Author's Accepted Manuscript

Staged Tubularized Auto-Graft (STAG) Repair for Primary Proximal Hypospadias

with ≥30° Ventral Curvature

Warren Snodgrass , Nicol Bush

PII: S0022-5347(17)45450-4
DOI: 10.1016/j.juro.2017.04.019
Reference: JURO 14681

To appear in: The Journal of Urology

Accepted Date: 4 April 2017

Please cite this article as: Snodgrass W, Bush N, Staged Tubularized Auto-Graft (STAG) Repair for
Primary Proximal Hypospadias with ≥30° Ventral Curvature, The Journal of Urology® (2017), doi:
10.1016/j.juro.2017.04.019.

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 ACCEPTED MANUSCRIPT

STAGED TUBULARIZED AUTO-GRAFT (STAG) REPAIR FOR PRIMARY PROXIMAL HYPOSPADIAS WITH
≥30° VENTRAL CURVATURE

Warren Snodgrass, MD snodgrass@parcurology.com

Nicol Bush, MD, MCS bush@parcurology.com

PARC Urology

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Key words: proximal hypospadias, staged repair, graft repair, ventral curvature

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ABSTRACT

Purpose: We report outcomes in consecutive patients with primary proximal hypospadias and ventral

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curvature≥ 30° after degloving, all repaired by 2-stage tubularized autografts (STAG), a variation of the
Nicolle-Bracka procedure.

Materials and Methods: Consecutive boys with proximal hypospadias and ventral curvature (VC) ≥ 30°

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after degloving all underwent transection of the urethral plate. Those with persistent VC ≥ 30°
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additionally had 3 ventral corporotomies without corporal grafting for straightening. Staged graft
urethroplasty was performed using prepuce, or labial mucosa when the family requested
prepucioplasty. The goal in all cases was a straight penis with normally positioned neomeatus.
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Results: 43 boys completed both stages with postoperative follow up. Mean VC was 70°, requiring
corporotomies in 65%. There was no recurrent VC. Prepucial grafts were used in 88%. A skin graft or
scrotal flap was needed for ventral shaft coverage at the 2nd stage in 4 (9%).During follow up an
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average of 22 months, urethroplasty complications were diagnosed in 10 (23%), mostly glans

dehiscence and fistulas. Of these, 9 had 12 reoperations. Success was achieved in 42 (98%) patients.
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Conclusions: STAG achieved a straight penis with normally positioned neomeatus in boys with the
most severe proximal hypospadias in 77% of cases, increasing to 98% after 1 or 2 distal reoperations
for complications. There was no recurrent VC after 3 corporotomies without corporal grafting.
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Urethroplasty graft take was reliable.

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INTRODUCTION

Optimal means to repair severe hypospadias have not been determined. In part, this is due to a lack of
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consensus for defining “severe” hypospadias, and the inclusion of midshaft and more distal cases in
reports on proximal repairs. In addition, most series are retrospective and involve multiple surgeons,
which potentially add bias for selecting the surgical technique and diagnosing complications. These
shortcomings have been previously noted (1-4). Furthermore, despite complication rates and
reoperations that frequently exceed 50%, no study has described the eventual outcomes achieved.

We diagnose proximal hypospadias by meatal location on the proximal penile shaft to perineum at the
beginning of urethroplasty, after the penis is degloved and ventral curvature straightened. “Severe”
hypospadias specifically refers to those with ventral curvature (VC) ≥30° after degloving.
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Our algorithm for repair is determined by the extent of VC after the penis is degloved. Patients with
<30° undergo TIP, while those with ≥30° have 2-stage graft repair. The goal is a straight penis with a
meatal opening at the glans tip. We now report outcomes in this descriptive study of consecutive
patients with proximal hypospadias and VC ≥30°.

METHODS

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All patients undergoing hypospadias repair are entered into our quality improvement database,
recording pre-determined information describing surgery and follow up at the time of service. For this
report, data regarding proximal hypospadias repair with the 2nd stage performed from November

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2012, when the last technical modification was introduced (the glansplasty described below), to
February 2016 were reviewed with IRB approval.

