Urethroplasty For Hypospadias Research Articles

Unfavourable results in hypospadias

Hypospadias urethroplasty is considered difficult as the complications and unfavourable results are not uncommon. At the turn of the century, due to a better understanding of applied anatomy of hypospadias, new techniques were developed which significantly brought down the complication rate. However unfavourable results are still disturbing. An algorithm for selection of surgery has been presented. Forty three secondary surgeries were performed over 3 years for correction of unfavourable results. The urethrocutaneous fistula was the most common (21%) followed by meatal stenosis (14%) and narrow neourethra (14%). Common unfavourable results have been discussed. On the basis of experience with a large number of hypospadias urethroplasty ‘tips to avoid or minimise unfavourable results’ have been presented. However, one should assess the final outcome of urethroplasty using hypospadias objective scoring evaluation.

Effect of Double Layer Dartos Flap in Reduction of Fistula Rate Post Hypospadias Repair = استخدام طبقة مزدوجة من السديلة السلخية يقلل من حدوث الناسور الإحليلي بعد إجراء عمليات إصلاح المبال التحتي

Objective: To assess the impact of double layer dartos flap on urethro-cutaneous fistula rate reduction and to compare it with single layer dartos flap in Tubularized Incised Plate Urethroplasty (TIPU) for hypospadias in children. Methods: Between January 2008 and month 2011 retrospective charts review for 120 patients who had hypospadias repair by the author. 26 patients were excluded from the study because they were not suitable for TIPU procedure. Therefore, our study sample involved 94 children. Results: Mean age at time of surgery was 16 months (10-96 months), with a mean follow up of 18.2 months (10–36 months). All patients had hypospadias repair by utilizing TIPU. Patients were divided into two groups: Group one involved 50 patients had double layer dartos flap. Group two involved 44 patients had single-layer dartos flap. All patients had stent insertion at the time of repair. 6/44 patients [13.6%] developed fistula in group two and 2/50 patients [4%] in group one had fistula. Conclusions: Dartos coverage appears to have significant effect in reducing urethro-cutaneous fistula in TIPU repair. With double layer dartos coverage further reduction can be achieved.

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.

Modified Snodgrass tubularized incised plate urethroplasty prevents fistula formation in hypospadias

Urethrocutaneous fistula is a common complication after redo urethroplasty for hypospadias, or urethroplasty for patients with thin urethral plate. We modified Snodgrass' tubularized incised plate urethroplasty (STIPU) by stripping the most superficial skin from both sides of the U-shaped incision to expose more subcutaneous tissue along the suture line. Our modified STIPU would appear to be effective in preventing postoperative urethrocutaneous fistula formation in redo urethroplasty for hypospadias, and urethroplasty for patients with thin urethral plate.

Regenerative urethroplasty in reoperative hypospadias: Buried strip principle revisited

Aim:Reporting the feasibility of the Denis Browne (buried strip) principle along with tunica vaginalis (TV) pedicled wrapping of the strip in reoperative urethroplasty in hypospadias.Materials and Methods:Over a period of 5 years, 32 patients presented with failure of previous urethroplasty and the range of failure was between 2 and 6 times; mean 2.5 times. Mean age was 12.9 (range 2 to 26 years) years. “Buried strip” urethroplasty (i.e., without tubularization of urethral plate) and wrapping with TV were done along with supra pubic cystostomy (SPC) for diversion of urine. Mean follow-up was 29.8 (range 12 to 56 months) months.Results:One patient had fistula and vertical slit meatus was possible in 26 patients. The flow of urine was satisfactory in 31 patients and one patient developed pouch in penile urethra.Conclusions:The buried strip along with the additional coverage with TV was found to be simple and effective in salvaging the failed urethroplasty.

