TUNICA VAGINALIS FLAP REINFORCEMENT IN HYPOSPADIAS REPAIR

DR. G. HASANTHI , DR.K. JAYAPAL, DR. CH. BHASKARA RAO, DR. J.S. KISHORE,

DR. PAVAN

DEPARTMENT OF PAEDIATRIC SURGERY , GUNTUR MEDICAL COLLEGE ,GUNTUR.

INTRODUCTION

The surgery for hypospadias has evolved to comprise more than 150 techniques as on

today emphasizing the fact that no single repair technique has been clearly superior over the

other. The commonest complication of hypospadias repair irrespective of location of meatus ,

technique used and experience of surgeon , has been the formation of Urethro cutaneous (UC)

fistula. So every effort is directed to prevent this complication. Tunica Vaginalis (TV) flap

reinforcement of neourethra is one such technique to prevent fistula formation. Our study

highlights the usefulness of TV flap as intermediate cover in staged hypospadias repair and in

cases of redo – urethroplasty. .

AIMS and OBJECTIVES

Aim of the study was to study the outcomes of TV flap reinforcement in staged hypospadias

repair.

MATERIAL AND METHODS

This was a prospective study conducted in a tertiary care pediatric surgery centre in South India

over a period of three years from 2006 till 2009. A total of 40 (n=40) children were enrolled. 38
of these ( 95%) were up for stage II hypospadias repair and 2 of them (5%) needed redo-

urethroplasty for urethrocutaneous fistula following the primary repair. Ethical committee

clearance and individual consents were obtained for the study.

POSITION OF MEATUS

S.NO TYPE NO. OF CASES

(n=40)

1 PROXIMAL PENILE 21 (52.5%)

2 PS 12 (30%)

3 SCROTAL 2 (5%)

4 PERINEAL 3 (7.5%)

5 MULTIPLE FISTULA 2 ( 5%)

TECHNIQUE

All children received preoperative antibiotic prophylaxis with a broad spectrum antibiotic

. General anesthesia was used for surgery. Neourethra was developed over 7 fr infant feeding

tube using 5.0 Vicryl ( Ethicon Inc.) . Tunica vaginalis flap (TVF) was harvested by bringing the

testis with its tunica and cord into the operative field. Tunica vaginalis was incised near the

lower pole of the testis and a flap was raised off the testis and the cord structures, taking care not

to damage the vas and vessels. The parietal layer of tunica vaginalis was harvested as a

rectangular flap held by two stay sutures based on the pedicle of the spermatic fascia. Spermatic
fascia was dissected from the spermatic cord towards the superficial inguinal ring, to keep the

pedicle tension-free. Sufficient length of the flap was ensured by careful dissection even up to

the external ring. The testis was put back in the scrotum after achieving hemostasis. The TVF

was brought over the urethral tube to provide a cover along the entire length. For the portion

meant to go underneath the glans, the TVF was trimmed to prevent tight glans closure. The flap

was sutured over the neo-urethra by fixing it to Buck’s fascia using 5-0 interrupted vicryl suture.

Glansplasty was done with 5/0 vicryl sutures. The coronal collar of skin was also reconstructed

in continuity with the glansplasty. Skin cover (Bayers dorsal skin flaps) were done to conclude

the procedure. The catheter was left behind for stenting and urine diversion. This was followed

by skin cover and absorbant pressure dressing. The catheter was removed on post operative day

10 and voiding stream was observed before discharge. These children were followed up at two

weeks interval in the first month and once in three months. The outcomes looked into were

appearance of phallus , urinary stream and complications like urethrocutaneous( UC) fistulae,

stricture, stenosis etc.

The median operative time was 45 min suggesting a easy access to TV flap .

RESULTS

There were a total of 40 children enrolled in this study. 38 (95%) of them had undergone stage I

repair ( chordee correction and Byars’ flap placement). 2 had urethrocutaneous fistula after

primary repair needing redo-urethroplasty . The age ranged from 14 months to 12 years with a

median of 4.5 years. The primary location of the urethral meatus in these children was –

Proximal Penile (PP-21) , PenoScrotal (PS-12) , Scrotal (S- 2) , Perineal (P- 3). The follow up

duration ranged from 2 months to 24 months with a median of 6 months .

