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Shietal. BMC Pediatrics (2022) 22:393
https://doi.org/10.1186/s12887-022-03464-2
RESEARCH
One-stage tubularized urethroplasty
using thefree inner plate oftheforeskin
inthetreatment ofproximal hypospadias
Tong Shi*, Yan‑Kun Lin, Qiao Bao, Wei‑Hua Lao and Ke‑Yu Ouyang
Abstract
Objective: This study summarizes the short‑term efficacy of the one‑stage tubularized urethroplasty using the free
inner in proximal hypospadias.
Methods: A retrospective analysis was conducted on 42 patients with proximal hypospadias. All cases were treated
with one‑stage tubularized urethroplasty from January 2020 to June 2021. The postoperative complications like ure‑
thral fistula, urethral stricture, diverticulum, and split penis head were recorded.
Results: Patients were followed up for 3 to 15 months (an average of 8.5 months). A total of 26 cases (62%) were
repaired without any complication. Five patients (11.9%) developed urinary fistulas and underwent secondary repair:
three cases with anastomotic fistulas and two cases of coronal fistulas. Nine patients (21.4%) had stenosis of the head
segment of the penis, six (14.3%) had stenosis that was relieved by urethral dilatation combined with topical mometa‑
sone furoate 1 month after urethral catheter removal. Two patients (4.8%) had severe stenosis with secondary surgical
stenosis incision, and one (2.4%) had combined urethral diverticulum in which urethral stenosis incision and diverti‑
culectomy were performed.
Conclusions: Tubularized urethroplasty using the free inner bears the advantages of easy access, reduced short‑term
complications, low incidence of diverticula.
Keywords: Free inner plate of prepuce, Tubularized urethroplasty, Proximal hypospadias, Short‑term efficacy
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Introduction
Hypospadias is a common congenital defect of the geni-
tourinary system in children. e incidence of hypospa-
dias is approximately 18.6 in infant boys in Europe. Its
incidence is the highest in North America at 34.2 per
10,000 births (ranging from 6 to 129.8) and the lowest in
Asia at 0.6% per 10,000 births [1]. e pathogenic factors
of this disease remain complex. Mounting studies have
shown the lack of clarity regarding a definite etiology for
hypospadias, with some children suspected to be induced
by a single gene mutation [2, 3]. Hypospadias is associ-
ated with low birth weight, low endocrine levels, anti-epi-
leptic drugs, ovulation-promoting drugs, and advanced
maternal age [4]. Clinically, the affected patients are pri-
marily treated surgically. However, there are different
methods and types of surgery, with a varying scope of
application, surgical outcome, and prognosis [5]. ere-
fore, in clinical practice, the surgical approach should
be chosen appropriately to achieve better outcomes,
fewer complications, and improved prognosis [6]. Con-
troversy prevails in national and international research
regarding the performance of a one-stage or two-stage
urethroplasty for proximal hypospadias. Springer et al.
claimed that specialists in proximal hypospadias repair
Open Access
*Correspondence: 247397570@qq.com
Pediatric Urology, Guangdong Maternal and Child Health Hospital, No. 521,
Xingnan Avenue, Panyu District, Guangzhou 511400, China
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Page 2 of 6
Shietal. BMC Pediatrics (2022) 22:393
were consistent in their preference for one-or two-stage
surgery, while younger surgeons had a strong predilec-
tion for staged urethroplasty in patients [6, 7]. None of
the currently available procedures display a high level of
patient satisfaction. Duckett’s procedure is considered
one of the main surgeries for severe hypospadias with a
long urethral defect. However, such a method generally
exhibits a high incidence of postoperative urethral diver-
ticula due to the presence of a bloated and rotated penis
after forming a vascular pedicle. One study reported that
over 50% of patients treated for proximal and complex
hypospadias were dissatisfied with the appearance of
their penis [8].
Devine and Horton first reported the use of free
foreskin grafts in hypospadias surgery [9, 10]. Few
studies have been reported on free foreskin grafts. The
current retrospective analysis was conducted on 42
patients with proximal hypospadias. They underwent
one-stage tubularized urethroplasty using the free
inner plate of the foreskin by the same surgeon from
January 2020 to June 2021. All cases were treated with
one-stage tubularized urethroplasty with the free inner
plate of the prepuce. The bending degree of the penis,
the length of the urethral defect after correction of
penile bending, and postoperative complications like
the appearance of urethral fistula, urethral stricture,
diverticulum, and split penis head were recorded. The
report is as follows.
