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An official publication of the Society for Pediatric UrologyRichard M. Ehrlich, M.D., Founding Editor / William J. Miller, Founding Publisher

Dialogues in

Pediatric Urology

FROM THE EDITORAnthony A. Caldamone, M.D.

Volume 30, Number 5August, 2009

FROM THE GUEST EDITOR

One Step or Two Steps for ComplexHypospadias Forms: An Ongoing Dilemma

GUEST EDITOR:Antonio Macedo, Jr., MD

Federal University of São PauloSão Paulo, Brazil

Editor: Anthony A. Caldamone, M.D.

Associate Editors: Earl Y. Cheng, M.D.

Martin A. Koyle, M.D.Elizabeth B. Yerkes, M.D.

Editorial Board: Sami Arap, M.D.Marc Cendron, M.D.

Terry W. Hensle, M.D.David B. Joseph, M.D.

Pierre Mouriquand, M.D.Antonio Macedo, M.D.

Lane S. Palmer, M.D.Saburou Tanikaze, M.D.

Managing Editor: Lorraine M. O’Grady

Antonio Macedo, Jr., MDDepartment of Urology, Pediatric Urology Section, Chief

Federal University of São Paulo, São Paulo, Brazil

Hypospadias repair is one of the most exciting issues in our subspecialty due to the highlyvariable clinical presentations. Despite numerous advances in tissue transfer and refinementsin operative techniques, there is seldom a consensus when two or three pediatric urologists sittogether to discuss their preferable approaches. Preferences may vary in topics such as usinggrafts versus flaps, types of stents, urinary diversion and the polemic issue of treating in one ortwo steps.

Complex primary hypospadias repair is the main subject of this special edition of Dia-logues in Pediatric Urology. We invited herein some of the most recognized experts to presenttheir own concepts and preferences and to explain why they think that their “way of treating” isbetter. One aspect that most authors agree on is the importance of preservation of the urethralplate whenever possible. When ventral curvature is severe, a few surgeons will make additionalefforts to preserve the plate while others will cut it and then decide between reconstructing theurethral plate with dorsal grafts and going on to a two-step strategy.

I hope you enjoy the discussion and may the content here help you find your own “way”every time you are confronted by a difficult case of primary hypospadias.

Laurence Baskin, MD

UCSF Children’s Hospital, University of

California, San FranciscoAivar Bracka, MDWordsley Hospital

Stourbridge, West Midlands,United Kingdom

Howard M. Snyder, III, MD

Douglas A. Canning, MD

Children’s Hospital of Philadelphia,

University of Pennsylvania, Philadelphia

Warren T. Snodgrass, MD

UT Southwestern Medical Center and

Children’s Medical Center, Dallas

Roberto De Castro, MD

Maggiore Hospital, Bologna, Italy

Emilio Merlini, MD

Regina Margherita Children Hospital,

Turin, Italy

Adriano A. Calado, MD

Pernambuco State University, Recife –

Pernambuco, Brazil

PARTICIPANTS:

Proximal hypospadias continues to be a challenge for the pediatric urologists. Even in thebest of hands re-operation numbers are significant. My advice to the young pediatric urologistsis to become familiar with several different techniques and work with them and even modifythem to a point where you feel comfortable with most anatomical variations that may dictate thetype of repair you do.

This issue is a true dialogue. It represents contrasting opinions on one stage repairs versustwo stage repairs for complex hypospadias. Each of the authors has a significant experience inproximal hypospadias and most have gone through circuitous route in hypospadiology to get towhere they are today. As you read through the various repairs you will see that no one repairstands out as having the highest success rate. You will also note that all of these authors arequite honest in reporting their results. Proximal hypospadias repair calls for the ability toassess the individual anatomy and tailor your operation accordingly. It takes imagination and adesire to try new techniques.

Dr. Macedo and his contributors have put together a classic dialogue in pediatric urologycovering the spectrum of complex hypospadias repair. They are to be congratulated.

This will be the last issue of the Dialogues in Pediatric Urology that will appear in hardcopy.Due to increasing cost and decreasing industry support, the Executive Council of the Societyfor Pediatric Urology has decided to continue the Dialogues in Pediatric Urology with theonline version only. Should the economic environment change in the future we hope to be ableto present Dialogues in the hardcopy again.

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Dialogues in Pediatric Urology August, 2009

Rationale for the Treatment of Complex Hypospadias FormsLaurence Baskin, MD, Chief of Pediatric Urology, UCSF

UCSF Children’s Hospital, University of California, San Francisco

The treatment of hypospadias is both a science and an art withsurgical innovation and flexibility being key components for a suc-cessful outcome. The goal of hypospadias surgery is to have a func-tional penis with normal voiding and near as possible cosmetic resultsmimicking a normal phallus. It has become self-evident that patients(and parents) are willing to accept more than one operation to obtain adurable, functional, and cosmetically acceptable outcome. I believethat a controlled two-stage operation is always a better option thanunexpected complications from an overextended single stage repair.

Complex hypospadiascomes in many varieties. My al-gorithm for the treatment ofcomplex hypospadias applies toall hypospadias surgery (Figure1). When possible a single stagerepair is employed, with the ca-veat that the patient and familyas well as surgeon must be pre-pared for a controlled two-stageoperation when the local factorspreclude a one-stage surgery.The two key factors that drive aone versus two stage repair are:1) the need for repair of penilecurvature, which may lead to theresection of the urethral plate,and 2) the amount and qualityof the available skin for both the

urethroplasty and subsequent skin coverage of the penile shaft.Patients with virgin severe hypospadias (Figure 2) may have both

of these factors. In cases of severe penile curvature that requires re-section of the urethral plate (Figure 2C) with ventral grafting (dermisor tunica vaginalis) a simultaneous urethroplasty is an unwise choice.Time has shown that even in the most experienced surgical hands theuse of a complete tubularized island preputial flap urethroplasty yieldspoor results with an extremely high chance of reoperation secondaryto diverticulum formation.

I have found the finger test (Figure 3) a useful technique to deter-mine whether the dorsal midline plication will be successful for penilestraightening or in the rare but more severe cases of curvature, whetherresection of urethral plate and ventral grafting is necessary. The finger

test is performed after a complete dis-section of all tissue along the corpo-ral bodies to the penile scrotal junc-tion. In the rare case when the ure-thral plate is short or poorly developedit is also resected (in my hands neces-sitating a two stage repair). Artificialerection with injectable saline and a25-gauge needle along with a tourni-quet at the base of the penis will al-low assessment of the degree of pe-nile curvature. With the penis in theerect state, if it is not easily pliable toa straight position as illustrated in Fig-ure 3B, then midline dorsal plicationis not appropriate for correction ofpenile curvature. Figure 3C shows thecompleted repair in a penis that had apositive finger test where the curva-ture was easily corrected by using themidline dorsal plication with two 5-0-prolene sutures placed at the 12o’clock position at the point of maxi-mum curvature.

In virgin severe hypospadias, theamount of available dorsal hooded fore-skin may also be a limiting factor (Fig-ure 2A). If the foreskin is underdevel-oped, enough skin may not be availableto form a functional onlay flap.

I have also found the algorithm(Figure 1) useful for patients whohave had multiple surgeries with re-sultant complex hypospadiac anoma-lies. Figure 4 is an example of this type of patient with a proximalopening, a long skin bridge, a fistula, a diverticulum near the hypospa-diac urethra at the penoscrotal junction and significant ventral skinscarring especially at the coronal margin. The initial maneuver in thispatient was to excise the skin bridges and preserve the redundant ure-thral plate. The coronal ventral scarring was excised and the redun-dant urethral plate advanced into the glans. The urethral plate was

Figure 1 - Algorithm for thetreatment of hypospadias.

Figure 2 - Examples of Severe Hypospadias A-C (black arrow:hypospadiac urethral meatus).

Figure 3 - Finger test todetermine the severity of penilecurvature (see text).

Figure 4 - Patient with complex hypospadias A. preop; B. intraop with de-epithelized flap; C. completed repair.

(continued on next page)

A B C

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primarily tubularized and covered with de-epithelized subcutaneouspedicle flap (Figure 4B). Preoperative counseling was clear in that atwo-stage repair was to be expected, however, at surgery, the amountof available skin, and subcutaneous tissue allowed the patient to be re-paired in one stage (Figure 4C).

Patients who have had multiple previous surgeries with excessivescarring and a paucity of ventral skin are best treated with a two-stage“Bracka” buccal inlay graft at the first stage to augment needed skinfor the urethroplasty. At the second stage, performed at least 5 monthslater, urethroplasty protection can be difficult with little available sub-cutaneous tissue. In this situation (Figure 5), I do not hesitate to takeadvantage of a tunica vaginalis graft (Figure 5B, arrows) to protect theurethroplasty, adding protection, and protecting fistula formation inpatients with complex redo surgery (Figure 5C).

Patients with severe hypospadias may also have associatedpenoscrotal transposition of a more severe variety. Mild penoscrotal

transposition rarely needs to beaggressively reconstructed, be-cause at puberty this defect be-comes essentially a non-issuesecondary to pubic hair. Al-though rare, I have found a fewsituations where a three-stageapproach is a logical and suc-cessful option. In this case (Fig-ure 6), in the first stage penilecurvature is corrected. In thesecond stage the urethroplastyis completed and in the thirdstage, the correction of the se-vere penoscrotal transposition.Ultimately, our outcomes willbe judged on a normal cosmeticappearance and a functionaland durable urethra without di-verticulum, stricture, fistula, orhair bearing tissue.

In conclusion, complex hypospadias surgery requires attention tosurgical detail and flexibility in respect to surgical procedures. I wouldnot hesitate to perform a controlled two-stage surgery if: 1) penile cur-vature is not simply corrected by dorsal midline placation, requiringresection of the urethral plate with ventral grafting, and 2) adequate nor-mal skin and subcutaneous tissue is lacking. I follow the algorithm (Fig-ure 1), which I apply to all types of hypospadias surgery with the statedgoals of long-term functionality and a normal cosmetic appearance.

