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Tunica Vaginalis Flap; a Feasible Second-Layer for Proximal Hypospadias Re-Do Ahmed M

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Tunica Vaginalis Flap; a Feasible Second-Layer for Proximal Hypospadias Re-Do Ahmed M Annals of Pediatric Surgery, Vol3, No 1, January 2007 PP 44-47 Original Article Tunica Vaginalis Flap; A Feasible Second-Layer for Proximal Hypospadias Re-Do Ahmed M. Khairi ¥, Nour El-Kholi¥, Sherif M. Soliman *, Ahmed Demairy* ¥ Pediatric Surgery Units; Departments of Surgery, Alexandria University Faculty of Medicine, Alexandria, *Ain- Shams University Faculty of Medicine, Cairo, Egypt Background/ Purpose: Interposing vascularized flaps between the urethra and the skin sutures is recommended in hypospadias surgery. This decreases the rate of complications; mainly urethrocutaneous fistula. Although this is more needed in redo complicated cases, yet this is not always possible. The aim of this study was to evaluate our experience with the tunica vaginalis flap (TVF) and compare it with the use of the adjacent local para-urethral tissue as a second layer cover in complicated redo cases of proximal hypospadias. Materials & Methods: This is a retrospective study of the redo correction of proximal hypospadias cases with failed previous repairs, comparing the use TVF (group I) and the adjacent local para-urethral tissue (group II), as a second layer cover. The study included only the cases corrected by the modified Theirsch-Duplay technique. The age of the patients, types of hypospadias, the complications after the 1ry repair, the follow-up results were reported. Results: Between 1999 and 2006, 26 children with failed previous repairs of proximal hypospadias were corrected using the modified Theirsch-Duplay technique. Eleven cases had scrotal and 15 had proximal penile hypospadias as their original pathology. Nine cases presented with complete disruption and 17 with partial disruption of the primary repairs. During the follow-up period (6- 24; mean 9 months), in group I; (n=12 cases) 3 cases (25%) developed urethrocutaneous fistula and 1 case developed partial disruption, whereas in group II; (n=14 cases) 4 cases (29%) developed fistula, 2 partial disruption (14%) and 1 complete disruption (7%). In group I, the appearance of the scrotum was almost normal in all cases. Conclusion: TVF is a good option that should always be kept in mind in redo complicated cases of hypospadias. When the local tissues seem to be scarred, it offers a second-layer cover that is properly vascularized, virgin and with mostly any length that might be needed. Index Word: Hypospadias; Urethroplasty; Tunica vaginalis; Urethrocutaneous fistulae INTRODUCTION with this flap and compare it with the use of the local para-urethral tissue7,19 as a second layer cover in nterposing vascularized flaps between the complicated redo cases of proximal hypospadias. I urethra and the skin sutures is recommended in hypospadias surgery to decrease the rate of PATIENTS AND METHODS complications; mainly urethrocutaneous fistula.1,2 Although this is more needed in redo complicated This is a retrospective study of the redo corrections of cases , yet this is not always possible. More than 20 proximal hypospadias cases with failed previous years ago, tunica vaginalis flap (TVF) was suggested repairs (Fig. 1). It compares the use TVF (group I) and as a good vascular tissue that could be used in the adjacent local para-urethral tissues (group II), as a hypospadias surgery.3,4,5 We evaluate our experience second layer cover. The study included only the cases Correspondence to: Khairi A., e-mail: [email protected] Khair, A which have been corrected by Theirsch-Duplay junction, (Fig. 2). The parietal layer of tunica vaginalis technique. The age of the patients, types of was harvested as a square flap held by two stay hypospadias, the complications after the 1ry repair, sutures based on the pedicle of the spermatic fascia the follow-up results were reported. Statistical (Fig. 3). Spermatic fascia was dissected from the analysis was done using Chi-square (χ2) test, with spermatic cord towards the superficial inguinal ring, significant P value when less than 0.05. to keep the pedicle tension-free. The testis was repositioned in the hemi-scrotum. The flap was Technique: We started by marking the skin tube then sutured over the neo-urethra by fixing it to Buck’s degloving the penis till the penoscrotal junction, fascia using 6-0 interrupted vicryl suture. In group II, artificial erection to test for any residual chordee, the adjacent local para-urethral tissues were sutured which were corrected by dorsal tunica albuginea over the neo-urethra using running 6-0 vicryl suture plication (TAP), 6 if needed. Then the Thiersch- (polyglactin 910 Ethicon).7, 19 Glanuloplasty and skin Duplay8,9 tube was constructed over silicone catheter cover (Bayers dorsal skin flaps) were done to (French 8 or 10, depending on the child’s age) using conclude the procedure. The catheter was left behind running 6-0 vicryl suture (polyglactin 910 Ethicon). In for stenting and urine diversion for 10-14 days (Fig. 4). group I, the testis was delivered into the operative field from the same incision at the penoscrotal Fig 1. Scrotal hypospadias with failed previous repair; Fig 2. The testis is delivered through the same wound. notice the scarring of the local tissues. The parietal layer of the tunica vaginalis is dissected. The neo-urethra is not yet completely tubularized. Fig 3. The flap is now tension-free and ready to cover Fig 4. 