Three children (7.5%) had post operative wound infection requiring frequent change of dressings

and change in antibiotics ( P-1, PP-1,S-1). Three children (7.5%) had scrotal hematoma in the

immediate postoperative period which settled with conservative measures (PP-1, PS-2). The

appearance of phallus was satisfactory in all cases with no evidence of torsion , chordee or glans

breakdown. Two children (5 %) had developed UC fistula ( PP-1,PS-1). One child (2.5 %) had

meatal stenosis which settled with meatal calibration for a period of six months. Single

satisfactory urinary stream from the tip of the penis was seen in 37 children (92.5%) ( excluding

two children with UC fistula and one with meatal stenosis). Urethral diverticulum was seen in

none. The children who developed UC fistulae were reoperated after six months duration.

COMPLICATIONS

TYPE OF COMPLICATION NO OF CASES PERCENTAGE

WOUND INFECTION 3 7.5 %

SCROTAL HEMATOMA 3 7.5%

FISTULA 2 5%

MEATAL STENOSIS 1 2.5%

DIVERTICULUM 0 0

DISCUSSION
 Hypospadias is the most common congenital anomaly of penis [1]. Hypospadias is a

common pediatric urological condition with an incidence of 3.2 per 1000 live births. It is defined

as an arrest in the normal development of the urethra, foreskin and ventral aspect of penis.

Classically three abnormalities are found in the hypospadiac penis : an ectopic opening of the

urethral meatus , a ventral curvature of the penis (Chordee) and a hooded foreskin on the dorsum

of the penis and a lack of skin on the ventrum due to a V-shaped defect referred to as urethral

delta.

Producing a functioning phallus that allows a boy to void as a “pointer” instead of a

“squatter” and later becomes a sexually active adult elevates the surgeon to the ranks of the

divine.

Because of the wide variation in the anatomic presentation of Hypospadias, no single

method of urethroplasty is applicable to all cases. Around 300 procedures are described to repair

hypospadias. The presence of chordee alters our management with respect to choice of surgical

repair. Significant chordee is clinically defined as curvature greater than 20°.

The principles of repair involve straightening of penis ( orthoplasty ), creating a slit like

meatus at the tip of the penis ( urethroplasty and meatoplasty ), and proper skin coverage.

Surgical correction of proximal hypospadias is a technically challenging. Such surgeries

are associated with maximum number of failures and results in cripples.

Surgical techniques for hypospadias treatment have markedly improved during

the last two decades. Despite extensive advances in surgical technique, fine suture materials,
delicate instruments, proper tissue handling, advances in anesthesia, hypospadias patients face a

lot of postoperative complications. The commonest complication of hypospadias surgery is

fistula formation which almost always requires repeat and equally demanding surgery.[3] Hence,

every effort is made to prevent this complication. According to Horton and Devine the incidence

of fistula formation following hypospadias surgery is 15-45 %.Shapiro found the rate is of

6.25%. Ducket and Baskin estimated the incidence is 10-15%, Durham Smith in a study of

hypospadias surgery noted varied fistula rates for different procedures.[9] Flip-flap repair varied

from 2.2 to 35%, Island pedicle tube flap 4 to 35%, Free graft tube flap had a fistula rate of 15 to

50%.[9] Durham smith had a fistula rate of 3% in 500 cases.[10]

Many techniques have been introduced to avoid a UC fistula ; burying the repaired

urethra in the scrotum, staged- repair, overlapping denuded subcutaneous tissue, dartos flap,[5]

rotating skin flaps . However, successful outcomes were always faced by scarring, defective

vascularity and lack of the prepuce after failed previous repairs. Tunica vaginalis flap from the

parietal layer of testis cover of anastomosis of urethroplasty is one more option which helps in

the reduction of urethro-cutaneous fistulae.