Figure 5 - Buccal mucosa for revision hypospadias A. Afterbuccal inlay B. Intraop with tunica vaginalis graft for secondlayer C. Completed repair.

Figure 6 - Severe hypospadias threestage repair (see text).

Why Treating in 2 Steps is Often BetterAivar Bracka FRCS, Department of Plastic Surgery, Wordsley Hospital, Stourbridge West Midlands, United Kingdom

IntroductionThere can be little doubt that in terms of convenience and cost,

single-stage solutions are inherently attractive for hypospadias correc-tion. Indeed during the Duckett era it became almost unthinkable thatstage repairs might ever be resurrected. The available armamentariumof 1-stage repairs can in principle correct all degrees of hypospadias,even the most proximal forms, to achieve a straight penis with an api-cal meatus.

Currently it is fashionable to try and preserve the axial integrity ofthe urethral plate, which can be augmented either dorsally with aSnodgrass TIP, or ventrally with a preputial onlay flap. However thismay not be feasible in severe proximal forms of hypospadias whenassociated with a short tethered urethral plate and marked chordee.

In such cases it may be necessary or better to transect the urethralplate, and thus create a full circumference urethral substitution.

What are the relative merits of achieving this with 1-stage flaps,1-stage tubed grafts or 2-stage graft repairs?

1-stage flap repairsAsopa/Duckett 1-stage tubed prepucial island flaps (TPIF) enjoyed

widespread popularity during the 1980s. In complex perineal hypos-padias the TPIF procedure cannot always create a long enough tubethat is adequately vascularized at its extremities. Adding the TPIF ontoa Duplay tubing of the proximal plate is one solution, but adds an extra

anastomosis and may introduce hair bearing tissue in the proximal partof the urethroplasty. More radical and complex 1-stage tubed flap re-pairs such as the Koyanagi have, therefore, found favour in some quar-ters as a way of producing long enough tubes for the most proximalcases. To achieve this extra length of neo-urethra, ventral peno-scrotalskin is incorporated along with the inner prepuce, so there is again apotential for urethral hair in adult life. Furthermore the design of theflaps requires a commitment to the procedure from the very outset.

Little or no long-term follow-up has meant that patients have beendischarged before they were old enough to feel any concern about poormeatal aesthetics, junctional strictures, rotation deformities, and sub-sequent dilatation of the unsupported skin tube. Add to that the poten-tial for urethral hair growth later in adult life for those procedures thatincorporate shaft or scrotal skin into the repair.

A degree of aesthetic compromise of the glans/meatus configura-tion may seem a trivial price to pay for achieving the benefit of 1-stageconvenience, but long-term reviews show that teenagers and youngadults often regard the aesthetic outcome to be as important as the func-tional correction 1,2 . This cosmetic aspect is assuming ever greater im-portance as the modern Western male is increasingly in pursuit of theperfect body image. Witness the flourishing market in male cosmeticsurgery, beauty products and fragrances that would have been unthink-able just a few decades ago.


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1-stage graft repairs1-stage tubed free grafts have never enjoyed widespread accep-

tance. They share the cosmetic issues associated with the flap repairsand have the additional problem of a prohibitive complication rate.Fifty percent re-operation rates are not unusual.

2-stage graft repairsWhy consider the 2-stage graft alternative? The author developed

such a procedure back in the mid 1980s and for over a decade used thisas a universal repair for most hypospadias. In the mid 1990s, an auditof 600 consecutive cases (of all severities) showed this method to beversatile, simple and safe.3 During that era this method had the advantageof offering better cosmetic and functional refinement than could be ex-pected from the ubiquitous flap repairs that were in vogue at the time.

Although the TIP and graft augmented TIP (“Snodgraft”) repairsare now able to achieve comparable refinement in a single stage whenthe axial integrity of the urethral plate can be maintained, for thosecases where the plate has to be divided, then the 2-stage repair stillremains an excellent option. Indeed, in recent years, straw polls atinternational symposia have shown increasing uptake of this methodfor use in severe forms of hypospadias. Below are a dozen reasonswhy the reader might consider a 2-stage graft urethroplasty in prefer-ence to a 1-stage flap repair.

Advantages:1) Two-stage graft urethroplasty is technically less demanding thantubed island flap procedures. Being inherently simpler in executionthan the flap repairs, it can be used safely, not only in specialised pae-diatric centres 4, but also in general hospitals 5, in third world environ-ments 6, and by trainees.7

2) There is never a concern about finding enough tissue for recon-struction of even the longest defects. Usually the inner layer of theforeskin provides sufficient graft. The elasticity of the foreskin meansthat by harvesting the full width of the inner prepuce, this can then bestretched out to into a longer and narrower graft that is usually of ad-equate dimensions to create the requisite length of new urethral plate.If the foreskin hood is poorly developed or the patient has suffered themisfortune of a previous circumcision, this would create major prob-lems for the surgeon who uses flap repairs. With this technique, how-ever, it is not a problem because alternative graft sources such as oralmucosa or post-auricular skin grafts can be used in addition to, or in-stead of prepuce.3) This inherent versatility also makes this the ideal technique forfull circumference urethral substitution in re-operative salvage surgerywhere flap procedures may no longer be feasible. Although such pa-tients are usually already circumcised, a hairy, a badly fibrosed, or alichen sclerosus diseased urethra can easily be replaced using oralmucosa.4) Being able to use the same technique for both primary and salvagesurgery (in the latter situation it may be the only realistic option) meansfewer procedures to master. A larger experience with one versatilemethod, leads to more rapid progress along the learning curve and,therefore, better results.5) Familiarity with this method means that it is easy to master theother 2 repairs that are essential to the hypospadiologist’s armamen-tarium. Thus a TIP repair is essentially the same as the 2nd stage proce-dure with just the addition of a dorsal midline releasing incision in theurethral plate. Likewise familiarity with the 1st stage grafting proce-dure makes the “Snodgraft” (graft augmented TIP variant) a straight-

forward proposition. These 3 simple repairs are technically closely re-lated and form a natural progression of procedures with which it is pos-sible to repair almost any primary or re-operative hypospadias problem.6) Because this method does not incorporate scrotal or penile shaftskin into the new urethra, there is no risk of urethral hair problemsdeveloping in later adult life. Furthermore, in the author’s experience,irrespective of whether preputial Wolfe grafts, post-auricular Wolfegrafts, or oral mucosa grafts are used in the reconstruction, the newurethras develop normally during the rapid adolescent growth spurt.7) Unlike 1-stage options that try to avoid transection of the urethralplate and often resort to dorsal shortening procedures to straighten thepenis, this method allows full ventral dissection of the corpora andreduces the need for Nesbit procedures, thereby optimising availablepenile length.8) The graft-formed new urethral plate is well fixed to the corporaand glans sponge, and, therefore, produces a better supported neo-ure-thra than that of a tubed skin flap. Megalourethra with problems ofpost-micturition dribbling of urine, and retained ejaculations in adultlife, appears to be a common problem with 1-stage preputial flap ure-throplasties. As an early complication, megalourethra may be due tothe common difficulty surgeons have in estimating the correct flap widthfor the new urethra. In the longer term these complications may de-velop because the tighter terminal glans portion of the tubed flap leadsto relatively high voiding pressures, with subsequent dilatation of thelax, poorly supported neo-urethra proximal to the glans. Although thereis no published comparative data available, it is the impression of theauthor (who follows his patients through to maturity) and others whouse the 2-stage graft method, that these problems are inherently lesscommon with graft urethroplasties.9) It is easier to design a neo-urethra of ideal and even calibre, and tominimise the risk of junctional strictures. The urethra is fashioned froma wide, grafted urethral plate that has already had 6 months in which tomature, to complete any variable contraction that might occur, and toacquire a stable blood supply. Allowance is made for any contractionthat might take place, by making the graft a little wider than required atthe 1st stage. Surplus width can be discarded at the 2nd stage. If, be-cause of unfavourable healing, significant chordee remains or the graftednew plate is deemed to be unacceptable for tubing, then there is theopportunity to modify the plate before proceeding to the 2nd stage.10) Cosmesis is typically better than with flap urethroplasties. A natu-ral looking meatus can usually be achieved. During the 1st stage graft-ing procedure, the surgeon avoids placing sutures across the glans-graft junction, relying instead on the tie-over dressing to ensure graftfixation to the glans in the vicinity of the meatus. Because the newurethral plate within the clefted glans, and hence the meatal margins, isalready stable come the 2nd stage, a neat vertical slit meatus of predict-able size and devoid of suture marks can be safely fashioned.11) Glans anatomy, and hence urinary stream, are more normal. A natu-ral glans urethra consists of urothelium firmly fixed to the underlyingglans sponge, an anatomical feature most closely replicated by a graftrather than flap urethroplasty. A flap urethroplasty introduces glidingareolar tissue under the glans urothelium, thereby, potentially produc-ing unwanted mobility of the terminal urethra. Introducing this extraflap bulk may contribute to a more constricted glans urethra and highervoiding pressures. Achieving a smooth symmetrical meatus and stableterminal urethra minimises the risk of urinary spraying. Spraying andmisdirection of the urinary stream are very uncommon features in thepatients that the author has personally followed through to maturity.


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Indeed such symptoms are regarded as an indication for further inves-tigation.12) Unlike some of the alternative flap options, the 2-stage graft re-pair does not have to be pre-judged from the outset. For the surgeonwho wishes to explore a 1-stage plate augmenting option such as anextended TIP in the first instance, the 2-stage repair can be used as a fall-back option should preservation of the plate prove to be unsatisfactory.