Curvature was measured with an interphalangeal joint goniometer, with etiology assigned in a

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stepwise fashion as due to 1. skin/dartos, 2. urethral plate; 3. corporal disproportion. Those with <30°
VC after degloving and dartos excision had TIP repair. Patients with ≥30° underwent STAG (Staged
Tubularized AutoGraft) repair, a variation of the Nicolle-Bracka repair (5,6), as described below.

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Repair was recommended at age ≥6 months for maximum penile growth from postnatal mini-puberty.
Our protocol for preoperative testosterone based on glans width before the 1st stage ended in
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October 2012 (7), and no patients thereafter received testosterone stimulation.
SURGICAL TECHNIQUE
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All patients were operated by WS and NB as a surgical team.

Degloving
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The penis was degloved preserving the urethral plate (UP). Dorsally, the incision was made
approximately 3mm below the corona to conserve prepuce for the graft. Ventral penile and scrotal
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dartos extending up the penile shaft were then excised.

Straightening Ventral Curvature

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Artificial erection was done. VC <30° was corrected by a single midline dorsal plication using 5-0
polypropylene. Dorsal plication was never the primary treatment for VC ≥30°. Rather, in these the UP
was transected at the corona. Then the plate and formed urethra were dissected proximally to near
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the membranous segment. Artificial erection was repeated. Persistent curvature <30° was corrected
by dorsal plication, whereas persistent VC ≥30° was straightened by 3 transverse ventral
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corporotomies (Figure 1A).

With tourniquet compression, the point of greatest bending was marked with a transverse line from 4
to 8 o’clock. A parallel line was then marked 4mm below, and another 4mm beyond, this first line.
Incision along these marks extended through the tunica albuginea. Repeat erection was done using a
21-gauge butterfly, and, once straightening was confirmed, a single dorsal plication was additionally
placed. Corporotomies were not grafted. Any bleeding after tourniquet removal was controlled using
compression with topical 1:1000 epinephrine.
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Glans Dissection

A longitudinal midline incision was made and glans wings opened widely. Remaining UP was excised.

Proximal Urethroplasty

The urethra was gently stretched back distally and sutured back to the corpora without tension using
interrupted 6-0 polydioxanone, gaining approximately 1cm length and covering the corporotomies

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when possible. Some or all the UP was preserved, and the opening was spatulated. The distal end of
this proximal urethrostomy was sewn to the corpora at 12,2 and 10 o’clock using 7-0 polyglactin.

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Skin at the penoscrotal junction was incised from 6 to approximately 2 and 10 o’clock to release the
penile shaft skin. The scrotum was rotated ventrally, reducing transposition, and then penoscrotal or
scrotal skin adjacent to the proximal urethrostomy was sutured to the opening at 5,6 and 7 o’clock

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with 7-0 polyglactin. The scrotal incision was closed in layers.

Graft Harvest

Stay sutures held the corners of the prepuce. Inner prepuce was elevated and all dartos underlying the

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graft was excised (Figure 1B). Then the proximal shaft skin was brought ventrally around the penis and
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temporarily approximated at the penoscrotal junction to anchor it while sizing the graft. Next, distal
skin was similarly wrapped around the glans, and the graft outline was marked - removing all skin
distal to the mucosal collar.
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Penile shaft skin was sutured distally to the mucosal collar and proximally at the penoscrotal junction
with subepithelial 7-0 polyglactin.

Securing the Graft

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6-0 polypropylene stays were placed in the coronal edges of the glans wings. The widest distal portion
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of graft was first sewn to glans adjacent to these stays, using subepithelial sutures along the future
meatus to avoid suture marks. The graft was next secured to shaft skin on either side using
interrupted 7-0 polyglactin. The proximal end of the graft was incised to extend to either side of the
urethrostomy (Figure 1C).
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The graft was quilted to underlying corpora using interrupted 6-0 polyglactin sutures approximately 5
mm apart. The first row extended from the urethrostomy up the midline, with an additional row on
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either side (Figure 1D). Grafts were wider than the corporal bodies, and no attempt was made to
suture them to underlying structures lateral to the corpora to allow easier dissection at the second
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stage.

