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© 2016 Archives of International Surgery | Published by Wolters Kluwer - Medknow 121
One‑Stage repair of hypospadias using the
modied prepucial island ap technique:
Experience with 200 cases
ABSTRACT
Background: Surgical repair of hypospadias has taxed the skills of surgeons the world over. One‑stage repair is preferable because it
decreases operative trauma, allows use of virgin unscarred tissue, decreases number of hospitalizations, and hence is more economical
than two‑stage repairs. During the last 7 years, the author has managed 200 cases of hypospadias and their complications in a
tertiary care service hospital. This study aimed to evaluate the outcomes of using modified onlay island flap technique in the repair
of hypospadias with a narrow urethral plate.
Patients and Methods: In this prospective study conducted between June 2008 and June 2015, we performed modified onlay island
flap procedure for the repair of hypospadias with a narrow urethral plate – less than 7 mm. This technique was used for all types of
hypospadias with minimal or no chordee except penoscrotal. We did not require any tunica plication in our study.
Results: Two hundred patients with age ranging from 3 years to 10 years (average 5 years) underwent modified onlay island flap
repair; all had a narrow urethral plate of less than 7 mm; 30 (15%) had mild chordee. Meatus was located in coronal in 10 (5%) cases,
subcoronal in 120 (60%), midpenile in 50 (25%), and proximal penile in 20 (10%) patients. Chordee was corrected with degloving only
in 30 (15%) patients. Complications were meatal stenosis in none and urethrocutaneous fistula in 10 (5%) patients. Mean follow‑up
duration was 12 months.
Conclusion: This technique offers acceptable results regarding meatal stenosis, urethrocutaneous fistula, along with good aesthetic
outcome.
Key words: Hypospadias, modified, onlay island flap, urethroplasty
Aditya P. Singh, Arvind K. Shukla, Pramila Sharma, Ramji Prasad
Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
Address for correspondence: Dr. Aditya P. Singh,
Department of Pediatric Surgery, SMS Medical College, Jaipur,
Rajasthan, India.
E-mail: dr.adisms@gmail.com
after hypospadias repair are common.[2] Hence, new
modifications of repair techniques are usually attempted
with the aim of obtaining better results and fewer
complications.[3]
In this study, we objectively assessed the feasibility of
this technique. Complications such as fistula, wound
dehiscence, recurrent ventral curvature, meatal stenosis,
Introduction
One‑stage repair is naturally favored because it decreases
operative trauma, decreases the number of hospitalization,
and thus, is economical. Onlay preputial flap repair
was first described by Duckett[1] in 1987. Complications
Original Article
Access this article online
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DOI:
10.4103/2278-9596.194988
How to cite this article: Singh AP, Shukla AK, Sharma P, Prasad R.
One-Stage repair of hypospadias using the modied prepucial island
ap technique: Experience with 200 cases. Arch Int Surg 2016;6:121-6.
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122 Archives of International Surgery / April-June 2016 / Vol 6 / Issue 2
Singh, et al.: Modied prepucial island ap urethroplasty
diverticulum, torsion, skin necrosis, flap necrosis,
megameatus, extravasation of urine, and urethral stricture
were analyzed.
Patients and Methods
Between June 2008 and June 2015, modified onlay island
flap hypospadias repair was performed in 200 cases with
a narrow urethral plate (less than 7 mm) in our institute by
a single surgeon. Data were collected including patient’s
age at operation, along with data regarding types of
hypospadias, complications, and cosmetic outcomes.
Cosmetic outcome was assessed by parents and surgeon.
This surgical technique was selected in all types of
hypospadias except penoscrotal hypospadias and in those
with moderate‑to‑severe chordee. All patients followed up
for a minimum of 1 year. For urethral tube reconstruction,
inner prepucial layer was used as a flap based on the
leash of vessels running dorsally in its mesentery. Width of
this flap was kept after proper measurement. Flap length
was determined by measuring the distance from ectopic
urethral meatus to the tip of the glans.
