consisted of tubularized incised plate urethroplasty (26 patients) or onlay island flap urethroplasty (31). In patients requiring urethral plate transection the repair consisted of onlay island flap on albuginea (18 patients) or 2-stage repair (18). Complications were assessed by chart review. A customized questionnaire and the Pediatric Penile Perception Score were administered to parents to evaluate their perception of urinary symptoms and cosmetic outcomes, respectively. After a median followup of 4.5 years (range 2.2 to 8.4) complications developed in 21 patients (23%) without any difference among procedures or between patients who did and did not require urethral plate transection. Parents of 75 patients (80%) participated in the survey without differences among repairs (p = 0.35). Reported urinary symptoms were not different among repairs. For Pediatric Penile Perception Score the only difference concerned the question about penile length (p = 0.03), with the score being significantly better for the techniques requiring urethral plate transection (p = 0.05). The 2-stage repair had a significantly better score for the question about penile length and overall Pediatric Penile Perception Score than all other techniques. Overall complication rates were comparable among repairs and did not increase after urethral plate transection. Urinary symptoms as reported by parents were comparable among the procedures. Perceived penile length was significantly better after urethral plate transection. The 2-stage repair yielded the best cosmetic results.

Minimizing the postoperative complications of severe hypospadias using a simple technique

Background The aim of this study was to decrease complication rates in proximal hypospadias surgery. Methods A simple method of stenting using a polypropylene stent has been developed for the most severe form of hypospadias during the period from January 2008 to January 2011 in the Department of Pediatric Surgery. The total number of patients was 46. The patients were classified into group 1 (n= 23), in which a polypropylene stent was used, and group 2 (n= 23), in which a polypropylene stent was not used. Results In group 1, complications occurred in three patients (13.04%), whereas in group 2 it occurred in 12 patients (52.2%). The difference in the total number of complications between groups was highly significant (P < 0.001). In group 1, no patient needed redo surgery, and in group 2 four patients (17.39%) needed redo surgery (P < 0.05). All other patients responded to repeated dilatation in the follow-up. Conclusion Although the sample size was small, this simple modification can decrease the complication rate significantly in the most severe form of hypospadias. Keywords : polypropylene stent, proximal hypospadias, surgical complications, urethroplasty

Demonstration of Postoperative Effectiveness in Ventral Lengthening Using a Tunica Vaginalis Flap for Severe Penile Curvature With Hypospadias

To evaluate the postoperative effectiveness of ventral lengthening with a tunica vaginalis flap. Correcting penile curvature is an essential step in proximal hypospadias surgery. It is logical to lengthen the ventral radius using a graft; however, penile curvature would recur owing to a graft contracture with inadequate vascularization. Although a tunica vaginalis is considered a suitable material to be used as a flap instead of a graft, clinical application of this technique is uncommon. Information regarding the usefulness and effectiveness of this procedure is required. Between 2003 and 2008, we repaired 146 patients with hypospadias and the urethral plate was transected in 39 patients because of severe curvature. Significant severe curvature persisting even after transection of the plate was corrected with ventral corporeal lengthening procedures using a tunica vaginalis flap in 15 patients and postoperative results were evaluated. Straight penile erection was identified in all 15 boys at home by their parents. In 7 of the 15 boys, artificial erection was performed at the time of additional surgery; 5 degrees of curvature was found in 2 patients and 0 degree in 5. At the second session of surgery, we observed that penile straightening was maintained without recurrence of curvature. Additionally, the area in which the tunica vaginalis flap was placed on the ventrum did not contract. Therefore, lengthening the ventral aspect using a tunica vaginalis flap might be an important alternative for correction of severe penile curvature in hypospadias surgery.

