Tubularized Island Flap Research Articles

Hypopharyngeal reconstruction with gastro-omental free flap

Three types of reconstruction are possible following total laryngopharyngectomy (TLP) for advanced hypopharyngeal cancer: locoregional tubularized island flaps, gastric pull-up and free flaps. Gastro-omental free flap (GOFF) is rarely used in this setting. However, because of its composite nature, this flap has the advantage of being able to restore digestive continuity and reconstruct part of the skin of the neck when it needs to be sacrificed because of tumour invasion or poor trophicity. The GOFF is a reliable and robust flap particularly indicated in hostile environments: repeated neck surgery, atrophic and devascularized skin after radiotherapy, sepsis in the context of fistula and/or pharyngostomy. It requires the collaboration of two or even three surgical teams. In this article, we describe the flap harvesting technique and the complications and functional outcome.

Comparison of Two Tubularized Incised Plate Urethroplasty Techniques in Hypospadias Reconstructive Surgery

BACKGROUNDHypospadias repair is a challenging type of urogenital reconstructive surgery for which different techniques are currently used. The purpose of this study is to determine the outcomes of distal, mid-shaft and proximal hypospadias repair using two new variations of tubularized incised plate (TIP) urethroplasty (TIP-δ and TIP-ελ) and to compare their complication rates with other already known operative techniques made from the same surgical team.METHODSThis study included 269 boys with hypospadias. The preoperative meatal site was distal in 179 patients, mid-shaft in 44 and proximal in 46. The average age at the operation was 17 months. The technique applied in distal hypospadias was Mathieu in 77 patients, Snodgrass in 28 and (TIP)-δ in 74. The technique applied in mid-shaft hypospadias was a tubularized island flap (TIF) in 12 patients, onlay island flap (OIF) in 5 and TIP-ελ in 27. The operative technique for proximal hypospadias was TIF in 15 patients, OIF in 10 and TIP-ελ in 21. TIP-δ and TIP-ελ are two new variants of TIP operation that we have used in our clinic since 2010. Postoperative complications were recorded, and we compared the outcomes obtained by applying the techniques.RESULTSThe use of TIP-δ in the distal hypospadias and long TIP-ελ in the mid-shaft and proximal hypospadias resulted in significantly fewer complications than the other surgical methods across all cases of hypospadias (p<0.05).CONCLUSIONThe type of tissue used for neourethral coverage seems to play an important role in the outcome of hypospadias surgery.

The distribution of Preputial vessels in different severity of rat congenital hypospadias model: imaging study using micro-computerized tomography

BackgroundMicro-computerized tomography (micro-CT) is considered as an innovative non-invasive and high-resolution imaging technology. The current research aims to reconstruct the distribution of preputial vessels in different severity of rat congenital hypospadias model by micro-CT, and to provide an anatomic basis for the selection of preputial vessel pedicle flaps in surgery.MethodsPregnant rats were exposed to finasteride from gestational day 12 to 17. Depending on the position of the urethral meatus, the pups were divided into normal, mild hypospadias and severe hypospadias groups. Six months after birth, the preputial blood vessels were observed in vascular perfusion with Microfil (a silicone-based polymer) and scanned by micro-CT. CTvox and NRecon were utilized to reconstruct 3-dimentional (3D) images. A pathological analysis of the specimen was taken in order to determine the position of Microfil.ResultsThe normal group and the mild hypospadias group had similar preputial image characteristics. At the junction of the inner and outer prepuce, the deep layer vessels of the superficial fascia were transversely distributed and formed a vascular ring-like structure. Among the severe hypospadias group, five had sufficient blood circulation while six had insufficient blood circulation. In sufficient blood circulation type, the ring-like vessels were found at the junction of the inner and outer prepuce similar to that of the normal and mild hypospadias group. However, only a small amount of capillary supply to this area in the insufficient type.ConclusionThe junction of the inner and outer prepuce with abundant blood circulation was suitable to be a vascular pedicle flap. The tubularized preputial island flaps were consistent with the ring-like vessels area, and the original blood supply was retained to the greatest extent.