Surgical technique
The patients were at least 3 years of age to have acceptable
size structures. We included this age group because the
children become more cooperative at this age. If the penis
was relatively small, preoperative aqueous testosterone
injection (1–2 mg/kg) was given to enlarge its size. Two
to three injections were given at 2 weeks interval, and
operation was done after 1 month of last injection. Surgery
was performed under general anesthesia with infiltration of
1:100000 xylocaine and adrenalin solution. Racket‑shaped
incision of the skin was performed with preservation of
the urethral plate. Circumcoronal incision was done 5 mm
proximal to the coronal margin extending proximally by two
vertical incisions 6–8 mm apart along the urethral plate
up to the proposed site of the urethral meatus and then
going around the ectopic urethral meatus and extending
in midline proximally. Phallus was degloved completely.
The urethral plate was preserved in the all cases. Chordee
correction was obtained by only degloving.
For urethral tube reconstruction inner prepucial layer
was used as a rectangular flap [Figure 1a]. We measured
the length of the urethral plate and access the prepuce
available for flap. Rectangular flap should be equal to or
more than the urethral plate. Flap based on the leash of
vessels running dorsally in its mesentery. The flap along
with its mesentery was sufficiently mobilized to rotate it
ventrally to the ectopic meatus and sutured to the edge
of the urethral plate using continuous 6‑0 Vicryl sutures.
We did not separate it completely. Keeping a 8 Fr silastic
NG tube as a urethral stent, the width of rectangular flap
was again measured and the excess part was cut; then,
the other edge of the flap was sutured to the opposite
edge of the urethral plate to fashion a neourethra
[Figure 1b and c]. Anteriorly, the remaining part of the flap
was folded proximally and incorporated in glanuloplasty
[Figures 1d, 2a and b]. The prepucial mesentery was then
used to cover the suture line by stitching it across the
neourethra. Glanuloplasty was carried out in 2 layers in the
all cases and a cover was provided using lateral penile flaps
with lateral suture line [Figure 2c]. NG tube was replaced
with 6 Fr NG silastic tube. Simple penile dressing was
performed in all cases. Urinary diversion was carried out in
all the cases and in all age group using 6F‑feeding tube. We
anchored the feeding tube with the glans using prolene 4‑0
sutures. Dressing was changed on the 7th postoperative day
and catheter removed on the 10th postoperative day. Simple
penile dressing after hypospadias surgery is the protocol
in our institute. The urethra was stented for 10 days
postoperatively. All patients were operated on by a single
surgeon. Patients were seen at the time of catheter removal,
at 1 week postoperatively, and then at 2 weeks, 1 month,
3 months, 6 months, and 12 months postoperatively.
Results
Two hundred patients (all had a narrow urethral plate
less than 7 mm) underwent modified onlay island flap
repair during a period of 7 years. The age of the patients
ranged from 3 to 10 (average 5 years) years. The types of
hypospadias were coronal in 10 (5%) cases, subcoronal in
120 (60%), midpenile in 50 (25%), and proximal penile in
Figure 1: (a) Rectangular ap; (b) neourethra formation; (c) second
interrupted layer; (d) glanuloplasty in two layers
ab
cd
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Archives of International Surgery / April-June 2016 / Vol 6 / Issue 2 123
Singh, et al.: Modied prepucial island ap urethroplasty
20 (10%) patients [Table 1]. Thirty patients (15%) had mild
chordee. Chordee was corrected with degloving only. We
excluded cases with moderate‑to‑severe chordee because
these require two‑stage repairs in our case selection
criteria to minimize the complications. We preserved
urethral plate in all cases. Complications were meatal
stenosis in none, urethrocutaneous fistula in 10 (5%), mild
torsion 20 (10%), wound dehiscence 4 (2%), skin necrosis
in 2 (1%), flap necrosis in none, residual chordee in none,
diverticulum in 10 (5%), stricture in none, extravasation
of urine 2 (1%), and megameatus in 2 (1%) cases [Table 2].
All case had acceptable voiding in single good urinary
stream, satisfactory cosmetics result and appearance.
with our modified technique, meatus was vertical slit like
and at the tip of the penis. penis looks like a circumcised
penis. Follow‑up period was 12 months in our study.