2-weeks later; the dressing is just removed, the the tubularized neo-urethra. The testis is repositioned catheter still in place. Note the normal shape of the in the hemi-scrotum scrotum. 45 Vol 3, No 1, Jan., 2007 Khair, A cases, whereas, group II (the local para-urethral RESULTS tissues) included 14 cases. The follow-up period ranged between 6- 24; (mean 9 months). Though Between 1999 and 2006, 26 children with failed insignificant statistically, urethrocutaneous fistulae previous (1-3; mean 2) repairs of proximal developed in 3 cases (25%) in group I and in 4 cases hypospadias were corrected by the authors using the (29%) in group II, partial disruption 1 case (8%) in Thiersch-Duplay technique. The age ranged from 2 to group I and in 2 cases (14%) in group II, and complete 9 years (mean 4 years). They were done 6-14 (mean 8) disruption in 1 case group II and non in group I. The months after the last operations. Eleven cases had overall complications rate was less in group I (33% scrotal and 15 had proximal penile hypospadias as versus 50%; χ2=0.731 with P value > 0.05; insignificant their original pathology. Nine cases presented with statistically) (table 1). In group I, the scrotal complete disruption and 17 with partial disruption of appearance was almost normal in all cases. their previous repairs. Group I (TVF) included 12 Table 1. Tunica vaginalis flap versus adjacent local tissue as a 2nd layer cover in redo correction of proximal hypospadias; (Thiersch-Duplay technique) (n= 26); Post-operative complications. Group I Group II Complication χ2 (TVF) (n: 12) (Local tissue) (n:14) 1- Urethrocutaneous fistula 3 (25%) 4 (29%) 0.038 2- Partial disruption 1(8%) 2 (14%) 0.23 3- Complete disruption 0 1(7%) 0.912 4- Overall complications 4 (33%) 7 (50%) 0.731 (χ2 > 3.84 correlates to a P value < .05). DISCUSSION repairs. Many surgeons still use the adjacent tissue as a cover layer.7, 19 Despite the improvements that have been made in the techniques of hypospadias surgery, some patients still More than 20 years ago, Snow 3 introduced the use of present with failed repairs.4 Repairing such cases is a the parietal layer of tunica vaginalis as a flap to cover challenging undertaking. Many techniques have been the reconstructed neo-urethra. The place of tunica introduced in such situations; burying the repaired vaginalis in hypospadias surgery has been more than urethra in the scrotum, 10 staged- repair,11,12 coverage for urethroplasty.16 others even used it overlapping denuded subcutaneous tissue, 13 rotating successfully for substitution urethroplasty. 17 skin flaps.14,15 However, successful outcomes were always faced by scarring, defective vascularity and The main advantage in situations of redo cases is that lack of the prepuce after failed previous repairs. it brings its vascular supply from outside source and does not rely on the vascularity of the local tissues Some authors suggested using the adjacent local that might be scarred or destroyed because of the spongiosus tissues to cover the reconstructed neo- previous repairs. Also, its pedicle length can safely be urethra.7, 19 In addition to the relative easiness of the increased up to the external inguinal ring which technique, it strengthens the repair and at the same means that it can cover any length of the neo-urethra time act as a vascular cover layer. from the very proximal hypospadias till the distal neo-meatus. Though this adjacent local tissue cover has been proved to be statistically inferior to the use of the During surgery, the dissection of the flap was not dorsal subcutaneous pedicle flap, 20 yet during repair difficult. However, an important point to be of redo cases, the dorsal subcutaneous option is considered was the length of the flap. We noticed that usually not available and mostly lost in the previous inadequate pedicle length can cause tethering of the Annals of Pediatric Surgery 46 Khair, A testis. In one case the testis could not be properly re- 7. Shehata S: The use of spongioplasty in hypospadias repair. positioned in the hemi-scrotum after flap harvesting, Presented at 21st Annual Meeting of the Egyptian Pediatric Surgical Association (EPSA) in collaboration with 5th Pan and we had to redeliver the testis again into the field African Pediatric Surgical Association (PAPSA), Alexandria, and complete the dissection to a higher level. This was Egypt. 16-18 November, 2005.
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