A novel technique for repair of mid-penile hypospadias using a preputial skin flap: results of 110 patients

Several techniques have been used to repair mid-penile hypospadias; however, high failure rates and major complications have been reported. In this study, we describe a novel technique using a well-vascularized flap of the inner and outer preputial skin. A total of 110 male children with hypospadias underwent repair by our technique between 2008 and 2015. The inclusion criteria were children with mid-penile or slightly more proximal hypospadias, with or without ventral chordae, and an intact prepuce of the cobra eyes variety. Recurrent cases, patients with other preputial types, and circumcised children were excluded from this study. The prepared flap was sutured in its natural longitudinal orientation to the created urethral plate strip to form a neo-urethra over a urethral catheter. Outcome measures included surgical success without the formation of a urethra-cutaneous fistula, no ischaemia of the flaps, glans dehiscence or infection and functional outcome and cosmetic appearance. The median follow-up duration was 3.3 years. There were 63 cases of mid-penile hypospadias (57.3 %), and in 47 cases (42.7 %), the meatus was slightly more proximal. The age of the patients ranged from 1.1 to 8.0 years, with a mean age of 4.6 +/- 1.2 years. Surgery was successful in 106 (96.4 %) cases. Minor complications occurred in 11 patients (10 %) and included oedema of glans in ten patients and bluish discoloration on the ventral aspect of the glans close to the suture line in three patients. All patients improved within 2 weeks after surgery. Long-term follow-up revealed a properly functioning urethra with a forward, projectile, single, compact, and rifled urinary stream of adequate calibre and cosmetically acceptable repair. No cases of meatal retraction, meatal stenosis, urethral stricture, or acquired urethral diverticulum occurred. Our technique is different from the split prepuce in situ technique. We create a narrow strip of the urethral plate that facilitates glanular closure, and we use the inner and adjacent outer skin in a vertical manner to preserve excess skin for penile coverage. Prepuce is split at midline to preserve more preputial skin with favourable dartos tissue for penile skin coverage. The glans is closed using a stitch-by-stitch method that has not been described previously. This study presents a novel technique for mid-penile hypospadias repair using a preputial skin flap with excellent results in terms of short- and long-term outcomes.