1. 0022-5347/94/1524-1232$03.00/0
THE JOURNAL OF UROLOGY Vol. 152, 1232-1237, October 1994
Copyright © 1994 by AMERICAN UROLOGICAL AsSOCIATION, INC. Printed in U.8.A.
ONE-STAGE REPAIR OF HYPOSPADIAS: IS THERE NO SIMPLE
METHOD UNIVERSALLY APPLICABLE TO ALL TYPES OF
HYPO SPAD lAS?
TOMOHIKO KOYANAGI, KATSUYA NONOMURA, TETSUFUMI YAMASHITA, KOUICHI KANAGAWA
AND HIDEHIRO KAKIZAKI
From the Department of Urology, Hokkaido Uniuersity School of Medicine, Sapporo, Japan
ABSTRACT
A simple method ofhypospadias repair is described. The operative technique consists of7 steps,
including 1) outlining the skin incision and dartos mobilization; 2) artificial erection, harvesting
parameatal foreskin flap and release of chordee as needed; 3) glans splitting and creation of
glanular wings; 4) l-stage urethroplasty with parameatal foreskin flap; 5) meatal glanuloplasty;
6) creation of Byars' flap s of the skin, and 7) skin closure. Central to the technique is the
feasibility of the choice of l-stage urethroplasty with meatal based manta-wing flap or with
parameatal based and fully extended circumferential foreskin flap even after the skin incision is
made, which enables its application to all types of hypospadias. Of 120 patients the l-stage
urethroplasty was performed with meatal based manta-wing flap in 50, and with parameatal
based and fully extended circumferential foreskin flap in 70. Primary success was obtained in
82% ofthe cases with meatal based manta-wing flap, and in 53% with parameatal based and fully
extended circumferential foreskin flap. Complications requiring secondary repair occurred in 42
cases (9 with meatal based manta-wing flap, and 33 with parameatal based and fully extended
circumferential foreskin flap) but repair was successful in 32. Thus, the overall success rate was
91% (96% with meatal based manta-wing flap, and 87% with parameatal based and fully
extend d circumferential foreskin flap). Additional repair 10 secondary, 2 tertiary and 1 qua-
ternary) is planned in 13 cases. The technique of l-stage urethroplasty with parameatal foreskin
flap is recommended as a simple and reliable treatment for hypospadias with a reasonable
success rateo
KEy WORDS: hypospadias; penis; urethra; surgery, operative
Numerous operative techniques have been reported for the In step 2 artificial erection, harvesting parameatal fore-
repair of hypospadias. Those who engage in the treatment of skin flap(s) and correction of chordee are performed as
this difficult problem must be well acquainted with a variety needed. After dartos mobilization and artificial erection are
ofthese techniques, which reportedly number more than 200. done and if chordee is absent, as in most cases of distal
A l-stage repair has evolved in the last 2 decades and is now hypospadias,7 an adequate length of flap is harvested from
the standard treatment.1 In the majority of distal hypospa- either side of the parameatal foreskin (figs. 2, e to F and 3).
dias cases a remarkably high success rate can be expected If chordee is present, as in most cases of proximal hypospa-
with a single stage repair.2 Nevertheless, in the repair of dias, flaps are harvested from both sides of the parameatal
proximal hypospadias in which the deformity is much more foreskin and joined by transecting the urethral plate. The
severe the l-stage techniques have a limited role and only a urethra with bilateral parameatal foreskin flaps is detached
few will correct all ofthe concurrent deformities (for example from the ventral corpora as in classic chordee correction until
hypospadiac urethra with severe chordee, ventrally tilted the shaft straightens (figs. 4, e to G and 5).
globular glans with dorsal skin hood and pro-penile bifid In step 3 the glans are split and glanular wings are cre-
scrotum).3,4 Consequently a staged repair is still recom- ated. When chordee is absent or released by dartos mobiliza-
mended for these difficult cases.5 However, if a simple single tion alone an incision parallel to both sides of the urethral
stage method were universally applicable to all types of hy- groove is made and the glans is split, thus preserving the
pospadias, from mild (glanular and coronal) to moderate urethral plate (figs. 2, F and G, and 3). When the urethra is
(penile and distal-to-penoscrotal) to more severe (scrotal and severed the glans is split by a vertical midline incision. The
perineal) it would be of immense benefit. We believe that a incision is deepened to the level of the corpora, and glanular
l-stage urethroplasty with parameatal foreskin flap is the wings are created by judicious lateralization of the glanular
technique that will meet this demand.6
substance, literally splitting the glans (figs. 4, H to J and 5).8
OPERATIVE TECHNIQUE
Because of the separate origin of the glans, urethra and
corporeal body,9 this dissection can usually be accomplished
The steps of the procedure are outlined in figure 1. In step anatomically without undue bleeding.