Discussion
Hypospadias is one of the most common congenital
genital anomalies in males. The current trend is surgery
in early infancy (between 6 to 9 months old). Surgical
repair of hypospadias has remained one of the most taxing
problems for reconstructive surgeons, urologists, and
pediatric surgeons alike because of the high complication
rate. The very fact that there are approximately 250
different operations to manage this tricky problem itself
is a testimony that no single operation is favored by all
surgeons the world over because no single technique
provides uniformly good results. A perfect hypospadias
repair should reconstruct the urethral continuity keeping
sufficient caliber, correct phallus curvature, and provide
an acceptable appearance with low complications.
The purpose of primary hypospadias repair is to achieve
both good cosmetic and functional outcomes. It requires
reconstruction of a straight penis, with an acceptable
calibre of neourethra, and a vertical slit‑like meatus.[4]
There are recent reports suggesting an increase in the
incidence of hypospadias possibly related to environmental
estrogen‑like compounds. A study carried out in Finland
revealed an increase of prevalence by approximately
three times.[5] Technique of repair is based on a number
of factors such as degree of curvature, site of the meatus,
width of urethral plate, and surgeon’s choice. In onlay
flap repair, careful protection of the vasculature of the
flap and prevention of overlapping suture lines generate a
waterproof closure with a minimum risk of postoperative
fistula. In our study, we mobilized the mesentery of the
rectangular flap not completely but sufficiently to reach
the native urethral plate. One‑stage repair for hypospadias
was introduced in 1955 using full thickness skin grafts
from prepuce. The advantage of correcting the chordee and
reconstruction of neourethra in a single operative sitting
and the associated low morbidity are responsible for the
popularity of one‑stage repair. However, certain surgeons
remain unhappy with the limitations and drawbacks
of one‑stage repair and continue to practice two‑stage
repairs.
In the present study, external urethral meatus was located
at coronal in 10 (5%) cases, subcoronal in 120 (60%),
midpenile in 50 (25%), and proximal penile in 20 (10%)
patients. These results are not similar with the results
Figure 2: (a) Extra anterior part of the ap; (b) extra ap sutured with
glans; (c) lateral skin closure and complete view postoperatively;
(d) single urine stream
ab
cd
Table 1: Types of hypospadias
Types of hypospadias Number of patients %
Coronal 10 05
Subcoronal 120 60
Mid penile 50 25
Proximal penile 20 10
Total 200 100
Table 2: Complications
Type of complication Number of patients %
Meatal stenosis 00 00
Urethrocutaneous fistula 10 05
Mild torsion 20 10
Wound dehiscence 04 02
Skin necrosis 02 01
Flap necrosis 00 00
Residual chordee 00 00
Diverticulum 10 05
Stricture 00 00
Megameatus 02 01
Extravasation of urine 02 01
Total 50 25
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124 Archives of International Surgery / April-June 2016 / Vol 6 / Issue 2
Singh, et al.: Modied prepucial island ap urethroplasty
reported Welch in1979.[6] Snodgrass
et al
. carried out
subepithelial biopsies of urethral plate in 17 patients
and found no histological evidence of fibrous bands,[7]
concluding that there is no requirement of violating the
integrity of urethral plate. In our study, we preserved
urethral plate in all cases. In all cases, inner prepucial
layer was used as an onlay flap over the preserved urethral
plate to reconstruct the neourethra. We compare our
results with the tubularized incised plate (TIP) because
the principle of surgery same for both as native urethral
plate saving procedure. Although the TIP might be the most
common procedure to repair distal hypospadias because
it is reportedly simple and gives better cosmetic outcomes
than flap repairs; in the TIP procedure, some features
of the urethral plate, especially a flat and narrow plate,
potentially increases the risk of complications, i.e., meatal
stenosis and urethrocutaneous fistula.[8] In the present
study, patients had a narrow urethral plate (<7 mm), and
hence the TIP procedure was not an ideal treatment option.
An advantage of the onlay island flap technique is the use
of preputial skin, which is often available, is hairless, and
large enough to construct the defective urethral floor, and
is often otherwise discarded.