References1. Bracka A: A long-term view of hypospadias. Br J Plast Surg, 42: 251-5, 1989.2. Mureau MA et al: Psychosexual adjustment of children and adolescents after differenttypes of hypospadias surgery: a norm-related study. J Urol, 154: 1902-8, 1995.3. Bracka A: Hypospadias repair: the 2-stage alternative. Br J Urol, 76: 31-41, 1995.4. Johal NS, Nitkunan T, O’Malley K, Cuckow PM: The 2-stage repair for severe primaryhypospadias. Eur Urol, 50: 366-71, 20065. Price RD, Lambe GF, Jones RP: Two-stage hypospadias repair: audit in a district generalhospital. Br J Plast Surg, 56: 752-8, 2003.6. Obaidullah MA: Ten-year review of hypospadias surgery from a single centre. Br J PlastSurg, 58: 780-9, 2005.7. Titley OG, Bracka A: A 5-year audit of trainees experience and outcomes with two-stagehypospadias surgery. Br J Plast Surg, 51:370-5, 1998.

The Use of Flaps in Complex HypospadiasHoward M. Snyder, III, MD and Douglas A. Canning, MD

Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia

I. Introduction: Rational for One-Stage RepairThe basic rationale for a one-stage repair of hypospadias is that

there is always sufficient well vascularized tissue and skin for a pri-mary repair. In the last 25 years one of us (HMS) has never found aprimary hypospadias case, regardless of how severe, that could not berepaired with a one-stage repair with always excess skin to be dis-carded at the end of the case. A knowledge of the vascularity of thisanomaly is critical to being able to carry out a one-stage repair. How-ever, the vascularity is consistent and reliable and once a familiaritywith it is gained, the vascularity permits a quite extensive case to bedone safely with reliable good functional and cosmetic results.

The dorsal hooded prepuce is consistently supplied with four smallarteries which are the terminal end of the pudendal system. By care-fully protecting this pedicle during mobilization of the pedicle it caneasily reach to the ventrum for a transfer of a island pedicle flap. In-deed the island pedicle can be used even more posteriorly and has beenutilized to repair a bulbar stricture.

The key to understanding the preservation of the spongiosum is torealize it inserts into the skin just immediately lateral to the urethralplate as well as into the corporal bodies. To preserve the spongiosumfor incorporation in hypospadias surgery requires dissection lateral tothe insertion of the spongiosum into the skin to elevate the ventral skinwhich then permits a sharp division of the attachment of the spongiosumto the skin in a dissection plane immediately parallel to the intrinsicblood supply of the outer skin. This division usually is easiest if startedproximally. By careful dissection of the spongiosum in this fashion,an excellent spongiosum can be consistently preserved for later incor-poration in the hypospadias reconstruction.

The third aspect of vasculature in hypospadias surgery is the real-

ization that the intrinsic blood supply to the penile skin, if carefullypreserved, is adequate to support the blood flow to the skin of the en-tire shaft. The key to protecting the intrinsic blood vessels of the skinis to keep the dissecting scissors parallel to the outer skin so that thescissors tips do not damage the intrinsic vessels. In this way the outerskin can be reliably preserved and can be used accordingly for thedesign of an adequate skin fit at the end of the case.

An excellent cosmetic result from a one-stage repair depends on acombination of factors. First, is the design of the glansplasty. Thatensures the formation of a slit-like meatus on a conically reconstructedglans as described below. Second, a generous dorsal to ventral skinshift must be designed so that there is symmetry of the amount of skinleft covering the repair at the completion of the case dorsal to ventraland right to left. Any irregularity in skin design here will result in alopsided-looking penis and inadequate result. We continue to verycarefully and always measure the amount of skin to be left. Next, theimportance of a well-designed skin fit at the penoscrotal junction mustbe emphasized. There must be a snug skin fit at the base of the penis sothat there is a well defined step off at the junction of the penile shaftwith the scrotum. If this is not made properly, the base of the penis willlook like a pyramid and there will be a poor cosmetic result. The useof Firlit skin flaps can be a routine part of these repairs and gives anormal mucosal collar to the ventrum of the penis improving skin fitand appearance.1 If there is a cleft scrotum, this can be corrected bylateral dissection after the primary incision to expose the tunica vaginalison each side. In doing this, all the vertical tethering bands that createthe cleft scrotum will be divided. Any abnormal remaining shiny skinthat is not healthy rugated scrotum should be excised before a carefuleverting closure of the scrotum is carried out. In this way, a cleft scro-

tum can be consistently reliably repaired.Last, we would emphasize that the useof subcuticular interrupted sutures is theonly way we know to prevent the devel-opment of suture sinuses. Often suturesinuses, which reflect the rapid ingrowthof genital epithelium along sutureswhich transgress the surface, do not be-come evident for many years until pa-tients become pubertal and have moresebum and dirt in the sinuses that make

(continued on next page)Figure 2 - Incorporation ofabortive spongiosum intourethroplasty

Figure 1B– Island tube repairFigure 1A - Island tube repair

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them evident. Since we started utilizing subcuticular suturing just un-der 20 years ago, the cosmetic results have been much better. Initiallythe wound also looks much less inflamed because of the smaller amountof inflammatory producing suture material which is left near the skin.

II. Specific Techniques: Island Tube RepairAlthough the island tube repair pioneered by Harry Asopa2 and

then developed and popularized by John Duckett3,4 was our most com-mon technique for severe hypospadias in the early 1980’s, today it israrely used. This is because we realized in the mid 1980’s as the islandonlay technique was developed, that in only about 10% of the mostsevere hypospadias cases is the urethral plate actually truly short andrequires division. The technical points that make the island tube repairsuccessful can briefly be summarized. First, it is important to avoidexcess epithelium being incorporated in the tube. The inner prepuceas it is formed into a tube has to be carefully stretched to avoid incor-porating excess skin. Generally for a infant only 12 to 14 mm of epi-thelium is tubularized. Interrupted sutures creating an inverting anas-tomosis of one skin edge to the other permit the tube to be stretched.The proximal anastomosis of the tube to the native urethra should bespatulated widely and the anastomosis tacked down with tethering cor-ner sutures that catch the tunica albuginea of the corporal bodies aswell as the tube and native urethra with spongiosum support. When itwas realized this step was important, we significantly reduced the num-ber of proximal anastomotic strictures that we saw. The suture line isalways rotated so that it is buried against the corporal bodies whichhelps to decrease the likelihood of a fistula. The island tube is rou-tinely covered by bringing pedicle tissue over it with a few tackingsutures on the far side of the transferred pedicle. The Firlit skirt flapsoft tissue support, as it is brought to the midline in the final stages ofreconstruction, also helps to burry the suture line. The rotationalglansplasty contributes further by creating a broad surface of glanswhich separates the reconstructed urethra from the surface of the re-pair. Lastly, in forming the meatus it is important to try to avoid acircular anastomosis and if one is carried out to remember that woundcontracture will tend to make a circular suture line smaller and accord-ingly, if meatal stenosis is going to be avoided, the meatus will need tobe made appropriately larger.

III. Specific Techniques: Island Only RepairIn general after the ventral skin is dropped back the urethral plate

measures 5 to 6 mm in width in a small infant. Accordingly, only a1cm wide onlay flap is required to complete the substitution urethro-plasty. Indeed it is imperative to avoid excess epithelium being intro-duced if the formation of a diverticulum is to be avoided. At each endof the design of the onlay flap, it should taper as there is no need forextra epithelium at the proximal anastomosis and as distally the size ofthe meatus at the apex of the ventral glansplasty is determined by thedorsal tissue rearrangement as described below in the design of aglansplasty. Leaving too much neourethra distally can lead to disten-tion and kinking at the glans edge to create the physiology of an ante-rior urethral valve, which in turn will then lead to the formation of asizeable urethral diverticulum. After the design of the onlay flap, it issutured into place beginning with the suture line beneath the pedicleutilizing running 6-0 polydiaxanone suture. The monofilament suturehelps to avoid the frustrating drag through the tissue that is seen withbraided sutures. These sutures are usually placed from inside the na-tive urethra outward in order to facilitate gathering up a generous biteof the supporting spongiosum. As the suture line is completed distally

the glans should be drawn together setting up the first stitch of theglansplasty at its ventral apex. Before glansplasty reconstruction isbegun, redundant tissue from the pedicle is tacked over the suture lineas mentioned above which helps to avoid fistulas.

IV. Design of a GlansplastyThis is one of the aspects of hypospadias surgery which has been

least well described in operative technique articles. It is critical to thecreation of a good cosmetic result and the avoidance of meatal steno-sis. The determination of the apex of the ventral glansplasty is thesingle most important initial decision that must be made as the hypos-padias surgery is designed for an individual case. This point is wherethe flat ventral surface of the glans begins to curve around the meatus.If holding stitches are placed in the corners of the dorsal foreskin, inthe majority of patients the insertion of the foreskin into the glans willshow where the flat surface can be traced up to the point where it be-gins to curve around the meatus. If the apex point on each side is heldwith a forcep, then the amount of epithelium that will be within themeatus can be easily determined. If this is less than 14 to 15 mm thenan incision in the dorsal plate will permit secondary epithelializationof this area to lead to an adequate meatus and the avoidance of meatalstenosis.5 The size of the meatus is usually adequate if a groove 12 to14 mm is designed in an infant and up to 25 mm for a teenager who ismore mature. Credit should be given to Warren Snodgrass for the rec-ognition that the closure of this vertical incision that we used to advo-cate is not necessary.6 Secondary epithelialization occurs rapidly andgives a more normal slit like configuration to the meatus.7 In creatingthe subcoronal incision that will define the inner mucosal collar whichwill be part of the final skin reconstruction, today we routinely use theventral skirt flaps as described by Firlit in 1987.1

The glans wings on each side are elevated carefully maintaining adissection plane just above the insertion of the spongiosal into the glansto avoid severing the spongiosal attachments into the glans which will,if that occurs, result in a shortening of the spongiosum support for theurethral plate. The glans wings are mobilized keeping the scissors tipscarefully parallel to the corporal bodies and mobilizing the glans ad-equately to permit a comfortable rotation around the urethroplasty. Asthe glans vasculature in hypospadias is dependant on the dorsal vascu-lar bundle, there is no danger of devascularizing the glans as it is ven-trally mobilized. After the completion of the urethroplasty, theglansplasty is then completed by rotation of the mobilized glans wingsover the urethroplasty with interrupted hormonal mattress sutures. Inthe first year of life, 6-0 polydiaxanone sutures are used and in chil-dren over a year of age usually 5-0 vicryl. The sutures are placedparallel to the surface of the glans and 2 to 3 mm below the cut edge ofthe flat glans surface. As these sutures are tied this completes the rota-tion of the glans into a conical configuration that was aborted embryo-logically. A second immediately subcuticular Maxon layer ensures asmooth approximation of the glans edge and should result in an almostimperceptible eventual midline scar. As the glanuloplasty is completedit will bring to the midline the Firlit skirt flaps that were part of theinitial design. The skirt flaps are then sutured in place with interruptedsubcuticular sutures.

