BACKGROUND: Proximal hypospadias is commonly repaired using 2-stage flap or graft techniques. Although recent reports suggest graft repairs have better outcomes, our experience found significant graft and skin complications with 2-stage STAG. These were associated with placing grafts over corporotomies and/or unreliable skin vascularization of the graft edges. That led us to delay urethroplasty grafting to a second, additional, stage after healing from straightening and shaft skin rearrangement. We now compare results of primary STAG (STraighten And Graft) vs this 3-stage STAC (STraighten And Close). METHODS: A total of 332 consecutive patients with proximal hypospadias and ventral curvature (VC) ≥ 30º completed primary repair by STAG (n= 220, 2014-mid 2022) and STAC (n= 122, after mid 2022). All had 3 corporotomies for straightening ventral curvature and the meatus placed at the glans tip. Testosterone was not used. Nearly all had prepucial grafts, with dimensions measured at placement and the subsequent procedure. Graft complications included ≥50% loss requiring patch or total regrafting, or less contracture managed by inlay graft or transection of focal scar. Skin complications were need for scrotal flaps or Cecils to cover the shaft, or additional surgery to revise scars or replace deficient penile skin by grafting. Urethroplasty complications were fistulas, glans dehiscence, meatal stenosis, strictures or diverticulum. RESULTS: Groups had similar mean age, extents of hypospadias, and glans width, although STAC had greater mean ventral curvature (73° vs 57°, p=0.0001). Graft complications occurred in 50 (23%) STAG (37 patch or regrafting, 3 inlays, 10 scar release) versus 8 (7%) STAC (6 patch or regrafting, 1 inlay, 1 scar release), p=0.0001. Skin complications developed in 17 (8%) STAG (2 scrotal flaps, 8 Cecils, 5 revisions, 2 skin grafts), versus 10 (8%) STAC. All STAC skin contractures occurred after stage 1 in association with other skin anomalies (penile skin torsion, single dorsal midline humps), and were corrected before urethroplasty grafting. No STAC required a scrotal flap, Cecil or shaft skin graft. With similar follow up of 26 and 22 months, 23% STAG vs 13% STAC had a urethroplasty complication, p=0.037. These were mostly fistulas and glans dehiscences, although there were additionally 3 meatal stenoses, 1 stricture and 1 diverticulum after STAG. STAG patients underwent an average of 2.7 operations (2-10), including 4 in which a graft healthy to tubularize was never achieved. All STAC patients completed repair with an average of 3.2 operations. CONCLUSIONS:
Similar to other reports, we found many patients undergoing a planned 2-stage repair had 3 or more operations. In contrast, grafts and shaft skin were healthier after STAC, resulting in most repairs being completed by the planned 3-stages. These also had significantly fewer postoperative complications despite STAC patients having more severe ventral curvature initially. Delaying urethroplasty grafting until after penile straightening and skin rearrangement are completed ensured better graft and skin healing and a more successful urethroplasty.
