Isolated Male Epispadias Repair: Long-Term Outcomes.

Isolated male epispadias is one of the most severe congenital genital anomalies that require surgical correction. The goals of the surgery are to reach good aesthetic and functional outcomes. The aim of this retrospective study was to analyze the long-term outcomes of surgical reconstruction of male epispadias. A total of 31 patients with a mean age of 17 years, who underwent surgical repair of isolated male epispadias from January 2000 to January 2015, were involved. The main outcome measures were defined as: aesthetic outcome, continence, postoperative complications, sexual function, and quality of life. The follow-up period ranged from 8 to 23 years, with an average of 14.4 years. Each patients underwent an average of 2.2 surgical procedures in this period. The most common postoperative complications were urethral fistula and residual curvature, in 22.6% and 12.9%, respectively. Satisfactory aesthetic outcome was reported in 71.4% of cases. The repair of male epispadias usually includes more than two procedures with satisfactory aesthetic outcome. Unsolved urinary incontinence remains a significant issue and has a high impact on the quality of life. Follow-up should be extended even after complete sexual maturity. Comprehensive long-term evaluation is necessary for proper treatment of isolated epispadias.

Musculocutaneous Latissimus Dorsi Phalloplasty: Technique and Tips.

BACKGROUND: Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral extension at later stages. This surgery allows for a neophallus of adequate length and girth, and minimal donor site morbidity, but is technically complex. OBJECTIVE: This video demonstrates a step-by-step technique and tips to optimize outcomes and simplify the operation for the MLD phalloplasty. MATERIALS AND METHODS: A 33-year-old transmale who previously underwent metoidioplasty presented for an MLD phalloplasty. With the patient in a supine position, the superficial femoral artery and saphenous vein are isolated at the recipient site. The patient is repositioned into a lateral flank position, the flap harvested and tubularized, and inferior aspects of the wound closed prior to harvesting the thoracodorsal artery (TDA) and thoracodorsal vein (TDV) to minimize cold ischemia time. The TDA and TDV are dissected to their root at the subscapular artery and vein. The artery is removed with a patch of the subscapular artery. The patient is initially in a supine position and then returned to a supine position to minimize ischemia time of the flap. The neophallus is attached to the previously created recipient site, and an end-to-side anastomosis is created between the superficial femoral artery and TDA and an end-to-end anastomosis between the saphenous vein and the TDV. If the patient has a thick latissimus dorsi muscle or subcutaneous fat, a split-thickness skin graft can be used to close the ventral phallus to minimize tension on the tubularized neophallus and provide a plate for a future urethral lengthening procedure. Positioning and close post-op monitoring of the neophallus are critical. RESULTS: A neophallus of adequate length and girth is created with the option for future urethral extension and penile prosthesis placement. CONCLUSION: Our video demonstrates the technique for a gender-affirming MLD phalloplasty in a transman and tips to optimize outcomes and simplify the operation.

Penile Microdissection: A Live Donor Feasibility Study in Feminizing Gender-Affirming Surgery.

Femininizing gender affirmation surgery includes the creation of external female genitalia such as a new clitoris, labia, and vagina with removal of the glans and urethral remnants and full corpora cavernosa. We evaluated the possibility of using preserved cavernosal bodies with glans and urethral remnants for potential live-donor penile transplantation. Between March 2021 and February 2023, penile microvascular dissection followed by gender-affirming vaginoplasty was performed in 41 patients aged 18 to 57 years (mean 30.5 years). The mean follow-up was 15 months (ranging from 6 to 26 months). The removed penile entities were properly measured. The corpora cavernosa were completely preserved in all cases; the length of remaining anterior urethra ranged from 12.70 cm to 16.40 cm, while the mean glans remnant volume was 85.37% of the total volume. All patients reported satisfactory results after gender-affirming vaginoplasty. Microvascular penile dissection in gender-affirming vaginoplasty is simple and safe, suggesting a good possibility of using the full corpora cavernosa, glans, and anterior urethra remnants for live-donor penile transplantation.

Adult non-urethral complications after hypospadias repair in childhood: presentation, treatment and outcomes.