An 8Fr foley catheter was inserted. Then a rolled petroleum gauze was secured snugly over the graft
with a tie-over bandage.

Postoperative Care

The catheter and bandage were removed 6-7 days postoperatively. No subsequent graft treatment
was routinely recommended. The second operation was scheduled 6 months later.
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Penile straightening was confirmed by parent reports and direct observation of erections before the
second stage. Any question was resolved by artificial erection during the second stage.

Second Stage Urethroplasty

Glans wings were injected with 1:100,000 epinephrine, and then mirror-image incisions made,
extending on each side down the edge of the neoplate and entering the proximal urethrostomy from

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5 to 7 o’clock to exclude shaft/ scrotal skin sewn there at the first stage. The incision continued down
the scrotal raphe (Figure 2A).

Glans wings were dissected laterally to 3 and 9 o’clock, and then superiorly another 4 mm off the

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corpora on each side (Figure 2B).

Urethroplasty

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All grafts were >10mm wide. A 6Fr stent was inserted. 2-layer subepithelial neoplate tubularization
was done, using interrupted 7-0 polyglactin and then continuous 7-0 polydiaxanone. As with TIP
urethroplasty, the first suture was placed distally at approximately the mid-glans level, 3-4mm below

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the future meatus, creating an oval, not rounded, opening (Figure 2C).
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Neourethra Coverage Flap

A tunica vaginalis flap was harvested and dissected proximally to the external ring. The testicle was
pexed and its hemiscrotal compartment sutured closed. The flap covered the entire neourethra.
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Glansplasty

Glans wings were approximated over the neourethra using 3 interrupted subepithelial 6-0 polyglactin
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stitches. The first was placed at approximately the mid portion of the glans wings, and the last at the
corona. As in TIP repair, glans wings were not sutured to the neourethra (Figure 2D).
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Scrotoplasty

The scrotal wall at 3 and 9 o’clock was sutured to the corpora on either side of the neourethra to
reduce transposition and prevent secondary concealed penis.
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Skin Closure

Penile shaft skin was closed in the midline median raphe using interrupted subepithelial sutures.
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Catheter drainage continued for 2 weeks.

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OUTCOMES

The goal was a straight penis with the meatus normally enclosed within the glans (Figure 3), defined as
glans wings fusion from meatus to corona within the normal range (mean 4.7mm, minimum ≥2mm)
(8). “Glans fusion” was measured again postoperatively.

The primary outcome was urethroplasty complications (UC). Fistulas were neourethra leaks. Glans
dehiscence was separation of the wings with fusion <2mm. Meatal stenosis was stranguria with
calibration <8Fr, while stricture was symptomatic narrowing <8Fr proximal to the meatus. A
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diverticulum was visible ballooning during voiding. Recurrent VC was bending ≥30°. Reoperations
were done 6 months after the last procedure.

Follow up was time to diagnosis of a complication, or the last visit.

Secondary outcomes included the number of procedures to achieve the goal, 1st stage graft
contracture with recurrent curvature, and inadequate shaft skin for second stage closure.

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RESULTS

A total of 60 boys, mean age 13.7months (3-100) underwent primary proximal hypospadias repair, 8

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by
TIP and 52 by STAG (Figure 4). Of 52 STAG, 43 completed both stages with follow up. Of these 43, 13
(30%) were premature at <37 weeks gestation, 2 had mixed gonadal dysgenesis, 1 had imperforate

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anus and 1 had chromosome ring 13 syndrome. Preoperative testosterone before the 1st stage was
received by 6 (14%), 5 for glans <14mm by prior protocol and 1 before referral.

Mean VC after degloving and dartos excision was 70° (30-120). Straightening was achieved primarily

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by UP transection in 15 (35%) and by 3 transverse corporotomies in 28 (65%). No patient developed
recurrent VC.
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Meatal location was proximal shaft (n=5), penoscrotal (n=17), scrotal (n=7) and perineal (n=9). Mean
glans width was 13.3mm (8-18), with 20 (48%) <14mm.Urethroplasty graft was lower lip in 5, 1
following ritual circumcision and 4 desiring prepucioplasty, and foreskin in the remainder. There were
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no graft contractions requiring re-grafting.

