Tunica Vaginalis Flap Research Articles

Enhancing Tubularized Incised Plate (TIP) Technique for Hypospadias Repair: The Role of Tunica Vaginalis Flap in Minimizing Urethrocutaneous Fistula

Enhancing Tubularized Incised Plate (TIP) Technique for Hypospadias Repair: The Role of Tunica Vaginalis Flap in Minimizing Urethrocutaneous Fistula

“Detubularised Non Augmented Urethroplasty”- A Promising Option for Pananterior Urethral Stricture: A Case Series

Pananterior urethral stricture involving the penile and bulbar urethra is a challenging urological condition in the Indian population. In India, Balanitis Xerotica Obliterans (BXO) or Lichen Sclerosus (LS) is the most common cause of pananterior urethral stricture. Various surgical techniques have been described in the literature for present condition, with varied outcomes. However, there is still a need for a simple and effective procedure to address this problem. Hereby, the authors present a case series that included five male patients with BXO and pananterior urethral stricture who underwent Detubularised Non Augmented (DNA) urethroplasty between January 2022 and December 2022. The median age of the patients was 45 years, with a mean stricture length of 13 cm. The median follow-up period was 11 months. During the procedure, a scroto-perineal incision was made, and the anterior urethra was ventrally cut open from the meatus to the junction of the stricturous and normal urethra. A right-sided Tunica Vaginalis (TV) flap was raised (left is left), and the cut-open anterior urethra was wrapped with the TV flap, creating a “controlled fistula” at the proximal end of the detubularised urethra. The average operative time was 1.5 hours. The success of the procedure was determined by a postoperative peak flow rate of 12 mL/sec or more, with no further need for urethral dilatation or direct vision internal urethrotomy. The procedure was successful in 4 out of 5 cases (80%). One patient developed a narrowed urethra during follow-up and required serial catheter upgradation for urethral dilatation. In conclusion, DNA urethroplasty was found to be a simple and effective treatment option for the notorious pananterior urethral stricture associated with BXO.

Application of Tunica Vaginalis Flap for Epispadias Repair in the Epispadias-Exstrophy Complex

To describe long-term outcomes and experience with the tunica vaginalis flap (TVF) as a tissue augment for complex epispadias repair. A prospectively maintained institutional database was reviewed for patients who underwent epispadias repair with TVF from 2010 to 2021. Evaluation of patient characteristics between those who developed dehiscence or UCF and those who did not was performed via Mann-Whitney U, Kruskal-Wallis, or Fisher's exact test, as appropriate. A total of 47 male patients were identified, of whom, 1 (2.1%) had cloacal exstrophy, 38 (80.9%) had classic bladder exstrophy or a variant, and 8 (17.0%) had epispadias as their primary exstrophy-epispadias complex diagnosis. The median age at epispadias repair was 13 months (IQR 11 - 19). The overall rate of fistula or dehiscence development was 19.1% (9 patients), of whom, 7 developed urethrocutaneous fistulae, 1 dehiscence, and 1 both. Notably, 0 of the 5 patients who had undergone prior epispadias repair and 0 of the 8 patients with a diagnosis of isolated epispadias developed a UCF or dehiscence after repair with TVF. Differences in age at repair, primary EEC diagnosis, prior epispadias repair, pre-repair testosterone, fibrin sealant utilization, closure layers, stent removal time, and bladder capacity at repair were not statistically significant (P>.05) CONCLUSION: Our expanded evaluation indicates that utilization of the tunica vaginalis as an adjunct to epispadias repair may provide durable protection against fistula development in EEC patients who have undergone prior epispadias repair and in primary repair of patients with isolated epispadias.