TIP is a common operation in hypospadias reconstruction,
however, our experience shows that risk of stricture and
fistula is relatively high and requires an acceptable wide
urethral plate for urethroplasty. However, in the study
by Sozubir
et al
.,[9] complications after TIP repair were
equivalent to other current techniques where caution in
technical details could decrease these complications. The
authors believed that this procedure regularly generated
a vertical meatus and a good aesthetic result. Snodgrass
et al
.[10] used the TIP procedure for distal and proximal
hypospadias, and the main complication in their patients
was fistula. Despite the use of a dartos flap in all cases,
fistula occurred in 5% of distal and 19% of proximal repairs.
Snodgrass
et al
.[10] used TIP urethroplasty for hypospadias
reoperation, however, when it was employed in proximal
hypospadias, they encountered a complication rate of 33%
with 21% incidence of fistula and persistent chordee in
some patients. In our study, we had only 10 (5%) fistula.
Results of hypospadias repair vary in different centres.
Cheng
et al
.[11] reported a large multicenter series of
patients with both distal and proximal hypospadias who
experienced TIP repair with less than 1% occurrence of
fistulas. They approximated the corpus spongiosum over
the neourethra during proximal repair and protected
neouretra with dartos layer and glans wings. In this
study, the only parameter for selection of patients was
urethral plate diameter less than 7 mm and type of
hypospadias was not an effective factor. The advantage of
this technique is the preservation of the native urethral
plate in neourethra.
Sarhan
et al
.[12] in a single‑centre study with 500 cases
reported the TIP procedure to be a reliable technique for
the management of both distal and proximal hypospadias
in both primary and reoperative cases with a small rate of
complications, however, urethral plate diameter was not
mentioned. Postoperative meatal/neourethral stenosis
after TIP is common, and hence Shimotakahara[13] collected
a dorsal inlay graft from the inner prepuce and sutured it to
the midline incision of the urethral plate. We included only
cases with mild chordee 30 (15%), so they were corrected
by degloving only and did not require any transection of
the urethral plate or dorsal tunica plication to correct the
chordee. Although TIP urethroplasty is a choice procedure
in distal penile hypospadias for some surgeons, now some
authors prefer to use the onlay flap technique, particularly
in cases of a small phallus with narrow plate or conical
glans, which makes tubularization difficult.[14]
In 1987, Elder reported the first one‑stage hypospadias
repair using an onlay island flap, although the preputial
island flap had been done previously. It permits for
repair of distal and midshaft hypospadias.[1] Ehab
et al
.[15]
evaluated the consequences of using a distally folded
onlay flap in the repair of distal penile hypospadias in
36 patients, however, they had only two urethrocutaneous
fistula and they used onlay flap for distal type; in our study,
it was used for all types except penoscrotal. Mamdouh
et al
.[16] conducted a study among 45 patients with similar
mid‑penile hypospadias deformities; they designed a
comparative study between the TIP and onlay preputial
island flap and reported no differences between the
two techniques. Braga
et al
.[17] retrospectively analyzed
patients with penoscrotal hypospadias; 35 children
underwent TIP and 40 underwent onlay urethroplasty.
They reported complication rates of 60% for TIP and 45%
for the onlay flap. Leslie
et al
.[18] used tunica vaginalis graft
plus onlay preputial island flap in urethral reconstructive
surgery in rabbits in one‑stage for complex hypospadias
with divided urethral plate. Silva
et al
.[19] compared three
different urethroplasty techniques (onlay, buccal mucosa,
Koyanagi type I) in severe hypospadias. The fistula was
shown in 15% in onlay group, 32% in the buccal mucosa
group, and 19.2% in the Koyanagi cases. Patel
et al
.[20]
explained a technique called the split onlay skin flap,
which had fistula in 6 patients. Subramanian
et al
.[21]
described several surgical techniques in hypospadiasis
along with their complications.
