Further experience with the double onlay preputial flap for hypospadias repair

Severe hypospadias can be safely and reliably repaired in 1 stage using island flaps of preputial skin. However, problems with conventional techniques include penile asymmetry resulting from rotation of the vascular pedicle around 1 side of the penile shaft and at times doubtful viability of the Byars flaps used for ventral skin coverage. We describe how some of these problems can be resolved using the double onlay preputial flap for hypospadias repair.

We reviewed the records of 47 children who underwent 1-stage double onlay preputial flap hypospadias repair at our institution between June 1994 and July 1998. Patient age ranged from 6 months to 9 years (mean 12.2 months). The urethral meatus was at the midshaft in 12 patients (25%), penoscrotal in 30 (64%) and perineal in 5 (11%). Chordee repair required dorsal plication in 29 patients, 7 of whom required an additional ventral incision of the tunica albuginea and tunica vaginalis autograft with preservation of the urethral plate to complete the repair. Scrotal transposition and bifid scrotum were repaired at the time of hypospadias repair in 9 patients.

Followup was 3 to 47 months (mean 15.2 months). Complications requiring reoperation occurred in 12 patients (25%). In 8 (17%) boys a fistula developed, of whom 6 had perineal and 2 had penoscrotal hypospadias. Fistula closure was required in all patients. Successful closure was achieved with 1 procedure in 6 patients, required an additional fistula repair in 1 and remains to be determined in 1. Diverticula, meatal recession and persistent penile curvature requiring repeat dorsal plication occurred in 4 (9%), 2 (4%) and 2 (4%) patients, respectively. Revision for a bulky ventral skin strip was required in 1 boy (2%). All complications occurred in patients with the more proximal hypospadias.

The double onlay preputial flap technique for hypospadias repair offers good cosmetic and functional results. Given the high incidence of penoscrotal and perineal hypospadias (75%) in our series complication rates are comparable or better than those of other techniques.