Application of the onlay island flap urethroplasty to penile hypospadias with severe chordee

The onlay island flap urethroplasty was originally used to repair anterior hypospadias without chordee and was later used to repair penile hypospadias with a well developed urethral plate exhibiting little or no chordee after release of skin tethering. It is possible to treat all cases of penile hypospadias even with severe chordee by releasing the chordee without dividing the urethral plate and by reconstructing the urethra with an onlay island flap.     

Onlay island flap in the repair of mid and distal penile hypospadias without chordee

The onlay island flap is a variation of the transverse preputial island flap for hypospadias repair. It is useful in patients without fibrous chordee whose meatus is mid penile or subcoronal. This technique was used in 50 patients and the results were compared to those of 34 patients undergoing the Mathieu meatal-based flap (flip-flap) during the same period. The cosmetic results with the onlay island flap were quite satisfactory and the complication rate was 6 per cent, which was identical to that observed with the Mathieu repair. The onlay island flap is applicable particularly in patients with mid shaft hypospadias without chordee, if the meatus is too proximal for a Mathieu repair and in patients with distal penile hypospadias with deficient ventral skin.     

Onlay island flap urethroplasty: variation on a theme.

The onlay island flap urethroplasty is useful in patients with distal, mid shaft and proximal hypospadias who have a well developed urethral plate and exhibit little or no curvature after release of chordee. The technique described has 2 main features: 1) use of the entire inner prepuce of the foreskin facilitates its mobilization and protects the vascular pedicle, and 2) additional soft tissue coverage is gained by removing the excess preputial mucosa not used for the neourethra. This extra soft tissue covering of the suture lines should prevent fistula formation. During the last 4 1/2 years the onlay island flap has been used for repair of hypospadias in 61 patients. The complication rate (6%) is low and compares favorably with other techniques. Further refinements in the onlay flap hypospadias repair should decrease the complication rate and widen its applicability.     

A modified tubularised incised plate urethroplasty technique and a revised hypospadias algorithm

To simplify and standardize surgical management of hypospadias, a modified tubularised incised plate (TIP) urethroplasty (Snodgrass) technique has been described and a revised hypospadias management algorithm has been formulated. The study aims to evaluate the viability of the described procedure in different types of hypospadias and tests the validity of the algorithm. The modification described is recruitment of penile and glandular skin lateral to the urethral plate to facilitate tubularisation. The algorithm starts with penile degloving with preservation of urethral plate. Snodgrass repair was done in cases with no chordee and where skin chordee resolved by skin take down. Modified Snodgrass repair was done in cases where urethral plate was narrow. Another modification proposed by us is single layer penile skin closure instead of an added dartos flap, which was done in both classical and modified Snodgrass repair. Cases of severe chordee not resolved by skin take down were repaired by transverse preputial island flap (TPIF) and Bracka''s technique. Dorsal plication was not used as an orthoplasty modality. It was possible to repair 68.89% of the cases by Snodgrass repair. These patients either had no chordee or had superficial skin tethering (skin chordee) which resolved on degolving. All these cases were coronal, distal and mid penile hypospadias. Remaining cases were mid, proximal and penoscrotal with true fibrous chordee and were repaired by TPIF or Bracka''s technique. The Snodgrass technique had a fistula rate of 9.67%. Acceptably, low fistula rate and simple execution make the proposed modification of classical Snodgrass repair a viable option. The proposed algorithm proves to be a useful tool for standardised and logical preoperative decision making. It also defines indications of the three techniques vis-à-vis the type of hypospadias.     

PREOPERATIVE TREATMENT WITH HUMAN CHORIONIC GONADOTROPIN IN INFANCY DECREASES THE SEVERITY OF PROXIMAL HYPOSPADIAS AND CHORDEE