V. Skin ClosureFor an excellent cosmetic result, it is important that the surgeon

not let down his guard at this critical step. No matter how well theurethroplasty is carried out, if the skin fit is not an excellent one at the


7


end of the case, the family will be displeased with the result. Thedorsal preputial skin is split in the midline after the ventral penoscrotaljunction point has been determined and constructed. This is importantbecause once the penoscrotal junction has been clearly defined ven-trally, then the amount of skin that will cover the shaft of the penisventrally can be determined and matched dorsally. After the appropri-ate skin split dorsally, then a slide-around step moves the penile skinventrally for a midline closure. A midline closure is almost alwayspossible and creates the illusion of a normal penile ventral midlineraphe. Great care is taken as this step is carried out to ensure by pre-cise measurement that the skin fit dorsal compared to ventral and rightcompared to left is perfect. Any asymmetry will unduly compromisethe surgery. There is always excess skin that has to be trimmed andthen the closure is completed with further interrupted subcuticular 6-0Maxon sutures.

VI. AncillariesWe routinely use 1% xylocaine with epinephrine infiltration in the

area of surgery. This helps to separate the tissues for more accuratesurgical planes and also provides an element of hemostasis. We do notunder any circumstance use a tourniquet around the penis as if carefulattention is paid to the vascular anatomy as has been described above,there simply will not be any significant bleeding during the case. Anysubstantial bleeding in a hypospadias case reflects usually either get-ting into the spongiosum ventrally or into the pedicle dorsally. All ourcases do also receive regional block anesthesia and are done on anoutpatient basis regardless of the severity of the hypospadias or thelength of the reconstruction.

A 6 French silastic intra-urethral stent is our preferred bladder drain-age. This material can be obtained from the manufacturers of theventriculo-peritoneal shunt tubing inexpensively which we then divideinto 15 cm long pieces, package and sterilize in 100 cm segments. Thecost ends up being about $2.50 per stent. When the stent is placed, afew extra small holes at the bladder end ensure good drainage. Thestent is left protruding from the urethral meatus a couple of centime-ters and a Prolene suture is taken through the stent and placed throughthe inner surface of the meatus with a good generous bite of the glanson each side to secure the stent in place. By keeping the Prolene suturewithin the meatus, ugly punctate scars on the surface of the glans fromthe holding suture are avoided. Generally the stent is left in place for12 to 14 days, but in a major scrotal hypospadias repair, the stent maybe left in as long as 21 days. It is important to emphasize that in doinga complex case, the placement of the stent as the island tube or islandonlay repair progresses early is very helpful, as in those cases there isoften a utricle and maneuvering the stent into the bladder with a smallprobe is much easier accomplished early rather than at the completionof the entire repair.

The dressing we use was devised by John Duckett many years agoand is referred to as sandwich dressing. Two pieces of telfa are placedagainst the penis dorsally and ventrally. Then small pieces of gauzeare placed dorsally and ventrally and last Tegaderm is used to hold thepenis down against the abdominal wall aimed at the umbilicus. The stentwhich carefully is kept out of the Tegaderm dressing is directed upward.

For postoperative care, we emphasize to the family giving abun-dant fluid to drink as it is only dehydration and amorphous phosphatesin the urine that have caused these stents to become obstructed. Thedressing is typically left in place for 36 hours and then the Tegadermteased off and the rest of the dressing soaked off in a comfortable tepidtub. Subsequently, the child’s only care is to be placed into a comfort-

able tepid tub twice a day for 15 to 20 minutes. By avoiding any soapin the water, it does not do any harm for the stent to go beneath thesurface. The families are instructed to avoid straddle-type activitiesfor the child until the urethral stent is removed.

The medications that we routinely use are acetaminophen withcodeine in a dose of 0.5 to 1.0 mg per kilogram every 4 hours orally.Bladder spasms are minimal with a soft silastic plastic stent but aredealt with by routine oxybutynin 0.2 mg per kilo every 8 hours for thefirst 48 hours. After that, most parents find they can reduce the dose tojust once before the child is put to sleep. We do continue to use antibi-otic prophylaxis with trimethoprim-sulfamethoxazole at ½ to 1 tea-spoon per day until the urethral stent has been removed.

VII.OutcomeWe have carefully reviewed our experience with hypospadias sur-

gery by these techniques. A review of our early experience with theonlay technique suggested a fistula rate of about 5%.8 In a personalseries of (HMS) reported, 36 onlay hypospadias repairs were carriedout in sequence without 1 fistula.9 However, no hypospadias surgeonis immune from that complication and patients have had fistulas subse-quent to that series. In this series of 36 consecutive patients, it is im-portant to realize that only 4 needed a midline dorsal plicating suturefor minor residual bending of the penis. Three patients in this series,however, did come to redo surgery for the development of a urethraldiverticulum. As none in the series had meatal stenosis, the cause ofthe diverticulum was almost certainly excess epithelium incorporatedinto the onlay repair. Patel et al have also carried out an extended longterm follow-up of island tube and onlay hypospadias repairs.10 Theconclusion from that paper was that if early complications do not de-velop, the likelihood of late problems eventually turning up is extremelysmall. It is evident that the genital skin grows well during the growthand development of the child and will continue to lifelong support anexcellent urethral reconstruction.

References1. Firlit CF: The mucosal collar in hypospadias surgery. J Urol, 127: 80-82, 1987.2. Asopa HS, Elhence IP, Atri SP, et al: One stage correction of penile hypospadias using aforeskin tube. Int Surg, 55:435, 1971.3. Duckett JW: Transverse preputial island flap technique for repair of severe hypospadias.Urol Clin North Am, 7:423, 1980.4. Duckett JW: Hypospadias. Contemp Urol. April, 19925. Snodgrass WT: Tubularized, incised plate urethroplasty for distal hypospadias. J Urol,151:464, 1994.6. Rich MA, Keeting MA, Snyder HM et al: “Hinging” the urethral plate in hypospadiasmeatoplasty. J Urol, 142:1551, 1989.7. Snodgrass WT, Patterson K, Plaire JG, et al: Histology of the urethral plate: implicationsfor hypospadias repair. J Urol, 164:988, 2000.8. Elder JS, Duckett JW, Snyder HM: Onlay island flap in the repair of mid and distal penilehypospadias without chordee. J Urol, 138: 376-379, 1987.9. Cooper CS, Noh PH, and Snyder, HM: Preservation of urethral plate spongiosum techniqueto reduce hypospadias fistulas. Urology, 57(2) 351-354, 2001.10. Patel RP, Shukla AR, Snyder HM, 3rd: The island tube and island onlay hypospadiasrepairs offer excellent long-term outcomes: a 14-year follow-up. J Urol, 172(4 Pt 2) 1717-9, discussion 1719, 2004.

Other Selected ReferencesAvellán L and Knuttson F: Microscopic studies of curvature-causing structures inhypospadias. Scand J Plast Reconstru Surg, 14: 249-258, 1980.Baskin LS, Duckett JW, Ueoka K, et al: Changing concepts of hypospadias curvature lead tomore only island flap procedures. J Urol, 151:191-196, 1994.Baskin LS, Erol A, Li YW, et al: Anatomic studies of hypospadias. J Urol, 150:1108, 1998.Hollowell JG, Keating MA, Snyder HM III, et al: Preservation of the urethral plate inhypospadias repair: extended applications and further experience with the onlay island flapurethroplasty. J Urol, 143:98-100, 1990.Horton CE, Devine CJ Jr, and Baran N: Pictorial history of hypospadias repair techniques.In: Horton CE (Ed): Plastic and Reconstructive Surgery of the Genital Area. Boston, LittleBrown, 1973; 237-248.

8



Proximal Hypospadias RepairWarren T. Snodgrass, M.D.

UT Southwestern Medical Center and Children’s Medical Center, Dallas

The main determinant for urethroplasty technique in proximalhypospadias repair is the perceived extent of ventral curvature (VC).Cases with minimal VC today are corrected by either onlay flaps or thetubularized incised plate technique (TIP), while those with greater VCleading to transection of the urethral plate (UP) undergo 1 stagetubularized prepucial flaps or Koyanagi-type procedures, or 2 stageflap or graft repairs. I recently reported decision-making in 91 boysseen from 2000 to 2005 with midshaft to perineal hypospadias.1 All 35with midshaft defects underwent TIP. Of the remaining 56 cases ofproximal shaft to perineal hypospadias, TIP was used in 36 (64%) while2 stage repairs were performed in the remaining 20 (36%) that hadpersistent VC greater than 30 degrees after degloving the penis andreleasing ventral dartos tissues.

Straightening in these cases often included ventral dermal grafts.Choices for urethroplasty included a tubularized prepucial flap, butmy general dissatisfaction with flaps led me to other considerations.While Howard Snyder will defend prepucial flaps, I continue to chal-lenge him and others who use them to report their outcomes specifi-cally for penoscrotal to perineal hypospadias, as the Toronto group didthis year2, since much of the available data comes from series of pre-dominantly mid to distal repairs. Similarly, I did not use prepucial graftsthat Aivar Bracka would champion, because I would not place a fore-skin graft on a dermal corporal graft. I am philosophically unconvincedby the Koyanagi approach since the decision to transect the UP is madeat the onset, while my experience showed two thirds the urethra platescan be preserved in proximal cases.

