The Role of Vascularized Dorsal Subcutaneous Flap for Decreasing Fistula Formation Following Hypospadias Repair: A Preliminary Experience

Objective: To evaluate the value of covering the neourethra using vascularized dorsal subcutaneous flap in order to decrease urethrocutaneous fistula in hypospadias repair. Patients and Methods: This is a retrospective study of 130 children (aged 1-14 years) who had different types of hypospadias and underwent different types of repair between August 2004 and December 2006 at King Hussein Medical Center. The study sample includes 66 children with distal penile hypospadias, 28 children with midshaft, 8 children with proximal hypospadias, of which 3 underwent first stage repair, 20 children with urethrocutaneous fistula, and 8 with complete failure of previous repair. Longitudinal vascularized dorsal subcutaneous flap was harvested from the excessive dorsal preputal and penile hypospadiac skin, and then used in all cases as a covering for different types of urethral repair in double breasting Byar’s flap fashion which sutured to the glans wings around the neomeatus and to the corpora adjacent to the neourethra using 7/0 and 6/0 polyglactin sutures, resulting in complete covering of the neourethra with well-vascularized dorsal subcutaneous flap. Tubularized Incised Plate (TIP) repair was used in the majority of cases, known as Snodgrass repair, while Mathieu repair and urethrocutaneous fistula repair were done in the rest of cases. The chordee was corrected when present, and the glans closure was finalized in 2 layers. Most cases performed were over urethral stent, and in few complicated cases sialastic foley catheter and suprapubic cystocath for urinary diversion were used. Results: In monitoring results during the follow-up period, which extended over 18 months with a median of 6 months, the operations were successful. Three children had urethrocutaneous fistula, of which 2 had previous repair, and one had complete failure. Eight children had meatal stenosis which responded to dilatation in 6 children and meatoplasty in 2 children. Conclusion: We suggest that in hypospadias surgery, covering of the neourethra with well- vascularized dorsal or adjacent subcutaneous flap should be part of the procedure. It decreases urethrocutaneous fistula formation especially if the careful harvesting technique is utilized.