|Year : 2020 | Volume
| Issue : 3 | Page : 256-259
Onlay preputial flap urethroplasty for children with mid- or proximal penile hypospadias with chordee
RB Nerli1, Priyeshkumar Patel2, Shridhar C Ghagane3, Sushant Deole2, Sreeharsha Nutalapati2, Murigendra B Hiremath3, Neeraj S Dixit3
1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University); Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
2 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belagavi, Karnataka, India
3 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Submission||30-Jan-2020|
|Date of Acceptance||22-Apr-2020|
|Date of Web Publication||05-Oct-2020|
Dr. R B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi - 590 010, Karnataka; Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: We report our results of preputial flap onlay urethroplasty for the one-stage repair of mid- and proximal penile hypospadias with chordee.
Materials and Methods: We retrospectively reviewed the hospital data base for children undergoing onlay flap urethroplasty and hypospadias repair for mid- or proximal penile hypospadias with chordee.
Results: During the study period January 2000–December 2017, 21 children underwent onlay preputial flap urethroplasty. The procedure was successful in 15 (71.42%) children with no need to undergo further procedures or operations. There were five urethrocutaneous fistulas and dehiscence of glans in one.
Conclusions: An onlay urethroplasty using the preputial flap yields results comparable to those of staged techniques and results in fewer procedures under anesthesia in children.
Keywords: Double face flap, hypospadias, one-stage repair, onlay urethroplasty, preputial flap, uroflow
|How to cite this article:|
Nerli R B, Patel P, Ghagane SC, Deole S, Nutalapati S, Hiremath MB, Dixit NS. Onlay preputial flap urethroplasty for children with mid- or proximal penile hypospadias with chordee. Indian J Health Sci Biomed Res 2020;13:256-9
|How to cite this URL:|
Nerli R B, Patel P, Ghagane SC, Deole S, Nutalapati S, Hiremath MB, Dixit NS. Onlay preputial flap urethroplasty for children with mid- or proximal penile hypospadias with chordee. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2020 Dec 2];13:256-9. Available from: https://www.ijournalhs.org/text.asp?2020/13/3/256/297195
| Introduction|| |
Onlay preputial flaps are single-stage alternatives to tubularized incised plate urethroplasty, whereas tubularized preputial flaps are single-stage alternatives to two-stage graft repairs. The repair of mid- and proximal penile hypospadias with a ventral curvature of >20° after releasing the ventral penile skin continues to challenge surgeons, and there is no agreement as to the best technique for its correction. The repair of mid- and proximal penile hypospadias has also functional implications, and trends have swung between staged repairs ,, to one-stage repair.,, At present, the prevailing tendency favors the use of stage repair advocated by Altarac et al.,,
Barroso et al. reported their series of onlay flap urethroplasty wherein 75% of the children required only one operation for complete resolution of the problem along with durable results at a mean follow-up of 14 years in 30 patients. Similarly, González et al. retrospectively reviewed the charts of patients undergoing hypospadias repair using a preputial only flap urethroplasty. Forty-nine children with marked penile curvature underwent surgery at a mean age of 22 months (11–110) and with a mean duration of follow-up of 23.4 months (1–79). In 48 cases, the urethral plate was preserved without dividing it. The penile curvature was corrected with cordectomy alone in 10 patients, 38 required a dorsal plication of the tunica albuginea, and 1 required an additional ventral dermal graft. In 38 patients (77.5%), the initial operation was successful, and no further operations were needed. There were eight urethrocutaneous fistulas and three dehiscences of the glans approximation. One patient suffered a wound infection and partial loss of the flap. We report our experience with preputial onlay flap urethroplasty in children with mid/proximal penile hypospadias with chordee.
| Materials and Methods|| |
This study is a retrospective review of patients' records operated at our institution. Patients' records were located from an electronic database search for onlay urethroplasty and hypospadias repair. Ethical approval was obtained from the institutional/university ethical committee for this review.
All children undergoing hypospadias repair using a preputial onlay flap urethroplasty were included in the study. Whenever the ventral skin was deficient, a double-face preputial flap was used to cover up the deficiency [Figure 1]a. All flaps were prepared using the total preputial flap (TPF) technique and were transferred ventrally either by circumambulating the penis or by creating a buttonhole in its pedicle to avoid penile rotation.
|Figure 1: (a) Mid-penile hypospadias with chordee (b) A parallel incision is made 5 mm proximal to the coronal sulcus (c) The penis is degloved (d) fibrotic paraurethral tissue is excised|
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Excluded children undergoing circumcision previously or operation for correction of hypospadias. Demographic data, duration of follow-up, complications, and reoperations were noted. A successful result was defined as a straight penis, a glanular meatus, and absence of voiding symptoms. An uroflow was obtained whenever possible during the follow-up visits.
Whenever the penile length and the width of the glans were deemed inadequate for a one-stage procedure, preoperative testosterone was administered at a dose of 2 mg/kg body weight of the child, monthly once × 3. If the response was noted to be adequate, then the operation was carried out within 4 weeks of the last administration.
