Ventral based dartos flap for the prevention of the urethrocutaneous fistula urethroplasty

Background:   Urethrocutaneous fistula is a common complication of urethroplasty for hypospadias even when a microsurgical technique is applied.
Methods:   From January 1999 to November 2006, we applied the ventral based dartos flap wrapping technique to prevent the occurrence of urethrocutaneous fistula in 34 patients with hypospadias.
Results:   Hypospadias was repaired without fistula formation in 31 patients while three patients developed a tiny fistula, which was later closed successfully by a simple procedure.
Conclusion:   We conclude that the ventral based dartos flap wrapping technique could be an alternative to the dorsal dartos flap for covering the neourethra with a vascularized flap because the procedure is very simple, and complications rarely occur.     

肉膜蒂阴茎阴囊联合皮瓣治疗重度或复杂性尿道下裂

目的：探讨重度或复杂性尿道下裂新尿道取材途径。方法：在单一皮瓣不够的情况下彩肉膜蒂阴茎阴囊联合皮瓣作新尿道。结果：47例中术后尿瘘2例。尿道狭窄1例。并发症发生率6.4%，结论：重度或复杂性尿道下裂可采用肉膜蒂阴茎阴囊联合皮瓣作新尿道。     

Dartos flap interposition in the surgical repair of rectourethral fistulas

BACKGROUND: Multilayer closures are important techniques in urethral fistula repair. We report our experience with dartos flap interposition in the repair of rectourethral fistula. METHODS/RESULTS: A tip of a V-shaped scrotal skin flap is mobilized and de-epithelialized to develop a dartos flap. Two patients with a rectourethral fistula underwent fistula closure covered with this dartos flap. The surgical repair was successful in both cases and neither patient showed any late complication. CONCLUSIONS: A scrotal dartos flap is well vascularized and easy to mobilize. We believe this technique is helpful in preventing postoperative complications following complex posterior urethral surgery.     

应用阴囊筋膜血管网皮瓣的尿道再修复

目的：探讨阴囊筋膜血管网皮瓣在尿道下裂再修复中的应用。方法：阴囊皮肤存在多源性血供系统，4组血管终末支相互吻合，形成完整的动脉环路在肉膜内走行，通过筋膜层滋养皮肤。基于此项解剖学基础，术中设计不含知名动脉的阴囊筋膜血管网皮瓣，用于修复原已采用阴囊纵隔皮瓣或其他轴型皮瓣进行尿道下裂矫治而失败的病例。结果：本组20例患者，阴茎型5例，阴茎阴囊型8例，阴囊型7例。除1例出现尿瘘，经处理后痊愈，19例尿道重建成功，效果满意。结论：应用阴囊筋膜血管网皮瓣重建尿道是尿道下裂再修复较为理想的方法。     

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.     

Outcome of hypospadias fistula repair

Objectives To examine the long-term results of hypospadias fistula repair, the factors involved in recurrence and the outcome in cases where this has occurred. Patients and methods The study comprised 113 children undergoing urethrocutaneous fistula repair between 1984 and 1996. Most of the fistulae were closed in two to three layers, with or without a transpositional skin flap. Tunica vaginalis or a scrotal dartos flap was used in patients with inadequate vascularized tissue adjacent to the fistula. Success rates were calculated for each attempt at fistula repair until the patient was cured. Results The median (range) age at primary fistula repair was 40 (18-169) months and the median follow-up after the most recent repair 7.5 (2.3-17) years. The overall success rate of primary fistula repair was 71%. Fistulae which were >2 mm (11 of 21, 52%) were more likely to recur than were those < or = 2 mm (22 of 92, 24%). Recurrence did not relate to the initial form of hypospadias repair, to the means of skin closure nor, with the exception of multiple lesions, to the location of the fistula. The success rates of subsequent repairs were 70% at the second and 50% at the third, fourth and fifth repairs. One child was cured at the sixth attempt. The use of tunica vaginalis or scrotal dartos as a 'waterproofing' layer was limited to the third or subsequent repairs and was successful in five of six cases. Conclusion A simple layered closure with or with no transpositional skin flap is effective in 71% of repairs. For recurrent fistulae, tissues from an unscarred area (tunica vaginalis or scrotal dartos layer) should be used to cover the fistula.     

