Hypospadias remains a technically challenging operation with success rates appearing linked closely to surgeon experience. Primary hypospadias repair success rates have been quoted as high as 95% but nonetheless some cases require multiple procedures for ultimate reconstruction. Schwentner et al reported their experience with single stage dorsal inlay urethroplasty using skin grafts for complex reoperations.

They had a total of 31 patients (mean age 13.8 years) with failed previous hypospadias surgery in the study. Indications for reoperation included fistulas, strictures, diverticula and repair breakdown. The urethral plate had been removed or was severely scarred in all patients. A free penile or groin skin graft was sutured and quilted to the corpora cavernosa. The neourethra was tubularized and covered with a tunica vaginalis or dartos flap, followed by a glans plasty. Postoperatively, they performed urethrograms, urethral ultrasound and flow measurements.

In their study they found that foreskin was used in 15 cases, penile skin in 12 and inguinal skin in 4. Average graft length was 3.92 cm. A total of 20 patients required a glans plasty with a skin graft extending to the tip of the glans. After a mean follow-up of 30.71 months, 5 patients underwent redo surgery, with an overall complication rate of 16.1%. Urethral stricture of the proximal anastomosis was the most common complication.

The group concluded that this single stage approach using dorsal skin grafts is a reliable method to create a substitute urethral plate for tubularization. They found their complication rates equivalent to those of staged procedures. They state that foreskin should be used as a graft donor site to optimize the outcome if available. Dr. Warren Snodgrass provided an editorial comment, which in summary favored this approach for this type of hypospadias population.

By Pasquale Casale, MD

Journal of Urology 175(5): 1827-1877, May 2006.
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