Purpose: This study aimed to evaluate a group of adult patients with non-urethral complications after hypospadias repair in childhood, their surgical treatment, and outcomes. Materials and methods: We analyzed 97 patients, mean age 22.5 years, who were treated in our center between January 2009 and December 2020, for non-urethral complications after previous hypospadias repair in childhood. Non-urethral complications were defined as glans deformity, residual curvature and trapped penis due to insufficient penile skin. A radical surgical approach was used to correct all deformities, in a one-stage or a two-stage procedure. A successful outcome was defined as a straight penis with good length, anatomically regular glans, and cosmetically acceptable appearance, without need for additional surgeries. Sexual function was evaluated using International Index of Erectile Function. Results: Mean follow-up was 75 months (ranged from 24 to 168 months). One-stage and two-stage repair were performed in 85.5% and 14.5% of cases, respectively. A higher success rate was noted after one-stage repair (94% compared to 86%). Complications included four cases of penile curvature with late onset, one case of glans dehiscence and partial skin necrosis. Erectile dysfunction was determined in 24% of patients. Discussion: Non-urethral complications may occur many years after primary hypospadias repair, with a strong impact on the quality of life. Treatment is individualized and usually involves a radical surgical approach to correct all associated deformities and to achieve successful cosmetic and psychosexual outcomes.

Updates on metoidioplasty.

AIMS: Metoidioplasty presents a variant of phalloplasty in transmen who require simple and safe genital gender affirmation surgery (GAS). The aim is to evaluate updates on the technique, as well as personal experience. METHODS: The surgical steps of metoidioplasty are removal of the vagina, clitoral straightening and lengthening, urethral lengthening using available flaps and grafts, and creation of the scrotum with testicular prostheses implantation. The surgical goal is to achieve appearance of male genitalia, voiding in standing position, and full erogenous sensitivity. Modifications of the technique have developed due to recent advances in anatomy and new requests from transmen. Besides full metoidioplasty, other variants include metoidioplasty before, after or simultaneously with total phalloplasty. Each variant has its' own advantages, which must be discussed with the candidate preoperatively. RESULTS: A total of 938 transmen with the mean age of 29 years underwent one-stage metoidioplasty between January 2004 and January 2022. In majority of cases (65%) metoidioplasty was performed as a final option, and the length of the neophallus ranged between 4 and 10 cm. Urethral complications occurred in 143 cases, dislocation and rejection of testicular implant in 55 and vaginal remnant in 92 cases. Voiding in standing position was reported in almost all cases (99%), and 12.5% of transmen requested phalloplasty after metoidioplasty. CONCLUSION: Metoidioplasty is a safe, one-stage procedure with good esthetic and functional outcomes. It includes a wide spectrum of variants that can be offered to transmen as a part of genital reconstruction, with goal of achieving patients' satisfaction.

Penile Prosthesis in Transgender Men after Phalloplasty.

A penile prosthesis can be successfully implanted after phalloplasty in transgender men to permit sexual intercourse. A prosthesis can be categorized as malleable or inflatable. The most common penile prosthesis implanted after masculinizing genital surgery is the inflatable prosthesis but this can be a challenging operation with high complication rates. Penile prosthesis in transgender patients differs from cis-patients in many respects but one critical difference is the absence of the tough, protective tunica of the corporal body to contain the prosthesis. This causes greater mobility of the prosthesis under the skin and increases the risk of migration and erosion of the device through the skin. In addition, to overcome the absence of a corpora cavernosa, the proximal portion of the prosthesis must be anchored to bone. Complications include injury to the urethra, vascular injury, skin breakdown, infection, device migration, device failure, extrusion, and erosion. There is no robust data on the use of penile prosthesis in transgender men with only multiple reports of small numbers of patients. While successful implantation can improve patients' quality of life, surgeons should counsel patients about the relatively high risk of the need for revision surgery.

Metoidioplasty in Gender Affirmation: A Review.

Metoidioplasty is a variant of the gender affirmation technique neophalloplasty, where a hormonally enlarged clitoris is reconstructed to become a small penis. The goals of metoidioplasty are male appearance of the genitalia, voiding in standing position, and completely preserved erogenous sensation of the neophallus. However, it does not enable penetrative sexual intercourse due to the small dimensions of the neophallus. Basic principles of metoidioplasty were established 50 years ago, and many refinements of the technique have been reported since. The latest improvements are based on the advances in urethroplasty, perioperative care, and new insights into female genital anatomy. The current metoidioplasty technique is a one-stage procedure that includes vaginectomy, straightening and lengthening of the clitoris, urethral reconstruction by combined flaps and grafts, and scrotoplasty with insertion of testicular implants. Good aesthetic, functional, and psychosexual outcomes are achieved with this type of neophalloplasty.