Fenestrated sheet split-thickness skin grafting for reconstruction of penile skin loss in pediatric population

ObjectivesWe aimed to evaluate our experience with fenestrated sheet split-thickness skin grafts (STSGs) in the pediatric population. Materials and methodsWe retrospectively studied a cohort of 17 children 2–18years old who underwent skin grafting owing to circumcision injuries (2 patients), traumatic penile injury (1) and after previous multiple hypospadias surgery (14). Fenestrated 0.012in sheet STSGs from thigh area (15 patients) and buttock area (2) were fashioned to resurface the denuded penis following reconstruction. The median follow up was 13years (range 1–19years). ResultsThere was 94% take of the grafts. One patient required additional grafting following first graft infection. Six patients underwent concomitant surgery at the time of grafting (4 chordee repair and 2 meatoplasty). Two patients had slight chordee at 3 and 6years postoperatively, and 2 with the history of preputial tubularized island flap hypospadias repair had developed a urethral stricture, which required staged repair with buccal mucosa 12 and 14years following primary hypospadias repair. Six sexually active patients reported normal sexual intercourse and sensation following grafting. None of the patients demonstrated shrinkage of the STSGs over the follow up period. ConclusionsOur data demonstrated that the use of fenestrated sheet STSGs in patients with penile skin loss yields satisfactory functional and cosmetic outcomes. The buttocks might be considered as a preferable donor site in terms of avoiding a visible scar.

Redo hypospadias repair: experience at a tertiary care children’s hospital

Treatment of patients with failed hypospadias repairs can be challenging. Our study aimed to determine the best type of redo repair depending on the location and size of the urethral meatus, the status of the urethral plate and genital skin, the severity of residual chordee and the amount of scar tissue. The Institutional Review Board approved our retrospective chart review of patients who had a redo hypospadias repair at our institution over the past 6 years. We recorded the type and number of previous repair(s), the type and number of redo procedure(s),as well as the complications and functional outcomes. There were 28 patients, aged 1-12 (mean 3.8) years, with failed hypospadias repairs. The initial severity of the hypospadias were as follows: perineal (1), penoscrotal (9), proximal shaft (1), mid-shaft (9), distal shaft (4), coronal (3) and mega-meatus (1). Of all the patients, 24 had 1 repair, 3 had 2 repairs and 1 had 3 repairs. The initial repairs comprised 11 tubularized island flaps (TIFs), 8 Snodgrass tubularized incised plate (TIP) techniques, 5 Mathieu repairs, 1 Meatal Advancement and GlanuloPlasty Incorporated (MAGPI) technique, 1 Pyramid, 1 Arap technique and 1 Thiersch-Duplay repair. Twenty-one of 28 patients had 1 redo operation, 5 had 2 redo operations, 1 had 3 redo operations and 1 had 4 redo operations, for a total of 38 redo operations. Of these, 26 were TIP techniques (68.4%), 3 were Mathieu (7.9%), 3 were TIF repairs (7.9%), 2 were onlay island flaps (5.3%) and 4 were buccal mucosal grafts (10.5%). Follow-up was 1-5 years (mean 3.5 yr). The final locations of urethral meatus included glans (18), corona (6), mid-shaft (3) and penoscrotal (1). Complications after redo surgery comprised 4 urethrocutaneous fistulae, 2 meatal stenoses, 1 urethral stricture and 3 dehiscences. Sixteen patients were followed with yearly uroflow with a Q-mean (mean uroflow) range of 3-14 mL/s (mean 8.1 mL/s). The majority of hypospadias failures can be salvaged with one operation. The TIP repair is our procedure of choice in most cases. In the setting of a poor urethral plate, TIF or buccal mucosa may be necessary. Complications are not infrequent in redo procedures.