Initially I performed staged Byar’s flap repairs, with the modifica-tion of preserving the glanular UP rather than advancing skin betweenthe glans wings. However, despite tubularizing a strip no more than 10to 12 mm wide at the 2nd stage, diverticulum reliably developed, whichI believe reflects relatively fixed resistance in the glanular urethra (with-out stenosis) transmitted to prepucial skin designed by nature to stretch.Furthermore, the vascular pedicle inhibits attachment of Byar’s flapsto the corpora, additionally promoting diverticulum from the inevita-bly turbulent urine flow through a skin-lined neourethra.

Dissatisfaction with Byar’s /TIP outcomes then led to buccal graftsto replace the UP, initially extending from the native urethra to theglans tip, and later interposed between the urethra and preserved glanularUP when problems arose with buccal grafts within the glans wings ininfants. To avoid grafts on grafts, I first used buccal tissue both to fillthe defect from corporotomy during straightening and for later ure-throplasty, taking advantage of its relative thickness compared to othergraft sources. Then I started doing multiple superficial incisions (“fairycuts”) rather than one deep incision in the ventral corpora and placedthe buccal graft over them. Urethroplasty results with all these buccalgraft repairs were better, but complications remained unacceptably highat 55%.

Several lessons were learned from these cases and others I sawduring this time after initial surgery by pediatric urologists elsewhere:1. The true extent of VC cannot be accurately determined preopera-tively – again, one should not enter the OR committed to transectingthe UP as was once routine practice for proximal repairs2. Ventral lengthening and straightening can be reliably achieved byfairy cuts rather than single corporal incisions requiring grafts.

3. Secure glans wing closure increases the risk for diverticulum afterskin flap urethroplasties. A corollary is that a well-fused glans with anormally situated meatus seems the exception after skin flap urethro-plasty, as the wings tend to separate during healing.

Mollard reported that the spongiosum and urethral plate could bedissected from the corpora to lessen VC, first in a French article andsubsequently in the Journal of Urology.3 He found bending could becorrected in most cases of proximal shaft hypospadias, and over halfthose with perineal defects, by this maneuver occasionally supplementedwith a dorsal plication. Urethroplasty was completed with 1 stage UPtubularization. He noted the UP became functionally longer and nar-rower by this dissection, but stressed it remained well-vascularized.Monfort et al used the same approach, stating dissection under the UPcontinued proximally for approximately 2 cm under the native urethra.4

Recently, Kajbafzadeh et al reported UP elevation combined withventral corpora grafting to both straighten VC and perform TIP ure-throplasty in 13 (72%) of 18 boys with penoscrotal to perineal hypos-padias.5 The UP was transected in the remaining cases when it appearedthe UP still contributed to bending as in 3 cases, or appeared “unhealthy”as in 2 cases.

Previously after transecting the UP, I would frequently next takedown attachments anchoring the normal urethra to the corpora, dis-secting proximally to near the urogenital diaphragm. The native ure-thra then could be gently stretched and re-attached to the corpora fur-ther distally, taking advantage of its elasticity to bring the proximalmeatus out of the scrotum to make the 2nd stage tubularization easierand less likely to include hair-bearing skin. Consequently I was imme-diately receptive to Bhat’s idea to perform this same mobilization be-fore transecting the UP.6

Now I begin a proximal repair with a U-shaped incision alongsidethe UP to 2 mm proximal to the ectopic meatus. A midline extension iscarried down the median raphe of the scrotum to give additional expo-sure. Ventral dartos, which often is deficient in proximal cases, is nextdissected down to Buck’s fascia. In all cases the corpus spongiosumrunning alongside the UP is dissected from the corpora for laterspongioplasty. Then artificial erection is performed. Minor VC lessthan 30 degrees is corrected by a single midline dorsal plication using6-0 polypropylene. Greater VC prompts dissection under the entire UP.Persistent curvature greater than 30 degrees then leads to mobilizationof the formed urethra proximally as described above. Fairy cuts aremade in the region of greatest bending, and a single dorsal plication isalso done to ensure straightening (except when foreskin reconstruc-tion is desired, in which case the dorsal shaft is not degloved and fairycuts are made without dorsal plication). The urethra is then gentlystretched distally and re-attached to the corpora. UP incision is madewithout dividing the plate into separate strips, and TIP is completedwith a 2 layer closure, the first using subepithelial interrupted 7-0polyglactin and the second a continuous suture using 7-0 polydiaxone.Spongioplasty covers the neourethra from the glans proximally, andthen a testicle is exposed and a tunica vaginalis flap developed for anadditional barrier layer over the entire neourethra before glansplasty.

9


All the authors reporting UP mobilization found it reduced or cor-rected VC, but maintained vascularity to the plate. The maneuver takesadvantage of urethral and UP elasticity to allow the bent penis to bestraightened, even with ventral lengthening, without transecting theplate. Urethroplasty can then be completed by either onlay flap or UPtubularization.

My experience comprises 12 patients in the past 2 years, 3 withUP elevation alone and the other 9 with additional urethral dissection.All underwent TIP with tunica vaginalis barrier flap. With follow-up aminimum of 3 months (mean 7 months, range 0- 11) there have beenno fistulas, stenoses, or recurrent VC. During the past 2 years a total of20 patients have undergone proximal hypospadias repair, 7 by stan-dard TIP, 12 with UP elevation and TIP, and only 1 by a 2 stage graftwhen the UP remained short after complete mobilization.

In reviewing this experience several points should be re-empha-sized:1. “All” midshaft hypospadias can be repaired by TIP.2. Proximal hypospadias with VC less than 30 degrees can be re-paired using TIP.3. When VC exceeds 30 degrees after the penis is degloved and ven-tral dartos dissected, traditional management calls for UP transection,ventral corporal grafting, and urethroplasty by either tubularized pre-pucial flaps or staged techniques.

4. Alternatively, when VC is greater than 30 degrees, the UP can beelevated from the corpora, this dissection then continuing to releasethe urethra proximally. Ventral lengthening can be achieved by graft-ing or fairy cuts, preserving the UP for single stage urethroplasty.

Optimal management is not yet defined, but it appears transectionof the UP might be avoidable today in many cases where it was previ-ously considered routine.

References1. Snodgrass W, Yucel S: Tubularized incised plate for mid shaft and proximal hypospadiasrepair. J Urol, 177: 698, 2007.2. Braga LH, Pippi Salle J L, Lorenzo AJ et al.: Comparative analysis of tubularized incisedplate versus onlay island flap urethroplasty for penoscrotal hypospadias. J Urol, 178: 1451,2007.3. Mollard P, Castagnola C: Hypospadias: the release of chordee without dividing the urethralplate and onlay island flap (92 cases). J Urol, 152: 1238, 1994.4. Monfort G, Di Benedetto V, Meyrat BJ: Posterior hypospadias: the French operation. EurJ Pediatr Surg, 5: 352, 1995.5. Kajbafzadeh AM, Arshadi H, Payabvash S et al.: Proximal hypospadias with severechordee: single stage repair using corporeal tunica vaginalis free graft. J Urol, 178: 1036,2007.6. Bhat A: Extended urethral mobilization in incised plate urethroplasty for severehypospadias: a variation in technique to improve chordee correction. J Urol, 178: 1031,2007.

PARTICIPATING SOCIETIES:

American Academy of Pediatrics, Section on Urology

Asian Pacific Association of Paediatric Urologists

European Society for Paediatric Urology

Egyptian Urological Association/ Pan African UrologicalSurgeons’ Association

International Children’s Continence Society

Society for Fetal Urology

Sociedad Iberoamericana de Urologia Pediatrica

Society for Pediatric Urology

Pediatric Urology Nurse Specialists

American Urological Association

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Figure 1 - A. Severe form of proximal hypospadias. B. Stay stitches inthe ventrally open prepuce and glans penis allow marking the Koyanagi-Nonomura flap. C. Drawing of the flap, which is composed of 3 parts:parameatal, paracoronal and preputial. Actually, flap dissection neverstarts at this initial point of the procedure and flap is never separatedfrom the adjacent subcutaneous tissue, not to jeopardize its blood supply.

The Koyanagi-Nonomura Technique (2 In 1 Procedure):A Valuable Alternative?

Roberto De Castro, MD, Division of Pediatric Surgery, Maggiore Hospital, Bologna. ItalyEmilio Merlini, MD, Division of Pediatric Urology, Regina Margherita Children Hospital, Turin, Italy

In the treatment of primary scrotal and perineal hypospadias, amongseveral possibilities (1 or 2-stages repair, using flap, graft or a combi-nation of the two), our preference is for a 1-stage flap technique. Wecall our method “the 2-stages in 1-time procedure” (2 in 1 procedure).It represents an evolution of the original technique described in 1984by Koyanagi et al.1, incorporating the major modifications later sug-gested by various authors2-5, utilizing some of the principles introducedby Bracka6 in his two-stages graft-repair in the preparation of the newurethral plate, and resembling both the Yoke repair described by Snowand Cartwright7 and the first stage of Retik’s 2-stage repair.8 We wouldlike to underline that we never applied the 2 in 1 procedure in redoproximal hypospadias repair, as, in our opinion, that should always betreated with the Bracka’s 2-stage graft procedure. We also emphasizethat, in our practice, in the great majority of high scrotal and penoscrotalhypospadias, regardless the presence of penile curvature and partialpenoscrotal transposition, the original urethral plate can be used and,therefore, they should be repaired following the classical Snodgrassprinciple of urethral plate augmentation with a midline incision9. Ac-cording to this strict case selection, we utilized the 2 in 1 procedureonly in the most severe forms of hypospadias (mid-scrotal and perineal),which occur in about 1 every 30 cases of hypospadias treated in ourinstitutions (Fig. 1A).