PURPOSE: We determined whether human chorionic gonadotropin (HCG) pretreatment of severe proximal penoscrotal hypospadias and chordee causes sufficient penile shaft or skin enlargement to enhance surgical repair and improve patient outcome. MATERIALS AND METHODS: A total of 12 boys 6 to 12 months old with proximal hypospadias and severe chordee received a course of HCG for 5 weeks immediately preceding hypospadias repair. RESULTS: Chordee decreased and penile length increased in all cases (mean increase 94%). Penile length gain was disproportional. Most of the increase in length was proximal to the urethral meatus, which moved the meatus distally an average of 11.4 mm. (range 6.0 to 19.0), producing a mean increase of 586% in the distance between the penoscrotal junction and meatus. In contrast, there was no statistically significant increase in penile shaft length distal to the urethral meatus. Surgical treatment was facilitated by HCG pretreatment. Three meatal based repairs were performed, only 1 urethral fistula developed and chordee was corrected by penile degloving only in 8 cases. CONCLUSIONS: HCG pretreatment in infancy produces disproportional penile enlargement, which advances the meatus distally to decrease the severity of hypospadias and chordee. This response pattern simplifies the required surgical procedure and appears to improve surgical results. It may benefit select patients, and provide insights into the endocrinopathy of hypospadias and the embryopathy of the hypospadias-chordee complex.     

A combined tubularized/onlay graft technique for total correction of severe hypospadias.

BACKGROUND/PURPOSE: A combined tubularized/onlay graft technique is described for the complete correction of chordee with urethroplasty in a single stage in cases of severe hypospadias. METHODS: Twenty-two patients with severe hypospadias ranging in age from 9 months to 11 years underwent single-stage correction using a technique developed by the author. In this method, chordee is first completely excised by removing all fibrotic tissue both proximal and distal to the urethral orifice, preserving the meatal groove. A dorsolateral preputial flap is then raised and tubularized to form the neourethra. The proximal end of this tube is anastomosed to the urethral opening using a continuous absorbable suture. Two parallel incisions are made in the glans on either side of the meatal groove. The distal part of the neourethral flap is laid over the groove and sutured on either side to create the glanular part of the urethra, after which the glans is reconstructed with the new meatal opening at the tip. The neourethral suture line is covered with a layer of vascularized subcutaneous tissue to protect against fistula formation, and the rest of the preputial skin is transferred ventrally to provide cover for the penile shaft. RESULTS: There were no major complications with minimum follow-up of 20 months. Meatal stenosis developed in two patients, and one had stricture at the proximal anastomosis. These were treated successfully with minor corrective procedures. All other patients had good results, and there were no cases of fistula. CONCLUSIONS: The method described has proved successful in the surgical correction of severe hypospadias in a single stage. It is easily adapted to permit urethral reconstruction after varying degrees of tissue excision required to obtain satisfactory correction of chordee. Patients do not need to undergo multiple procedures, and no major complications were encountered in this series.     

CONGENITAL ANTERIOR URETHROCUTANEOUS FISTULA

PURPOSE: Congenital anterior urethrocutaneous fistula is a rare anomaly that may present in an isolated fashion or in association with other penile abnormalities, such as chordee or hypospadias. There have been 18 cases of congenital anterior urethrocutaneous fistula reported in the literature. We present 14 additional cases of congenital anterior urethrocutaneous fistula. MATERIALS AND METHODS: We treated 14 patients with congenital anterior urethrocutaneous fistula, of whom 9 were uncircumcised at presentation. Two patients had evidence of chordee and 4 had distal hypospadias. RESULTS: The type of repair was determined by the anatomical variations of this anomaly. All cases were corrected electively by various techniques based on the degree of the defect, including primary closure via a Thiersch-Duplay urethroplasty, pedicle flap urethroplasty, hinged flap urethroplasty and interpositioned island pedicle tube or onlay urethroplasty. CONCLUSIONS: To our knowledge the embryological events that cause anterior urethrocutaneous fistula are unclear but they likely result from a defective urethral plate or an abnormality of the infolding of the urethral groove. Surgical technique must be individualized to fit the defect. While there has been considerable skepticism regarding the existence of congenital urethrocutaneous fistula, the fact that 9 of our 14 patients were uncircumcised confirms the congenital nature of this lesion.     

Urethral plate salvage with dorsal graft promotes successful penile flap onlay reconstruction of severe pendulous strictures

PURPOSE: A modified 1-stage penile flap onlay reconstruction is presented for patients with a long stricture in whom the urethral plate is deficient or absent. MATERIALS AND METHODS: Of 37 patients who underwent transverse penile island flap onlay urethroplasty 3 men and 1 boy required simultaneous augmentation (2) or replacement (2) of an inadequate urethral plate. The 15-year-old boy had persistent severe chordee after multiple hypospadias procedures. A dorsal buccal mucosal graft was used in 3 cases and cadaveric dermal graft was used in 1. The goal of dorsal graft application in each case was to create a uniform urethral plate 1 cm. wide to promote successful 1-stage penile flap onlay reconstruction. RESULTS: No patient has required further instrumentation and all void without difficulty. In the 15-year-old boy chordee has completely resolved. CONCLUSIONS: Using dorsal grafts to salvage an inadequate urethral plate during 1-stage penile island flap onlay reconstruction obviates flap tubularization.     

