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.     

Treatment of proximal hypospadias with a tubularized island flap urethroplasty and the onlay technique: a comparative study

BACKGROUND/PURPOSE: The onlay island flap urethroplasty was first described in the repair of mid and distal penile hypospadias. Since then, this technique has been increasingly used in more severe cases of hypospadias, because of the complications of tubularized flaps, mainly megaurethra and proximal anastomotic strictures. The aim of this study was to compare the morbidity of these 2 techniques. METHODS: Between April 1994 and December 1998, 80 patients underwent surgical treatment for hypospadias. A tubularized island flap (Ducketttechnique) was performed in 42 cases, and the onlay island flap technique was used in 38 patients. The authors retrospectively compared the complication rate and type of these 2 procedures. RESULTS: Altogether, fistula was the most frequent complication without any significant difference between the 2 groups (21.4% for Duckett technique and 18.4% for onlay repair; P > .05). However, the anastomotic stricture was much more common in the tubularized flap group (7.14% v 2.63%; P < .05). Moreover, a megaurethra was found only in the Duckett technique group (4.7%). There was no case of chordee recurrence, but 6 patients (15.7%) treated with the onlay technique required urethrolysis including dissection of the chord behind the urethral plate, and in the other 3 patients of the same group (7.9%), a dorsal Nesbit plication also was necessary. In all these cases, the urethroplasty included an island cutaneous flap to provide ventral coverage to the neourethra. CONCLUSIONS: The authors conclude that both techniques present similar complications. However, proximal strictures and megaurethra are more common after the Duckett technique. This procedure is of choice in patients with scrotal hypospadias. Conversely, the onlay repair should be completed with other procedures (urethrolysis, dorsal Nesbit plication) to obtain good results in patients with severe degree of chordee.     

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.     

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.     

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.     

Folding and everting distal end of graft flap to reduce orifice stenosis following onlay urethroplasty

Aim: Orifice stenosis remained to be a common complication of hypospadias repair. We had modified the preputial island flap urethroplasty by folding and everting the distal end of the pedicle graft flap to prevent the neo-orifice from stenosis. Methods: Sixteen patients had undergone hypospadias repair using a modified onlay island flap technique. A urethral catheter was retained for 8 days to 10 days after operation. Results: Satisfactory results were seen in all the patients with a cosmetically fine appearance. One patient had a urinary tract infection and another,urethrocutaneous fistula and both were amply treated. No glanular adhesion or stenosis occurred. A long-term follow up of 6 months to 4 years (mean: 2 years) in 15 patients did not find any complication. Conclusion: The modified preputial island flap urethroplasty technique is an easy, reliable and effective approach to reduce orifice stenosis in hypospadias repair. ( Asian J Androl 2003 Jun; 5:159-161 )     

INLAY-ONLAY FLAP URETHROPLASTY FOR HYPOSPADIAS AND URETHRAL STRICTURE REPAIR

Purpose

The absence of a segment of the urethral plate renders the onlay urethroplasty procedure impossible. The plate may be too short (in hypospadias), or sacred after previous repair or due to a dense urethral stricture. A modified approach with restoration of urethral plate continuity is proposed instead of the tubularized island flap associated with higher complication rates.

Material and Methods

In 12 of 20 patients with a partially deficient urethral plate the inlay-onlay preputial island flap was used. The wider part of the flap is inlaid in place of the missing plate and anastomosed to the residual plate. Formation of the urethra is then completed with standard onlay overlapping of the flap. In another 8 patients the combined (partially tubularized in advance) tube-onlay flap was used.

Results

The inlay-onlay flap technique was used in 3 new hypospadias patients, in 4 with a scarred, hair-bearing plate after previous operations and in 5 with virtually no urethral plate because of a dense urethral stricture. No urethral complications were encountered. Of the 8 patients undergoing the combined tube-onlay repair 3 had complications, including meatal stenosis (2) and partial dehiscence (1).

Conclusions

Inlay-onlay flap urethroplasty allows correction of complex cases of hypospadias or urethral stricture with a partially deficient urethral plate in 1 stage with a low complication rate.     