2 in 1 TechniqueThe patient is positioned in a gentle lithotomy position. A sagit-

tally oriented stay suture in the dorsal aspect of the glans and 2 extrastay sutures in the prepuce allow marking the Koyanagi-Nonomuraflap, which is not dissected at this stage (Fig. 1B,C). A circumferentialincision is started dorsally and completed anteriorly, severing the ure-thral plate (Fig. 2A). Ventrally, the dissection is deepened to removethe atretic urethral plate and corpus spongiosum (Fig. 2B); laterally allfibrous bands contributing to penile curvature are removed. Frequently,the dissection is extended proximally to the urethral meatus, between

the corpus spongiosum that surrounds the urethra and corporacavernosa. The urethra is, therefore, detached from the corpora for theneeded length and mobilized in a proximal direction. When all the fi-brous bands are detached, residual intrinsic curvature of the corporacavernosa is tested with an artificial erection, injecting saline insidethe corpora (Fig. 2C). Residual curvature, if present, is treated accord-ing to the preferred technique (Fig. 2D). Keeping the penis on tractionwith the glandular stay suture, a transverse incision is carried out dor-sally on the penile skin considerably below the prepuce, leaving proxi-mally just an adequate amount of penile skin to create a skin cylinderto cover the penis at the end of the procedure (Fig. 3 A-C). The incisionis deepened through the skin, while the dartos layer is carefully sepa-rated in the midline, paying attention not to damage the longitudinallyrunning blood vessels. The inner portion of the foreskin is left un-touched. The incision is kept to the minimal length sufficient to allowthe passage of the glans through the buttonhole (Fig. 3D). The entireforeskin and part of the dorsal penile skin are transposed ventrally (Fig.4A). Dorsal and ventral foreskin are incised in the midline and the twolayers are carefully unfurled, leaving inner foreskin medially and outer

Figure 2 – A. The procedure starts with a coronal incision, cutting theurethral plate. B. De-gloving the corpora. C. Artificial erection canshow persistent penile curvature. D. Absence of the urethral plate allowsany surgeon’s preference penile curvature repairs.

Figure 3 – A-C. A hole is made dorsally on the penile skin a fewmillimeters below the prepuce, leaving proximally the correct amountof penile skin to cover the corpora at the end of the procedure. D. Thede-gloved penis is passed through the hole.


11


foreskin laterally (Fig. 4C). The glans is incised in the midline up tothe tip, and the plane between the corpora and the glans cap is sharplydeveloped, stopping at the coronal plane and creating two generousglandular wings (Fig. 4B). The medial margins of two flaps, made ofthe unfurled prepuce in continuity with the parameatal skin, are joinedtogether with interrupted sutures which start proximally at the urethralmeatus and extend distally to create a new urethral plate. Every stitchincorporates a little bite of the underlying corpora cavernosa in orderto stabilize the urethral plate. The distal edge of the new urethral plateis matured to the glans margin, trying to use as few stitches as possibleto avoid skin marks at the future urethral meatus (Fig. 4 D,E).

A “U” shaped incision is started proximal to the original meatusand carried on distally with two longitudinal parallel arms, defining alongitudinal strip and reaching the tip of the glans (Fig. 5A). The inci-sion is superficial, going through only skin and leaving the blood sup-ply, running in the underlying dartos layer, intact. The strip is tubularizedwith inverting, subcuticular stitches (Fig. 5B). The suture ends at theproposed site of the meatus. The suture line is reinforced with a secondrunning suture, picking lateral dartos tissue. The new urethra is cov-ered, additionally, with a tunica vaginalis flap. Glans wings are ap-proximated in two layers and the meatus is matured with few sutures.The penile skin is sutured at the corona and, ventrally, at the midlinewith fast absorbable sutures (Fig. 5 C,D). Drainage of urine is accom-plished with a transurethral 7 Fr. Silastic stent catheter, left free to dripbetween two nappies and removed nine days later.5

The ResultsFifty consecutive boys with scrotal/perineal hypospadias were

treated from 1998 to 2005 in different institutions, using the 2 in 1procedure. Age at operation ranged from four months to eighteen yearswith an average of 22 months. Our preferred age for surgery is be-tween six and twelve months.

Outcome was considered satisfactory in twenty-eight patients(56%) at follow up outpatient visit, three to twelve months after sur-gery. Seven patients (14%) had a coronal meatus, good urinary-flow,acceptable glans appearance and no re-operation was performed. To-tal-number of re-operations was fifteen (30%):

10 due to meatal stenosis (associated with urethrocutaneous fis-tula or multiple fistulas, sometimes associated with distal urethral stric-ture and/or urethral ballooning);

3 due to an isolated urethrocutaneous fistula;due to an untreatable long urethral stricture;due to skin infection resulted in sub-total dehiscence.

DiscussionThe idea of combining the advantages of a single stage repair with

the safety of a staged reconstruction led us to develop the 2 in 1 Proce-dure. The procedure stems from the Koyanagi-Nonomura one-stagerepair1, its additional refinements, and its further modifications2 - 5, withthe main purpose to optimize the vascularity of the flaps and the penileskin. In the 2 in 1 procedure, after straightening of the shaft, the pre-puce and some dorsal penile skin are brought anteriorly creating a newurethral plate. The new urethral plate is secured to the corpora on theirventral aspect and inside the divided glans penis.

In comparison with other one-stage techniques, the 2 in 1 Proce-dure seems to be easier and less time consuming. It allows the simulta-neous treatment of penile curvature and penoscrotal transposition andit is not influenced by the amount of available preputial skin. Rate andrange of complications are acceptable, considering the fact that onlythe most severe and challenging hypospadias are currently treated withthe herein presented method. Postoperative management is quite simpleand similar to that of post-op of simple hypospadias repair with urineis drained with a stent dripping between two nappies, allowing earlydischarge from the hospital.

In conclusion, we believe that the 2 in 1 Procedure is a safe alter-native that allows treating most severe primary hypospadias forms withonly one operation performed at young age and with the perspective ofobtaining satisfactory functional, anatomical and aesthetic results.

Bibliography1. Koyanagi T, Nonomura K, Gotoh T, et al. : One-stage repair of perineal hypospadias andscrotal transposition. Eur Urol, 10: 364, 1984.2. Glassberg KI, Hansbrough F, Horowitz M: The Koyanagi-Nonomura 1-stage bucket repairof severe hypospadias with and without penoscrotal transposition. J Urol, 160: 1104, 1998.3. De Castro R, Abu Daia J, Al Abdul Aaly MI: Augmented Koyanagi-Nonomura one- stagebucket repair for perineal hypospadias: preliminary results. BJU Int., 87: 414, 2001.4. Emir H, Jayanthi VR, Nitahara K, et al.: Modification of the Koyanagi technique for thesingle stage repair of proximal hypospadias. J Urol, 164: 973, 2000.5. Hayashi Y, Kojima Y, Mizuno K, et al: The modified Koyanagi repair for severe proximalhypospadias. BJU Int., 87: 235, 2001.6. Snow BW, Cartwright PC: The Yoke hypospadias repair. J Pediatr Surg, 29: 557, 1994.7. Bracka A: Hypospadias repair: the two-stage alternative. BJU Int., 76: 31, 1995.8. Retik AB, Bauer SB, Mandell J: Management of severe hypospadias with 2-steg repair. JUrol, 152: 749, 1994.9. Snodgrass W, Yucel S: Tubularized incised plate for mid shaft and proximal hypospadiasrepair. J Urol, 177: 698, 2007.

Figure 5 A-D. The long skin flap is designed, gently dissected avoidinginterruption of the blood supply coming through the subcutaneous tissue,tubularized in 2 layers, and covered with a tunica vaginalis flap.

Figure 4 – A. The foreskin together with some dorsal penile skin istransferred ventrally. B. Two large glands wings are created. C-E.Preputial and penile skin is fashioned and sutured on the corpora and inthe glans recreating a firm urethral plate. Despite working with a flap,some of the typical rules of a first stage Bracka graft repair are applied.

12


The Three-In-One Technique for One-Stage ComplexHypospadia Repair

Hypospadias repair is regarded as a challenging operation and com-plex primary forms can be treated according to different strategies. Someof my reconstructive ancestors have presented their opinions and argu-ments for a two-step strategy. Most of their arguments are logical, but inmy opinion our decisions should also take into account parent’s concernsand the desire for correction with a single operation, especially when thesurgeon feels comfortable enough to adopt both concepts and have com-parable results in either a one or two-step technique. It is unquestionablethat treating the patient in one step will require a surgeon with expertise inreconstructive surgery with skills in flap and graft handling. On the otherhand, any pediatric urologist that deals with proximal hypospadias needsthis background anyway. “The three-in-one technique” is simply the in-corporation of well known steps of hypospadias repair at the same time:1. Incision of the urethral plate for straightening the penis.2. Dorsal grafting in the corpora cavernosa replacing the defect

created by the incision in order to reconstruct the urethral plate.3. Internal preputial flap for onlay urethroplasty.4. Second flap of tunica vaginalis and cremaster to cover the

neourethra and avoid a fistula.In 2004, we described this new approach of one-stage urethroplasty

using a free buccal mucosa graft to lengthen the urethral plate, allowingfor complete resection of chordee with no residual curvature.1 This methodproduces a safe reconstruction in only one surgical stage and is in accor-dance with the present tendency of onlay reconstruction of the urethra.2 Asall of us are aware, dorsal buccal mucosa graft in urethroplasty is a safemethod and has been popularized in adults by Barbagli and in hypospa-dias cripples and severe hypospadias forms by Bracka. Buccal mucosa is aversatile alternative of donor site and proved to have good integration tothe adjacent urethra in an experimental model in rabbits.3

TechniqueAfter section of the urethral plate to correct ventral curvature, the

original plate is anchored to the proximal penile shaft by 6-0 PDS sutures(Fig 1). The glans is further sectioned in the midline to produce two wideglandular wings and allow dorsal placement of the buccal mucosa graftalso in the glandular area up to the desired neo-meatus.

