Tube-onlay-tube tunica vaginalis flap for proximal primary and reoperative adult hypospadias

PURPOSE: We describe the surgical technique of and report the results in the first 20 patients who underwent combined onlay-tube construction of a tunica vaginalis flap. MATERIALS AND METHODS: We repaired 20 cases of proximal primary (8) and repeat (12), adult hypospadias using a tube-onlay in 4, an onlay-tube in 3, a tube-onlay-tube in 9 and an onlay-tube-onlay in 4. In 15 patients contralateral tunica vaginalis was used as a blanket wrap. Three to 6 months postoperatively after obtaining informed consent retrograde urethrography, cystourethroscopy, uroflowmetry and urethral biopsy were done in 20, 17, 10 and 13 patients, respectively. RESULTS: No fistula or diverticulum developed. Complications occurred in 3 patients (15%), including urethral stricture, meatal stenosis and urethral stricture, and meatal regression and urethral stricture in 1 each. All strictures occurred in the distal urethra in reoperative cases. At long-term followup there was no recurrent stricture or meatal stenosis after internal urethrotomy and dilation. Urethral biopsy in all 13 patients showed a stratified epithelium indistinguishable from native urethra. The reasons for delayed presentation include perceiving hypospadias as a normal variation (paribor or cut by angels), losing hope for a cure after multiple failed repairs, being told by urologists that repair is futile and pressure by wives for cosmetic or fertility reasons. CONCLUSIONS: The place of tunica vaginalis in hypospadias surgery is more than coverage for urethroplasty. It can be successfully used for substitution urethroplasty. As an extension to the principles of the onlay flap and the concept of urethral plate preservation, combined onlay-tube constructions of tunica vaginalis, including a tube-onlay-tube flap, are successfully applicable to proximal hypospadias, especially in reoperative cases. Urothelialization of the tunica vaginalis occurs within months of surgery.