Recurrent ventral curvature after corporoplasty with tunica vaginalis flap

Optimal means to correct ventral curvature (VC) is debated. Our preferred technique for curvature greater than 45° is corporoplasty using tunica vaginalis flap (TVF). We describe our complications with TVF for ventral lengthening. Forty-four boys who underwent ventral lengthening with a corporoplasty with TVF were identified in a prospective database for proximal hypospadias repair by a single surgeon from 2008 to 2021. Corporotomy was performed by incising the tunica albuginea of the corpora cavernosa transversely at the point of maximum curvature. Harvested TVF was tailored to the size of the corporotomy and anastomosed to the edges of the tunica albuginea and on laid to the corporal defect with the mesothelial side of the TVF abutting the erectile tissue. Median age at surgery was 1.0 years (IQR 0.72-1.82). Median follow-up time was 4.9 years (IQR 2.6-8.0). Thirteen patients (27%) were older than 10 years of age at last follow up (median 13.3, range 10-20). Twenty-two boys (50%) received preoperative testosterone. The most common location of the meatus after degloving was penoscrotal (41%). Median VC after degloving was 90° (IQR 80-100). The urethral plate was transected in 43/44 (98%) of boys, improving median VC to 60° (IQR 40-60). After corporotomy, the median longitudinal distracted distance was 15mm (IQR 12-17). Urethral reconstruction was most commonly achieved with the transverse island preputial flap technique or its modifications (39/44; 89%). Erections were reported in 42 boys (95%). None developed corporal diverticula, and two patients (4.5%) had ascended testis associated with TVF harvest. Seven percent of boys had recurrent ventral curvature (RVC; 3/44). Median RVC was 30° (IQR 30-45). One patient had RVC at the penoscrotal junction (not at site of prior corporoplasty) identified 11 years post operatively at age 15, and underwent dorsal plication. The other 2 patients were diagnosed less than 1 year post operatively. Both patients received testosterone due to small glans size, had double-face tubularized transverse island preputial flap as urethral and ventral skin coverage, and had endocrine and genetic consultation. Both had scarring of the preputial flap and of the corporoplasty. Scar excision and superficial transverse incisions on the tunica albuginea corrected RVC. The five-year outcome of ventral penile lengthening using TVF for corporoplasty is favorable with 7% of boys with RVC, and 4.5% with ascended testes associated with TVF harvest. None developed corporal diverticula.

To Compare the Outcomes of Dorsal Dartos Flap, Tunica Vaginalis Flap and Durham Smith De-Epithelialized Dartos Based Flap as Secondary Interposition Cover after Tubularized Incised Plate Urethroplasty in Reducing Post-Operative Complications

Interposition flaps are mainstay in the success of hypospadias surgery because they lead to decrease in complications of hypospadias repair significantly especially urethrocutaneous fistula by buttressing the neo urethral suture line. Many interposition flaps have been tried with varying outcome results. Most commonly used interposition flaps are Tunica vaginalis flap and dorsal dartos flap however, recently interest have also researched in Durham smith de-epithelialized dartos based overlay flap. Though there are many publications comparing outcome of dorsal dartos and tunica vaginalis flap but hardly any study that has compared all three interposition flaps. So, we aimed to compare the outcomes of dorsal dartos flap (DF), tunica vaginalis flap (TVF) and Durham smith de-epithelialized dartos based overlay flap as interposition layer in TIP urethroplasty. Aim: To compare the outcomes of dorsal dartos flap (DF), tunica vaginalis flap (TVF) and Durham smith de-epithelialized dartos based flap as secondary interposition cover after Tubularized incised plate urethroplastyin reducing post-operative complication. Materials and Methods: A retrospective study was conducted in which case records of 78 patients who had undergone repair for distal and midpenile hypospadias with minimal chordee and favorable anatomy by the Tubularized incised plate urethroplasty with interposition flap over 2 years (2017-2019) were reviewed. Patients were divided in three groups with 26 subjects in each group. Group A consisted of patients with dorsal dartos interposition flap, Group B comprised of patients with Tunica vaginalis interposition flap and Group C consisted of patients with Durham smith deepithelialized dartos based overlay cover. Outcome variables noted were the complications including wound dehiscence, Urethrocutaneous fistula, Meatal stenosis, Penile torsion, skin necrosis and preputial edema. Statistical methods were applied to compare these complications in all three groups.

