Flip it to DIG it -- Combining a reverse pedicled Dartos flap with a dorsal inlay graft
Maya R. Overland, MD PhD, Mark R. Zaontz, MD.
Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
Background: Successful repair of hypospadias complications requires the pediatric urologist to maintain a plethora of techniques in their toolbox and to judiciously chose the correct approach for each unique scenario. Even in the most experienced hands, failure rates after re-do repairs remain frustratingly high, given limitations in the quality and quantity of the tissues available to work with. As a field, we must continue to evolve and refine new approaches for better outcomes. In the case of a urethrocutaneous fistula, any narrowing of the urethra distal to the fistula must be addressed to ensure a successful repair. The dorsal inlay graft (DIG) has been shown in small series to be more successful than an onlay augmentation as a strategy to add urethral caliber.
However, spare skin is often at a premium in revision cases and the site of harvest must either be carefully chosen to avoid creating a waist-neck deformity or the graft must be obtained from elsewhere, requiring an additional incision and added morbidity. We present here an approach combining a dorsal inlay graft with a reverse pedicled Dartos flap for coverage of the repair, parsimoniously reusing the excised epithelium from the flap as the graft.
METHODS - The index patient is a 4-year-old boy with a history of a tubularized incised plate (TIP) repair with subsequent recurrent urethrocutaneous fistula, referred after two prior failed primary repairs, now again presenting with a split urinary stream. The urethral meatus calibrated to less than 10 French and was cut back to the subcoronal fistula. The ventral penile incision was extended proximally by a distance to match the planned length of the urethroplasty and a reverse pedicled Dartos flap was developed from here, saving the excised skin. We incised the dorsal urethral plate and quilted in the graft with 7-0 Maxon sutures ensuring that it lay flush with the incised plate, in order to ensure that we created a deeply grooved urethral plate that was fully surfaced over by the graft. This added significant width to the urethral plate, allowing it to then be easily tubularized without tension. The urethroplasty suture line was covered with the reverse pedicled flap and skin was closed at midline.
RESULTS - The repair has healed nicely with no recurrence of the fistula, and the patient has been voiding well with a strong single stream.
CONCLUSIONS - We recommend consideration of this combined approach in re-do repairs where it is important to widen the lumen of the neourethra, in particular for cases where little to no excess skin remains available.
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