Musculocutaneous Latissimus Dorsi Phalloplasty.

The treatment of gender dysphoria consists of psychiatric evaluation, initiation of hormonal therapy, and the final step in an individual's transition, performing gender-affirming surgery. Construction of the neophallus is one of the most demanding tasks in genital affirming surgery of transgender men. The main objectives of phalloplasty are to achieve a cosmetically acceptable and functional phallus, with a neourethra that allows voiding in standing position, sufficient length and strength for possible penetrative intercourse, preserved tactile and orgasmic sensation, and acceptable donor site morbidity. The musculocutaneous latissimus dorsi flap has reliable and suitable anatomy (good size, volume, and length of neurovascular pedicle) to meet the esthetic and functional requirements of neophallus reconstruction. Despite many advantages, the main disadvantage of this flap is the lack of sensitivity. Although the radial free forearm flap technique is the most commonly performed procedure, musculus latissimus dorsi flap is an acceptable choice in gender-affirming surgery.

Laparoscopy Assisted Peritoneal Pull-Through Vaginoplasty in Transgender Women.

BACKGROUND: Penile inversion vaginoplasty still remains the gold standard in genital gender affirming surgeries in transwomen. However, insufficiency of the penile skin due to either radical circumcision or puberty blockers presents great challenge in vaginal reconstruction. Peritoneal pull-through vaginoplasty is well known technique for the treatment of vaginal absence in cis-woman due to vaginal agenesis or trauma. OBJECTIVE: We describe our laparoscopy assisted technique of using peritoneal flaps for neovaginal construction in male to female gender affirming surgery METHODS: In period from March 2016 to June 2021, 52 transwomen, aged from 19 to 52 years (mean 27) underwent laparoscopy assisted peritoneal pull-through vaginoplasty. Indications were genital skin insufficiency (radical circumcision in 16, scrotal skin insufficiency in 3 and lichen sclerosis in 3 cases) and prepubertal blockers in 22 and 17 cases, respectively. In remaining 13 candidates, peritoneal pull-through vaginoplasty was preferable method of choice. Two peritoneal flaps are harvested from posterior bladder wall and anterior rectosigmoid peritoneum, using laparoscopy approach. Vaginal channel is created by combined perineal and laparoscopy approaches. Good vascularized peritoneal flaps are maximally mobilized and pulled-through to be joined with inverted penile skin. Peritoneal flaps are joined laterally to create neovagina. Gender affirming surgery is completed with reconstruction of external female genitalia, clitoris, labia minora and majora, and urethra. Vaginal packing is placed for 7 days postoperatively and followed by proper vaginal dilation for the first 12 months postoperatively. RESULTS: Follow-up ranged from 6 to 69 months (mean 29 months). Complications occurred in 7 cases: 3 had prolonged hematoma of the labia majora, one had neovaginal introitus dehiscence and one had superficial necrosis of the left labia majora. None of the complications required additional surgeries. The depth of the neovagina at the control check-up in 6 months after surgery was 14.7 ± 0.5 cm, while width was about 3.4 ± 0.4 cm. Majority of patients (≈96%) were satisfied with the new genitalia, sensitivity, lubrication and possibility of engaging in sexual intercourse according to self-reports. One patient required reduction of the size of her clitoris because of hypersensitivity and the other one requested laser treatment of the incisional scars. CONCLUSION: Although known for quite a long time in vaginal reconstruction for cis-women with vaginal agenesis and different forms of vaginal absence, peritoneal pull-through vaginoplasty offers promising outcomes in transgender women, as an option that will give self-lubricating neovagina, with insignificant scarring and complications and high degree of patient's satisfaction.

Metoidioplasty: Surgical Options and Outcomes in 813 Cases.

