Hypospadias 2 new techniques: longitudinal preputial flap & single-stage dorsal onlay graft

1. 2 new techniques for hypospadias repair:
longitudinal preputial onlay flap
& Dorsal inlay TIP
M.A.wadood & Kareem Omr

2. longitudinal preputial onlay
island flap

3. Longitudinal preputial island flap
• Rushton and Belman used it in split-
prepuce onlay flap (Longitudinal flap) in
1998.
Dr Harry G Rushton / Dr A Barry Belman

4. Comparative study of
Longitudinal preputial island flap
• A study on Ain Shams urology department
on 60 patients with proximal and distal
hypospadias who were equally distributed
into 3 groups:
1. Lonitudinal preputial flap.
2. Transverse preputial flap.
3. TIP procedure.

5. Longitudinal preputial island flap
U-shaped incision of urethral plate Outer skin of preputial onlay is de-
prepuce is split in the dorsal midline epithelialized

6. Longitudinal preputial island flap
onlay flap is sutured to the urethral C, The onlay flap is sutured to the
plate beginning with a running 7-0 urethral plate beginning with a running 7-
polyglactin suture 0 polyglactin suture and, D, completed
with subcuticular technique

7. Longitudinal preputial island flap
Edges of the vascular pedicle are skin coverage and securing of an 8-Fr
secured lateral to neourethral suture intravesical stent to the glans.
lines as second-layer coverage.

8. Longitudinal preputial island flap
(1)

9. Longitudinal preputial island flap
(2)

10. Longitudinal preputial island flap
(3)

11. Longitudinal preputial island flap
(4)

12. Transverse preputial island flap

13. Longitudinal vs Transverse
preputial island flap
• The study compared functional and
cosmetic outcome, and the incidence of
complications.
• TIP technique, it is still a simpler less time
consuming procedure than the onlay flap
technique but with higher incidence of
complications.
Long. Transverse TIP
Mean operative time 127 mins 118 mins 78 mins
Intraop. Bleeding Minimal Minimal minimal

14. Longitudinal vs Transverse
preputial island flap
• No statistically significant difference were
found in the rate of complicatons between
the longitudinal flap and the transverse
flap groups as regards: hematoma, skin
necrosis, fistulation, meatal stenosis or
stricture.

15. Long. Transverse TIP
Complication cases % cases % cases %
Penile edema/inflammation 2 10% 3 15% 1 5%
Penile hematoma 1 5% _ _
Wound infection 1 5% 1 5% 2 10%
Skin discoloration _ 1 5% _
Skin sloughing _ _ _
Encrustation 1 5% 1 5% 2 10%
Fistulation 1 5% 1 5% 2 10%
Disruption 1 5% 1 5% 2 10%
Meatal stenosis _ _ 1 5%
Urethral stricture _ _ _
Unresolved torsion _ _ _
Penile curvature _ _ _
Poor cosmesis 1 5% 1 5% _
Complication rate 7 35% 7 35% 8 40%
Reoperation rate 3 15% 2 10% 4 20%

16. Longitudinal prep. Flap advantages
• The study showed the following
advantages for the longitudinal flap group:
1. Easier dissection of the pedicle and less
time consuming than the transverse flap.
2. Less incidence of skin ischemia and
postoperative penile rotation.

17. Longitudinal prep. Flap advantages
3. If any insult occurs to the longitudinal flap, it
can be discarded and the other half of the
prepuce utilized.
4. The study suggested that longitudinal flap can
be used as transverse flap with same
effeciency in proximal hypospadias by referring
to the outer preputial surface if needed.
5. availability of Skin for penile coverage and
Dartos for 2nd layer coverage.

18. Research Point
• Longitudinal preputial island flap is a new
promising technique for management of
distal and proximal hypospadias.
• However, the literature lakes studies
comparing longitudinal flaps with
transverse flaps especially in proximal
hypospadias where the role of the
longitudinal flap is much questioned.

19. Single Stage Dorsal inlay
TIP

20. The original TIP procedure
• Snodgrass described the
TIP technique for
hypospadias repair in 1994
as a means to widen and
improve the mobilization of
the urethral plate when
performing a Thiersch–
Duplay urethroplasty.
Dr Warren Snodgrass

21. TIP pros
• TIP hypospadias repair has gained
widespread acceptance because of:
1. ability to correct different meatal variants.
2. Simplicity.
3. low complication rate.
4. creation of a normal appearing glanular
meatus.

22. TIP cons
• Use of TIP urethroplasty in cases of
reoperative hypospadias has also been
reported.
• However, TIP procedure was reported to
have higher incidence of meatal stenosis
and urethral stricture when compared to
flap based repairs for hypospadias.

23. Single stage Dorsal inlay TIP
• First described by Hensle and
colleagues in 2002 for
hypospadias reoperation.
• Hensle performed a single stage
urethral plate augmentation with
tubularization and dorsal incision
instead of a 2 stage procedure.

24. Technique of
Single stage Dorsal inlay TIP
• U-shaped incisionaround the • Incision of the dorsum of the
plate plate

25. Technique of
Single stage Dorsal inlay TIP
graft obtained from penile or hairless groin skin or
buccal mucosa

26. Technique of
Single stage Dorsal inlay TIP
• Graft quilted into place onto the • Tubularization of the plate is
corpora cavernosa using done
absorbable sutures at 0.5- to
1.0-cm intervals to facilitate
revascularization.

27. Dorsal Inlay TIP for hypospadias
reoperation
• Hensle and colleagues in 2002 described
the procedure in patients with a mean
of 4 prior operations including those
with urethral plate scar.
• It was noted that although the recipient
bed is potentially scarred, dorsal free
grafts still reliably establish neovascularity.

28. Dorsal Inlay TIP for hypospadias
reoperation
• Same technique was also
used by
Schwentner and colleagues (2006) in 31
patients. Another series by Ye and
colleagues (2008) in 53 patients and
Snodgrass and colleagues (2009) in 13
patients.

29. Dorsal Inlay TIP for hypospadias
reoperation
• The studies was performed on patients
with mean prior repairs of 1.9 to 4 and
showed mean complication rates of 15%.
• Complications were less than those of
original TIP procedures (mean of 24%).

30. Dorsal Inlay TIP for hypospadias
reoperation
• Complications were less than those of
original TIP procedures (mean of 24%).
Technique No. of patients No. with rate
complications
Reoperative 364 89 24%
TIP Repair
Inlay Grafts 97 15 16%

31. Dorsal Inlay TIP for primary
hypospadias repair
• The technique was also used for primary
hypospadias repair by Silay and
colleagues in 2006.
• This study results showed no cases of
stenosis and good uroflow results and
fistula rate of 13%.

32. Dorsal inlay TIP advantages
• Dorsal inlay graft urethroplasty has been
described as an effective method for
hypospadias repair especially in
reoperation and leads to good cosmetic
outcome with low risk of complications.
• The main advantages of this procedure
are early removal of the urethral catheter
and reducing the risk of meatal stenosis
and urethral stricture.

33. Research Point
• Single stage dorsal inlay TIP is a promising
technique which was introduced in reoperative
cases of hypospadias.
• The technique needs further studies in re-
operative cases to establish its role.
• other studies are needed to compare it with the
original TIP procedure as regard beneficial effect
on decreasing complications as stricture &
meatal stenosis.

34. THANK YOU