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.

Surgical Outcome of Different Types of Primary Hypospadias Repair During Three Decades in a Single Center

To evaluate the surgical outcome of different techniques of primary hypospadias repair in a single department. We retrospectively evaluated the medical files of all patients who had undergone primary hypospadias repair at our department during the past 3 decades (1978-2009). A total of 820 patients were divided into 3 groups. The first group of 309 patients (37.7%) had glanular hypospadias, the second group of 398 patients (48.5%) had distal hypospadias, and the third group of 113 patients (13.8%) had proximal hypospadias. Of these 820 patients, 67 (8.2%) required corpoplasty to straighten the penis. In the first group, 67 (21.7%) children underwent meatal advancement or meatoplasty, 211 (68.3%) underwent meatal advancement and glanduloplasty, 8 (2.6%) underwent tubularized incised plate hypospadias repair, and 23 (7.4%) underwent Mathieu flap hypospadias repair. In the second group, 196 (49.2%) underwent Mathieu hypospadias repair, 38 (9.5%) underwent tubularized incised plate repair, 142 (35.7%) underwent meatal advancement and glanduloplasty, and 22 (5.5%) underwent onlay-type hypospadias repair. In the third group, 28 (24.8%) underwent 2-stage hypospadias repair, 85 (75.2%) underwent single-stage surgery (including 68 [60.2%] onlay and 11 [9.7%] tubularized island flap), and 6 (5.3%) underwent tubularized incised plate hypospadias repair. Immediate complications developed in 46 (14.9%) in the first, 123 (30.9%) in the second, and 66 (58.4%) in the third group; 38 (4.6%) required additional surgery during or after adolescence. Our data have shown that despite the numerous techniques used for hypospadias surgery, the incidence of complications is still high in patients who undergo hypospadias repair.

Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair

Urethrocutaneous fistula is one of the most common complications after hypospadias surgery. The incidence of fistula development has varied from 4% to 20% in larger series. We sought to investigate the role of fibrin glue (Tisseel manufactured by Baxter India Pvt Ltd, Chennai, India) to reduce the chances of fistula formation in cases in proximal penile hypospadias. Method A total of 120 patients with proximal penile hypospadias (patients having urethral meatus at posterior third of penile shaft and at penoscrotal junction) were included in the present study. Patients were randomly allocated into 2 groups of 60 each by using Strata 9 software random number table. In group A, fibrin glue was used as a sealant after hypospadias surgery, whereas in group B, no sealant was used. All the operations were performed by single surgeon using transverse preputial tubularized island flap urethroplasty. Result Fistula formation occurred in 6 cases in group A (10%) and 19 cases in group B (32%) ( P = .027). The fistulae observed in fibrin glue group A were single and small in size (<1 mm). Multiple (≥2 fistulae) and larger fistulae (>2 mm) were observed in group B. Overall complication was significantly higher in group B ( P = .006). Conclusion Fibrin glue in hypospadias repair does not eliminate fistula formation. However, it seems that it minimizes the incidence of fistula formation.