Introduction: Metoidioplasty is a variant of phalloplasty for transmen that includes the creation of the neophallus from a hormonally enlarged clitoris, urethral lengthening and scrotoplasty. The procedure results in male appearance of genitalia, voiding in standing position and preserved sexual arousal, but without possibility for penetrative intercourse. We evaluated outcomes of metoidioplasty at our center, based on latest surgical refinements. Methods: During the period of 14 years (from February 2006 to April 2020), 813 transmen with mean age of 24.4 years and mean body mass index of 24.6, underwent one stage metoidioplasty. Hysterectomy was simultaneously performed in 156, and mastectomy in 58 cases. Hysterectomy, mastectomy and metoidioplasty were done as a one-stage procedure in 46 transmen. Patients are divided in 5 groups, depending on the type of urethroplasty. Postoperative questionnaires were used to evaluate cosmetic and functional outcomes, as well as patients' satisfaction. Results: Follow-up ranged from 16 to 180 months (mean 94 months). Mean surgery time was 170 minutes and mean hospital stay was 3 days. Length of the neophallus ranged from 4.8 cm to 10.2 cm (mean 5.6 cm). Urethroplasty was complication-free in 89.5% of cases, and ranged between 81% to 90.3% in different groups. Urethral fistula and stricture occured in 8.85% and 1.70% of cases, respectively. Other complications included testicular implant rejection in 2%, testicular displacement in 3.20% and vaginal remnant in 9.60% of cases. From 655 patients who answered the questionnaire, 79% were totally satisfied and 20% mainly satisfied with the result of surgery. All patients reported voiding in standing position and good sexual arousal of the neophallus, without possibility for penetrative intercourse due to small size of the neophallus. Conclusion: Metoidioplasty has good cosmetic and functional outcomes, with low complication rate and high level of patients' satisfaction. In transmen who request total phalloplasty after metoidioplasty, all available phalloplasty techniques are feasable.

T-condylar humerus fracture in children: treatment options and outcomes.

Intracondylar T-type fractures of distal humerus represent a rare condition in paediatric population with unknown incidence since the literature is limited to case reports or case series. The main purpose of this article is to provide a comprehensive review of the current literature about the incidence and diagnostic modalities, as well as to evaluate all treatment options with results and complications. Review of the literature identified nine institutional reports in the period between 1984 and 2015, involving a total of 135 children and adolescents. Treatment options were open reduction with internal fixation and closed reduction in 118 and 17 cases, respectively. Open reduction was performed by different surgical approaches: triceps-sliding, triceps-splitting and olecranon osteotomy. Reported follow-up ranged from ten to 49 months. Outcomes were estimated by various tests, which are mainly based on range of motion. Patients younger than ten years generally had a better range of motion then older patients. Transient neuropathy and elbow stiffness were the most common complications, reported in 16.3% and 9.6% of cases, respectively. Despite the small number of reported clinical series, it is widely accepted that this fracture should be treated by open reduction with internal fixation to reduce and stabilise the displaced intra-articular fragments and to achieve anatomical congruity of the joint and integrity of medial and lateral columns.

Metoidioplasty With Urethral Lengthening: A Stepwise Approach.

BACKGROUND: Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate. OBJECTIVE: To demonstrate an adaptation of the Belgrade technique of gender-affirming metoidioplasty and describe outcomes. METHODS: We identified 33 patients of which 12 underwent simple metoidioplasty and 21 underwent metoidioplasty with urethral lengthening between 2016 and 2020. Prior to surgery, all patients underwent at least 1 year of testosterone therapy to maximize clitoral growth. The clitoris is degloved and the superficial suspensory ligament divided to maximize phallic length. Labia minora flaps are developed and the urethral plate is divided to allow for maximal ventral extension. The resultant urethral defect is bridged with a buccal mucosa graft. To construct the ventral aspect of the urethra, an anterior vaginal wall flap and labia minora flap are sutured to the urethral plate and tubularized over a 16 Fr catheter. The medial aspect of the contralateral labia minora is de-epithelialized and overlaps the urethra, serving as ventral skin coverage for the phallic shaft. Bilateral labia majora flaps are then rotated anteriorly and superiorly to create a neoscrotum using the Ghent technique. RESULTS: For metoidioplasty with urethral lengthening, the median operative time was 408 minutes, estimated blood loss 400 mL, and length of stay 3 days. Of the 21 patients, 10 (47%) elected to undergo second stage scrotoplasty, 7 (33%) underwent testicular implant placement, and 2 (9%) required revision urethroplasty. Of the 10 patients (48%) who experienced postoperative complications, 7 were Clavien-Dindo grade I-II. There were no fistulae at a median follow-up time of 5.5 months (range 1-27.2). CONCLUSION: We provide a stepwise approach to metoidioplasty with urethral lengthening using a modified Belgrade technique, which was associated with a low rate of urethral complications.

Outcomes and special techniques for treatment of penile amputation injury.