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Archives of International Surgery / April-June 2016 / Vol 6 / Issue 2 125
Singh, et al.: Modied prepucial island ap urethroplasty
There was no case of meatal stenosis in our study because
we created neourethra over 8 to 10 Fr size of NG tube and
folded the extra anterior part of the rectangular flap on
itself proximally and sutured with glanuloplasty to cover
the raw area. It was wide enough and hence we did not
require meatal dilatation routinely in follow‑up visit; we
do not recommend it. The key of success in our study is
the minimal mobilization of flap and case selection for
the technique. Owing to minimal mobilization of the flap,
we had only 4 (2%) wound infections, 2 (1%) skin necrosis,
and no flap necrosis in our study. Still we had 20 (10%)
cases of mild torsion and diverticulum in 10 (5%) cases in
our study. Diverticulum is caused by a technical error in
the measurement of the flap (large). This is a low rate of
diverticulum because we measured the rectangular flap
during the neourethra formation. We had no complications
related to stricture formation in our study because
we cut the ectopic urethral meatus back till normal
urethra. There were two cases of the megameatus due to
over measurement of the meatus as a technical error in
our study.
In our series, we found a very low complication rate
in cases where prepucial flap was used as onlay flap.
Urethrocutaneous fistula occurred in 10 (5%) cases where
prepucial onlay flap was sutured to the preserved urethral
plate. Barroso
et al
. have reported excellent results
with one‑stage double onlay prepucial flap for severe
hypospadias.[22] They reported complication rate of 25% in
his series of 47 cases; we encountered a complication rate
of 25% in our cases managed by modified onlay prepucial
flap technique which is comparable. An urethrocutaneous
fistula developed postoperatively in 5% of cases. Baskin
and Duckett reported this complication in 6% of their
cases postoperatively.[22‑24] We encountered penile edema in
40 (20%) cases. It resolved in follow‑up visits. Hence, we did
not mention it as a complication in our study. There were
2 (1%) cases of extravasation of urine as a complication in
our study. It was due to lateral skin closure.
We follow case selection criteria for modified onlay
preputial flap technique at our institute. We prefer it for
distal penile, mid penile, and proximal hypospadias with
minimal or no chordee and with good prepuce. Modified
onlay island flap technique is versatile technique for single
stage hypospadias repair.
Conclusion
We concluded that the key of success in our study of
modified onlay island flap technique were proper case
selection criteria, minimal mobilization of the mesentery
of the flap, meticulous measurement of the rectangular
flap length and width, and folding of the distal flap over
itself proximally. These resulted in minimal complications,
with pleasing cosmetic and functional result in our study.
The overall complication rate as well as the rate of
postoperative urethrocutaneous fistula was minimal and
is comparable with those reported by others.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
References
1. Elder JE, Duckett JW, Snyder HM. Onlay island flap in the
repair of mid and distal penile hypospadias without chordee.
J Urol 1987;138:376‑9.
2. Rickwood A, Anderson P. One‑stage hypospadias repair.
Experience of 367 cases. Br J Urol 1991;67:424‑8.
3. Kiss A, Nyirády P, Pirót L, Merksz M. Combined use of
perimeatal‑based flap urethroplasty (Mathieu) with midline
incision or urethral plate in hypospadias repair. Eur J Pediatr
Surg 2003;13:383‑5.
4. Manzoni G, Bracka A, Palminterie E, Marrocco G.
Hypospadias surgery: When, what and by whom? BJU Int
2004;94:1188‑95.
5. Aho M, Koivisto AM, Tammela TL, Auvinen A. Is the
incidence of hypospadias increasing. Analysis of Finnish
hospital discharge data 1970‑1994. Environ Health Perspect
2000;108:463‑5.
6. Duckett JW. Transverse prepucial island flap technique
for repair of severe hypospadias. Urol Clin North Am
1980;7:723.
7. Snodgrass W, Patterson K, Plaire JC, Grady R, Mitchell ME.
Histology of the urethral plate: Implications for hypospadias
repair. J Urol 2000;164:988‑99.
8. Sarhan O, Saad M, Helmy T, Hafez A. Effect of suturing
technique and urethral plate characteristics on complication
rate following hypospadias repair: A prospective randomized
study. J Urol 2009;182:682‑6.