Split onlay skin flap for the salvage hypospadias repair

PURPOSE: Following failed hypospadias repair absence of the penile foreskin, a shortage of ventral skin and residual chordee may all contribute to poor long-term results. We describe a technique called the split onlay skin (SOS) flap that has improved our surgical outcomes in boys requiring salvage hypospadias repair. MATERIALS AND METHODS: The SOS flap uses a transverse island of penile shaft skin that is mobilized on its vascular pedicle and rotated into position to the ventrum of the penis at the site of the urethral defect. The flap is transected transversely, and half of the flap is used as an onlay to repair the urethra and the other half is used for additional skin coverage where needed on the penile shaft. We treated 11 boys 30 to 124 months old (mean age 60.3 months) who had a mean of 2 previous failed hypospadias repairs. All 11 boys presented with complex combinations of urethrocutaneous fistulas, stricture or urethral diverticula. RESULTS: Of the 11 patients 6 (54.5%) had development of postoperative fistulas. Five of these fistulas were surgically closed with no further complications. One penoscrotal fistula closed spontaneously after 7 months. Mild chordee from contraction of the flap and a urethral diverticulum developed in 1 boy. At a mean followup of 24.5 months all patients, including those who underwent closure of the secondary fistula, were voiding well with excellent appearance. CONCLUSIONS: In cases where little local tissue is present the SOS flap procedure is an excellent way to transfer healthy dorsal tissue to the ventrum for an onlay salvage urethroplasty while providing additional coverage of the urethral defect and a tension-free skin closure. Despite the high fistula rate we encountered following the initial SOS procedure, we endorse this technique because the transferred dartos provides additional tissue, which facilitates subsequent fistula repair. These boys can achieve a successful cosmetic result without incorporation of scrotal tissue or a free graft, which we believe leads to more predictable results.     

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.     

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。     

Complications of the preputial island flap-tube urethroplasty.

OBJECTIVE: To report the long-term results of hypospadias repair using tubularized transverse preputial island flaps. PATIENTS AND METHODS: Seventy-four patients (mean age 7 years, range 2-19) underwent a transverse preputial island flap-tube repair for hypospadias. All patients had chordee, 14 had anterior, 41 mid-penile and 19 penoscrotal hypospadias. The mean (range) follow-up was 43 (14-77) months and the outcome assessed by function and cosmesis. RESULTS: The repair was functionally and cosmetically successful in 43 patients (58%) as a single-stage repair. Necrosis and sloughing of the neourethra occurred in five patients (7%), urethrocutaneous fistula in 17 (23%), strictures in seven (9%), diverticula in three (4%) and insignificant urethral misalignment was detected by urethrography in three (4%); thus the overall complication rate was 42%. All of these complications were treated successfully in one or two re-operations. CONCLUSIONS: The transverse preputial island flap-tube repair of hypospadias is a demanding technique. Even in experienced hands it has a relatively high complication rate. Every effort should be made to preserve the urethral plate during orthoplasty, minimizing the need to use tubularized preputial island flaps and expanding the application of onlay procedures.     

An objective assessment of the results of hypospadias surgery

OBJECTIVE: To compare the cosmetic result of tubularized incised-plate urethroplasty (Snodgrass method) with that of two established techniques, the meatal-based flap and onlay island flap repair. SUBJECTS AND METHODS: Photographs of the penis after hypospadias repair in 32 boys were assessed by a panel of five independent health professionals, including four surgeons with variable paediatric urological experience and a urology nurse. Twenty patients had a distal and 12 a proximal meatus. The Snodgrass technique was applied by one paediatric urologist for either distal (10) or proximal (six) hypospadias. A Mathieu repair was used for distal hypospadias (10) and an onlay preputial island flap for proximal hypospadias (six) by a second paediatric urologist. The panel was asked to grade cosmesis as poor, unsatisfactory, satisfactory or very good (points 1-4) for each of the following aspects of penile appearance: meatus, glans, shaft and overall appearance. Photographs were taken in a standard way, with a standard distance, lighting and two views, one of the dorsal surface and one ventral, for each patient. Signed written consent for the study was obtained from each family. RESULTS: The mean assessment score for any aspect of cosmesis was significantly higher for the Snodgrass technique (P < 0.05). The mean score (95% confidence interval) for the meatus was 0.76 (0.4-1.1) points higher for the patients with a Snodgrass repair than those with a Mathieu or onlay island flap repair (P = 0.002). Correspondingly, the values for the glans were 0.67 (0.38-0.97) (P = 0.003), shaft 0.42 (0.16-0.69) (P = 0.01) and overall appearance 0.62 (0.24-1.0) (P = 0.01) points higher for the Snodgrass repair. The Snodgrass technique was more effective in producing a vertically orientated meatus (87.5%) than the Mathieu and Duckett onlay repairs (37.5%; P = 0.009). CONCLUSION: The Snodgrass technique, as assessed by this panel, had a better cosmetic outcome than the Mathieu and Duckett onlay island flap repairs. The assessment of cosmesis in hypospadias surgery is potentially more objective when several health professionals, not involved in the surgery, compared the various methods of repair.     