Mean follow up was 22months (1.5- 42, median 18) in those without complications. UC occurred in 10
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(24%), diagnosed at a mean of 9months (median 8m, 1.5-24), including glans dehiscence (n=7), fistula
(n=2) or diverticulum (n=1). No patient developed recurrent VC. There was no meatal stenosis or
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urethral stricture. Of these, 9 patients had 12 reoperations to achieve success. There was no
difference in complications in those with versus without corporotomies (7/28 vs 3/15, p= 0.7).

Glans fusion length, measured in 28 without glans dehiscence, averaged 3.8mm (2.5-6).
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4 had deficient ventral shaft skin after prepucial grafts, successfully corrected at the 2nd stage by skin
graft (n=2) or scrotal flap (n=2).
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DISCUSSION

We defined success as a straight penis with the neomeatus normally enclosed within the glans,
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measured objectively. Of 60 patients with proximal hypospadias, 50 completed initial repair with
follow up. There were 7 TIP with success achieved in 86%. Initial STAG success was 77%. Of 9 STAG
patients with UC, 98% achieved success following 1 (75%) or 2 (25%) reoperations.

STAG represents evolution of the Nicolle-Bracka repair with the following modifications: 3 transverse
corporotomies to straighten persistent curvature after transection of the urethral plate, more
extensive glans dissection to reduce risk of glans dehiscence, and 3-stitch subepithelial glansplasty to
achieve normal glans fusion length.
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Those undergoing STAG represent the most challenging primary hypospadias repairs. Others have
used dorsal plications for curvature ≤ 45° to preserve the UP, but 1 study found significantly more
recurrent curvature following this versus straightening that included plate transection or ventral
corporal lengthening (9). We previously mobilized the UP without transection, but strictures caused us
to abandon that procedure (10). Of those patients, 15% developed recurrent curvature (11).

Recurrent curvature is a significant complication, as bending ≥30° is associated with sexual dysfunction

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(12,13), and straightening requires neourethra excision, ventral corporotomies, and staged oral graft
urethroplasty, since prepuce has usually been removed. Consequently, we transected the UP for
curvature ≥ 30° after degloving and dartos removal. This straightened or reduced bending to <30° in

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33% of cases, while 67% additionally required ventral lengthening. We used 3 corporotomies without
grafting the corpora to avoid placing a urethral graft onto a corporal graft, and observed no recurrent
bending. We initially called these “fairy cuts”, following Devine and Horton (14), but this implies

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superficial incisions, whereas we incised completely through the tunica albuginea. We have used this
technique in 8 men with persistent ventral curvature after childhood hypospadias repair and 1
undergoing primary proximal repair, with all reporting straightening and no postoperative erectile

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dysfunction (unpublished data).

Although 1-stage urethroplasty is possible after UP transection, 2-stage prepucial graft repairs are
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increasingly reported. Pippi-Salle et al (15) followed a similar decision-making process, and reported
outcomes in 60 boys, of which 75% had ventral lengthening by 3 transverse corporotomies. UC
occurred in 33%, mostly fistulas and glans dehiscence, with 1 stricture and 1 diverticulum. Castagnetti
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et al (16) reported results in 18 boys with curvature >30°, with 28% UC. Finally, Ferro et al (17)
reviewed 43 boys, reporting fistulas, dehiscence and 1 diverticulum in 23%.
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In contrast, several recent studies found higher complication rates after 2-stage prepucial flap (Byars)
repairs in patients with apparently less VC. For example, McNamara et al (18) reported straightening
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by degloving alone in 41%, and ventral lengthening in only 25% of 134 patients. UC developed in 53%,
including 13% meatal stenosis, 12% stricture, and 9% diverticula. A median 2 reoperations were done,
ranging to 18 additional procedures. Similarly, Stanasel et al (19) reported ventral lengthening in only
33%, with UC in 66%, including 8% meatal stenosis, 14% urethral stricture, and 14% diverticula.
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Finally, Long et al (20) reported 70% complications in 81 boys, including 9% meatal stenosis and 11%
diverticula.