The surgical repair of hypoaspadias in more proximal cases is done in 2 stages. The 1st

stage procedure consists of corrrection of penile shaft curvature and second stage repair involves

the creation of neourethra. The neo urethra needs a cover of an intermediate layer in order to

have good functional and cosmetic results. By using a water-tight second layer during

reoperation, incidence of urethrocutaneous fistula can be reduced. The use of interposition flaps

is well documented in the literature. Those harvested from the prepuce are the triangular soft

tissue flaps[11] and Belman flaps[2]. Penile skin based flap is Smith D flap,[1] whereas Buck's

fascial flap is harvested from penile shaft. Corpus spongiosum either from the normal native
urethra as a turnover perimeatal flap or from the diverging spongiosa[3] has also been used.

Either a scrotal dartos flap from the scrotum[4,5] or a TVF[6] from the testis can also be used.

More than 20 years ago, tunica vaginalis flap (TVF) was suggested as a good vascular

tissue that could be used in hypospadias surgery.3,4,5.. The place of tunica vaginalis in

hypospadias surgery has been more than coverage for urethroplasty. Others even used it

successfully for substitution urethroplasty .Introduction of this flap is credited to Snow et al in

1986. Tunica vaginalis as graft supplement for deficient tunica albugenia in occasional case of

severe chordee has been used since a long time. It was in fact preferred by Baskin et al , for its

elastic nature, an advantage over lyophilized dura or dermis. The tunica vaginalis flap (TVF) has

sound vascularity, as it has a separate blood supply and does not depend on the vascularity of

penile skin, unlike the dartos fascia. Parietal layer of tunica vaginalis from testis acts as a water

proofing layer over reconstructed neo- urethra decreasing fistula rate. The flap itself is thin so its

passage through the penile shaft will not cause aesthetic problems. Its pedicle length can safely

be increased up to the external inguinal ring. Care must be taken while increasing pedicle length

as the tissue becomes more flimsy proximally and at the same time inadequate pedicle length can

cause tethering of the testis at a higher level compared to the normal side in an erect position.

Tunica vaginalis flap is used to provide robust cover to neourethra. It also provides a

barrier between suture lines. Snow et al have used tunica vaginalis flap during proximal

hypospadias repair. Rate of fistula formation after tunica vaginalis wrap was 9% (Brent w snow

et al 1995). When they combined TVF with use of intraoperative microscope the reported fistula

rate was 0% with 2.2% complications rate like scrotal heamatoma and abscess. In our study the

fistula formation is 5 % . Mesutgurdal et al psi 2003 reported UC fistula in 1 out of 9 patients

who were reinforced with tunica vaginalis flap. Yog raj handoo reported 1 UC fistula out of 20
patients with reinforcing tunica vaginalis flap. The long term follow up of patient with

urethroplasty using tunica vaginalis flap was reported by Pattars and Ruston.

The fistula rate in our study with tunica vaginalis falp reinforcement was 5% (2 out of 40

cases). These results are similar to the above authors study. But in our study operative

microscope or magnification lens was not used during repair, as stated by Snow et al who

reported 0% fistula rate with use of operative microscope and tunica vaginalis flap. The use of

tunica vaginalis flap in addition to the advanced operative techniques will be the best option for

successful hypospadias surgery in reducing the fistula rate to 0%.

This study follows up range about 31 months. Further follow up is required to note

complications like penile torque as observed by Pattaras & Ruston et al.

In our cases, having an additional layer on the neo-urethra gave confidence in allowing

the patient to void through neo-meatus and ultimately repair healed without fistula. Scrotal

hematoma and scrotal abscess can occur but most of them could be managed conservatively as

was the case in 3 of our cases. Absence of testicular complication in our patients points to the

safety of this procedure.

CONCLUSION

Urethrocutaneous fistula is most common complication after hypospadias surgery.Tunica

vaginalis flap as interposition cover of neo-urethral tube helps in reduction of fistulae rate in all

hypospadias procedures with minimal complication rate. Suture line breakdown also heals

without fistula formation if otherwise meticulous repair has been done which is the prerequisite
for hypospadias surgery. It gives the surgeon extra confidence that fistula will not occur in an

unlikely event of early catheter extrusion or catheter blockade without having to resort to

suprapubic cystostomy. Even if fistula occurs , it is usually small and manageable. This study

again confirms interposition layer as a must for reduction of fistulae in hypospadias surgery.