To Compare the Outcomes of Dartos Flap and Tunica Vaginalis Flap as Secondary Cover after Second Stage Durham Smith Repair in Reducing Post-Operative Complications

Background: Interposition flaps are mainstay in the success of hypospadias surgery because they lead to decrease in complications of hypospadias repair significantly especially urethrocutaneous fistula by buttressing the neo urethral suture line. Many interposition flaps have been tried with varying outcome results. Most commonly used interposition flaps are Tunica vaginalis flap and dorsal dartos flap however, recently interest have also researched in Durham smith de-epithelialized dartos based overlay flap. Though there are many publications comparing outcome of dorsal dartos and tunica vaginalis flap but hardly any study that has compared all three interposition flaps. So, we aimed to compare the outcomes of dorsal dartos flap (DF), tunica vaginalis flap (TVF) and Durham smith de-epithelialized dartos based overlay flap as interposition layer in TIP urethroplasty. Aim: To compare the outcomes of dorsal dartos flap (DF), tunica vaginalis flap (TVF) and Durham smith de-epithelialized dartos based flap as secondary interposition cover after Tubularized incised plate urethroplastyin reducing post-operative complication. Materials and Methods: A retrospective study was conducted in which case records of 78 patients who had undergone repair for distal and midpenile hypospadias with minimal chordee and favorable anatomy by the Tubularized incised plate urethroplasty with interposition flap over 2 years (2017-2019) were reviewed. Patients were divided in three groups with 26 subjects in each group. Group A consisted of patients with dorsal dartos interposition flap, Group B comprised of patients with Tunica vaginalis interposition flap and Group C consisted of patients with Durham smith deepithelialized dartos based overlay cover. Outcome variables noted were the complications including wound dehiscence, Urethrocutaneous fistula, Meatal stenosis, Penile torsion, skin necrosis and preputial edema. Statistical methods were applied to compare these complications in all three groups. Results: Total number of complications in group A were 11(42.3%) and most common complications were skin necrosis (n=7, 26.9%) and urethrocutaneous fistula (n=6, 23.1%). Total number of complications in group B were 7(26.9%) while Chordee and preputial edema (n=6, 23.1% each) were among the most common complications. 9(34.6%) patients developed complications in group C and most common complications were penile torsion (n=6, 23.1%) and urethrocutaneous fistula (n=4, 15.4%). Conclusion: We have seen in our study that TV flap is a good option as second cover with lesser complications especially in terms of fistula related complications while Durham smith onlay cover found to be equally better option as it showed no skin complications and other complications were almost comparable to TV flap cover.

Orchio-Septopexy: A new technique to cover and fix detorsed testis undergoing fasciotomy of tunica albuginea.

ABSTRACTPurpose Compartment Syndrome (CS) has been recognized as a potential factor that worsens testicular viability after detorsion, especially in borderline cases of prolonged ischemia. Fasciotomy of the testicular tunica albuginea to relieve the pressure associated with CS has been proposed to accommodate edema after detorsion, embracing the raw fasciotomy area with tunica vaginalis flap (TVF) or graft. Fashioning the TVF can be tedious in cases of severe scrotal edema. Herein we present a technique that facilitates and expedites the procedure, maintaining the fasciotomy area decompressed.Materials and Methods In testicular torsion, where the testis remains with dark coloration and questionable viability after detorsion a longitudinal releasing incision is made in the tunica albuginea (fasciotomy) to decrease compartmental pressure. If signs of parenchymal recovery (bleeding points, better color) are seen an orchio-septopexy is performed, suturing the incised albuginea’s edges to the septum with a running suture, avoiding CS as well as re-torsion.Results Orchio-septopexy was performed in 11 cases with a mean age of 11.9 years (3-17). All cases had clinic follow-up and testicular Doppler US with a mean of 9.5 months (6-24). 6/11 cases (54%) were salvaged, with good vascularity in the Doppler US and maintained more than 50% testicular volume compared to the contralateral side.Conclusion Orchio-septopexy after testicular fasciotomy is a simple and fast technique that can be utilized in cases of prolonged testicular ischemia and questionable viability. More than half of the testes recovered, encouraging us to propose its utilization as well as its validation by other surgeons.

Role of tunica vaginalis flap and dartos flap in tubularized incisional plate for primary hypospadias repair: A retrospective monocentric study.