INTRODUCTION: Management of severe penile trauma presents great challenges for reconstructive urologists since these injuries vary from abrasions to total emasculation. A review of our case experience with penile amputation is presented, emphasizing techniques used to salvage or reconstruct the most difficult of penile injury cases. MATERIALS AND METHODS: A total of 13 patients with penile amputation injury referred to us between 2007 and 2016 were analyzed. Mean age at surgery was 16 years (ranged from 4 to 29 years). Etiology of penile amputation (partial or total) combined with management and outcomes were evaluated. Management included different surgical procedures with the aim to achieve good functional and esthetical outcomes. Postoperative questionnaire was used for assessment of patient's overall satisfaction. RESULTS: Follow-up ranged from 13 to 182 months (mean 53). Causes of penile injury were iatrogenic trauma (8), self-amputation (2), electrocution (1), intentional sexual assault (1) and mother's hair strangulation (1). Outcome criteria including aesthetic appearance, urinary function and ability to engage in satisfactory coitus, were noted in 11 cases (85%). Two cases with ensuing complications relating to the total phalloplasty required additional treatment due to urethral fistula. CONCLUSIONS: Severe penile injuries should be treated on a case by case basis utilizing the most propitious techniques. We respectfully propose that the needs of such patients are best served by referral centers with extensive experience.

Metoidioplasty.

Gender affirmation surgery for transmale patients is still challenging, as creation of the neophallus is one of the most demanding steps in surgical treatment. Metoidioplasty, as a one-stage procedure, can be considered in patients who desire gender affirmation surgery without undergoing a complex, multistage procedure with creation of an adult-sized neophallus. Metoidioplasty presents one of the variants of phalloplasty for patients in whom the clitoris is large enough under testosterone treatment. Advanced urethral reconstruction provides low complication rates with satisfying results of standing micturition.

The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series.

INTRODUCTION: Some transgender men express the wish to undergo genital gender-affirming surgery. Metoidioplasty and phalloplasty are procedures that are performed to construct a neophallus. Genital gender-affirming surgery contributes to physical well-being, but dissatisfaction with the surgical results may occur. Disadvantages of metoidioplasty are the relatively small neophallus, the inability to have penetrative sex, and often difficulty with voiding while standing. Therefore, some transgender men opt to undergo a secondary phalloplasty after metoidioplasty. Literature on secondary phalloplasty is scarce. AIM: Explore the reasons for secondary phalloplasty, describe the surgical techniques, and report on the clinical outcomes. METHODS: Transgender men who underwent secondary phalloplasty after metoidioplasty were retrospectively identified in 8 gender surgery clinics (Amsterdam, Belgrade, Bordeaux, Austin, Ghent, Helsinki, Miami, and Montreal). Preoperative consultation, patient motivation for secondary phalloplasty, surgical technique, perioperative characteristics, complications, and clinical outcomes were recorded. MAIN OUTCOME MEASURE: The main outcome measures were surgical techniques, patient motivation, and outcomes of secondary phalloplasty after metoidioplasty in transgender men. RESULTS: Eighty-three patients were identified. The median follow-up was 7.5 years (range 0.8-39). Indicated reasons to undergo secondary phalloplasty were to have a larger phallus (n = 32; 38.6%), to be able to have penetrative sexual intercourse (n = 25; 30.1%), have had metoidioplasty performed as a first step toward phalloplasty (n = 17; 20.5%), and to void while standing (n = 15; 18.1%). Each center had preferential techniques for phalloplasty. A wide variety of surgical techniques were used to perform secondary phalloplasty. Intraoperative complications (revision of microvascular anastomosis) occurred in 3 patients (5.5%) undergoing free flap phalloplasty. Total flap failure occurred in 1 patient (1.2%). Urethral fistulas occurred in 23 patients (30.3%) and strictures in 27 patients (35.6%). CLINICAL IMPLICATIONS: A secondary phalloplasty is a suitable option for patients who previously underwent metoidioplasty. STRENGTHS & LIMITATIONS: This is the first study to report on secondary phalloplasty in collaboration with 8 specialized gender clinics. The main limitation was the retrospective design. CONCLUSION: In high-volume centers specialized in gender affirming surgery, a secondary phalloplasty in transgender men can be performed after metoidioplasty with complication rates similar to primary phalloplasty. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med 2019;16:1849-1859.

Metoidioplasty: techniques and outcomes.