Lengthening urethral plate with inner preputial skin grafts: a modification of the onlay technique

PURPOSE: The onlay technique for primary hypospadias with severe chordee usually requires dorsal plication for residual curvature. To avoid this we use an inner preputial skin graft to reconstruct the urethral plate. MATERIALS AND METHODS: The urethral plate is divided with a transverse incision near the meatus and penile straightening is achieved. After this a fitting inner preputial skin is grafted between the meatus and urethral plate, and the ventral side of the neourethra is formed with an onlay island flap. RESULTS: A total of 21 patients have undergone this procedure. At a mean followup of 10 months a urethrocutaneous fistula developed in 2 patients and glans dehiscence developed in 1. The complication rate was 14.3%. No anastomotic stricture or megaurethra were found. All patients had excellent cosmetic results. CONCLUSIONS: Lengthening the urethral plate with an inner preputial skin graft allows adequate correction of severe chordee. We think that it is a useful procedure in select cases of primary hypospadias with severe inward curvature.     

加盖与管形包皮岛状皮瓣法在尿道下裂治疗中的应用

目的评价加盖包皮岛状皮瓣法（Onlay island flap法）与管形包皮岛状皮瓣法（Tubularized island flap法）手术治疗尿道下裂的适应证及疗效.方法总结分析166例尿道下裂修复手术及术后并发症.患儿年龄1～15岁,平均5.1岁.冠状沟型及阴茎体前型尿道下裂36例,阴茎体型81例,阴茎根型36例,阴囊及会阴型13例,其中外院行阴茎下弯矫正术后11例.合并阴茎下弯139例,轻度43例,中度43例,重度53例.采用加盖包皮岛状皮瓣法79例,管形包皮岛状皮瓣法87例.结果 166例手术成功率为90.4%.166例随访2年均未发生尿道狭窄、尿道憩室、阴茎皮肤坏死等合并症.加盖包皮岛状皮瓣法术后发生尿瘘4例（5.1%）,阴茎下弯复发7例（8.9%）,手术成功率为86.1%.管形包皮岛状皮瓣法术后发生尿瘘4例（4.6%）,阴茎下弯复发1例（1.1%）,手术成功率为94.2%.2种术式尿瘘发生率比较,差异无统计学意义;而阴茎下弯复发率比较,差异有统计学意义.结论加盖包皮岛状皮瓣法适用于尿道板发育好的阴茎体及阴茎根型病例,管形包皮岛状皮瓣适用于尿道口位于冠状沟至会阴合并重度阴茎下弯的各型尿道下裂.     

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

Purpose

Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair.

Materials and Methods

The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995.

Results

Of 6 patients cosmesis was excellent in 84 percent, erections were straight in 100 percent, and urinary streams were of good quality and without fistula in 100 percent after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year.

Conclusions

The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.     

微创钨针在横形包皮岛状皮瓣法尿道下裂一期修复术中的应用

目的 总结微创钨针在横形包皮岛状皮瓣管状尿道成形法尿道下裂一期修复术的应用方法及术后效果。方法 我科2013年5月至2019年10月收治的其中226例尿道下裂患者,年龄6月~26岁（平均3.8岁）,其中阴茎体型119例,阴茎阴囊型83例,阴囊型及会阴型24例。术中应用微创钨针进行阴茎矫直、阴茎包皮脱套、横形包皮岛状皮瓣的切取及解剖等操作,将成形的横形包皮岛状皮瓣缝合成管状尿道,对各型尿道下裂进行一期尿道重建术。结果 术后7~8天拔除硅胶尿管排尿后,共发现12例伤口愈合不良、尿外渗及尿瘘形成。全部病例随访3月~2年,共发现尿瘘及尿道部分裂开24例,尿道外口狭窄2例,尿道（吻合口）狭窄3例,尿道憩室1例,阴茎下弯复发2例,总的并发症发生率为32/226（14.2%）。结论 在尿道下裂一期修复手术中,合理应用微创钨针的电切及电凝功能的优势特点,可精细分离解剖横形包皮岛状皮瓣,可安全有效获取尿道再造所需要的血运良好的包皮瓣等组织,有利于提高手术效率、减轻组织的损伤,可促进组织愈合、降低术后并发症。     