In the tubularized incised plate (TIP) procedure, flap interposition between the skin and neourethra is highly recommended to decrease the postoperative fistula rate. However, there is no consensus regarding the ideal flap for this procedure. This study aimed to report our experiences in the one-stage TIP hypospadias surgery utilizing dartos flap (DF) (penile skin subcutaneous tissue) and tunica vaginalis flap (TVF) (parietal layer of the testis) as a tissue coverage of neourethra. In a retrospective study from Sep 2018 to May 2021, 16 cases of hypospadias with different types, ranging from midpenile to penoscrotal types, were managed with TIP urethroplasty using DF or TVF as a tissue coverage of neourethra were enrolled. The demographic characteristics of the participants, type of hypospadias, outcome, and complications were analyzed and compared. We used TVF and DF as soft tissue coverage in 11 (68.8%) and 5 (31.3%) patients, respectively. The mean age was 56.38 ± 47.83 months. Mid-penile, proximal, and penoscrotal hypospadias were presented in 3 (18.8%), 8 (50.0%), and 5(31.2%) patients, respectively. The total success rate was 14 (87.5%), while 2 (12.5%) patients developed a urethrocutaneous fistula, which required delayed closure later. In comparison between TVF and DF groups: the TVF was applied in all patients with moderate and severe chordee and all patients with penoscrotal hypospadias, and six patients with proximal hypospadias, while only three patients with mild chordee and two patients with proximal hypospadias used the DF and showed statistical significance between groups (p < 0.001 and 0.012) respectively. The success rate was 90.9% vs. 80.0% in TVF and DF groups, respectively, with no statistical significance between groups (p = 1.000). In the primary TIP repair, the TVF is a practical option as a DF for the interposition cover of a neourethra, especially in penoscrotal and proximal hypospadias with severe chordee.

A meta-analysis comparing dorsal plication and ventral lengthening for chordee correction during primary proximal hypospadias repair.

Recurrent chordee (RC) is an important complication of proximal hypospadias repair. In this meta-analysis we compared RC incidence following dorsal plication (DP) versus ventral lengthening (VL). We searched the databases to identify all papers between 2001 and 2021 pertaining to proximal hypospadias and recurrent chordee. Duplicate publications, review articles and incomplete articles were excluded. Meta-analysis of heterogeneity was reported with I2 statistics. The pooled outcomes were compared to Chi square/Fishers exact test. A total of 17 articles were included covering 582 patients. The I2 statistics for prevalence of RC among different publications showed no heterogeneity for DP (I2 = 0%) and low heterogeneity for VL (I2 = 26%). RC was noticed in 31/122 (25.4%; 95% CI 18%-33%) among patients who had DP alone while it was significantly lower, 24/460 (5.3%; 95% CI 4%-8%) when VL was used (p = 0.0001). When compared to DP, all VL techniques had significantly lower incidence of RC. Among the VL techniques lowest incidence of RC was found for ventral corporotomies (4%) followed by small-intestinal- submucosa (SIS 4.2%) and tunica vaginalis flap (TVF)/free graft-TVFG (5%). Among the VL subtypes: the proportion of RC with use of TVF (4/70, 5.7%) and TVFG (3/69, 4.3%) for corporoplasty was comparable (p = 1); single-layer SIS was associated with significantly less RC (1/90, 1.1%) than 4-layer SIS (5/51, 9.8%; p = 0.02). For correction of severe ventral chordee during primary proximal hypospadias repair, dorsal plication carries a higher risk of recurrence compared to ventral lengthening procedures.

A new option to prevent fistulas in anterior urethroplasty in patients with kippered urethra: the tunica vaginalis flap.

ABSTRACTThe objective of this study is describing a technique with the use of a tunica vaginalis flap (TVF) to cover the suture line during anterior urethroplasty in patients with kippered urethra due to chronic indwelling catheterization (CIC). We studied 5 patients (mean age=50.2) with a neurogenic bladder that developed urethral erosion after a long period of CIC. Foley catheter was removed on the 14th postoperative day. One patient developed wound infection and utethrocutaneous fistula, which was conservatively managed and after 12 months of follow-up all the patients didn't report difficulties in intermittent self-catheterization. In conclusion, a urethroplasty with TVF technique may be a viable method for repairing penile urethral erosions, but further studies are required with a bigger sample to confirm our results.