Multicentric experience on double dartos flap protection in tubularized incised plate urethroplasty for distal and midpenile hypospadias

We report a multicenter experience using double dartos flap to protect the neourethra in TIP urethroplasty for distal and midpenile hypospadias. A total of 394 patients underwent tubularized incised plate urethroplasty for primary distal and midpenile hypospadias using double dartos flap protection by ten pediatric surgeons and urologists at five different institutions. Tubularized incised plate urethroplasty protected by a double dartos flap was simple to perform and flaps were easy to obtain. Complications occurred in 23 patients (5.83%): fistulas 1.01% (4 cases), stenosis 0.25% (1 case), mild stenosis 2.53% (10 cases), dehiscence of ventral cutis 0.50% (2 cases) and penile torsion 1.26% (5 cases). All fistulae had a spontaneous resolution. Double dartos flap to protect tubularized incised plate urethroplasty is safe with a low complication rate. The neourethra is covered entirely with a double layer of vascularized tissue and the double coverage appears a good choice for preventing urethrocutaneous fistula formation.

Feasibility of repair of distal penile hypospadias as a day-case surgery

Objective The aim of this study was to present the outcomes of children with distal hypospadias who were operated on outpatient basis. Methods Atotal of 47 consecutive children underwent surgical repair of distal hypospadias in our department. Urethroplasties were performed by the following techniques: stentless meatal advancement-glanuloplasty (MAGPI) or glans approximation procedure (GAP) for glanular hypospadias (14) and tubularized incised plate (TIP) urethroplasty for coronal, subcoronal and midpenil hypospadias with an indwelling urethral catheter or short stent (33). The indwelling urinary catheters were managed by the double diaper technique. Patients were discharged within 6 h after operation. Dressings and catheters were removed on the postoperative day 2 and 6, respectively. Results Voiding difficulty and urinary retention on early postoperative period were observed in 8 patients. Except meatal stenosis in 4 cases and meatal retractions in 2 cases, there were no major complications in any of our patients during the follow-up period, no postoperative fistula or urethral stricture. Conclusion In children, repair of distal penile hypospadias on outpatient basis is feasible. Catheters, urethral stents, drug therapy and dressing are not justifications for hospitalization in such cases. Keywords: hospital stay, hypospadias, outpatient, urethroplasty, wound dressing

Prepuce preserving versus conventional Mathieu urethroplasty for distal hypospadias – A prospective randomized study

ObjectivesTo evaluate the impact of prepuce preservation during Mathieu repair for distal hypospadias. MethodsThis prospective randomized comparative study, carried out in Assiut University Hospital, between 2006 and 2009, included 200 patients with distal penile or coronal hypospadias. They underwent either Mathieu repair with prepuce preservation (group I, n = 100) or traditional Mathieu repair with circumcision (group II, n = 100). Follow up was at 2 weeks, and 1 and 3 months postoperatively, which only 153 patients completed (I: n = 86 and II: n = 67). ResultsThe mean operative time was 64.5 min in group I and 121.7 min in group II (p < 0.001). All patients in group I developed postoperative preputial edema. Patients from group I who had a successful operation underwent circumcision at least 3 months later. Urethrocutaneous fistulae developed in 7 and 6 patients in group I and II respectively (p = 0.967). Fistula closure was done at least 3 months postoperatively, and there was no significant difference in success between the two groups. Two cases of glanular dehiscence were detected (one in each group); the patient from group I had a successful onlay island flap repair. ConclusionsPreputial preservation during Mathieu repair is a time-saving procedure with similar complication rate to traditional repair. Valuable local tissue is preserved to deal with complications that may occur.

Editorial Comment

No AccessJournal of UrologyPediatric Urology1 May 2011Editorial Comment Luis H. Braga Luis H. BragaLuis H. Braga More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.12.110AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 185(5), pp. 1850–1851 References 1 : Is statistical significance sufficient?: Importance of interaction and confounding in hypospadias analysis . J Urol2010; 184: 2510. Link, Google Scholar 2 : Tubularized, incised plate urethroplasty for distal hypospadias. J Urol1994; 151: 464. Link, Google Scholar 3 : Multivariable analysis: a primer for readers of medical research. Ann Intern Med2003; 138: 644. Google Scholar 4 : 5Alpha-dihydrotestosterone (DHT) retards wound closure by inhibiting re-epithelialization. J Pathol2009; 217: 73. Google Scholar Division of Urology, McMaster University Children's Hospital, Hamilton, Ontario, Canada© 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 5May 2011Page: 1850-1851 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luis H. Braga More articles by this author Expand All Advertisement PDF downloadLoading ...