Chordee without hypospadias: report of 79 Chinese prepubertal patients

A series of Chinese prepubertal patients with congenital chordee without hypospadias is presented and the clinical data described. From July 1999 to September 2006, 79 boys with congenital chordee without hypospadias were treated in the Department of Pediatric Surgery, West China Hospital of Sichuan University, China. The ages ranged from 21 months to 14 years, with a mean of 76.8 months (6.4 years). The patients were categorized according to structural defect into 4 groups, with the aid of intraoperative artificial erection. Group I included those with skin tethering (28 cases, 35.4%); group II, fascial chordee (22, 27.8%); group III, corporal disproportion (10, 12.7%); and group IV, urethral tethering (19, 24.1%). Chordee-related structural defect was considered the only criterion for classification, and urethral dysgenesis influenced the choice of surgical procedure. The chordee in group I patients was corrected with penile degloving; group II, release of dense fibrous tissue in addition; group III, dorsal-midline-plication-based correction; and group IV, longitudinal-island-flap-urethroplasty-based repair. At a mean follow-up of 14.8 months (range, 2 to 63), all patients had penile straightening except 1 group III patient with residual curvature that was managed upon reoperation. Glans dehiscence occurred in 1 group II patient who underwent a tubularized incised plate urethroplasty. Urethrocutaneous fistula and urethral stricture were found in 2 group IV patients who underwent island flap urethroplasty. With the categorization based on structural defect, chordee without hypospadias may be managed well with minimized complications.     

Urethral advancement and glanuloplasty with V flap of the glans in the repair of anterior hypospadias

BACKGROUND: Hypospadias is a common urethral anomaly in boys. More than 65% of hypospadias cases are anterior (glanular, coronal and distal penile shaft). More than 200 original techniques have been applied to correct hypospadias. Each of these techniques has some complications, the most common of which are fistula and meatal stenosis. METHODS: A total of 74 boys with anterior hypospadias underwent the procedure of urethral advancement and glanuloplasty (UAGP) with V flap of the glans in our medical centres between March 1994 and March 2000. The procedure included degloving, correction of chordee, urethral mobilization and glans plasty. RESULTS: Cosmetic results were excellent in most patients. There was no fistula, and meatal stenosis was also not observed after applying V flap of the glans. In a 1-6-year follow-up (mean +/- SD, 3.15 +/- 1.79 years), the results, functionally and cosmetically, were satisfactory in all cases, with no long-term complication or chordee. CONCLUSION: Our findings suggest that UAGP is an excellent technique for repairing anterior hypospadias with satisfactory results and low complication rate.     

Tubularization of the incised urethral plate (Snodgrass procedure) for primary hypospadias surgery

OBJECTIVE: To evaluate the Snodgrass procedure for patients with hypospadias who have not undergone previous surgery and whose urethral plate is too narrow for tubularization alone. PATIENTS AND METHODS: Thirty-two boys (mean age 18 months) underwent primary hypospadiac surgery performed by one surgeon (P.S.M.). Twenty-five boys had a distal hypospadias (coronal, subcoronal) and seven had a more proximal defect (penile shaft, penoscrotal). The operation involved incision of the urethral plate, which was then tubularized (Snodgrass procedure). The neourethra was then covered with a de-epithelialized pedicled dartos flap from the inner prepuce before glans and skin closure. RESULTS: With a mean follow-up of 10 months (range 2-14) there were two complications; one child with a coronal hypospadias developed a fistula whist one with a penile shaft defect had complete breakdown of the neourethra. The cosmetic appearance in the other 30 patients is that of a normal slit-like terminal meatus. CONCLUSION: Tubularization of the incised urethral plate is a safe advance in the surgery of hypospadias. We recommend it for both distal and proximal defects, in patients where the urethral plate is insufficient for tubularization alone.     

Lengthening the urethral plate with a double flap technique: a new procedure for correction of primary hypospadias with chordee.