尿道口周蒂阴囊纵隔皮瓣一期修复尿道下裂

目的 探讨应用异位尿道口周肉膜蒂阴囊纵隔皮瓣一期修复尿道下裂的可行性。方法 1998年以来应用上述方法一期修复尿道下裂31例。结果 28例痊愈，2例无尿瘘，1例尿道狭窄，阴茎阴囊角正常，阴茎伸展自如。结论 该皮瓣血运良好，用于一期治疗尿道下裂疗效确切，阴茎、阴囊间无相互牵扯，操作比较简单，值得推广应用。     

Dorsal double-layer dartos flap for preventing fistulae formation in the Snodgrass technique

INTRODUCTION: The Snodgrass technique and its modifications have become a preferred method for all varieties of hypospadias in the past decade. However, fistula is the most common complication of this technique. The aim of this study was to investigate the importance of the single and double flap to prevent fistula formation in the Snodgrass procedure. MATERIALS AND METHODS: Tubularized incised plate urethroplasty, using a single or the double flap, was undertaken in 74 consecutive boys (median age 6.6 years old, range 1-15) within the last 4 years. In the first 29 patients (group 1), a dorsolateral flap was rotated laterally for covering the neourethra and in the remaining 45 patients (group 2) the neourethra was covered with dorsal double dartos flaps. RESULT: In group 1, fistula in 4 patients and partial glanular dehiscence in 1 patient were detected. There was no fistula formation in group 2. CONCLUSION: For preventing fistula formation, urethral covering by a well-vascularized dorsal double-layer dartos flap should be the basic part of the Snodgrass procedure.     

“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.     

Nueva técnica de fijación de dartos en la reparación de hipospadias

ObjectiveThis study investigates the impact of the use of dartos covering to augment the neourethra on functional and cosmetic results. To evaluate a novel technique demonstrating how to fix dartos flap to cover the neourethra as a barrier in hypospadias repair.Patients and methodsThis study comprised 204 male patients with different degree of hypospadias (DPH: 132, coronal hypospadias: 46, MPH: 26). Their ages ranged from 1-23 ys (mean age: 2ys). Penile chordee was in (DPH: 45, coronal hypospadias: 33, MPH: 26). All patients had abnormal downward directed urinary stream. Hypospadias repair was performed by the classic TIP technique in addition to our novel modification of dartos covering. Patients were submitted to 5 years of follow-up including clinical examination of the functional and cosmetic parameters.ResultsSuccess rates were reported in 200 patients, 3 patients had complications with subcoronal urethrocutaneous fistula and one patient with complete repair disruption.ConclusionTriple dartos fixation is a simple technique for all hypospadiologists to minimize urethrocutaneous fistula as common complication of hypospadias repair with good functional and cosmetic results.     

Longitudinal dorsal dartos flap for prevention of fistula after a Snodgrass hypospadias procedure

OBJECTIVES: The Snodgrass technique presents the procedure of choice for distal hypospadias. Fistula formation is the most common complication with various rates. We evaluated the importance of a urethral covering using vascularized dorsal subcutaneous tissue for fistula prevention. METHODS: Our study included 126 patients, aged 10 months to 16 years, who underwent hypospadias repair from April 1998 through June 2005. Of the patients, 89 had distal, 30 had midshaft and 7 had penoscrotal hypospadias. All patients underwent standard tubularized incised plate urethroplasty, which was followed by reconstruction of new surrounding urethral tissue. A longitudinal dorsal dartos flap was harvested and transposed to the ventral side by the buttonhole manoeuvre. The flap was sutured to the glans and the corpora cavernosa to completely cover the neourethra with well-vascularized subcutaneous tissue. RESULTS: Mean follow-up was 32 (6-87) months. A successful result without fistula was achieved in all 126 patients. In six patients, temporary stenosis of the glandular urethra occurred and was solved by dilation. CONCLUSIONS: A urethral covering should be performed as part of the Snodgrass procedure. A dorsal well-vascularized dartos flap that is buttonholed ventrally represents a good choice for fistula prevention. Redundancy of the flap and its excellent vascularization depend on the harvesting technique.     

