PRIMARY REPAIR OF PROXIMAL (GRADE IV) HYPOSPADIAS UTILIZING TUNICA VAGINALIS VASCULARISED FLAP

Abstract

Background: Proximal (grade IV) hypospadias like scrotal and perineal are considered as severe challenging types for surgeons, problematic for the patients and their families, More than three hundreds surgical techniques were used to manage different type of hypospadias . Most of them associated with high incidence of complications. These complications are much more common in the proximal types as in our study. Post-operative fistula formation is expected complications. Utilising the tunica vaginalis as an additional layer during repair may prevent such complications. In this study we evaluated the benefits of using the tunica vaginalis flap as a supportive layer in the primary repair. Most related literatures about this subject used this technique after surgery to manage cases with post-operative fistulas. In the contrary we used this technique during the formal surgery to cover the new urethra to prevent fistula formation not after surgery. Aims of the study: A retrospective study, on fourteen patients with severe hypospadias (Proximal types), to evaluate the role of tunica vaginalis flap in the primary repair of the hypospadias. Patients and Methods: Between January 2016 and January 2024, fourteen children with Grade IV hypospadias were operated on. Only severe cases were treated with this method other simpler and more common cases were treated by different surgeries like Snodgrass technique. The age range was 2 to 16 years. All of them had 2 staged repair the first stage was correcting the chordae by incising the urethral plate excising the fibrous chordae tissues then covering the bare shaft with dorsal flaps. The tunica flap was used in the second stage which was done 6 to 12 months later. Folly's catheter was used for ten to fourteen days after surgery. And the patients were followed for a variable time 3months to 2 years period for the development of complications like fistula formation or stricture. Cosmetic considerations were also noted. Results: All the fourteen patients had proximal types (Grade IV) hypospadias. After surgery all patients had a good cosmetic outcome no fistula formation two had mild distal urethral stricture cured after few urethral dilatation. No post-operative penile torsion was noted. Two patients developed local infection treated conservatively. One patient had partial glanular dehiscence at the distal end which had no clinical significance. One patient complained from on and off penile cutaneous swelling lasted 3 weeks. Conclusions: Using tunica vaginalis vascularised flap to cover the new urethra in severe proximal hypospadias during the second stage seems to be a successful way in preventing fistula formation without increasing the patient's morbidity.