PURPOSE: We describe a new 1-stage technique for the surgical treatment of primary hypospadias with chordee dividing the urethral plate into 2 flaps. MATERIAL AND METHODS: The urethral plate is divided into 2 flaps in an oblique fashion. Penis straightening is achieved with resection of the fibrous ventral tissue after mobilization of the plate. The ventral side of the neo-urethra is harvested from the preputium penis with an onlay island flap or penile skin with the Mathieu "flip-flap" procedure. RESULTS: The new 1-stage procedure has been used in 6 patients. After 10-month followup a fistula developed in only 1 patient who required a new surgical procedure for correction. No meatal stenosis or urethral stricture was noticed. No dorsal plication sutures were required. All 6 patients who underwent a successful procedure had excellent cosmetic results. CONCLUSIONS: This technique is a valid surgical option in patients with hypospadias with severe chordee when we believe that the short plate tethers the penis, avoiding adequate straightening.     

“Limited” double dorsal dartos flap coverage. An effective alternative to conventional flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias

OBJECTIVES: Double dorsal dartos flap coverage of the neourethra has been reported to be superior to single flap coverage for the prevention of urethrocutaneous fistula following hypospadias surgery. Conventional flap coverage involves covering the entire neourethra with vascularised flap. We describe a "limited" double dorsal dartos flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias. MATERIALS AND METHODS: In a prospective study conducted between Feb 2003 and Feb 2007, 31 patients with primary subcoronal hypospadias who had a flat and narrow urethral plate with a healthy urethral meatus and minimal or no chordee underwent Mathieu hypospadias repair. A "limited" double dorsal dartos flap coverage of the neourethra was done in all patients. This involved covering only that portion of the neourethra which remained exposed after glans closure, i.e. the proximal neourethra. Primary surgical outcome assessed was the development of urethrocutaneous fistula following surgery. RESULTS: The mean age at the time of repair was seven years and mean follow up was eight months. There was no flap loss, urethrocutaneous fistula formation, or glanular dehiscence in any of the 31 patients. One patient developed meatal stenosis which was managed by dilatation. One patient developed superficial sloughing of the penile skin. Overall complication rate was 6.45%. CONCLUSION: "Limited" double dorsal dartos flap coverage of the neourethra seems to be an effective method to reduce the fistulous complication rate following Mathieu repair for subcoronal hypospadias. A larger comparative study needs to be done to evaluate conventional neourethral coverage with "limited" neourethral coverage.     

Preservation of the urethral plate in hypospadias repair: extended applications and further experience with the onlay island flap urethroplasty

The onlay island flap urethroplasty, a variant of the transverse preputial (tubularized) island flap, was originally described for repair of anterior hypospadias. However, many cases of mid and proximal hypospadias have a well developed urethral plate and exhibit little or no chordee after release of skin tethering. Patients with this combination of findings are ideal candidates for onlay island flap urethroplasty regardless of initial meatal position. During the last 5 years the onlay island flap has been used for repair of mid to posterior hypospadias in 31 patients (38% of the cases). These are variants that formerly would have required more extensive urethroplasty. Because of the technical advantages of the onlay island flap this alteration in technique selection has resulted in fewer complications. When applied to mid and posterior hypospadias the onlay island flap maintained a significantly lower complication rate (10%) compared to other standard techniques. Preservation of the urethral plate in hypospadias repair is a principle with significant implications to an extended variety of hypospadias.     

Chordee without hypospadias: experience with 33 cases.

We treated 33 patients 6 months to 19 years old with penile chordee without hypospadias from 1966 to 1990. In all cases the penile shaft was degloved, the urethra was widely mobilized and chordee was resected. The shaft skin then was closed, usually using Byars' flaps to shift some preputial skin ventrally. This method sufficed to straighten the penis in 10 patients. In 3 patients urethral mobilization plus placement of a dermal graft to the shaft accomplished straightening of the penis. A total of 20 patients also required lengthening of the penile urethra. Lengthening was done with a graft taken from the prepuce in 14 patients, bladder in 2 and arm in 4. Four of those patients also required a dermal graft to the shaft. There were 8 complications in 7 patients, including anastomotic stenosis, ballooning of a graft, balanitis xerotica obliterans in a graft, urethral fistula and persistent chordee. Reoperation corrected each complication. All end results were satisfactory.