The distance between the incomplete urethral plate and the glans isthen measured to define the necessary length of the buccal mucosa graft,taking into account 20% shrinkage of the harvest graft.

Buccal mucosa is harvested from the lower lip, with extension to theinside aspect of the cheek when a longer graft is necessary. The harvestsite is left open and the graft prepared by removal of submucosal fattytissue. The graft is then sutured to the ventral penile shaft area by inter-rupted 6-0 PDS sutures to restore the defect of the urethral plate and toprepare the foundations of the neourethra (Fig 2-6). The mucosal layer ofthe buccal mucosa faces the future neourethra. A transverse preputial flapis obtained and anastomosed “onlay” to the reconstructed neouretha withrunning 6-0 PDS sutures with care to anchor the sutures of the buccalmucosa “track” also to the Buck´s fascia to stabilize the anastomosis. Thescrotal fascia is opened in the site opposite the placement of the pedicle ofthe preputial flap and a careful dissection of the tunica vaginalis and cre-masteric tissue was performed isolating it from testicular cord structures.This second flap is used to cover the neourethra and fixed to the corporaby angular interrupted 6-0 PDS sutures (Fig 3). The penile skin is recon-structed and in cases of lack of ventral skin with associated penoscrotal

transposition, two additional scrotal skinflaps are produced and mobilized ven-trally to achieve a better cosmetic ap-pearance of both the penis shaft and thescrotum (Fig 4). We can see the differ-ent steps of the description of the tech-nique in one patient and the final aspectafter two months (Fig 5, 6, 7, 8).

In all cases a 6 Fr silicone tube isleft within the urethra for 7 to 10 daysand a cystostomy tube for 2 to 3 weeks.Initial dressings were left untouched forat least 3 days postoperatively.

Clinical DataFrom March 2002 to December

2005, a total of 22 patients underwentone-stage primary complex hypospa-dias repair using the three-in-one tech-nique. We performed 9 scrotal, 8penoscrotal and 4 perineal repairs. Ourseries consisted of children less than 6years of age, except for one adult (28years) with a complex perineal hypos-padias that had been brought up as afemale in the countryside of Brazil be-fore he was referred to our institution.

Mean age at surgery was 2.4 years(1 to 6) in 21 patients (excluding theadult patient). Complications included3 cases of urethral diverticula, 3 uncom-plicated fistulas, 2 meatal stenosis andone patient developed excessive ven-tral skin retraction. The overall compli-cation rate was 40.9%. One fistulaclosed spontaneously, whereas the othertwo required surgical revision and werecorrected in an outpatient regimen.

The most complex complication inthis series was a urethral diverticula thatrequired open reconstruction. Two pa-tients underwent outpatient meatotomyand one other had open surgical releaseof the ventral scared tissue. The redorate in the series was 36.3%. No compli-cations related to the harvest site were seen.

Clinical complications withoutmajor consequences to the patients werefound in 4 patients consisting of 2 UTIand 2 epididymo-orchitis. Mean fol-low-up for this first series is 4.2 years(2.5 to 6).


Fig 1: Penis degloved, urethralplate sectioned in the subcoronalarea and the two flaps prepared.

Antonio Macedo, Jr., MD, Department of Urology,Pediatric Urology Section, Chief, Federal University of São Paulo, São Paulo, Brazil

Fig 2: Dorsal grafting of buccalmucosa to reconstruct theurethral plate and allow onlayanastomosis of the flap.

Fig 3: Cremasteric/vaginalis flapto cover the neourethra.

Fig 4: Final aspect of the surgeryappearance.


13


CommentsThe goals of hypospadias surgery remain the creation of a straight,

cosmetically acceptable phallus consisting of an orthotopic slit-like ure-thral meatus and conically shaped glans and adequate skin coverage withan appropriate mucosal collar.4 Proximal hypospadias remains a chal-lenging and controversial aspect of pediatric urology. Unlike distal andmid shaft repairs, numerous techniques are reported for proximal hypos-padias, which translates to the fact that no single repair has clearly demon-strated superiority with respect to complication rate, cosmesis and long-term outcome. Proximal hypospadias with chordee is the most challeng-ing variant of hypospadias to reconstruct. Surgical techniques have beendescribed that may be broadly classified as 1, 2 or multiple stage procedures.

To repair proximal severe hypospadias Duckett reported the use of atransverse tubularized island flap made of inner preputial skin to fashion aneourethra.5 However, contrary to Duckett’s initial results, somewhat highcomplication rates have been reported and this technique has been largelyabandoned because of their prohibitive long-term complication rate.6,7 Toachieve better results, the onlay island flap technique with preservation ofthe urethral plate has become the most common approach for severe hy-pospadias.

At present, in the majority of posterior hypospadias, including perinealhypospadias, the urethral plate can be preserved and a vascularized flapused in an onlay fashion. In the rare case when the urethral plate needs to beresected, a 2-stage technique can be used.

We agree that most hypospadias repairs should be done withouttransecting the urethral plate. Nevertheless, we know that in some patientswith severely curved hypospadias we cannot achieve adequate penilestraightening without resecting the plate. While a 2-stage approach to thesedifficult cases has been advocated, we have used a new repair technique asa one-stage procedure named the “three-in-one” technique.1

With advances in suture materials, use of optical magnification andmicrosurgical instrumentation, hypospadias repair in one stage has devel-oped into a safe and reliable procedure, with very high reported successrates. We think that lengthening the urethral plate with a buccal mucosa

graft is an optimal procedure in casesof severe chordee. Our complicationrate of about 40% is acceptable, espe-cially if we consider that 60% of ourpatients were successfully treated in onesingle surgery. Recent studies of out-comes following 2-stage repairs reportreoperation rates of 5% to 41% afterthe planned stage 2 repair.8,9,10

Our results with the “three-in-one”technique have had a trial that was longenough to support the feasibility of thistype of surgery. Besides the desirabil-

ity of completing the reconstruction in one operation, a one-stage opera-tion has the additional advantage of using skin that is unscarred from pre-vious surgical procedures, the normal blood supply of which has not beendisrupted.

Furthermore the approach has been adapted from the Barbagli´s wellestablished technique for urethral stricture11, and we previously investi-gated the healing of dorsal buccal mucosa grafts in a experimental modelin rabbits showing that the graft keeps its histological properties fully inte-grated to the urethral epithelium.3 Recently we have been interested inevaluating the tunica vaginalis as an optional graft to reconstruct the ure-thral plate and both experimental12 and initial clinical data are promising.13

In conclusion, we believe that there is also a psychological benefit tothe family and, ultimately, to the boy to enable him to appear as normal aspossible at the first stage, as this technique does, and to leave the secondstage for minor skin moving and correction of any complications fromurethroplasty. We agree that considerable expertise in hypospadias sur-gery might be required to perform this technique whereas a two-stage pro-cedure is much more straight-forward. One should bear in mind that suchcomplex hypospadias forms are naturally referred to “hypospadiologists”and “three-in-one” technique offers a reliable one-stage repair, being ourprocedure of choice for most difficult cases of severe hypospadias.

References1. Macedo A Jr, Srougi M: Onlay urethroplasty after sectioning of the urethral plate: earlyclinical experience with a new approach - the ‘three-in-one’ technique. BJU Int, 93(7):1107-9, 2004.2. Macedo A Jr. Re: Combined buccal mucosa graft and local flap for urethral reconstructionin various forms of hypospadias. J Urol, 2006 May; 175(5):1966.3. Souza GF, Calado AA, Delcelo R, Ortiz V, Macedo A Jr: Histopathological evaluation ofurethroplasty with dorsal buccal mucosa: an experimental study in rabbits. Int Braz J Urol,34(3):345-54, 2008.4. Mouriquand PD, Mure PY: Current concepts in hypospadiology. BJU Int, 93 Suppl 3:26-34, 2004 May.5. Duckett J: Transverse preputial island flap technique for repair of severe hypospadias.Urol Clin North Am, 7:423 – 31, 1980.6. Elbakry A: Complications of the preputial island flap-tube urethroplasty. BJU Int, Jul;84(1):89-94, 1999.7. Parsons K, Abercrombie GF: Transverse preputial island flap neourethroplasty. Br JUrol, 25: 186–4, 1984.8. Retik AB, Bauer SB, Mandell J, Peters CA, Colodny A, Atala A: Management of severehypospadias with a 2-stage repair. J Urol, 152: 749, 1994.9. Greenfield SP, Sadler BT, Wan J: Two-stage repair for severe hypospadias. J Urol, 152:498, 1994.10. Gershbaum MD, Stock JA, Hanna MK: A case for 2-stage repair of perineoscrotalhypospadias with severe chordee. J Urol, 168: 1727, 2002.11. Barbagli G, Selli C, di Cello V, Mottola A: A one-stage dorsal free-graft urethroplasty forbulbar urethral strictures. Br J Urol, 1996 Dec;78(6):929-32, 1996.12. Calado AA, Macedo A Jr, Delcelo R, de Figueiredo LF, Ortiz V, Srougi M: The tunicavaginalis dorsal graft urethroplasty: experimental study in rabbits. J Urol, 2005Aug;174(2):765-70, 2005.13. Foinquinos RAC, Calado AA, Souza JR, Griz A, Macedo A Jr, Ortiz V: The TunicaVaginalis dorsal graft urethroplasty: Initial Experience. Int Braz J Urol, 33(4):523-9;discussion 529-31, 2007.

Fig 7: The neourethra after completion ofthe two layer anastomosis.

Fig 6: The urethral plate is reconstructed. Fig 8: Cosmetic appearance after 2 monthsof surgery.

Fig 5: Incision lines are marked.

