Hypospadias repair by skin flaps: a comparison of onlay preputial island flaps with either Mathieu's meatal-based or Duckett's tubularized preputial flaps.

OBJECTIVES: To evaluate the success of different skin flaps in the one-stage correction of primary hypospadias, with particular emphasis on comparing onlay preputial island flaps with Mathieu's meatal-based and Duckett's preputial tubularized flaps. PATIENTS AND METHODS: During a 12-year period, 418 patients underwent single-stage primary hypospadias repair using skin flaps, carried out by one surgeon. The surgical techniques used included Mathieu's repair in 216 (52%), Duckett's in 148 (35%), onlay preputial flaps in 42 (10%) and the Mustarde flap procedure in 12 (3%). The surgical results were reviewed, assessing complications and the functional and cosmetic outcome. RESULTS: At a mean follow-up of 23 months the initial overall complication rate for flap procedures was 22%; however, after a mean of 1.4 procedures, the final success rate was 95%. The complication rate was significantly (P<0.05) higher in patients with a proximal urethral meatus, with severe chordee or in repairs involving transection of the urethral plate. However, the complication rates were not significantly different when the patients underwent repair when aged <2 years or >2 years. Despite no significant difference in overall complication rates, onlay procedures tended to be used in more severe hypospadias than was Mathieu's repair. Duckett's repair caused a significantly higher overall complication rate as fistulae, strictures, meatal stenoses and tubular abnormalities than did onlay procedures. The use of double-faced preputial island flaps resulted in an inferior cosmetic appearance than the use of single-faced flaps, but the overall complication rates did not differ significantly between these techniques. CONCLUSIONS: Hypospadias repair using skin flaps offered a reliable and durable outcome. However, complication rates were greater in patients with severe hypospadias and with techniques requiring transection of the urethral plate. The onlay preputial island-flap technique was more widely applicable than was Mathieu's repair and had a lower complication rate than Duckett's procedure.     

The dorsal inlay graft for hypospadias repair

PURPOSE: Hypospadias is a common genitourinary anomaly affecting every 1/300 male newborns. The goals of hypospadiac surgery include a straight penis with a urethral meatus at the tip of the glans, a well vascularized neourethra of adequate caliber with a solid, straight urinary stream and achievement of sexual function when mature. Current theory advocates preservation of the urethral plate with chordee correction. Hypospadias repair without an adequate urethral plate to roll into a tube requires longitudinal incision of the plate or a transverse preputial island flap. We describe a technique of 1-stage urethroplasty using an inner preputial based dorsal inlay graft. MATERIALS AND METHODS: After the penis is degloved and chordee corrected incisions are made bilaterally along the urethral plate from the native urethral meatus to the glans tip. The urethral plate is incised longitudinally. A graft harvested from the inner prepuce is defatted and sutured onto the incised urethral plate. The neourethra is rolled into a tube in Thiersch-Duplay fashion. RESULTS: This technique was used in 32 patients. The original urethral meatus was coronal to penoscrotal and chordee release was performed concomitantly. At 21 months of followup no patient had a stricture, fistula or diverticulum at the inlay graft site. CONCLUSIONS: This technique successfully fulfills all traditional hypospadias repair criteria. We believe that the dorsal inlay graft after incision of the urethral plate is a rapid, easy and successful addition to the armamentarium of the "hypospadiologist."     

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.     

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.     

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.     

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.     

包皮内板游离移植耦合包皮岛状瓣治疗阴茎型尿道下裂

目的探索一种新的尿道下裂手术方法。方法应用包皮内板游离移植，耦合包皮岛状皮瓣再造尿道冶疗阴茎型尿道下裂。结果2002年10月至2004年3月共治疗10例阴茎型尿道下裂患者，术后随访1年，效果满意，再造尿道形态逼真，无一例发生尿瘘、尿道狭窄等并发症。结论本法综合运用了皮片、皮瓣移植的优点，手术方法简单，成功率高，是一种较理想的阴茎型尿道下裂修复方法。     

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 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.     

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.     

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.     

Can a slit-like meatus be achieved with the V-incision sutured meatoplasty for onlay island flap hypospadias repair?

