Abstract
Background
Choosing between flaps or grafts to substitute the urethral plate in 2-stage hypospadias
repair has been a matter of debate with no consensus in the literature. Flaps have
reliable blood supply that maybe theoretically less liable for strictures or contractures.
Grafts are more versatile, which can be used in primary and recurrent cases when healthy
local skin is deficient.In this report, our aim was to compare outcomes of grafts
and flaps when used to substitute the urethral plate in two-stage repair of primary
proximal hypospadias with ventral curvature.
Methods
This retrospective study included primary cases of hypospadias with significant curvature
who underwent two-stage repair using either grafts or flaps to substitute the urethral
plate in the first stage. Cases included in the study were divided into two groups
according to the technique of substituting the urethral plate at the first stage of
repair. During first part of the study period (2015 through 2018), we mostly used
grafts to substitute the urethral plate (group A); later, we shifted to skin flaps
(Group B) during the period 2019 through 2021.
Results
The study included 37 boys with primary proximal hypospadias who underwent two-stage
hypospadias repair. The meatus position was penoscrotal in 18, scrotal in 16, and
perineal in three. Inner preputial graft was used to substitute the urethral plate
in 18 cases (group A), while dorsal skin flaps were used in 19 (group B). Out of the
37 cases, 27 were available at follow-up after second stage (group A = 14; group B = 13).
Follow up period ranged between 6 and 42 months (mean 19.7; median 18.5). Overall,
14 cases required reoperations for different indications: partial disruptions of distal
part of the repair in six, closure of urethro-cutaneous fistula in six, and urethral
strictures in two. The rate of complications was higher in group A (10 cases: 71%)
compared to group B (4 cases: 31%) (Fisher exact test, p-value = 0.057).
Conclusion
Grafts were associated with higher complication rate than flaps when used to substitute
the urethral plate in two-stage repair of proximal hypospadias with chordee.
Type of Study and Level of Evidence
This is non-randomized comparative study (level III evidence).
Keywords
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References
- Surgical management of primary severe hypospadias in children: systematic 20-year review.J Urol. 2010; 184: 1469-1475
- Surgical repair of hypospadias.Surg Clin. 1950; 30: 1371-1378
- The island flap technique for hypospadias repair.Urol Clin. 1981; 8: 503-511
- Changing concepts of hypospadias curvature lead to more onlay island flap procedures.J Urol. 1994; 151: 191-196
- Proximal hypospadias: a persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period.J Pediatr Urol. 2016; 12: 28.e1-28.e7
- Intermediate-term followup of proximal hypospadias repair reveals high complication rate.J Urol. 2017; 197: 852-858
- Trends in hypospadias surgery: results of a worldwide survey.Eur Urol. 2011; 60: 1184-1189
- Plastic procedures for correction of hypospadias.J Urol. 1941; 45: 699-702
- Flap versus graft 2-stage repair of severe hypospadias with chordee.J Urol. 2015; 193: 760-761
- Flap versus graft 2-stage repair of severe hypospadias with chordee.J Urol. 2015; 193: 761-762
- Flaps versus grafts.in: Hadidi A. Hypospadias surgery: an illustrated textbook. Springer Nature Switzerland, 2022: 793 (746)
- A standardized classification of hypospadias.J Pediatr Urol. 2012; 8: 410-414
- The surgical approach to two-stage hypospadias repair.in: Bhat A. Hypospadiology: principles and practices. Springer Nature Singapore, 2022: 187-200
- A de-epithelialised overlap flap technique in the repair of hypospadias.Br J Plast Surg. 1973; 26: 106
- Tubularized incised plate Urethroplasty for primary hypospadias repair: versatility versus limitations.Journal of Genital Surgery. 2019; 1: 1-9https://doi.org/10.21608/jgs.2017.1114.1000
- Renaissance of urethroplasty: the belt technique of hypospadias repair.J Urol. 1971; 106: 782-785
- A method for hypospadias repair.Plast Reconstr Surg. 1962; 30: 368-373
- Improved repairs in 100 cases of penile hypospadias.Br J Plast Surg. 1976; 29: 150-157
- Hypospadias repair: the two-stage alternative.Br J Urol. 1995; 76: 3141
- Staged tubularized autograft repair for primary proximal hypospadias with 30-degree or greater ventral curvature.J Urol. 2017; 198: 680-688
- Surgical management of primary severe hypospadias in children: an update focusing on penile curvature.Nat Rev Urol. 2022 Mar; 19 (Epub 2022 Jan 17. PMID: 35039660): 147-160https://doi.org/10.1038/s41585-021-00555-0
- Primary severe hypospadias: comparison of reoperation rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs.J Urol. 2013; 189: 1508-1513
- Staged repair of proximal hypospadias: reporting outcome of staged tubularized autograft repair (STAG).J Pediatr Surg. 2020; 55: 2710-2716
- Resurfacing the penis of complex hypospadias repair (“Hypospadias cripples”).J Urol. 2017; 197: 859-864
Article info
Publication history
Published online: March 15, 2023
Accepted:
March 13,
2023
Received in revised form:
March 9,
2023
Received:
December 16,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2023 Elsevier Inc. All rights reserved.
