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A Two Stage Technique For Proximal Hypospadias With Severe Curvature: Creation Of Urethral Plate By Using Vascularized Preputial Island Flap
CENK S. BUYUKUNAL, Prof M.D, Rahsan Ozcan, M.D, Senol Emre, M.D, Mehmet Elicevik, Assoc.Prof., Yunus Soylet, Prof. M.D.
CERRAHPASA MEDICAL FACULTY UNIVERSITY OF ISTANBUL, ISTANBUL, Turkey.

BACKGROUND:In some proximal hypospadias cases with very severe curvature, it is inevitable to cut the urethral plate .Two stage techniques by using inner free preputial grafts or buccal mocasal grafts became very popular for these cases.The aim of this study is to present early and late functional and cosmetic results of a two stage technique ,which is performed by using a “vascularized preputial island flap” for the creation of a well vascularized thick urethral plate.
METHODS:This is a two stage technique. 1st stage - after the correction of severe ventral curvature, a rectangulaire vascularized island flap is prepared from the dorsal preputial mucosa(JW Duckett’s technique).The length of the flap is designed according o the length of urethral gap .This non-tubularized flap is layed between the proximal urethral meatus and inside the glanular wings.Few tiny incisions and 3-4 fixation sutures are placed to ease the adhesion between the flap and tunica albuginea. A Foley cathater used for the drainage until the seventh postop day. Bactigrass and sponge combination is used for dressing.
2nd stage- six to eight months after the initial operation,urethroplasty was carried on by tubularizing the created plate(Duphley’s principle) in two layers.Due to the existance of a very healthy dartos tissue from the first stage, dartos patch or tunica vaginalis flap was used as a third layer. After the the glanuloplasty a urinary silicon catheter was inserted and kept for 7-8 days.Silicon foam was our dressing of choice.Follow-up made by routine clinical examinations,uroflow studies and urethrograms.
RESULTS:This technique has been used in 33 selected patients(mean age : 4.4 , r:1-17 yrs).Healthy and thick uretral plate has been created in all patients.Small tiny incisions and fixation sutures between the flap and penile shaft was responsible for the prevention of any fluid accumulation beneath the flap and creation of very healthy urethral plate. Fistula formation was seen in 5 patients and meatal stenosis in 2.Esthetic results seems much better than our previous cases treated by using single stage techniques.
Follow up period was between eight months to seven years.No diverticular formation or serious urethral dilatation problem was seen .
CONCLUSIONS:This technique is an alternative for two stage free graft techniques.Due to preservation of vascular supply a thick, nonfibrotic,healthy plate can be obtained.In this technique every part of penile skin is used for the creation of urethral plate and the coverage of ventral surface. Uroflow studies and demonstration of voiding patterns of these cases(by direct vision or video clips) is very useful for the evaluation of long-term outcomes.There are limitations for this technique: the presented technique can not be used in circumcized boys and cases without a sufficient dorsal preputial tissue due to multiple previous operations.


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