Despite widespread belief that flaps are inherently better vascularized than staged grafts, neither we
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nor the authors mentioned above reported 1st stage graft failures. All graft series report few or no
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urethral stenoses or diverticula, despite using the same prepucial tissue as Byars flaps. If partial graft
contracture occurs, it is corrected using 0.1% betamethasone cream for 6-12 weeks, or by partial
excision and re-grafting before 2nd stage tubularization.

Prepucial grafts create a large, smooth neo-plate well-affixed to the corpora, which contrasts with
Byars flaps that are often irregular with a midline scar and poorer corporal adherence. Prepuce is also
preferable to oral mucosa for grafts. There is virtually no donor site morbidity following prepucial
harvest, and the grafts heal subjectively more thin than do those from oral mucosa. This is an
important consideration, given that many patients have a small glans. Additionally, the wide graft
provides additional penile skin to re-cover the shaft, reducing need for additional grafts or flaps.
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We found prepuce sufficient for both urethroplasty and skin coverage in most patients despite
curvature ≥70° in half of them, which increases likelihood for shaft skin deficiency after straightening.
Deficiency was initially corrected using full-thickness skin grafts, but these have variable take when
placed onto fresh tunica vaginalis flaps. We now prefer scrotal flaps, which can either be replaced
later with a skin graft, or depilated at puberty.

Our most frequent complication was glans dehiscence, although this occurred less often with glans

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wings dissection used in this series (21). 6 of these 7 patients had reoperation, which successfully
closed the glans, but resulted in a new fistula in 3. These, and 2 additional isolated fistulas were
successfully repaired in 1 procedure we previously described (22).

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Ours is the first study of severe hypospadias describing outcomes from primary surgery and
reoperations in all patients. Additionally, we stringently defined complications before the study. This

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contrasts with reports cited above, which were retrospective and involved multiple surgeons lacking
agreed upon criteria for diagnosis– meaning complications likely were underreported. Furthermore,
we defined surgical success, and introduce glans fusion as a new objective measure of glansplasty.

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CONCLUSIONS

STAG successfully corrected 77% of consecutive boys with severe hypospadias, increasing to 98% with
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reoperations. Others report similar results, versus substantially higher UC in recent reports utilizing
prepucial flaps. 3 ventral corporotomies successfully corrected VC, and urethroplasty grafts took
reliably. Prepuce was usually sufficient for urethroplasty and skin coverage.
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ABBREVIATIONS

STAG staged tubularized auto-graft

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UC urethroplasty complications
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UP urethral plate

VC ventral curvature
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References
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1. Castagnetti M, El-Ghoneimi A: Surgical management of primary severe hypospadias in

children: systematic 20-year review. J Urol 184: 1469, 2010
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2. Xioa D, Nie X, Wang W, Zhou J, Zhang M, Zhou Z, Gu M, Wang Z, Lu M: Comparison of

transverse island flap only and tubularized incised-plate urethroplasties for primary proximal
hypospadias: a systematic review and meta-analysis. PLOS one, September 8, 2014

3. Long CJ, Canning DA: Hypospadias: are we as good as we think when we correct proximal
hypospadias? J Pediatr Urol 12: 196, 201S6

4. Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD: Hypospadias dilemmas: a round table. J

Pediatr Urol 7: 145, 2011
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5. Nicolle FV: Improved repairs in 100 cases of penile hypospadias. Br J Plast Surg 29: 150, 1976

6. Bracka A: Hypospadias: the two-stage alternative. Br J Urol 76: 31, 1995

7. Bush NC, Keays M, Villaneuva C, Snodgrass W: Preoperative testosterone injection does not
decrease hypospadias urethroplasty complications. ESPU abstract, 2014

8. Hutton KAR and Babu R: Normal anatomy of the external urethral meatus in boys: implications

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for hypospadias repair. BJU Int 100: 161, 2007