The tunica-vaginalis flap to prevent postoperative fistula following severe hypospadias repair: Has the search for Holy Grail ended?

IntroductionFistula following hypospadias repair remains a bane of the hypospadiologist resulting in the evolution of various techniques. Despite all these, the incidence of postoperative fistula varies from 10 to 30% and it increases with the severity of the hypospadias. Hence, a study was conducted to evaluate the efficacy of tunica vaginalis flap in preventing fistula formation following severe hypospadias repair. Materials and methodsAn observational study was carried out in a tertiary center between 2008 and 2017. The study included children with severe hypospadias (Proximal penile, Penoscrotal, scrotal, and Perineal). In all the patients, a Tunica-Vaginalis flap was used to buttress the urethroplasty. All the patients were followed up for at least a year after the completion of treatment. ResultsA total of 210 patients were included in the study. Bracka’s two-stage repair was performed in 180 patients who had either Penoscrotal hypospadias or a meatus even more proximal. The rest 30 patients with proximal penile hypospadias underwent a single-stage Snodgrass repair. Four (2%) patients developed a fistula, all following two-stage repairs, and half of them required surgical repair. Two (1%) patients had a partial breakdown of repair and underwent a residual repair after six months. ConclusionThe Tunica-Vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.

Close Range Gun Shot Injury Bilateral Ruptured Testis Repair Using Tunica Vaginalis Flap

Close Range Gun Shot Injury Bilateral Ruptured Testis Repair Using Tunica Vaginalis Flap

Choosing an ideal second layer cover in snodgrass repair for various types of hypospadias.

In this study, we aimed to assess the results of tunica vaginalis flap (TVF), dorsal preputial dartos flap (DPF), and spongioplasty alone as additional cover after neourethra formation in a Snodgrass repair for various types of hypospadias as per the selection criteria decided. This was a non-randomized experimental study of 97 patients with primary hypospadias treated via Snodgrass repair using various second layers (tunica vaginalis flap, dorsal preputial dartos flap, and spongiosum alone) as per the selection criteria in a single center by a single surgeon. The outcome of the procedure was assessed in terms of cosmesis, chordee correction, urinary stream, and uroflowmetry. Of the 97 patients, we used dorsal preputial dartos flap in 42 (43.3%), tunica vaginalis in 38 (39.2%), and spongioplasty only in 17 (17.5%) for primary hypospadias. Urethrocutaneous fistula developed in four patients (three in DPF and one in the TVF groups). One patient each had skin necrosis, hematoma, and wound dehiscence in the DPF group. In the spongioplasty only group, one patient had meatal stenosis which was treated by meatoplasty after failing repeated periodic calibration. DPF should be preferably used for distal penile and TVF for mid and proximal penile hypospadias to ensure excellent result with minimum complications. Spongioplasty only as a second layer is sufficient to avoid the complications wherever it is thick and robust.

Colgajo de túnica vaginal en la prevención de fístulas postoperatorias tras reparación de hipospadias severos: ¿ha terminado la búsqueda del Santo Grial?

IntroductionFistula following hypospadias repair remains a bane for the hypospadiologist resulting in the evolution of various techniques. Despite all these, the incidence of postoperative fistula varies between 10 to 30% and it increases with the severity of the hypospadias. Hence, a study was conducted to evaluate the efficacy of tunica vaginalis flap in preventing fistula formation following severe hypospadias repair. Materials and methodsAn observational study was carried out in a tertiary center between 2008 and 2017. The study included children with severe hypospadias (proximal penile, penoscrotal, scrotal, and perineal). In all the patients, a tunica-vaginalis flap was used to buttress the urethroplasty. All the patients were followed up for at least a year after the completion of treatment. ResultsA total of 210 patients were included in the study. Bracka's 2-stage repair was performed in 180 patients who had either penoscrotal hypospadias or a meatus even more proximal. The rest 30 patients with proximal penile hypospadias underwent a single-stage Snodgrass repair. Four (2%) patients developed a fistula, all following 2-stage repairs, and half of them required surgical repair. Two (1%) patients had a partial breakdown of repair and underwent a residual repair after 6 months. ConclusionThe tunica-vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.