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.     

Successful hypospadias repair with ventral based vascular dartos pedicle for urethral coverage

PURPOSE: We describe an easy technique to reliably harvest a vascularized dartos pedicle for urethral coverage at the time of urethroplasty in hypospadias surgery. The complication of urethrocutaneous fistula in hypospadias surgery as a result of using this technique is also evaluated. MATERIALS AND METHODS: A retrospective review (July 1999 to September 2002) identified 180 pediatric patients who had undergone primary hypospadias surgery by a single surgeon. A modified technique of harvesting a vascularized dartos pedicle was incorporated in 111 hypospadias repairs. A ventral based vascularized dartos pedicle of tissue was used to cover a modified urethroplasty as described by Snodgrass. RESULTS: The intraoperative meatal position before urethroplasty was subcoronal in 95 cases, penile/midshaft in 11 and penoscrotal in 5. The majority of patients (90 of 111) were younger than 12 months at surgery. Ages ranged from 5 months to 16 years (mean 21.1 months). Of the 111 patients reconstruction using the ventral based vascularized dartos pedicle to cover the urethroplasty was successful in 109 (98.2%), and at followup they have an acceptable cosmetic result with no evidence of urethrocutaneous fistula. In 1 patient with distal hypospadias a urethrocutaneous fistula developed, which was recognized 20 months postoperatively. Another patient with penoscrotal hypospadias had a proximal fistula at 6 months. There were no recognized intraoperative urethral injuries or complications. Followup ranged from 3 to 38 months (mean 19.1). CONCLUSIONS: The ventral based vascularized dartos pedicle urethral coverage procedure is an easy and reliable technique to harvest adequate vascularized tissue to cover a hypospadias urethroplasty. In this small single surgeon series, this technique appears to have contributed to a low rate of urethrocutaneous fistulas after hypospadias repair.     

纵行阴茎腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用

目的:探讨阴茎纵行腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用价值。方法:对55例阴茎远端型尿道下裂患者先行尿道板纵切卷管尿道成形术(TIP)修复尿道,然后采用阴茎纵行腹外侧阴茎肉膜瓣对修复新尿道进行覆盖。结果:55例患者均获得类似包皮环切术后样外观,尿道外口开口于阴茎头顶端呈裂隙状;仅4例(7.3%)于冠状沟处发生尿道瘘。结论:在远端尿道下裂Ⅰ期修复术中,以阴茎纵行腹外侧肉膜瓣对新尿道加以覆盖,能有效降低尿道瘘的发生率,且修复后阴茎获得类似包皮环切术后样外观。     

阴囊纵隔皮瓣一期修复尿道下裂体会

目的:探讨一次性修复尿道下裂的手术疗效。方法：利用阴囊纵隔皮瓣再造尿道,一次性修复尿道下裂。结果：我们对28例4岁－16岁的儿童应用此手术方法,先先天性尿道下裂一期修复术,除有一例发生尿瘘、二期修复外,其余均获成功。其中对21例进行了3个月－12个月的随访,未见并发症发生。结论：用阴囊纵隔皮瓣一次性修复悄道下裂,为重建尿道提供了可靠的血供保证,减少了并发症的发生,达到了一定的美学效果。去除了病人因身体缺陷而承受的心理负担。     

Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair

OBJECTIVE: To evaluate the importance of urethral covering using vascularized dorsal subcutaneous tissue for preventing fistula in the Snodgrass hypospadias repair. PATIENTS AND METHODS: The study included 67 children (aged 1-11 years) who had hypospadias repaired between April 1998 and May 2003, including 51 with distal and 16 with midshaft hypospadias. In all children, a standard tubularized incised-plate urethroplasty was followed by reconstruction of new surrounding urethral tissue. A longitudinal dartos flap was harvested from excessive dorsal preputial and penile hypospadiac skin, and transposed to the ventral side by a buttonhole manoeuvre; it was sutured to the glans wings around the neomeatus, and to the corpora cavernosa over the neourethra. Thus the neourethra was completely covered with well-vascularized subcutaneous tissue. RESULTS: At a mean (range) follow-up of 21 (6-65) months, the result was successful, with no fistula or urethral stenosis, in all 67 children. CONCLUSION: We suggest that urethral covering should be part of the Snodgrass procedure. A dorsal well-vascularized dartos flap, buttonholed ventrally, is a good choice for preventing fistula. Redundancy of the flap and its excellent vascularization depends on the harvesting technique.     