14


The Tunica Vaginalis: A Versatile Dorsal Graft for UrethroplastyAdriano A. Calado, Division of Pediatric Urology

Pernambuco State University, Recife – Pernambuco, Brazil

Defects in the male urethra caused by congenital malformationsor traumatic injuries have created a need for tissues that can serve asadequate urethral substitutes. Various donor tissues have been usedclinically for urethral repair, including vascularized skin flaps from theprepuce, scrotum or penile shaft, full thickness free skin grafts, vesicalor buccal mucosa grafts, and tunica vaginalis, ureter, artery, vein andappendix tissue.1 Actually, vascularized skin flaps are the preferredmaterial for use in urethral reconstructions when available, mainly forprimary urethral repairs. However, many problems still remain withthe current methods, making it a field of further exploration for recon-structive urologists.

The goals of primary hypospadias repair include straightening thecurvature of the penis, extending the meatus to the glans tip, and revis-ing the abnormal prepuce by either circumcision or foreskin recon-struction to allow satisfactory urination and sexual function.2 Correc-tion of penile chordee is the initial step in the management of hypospa-dias. In most instances releasing the tight ventral skin is sufficient forcorrecting mild penile chordee. In these cases, when the urethral platedoes not require transection, a one-stage repair is used. Actually, foranterior hypospadias the most commonly accepted procedures are themeatal advancement glansplasty (MAGPI), tha glans approximationprocedure (GAP), the Mathieu or flip-flap, and the Snodgrass modifi-cation or tubularized incised plate urethroplasty.3

For the treatment of posterior hypospadias the benefits of urethralplate preservation and advantages of onlays over tubes are well known3,4,and at present, in the majority of posterior hypospadias, the urethralplate can be preserved and a vascularized flap used in an onlay fashionor a Snodgrass modification with tubularization. However, in the pres-ence of severe proximal forms, with significant chordee, urethral platetransection becomes inevitable, and a full circumferential substitutionurethroplasty is then required.

Single stage tubularized repairs, the most popular being the Ducketttubularized preputial island flap, have been largely abandoned becauseof their prohibitive long-term complication rate.5 Nevertheless, in someof these cases the prepuce may be inadequate for urethroplasty or alto-gether absent following circumcision. Similarly in reoperative casesthere may be significant scarring of the tissues, so that substitutionurethroplasty is needed, and skin may not be available, justifying theconsideration of replacement urethroplasty.

The advent of buccal mucosa as a urethral substitution materialhas revolutionized the management of these challenging cases.6,7 Un-like bladder mucosa, which is an obligatory wet mucosa that, there-fore, has to be used as a one-stage tube and kept away from the meatus,buccal mucosa is a robust material that can be left exposed to the airfor long periods. For this reason it can be used for two-stageurehtroplasty in much the same way as a full-thickness skin graft.

For a subset of patients with scrotal or perineal hypospadias, asmall phallus and severe chordee, a two-stage repair such as describedby Bracka is regarded by many as a better option.8 In the first stage, thepenis is straightened and the scarred urethra is discarded. Buccal mu-cosa is harvested from either the check or lip and grafted to the pre-pared bed. The second stage urethroplasty is undertaken at least 6months after the first stage. These patients, if treated with one-stagerepair, usually need a composite graft. Some centers reported unsatis-

factory experience with the operative results in such patients managedwith one-stage repair.

Recently our group described an original one-stage approach totreating primary complex hypospadias using buccal mucosa to recon-struct the urethral plate in such patients when preservation of the ure-thral plate is not possible.9 Despite these advances in urethroplasty tech-nique, certain proximal and reoperative cases remain a problem for themodern hypospadias surgeon. Complications occur even in the besthands. Thus, creative additions to current techniques are still needed.

The search for an ideal urethral substitute carries on as investiga-tors continue to evaluate various materials for substitution urethroplasty.In 1986 Snow used tunica vaginalis as a wrap around the neourethraduring hypospadias repair.10 Apart from a blanket wrap experience withtunica vaginalis in hypospadias surgery has been limited. Snow andCartwright tubularized tunica vaginalis in 3 reoperative cases and ob-served meatal stenosis in all.11 Meatal stenosis occurred in 3 of 5 pa-tients and urethral stricture developed in 3 of 5 in the experience ofJoseph and Perez with tunica vaginalis onlay flaps.12 No fistula oc-curred. Khoury et al used a vascularized tube flap of tunica vaginalis toreplace the penile urethra in 12 rabbits.13 Two of the 10 flaps that wereavailable for assessment became necrotic due to compression of thevascular pedicle and anastomotic stricture developed in 1 rabbit. Thehealing process was satisfactory clinically and histologically in the re-maining 7 flaps. Theodorescou et al studied 26 rabbits with an onlay ora tube flap. All 16 rabbits in the onlay group had excellent flap viabil-ity and a 100% urethral patency rate.14 The mesothelial lining of thetunica was replaced by a stratified epithelial lining similar to nativeurethra. All 8 rabbits with tube flaps died of urinary retention. Theyshowed neourethral contracture, probably secondary to striated cre-masteric muscle elements brought with the tunica during mobilization.The lumen of the tube was completely collapsed as a result of contrac-tion of the cremasteric muscle, which was part of the flap. No evidence ofischemia was found and vessels to the flap were patent on microscopy.

These studies influenced us to explore the use of tunica vaginalisas an alternative material for urethral reconstruction. Using an animalmodel we evaluated a tunica vaginalis graft as a substitute for buccalmucosa in dorsal urethroplasty. All animals demonstrated a patent andfunctional urethra, as evidenced by radiographic and histological analy-ses (Figure 1). The explanation of our good results is probably thatdorsal placement of the graft enhanced graft immobilization and thedirect blood supply from the corpora perforating the vessels was prob-ably responsible for good graft incorporation.15

Based on our in vivo (experimental) experience with tunicavaginalis graft urethroplasty, a pilot clinical study is being performedin our university clinical hospital to evaluate the safety and efficacy ofthis new technique to correct severe urethral strictures. Recently wepublished our short-term experience with tunica vaginalis grafts, placeddorsally, for the treatment of anterior urethral strictures.16 Preliminaryresults on 11 patients demonstrate that in our initial experience all pa-tients had anatomically and functionally patent urethras as demonstratedby retrograde urethrography and uroflowmetry. The most importantlimitation of this study is the length of followup.


15


Our experience, although on a small number of patients, is an es-sential step to evaluation of the role of tunica vaginalis urethroplasty.The initial results show that tunica vaginalis is a very good substituteon which natural urothelium grows. In terms of the registered compli-cations the results are very promising.

Regarding the place of tunica vaginalis in the algorithm for hy-pospadias repair, we recommend this technique in circumcised patientswith primary proximal hypospadias and severe chordee requiringtransection of the urethral plate when there is no adequate genital skin.We emphasize that this technique is reserved for especially difficultcircumstances.

More clinical work must be done before most urologists will befully comfortable with using tunica vaginalis urethroplasty. However,no hesitation should exist in performing more urethroplasty procedureswith tunica vaginalis as the grafting material. Long-term outcomes andmulticenter experiences with this approach are definitely needed toconfirm the good short-term results.

Fig. 1 - A 4 cm. urethral stricture treated by dorsal tunica vaginalis grafturethroplasty.

References1. Mouriquand PD, Mure PY: Current concepts in hypospadiology. BJU Int, 93 Suppl 3:26-34, 2004.2. Manzoni G, Bracka A, Palminteri E, Marrocco G. Hypospadias surgery: when, what andby whom? BJU Int, 94(8):1188-95, 2004.3. Baskin LS, Ebbers MB: Hypospadias: anatomy, etiology, and technique. J Pediatr Surg,41(3):463-72, 2006.4. Erol A, Baskin LS, Li YW, Liu WH: Anatomical studies of the urethral plate: whypreservation of the urethral plate is important in hypospadias repair. BJU Int, 85(6):728-34,2000.5. Parsons KF, Abercrombie GF: Transverse preputial island flap neo-urethroplasty. Br JUrol, 4(6):745-7, 1982.6. Markiewicz MR, Lukose MA, Margarone JE 3rd, Barbagli G, Miller KS, Chuang SK: Theoral mucosa graft: a systematic review. J Urol, 178(2):387-94, 2007.7. Hensle TW, Kearney MC, Bingham JB: Buccal mucosa grafts for hypospadias surgery:long-term results. J Urol, 168(4 Pt 2):1734-6, 2002.8. Bracka A: Hypospadias repair: the two-stage alternative. Br J Urol,76:31-41, 1995.9. Macedo A Jr, Srougi M: Onlay urethroplasty after sectioning of the urethral plate: earlyclinical experience with a new approach - the ‘three-in-one’ technique. BJU Int, 93(7):1107-9, 2004.10. Snow BW: Use of tunica vaginalis to prevent fistulas in hypospadias surgery. J Urol,136(4):861-3, 1986.11. Snow BW, Cartwright PC: Tunica vaginalis urethroplasty. Urology, 40(5):442-5, 1992.12. Joseph DB, Pérez LM. Tunica vaginalis onlay urethroplasty as a salvage repair. J Urol,162(3 Pt 2):1146-7, 1999.13. Khoury AE, Olson ME, McLorie GA, Churchill BM: Urethral replacement with tunicavaginalis: a pilot study. J Urol, 142(2 Pt 2):628-30, 1986.14. Theodorescu D, Balcom A, Smith CR, McLorie GA, Churchill BM, Khoury AE: Urethralreplacement with vascularized tunica vaginalis: defining the optimal form of use. J Urol,159(5):1708-11, 1998.15. Calado AA, Macedo A Jr, Delcelo R, de Figueiredo LF, Ortiz V, Srougi M: The tunicavaginalis dorsal graft urethroplasty: experimental study in rabbits. J Urol, 174(2):765-70,2005.16. Foinquinos RC, Calado AA, Janio R, Griz A, Macedo A Jr, Ortiz V: The tunica vaginalisdorsal graft urethroplasty: initial experience. Int Braz J Urol, 33(4):523-9, 2007.

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