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One-stagecomplexprimaryhypospadiarepair
combiningbuccalmucosagraft,preputialflap
andtunicalvaginalisflap(thethree-in-one
technique)
ArticleinJournalofpediatricurology·February2011
DOI:10.1016/j.jpurol.2010.10.006·Source:PubMed
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Journal of Pediatric Urology (2011) 7, 76.e1e76.e2
VIDEO BANK
One-stage complex primary hypospadia repair
combining buccal mucosa graft, preputial flap and
tunical vaginalis flap (the three-in-one technique)
Antonio Macedo a,*, Riberto Liguori b, Gilmar Garrone b, Sérgio Ottoni b
a
b
Department of Urology, Federal University of São Paulo, São Paulo, Brazil
Federal University of São Paulo, Pediatric Urology Section, Rua Maestro Cardim, 560 São Paulo, Brazil
Received 25 August 2010; accepted 16 October 2010
Available online 4 December 2010
KEYWORDS
Hypospadia;
Urethra;
Reconstruction;
Penile surgery
Abstract Objective: Complex hypospadia repair can be performed according to different
strategies, mostly in one or two stages. We present a detailed video of one patient operated
according to the three-in-one technique, which combines dorsal buccal mucosa grafting for
reconstruction of the incised urethral plate and a preputial flap onlay urethroplasty covered
by a tunica vaginalis graft.
Method: After sectioning of the urethral plate to correct ventral curvature, the original plate
is anchored to the proximal penile shaft. Buccal mucosa is harvested from the lower lip and
sutured to the ventral penile shaft area. A transverse preputial flap is obtained and anastomosed ‘onlay’ to the reconstructed neouretha. The scrotal fascia is opened at the site opposite
to the placement of the pedicle of the preputial flap and a careful dissection of the tunica
vaginalis and cremasteric tissue is performed. This second flap is used to cover the neourethra
and is fixed to the corpora by angular interrupted 6-0 PDS sutures.
Results: Our series of 35 patients resulted in 68.5% success after a single operation, whereas
31.5% needed a second repair.
Conclusion: The technique gives excellent results and can be considered an alternative to onestage repair in primary cases.
ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author.
E-mail address: [email protected] (A. Macedo).
1477-5131/$36 ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpurol.2010.10.006
A. Macedo et al.
Introduction
Hypospadias repair is regarded as a challenging operation
and complex primary forms can be treated according to
different strategies. Most authors present arguments for
a two-step strategy, considering that after sectioning the
urethral plate, the use of Byars flaps or grafts like buccal
mucosa to re-establish the ventral penile covering could
provide a safer urethroplasty on a second setting. Most of
their arguments are logical, but we believe that it is possible
to combine different and well-accepted principles of
urethral repair in one operation with comparable results. In
2004, we described a one-stage urethroplasty approach
consisting of using a free buccal mucosa graft to lengthen the
urethral plate, allowing for complete resection of chordee
and enabling an onlay transverse flap anastomosis covered at
the end by a second flap of tunica vaginalis and cremasteric
tissue [1e3]. We now present a detailed video of one patient
operated according to this technique, aiming to show that all
of the principles involved in the strategy are well established
and familiar to surgeons used to this problem.
The following is the Supplementary video related to this
article:
Method
After sectioning of the urethral plate to correct ventral
curvature, the original plate is anchored to the proximal
penile shaft by 6-0 PDS sutures. The glans is further
sectioned in the midline to produce two wide open glanular
wings and allow dorsal placement of the buccal mucosa
graft also in the glanular area up to the desired neomeatus. Buccal mucosa is harvested from the lower lip,
with extension to the inside aspect of the cheek when
a longer graft is necessary. The harvest site is left open and
the graft prepared by removal of submucosal fatty tissue.
The graft is then sutured to the ventral penile shaft area by
interrupted 6-0 PDS sutures to restore the defect of the
urethral plate and to prepare the foundations of the neourethra. The mucous layer of the buccal mucosa faces the
future neourethra. A transverse preputial flap is obtained
and anastomosed ‘onlay’ to the reconstructed neouretha
by running 6-0 PDS sutures, taking care to anchor the suture
of the buccal mucosa ‘track’ also to the Buck’s fascia to
stabilize the anastomosis. The scrotal fascia is opened at
76.e2
the site opposite to the placement of the pedicle of the
preputial flap, and careful dissection of the tunica vaginalis
and cremasteric tissue is performed, isolating it from
testicular chord structures. This second flap is used to cover
the neourethra and is fixed to the corpora by angular
interrupted 6-0 PDS sutures. The penile skin is reconstructed. In cases of paucity of ventral skin with association
of penoscrotal transposition, two additional scrotal skin
flaps were produced and mobilized ventrally to achieve
a better cosmetic appearance of both the penis shaft and
the scrotum.
In all cases, a 6-Fr silicone tube was left inside the
urethra for 7e10 days and a cystostomy tube for 2e3
weeks. Initial dressings were left untouched for at least
3 days postoperatively.
Results and conclusion
Our series of 35 patients resulted in 68.5% success after
a single operation, with 31.5% needing a second repair. We
conclude that the excellent results provided by this technique indicate that it can be used as an alternative to onestage repair in primary cases.
Conflict of Interest
None.
Funding
None.
References
[1] Macedo Jr A, Srougi M. Onlay urethroplasty after sectioning of
the urethral plate: early clinical experience with a new
approach e the ‘three-in-one’ technique. BJU Int 2004;93:
1107.
[2] Macedo Jr A. Re: combined buccal mucosa graft and local flap
for urethral reconstruction in various forms of hypospadias.
J Urol 2006;175:1966.
[3] Souza GF, Calado AA, Delcelo R, Ortiz V, Macedo Jr A. Histopathological evaluation of urethroplasty with dorsal buccal mucosa: an
experimental study in rabbits. Int Braz J Urol 2008;34:345.