Material andmethods
General data
A retrospective analysis was conducted on 42 chil-
dren aged 18months to 6years old with a mean age
of (40.5 ± 21.4) months old. The children with severe
hypospadias were admitted from January 2020 to June
2021 and underwent one-stage urethroplasty using the
free inner plate of the prepuce. All procedures were
performed by the same experienced surgeon. The
median follow-up time was 8months (1–16months).
Eligible patients were followed up regularly in the
clinic via WeChat, video calls, and outpatient vis-
its 2weeks, 3months, 6months, and 1year after the
surgery. The 42 patients included five perineal cases
(12%), 11 scrotal cases (26%), and 26 penile root cases
(62%).
Operation method
e technique of tubularized urethroplasty using the
free inner plate of the foreskin was adopted. e penis
head was pulled (Fig.1), a circular incision was made
0.6–0.7cm below the coronal sulcus, and the urethral
plate was transected. A U-shaped skin flap was made
along both sides of the cavernous body of the urethra,
and the ventral thin part of the urethra was cut to reach
the bifurcation position of the urethral cavernous body.
e scrotum was cut longitudinally at the proximal
midline of the urethral orifice. e penis was detached,
and the ventral dense fibers were completely loosened
to reach the bulbar part of the urethra. e urethral
plate was transected and dissected deeply along the
superficial white membrane of the corpus caverno-
sum; this fully loosened and corrected the bowstring
relationship between the urethral plate and the corpus
cavernosum. Saline was injected into the corpus cav-
ernosum, and an artificial erection test was performed
to check the correction of the curved urethral penis.
e residual urethral plate was cut, and the marginal
unhealthy tissues were removed. e traction thread
was sewed on the dorsal prepuce inner plate. e
width was determined by the distance between the dis-
tal part of the penis head and the urethral stump, and
the length was determined as twice the circumference
of the urinary catheter; the skin was cut by transverse
rectangular skin tangent. e subcutaneous connec-
tive tissue was separated from the edge of the skin flap,
and the skin in the edge area was fully extended. A 10F
urine tube was used to wrap the free skin flap (Fig.2),
a 7–0 absorbable thread was used to sew the wound
tube continuously and then intermittently to form a
free skin tube, and the two ends of the skin tube were
trimmed with oval slopes (to reduce anastomotic ste-
nosis and urethral stricture). A 7–0 absorbable thread
was used to stitch the stump of the urethral plate inter-
mittently to the anastomosis. e penis was dissected
in a wing-shaped line, and the redundant tissues of the
corpus cavernosum on both sides of the penis were
deeply trimmed to reduce the volume of the penis. A
7–0 absorbable thread was used to sew the corpus
Fig. 1 Preoperative appearance
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Page 3 of 6
Shietal. BMC Pediatrics (2022) 22:393
cavernosum on the penis head to wrap the distal sec-
tion of the skin tube to form the penis head. Using a
7–0 absorbable thread, the distal part of the skin tube
and the penis head were sutured to form the urethral
orifice. e urethra was covered with bush fascia and
subcutaneous tissue, and the anastomosis was covered
with scrotal fascia; this was followed by trimming and
suturing of the foreskin (Fig.3). e gauze and elastic
adhesive tape were used to press and fix the perineum.
ree days after the operation, the outer layer was
not pressurized, and overflow, infection, necrosis, and
bleeding were observed. e membrane was removed
and the dressing was changed. If no obvious abnormal-
ity was found, the membrane was removed seven days
after the operation, and the wound was washed with
0.1% Anduofu. e urinary catheter was removed two
to three weeks after the operation.
Results
e hypospadias included five perineal types (12%), 11
scrotal types (26%), and 26 penile root types (62%) with
a median length of the free-formed urethra of 35 mm
(range: 30–60mm, mean value: 38mm).
A total of 26 cases (62%) were repaired in the one-stage
surgery without any complication. Five patients (11.9%)
developed urinary fistulas and underwent secondary
repair, including three cases with anastomotic fistulas
and two cases of coronal fistulas. Nine patients (21.4%)
had stenosis of the head segment of the penis, six (14.3%)
had stenosis that was relieved by urethral dilatation com-
bined with topical mometasone furoate 1 month after
urethral catheter removal. Two patients (4.8%) had severe
stenosis with secondary surgical stenosis incision, and
one (2.4%) had combined urethral diverticulum in which
urethral stenosis incision and diverticulectomy were per-
formed. No residual recurved penis and penis head split
was observed after the operation.