Straightening Ventral Curvature While Preserving the Urethral Plate in Proximal Hypospadias Repair

We report the efficacy of an expanded algorithm for penile straightening in proximal hypospadias surgery to preserve the urethral plate for urethroplasty. We also compared ventral corporotomy with grafting to multiple superficial ventral corporotomies without grafting for straightening greater than 30-degree ventral curvature. The need for urethral plate transection was compared in 2 groups comprising consecutive patients with proximal shaft to perineal hypospadias repair done by one of us (WS). The 47 patients in group 1 underwent surgery from 2000 to 2005 and had ventral curvature greater than 30 degrees after degloving, leading to urethral plate transection, while in 23 in group 2 from 2006 to 2008 mobilization of the corpus spongiosum/urethral plate and proximal urethra were also performed before urethral plate transection. Patients in group 1 with greater than 30-degree ventral curvature after urethral plate transection underwent ventral corporotomy with grafting (7) or multiple transverse corporotomies without grafting (4), while those in group 2 with greater than 30-degree ventral curvature after corpus spongiosum/urethral plate and urethral mobilization underwent multiple transverse corporotomies without grafting. Excluding 10 group 1 and 3 group 2 boys without ventral curvature after degloving the rate of urethral plate transection significantly decreased from 54% to 15% using the expanded algorithm (p = 0.005). At a mean followup of 11 months in those with corpus spongiosum/urethral plate and urethral mobilization there was no recognized recurrent ventral curvature. Seven patients with greater than 30-degree ventral curvature underwent ventral corporotomy with grafting, while 11 underwent multiple transverse corporotomies without grafting. At a mean followup of 27 and 19 months, respectively, no patient had recurrent ventral curvature. Mobilization of the corpus spongiosum/urethral plate and the urethra in proximal hypospadias cases with greater than 30-degree ventral curvature after penile degloving decreases the need for urethral plate transection. Ventral lengthening to correct corporeal disproportion can be achieved by corporotomy with grafting or by multiple transverse incisions without grafting.

Patient and surgeon evaluation of outcome in hypospadias repair

Purpose Despite increased emphasis on cosmetic outcomes of hypospadias surgery, few reports objectively determine appearance. Furthermore, prior studies demonstrate patient and surgeon assessments may vary significantly. We used a standardized questionnaire to survey parent and surgeon perception after TIP repair. Material and methods A Likert scale questionnaire (responses from 1, very abnormal, to 5, normal) was developed concerning 6 items: overall penile appearance, cosmesis of meatus and skin, penile size, straightness, and voided stream. Parents and surgeon independently completed surveys 6 weeks after primary TIP repair; similar surveys after circumcision provided normal controls. Maximum score was 30. Results Hypospadias patients comprised 50 distal and 15 midshaft to scrotal TIP repairs. There were 22 circumcision controls. Mean score by parents for hypospadias repair was 28 +/- 3, compared to 27.7 +/- 3 after circumcision. Questions regarding straight erection and voided stream were not answered by the surgeon in all patients, so comparison between parents and surgeon were based on the other 4 parameters with a maximum score of 20. Parents of patients and controls scored 18.3 +/-2 and 17.6 +/- 3, respectively, versus surgeon scores of 18.9 +/- 2 and 18.6 +/-2. Pearson's test showed statistically significant agreement and the correlation coefficient between parents and surgeon was 0.6 and 0.5 for controls and hypospadias repairs, respectively. There were no differences in evaluations for distal versus proximal hypospadias surgery. Conclusions Parents and surgeon agree TIP results in penile appearance are indistinguishable from normal circumcised penis. Similar surveys should be performed after alternative repairs. Despite increased emphasis on cosmetic outcomes of hypospadias surgery, few reports objectively determine appearance. Furthermore, prior studies demonstrate patient and surgeon assessments may vary significantly. We used a standardized questionnaire to survey parent and surgeon perception after TIP repair. A Likert scale questionnaire (responses from 1, very abnormal, to 5, normal) was developed concerning 6 items: overall penile appearance, cosmesis of meatus and skin, penile size, straightness, and voided stream. Parents and surgeon independently completed surveys 6 weeks after primary TIP repair; similar surveys after circumcision provided normal controls. Maximum score was 30. Hypospadias patients comprised 50 distal and 15 midshaft to scrotal TIP repairs. There were 22 circumcision controls. Mean score by parents for hypospadias repair was 28 +/- 3, compared to 27.7 +/- 3 after circumcision. Questions regarding straight erection and voided stream were not answered by the surgeon in all patients, so comparison between parents and surgeon were based on the other 4 parameters with a maximum score of 20. Parents of patients and controls scored 18.3 +/-2 and 17.6 +/- 3, respectively, versus surgeon scores of 18.9 +/- 2 and 18.6 +/-2. Pearson's test showed statistically significant agreement and the correlation coefficient between parents and surgeon was 0.6 and 0.5 for controls and hypospadias repairs, respectively. There were no differences in evaluations for distal versus proximal hypospadias surgery. Parents and surgeon agree TIP results in penile appearance are indistinguishable from normal circumcised penis. Similar surveys should be performed after alternative repairs.