9. Sozubir S, Snodgrass W. A New Algorithm for Primary
Hypospadias Repair Based On Tip Urethroplasty. J Pediatr
Surg 2003:38:1157‑61.
10. Snodgrass WT, Lorenzo A. Tabularized incised‑plate
urethroplasty for proximal hypospadias. Br J Urol Int
2002;89:90‑3.
11. Cheng EY, Vemulapalli SN, Kropp BP, Pope JC 4th, Furness
PD 3rd, Kaplan WE, et al. Snodgrass hypospadias repair with
vascularized dartos flap: The perfect repair for virgin cases
of hypospadias. J Urol 2002;168:1723‑6.
12. Sarhan OM, El‑Hefnawy AS, Hafez AT, Elsherbiny MT,
Dawaba ME, Ghali AM. Factors affecting outcome of
tubularized incised plate (TIP) urethroplasty: Single‑center
experience with 500 cases. J Pediatr Urol 2009;5:378‑82.
13. Shimotakahara A, Nakazawa N, Wada A, Nagata S, Koga H,
Takahashi T, et al. Tubularized incised plate urethroplasty
with dorsal inlay graft prevents meatal/neourethral stenosis:
[Downloaded free from http://www.archintsurg.org on Thursday, December 01, 2016, IP: 116.203.94.1]
126 Archives of International Surgery / April-June 2016 / Vol 6 / Issue 2
Singh, et al.: Modied prepucial island ap urethroplasty
A single surgeon’s experience. J Pediatr Surg 2011;46:2370‑2.
14. Borer JG, Bauer SB, Peters CA, Diamond DA, Atala A,
Cilento BG, et al. Tubularized incised plate urethroplasty:
Expanded use in primary and repeat surgery for hypospadias.
J Urol 2001;165:581‑5.
15. Elsayed ER, Khalil S, Abd Samad K, Abdalla MM. Evaluation
of distally folded onlay flap in repair of distal penile
hypospadias. J Pediatr Urol 2012;8:103‑7.
16. Mamdouh A, Khaled HK, Omar M, Ali M. Comparative
Study between the Tubularized Incised Plate Urethroplasty
and Single Faced Onlay Preputial Island Flap in the
Management of Mid‑Penile Hypospadias. Ann Pediatr Surg
2005;1:32‑7.
17. Braga LH, Pippi Salle JL, Lorenzo AJ, Skeldon S, Dave S,
Farhat WA, et al. Comparative Analysis of Tubularized
Incised Plate versus Onlay Island Flap Urethroplasty for
Penoscrotal Hypospadias. J Urol 2007;178:1451‑7.
18. Leslie B, Barboza LL, Souza PO, Silva PS, Delcelo R, Ortiz V,
et al. Dorsal tunica vaginalis graft plus onlay preputial island
flap urethroplasty: Experimental study in rabbits. J Pediatr
Urol 2009;5:93‑9.
19. de Mattos e Silva E, Gorduza DB, Catti M, Valmalle AF,
Demède D, Hameury F, et al. Outcome of Severe Hypospadias
Repair Using Three Different Techniques. J Pediatr Urol
2009;5:205‑11.
20. Patel RP, Shukla AR, Leone NT, Carr MC, Canning DA. Split
Onlay Skin Flap for the Salvage Hypospadias Repair. J Urol
2005;173:1718‑20.
21. Subramaniam R, Spinoit AF, Hoebeke P. Hypospadias Repair:
An Overview of the Actual Techniques. Semin Plast Surg
2011;25:206‑12.
22. Barroso UJR, Jednak R, Spencer Barthold J, Gonzalez R.
Further experience with the double onlay flap for hypospadias
repair. J Urol 2000;164:998‑1001.
23. Duckett JW. Transverse prepucial island flap technique for
repair of severe hypospadias. Urol Clin North Am 1980;7:723.
24. Duckett JW, Coplen D, Ewalt D, Baskin LS. Buccal mucosal
urethral replacement. J Urol 1995;153:1660‑3.
[Downloaded free from http://www.archintsurg.org on Thursday, December 01, 2016, IP: 116.203.94.1]