Discussion
Severe hypospadias is a common pediatric urological
condition that is accompanied by urethral dysplasia and
may result in severe chordee [11]. e urethral plate is
severed to straighten the penis in affected children. is
causes a long segment of the urethra to be defective and
requires repair and reconstruction [6]. Such a surgi-
cal method remains controversial up to a point owing
to the difficulty of the operation and the postoperative
complications. Currently, some variations can be noted
in the clinical approach toward treating the disease at
the national and international levels. e hypospadias
surgery ensures that the penis is essentially normal in
appearance and can be erected and straightened normally
while ensuring proper urinary flow and a normal ure-
thral opening [12]. Most scholars mainly adopt a staged
Fig. 2 a The free skin flap. b loosened and corrected the bowstring relationship between the urethral plate and the corpus cavernosum. c the distal
part of the skin tube and the penis head were sutured to form the urethral orifice. d The urethra was covered with bush fascia and subcutaneous
tissue
Fig. 3 Postoperative appearance
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Shietal. BMC Pediatrics (2022) 22:393
surgical treatment [13]. However, in the one-stage repair,
the urethroplasty using the transverse penile island flap
(Duckett method) is preferred [14]. To maximize the
effectiveness of the treatment and reduce complications,
it is necessary to improve continuously the technical pro-
ficiency of performing one-stage repair of hypospadias.
In the treatment of severe hypospadias, the first step
is to transect the urethral plate to correct the downward
curvature of the penis as much as possible, regardless of
the surgical option [15]. During the urethroplasty, the
risk of surgical failure and postoperative complications
is greatly increased if the newly formed urethra fails to
secure the blood supply [16]. e tubularized urethro-
plasty using the free inner plate of the foreskin is a novel
surgical procedure that has been used in several centers
since Devine and Horton first reported its application
in the hypospadias. However, results to date have var-
ied in different reports and are less well reported. Some
researchers have even concluded that free foreskin grafts
are not suitable for hypospadias surgery due to their high
rate of complications [17]. In contrast, a recent article
reported that one-stage tubularized urethroplasty using
the free inner plate of foreskin achieved good functional
and cosmetic results with a low rate of postoperative
complications [18]. is offers greater advantages com-
pared to conventional surgery.
ere were five perineal types (12%), 11 scrotal types
(26%), and 26 penile root types (62%) with a median
length of the free-formed urethra of 35 mm (range:
30–60mm, mean value: 38mm). e risk and difficulty
in performing the tubularized urethroplasty lie in the
reconstruction of the blood supply. During the opera-
tion, it was necessary to ensure that the skin was thinly
incised and the subcutaneous tissue was removed as
much as possible when the inner plate of the prepuce was
dissociated. is precaution ensured a quick absorption
of nutrition from the wound surface of the surround-
ing tissue. e width of the free foreskin was about 1.2–
1.5cm, about 2 times that of the urinary catheter. It was
essential to ascertain that the type of the urinary catheter
matched the width of the free foreskin. e use of a very
small catheter may result in insufficient pressure, and the
skin patch and the receiving area may not combine firmly
to form a dead space. Moreover, it also avoids the situ-
ation of nutrition deficiency and necrosis caused by the
obstruction of the growth of new blood vessels into the
skin. In addition, as shown in Fig.2 b, the fibrous connec-
tive tissue on the ventral side of the corpus cavernosum
was completely separated and removed to ensure suffi-
cient blood supply to the fascia tissue. Proper pressuriza-
tion ensured that the free skin tube and the ventral side
of the penis were well attached and the blood supply to
the fascia tissue is not obstructed.