OBJECTIVES: To evaluate whether the V-incision sutured meatoplasty (VSM) is useful for configuring the constructed meatus after the onlay flap and the Mathieu flip-flap repair for hypospadias, as the transverse preputial onlay island urethroplasty is excellent for repairing anterior hypospadias with no chordee, and a slit-like normal meatus cannot be constructed in many patients who had the original onlay island-flap repair PATIENTS AND METHODS: The configuration of the meatus which was repaired by the onlay island flap technique with VSM (group 2) was evaluated and compared with that of the original onlay technique (group 1). Group 1 consisted of 30 patients treated with only the classic onlay procedure as primary hypospadias repair (1999-2001). Group 2 consisted of 22 patients treated using the onlay procedure with VSM as primary hypospadias repair (2002-2004). RESULTS: There were complications after surgery in four (18%) of 22 patients in group 1 and in five (17%) of 30 in group 2, with no significant difference. A slit-like meatus was achieved in eight (27%) of 30 in group 1 and in 12 (55%) of 22 in group 2. There was a significant difference between the groups in meatal configuration (P = 0.04). CONCLUSION: The VSM is a useful technique to make a slit-like meatus for onlay island flap urethroplasty and flip-flap hypospadias repair, although the technique cannot always achieve the intended result.     

Augmented Duckett repair for severe hypospadias

In severe cases of hypospadias the meatus, either before or after release of the chordee, may lie in a position that is so proximal that there may not be enough inner foreskin available for an island pedicle tube to bridge the long gap between the meatus and the tip of the glans. In such cases a proximal add-on neourethra can be fashioned from nonhair-bearing interscrotal tissue or ventral penile skin overlying the fibrous chordee-causing tissue. The end result is a Duckett transverse preputial tube that is anastomosed proximally to a Thiersch-Duplay neourethra and distally to the tip of the glans. This procedure allows the surgeon to bridge large gaps with a 1-stage repair and avoids the necessity of a free graft.     

Treatment of severe scrotal hypospadias with onlay-type urethroplasty using mouth mucosa

Failure in repairing severe hypospadias complicated with fistula and cutaneous retraction is often associated with lack of subcutaneous tissue and skin providing protection to the neourethra. We report the results of treatment in 6 patients with scrotal hypospadias with severe deviation and scarce dorsal prepuce. A neourethra was created by the onlay technique applying an oral mucosa graft and preserving in all cases the dorsal preputial skin for the island cutaneous flap. All patients had hypospadias without previous repairs excepting one of them, who had had one first time hypospadias repair in other hospital. Patients age ranged between 2 years and 3 months, and 4 years (mean: 2 years and 9 months). In all cases, hypospadias was scrotal type with severe deviation and scarce dorsal prepuce. All patients had prior hormone stimulation with dehydrotestosterone 3%. Surgical repair was performed in one-stage. Urethroplasty included preservation of the urethral plate, oral mucosa graft to provide ventral coverage, and island cutaneous flap with the dorsal preputial skin. In all cases, the chord was dissected behind the urethral plate. In 3 patients a dorsal Nesbit plication was necessary to obtain a complete straighten penis. Results in all 6 cases were satisfactory. Only one patient had a small leakage at the previous neomeatus. The other five patients are asymptomatic. Follow-up ranges from 6 months to 2 years. We conclude that urethroplasty in association with a well vascularized island flap of dorsal preputial skin decrease the incidence of fistulae. In patients with severe hypospadias with scarce dorsal prepuce urethroplasty should be completed with oral mucosa grafts preserving dorsal preputial skin for the ventral cutaneous plasty.     

The two-stage repair for severe primary hypospadias

OBJECTIVES: The repair of severe primary hypospadias represents a major surgical challenge. After initial enthusiasm for single-stage procedures, many paediatric urologists have turned to the alternative two-stage approach after experiencing disappointing results. A single surgeon's experience of the two-stage procedure is reported. METHODS: Between 1998 and 2003, 62 boys underwent a two-stage reconstruction for primary hypospadias. Indications for staged repair included proximal meatus (mid-shaft [18 patients], peno-scrotal [23] or perineal [two]), moderate or severe chordee (38 patients), poor glans groove, and lichen sclerosis. Inner prepuce was the graft of choice. Median age was 27.6 months at completion of surgery and median follow-up was 26 months. RESULTS: All grafts took well and none of the 62 patients needed revision. One patient developed a haematoma. Maturation of the graft for at least six months ensured the best conditions for the second-stage closure. Overall the cosmetic and functional results after the second stage were excellent. The outcomes were determined by the parents' and surgeon's assessment of function and the cosmetic appearance. Complications included partial glans dehiscense (three patients), residual mild curvature (three) and meatal stenosis (three). CONCLUSION: The two-stage repair has proved to be a reliable and reproducible technique with a low complication rate in a difficult cohort of hypospadias patients. Inner preputial skin grafts take very successfully on the ventral surface of the penis, and splitting the glans enables a slit-like meatus to be achieved. Excellent cosmetic results can be anticipated.     