1 the skin incision and dartos mobilization are outlined. In step 4 the l-stage urethroplasty with parameatal fore-
Regardless of the type of hypospadias a skin incision is made skin flap is performed. When the urethral plate is preserved
encircling proximal to the meatus and extending dorsolater- the parameatal foreskin flap is simply onlayed to form the
ally, including adequate parameatal foreskin (figs. 2, A and neourethra (figs. 2, H and 3).10 When the urethral plate is
B, 3, 4, A and B, and 5). transected and severed the neourethra is formed by tubular-
izing bilateral parameatal foreskin flaps, and is anchored to
Accepted for publication February 25, 1994. the tip of the split glans.ll Due to urethral mobilization at
1232

2. ONE-STAGE REPAIR OF HYPOSPADIAS 1233
lar and frenal portions of the distal urethra. The rest of the
slightly protruding urethral edge is everted and sutured to
the glanular edge in a semi-cufffashion. When complete, the
vertically slit meatus opens at the most distal end of the
Step l. Outlining of skin incision snd dartos mobilization glans, which was restored to a normal cone shape from a
somewhat ventrally tilted and globular shape (figs. 2,1 and 3
to 5).
Step 2. In step 6 Byars' flaps are created with the dorsal foreskin
and its subcutaneous tissue (figs. 2, J and 3 to 5). In step 7
___ ehordee _ the skin is closed (figs. 2, K and 3 to 5). Steps 6 and 7 are
(-) (+) essentially the same as reported previously.lO, 11However, in
proximal hypospadias when a pro-penile bifid scrotum is
quot;quot; Harvesting PF / often a concurrent deformity, at step 1 the scrotum must be
/ Bilateral mobilized extensively and at step 6 Byars' flaps must be created
Unilateral PF PF with with enough subcutaneous tissue to reposition it ventral and
posterior to the penile shaft.11 The specific details of each
step have been described previously.1O-12
Postoperatively, all cases are managed with urethral
drainage using an indwelling 6F silicone catheter for 1week
Step 3. in those with meatal based manta-wing flap and for 2 weeks in
those with parameatal based and fully extended circumfer-
ential foreskin flap. Wound dressing and treatment after
Step 4. removing the catheter have been reported previously.lO. 11
Step S.
RESULTS
In the last 10 years 120 patients 2 to 12 years old (mean
Step 6. Byarsization of dorsal foreskin sud subcutaneous tissue age 3.7 years) underwent this procedure, including 50
treated with meatal based manta-wing flap and 70 treated
with parameatal based and fully extended circumferential
Step 7. foreskin flap. In a third of the procedures with parameatal
based and fully extended circumferential foreskin flap dartos
FIG. 1. Flowehart of operative teehnique. PF, parameatal flap. mobilization alone was insufficient to release the chordee in
OUPF-II, l-stage urethroplasty with meatal based manta-wing fore- what seemed to be distal hypospadias. Overall 70 cases were
skin flap. OUPF-N, l-stage urethroplasty with parameatal based cured primarily without complications. Small fistulas oc-
and fully extended eireumferential foreskin flap. curred in 8 cases but they all healed within 2 months. In-
cluding these cases, primary success was accomplished in
82% (41 of 50 cases) and in 53% (37 of 70 cases). Complica-
correction of chordee (step 2) there should not be any tension tions necessitated secondary repair in 42 cases, including
in anchoring the neourethra to the glans (figs. 4, K to M mea tal stricture requiring recession or glanular dehiscence
and 5). with meatal recession in 15 (3 with meatal based manta-wing
In step 5 the glans wings are approximated over the neo- flap, and 12 with parameatal based and fully extended cir-
urethra as well as paraglanular foreskin to cover the glanu- cumferential foreskin flap), urethrocutaneous fistula in 21 (6
D!§
FIG. 2. Sehematie of l-stage urethroplasty with meatal based manta-wing foreskin flap

3. 1234 ONE-STAGE REPAIR OF HYPOSPADIAS
FIG. 3. Photographof l-stage urethroplastywith meatal based manta-wingforeskinflap
with meatal based manta-wing flap, and 15 with parameatal success rate was 91% (96% with meatal based manta-wing
based and fully extended circumferential foreskin flap) and flap, and 87% with parameatal based and fully extended
urethral stricture in 6 with parameatal based and fully ex- circumferential foreskin flap). Functional and cosmetic out-
tended circumferential foreskin flap. Secondary procedures come was satisfactory with both techniques (fig. 6). Addi-
in 32 cases (extension urethroplasty in 15 and fistula closure in tional repair is planned in 13 cases (10 secondary, 2 tertiary
17) provided satisfactory results in 29. Thus, the overall and 1 quaternary).