The Hypospadias, Chordee, Orthoplasty and The Prepucial Hood

1.1. Purpose: Making the surgeons aware of the significance of penile chordee, need of optimal straightening of penile shaft (orthoplasty) and appropriate use of well-developed prepucial hood for re-construction of an ideal neo-urethral plate and a near normal neo-urethra by its tubularization and finally re-enforcement of the neo-urethra by prepucial dartos fascial flap to minimize post-operative morbidities. 1.2. Aims and Objectives: Exact assessment of characteristics of chordee by artificial erection of penis, achieving acceptable orthoplasty before commencing upon final neo-urethroplasty and making maximum use of prepucial hood skin in (i) formation of neo-urethral plate and to have an ideal near normal non-hairy and resistance free neo-urethra and or (ii) designing and harvesting various types of skin and or water proofing flaps because of its axial vascularity. 1.3. Material and Methods: Material related to the penile chordee, orthoplasty and appropriate utilization of prepucial hood was collected from the photographic record of hypospadias patients who attended “Hypospadias and VVFs Clinic” between 2004- 2016. Based upon the characteristics of penile shaft and its chordee, various surgical techniques used for acceptable correction of the chordee (orthoplasty) were circum-coronal degloving of penile shaft up to its root, excision of chordee, Dorsal Tunica Albuginea Plication (DTAP), Double Dorsal Tunica Albuginea Plication (DDTAP), Ventral Tunica Albuginea Plication (VTAP), Inner Prepucial Full Thickness Skin Graft (IPFTSG), outer Prepucial Full Thickness Skin Graft (OPFTSG), Dermal Graft (DG), Tunica Vag inalis Graft (TVG) and Tunica Vaginalis Flap (TVF). Accidental breach in Tunica Albuginea (TA) was identified and repaired in water tight fashion. Special care was taken to prevent injury to Dorsal Neuro-Vascular Bundle (DNVB). Hypospadiacs with Bala- clinicsofsurgery.com 2 nitis Xerotica Obliterans (BXO) were excluded from study. 1.4. Observations: Neo-urethroplasty in an uncorrected chordee is deemed to be associated with subsequent anatomical, functional and aesthetic problems, thereby warranting re-do orthoplasty and neo-urethroplasty including total dismantling of the previous surgical repair. The presence of fully developed prepucial hood proved to be a boon to the surgeon in repairing both the fresh as well as re-do cases of neo-urethroplasty and also in harvesting water-proofing flaps to decrease post-operative morbidities. Presence of Undescended Testis (UDT), Inguinal Hernia (IH) and Ano-Rectal Malformation (ARM) are to be corrected on priority.

Detorsion Plus Tunica Vaginalis Flap Coverage in the Management of Ischemic Testis Following Torsion: Experience in Dhaka Shishu (Children) Hospital

Background: Testicular torsion leads to devastating consequences in young boys, about 42% undergo an Orchiectomy resulting in reduced fertility, testicular hormonal dysfunction and psychological trauma.&#x0D; Objective: The aim was to evaluate the testicular salvage rate after detorsion plus tunica albuginea incision with tunica vaginalis flap coverage with orchiopexy.&#x0D; Methods: This was an observational study conducted from January 2016 to December 2017. Data were collected from operation theater and surgery ward register. Data were analyzed using SPSS version 20 statistical software. Continuous data were presented as mean ± SD and categorical data were presented as percentage. Results: Total numbers of patients were 15. Most of the patients presented after 24 hours. Rate of atrophy of testis after orchiopexy was higher in patients presented after 24 hours. Only 4 patients had recognizable testicular atrophy. Surgical site infection was not present in this study. Conclusion: Tunica albuginea incision with tunica vaginalis flap coverage after detorsion with orchiopexy provides more salvage rate in the management of ischemic testis following torsion.&#x0D; DS (Child) H J 2019; 35(2) : 141-144

Tunica Vaginalis Flap Versus Inner Preputial Dartos Flap as Waterproof Layer for Proximal Staged Hypospadias Repair: A Comparative Study