Impact of patient age on distal hypospadias repair: A surgical perspective

Objectives To assess whether the age at which the initial hypospadias repair is performed influences the complication rate of hypospadias repair. Methods The records of 325 consecutive patients who underwent initial hypospadias repair were reviewed. The patients with glanular and coronal hypospadias underwent repair with either meatoplasty and glanuloplasty or a glans approximation procedure. Patients with subcoronal hypospadias and penile hypospadias underwent repair with tubularized incised plate urethroplasty. The patients were divided into 6-month age groups, and the complication rates were analyzed by age group using the chi-square test. Results A total of 325 hypospadias repairs were performed from January 1999 to January 2005 by a single surgeon. Of the 325 cases, 194 tubularized incised plate procedures were performed, 69 meatoplasty and glanuloplasty procedures were performed, and 53 glans approximation procedures were performed. Nine tubularized island flap urethroplasties performed for penoscrotal hypospadias were excluded because we did not perform a significant number of proximal urethroplasties. Nineteen patients (6.0%) developed urethrocutaneous fistulas and six (1.9%) demonstrated dehiscence. Overall, 2 patients (2.2%) who underwent surgical repair within the first 6 months of age developed complications compared with 23 patients (10.3%) who underwent initial hypospadias repair when they were older than 6 months of age ( P = 0.006). Conclusions Tubularized incised plate, meatoplasty and glanuloplasty, and glans approximation urethroplasty are all excellent options for the surgical correction of hypospadias in the appropriately selected patient. The results of our study have indicated that complications are minimized when hypospadias repair is performed when the patient is 4 to 6 months of age.

Long-Term Followup of Visual Internal Urethrotomy for Management of Short (Less Than 1 Cm) Penile Urethral Strictures Following Hypospadias Repair

We reviewed the results of direct vision urethrotomy for short (less than 1 cm) penile urethral strictures following hypospadias surgery. Patients with less than 1 cm anterior penile urethral strictures located proximal to the meatus underwent direct vision urethrotomy. Based on the type of initial urethroplasty patients were randomly divided into treatment with direct vision urethrotomy vs direct vision urethrotomy plus clean intermittent catheterization for 3 months. Success was defined as absent obstructive voiding symptoms and a normal urine flow 2 years following the last patient instrumentation. Of patients with urethral strictures following hypospadias repair 44% (32) had previously undergone tubularized graft urethroplasty and 56% (40) had previously undergone flap urethroplasty, including a tubularized island flap in 18, an onlay flap in 11 and urethral plate urethroplasty in 11. Direct vision urethrotomy alone was performed in 51% of patients (37), and direct vision urethrotomy and clean intermittent catheterization were performed in 49% (35). Success with the 2 methods was similar, that is 24% (9 of 37 patients) vs 22% (8 of 35). Following direct vision urethrotomy all patients with tubularized graft urethroplasty showed failure (0 of 32). Success was noted in 11% of patients (2 of 18) with tubularized island flap urethroplasty compared to 72% (8 of 11) with onlay urethroplasty and 63% (7 of 11) with urethral plate urethroplasty (each p <0.05). The addition of clean intermittent catheterization to direct vision urethrotomy does not improve the likelihood of success. Direct vision urethrotomy for short (less than 1 cm) urethral stricture usually fails following any type of tubularized graft or flap urethroplasty but it had moderate success following onlay flap and urethral plate urethroplasties.

Multiple failed urethroplasties: definitive repair with the Duckett island-flap technique

Background/Purpose: The correction of postoperative complications after hypospadias repair presents frequently serious problems, and the results are not always satisfactory. The aim of this study is to present our experience with the tubularized island flap technique (Duckett procedure) in patients who had been submitted to repeated unsuccessful attempts for the repair of hypospadias and its complications. Methods: During an 8-year period (1994 through 2001), 21 patients, aged 4 to 18 years, presented with severe recurrent hypospadias (3 to 13 times). In all patients, the urethral orifice was quite proximal because of disruption of the neourethra and was associated with severe penile ventriflexion. In addition, there were diverticula with hair ingrowth in 5 boys and lack of the prepuce in 4. All patients underwent the Duckett island-flap technique. The inner layer of the prepuce was used in 17. The dorsal penile skin was used for the island flap formation in the remaining 4 patients in whom the prepuce had been resected during the previous operations. Results: After repair, the meatus was located at the top of the glans in all patients. There were 5 complications (24%): distal fistula near the glans (n = 1), meatal stenosis (n = 1), diverticula at the proximal anastomosis (n = 2), and anastomotic stenosis (n = 1). All of them were treated successfully by meatotomy, fistula closure, diverticula tapering, and dilatations, respectively. Conclusions: The island-flap technique gives satisfactory results in patients with multiple failed urethroplasties; it is applicable even in boys with resected prepuce and has an acceptable complication rate.