4. ONE-STAGE REPAIR OF HYPOSPADIAS 1235
H
~
i n
FIG. 4. Sehematie of l-stage urethroplasty with parameatal based and fully extended eireumferential foreskin flap
e A B o
Step 7
FIG. 5. Photograph of l-stage urethroplasty with parameatal based and fully extended eireumferential foreskin flap

5. 1236 ONE-STAGE REPAIR OF HYPOSPADIAS
A advancement and glanuloplasty or the flip-flap technique is
probably indicated.
With our procedure the neourethra is in natural continuity
with the old urethra, allowing less chance of complication at
the junction. Urethras thus formed continue to grow, as
illustrated by our 13-year-old patients. Compared to the
glans piercing technique, our meatal glanuloplasty seems to
be embryologically as well as anatomically more sound,9 and
it provides cosmetically and functionally satisfactory results.
Moreover, the skin closure allows a pro-penile scrotum to be
repositioned ventral and posterior to the penile shaft, which
enables substantial correction of concurrent deformities even
in the severest form ofhypospadias, all in a single stage. We
recommend that the l-stage urethroplasty with parameatal
foreskin flap be added to the armamentarium as a simple and
reliable l-stage method for all types of hypospadias with a
reasonable rate of success.
FIG. 6. Outcome of l-stage urethroplasty with meatal based
manta-wing foreskin flap (A), and parameatal based and fully ex-
tended circumferential foreskin flap (E). REFERENCES
1. Duckett, J. W.: Hypospadias. In: Campbell's Urology, 6th ed.
Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D.
Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 2, chapt.
DISCUSSION 50, p. 1897, 1992.
2. Wacksman, J., Sheldon, C. and King, L. R: Distal hypospadias
Although it is an established fact that chordee is some- repair. In: Reconstructive Urology. Edited by G. Webster, R.
times absent or is relieved by dartos mobilization alone, it is Kirby, L. King and B. Goldwasser. Boston: Blackwell Scien-
difficult to predict the severity of chordee preoperatively. In tific, vol. 2, chapt. 53, pp. 749-762, 1993.
glanular or coronal hypospadias it is absent in most cases, 3. Ehrlich, R. M. and Scardino, P. T.: Surgical correction ofscrotal
thus enabling repair with meatal advancement and glanulo- transposition and perineal hypospadias. J. PedoSurg., 17: 175,
1982.
plasty, and/or the flip-flap technique.2 In other distal-to- 4. Woodard, J. R and Parrott, T. S.: Management of severe peri-
penoscrotal hypospadias dartos mobilization alone is often neal hypospadias with bifid scrotum. J. Urol., part 2, 145:
adequate to relieve chordee,7 allowing various l-stage re- 245A, abstract 132, 1991.
pairs with preservation of the urethral plate.13. 14Artificial 5. Duckett, J. W.: Hypospadias. In: Reconstructive Urology. Edited
erection with the patient under anesthesia before skin inci- by G. Webster, R Kirby, L. King and B. Goldwasser. Boston:
sion may be helpful in selecting the operation of choice but it Blackwell Scientific, vol. 2, chapt. 54, pp. 763-780, 1993.
seems cumbersome. Furthermore, in what appears to be dis- 6. Koyanagi, T., Nonomura, K and Asano, Y.: One stage urethro-
tal-to-penoscrotal hypospadias dartos mobilization alone plasty with parameatal foreskin-flap (OUPF): simple method
fails to relieve chordee in a third of the cases.6 Although universally applicable to all types of hypospadias repair. J.