Application of tunica vaginalis flap for multi-fistulas after urethroplasty in hypospadias

To discussed a new technique for multi-fistulas after urethroplasty in hypospadias. 8 cases with postoperative multi-fistulas, which were not successfully repaired by previous treatment, were reoperated with tunica vaginalis flap combined with urethral stent and elastic dressing. The multi-fistulas were located between glan and scrotum. The number of fistulas was 3-7 (median, 5). Primary healing was achieved in all the 8 cases. The micturition and esthetic result were satisfied. 5 cases were followed up for 8-10 months with no recurrence of fistula. There was also no dysuria and penile curvature. Tunica vaginalis flap combined with urethral stent and elastic dressing is an effective technique for multi-fistulas after urethroplasty. It is easily performed with reliable result.

Staged buccal mucosa urethroplasty in reoperative hypospadias

Introduction:Repeated attempts at surgical repair of serious complications involving either the partial or complete breakdown of the hypospadias repair are less likely to succeed because the penis is densely scarred, or significantly shortened, and the skin over the penis is immobile and hypovascular. Buccal mucosa (BM) has become the preferred material for reconstruction, whenever a child with skin-deficient hypospadias needs reoperation. We report the results of our surgical experience with staged reoperation using BM, in the repair of hypospadias in children with complications after multiple failed repairs.Materials and Methods:Children needing reoperation for hypospadias underwent a staged repair using buccal mucosa. The complications were noted.Results:Twenty-one children aged 3 – 16 years underwent this staged repair during the period May 2000 – April 2010. Two of these 21 children had a failed first stage. One child developed a urethro-cutaneous fistula following the second stage, which was corrected in an additional stage.Conclusions:The use of the buccal mucosa graft for urethral reconstruction in a child with hypospadias, needing a reoperation, is a successful method, with a low incidence of complications.

Re: O’Connor KM and Kiely EA: Lessons learned using Snodgrass hypospadias repair (Irish J Med Sci 175:37)

The authors reviewed experience with TIP repair for distal hypospadias, finding 21% developed meatal stenosis. Unfortunately, they did not describe their postoperative assessment and so the reasons the diagnosis was suspected, means it was established, and time following surgery it occurred are not reported. As the authors note, meatal stenosis is a well-known complication from hypospadias urethroplasty. However, review of published series on TIP repair indicates this complication occurred in only 1.5% of patients [1], and in my own experience has been found in less than 1%. I perform a single calibration of the neomeatus 6 months postoperatively to confirm a size [ 8Fr in young boys. This low incidence of meatal stenosis in contrast to that reported by the authors most likely indicates technical error. The fact stenosis occurred in their first 2, but not the last 2, years performing TIP further reinforces this impression. Furthermore, the authors themselves state technical modifications improved their results. It is worth emphasizing deep incision of the urethral plate and care to avoid tubularizing the neourethra too far distally both decrease likelihood for stenosis. I tubularize the neourethra to approximately 3 mm from the tip of the glans, and then independently perform glansplasty without securing the neomeatus to the glans wings. In the Introduction, the authors state urethral plate incision should not extend beyond the midglans, but failure to carry the incision further distally to near the end of the plate could contribute to subsequent stenosis. I have never performed postoperative meatal dilation. The fact less than 5% of patients are at risk for meatal stenosis calls to question the authors’ recommendation for routine dilation for all boys the first months after surgery. While it may be ‘‘relatively painless’’, it is certainly not completely painless and may cause unnecessary anxiety for both the child and his mother.