9. Braga LHP, Lorenzo AJ, Bagli DJ, Dave S, Eeg K, Forhat WA, Pippi Salle JL, and Khoury AE:

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Ventral penile lengthening versus dorsal plication for severe ventral curvature in children with
proximal hypospadias. J Urol 180: 1743, 2008

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10. Snodgrass W, Granberg C and Bush NC: Urethral strictures following urethral plate and
proximal urethral elevation during proximal TIP hypospadias repair. J Pediatr Urol 9: 990, 2013

11. Snodgrass W and Bush N: unpublished data

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12. Greenfield JM, Lucas S, and Levine LA: Factors affecting the loss of length associated with
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tunica albuginea plication for correction of penile curvature. J Urol 175: 238, 2006

13. Gholami SS and Lue TF: Correction of penile curvature using the 16-dot plication technique: a
review of 132 patients. J Urol 167: 2066, 2002
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14. Devine CJ Jr: Chordee in hypospadias. In: Urologic Surgery, 3rd ed. Edited by J Glenn.
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Philadelphia: JB Lippincott Co 1983

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15. Pippi Salle JL, Sayed S, Salle A, Bagli D, Farhat W, Koyle M, Lorenzo AJ: Proximal hypospadias: a
persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-
year period. J Pediatr Urol 12: 28e, 2016
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16. Castagnetti M, Zhapa E, Rigamonti W: Primary severe hypospadias: comparison of reoperative

rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs. J
Urol 189:1508, 2013
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17. Ferro F, Zaccara A, Spagnoli A, Lucchetti MC, Capitanucci L, Villa M: Skin graft for 2-stage
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treatment of severe hypospadias: back to the future? J Urol 168: 1730, 2002

18. McNamara ER, Schaeffer AJ, Seager CM, Rosoklija I, Retik AB, Diamond DA and Cendron MC:
Management of proximal hypospadias with 2-stage repair: 20 year experience. J Urol
194:1080, 2015

19. Stanasel I, Le HK, Bilgutay A, Roth DA, Gonzales ET, JR, Janzen N, Koh CJ, Gargollo P and Seth A:
Complications following staged hypospadias repair using transposed prepucial skin flaps. J Urol
194: 512, 2015
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20. Long C, Chu D, Tenney R, Morris A, Zderic S, Kolon T, Canning DA: Intermediate term follow up
of proximal hypospadias reveals high complication rate. SPU abstract, 2016

21. Snodgrass WT, Bush NB: Extended glans wings dissection reduces hypospadias complications.
SPU abstract, 2016

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22. Snodgrass W, Grimsby G, Bush NC: Coronal fistula repair under the glans without reoperative
hypospadias glansplasty or urinary diversion. J Pediatr Urol 11: 39, 2015

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A B C D

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Figure 1. First Stage Prepucial Graft Key Steps

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A, 3 ventral transverse corporotomies through the tunica albuginea from 4 to 8 o’clock. The
middle incision is made at the point of greatest bending
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B, Prepucial graft after excision of underlying dartos is ready to be harvested along the line
previously marked at the corona while holding the shaft skin proximally at the penoscrotal junction

C, Wide, smooth appearance of the graft before quilting.

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D, Appearance after quilting. Note the graft extends to either side of the proximal urethrostomy
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B C D
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Figure 2. Key Steps of Second Stage Urethroplasty

A, Smooth, wide appearance of graft 6 months after 1st stage repair. Lines for incisions define the

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neourethral plate and then extend down scrotal raphe

B, Opening glans wings first laterally to 3 and 9 o’clock, and then superiorally on either side along the
corpora for another 4mm

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C, 2-layer urethroplasty, before coverage by tunica vaginalis flap
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D, Appearance after glansplasty and skin closure
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A B

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Figure 3

A, Severe perineal hypospadias with scrotal transposition

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B, Final postoperative appearance. Arrows indicate the glans wings fusion length from lower meatus
to corona, which should be >2mm and averaged 3.8mm

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Figure 4. Outcomes of consecutive proximal hypospadias repairs

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ABBREVIATIONS

STAG staged tubularized auto-graft

UC urethroplasty complications

UP urethral plate

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VC ventral curvature

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