Single-Stage Procedure for Severe Hypospadias: Onlay-Tube-Onlay Modification of the Transverse Island Preputial Flap
Recent advances in hypospadias repair enable excellent functional and cosmetic results for treatment of severe hypospadias. We have utilised flaps rather than grafts in almost all cases. In this chapter, we illustrate our current approach to single-stage
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Jyoti Upadhyay, Anthony Khoury
Recent advances in hypospadias repair enable excellent functional and cosmetic results for treatment of severe hypospadias. Wehave utilised flaps rather than grafts in almost all cases. In this chapter, we illustrate our current approach to single-stage repair of severe penoscrotallperineal hypospadias. In most of these cases, division of the urethral plate, which is often necessary, is performed in the midportion to allowa "combination flap" for the urethroplasty. Here we describe our technique with special emphasis on the correction of severe chordee utilising ventral lengthening procedures rather than dorsal plication in addition to a combined onlay-tube-onlay preputial flap for the urethroplasty. Introduction
Irrespective of the classification utilised for major or severe or proximal hypospadias, increased cosmetic expectations along with a better understanding of the pathophysiology of this deformity have resulted in an array of new surgical techniques and modifications . Two major components of all repairs are reconstruction of the urethra with a normally positioned meatus (urethroplasty) and correction of the curvature (orthoplasty). Urethral reconstruction may incorporate adjacent skin flaps, free skin grafts, and mobilised vascularised flaps. It was not until the 1970sthat the procedures for severe hypospadias dramatically changed with the work of Asopa, Duckett, Snyder, Mollard and their coworkers (Asopa et al. 1971; Duckett 1981; EIder et al. 1987; Mollard et al. 1991). Regardless of the technique used, vascularised flaps have been reported to be generally superior to free skin grafts (Borer and Retik 1999). There has also been a change with regard to the management of the urethral plate for repair of curvature (Baskin et al. 1994; Borer and Retik 1999). In the past, the urethral plate was often excised because it was thought to be responsible for the severe curvature associated with more
A. T. Hadidi et al. (eds.), Hypospadias Surgery © Springer-Verlag Berlin Heidelberg 2004
proximal cases of hypospadias (Baskin et al. 1994; Duckett 1980) Recognition that excision/division of the urethral plate was not routine1y necessary for correction of the curvature increased the number of onlay flaps for hypospadias repair (Baskin et al. 1994; EIder et al. 1987; Gearhart and Borland 1992; Hollowell et al. 1990). In the past few years, several modifications of the onlay flap for hypospadias repair have been reported (Gonzalez et al. 1996; Rushton and Belman 1998). The modern appro ach to repair of severe hypospadias attempts to preserve the urethral plate if possible. Neverthe1ess, in cases of severe chordee associated with an atretic or underdeveloped urethral plate, resection of the fibrovascular tethering tissue may be necessary as a component of orthoplasty. In this scenario, the transverse preputial island tube flap as reported by Asopa and Duckett (Asopa et al. 1971; Duckett 1981) is the most commonly performed repair. Historically, management of severe proximal hypospadi
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