SEVERE HYPOSPADIAS REPAIR WITH MEATAL BASED PARACORONAL SKIN FLAP: THE MODIFIED KOYANAGI REPAIR

Various techniques have been reported to repair severe hypospadias. The Koyanagi repair uses a meatal based foreskin flap. We modified this procedure and reviewed the outcome of the repair of severe hypospadias. The modified Koyanagi repair was performed in 151 children 7 months to 15 years old (mean age 3 years) with severe hypospadias. The records of these patients were reviewed. In all cases the meatus was at or proximal to the penoscrotal junction. Followup was 6 months to 16 years (mean 6 years). Flap design is the same as in the Koyanagi repair, although our modified technique requires removal of the subcutaneous tissue of the distal portion of the flap, which acts as a full-thickness free skin graft. A fistula developed in 19 patients (12.6%), meatal stenosis in 3 (2%) required meatoplasty and infection in 2 (1.3%) resulted in a regressed meatal position. Good cosmetic results were achieved in all except the latter 2 cases. Our modified Koyanagi repair affords an excellent cosmetic appearance. The complication rate is relatively low and compares favorably with that of other techniques.

COMPARISON OF FLAPS VERSUS GRAFTS IN PROXIMAL HYPOSPADIAS SURGERY

We analyzed the complication rate in patients who underwent proximal hypospadias repair using preputial skin as a flap or free graft. We retrospectively reviewed the records of 142 patients who underwent proximal hypospadias repair. Repairs were subdivided into tubed and onlay repairs within the flap and free graft groups. We analyzed postoperative complications, including fistulas, proximal strictures, diverticula and meatal stenosis. Median patient age at followup was 11.3 months and median followup was 9.4 months. Two-thirds of the repairs were performed with free grafts. A proximal stricture developed in 8 and 0 patients who underwent free tubed graft and free onlay repair, respectively (p = 0.047). Otherwise there was no significant difference in the complication rate of the various types of repair. Of the 43 patients who had stricture, fistula or meatal stenosis 29 (67%) presented more than 1 year after surgery. In repairs performed with free grafts there is a significantly higher proximal stricture rate when a tube rather than an onlay is used. Otherwise we noted no significant difference in the complication rates of flaps and grafts used to repair proximal hypospadias. A significant number of complications presented more than 1 year postoperatively and they may even present as late as 4 years. This finding suggests that longer followup may be necessary to assess completely the outcome of proximal hypospadias surgery.

The Dartos Flap as an Adjunct in Preventing Urethrocutaneous Fistulas in Repeat Hypospadias Surgery

Purpose Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair. Materials and Methods The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995. Results Of 6 patients cosmesis was excellent in 84 percent, erections were straight in 100 percent, and urinary streams were of good quality and without fistula in 100 percent after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year. Conclusions The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.