In Vivo Biomechanical Assessment of Anterior Rabbit Urethra After Repair of Surgically Created Hypospadias

We studied the in vivo biomechanical properties of the anterior urethra in a rabbit hypospadias simulation model at long-term followup after urethroplasty. A total of 38, 9-week-old white New Zealand male rabbits were randomized into active treatment and control groups. The active treatment group included hypospadias-like simulation and acute repair (sham, mobilization and advancement, tubularized incised posterior urethral plate). After 23 weeks all groups underwent biomechanical investigation using impedance planimetry. Cross-sectional area pressure measurements during bag distention were conducted at 3 different positions along the urethra, and biomechanical (tension-strain) relations were computed. The biomechanical parameters studied were urethral luminal dimension (cross-sectional area pressure relation) and its deformability to luminal pressure (tension-strain relation). The urethral cross-sectional area was significantly larger in the mobilization and advancement group compared to the tubularized incised plate group (p <0.001), shams and controls at the distal distention site (p <0.05), and other groups at the intermediate distention site (p <0.05). The strain-tension curves were not significantly different between the groups. All groups showed a nonlinear cross-sectional area pressure and circumferential wall tension-strain relationships in the 3 distention sites. The urethras exhibited a decreasing ability to be distended with increasing pressures, indicating self-protection against damage. At long-term followup no differences in tension-strain relations were found between groups, despite the fact that the mobilization and advancement group had enlarged urethras. Our hypospadias simulation animal model could be useful to test commonly used or new urethroplasty techniques and their functional (biomechanical) long-term results before clinical use.

Overnight urethral stenting after tubularized incised plate urethroplasty for distal hypospadias

The duration of urethral stenting after tubularized incised plate (TIP) urethroplasty for hypospadias varies among surgeons. Typically the catheter is left for up to 7 days with the goal of minimizing post-operative complications. We describe our experience with overnight stenting for distal TIP hypospadias repair. A retrospective chart review was performed on patients who underwent TIP hypospadias repair from 2003 to 2008. Patients who had their urethral catheter overnight were included in this analysis. Outcomes analyzed were the rates of: urethrocutaneous fistula, meatal stenosis, urethral stricture and urinary tract infections. A total of 64 patients underwent outpatient TIP hypospadias repair. Forty-nine patients had overnight urethral stenting with at least 12 months follow-up and were included in the analysis. Five of the 49 patients (10.2%) developed urethrocutaneous fistula. Of these five patients, two had undergone re-do hypospadias repair. The fistula rate in primary repairs was 3/45 (6.7%). There were no incidences of meatal stenosis, urinary tract infections or urethral strictures. In our experience, overnight urethral stenting for TIP hypospadias repair does not significantly affect the rates of urethrocutaneous fistula, meatal stenosis and urinary tract infections. Patients who have had a primary TIP hypospadias repair may have their urethral catheter removed safely on post-operative day one.

One Stage Urethroplasty in Severe Hypospadias -Buccal Mucosa Inlay with Penile Island Skin Flap Onlay

Purpose Severe forms of Hypospadias are usually associated with chordee and short or even absent urethral plate that result in a small and curved penis. In this case, the urethral plate should be divided for penile straightening and lengthening. In such cases the missing urethral plate needs to be augmented. Material and Methods We present the case of a 14 month old boy with a perineal Hypospadias, a 90° ventral penile curvature and a bifid scrotum.After completion of penile degloving, artificial erection reveals a severe ventral penile curvature.The short urethral plate is mobilised in the plane of Buck’s-Facia. The urethral plate is divided at the coronal level.The dorsal neurovascular bundle is carefully mobilised. With another artificial erection, the point of the maximal curvature is revealed and the intended correction marked with an Ellis-Clump.In order to straighten the penis, the marked area is incised longitudinally and sutured transversally. Renewed erection demonstrates the straightened penis.The distance between the original hypospadic meatus and the distal end of the divided urethral plate shows a 4cm gap that needs to be bridged.Buccal mucosa is harvested from the inner cheek and brought to the ventral aspect of the penis to be used as an inlay graft to fill in the gap of the missing urethral plate.After complete fixation of the buccal mucosa, the inlay is quilted to the tunica albuginea.Dorsal penile and preputial skin was used for creating the longitudinal island flap.The island flap is transposed ventrally with the buttonhole technique to be used as the onlay flap.The glanular wings are trimmed and the glans reconstructed.The bifid scrotum is corrected in the same session. Results A severe Hypospadias was corrected as a one-stage-procedure. No complications occurred. Conclusions Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe Hypospadias repairs.