Clinical experiences with different one-staged surgical methods for primary hypospadias cases

The success of various types of operations for primary hypospadias was assessed taking the location of meatus and the degree of chordee as the basis. Totally 258 patients with primary hypospadias were operated: 94 by meatal and urethral advencement, 110 by perimeatal flap and tube repair and 54 by preputial flap.The rates of success in cases with meatal advencement, perimeatal flap and preputial flap were found as 88%, 81% and 66%respectively.The success of treatment in hypospadias cases is closely related to the age of the patient, the experience of the surgeon and the choice of an appropriate method. However, the presence of chordee and the proximally located meatus are among the leading factors that influence the rate of success.     

Radical bulbar dissection to correct severe chordee and proximal hypospadias

PURPOSE: We describe a technique of proximal hypospadias correction that involves freeing the proximal normal bulbar urethra from perineal attachments to lengthen the ventral penis and decrease chordee. MATERIALS AND METHODS: Correction was performed in 9 patients with a mean age of 11.5 months who had proximal hypospadias and severe chordee that was perineal in 2, mid scrotal in 6 and penoscrotal in 1. After the penis was degloved the bulbar urethra was detethered to or beyond the perineal body without lifting the urethra from the corpora cavernosa. Any remaining penile chordee was corrected and the urethral plate was transected only when chordee persisted. When the urethral plate was intact and the penis straight, tubularized incised plate urethroplasty was done to correct hypospadias in 1 stage. Otherwise 2-stage repair was performed. RESULTS: Using this maneuver penile straightening was achieved in 2 of the 9 patients, resulting in a glanular urethral or penoscrotal meatus. Dorsal plication sutures required in 4 cases resulted in a mid shaft and penoscrotal meatus in 1 and 3, respectively. Residual chordee in the remaining 3 patients necessitated division of the urethral plate and 2-stage repair despite aggressive mobilization of the proximal urethra. Simultaneous tubularized incised plate urethroplasty was then performed in the 4 penoscrotal and 1 mid shaft meatus. All 6 patients who underwent a successful 1-stage procedure have excellent cosmetic results, while 1 required meatotomy. No fistula or chordee was present at a mean of 13.8 months of followup (range 3.9 to 27.1). CONCLUSIONS: This safe, rapid technique may compensate for significant penile tethering and chordee in a subpopulation of patients with proximal hypospadias, such as 6 of the 9 in our study. It also allows successful tubularized incised plate urethroplasty to be done simultaneously.     

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.     

尿道口蒂皮瓣与口腔黏膜联合一期修复尿道下裂

目的探讨尿道口蒂皮瓣与口腔黏膜对合重建尿道的方法.方法 2002年3月～2004年5月,采用尿道口蒂皮瓣与口腔黏膜联合重建尿道21例,年龄14个月～8岁.切断挛缩尿道板,彻底矫直阴茎后,将口腔黏膜移植于阴茎腹侧白膜,尿道口蒂皮瓣翻转后与口腔黏膜对合,形成管状尿道.结果术后所有患儿均获3～18个月随访,平均7个月.阴茎弯曲完全矫正,尿道外口位于阴茎头前端,阴茎外形良好,排尿通畅.2例发生尿瘘,其中1例自愈,1例术后6个月再修补成功.结论尿道口蒂皮瓣与口腔黏膜联合重建尿道能彻底矫正阴茎弯曲,提高手术成功率和改善术后阴茎外形.     

袖状蒂岛状环形包皮瓣尿道成形术一期修复会阴型尿道下裂

目的 探讨袖状蒂岛状环形包皮瓣尿道成形术一期修复会阴型尿道下裂的临床效果.方法 距冠状沟0.5 cm处环形切开包皮内板和尿道板,脱套以纠正阴茎下曲.沿尿道板两侧平行切开,近端绕尿道口后会合,呈U形,远端环绕包皮到背侧,使新尿道皮瓣呈环状.解剖供应皮瓣的深层皮下组织与阴茎皮肤,形成血管蒂.经纽扣样孔隙,转移环状皮瓣至腹侧.缝合岛状环形皮瓣的内、外缘,形成新尿道.术后尿液转流时间10～14 d,平均12.8 d.结果 1997年以来,于临床应用22例,一期手术成功18例(81.8%),尿瘘4例,均位于阴茎阴囊交界近端,其中伴尿道外口狭窄1例,经尿道扩张后治愈,另3例经再次修补后愈合.新尿道长度为3.50～18.00 cm,平均4.93 cm.术后随访6个月以上,外观的满意度为72.7%(16/22).结论 袖状蒂岛状环形包皮瓣具有血供丰富、尿道成形材料天然的优点,能一期纠正阴茎弯曲和尿道成形,特别适用于伴有阴茎严重弯曲或阴茎阴囊转位和阴囊分裂的会阴型尿道下裂患者.