As shown in Fig. 2 a, in the urethral reconstruction
with the free inner plate of the prepuce, the diameter
of the skin tube was the same, and both ends were oval.
is guaranteed the uniform extension of the epithelium
and avoided the skin tube formed by the pedicled skin
flap being too wide. It easily formed the diverticulum
and avoided the formation of the skin fold due to the
limitation of the pedicled tissue. is method improved
the function and cosmetic effect (Fig.4), for it eliminated
the secondary torsion caused by the vascular pedicle
and enlargement of the penis trunk [19]. is was par-
ticularly evident in patients with smaller penises. When
anastomosing with the original urethral orifice and
new urethroplasty, attention should be paid to the oval
shape of the anastomotic stoma, which can reduce the
occurrence of anastomotic stenosis. No cases of anas-
tomotic stenosis were found in this study. us, anasto-
motic stoma stenosis was avoided by this method. One
case noted in this group presented a secondary urethral
diverticulum with a thin urinary line, poor urethral dila-
tation, and significant urethral stricture in the head seg-
ment of the penis. e head segment of the penis was
covered by direct sutures as there was no subcutaneous
tissue covering the urethra. Whether the cause of steno-
sis of the head segment of the penis was related to the
inadmissibility of the penis head and the technique of
phalloplasty needs to be further explored. In this group,
26 cases (62%) were repaired in one stage without any
Fig. 4 Appearance 6 months after surgery
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Page 5 of 6
Shietal. BMC Pediatrics (2022) 22:393
complications. Five patients (11.9%) developed a uri-
nary fistula and received a secondary repair, below the
accepted level of urethral fistula. It was crucial to pre-
serve the well-vascularized tissues on both sides of the
urethral plate that covered the urethra for protection
when the penis and foreskin were decapsulated. e
caliber of the new urethra can be further optimized with
the support of the urethra and the reconstruction of the
blood supply to the outer fascia. e wide fascia remain-
ing after freeing the foreskin was well preserved and
transferred ventrally via the sides of the penis, ensur-
ing a loose and homogeneous circulatory support of the
inner plate skin tube. e free skin tube and the urethral
plate were anastomosed in a more flexible way for cap-
ping. e postoperative visit informed us that 90% of
children’s families were satisfied with the appearance but
were less satisfied with dysuria and urethral diverticu-
lum. During the operation, the transection of the ure-
thral plate and urethroplasty were long enough, and no
residual recurved penis was found in this study.
e limitations of our research included data obtained
from a single institution, the relatively small sample size,
and the lack of objective assessment of urination func-
tion. Due to the short follow-up period and the fact that
the children had not reached puberty, a post-pubertal
assessment, including sexual function could not be per-
formed. A multicenter study with larger sample size
is needed to confirm the effectiveness of the tubular-
ized urethroplasty. Mounting scholars supported that
tubularized urethroplasty using the free inner plate of
the foreskin must be abandoned due to the high rate of
complications, particularly in patients with moderate to
severe hypospadias. In contrast, our results suggested
that tubularized urethroplasty using the free inner plate
of the foreskin was an appropriate option for the repair
of hypospadias. Our procedure achieved good functional
and cosmetic results, with a relatively low short-termed
postoperative morbidity. Moreover, it reduced the pain
and family burden for secondary surgery in most children
with successful one-stage operation without complica-
tions. Addtionally, the small sample size and the short
follow-up time may influence the results. erefore, in
the next work, we plan to carry out more studies with
large sample sizes and prolong follow-up after surgery to
investigate on the long-term complications of one-stage
tubularized urethroplasty.
Acknowledgements
Not applicable.
Authors’ contributions
Conception and design: Tong Shi; Administrative support: Yankun Lin; Provi‑
sion of study materials or patients: Weihua Lao; Collection and assembly of
data: Qiao Bao; Data analysis and interpretation: Tong Shi; Manuscript writing:
All authors; Final approval of manuscript: All authors.
Funding
Not applicable.
Availability of data and materials
All data generated or analyzed during this study are included in this article.
Further inquiries can be directed to the corresponding author.
Declarations
Ethics approval and consent to participate
The approval for the study was received by the ethics committee/Institutional
Review Board of Guangdong Maternal and Child Health Hospital. The need for
informed consent was waived by the ethics committee/Institutional Review
Board of Guangdong Maternal and Child Health Hospital, because of the retro‑
spective nature of the study. The study was conducted in accordance with the
Declaration of Helsinki (as revised in 2013).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no relevant financial interests.
Received: 2 April 2022 Accepted: 27 June 2022
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18. Obara K, Hoshii T, Hoshino S, et al. Free Tube Graft Urethroplasty for Repair of
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19. Rober PE, Perlmutter AD, Reitelman C. Experience with 81, 1‑stage hypospa‑
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