Distally folded onlay flap : a new technique for repair of hypospadias

Objective: This study was carried out to evaluate the cosmetic and functional results of this new technique for repair of hypospadias. Patients and technique: 28 patients (2-22 years) with distal penile hypospadias were included in the study. Eleven of them had had a failed previous repair. An unhealthy urethral plate and/or thin ventral penile skin were found in 17 patients. The technique follows the steps of the island onlay preputial flap or dorsal penile fasciocutanous flap except in that the length of the flap is; at least; 1 cm longer than the length of the urethral plate. The proximal part of the flap is used for urethral reconstruction. The distal free part of the flap is reflected back to be sutured to the edges of the glanular wings and the penile skin. The urethral stent is removed after 5 days. The patients were followed monthly up to 6 months. Results: In 26 patients an excellent cosmetic appearance of both the penile shaft and glans was achieved with a slit-like or elliptic neo-meatus resulting in a good urine stream satisfying both the patients and their parents. Partial disruption of one side of the suture line and urethrocutanous fistula was reported in one patient each. These two complications were corrected surgically with good results. Conclusion: We conclude that this new technique that we named distally folded onlay flap is easy and versatile with excellent cosmetic and functional results and a low rate of complications when used for the repair of distal and mid-shaft hypospadias in either virgin or redo cases. It should also be considered as a salvage procedure when other techniques are no feasible options

Congenital penile curvature with orthotopic meatus : a report on the management of 62 cases following a systematic approach

Objectives We are presenting our experience with a systematic approach in the management of congenital penile curvature (CPC). Patients and Methods Between 1993 and 2000; 62 cases of CPC were treated. Ten of 34 cases (30) presenting with ventral curvature were corrected via excision of the dysgenetic tissue and complete mobilization of the corpus spongiosum only. Two cases (6) had a minimal corporeal disproportion that required a ventral longitudinal deep intercorporeal incision. Six cases (18) were managed with Nesbit's procedure; and tunica albuginea plication (TAP) was done in 8 cases (24). These cases required mobilization of the neurovascular bundle (NVB). Four patients (12) had a small phallus and required ventral grafts (dermal in two and venous grafts in another two). The remaining four patients (12) had a short urethra and were managed by excision of the tethering corpus urethrae and neourethral reconstruction. Cases presenting with lateral curvature (14 patients) were managed by a lateral longitudinal incision at the point of maximum curvature followed by TAP in 10 cases (71) and Nesbit's procedure in four (29). Dorsal curvatures (6 cases) were managed by ventral Nesbit in four (67) and ventral TAP in the remaining two cases (33). Patients with a complex curvature (8 cases) were managed by sequential TAP on an individual basis according to the results of intraoperative artificial erection in 5 cases (63) and by complete penile disassembly: The follow-up period ranged from 6 months to 2 years; and the results were satisfactory in the majority of patients. None of our patients developed impotence. Penile haematoma occurred in 6.4and penile numbness in 19(persistent in 3); while foreign body sensation was felt in 8. None of our patients experienced painful erections beyond three months after operation. A residual curvature was noticed in 9.6; and it required a second step Nesbit's procedure in only 3. Conclusion Management of CPC can result in a very high success rate as long as a systematic stepwise approach is applied with an appropriate preoperative patients counseling. We recommend the limited use of Nesbit's procedure (unless TAP fails to correct the curvature) together with a gentle handling of the NVB