Phalloplasty represents the latest step in female-to-male transitioning and still remains a great challenge for transgender surgeons. Since we have two options in this transitioning-metoidioplasty and total phalloplasty-the transgender surgeon has to fully inform the individual about all aspects such as surgical steps, outcomes, advantages and disadvantages, possible complications, and expectations. Total phalloplasty with the creation of a neophallus of a similar volume to that in genetic males, is a complex and multi-staged procedure. Many different tissues (i.e., flaps) can be used, and the ideal procedure is still not established. In contrast to the above complexities involved in total phalloplasty, metoidioplasty presents a simple and one-stage procedure for the creation of a neophallus from a hormonally enlarged clitoris. This technique is very promising for individuals who desire gender-affirmation surgery without having to undergo the difficult and multistage creation of a male-sized neophallus. Also, this technique prevents scarring to the extragenital region, making the final results more acceptable for transgender individuals. Our goal is to objectively present the techniques for metoidioplasty and to define their value based on postoperative results.

Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery.

PURPOSE: Despite a variety of free flaps that have been described for creation of the neophallus in gender affirmation surgery, none present an ideal solution. We evaluated our patients and outcomes after gender affirmation phalloplasty using musculocutaneous latissimus dorsi free flap. METHODS: Between January 2007 and May 2017, 129 female transsexuals, aged 20-53 years (mean 24 years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. RESULTS: The mean follow-up period was 43 months (ranged from 13 to 137 months). There were one partial and two total flap necrosis. The average size of the neophallus was 14.6 cm in length and 12.4 cm in girth. Total length of the reconstructed urethra during the first stage ranged from 13.4 to 21.7 cm (mean 15.8 cm), reaching the proximal third or the midshaft of the neophallus in 91% of cases. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively. CONCLUSION: Musculocutaneous latissimus dorsi flap is a good choice for phalloplasty in gender affirmation surgery. It provides an adequate amount of tissue with sufficient blood supply for safe urethral reconstruction and penile prosthesis implantation.

Buccal mucosa graft for simultaneous correction of severe chordee and urethroplasty as a one-stage repair of scrotal hypospadias (watch technique).

PURPOSE: Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation, in combination with longitudinal dorsal island skin flap, as a one-stage repair of severe hypospadias. METHODS: Between July 2014 and September 2017, 26 patients (aged from 12 to 22 months) underwent scrotal hypospadias repair. Short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special "watch" shape, with the spherical part in the middle and two rectangular parts on both sides. Tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. Longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with buccal graft. Penile skin reconstruction is performed using available penile skin. RESULTS: The mean follow-up was 22 months (range from 9 to 46 months). Satisfactory results were achieved in 22 patients. Two urethral fistulas were successfully repaired by minor surgery after 3 months, while one meatal stenosis and one urethral diverticulum were successfully treated by temporary urethral dilation. There were no cases of residual curvature. CONCLUSION: Specially shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single-stage repair of scrotal hypospadias with severe curvature.

Single-stage repair of obliterated anterior urethral strictures using buccal mucosa graft and dorsal penile skin flap.

OBJECTIVE: To present a single-stage repair of obliterative urethral strictures by simultaneous use of a buccal mucosa graft and longitudinal dorsal penile skin flap. METHODS: Between February 2007 and October 2016, 51 patients with obliterative anterior urethral stricture underwent single-stage substitution urethroplasty. A buccal mucosa graft was harvested and fixed to the corpora cavernosa as the dorsal part of the neourethra, and a vascularized dorsal penile skin flap was created, transposed ventrally and sutured to the buccal mucosa graft to form ventral part of the neourethra. RESULTS: The follow-up period was 12-129 months (mean 49 months). The mean age of the patients was 48 years (range 15-71 years). The mean length of the obliterated urethral segment, measured during the operative procedure, was 5.2 cm. The etiology of strictures was: unknown, hypospadias and trauma in 19, 27 and five patients, respectively. Five patients were lost to follow up, and 46 patients were analyzed for the outcome. At the end of the follow-up period, recurrence of the stricture occurred in seven (15.2%) patients, whereas 39 (84.8%) patients did not develop stricture. An additional three (6.5%) patients developed fistula, resulting in overall successful voiding in 36 (78.3%) patients. CONCLUSIONS: A combined buccal mucosa graft and longitudinal dorsal penile skin flap could be a good choice for one-stage substitution urethroplasty in complex obliterative urethral strictures, with an acceptable complication rate.