Urol., part 2,147: 317A, abstract 419,1992.
urethral mobilization may help, 15-17if it does not the ure- 7. Marshall, M., Jr., Beh, W. P., Johnson, S. H., III, Price, S. E., Jr.
thra must be transected before undergoing l-stage repair, of and Barnhouse, D. H.: Etiologic consideration in penoscrotal
which the currently most reliable is the transverse preputial hypospadias repair. J. Urol., 120: 229, 1978.
island flap (the Duckett procedure).18 This technique has 8. Turner-Warwick, R: Hypospadiac and epispadiac retrievo-
been used in the severest form ofhypospadias, combining the plasty. In: Reconstructive Urology. Edited by G. Webster, R
Thiersch-Duplay urethroplasty of the proximal urethra.3 A Kirby, L. King and B. Goldwasser. Boston: Blackwell Scien-
simple method applicable to all types of hypospadias is de- tific, vol. 2, chapt. 55, pp. 781-794, 1993.
sired because of such unexpected situations. 9. Altemus, A. R and Hutchins, G. M.: Development ofthe human
The l-stage urethroplasty with parameatal foreskin flap anterior urethra. J. Urol., 146: 1085, 1991.
10. Koyanagi, T., Nonomura, K, Asano, Y., Gotoh, T. and Togashi,
technique as described is unique in this regard. It requires no M.: Onlay urethroplasty with parameatal foreskin flap for
planned skin incision, as in most repairs, except the initial distal hypospadias. Eur. Urol., 19: 221, 1991. _
incision (step 1), which is essentially the same regardless of 11. Koyanagi, T., Nonomura, K, Kakizaki, H., Takeuchi, 1. and
the type ofhypospadias. The technique differs only at step 4. Yamashita, T.: Experience with one-stage repair of severe
After dartos mobilization there are just 2 ways to form the proximal hypospadias: operative technique and results. Eur.
neourethra (with meatal based manta-wing flap, and with Urol., 24: 106, 1993.
parameatal based and fully extended circumferential fore- 12. Nonomura, K, Koyanagi, T., Kakizaki, H., Takeuchi, 1. and
skin flap), the choice ofwhich is made at the time of artificial Moriya, K: One-stage repair with parameatal foreskin flap for
erection. Allowing this intraoperative choice depending on all types ofhypospadias. J. Urol., part 2,147: 188A,videotape
V-1,1992.
the degree of remaining chordee considerably simplifies the 13. King, L. R: Hypospadias-a one-stage repair without skin graft
procedure. based on a new principIe: chordee is sometimes produced by
Viability of the parameatal foreskin flap even in cases the skin alone. J. Urol., 103: 660, 1970.
treated with parameatal based and fully extended circumfer- 14. Elder, J. S., Duckett, J. W. and Snyder, H. M.: Onlay island flap
ential foreskin flap is well established.19 When blood flow in the repair ofmid and distal hypospadias without chordee. J.
measured on laser Doppler was compared at the tip of the Urol., 138: 376, 1987.
parameatal flap before and after harvesting there was only 15. Koyanagi, T., Matsuno, T., Nonomura, K and Sakakibara, N.:
an 18% reduction with parameatal based and fully extended Complete repair of severe penoscrotal hypospadias in 1 stage:
circumferential foreskin flap. In comparison to the meatal experience with urethral mobilization, wing flap-flipping ure-
throplasty and quot;glanulomeatoplasty.quot; J. Urol., 130: 1150,
based ventral midline flap, the parameatal flap also has 1983.
considerably better microcirculatory parameters (for exam- 16. Mollard, P., Mouriquand, P. and Felfela, T.: Application of the
ple flow reduction rates with the flip-flap and with meatal onlay island flap urethroplasty to penile hypospadias with
based manta-wing flap were 73% and 33%, respectively)/9 severe chordee. Brit. J. Urol., 68: 317,1991.
which is why we prefer the latter procedure when meatal 17. Monfort, G., Bretheau, D., di Benedetto, V. and Bankole, R:

6. ONE-STAGE REPAIR OF HYPOSPADIAS 1237
Posterior hypospadias repair: a new technical approach. Mo- The authors ask a question in the title: quot;Is there no simple method
bilization ofthe urethral plate and Duplay urethroplasty. Eur. universally applicable to all types of hypospadias?quot; Clearly, the
Urol., 22: 137, 1992. answer is, quot;No.quot;
18. Duckett, J. W.: The island flap technique for hypospadias repair. A. B. Belman
Urol. Clin. N. Amer., 8: 503, 1981.