The operative access to tunica vaginalis flap is easy and quick as evidenced by median

operative time of 45 minutes as observed in our study.

REFERENCES

0.W. Snodgrass, M. Koyle, G. Manzoni, R. Hurwitz, A. Calda- mone, and R. Ehrlich,

“Tubularized incised plate hypospadias repair for proximal hypospadias,” The Journal of

Urology, vol. 159, no. 6, pp. 2129–2131, 1998.

1. Smith D. A de-epithelialised overlap flap technique in the repair of hypospadias. Br J

Plast Surg. 1973;26:106–14. [PubMed]

2. Belman AB. De-epithelialized skin flap coverage in hypospadias repair. J Urol.

1988;140:1273. [PubMed]

3. Yerkes EB, Adams MC, Miller DA, Pope JC, 4th, Rink RC, Brock JW., 3rd Y-to -I

Wrap: Use of the distal spongiosum for hypospadias repair. J Urol. 2000;163:1536–8. discussion

1538-9. [PubMed]
 4. Motiwala HG. Dartos flap: An aid to urethral reconstruction. Br J Urol. 1993;72:260–

1. [PubMed]

5. Churchill BM, Van Savage JG, Khoury AE, Mclorie GA. The dartos flap as an adjunct

in preventing urethrocutaneous fistula in repeat hypospadias surgery. J Urol. 1996;156:2047–9.

[PubMed]

6. Snow BW. Use of tunica vaginalis to prevent fistula in hypospadas. J Urol.

1986;136:861–3. [PubMed]

7. Kirkali Z. Tunica vaginalis: An aid in hypospadias surgery. Br J Urol. 1990;65:530–2.

[PubMed]

8. Snow BW, Cartwright PC, Unger K. Tunica vaginalis blanket wrap to prevent urethra-

cutaneous fistulas an eight year experience. J Urol. 1995;153:472–3. [PubMed]

9. Handoo YR. Role of tunica vaginalis interposition layer in hypospadias surgery. Indian

J Plast Surg. 2006;39:152–6.

10 J. G. Pattaras and H. G. Rushton, “Penile torque after the use of tunica vaginalis

blanket wrap as an aid in hypospadias repair,” The Journal of Urology, vol. 161, no. 3, pp. 934–

935, 1999

11. Xue WY, Qu CB, Wang XL, Zhang FX, Kang CS. J Urol. 2003 Oct;170(4 Pt

2):1596-9

12. Routh JC, Wolpert JJ, Reinberg Y. Tunneled tunica vaginalis flap is an

effective technique for recurrent urethrocutaneous fistulas following tubularized incised plate

urethroplasty,J Urol. 2006 Oct;176(4 Pt 1):1578-80

 13. Ahmed M. Khairi, Nour El-Kholi, Sherif

14.M. Soliman , Ahmed Demairy Tunica Vaginalis Flap; A Feasible Second-Layer for

Proximal Hypospadias Re-Do Annals of Pediatric Surgery, Vol3, No 1, January 2007 PP 44-47

16. U. S. Chatterjee, M. K. Mandal, S. Basu, R. Das, and T. Majhi, “Comparative

study of dartos fascia and tunica vaginalis pedicle wrap for the tubularized incised plate in

primary hypospadias repair,” BJU International, vol. 94, no. 7, pp. 1102–1104, 2004.

17 R. B. Singh and N. M. Pavithran, “Tunica vaginalis inter- position flap in

the closure of massive disruption of the neourethral tube (macro urethrocutaneous fistulae),”

Pedi- atric Surgery International, vol. 20, no. 6, pp. 464–466, 2004.

18.Bhatnagar Amit1,Chauhan Kumar Adarsh2,Monga Y.P.3,Kansal Sandeep 1, IOSR

Journal of Dental and Medical Sciences (IOSR-JDMS)