Background: Hypospadias is an abnormality of anterior urethral and penile development in which the urethral opening is ectopically located on the ventral aspect of the penis proximal to the tip of the glans penis, which, in this condition, is splayed open. [1] The urethral opening may be located as far down as in the scrotum or perineum. The penis is more likely to have associated ventral shortening and curvature, called chordee, with more proximal urethral defects. Aim: To compare the outcome of using tunica vaginalis flap to dartos flap in proximal two stage hypospadias repair in reducing post-operative complication (dehiscence and fistula). Materials and Methods: In the defined period of January 2015 to June 2018, 47 male patients with clinical diagnosis of penoscrotal hypospadias, The age of the patients range from 2 years to 10 years, All these cases were managed in 2 stages repair with buccal mucosal graft, with either tunica vginalis flap (group A) (25 cases) , or preputial dartos flap (group B)(22 cases) as a second cover over new tubularized urethra. We compared between these two groups regarding complications rate. Result: we observed that tunica vaginalis flap was better than dartos flap (although it was statistically non significant p value 0.214 &gt; 0.05) specifically in fistula formation. Conclusion: we observed that tunica vaginalis flap had excellent outcome when used as a second layer over the neourethral suture line in term of decrease the fistula rate and wound dehiscence because of its good vascular features

739 - Effect of additional Tunica Vaginalis flap coverage protecting urethrocutaneous fistulas in tubularized incised plate urethroplasty: A prospective, randomized controlled trial

739 - Effect of additional Tunica Vaginalis flap coverage protecting urethrocutaneous fistulas in tubularized incised plate urethroplasty: A prospective, randomized controlled trial

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

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

Tunica vaginalis flap for salvaging testicular torsion: A matched cohort analysis

In testicular torsion, ischemia time from pain onset impacts testicular salvage. A tunica albuginea fasciotomy to relieve compartment pressure followed by a tunica vaginalis flap (TVF) may enhance salvage. To define the optimal window of ischemia time during which TVF may be most beneficial to avoid orchiectomy. A retrospective cohort study of males presenting with testicular torsion at a single tertiary-care institution from January, 2003 to March, 2017. Ischemia time was defined as duration of pain from onset to surgery. Because TVF would be an option to orchiectomy, and it was found that ischemia time was longer in testicles that underwent orchiectomy, matching was performed. Cases of torsion treated with TVF were matched 1:1 with cases treated with orchiectomy on age at surgery, and ischemia time. Outcomes included postoperative viability, defined as palpable testicular tissue with normal consistency, and atrophy, defined as palpable decrease in size relative to contralateral testicle. Sensitivity analyses were performed restricting to the subgroups with postoperative ultrasound, >6 months' follow-up, and additionally matching for degrees of twist. A total of 182 patients met eligibility criteria, of whom 49, 36, and 97 underwent orchiectomy, TVF, and septopexy alone, respectively. Median follow-up was 2.7 months; 26% of patients had postoperative ultrasound (61% of TVF group). In the orchiectomy, TVF, and septopexy groups, respectively, median ischemia times were 51, 11, and 8h, postoperative viability rates were 0, 86, and 95%, and postoperative atrophy rates were 0, 68, and 24%. After matching, 32 patients with TVF were matched to 32 patients who underwent orchiectomy. In the TVF group, postoperative viability occurred in 95% (19/20) vs 67% (8/12) of patients with ischemia times ≤24 and >24h, respectively. Atrophy occurred in 67% (12/18) vs 83% (10/12) of these same respective patients. Sensitivity analysis by ultrasound and longer follow-up found similar viability results, although atrophy rates were higher. Additional matching for degrees of twist showed lower viability and higher atrophy rates for increasing ischemia times. Patients who presented with testicular torsion with ischemia times ≤24h and who were being considered for orchiectomy may have benefitted most from TVF, albeit at high risk of atrophy. However, for ischemia times >24h, TVF may still have preserved testicular viability in two-thirds of cases. A limitation was short follow-up. A TVF was a valid alternative to orchiectomy for torsed testicles, albeit with high testicular atrophy rates.