One Stage Urethroplasty in Severe Hypospadias Using Buccal Mucosa and Longitudinal Penile Island Flap

Purpose The incorporation of the urethral plate into the neourethra is essential for a successful correction of Hypospadias. However, the quality and availability of the urethral plate is variable in severe forms of Hypospadias, thus it is often difficult to repair these using conventional methods. We present a single stage method of combining buccal mucosa and longitudinal onlay island penile flap for urethral reconstruction. Material and Methods During the period from October 2003 to June 2009, a total of 14 children with the mean age of 18 months (range 6-26 months) underwent this type of surgery. The indication was scrotal Hypospadias (n=8), perineal Hypospadias (n=4) and Hypospadias without Hypospadias (n=2). In all cases the urethral plate was too short and had to be divided. The penis is completely straightened using the Yachia technique. Longitudinal penile island flap was harvested with abundant and redundant vascularized subcutaneous tissue from dorsal penile and preputial skin. Buccal mucosa was grafted on the tunica albuginea in-between the divided parts of the urethral plate. Longitudinal vascularized skin flap was button-holed ventrally. The edges of the flap and buccal mucosa were sutured together in an onlay manner, to form the neourethra. Glans wings were reunited over the neourethra. The remaining penile skin was used to cover the penile body. Results The follow up was 2.8 years (range 3 months to 4,5 years). Good esthetic and functional results are achieved. The patients void easily through their neourethra. No fistulas or stenosis occurred. One Two children have a urethral diverticula. Conclusions Urethroplasty using buccal mucosa graft and vascularized penile skin flap represent a good choice in cases where the urethral plate is short, absent or of bad quality. The procedure has the advantage of an onlay procedure performed in a single stage.

The role of tunica vaginalis graft as the dorsal component of urethra in 1-stage and 2-stage hypospadias repair: experimental study in rabbits

Purpose The paucity of tissue for the urethroplasty in complex Hypospadias has opened a discussion and the search for alternative materials. The buccal mucosa is the most popular tissue used to date. We were interested to evaluate the use of tunica vaginalis graft as dorsal component of urethra anastomosed either to normal urethral mucosa, to a penile preputial flap and also as a graft in 2-stage Bracka strategy. Material and Methods We used a rabbit model and created a defect in the penile urethra and developed 3 experiments to study clinical outcome and histological healing of the neourethra with hematoxilin-eosine and Masson's trichrome staining techniques. For each experiment (n=16), 4 subgroups of sacrifice with 4 animals each were defined according to sacrifice date of 2, 4, 8 and 16 weeks. The difference of experiment 1 to 2 was that dorsal tunica vaginalis was anastomosed to normal urethra (E1) and to a transverse preputial flap (E2) whereas in experiment 3 (E3) the tunica vaginalis graft was left exposed to external environment. Results The macroscopical aspect of the surgery was uneventful in E1 and E2, whereas E3 showed an edematous and inflammatory aspect with progressive and spontaneous resolution after 4 weeks. The histological analysis of the graft was very similar in both clinical situations. The aspect of a mesotelial one cellular layer of tunica was progressive replaced by a 4-5 layer cuboid-cells epithelium at 16 weeks, suggesting metaplasia, since no follicles and keratin were seen. Interestingly, the “Bracka” tunica vaginalis surgery had the same histological appearance of dorsal TV urethroplasty when anastomosed either to normal urethra or to a foreskin flap. Conclusions The experimental findings suggest us that tunica vaginalis may have a role in urethral reconstruction when used as a dorsal graft attached to corpora and could be used as an alternative to other recognized options such as buccal mucosa and foreskin.

