Extending the Graft Harvesting Area in Severe Penoscrotal Hypospadias: The Rainbow Technique
Ziyad Alzahrani1, Geemitha Ratnayake1, Yaqoub Jafar1
1Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada.
Introduction:
Proximal hypospadias presents a significant challenge for urethral reconstruction due to the extent of the defect requiring repair. Staged repair with grafting is employed to address this challenge (1). Buccal mucosa and post-auricular skin grafts have been described, but prepuce tends to have lower contraction and failure rates (2, 3). However, the conventional rectangular preputial graft is often of insufficient length for larger defects. In this video, we introduce a novel rainbow technique for preputial skin harvesting in cases of severe proximal hypospadias where an extended graft length is required.
Materials And Methods:
A 2-year-old with penoscrotal hypospadias presenting with a scrotal meatus, bifid scrotum, and severe chordee (>90°) was planned for staged repair. The karyotype was 46,XY, and the hormonal profile was normal. Two doses of testosterone were administered preoperatively. During the first stage, chordee was corrected by dividing the urethral plate and performing three transverse corporotomies - one at the point of maximal curvature and one 5 mm above and below this incision. Only the superficial layer of the tunica albuginea was incised. This created a 6 cm ventral penile defect. As the inner preputial diameter measured 4 cm, the conventional rectangular preputial skin graft technique could not be performed. A semicircular, rainbow-like incision was made on the dorsal prepuce with a minimum width of 2 cm, yielding a graft 7 cm in length. This was used to cover the ventral penile surface, and a staged tubularized autograft (STAG)-type repair was performed.
Results:
The tie-over dressing was removed on postoperative day 4. Six-month follow-up demonstrated a well-integrated graft with no contraction. The child is awaiting second-stage hypospadias repair. We have performed this technique in 20 out of 175 staged cases of proximal hypospadias, where rectangular graft was insufficient, over 15 years at our institution.
Conclusion:
This technique serves as a valuable alternative when the conventional rectangular preputial graft harvest is insufficient to provide adequate graft length for first-stage hypospadias repair, eliminating the need for buccal mucosa.