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.     

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.     

Laser tissue soldering for hypospadias repair: results of a controlled prospective clinical trial

PURPOSE: Laser tissue soldering has been shown to provide safe and effective tissue closure by creating an immediate leak-free anastomosis with minimal scar formation. We compared the results of laser tissue soldering and conventional suturing for hypospadias repair. MATERIALS AND METHODS: A consecutive group of 138 boys 4 months to 8 years old (mean age 15 months) was divided into a standard suturing (84) and a sutureless laser (54) hypospadias repair group. Urethral repair was defined as simple (Thiersch-Duplay or Snodgrass) and complex (onlay island flap or tube) in 101 and 37 cases, respectively. Laser tissue soldering was performed with 50% human albumin solder doped with 2.5 mg./ml. indocyanine green dye using an 808 nm. diode laser at 0.5 W. In the laser group sutures were used for tissue alignment only. At surgery neourethral and penile length, operative time for neourethral construction and the number of sutures or throws were measured. Postoperatively patients were examined for complications of wound healing, stricture or fistula. RESULTS: Mean patient age, urethral defect severity, type of repair, neourethral length and stenting time plus or minus standard error of mean were not significantly different in the 2 groups. Mean operative time was a fifth as long for laser tissue soldering in simple and complex hypospadias repair compared to controls (1.5 +/- 0.1 and 5.1 +/- 0.3 versus 8.5 +/- 0.8 and 26.7 +/- 1.7 minutes, respectively, p <0.001). The mean number of sutures used for tissue alignment in the laser group for simple and complex repair was significantly less than in controls (3.0 +/- 0.2 and 8.2 +/- 0.6 versus 8.5 +/- 0.8 and 23.2 +/- 1.5, respectively, p <0.001). All patients were followed a mean of 12 months (minimum 6, maximum 22). The complication rate was 4.7% in the laser group and 10.7% in controls with fistula in 2 of 54 cases, and fistula and meatal stenosis in 7 and 2 of 84, respectively. CONCLUSIONS: These preliminary results indicate that laser tissue soldering for hypospadias repair may be performed in almost sutureless fashion and more rapidly than conventional suturing. The ease of the laser technique and the lower complication rate in the laser group indicate that laser tissue soldering is an acceptable means of tissue closure in hypospadias repair.     

One-stage reconstruction of moderately severe hypospadias

Single stage repair of moderately severe degrees of hypospadias with correction of chordee and reconstruction of the neourethra presents a difficult challenge for the surgeon. Traditionally, a 2-stage approach to correct these defects has been used. However, more recently a 1-stage repair with correction of chordee and creation of a neourethra has increased in popularity. From 1978 to 1985 we treated 86 patients with moderately severe hypospadias and chordee with a 1-stage technique using either a transverse island pedicle flap, a Hodgson III hypospadias repair or a free preputial skin graft. Despite an over-all complication rate of 50 per cent, our final results based on cosmesis and function were deemed excellent in 90 per cent of the cases. Of the 44 complications 23 were strictures, most frequently at the proximal anastomosis. Two-thirds of these strictures responded to a single dilation with the patient under anesthesia. Our fistula rate was 10 per cent and flap necrosis, meatal stenosis or prolapse and residual chordee accounted for the remaining 12 complications. Our experience indicates that a 1-stage repair for moderately severe hypospadias and chordee can be performed in patients with a satisfactory success rate of more than 90 per cent, minimal morbidity and an acceptable complication rate.     

应用显微外科技术预防尿道下裂术后尿瘘

目的：提高尿道下裂一期手术疗效，减少尿瘘等并发症发生。方法：应用显微外科技术，选择不同的术式一期修复尿道下裂17例，包括加盖带蒂包皮瓣尿道成形术(onlay island flap urthroplasty)4例，横形带蒂包皮瓣尿道成形术(Duckett术)8例，膀胱黏膜一期尿道成形术5例。结果：一期手术全部成功，无尿瘘、尿道狭窄、感染等严重并发症。结论：应用显微外科技术，能提高尿道下裂一期手术的成功率，减少尿瘘的发生。     

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

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