A strategy for repairing moderately severe hypospadias using onlay urethroplasty versus onlay-tube-onlay urethroplasty

Objectives Moderately severe hypospadias can be repaired by a simple onlay island flap procedure with penile dorsal plication in most patients. However, when the penile curvature could not be corrected, and the urethral plate could not be preserved by the procedure, a combined procedure of onlay and tubularized island flap is subsequently needed. Methods Onlay urethroplasty was performed to repair hypospadias in 39 patients with hypospadias. However, the combined procedure (onlay-tube-onlay urethroplasty) was performed on 6 patients who had severe penile curvature even after skin degloving. Results Hypospadias was repaired successfully without complications in 30 (90.9%) of the 33 patients by conventional onlay urethroplasty alone. Of the 6 patients who underwent onlay-tube-onlay urethroplasty, 1 patient developed fistula and 1 developed meatal stenosis, for a success rate of 66.7%. The complications in all patients were later resolved. Conclusions We recommend switching to onlay-tube-onlay urethroplasty when the attempt to repair moderately severe hypospadias by the simple onlay procedure has to be abandoned, and the urethral plate needs to be divided.

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.

One-stage repair of moderately severe hypospadias using a transverse preputial tubularized island flap.

Transverse preputial tubularized island flap (TPTIF) urethroplasty has been used for the repair of moderately severe hypospadias since Duckett described the procedure in 1980. In spite of the excellent results reported by Duckett, subsequent studies showed high complication rates. A TPTIF procedure modified to reduce the complication rate is presented. Between 1996 and 1997, 13 boys with moderately severe hypospadias were repaired with the TPTIF procedure. Patient age ranged from 10 months to 3 years with an average age of 23 months. To prevent urethrocutaneous fistula, the neourethra was constructed with a two-layer closure and the portion of anastomosis was wrapped between the native urethra and the neourethra with the tissue of the corpus spongiosum. The moderately severe hypospadias was repaired without complication in 12 of 13 patients. A urethrocutaneous fistula developed at the midshaft of the penis in one patient. No meatal stenosis, urethral stricture or diverticulum developed. Transverse preputial tubularized island flap urethroplasty provided excellent cosmetic and functional results for moderately severe hypospadias, and postoperative complications could be decreased by the two-layer closure of the neourethra and application of the wrapping technique of the proximal anastomosed portion with corpus spongiosum tissue.

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.

INLAY-ONLAY FLAP URETHROPLASTY FOR HYPOSPADIAS AND URETHRAL STRICTURE REPAIR

Purpose The absence of a segment of the urethral plate renders the onlay urethroplasty procedure impossible. The plate may be too short (in hypospadias), or sacred after previous repair or due to a dense urethral stricture. A modified approach with restoration of urethral plate continuity is proposed instead of the tubularized island flap associated with higher complication rates. Material and Methods In 12 of 20 patients with a partially deficient urethral plate the inlay-onlay preputial island flap was used. The wider part of the flap is inlaid in place of the missing plate and anastomosed to the residual plate. Formation of the urethra is then completed with standard onlay overlapping of the flap. In another 8 patients the combined (partially tubularized in advance) tube-onlay flap was used. Results The inlay-onlay flap technique was used in 3 new hypospadias patients, in 4 with a scarred, hair-bearing plate after previous operations and in 5 with virtually no urethral plate because of a dense urethral stricture. No urethral complications were encountered. Of the 8 patients undergoing the combined tube-onlay repair 3 had complications, including meatal stenosis (2) and partial dehiscence (1). Conclusions Inlay-onlay flap urethroplasty allows correction of complex cases of hypospadias or urethral stricture with a partially deficient urethral plate in 1 stage with a low complication rate.