逆行复合尿道板皮瓣联合阴囊瓦合皮瓣尿道成形修复重度尿道下裂

目的：探讨一种新的对重度尿道下裂的修复方法.方法：应用逆行复合尿道板皮瓣联合阴囊瓦合皮瓣尿道成形修复重度尿道尿道下裂患者.结果：手术获得成功.术后12d拔除导尿管自行排尿,无尿瘘和尿道狭窄发生.结论：逆行复合尿道板皮瓣血运丰富,伸延性好,手术操作简单,联合阴囊瓦合皮瓣尿道成形术可一期完成尿道下裂修复,成形效果好,是一期修复重度尿道下裂的一种比较理想的术式.     

Penile torsion repair using dorsal dartos flap rotation

PURPOSE: Counterclockwise penile torsion is a frequently noted congenital deformity. Previously proposed techniques of torsion repair are ineffective or pose significant operative risks. We introduce a novel technique using dorsal dartos flap rotation. MATERIALS AND METHODS: The penis is first degloved completely and a broad based dartos flap is mobilized from the dorsal penile skin. The flap is rotated around the right side of the penile shaft and attached to the ventral aspect, causing clockwise penile rotation. Final slight adjustments are made during skin closure. We applied this technique in 8 patients undergoing circumcision (2), chordee (4) or hypospadias (2) repair. RESULTS: This technique was effective for correcting penile torsion in all patients. At a mean followup of 8.3 months the cosmetic outcome was satisfactory with the complete correction of penile torsion. CONCLUSIONS: Rotational repositioning of a dorsal dartos flap is an effective technique for correcting penile torsion and it is easily applicable with other penile reconstruction procedures.     

带蒂阴茎、阴囊纵隔联合皮瓣正位尿道开口Ⅰ期尿道下裂成形术

目的 :探讨带蒂阴茎、阴囊纵隔联合皮瓣正位尿道开口Ⅰ期尿道下裂成形术的临床应用。　方法 :对 14 9例不同类型尿道下裂病人分别行带蒂阴茎、阴囊纵隔联合皮瓣正位尿道开口Ⅰ期成形术 ,并改进了引流形式。　结果 :一次排尿成功 12 2例 ,出现漏尿、包皮水肿 2 7例 ,其中尿道皮肤瘘 3例。　结论 :该手术方式适用于严重阴茎头型、阴茎型、轻度阴囊型的尿道下裂。该术式操作简单 ,易于掌握 ,但应注意术后感染的预防及引流管的护理     

组织瓣覆盖技术在尿道下裂手术及术后尿瘘修复中的应用

目的探讨组织瓣覆盖技术在尿道下裂手术及尿瘘修复手术的效果。方法1998年3月至2003年5月，73例尿道下裂手术及术后尿瘘修复手术中，采用5种组织瓣覆盖技术覆盖新尿道及尿瘘内口。尿道下裂组45例中采用带蒂背侧皮下组织瓣转移法27例，带蒂鞘膜瓣转移法3例，局部阴囊推进肉膜瓣法15例；尿瘘组28例中采用带蒂背侧皮下组织瓣转移法4例，局部X—V皮瓣法14例，局部U形组织瓣法10例。结果随访3～36个月，尿道下裂组45例术后3例出现尿瘘，尿瘘组28例均未再发尿瘘，成功率95．9％。结论尿道下裂手术及尿瘘修复手术中采用组织瓣多层覆盖技术，可提高手术成功率，降低术后尿瘘发生率。