Lateral-based Onlay Flap for Redo Hypospadias Repair (LABO-R)
Year: 2024
Type: article
Abstract: BACKGROUND Complete reoperation for failed hypospadias is a challenge. In cases with chordee <30°, a single-stage operation may be preferred. While Mathieu or Snodgraft procedure may be useful for reoperative distal hypospadias,[1] they are not suitable for more proximal cases. Onlay flaps utilizing the prepucial skin are not possible in most reoperations. In these situations, we have been using a modified onlay island flap repair similar to the lateral-based onay flap (LABO) technique described for primary hypospadias.[2] To our knowledge, this is the first report of the use of a modified LABO technique for reoperative hypospadias (LABO-R). TECHNIQUE Chordee (typically <30°) is corrected by dorsal plication. All scarred tissues are excised till the normal proximal urethra, preserving a central strip of the urethral plate (UP); Glans wings are dissected widely. The onlay flap (LABO-R) of appropriate length and width is marked on the lateral skin, extending along the subcoronal skin on the ipsilateral side. The flap is incised on its lateral margin and separated from the adjoining skin, preserving all the underlying dartos tissue with the flap so that the flap has adequate mesentery till its tip. It is mobilized sufficiently to be comfortably flipped toward the opposite side without causing significant penile rotation. Urethroplasty is commenced by approximating the medial margin of the flap and the adjacent edge of the UP with 7/0 or 6/0 polydioxanone suture, running proximally to distal. The LABO-R flap is then flipped over an appropriate-sized infant feeding tube, and the lateral edge of the flap is sutured to the opposite margin of the UP using another running suture. Finally, the dartos fascia forming the mesentery of the flap is used to provide waterproofing cover to the suture lines [Figure 1].Figure 1: (a) Failed midpenile hypospadias with chordee < 30°, complete dehiscence of previous repair. LABO R flap (*) marked on the skin on the right side. (b) The flap has been adequately mobilized on a wide dartos mesentery (m). The medial margin of the flap has been sutured to the right edge of the urethral plate. (c) LABO-R flap has been flipped over, and urethroplasty is completed by suturing the lateral margin of the flap to the left edge of the urethral plate. (d) Mesentery of the flap has been sutured to the opposite dartos to provide a waterproofing cover for urethroplasty suture lines. (e) The skin on the opposite (left) side has been brought to the right side to provide healthy skin cover while preventing overlapping suture lines and penile torsion. (f) 3-month postoperative follow-up pictureGlansplasty and meatoplasty are performed. In case of inadequate ventral skin available for skin closure, the penis is degloved on the dorsum, and the dorsal skin is rotated ventrally like a Byars flap; typically, the skin from the opposite side is brought across the midline and used for a tension-free skin closure, care being taken to avoid overlapping sutures lines and penile torsion. Penile dressing and urethral catheter are removed after 1 and 2 weeks, respectively. DISCUSSION We report a modification of the LABO technique (LABO-R) for reoperative hypospadias. In reoperative hypospadias, the previously relocated dartos tissue may not allow for extensive mobilization of skin flaps; thus, the onlay flap has to be obtained from the skin in proximity to the UP. The advantages of this technique include limited mobilization of the skin flap and nonoverlapping suture lines, preventing fistula formation and penile torsion. Case selection is subject to the availability of healthy and well-vascularized skin lateral to the UP. The presence of residual chordee >30° is a contraindication to this technique because such cases typically require UP division and staged repair. Over 3 years, we utilized this technique in 22 patients (age range 2–30 years) with 80% success; 4 patients had complications (2 UCFs which were successfully repaired later and 2 glans dehiscence which were left alone). Fifteen of 22 patients had 1 previous failed operation, while 5 and 2 patients had 2 and 3 previous failed operations, respectively. Thus, this technique could be utilized even in cases with multiple failed previous operations and in reoperative adult hypospadias also. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Language: English
Subfield: Urology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4404082696