Single-stage dorsal inlay full-thickness genital skin grafts for hypospadias reoperations: Extended follow up

To report our extended experience with single-stage genital skin graft urethroplasty for complex hypospadias reoperations. Thirty-one patients with failed hypospadias surgery were included. The urethral plate had been removed or was scarred in all. After excision of fibrotic tissue a free full-thickness skin graft was quilted to the corpora cavernosa. The neourethra was then tubularized followed by glanuloplasty. Voiding cystograms, urethral ultrasound and flow measurements were performed in all. Outcome was considered a failure when postoperative instrumentation was needed. Follow up was 78.45 +/- 18.18 months. Shaft skin was used in 13 and internal prepuce in 18. Average graft length was 3.66 +/-1.56cm. Eighteen patients required glanuloplasty. Initial graft healing was successful in all. There was no postoperative infection involving the inlay. We did not note complications from the graft donor sites. Four patients underwent redo surgery yielding a complication rate of 12.9%. Urethral stricture of the proximal anastomosis was most frequent. This single-stage approach using dorsal inlay skin grafts is reliable, creating a substitute urethral plate in the long term. Complication rates are equivalent to those of staged strategies. This is a safe option for hypospadias reoperations if the urethral plate is compromised.

Preputial reconstruction and tubularized incised plate urethroplasty in proximal hypospadias with ventral penile curvature

Aims:Objective of this study was to assess the feasibility and results of preputial reconstruction and tubularized incised plate urethroplasty (TIP) in patients of proximal hypospadias with ventral penile curvature.Materials and Methods:Twenty-seven patients of proximal hypospadias who underwent preputioplasty with TIP were evaluated retrospectively. Ventral curvature was corrected by mobilization of the urethral plate with the corpus spongiosum and the proximal urethra; dorsal plication was added according to the severity of curvature. Feasibility of preputial reconstruction was assessed by applying 3 stay sutures—the first to fix the skin at the corona, the second at the junction of the inner and outer preputial skin for pulling up the skin over the glans, and the third stay on penile skin at the level of the corona for retracting the skin. Preputial reconstruction consisted of a standard 3 layered re-approximation of the margins of the dorsal hood.Results:Age of the patients varied from 10 months to 21 years with an average of 6 years and 4 months. Ventral curvature (mild 10, moderate 13, and severe 4 cases) was corrected by the mobilization of the urethral plate and spongiosum in 14 patients, 11 cases had mobilization of the proximal urethra in addition and 2 patients required single stitch dorsal plication with the above-mentioned steps. Two patients developed urethral fistula and 1 had preputial dehiscence.Conclusions:Preputioplasty with TIP is feasible in proximal hypospadias with curvature without increasing the complication rate. Postoperative phimosis can be prevented by on-table testing of the adequacy of preputial skin by 3 stay sutures.

Double-Cross Flap Protection: New Technique for Coverage of Neourethra in Hypospadias Repair

We analyzed a new urethra preserving approach, double-cross flap protection, during tubularized incised plate urethroplasty. We compared the results of 57 patients treated with this new procedure and 80 patients treated with 2 different techniques. We studied 137 patients with hypospadias between October 2002 and March 2008. Patients were divided into 3 groups. Group 1 consisted of 40 patients (mean age 50 months) undergoing tubularized incised plate urethroplasty. Group 2 included 40 patients (mean age 48 months) undergoing tubularized incised plate urethroplasty with dorsal subcutaneous flap. Group 3 consisted of 57 patients (mean age 39 months) undergoing tubularized incised plate urethroplasty with 2 de-epithelialized preputial flaps twisted ventrally and sutured individually over the neourethra. All patients were operated on by the same surgeons. Statistical analysis of postoperative complications was performed by ANOVA and chi-square test. In Group 1 fistula developed in 6 patients (15%) and was associated with stenosis of the neourethra in 4 (10%). In Group 2 fistula developed in 4 patients (10%). In Group 3 no fistula was observed, but mild stenosis of the neomeatus developed in 3 patients (5.3%), which was treated with dilation. Thus, the incidence of fistula in group 3 was significantly less (p = 0.015). Double-cross flap protection is safe and significantly reduces the incidence of postoperative fistula.