Comparison of Onlay and Tubularized Island Flaps of Inner Preputial Skin for the Repair of Proximal Hypospadias

Purpose Transverse island flaps of inner preputial skin have provided a reliable technique for the repair of proximal hypospadias. The flap may be used to create a neourethra by tubularizing the flap after urethral transection or applying the flap as an onlay patch onto an intact urethral plate. We retrospectively analyzed our experience with these 2 techniques to compare outcomes. Materials and Methods During 11 years 132 patients underwent hypospadias repair by a single surgeon using an onlay (58) or tubularized (74) island flap technique. Surgical results were reviewed retrospectively. Results At a mean followup of 20.3 months the overall complication rate was 36% for tubularized and 31% for onlay repair, and fistula rates were 14 and 17%, respectively. Despite similar fistula rates tubularized repairs tended to have larger fistulas that required more complex repair (p = 0.0147). In 9 patients who underwent tubularized repair diverticula developed, whereas no diverticula developed after onlay repair (p = 0.0162). The rates of urethral stricture, wound infection, residual chordee and cosmetic complications were not statistically significantly different between repairs. The use of double faced repair in 30 patients provided no difference in outcome in comparison to the overall study cohort. Conclusions Hypospadias repair using transverse island flaps offers reliable and durable outcomes. While overall complication rates were not greatly different between tubularized and onlay flap repairs, onlay repair tended to result in fistulas of smaller size and diverticula did not develop.

Functional Evaluation of the Results of Hypospadias Surgery with Uroflowmetry

To determine the role of uroflowmetry in the evaluation of the functional results of hypospadias repair we retrospectively reviewed the records of 32 patients who underwent hypospadias repair with urethral reconstruction (mean age 2.4 years and mean followup 3.6 years). Patients with a plateau pattern and a maximum flow rate 2 standard deviations below the mean for age, body surface and voided volume on more than 1 determination were considered to have urethral obstruction. Urethroplasty had been performed with a meatal based flap in 11 cases, an onlay preputial flap in 5 and a tubularized preputial island flap in 16. Two of 11 patients with a meatal based flap, 5 of 16 with a tubularized preputial island flap and none with an onlay preputial flap had uroflow evidence of urethral stenosis. The 2 patients in the meatal based flap group responded to dilation with a normal flow. Of the tubularized preputial island flap group 3 patients required urethroplasty to correct a stricture and 2 had improvement with dilation alone. Three patients in the tubularized preputial island flap group had normal flow after treatment and 2 had improvement. Only 2 of the 7 patients with strictures were symptomatic. We conclude that uroflow examination is an important noninvasive tool to evaluate the functional results of urethroplasty in children and detect asymptomatic strictures.

Congenital penile curvature (chordee without hypospadias)

We treated 30 patients aged six months to nine years with congenital penile curvature from 1988 to 1993. Twenty-four patients appeared to have a primary curvature with normal corpus spongiosum. In 12 of these 24 patients dissecting skin and dartos fascia were adequate to straighten the penis. In the other 12 patients, artificial erection demonstrated a varied degree of convexity of the penis after the skin and dartos fascia release, implying a disproportion of the corpora cavernosa bodies. We corrected this deformity using dorsal tunica albuginea plications (TAP). The remaining 6 patients presented with a primary curvature and hypoplastic urethra. In 5 of these patients we divided the hypoplastic midportion of the urethra leaving the meatus naturally on the glans and replaced the midurethral segment using a tubularized island flap. Of these 5 patients 2 required TAP for penile straightening. The final patient with a hypoplastic urethra was managed by preserving the urethral plate and applying an onlay island flap urethroplasty. Complications were one fistula and two mild ventral penile curvatures, presently not severe enough for reoperation (mean follow-up 2.6 years). We present a systematic approach for the repair of congenital penile curvature using intraoperative artificial erection, TAP, and the island flap urethroplasty when needed.