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.     

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 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.     

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.     

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.     

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.     

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.     

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.     

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.     

A multicenter evaluation of technical preferences for primary hypospadias repair

PURPOSE: Considerable controversy exists regarding the optimal surgical technique for the repair of mid shaft and proximal hypospadias. We sought to evaluate differences in surgical preferences among an international cohort of pediatric urologists. MATERIALS AND METHODS: An anonymous questionnaire containing relevant demographic data as well as choices of technique to repair 5 representative hypospadias cases was developed and administered. RESULTS: Of 121 pediatric urologists contacted 101 completed the survey, representing an 83% response rate. The majority were full-time academic pediatric urologists who performed 6 to 10 hypospadias surgeries monthly. A total of 92 respondents (confidence interval [CI) 0.84 to 0.96) preferred the tubularized incised urethral plate (TIP) technique for the repair of distal hypospadias. Similarly, 82 (CI 0.72 to 0.88) preferred TIP for the repair of mid shaft hypospadias. The 2 most common techniques for repair of proximal hypospadias without chordee, preferred by 43 correspondents each (CI 0.33 to 0.53), were TIP and transverse island flap (TVIF) onlay. For repair of moderate (30-degree to 40-degree) chordee dorsal plication was preferred by 82 respondents, while a ventral approach was preferred by 12. When moderate chordee was associated TVIF onlay was preferred by 35 (CI 0.26 to 0.45) and TIP by 24 respondents (CI 0.16 to 0.34). For severe chordee (greater than 50 degrees) 31 respondents preferred dorsal plication, while 68 chose some form of ventral repair. Among the respondents 37 approach proximal hypospadias associated with severe chordee using a staged procedure, while 40 use a single stage procedure using a TVIF tube (CI 0.30 to 0.50). Using Spearman's rank correlation coefficient, no significant correlations were identified between respondent practice demographics and choice of repair for each hypothetical hypospadias case. CONCLUSIONS: In this cohort of pediatric urologists we observed that the majority prefers TIP to repair distal and mid shaft hypospadiac defects. Significant variability exists for preferred technique for proximal hypospadias and chordee correction. These results support the need for prospective trials comparing techniques for the repair of proximal hypospadias.     

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。     

尿道下裂手术方法选择

目的 探讨不同类型尿道下裂手术方法的疗效。方法 总结分析手术治疗1435例首诊尿道下裂病例资料。结果 一次手术成功例数：合并阴茎下弯者，采用Duckett带蒂岛状包皮瓣尿道成形术506／748例（67．6％），Denis Browne皮条埋藏法224／332例（67．5％），阴囊中间皮肤岛状皮瓣法36／37例（97．3％），游离移植物法21／42例（50％）；无合并阴茎下弯者采用MAGPI术式92／95例（96．8％），Mathieu法146／165例（88．5％），King法6／7例（85．7％），Onlay加盖岛状皮瓣法6／9例（66．7％）。结论 尿道下裂的修复应根据有无合并阴茎下弯及病人的具体条件选择手术方法。     

Onlay urethroplasty with parameatal foreskin flap for distal hypospadias.

A new technique of onlay flap urethroplasty is described. The cosmetic and functional results of this logical extension of our one-stage urethroplasty with parameatal foreskin-flap have been good. The onlay urethroplasty with parameatal foreskin flap was recommended for the repair of distal hypospadias without 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.     

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.     

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.     

Complete repair of bladder exstrophy: management of resultant hypospadias

PURPOSE: In our hands complete primary repair (CPR) of bladder exstrophy results in hypospadias in two-thirds of boys. To our knowledge hypospadias repair following CPR of bladder exstrophy has not been reported previously. We report our experience with hypospadias repair following CPR of bladder exstrophy. MATERIALS AND METHODS: A total of 22 boys with bladder exstrophy underwent CPR using Mitchell's technique between November 1998 and January 2002. The procedure resulted in hypospadias in 15 boys (68%). The site of the meatus was distal penile in 5 patients, mid penile in 3 and proximal penile in 7. Hypospadias repair was performed in all 15 boys. The 5 patients with distal penile hypospadias underwent repair consisting of Thiersch-Duplay urethroplasty with dorsal incision in 3 and tubularized vertical island flap with glanular tunnel in 2. All patients with mid (3) or proximal (7) penile hypospadias underwent Mustarde repair with glanular tunnel. RESULTS: Followup ranged from 6 to 18 months (median 13). The Thiersch-Duplay procedure with dorsal incision resulted in fistula/stenosis in 2 of 3 boys. None of the remaining 12 boys with tubularized penile flap urethroplasty (tubularized vertical island flap or Mustarde) with glanular tunneling had development of fistula or stenosis. Complete degloving of the penis and penile skin redistribution were not necessary with the Mustarde technique. CONCLUSIONS: Thiersch-Duplay urethroplasty with dorsal incision does not seem to be a good option for hypospadias repair following CPR of bladder exstrophy. The use of penile skin as a tubularized flap with glanular tunneling seems to yield excellent functional/cosmetic results.     

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.     

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.     

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.