A Parallel incision was made 5 mm proximal to the coronal sulcus dorsally that continues ventrally until it meets the lateral boundaries of the urethral plate [Figure 1]b. The incision is extended proximally along the sides of the urethral plate to surround the urethral meatus. The penile skin is degloved along Buck's fascia, [Figure 1]c and the fibrotic paraurethral tissue is excised [Figure 1]d. An artificial erection is performed injecting normal saline into a corpus cavernosus through a fine needle inserted through the glans. If residual curvature remains, the dorsal neurovascular bundle is lifted and a midline incision is made dorsally in the tunica albuginea. The length of the incision varies between 3 and 6 mm according to the severity of the curvature. The incision is closed transversally (Heineke–Mikulicz principle). If the curvature is very pronounced, the urethral plate is dissected of the corpora cavernosa as described by Mollard and Castagnola. If after this maneuver to the curvature persists, then a transverse incision is made in the ventral aspect of the tunica albuginea and covered with a graft of tunica vaginalis or dermis. After correction of the curvature, the artificial erection is repeated.
A preputial flap is prepared [Figure 2]a. The flap is transposed ventrally and rotated 90°. The urethral plate in the glans is outlined with parallel incisions, and the glanular wings are mobilized laterally to allow closure of the glans over the reconstructed urethra. The free edge of the outer [Figure 2]b layer of the preputial l flap is sutured to a side of the urethral plate with a running suture of 6-0/5-0 polydioxanone (Ethicon, Johnson and Johnson). The planned total width of the urethra (plate and portion of the flap) is outlined, and an incision is made through the skin only of the flap leaving the pedicle intact. The new free edge of the flap is sutured to the other border of [Figure 2]c the urethral plate with an extraepithelial running suture of 6-0/5 polydioxanone. When the ventral skin is deficient, a double-face preputial flap is used. An 8/10 Fr infant feeding tube is left in the urethra with the proximal end in the bladder. The distal portion of the flap used for the urethroplasty is trimmed as necessary, and the new urethral meatus is reconstructed using interrupted 5-0 sutures. The glans is approximated with two sutures of 5-0 polydioxanone, and the skin of the glans is closed with 6-0 sutures.
|Figure 2: (a) A preputial flap is prepared (b) A free edge of outer layer of the preputial flap is sutured to a side of the urethral plate (c) The new free edge of the flap is sutured to the other border of the urethral plate (d) A midline closer of the skin is performed|
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Dorsally, the free edge of the penile shaft skin is sutured to the dorsal corona. Attention is now directed at covering the ventral penile skin defect. If there is sufficient penile shaft skin, [Figure 2]d a midline closure is performed after excising the remaining preputial flap carefully preserving the blood supply to the flap used for the urethroplasty. The dorsal shaft skin is sutured to the corona. A lightly compressive dressing is applied. The infant feeding tube is left in place for 7–10 days. Follow-up visits were planned 2 weeks and 3 months postoperatively. An uroflow study is performed once the child is old or comfortable enough to pass urine on advice and in the absence of symptoms at the onset of puberty. Following puberty, the adolescent was questioned for erections and if it was associated with discomfort or pain.
| Results|| |
During the study period January 2000–December 2017, 21 children undergoing onlay preputial flap urethroplasty met the inclusion criteria. The severity of the hypospadias according to the meatal location was distal shaft with a hypoplastic penile urethra and marked chordee in 6 patients, mid-shaft in 8, and proximal penile in 7. All patients had penile curvature > 20° after degloving of the penile skin. The mean age of the children at the time of surgery was 56 months (28–144), and the mean duration of follow-up was 23.4 months (6–48). Preoperative testosterone was administered in 8 (38.09%) children.
The urethral plate could be preserved in all the children. In 18 cases, the onlay flap was based on the inner preputial layer and the ventral skin could be directly approximated easily without tension. In three other cases, a double preputial flap was used both as an onlay and to cover the ventral penis. The penile curvature was corrected with the release of skin and cordectomy alone in 4 children, 16 required a dorsal plication of the tunica albuginea, and 1 required an additional ventral dermal graft.
The procedure was successful in 15 (71.42%) children with no need to undergo further procedures or operations. There were five urethrocutaneous fistulas and dehiscence of the glans in one. None of the children had residual chordee. Superficial wound infection was seen in one child who further developed urethrocutaneous fistula. Three of the five fistulas were closed with a secondary procedure and the closure was successful. In two other children with fistula, a two-stage buccal mucosal graft urethroplasty was done as the onlay flap was partially necrosed. The glandular dehiscence was corrected in one setting.
Four (19%) of these 21 children had grown to adulthood (>18 years of age), and the uroflow was normal bell shaped curve. None of these four children had painful erections or persistence of chordee.
| Discussion|| |
Onlay island preputial flap urethroplasty was originally introduced as an alternative to meatal-based flap urethroplasty for the repair of anterior hypospadias. The indications for this procedure gradually extended to include repair of proximal hypospadias with and without different degrees of chordee, variants formerly requiring more extensive full tubularized island flap procedures. The preservation of a well-developed urethral plate represents an important principle in the management of variants of hypospadias.