19. Nonomura, K, Koyanagi, T., Imanaka, K and Asano, Y: Meas- Department of Urology
Children's Hospital National Medical Center
urement of blood flow in the parameatal foreskin flap for Washington, D. C.
urethroplasty in hypospadias repair. Eur. Urol., 21: 155, 1992.
Reply by Authors. In our earlier series in which only 1 of us (T. K)
EDITORIAL COMMENT performed the operation the complication rate associated with a
secondary operation was 8% (2 of25 cases) with meatal based manta-
The authors present their extensive ongoing experience with what wing foreskin flap (reference 10 in article) and 33% (6 of 18 cases)
I perceive as a complex hypospadias repair. They are to be compli- with parameatal based and fully extended circumferential foreskin
mented on their perseverance and on the illustrations, which finally flap. During the ensuing years a number of junior surgeons per-
clarifY their technique for me. However, even with their vast expe- formed the repair, which may explain the relatively higher compli-
rience the complication rate is higher with their procedure than that cation rate in the present series. Others have reported an even
currently achieved with other l-stage techniques. For hypospadias higher incidence (50%) of secondary operations with pedicle tube
without chordee they report an 18% complication rate (with meatal urethroplasty and other techniques (reference 4 in article).2 Under
based manta-wing flap). This group is amenable to a meatal based our current national health program under which every citizen is
flap (Mathieu) or the currently popular onlay repair. Complications entitled to uniform access to health care provided by the government
necessitating reoperation should be less than 5% and reoperations
are being performed by most on an outpatient basis, some without or an insurance company there is no urgency or impetus in promot-
the use of stents (the authors report 1 week of urethral stenting in ing short hospital stay or outpatient surgery. Rather the providers
this group). prefer inpatient care until the wound heals, which may explain the
The authors also report a 47% complication rate (1 applaud their longer urethral catheter drainage and which we plan to shorten in
honesty) with parameatal based and fully extended circumferen- the future. There might have been a few cases in which the pedicle
tial foreskin flap repair. They state that vascularity of the flap was harvested poorly, compromising its vasculature and con-
para meatal foreskin has been proved to be excellent on laser tributing to complications. That the flap was harvested adequately
Doppler. In my experience mea tal stenosis (and stricture?) is a was confirmed by the laser Doppler data. Consequently, the cause of
consequence of diminished vascularity. Judging from their results complication must lie elsewhere. Inadequate coverage of the neoure-
I suspect that vascularity is not as excellent as they believe. thra with Byars' foreskin flaps can result in fistula, as can inade-
Reoperation rate, even for those with severe hypospadias, should quate splitting and tight reapproximation of the glans over the
not exceed 15%. In our experience using a de-epithelialized flap or neourethra with glanular deshiscence and meatal recession. The
tunica vaginalis to cover the transverse island tube fewer than answer to the question in the title is quot;No,quot; when one considers the
10% of cases require a secondary procedure. I agree with their complexity of the deformity and enormous task demanded for its
comment that the currently most reliable repair is the transverse repair but quot;Yes,quot;when it comes to the choice ofthe repair applicable
preputial island flap. to all types of hypospadias.
The argument that they advance (that the initial skin incision is
similar for all degrees of hypospadias) to justify their assertion that 1. Nonomura, K, Koyanagi, T., Imanaka, K, Togashi, M., Asano,
the repair is applicable generally confuses me. Other than with Y and Tanda, K: One-stage total repair of severe hypospadias
meatal based repairs the skin incision for all others is basically the with scrotal transposition: experience in 18 cases. J. Pedo
same, subcoronal and proximal to the hypospadiac meatus. If an Surg., 23: 177, 1988.
onlay is used the urethral plate is spared. The erection test can then 2. Dewan, P. A., Dineen, M. D., Winkle, D., DuflY, P. G. and
be performed after the skin is dissected toward the penile base, if the Ransley, P. G.: Hypospadias: Duckett pedicle tube urethro-
surgeon prefers. plasty. Eur. Urol., 20: 39, 1991.