One-stage repair of mid- and proximal penile hypospadias preserving the urethral plate is possible using a preputial flap for the urethroplasty and coverage of the ventral penis. González et al. reported a success in 77.5% of cases. They were able to correct the chordee in all of their patients and achieve a straight penis without dividing the urethral plate which allowed the successful use of the onlay technique. They reported the use of the TPF  which ensured that both the skin used for the onlay and the skin used for ventral cover had excellent blood supply. They used a buttonhole at the base of the pedicle to transposition the preputial flap ventrally to prevent axial rotation of the penis which is an undesirable outcome that can be seen when the pedicle is brought along a side of the shaft.
The results obtained in our series of children are comparable to other reports using the onlay flap urethroplasty. In our series of 21 children, 71.42% were successfully treated in one single stage and needed no further interventions. The correction of the ventral curvature by removing all paraurethral fibrous tissues (cordectomy) and/or performing a Heineke–Mikulicz plasty in the dorsal midline of the tunica albuginea was possible in 20 of 21 children. The use of preoperative testosterone stimulation was not associated with an increase in the complication rate.
The use of onlay preputial graft is another option for single-stage repair, especially in cases of mid- or proximal penile hypospadias and the urethral plate is wide enough and/or the glanular groove is insufficient for other types of repair. Compared with flaps, the use of grafts may decrease the risk of penile torsion and prevent less bulk around the urethra, improving skin and glans closure. Cambareri et al. reviewed their records of 62 patients operated over 25 years period with a mean (range) follow-up of 47.4 (1–185) months. The meatal location was separated into distal (one patient), mid-shaft (19), and proximal (42). In all, 22 (35.5%) patients had complications. There were three main types of complications, including meatal stenosis in three (4.8%), stricture in three (4.8%), and fistula in 21 (33.9%). The mean (range) timing of presentation with a complication after surgery was 24.9 (1–127) months. In all, 54.5% of the patients with complications presented at ≥1 year after the initial surgery and 31.8% presented at ≥3 years.
| Conclusions|| |
We conclude that the repair of mid- and proximal penile hypospadias with chordee can be performed with preservation of the urethral plate in a majority of cases as long as the urethral plate is wide and healthy enough. An onlay urethroplasty using the preputial flap yields results comparable to those of staged techniques and results in fewer procedures under anesthesia in children.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Snodgrass WT, Bush NC. Hypospadias. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 11th
ed. Philadelphia: Elsevier; 2016. p. 3399.
Stein R. Hypospadias. Eur Urol Sup 2012;11:33-45.
Hautmann R, Lutzeyer W. Belt-fuqua technique: A useful alternative in hypospadias repair (author's transl). Urologe A 1980;19:373-5.
Hensle TW, Mollitt DL. Experience with the belt-fuqua hypospadias repair. J Urol 1981;125:703-5.
Greenfield SP, Sadler BT, Wan J. Two-stage repair for severe hypospadias. J Urol 1994;152:498-501.
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.
Barroso U Jr., Jednak R, Spencer Barthold J, González R. Further experience with the double onlay preputial flap for hypospadias repair. J Urol 2000;164:998-1001.
Patel RP, Shukla AR, Snyder HM 3rd
. The island tube and island onlay hypospadias repairs offer excellent long-term outcomes: A 14-year follow-up. J Urol 2004;172:1717-9.
Pfistermüller K, Manoharan S, Desai D, Cuckow P. Two-stage hypospadias repair with a free graft for severe primary and revision hypospadias: A single surgeon's experience with long-term follow-up. J Pediatr Urol 2017;13:35.
Altarac S, Papeš D, Bracka A. Two-stage hypospadias repair with inner preputial layer Wolfe graft (Aivar Bracka repair). BJU Int 2012;110:460-73.
Nerli RB, Neelagund SE, Guntaka A, Patil S, Hiremath SC, Jali SM, et al
. Staged buccal mucosa urethroplasty in reoperative hypospadias. Indian J Urol 2011;27:196-9.
] [Full text]
González R, Lingnau A, Ludwikowski BM. Results of onlay preputial flap urethroplasty for the single-stage repair of mid- and proximal hypospadias. Front Pediatr 2018;6:19.
Mollard P, Castagnola C. Hypospadias: The release of chordee without dividing – The urethral plate and onlay Island flap (92 cases). J Urol 1994;152:1238-40.
Ludwikowski B, González R. Total preputial flap: A reliable and versatile technique for urethral and penile reconstruction. Front Pediatr 2014;2:43.
Singal AK, Dubey M, Jain V. Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias. World J Urol 2016;34:1019-24.
Cambareri GM, Yap M, Kaplan GW. Hypospadias repair with onlay preputial graft: A 25-year experience with long-term follow-up. BJU Int 2016;118:451-7.
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