Reverse circumcision foreskin advancement flap for reconstructing penile shaft skin defects in adults with burn injuries in the perineal region.

AIM: Genital burns are rare injuries. Reconstruction of penile skin defects should consider cosmetic and functional outcomes. Skin grafts can develop scar contractures and carry hair follicles, causing unwanted results. These downsides remain unsolved issues. This work aimed to describe a new foreskin advancement flap method for completely reconstructing penile shaft skin defects in severely burned patients. MATERIALS AND METHODS: From 2021 to 2023, four patients with third-degree burns in the genital area were enrolled in this investigation. We describe a series of cases with deep burns to the penile shaft and surrounding area that needed debridement and reconstruction using a novel technique called "reverse circumcision," which consists of tangential excision of the penis and a foreskin advancement flap without longitudinal cuts with less morbidity, preservation of function, and a better aesthetic appearance. The patients had an average follow-up of nine months. RESULTS: The reverse circumcision technique was established for patients with severe burns in the genital area. The four patients were satisfied with the postoperative results and the aesthetic results of the procedure without reporting any complications. No scarring or contractures were observed on the glans or penile shaft after surgery. CONCLUSIONS: Compared with other flap methods, the use of a reverse circumcision foreskin advancement flap was more straightforward, feasible, and effective. In adults, the foreskin tissue completely covers the penile shaft skin defect. It is a viable reconstructive surgical technique that is easily reproducible and has excellent aesthetic and functional results. For this surgical technique, tissue transfers, bulky regional flaps, or skin grafts were not needed.

Double-face preputial island flap revisited: is it a reliable one-stage repair for severe hypospadias?

PURPOSE: We have studied outcome of double-face preputial island flap (DFPIF) technique in severe types of hypospadias: penoscrotal, scrotal and perineal. METHODS: We have used DFPIF in 75 boys at a median age of 1.1 years (1.0-1.5). The meatus was penoscrotal, scrotal or perineal after de-gloving the penis. The inner face of the foreskin was used for urethroplasty and the outer face for ventral skin covering. Modifications were added: proximal anastomosis was protected by a spongioplasty; in case of urethral plate transection, we anastomosed on onlay proximal and distal segments of the flap (onlay-tube-onlay) and the tubularized part was sutured to corpus cavernosa. FU was scheduled at one month then every 3 months for a year then annually. At each consultation, the surgeon filled out a detailed cosmetic and functional sheet including flowmeter. RESULTS: Thirty-four patients had onlay preputial flap repair with urethral plate preservation. Forty-one had the onlay-tube-onlay technique. All children had a curvature, 19 had a significant residual curvature after dissection, corrected by dorsal plication (n = 9) and ventral lengthening (n = 10). Median FU was 4.2 years (2.7-6.5). 36 children (48%) had complications and needed redo surgery: 12 fistulas, 11 diverticula, 7 meatal stenosis, 3 strictures and 2 residual curvatures. All children but three voided within the normal limits for their age. CONCLUSION: DFPIF remains a good option for a one-stage repair of severe hypospadias. After a median of 1.8 procedures, the final success rate was 96%. The healthy well-vascularized ventral skin allows safe redo surgery when needed.

Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias.

PURPOSE: To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique. METHODS: We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra. RESULTS: There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture. CONCLUSIONS: Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.

Preputial pedicle flap ICG blood flow assessment during proximal hypospadias repair: Development of a standardized protocol.

INTRODUCTION: Blood supply to preputial flap drives outcomes of hypospadias repair. Unfortunately, we only have surgeon's subjective assessment to evaluate flap perfusion which may not be accurate. Indocyanine green (ICG) has been used in a multitude of surgeries for perfusion assessment, however, no standardized protocol has been described for use of ICG in hypospadias repairs. The aim of this study is to develop a standardized protocol of ICG use in proximal hypospadias and establish perfusion patterns of preputial flaps. STUDY DESIGN: A pilot study was conducted using ICG in patients with proximal hypospadias undergoing first stage repair with a preputial flap. The Stryker SPY PHI system and novel quantification software, SPY-QP, were used for ICG imaging. An adaptive approach was taken to develop and implement a standardized protocol (Summary Figure). Per the protocol, ICG was administered at 3 time points which were felt to be critical for assessment of flap perfusion. Of the study patients who have undergone second stage repair, ICG was also used to reassess the flap prior to tubularization of the urethra. RESULTS: A total of 14 patients underwent first stage hypospadias repair with preputial flaps and intraoperative use of ICG. Median ICG uptake of the prepuce after degloving (dose 1) was 58.5% (IQR 43-76). ICG uptake decreased after flap harvest and mobilization (dose 2) with a median ICG uptake of 34% (IQR 26-46). ICG uptake remained stable after securing the flap in place and closing the skin (dose 3) with a median ICG uptake of 34% (IQR 25-48). ICG was able to delineate subtle findings in the preputial flaps not visible to the naked eye and in one case impacted intraoperative decision making. To date, 5 patients have undergone second stage repair. Flap assessment prior to tubularization of the urethra showed hypervascularity with a median ICG uptake of 159%. CONCLUSIONS: A standardized protocol for ICG use in proximal hypospadias was successfully developed and implemented. ICG uptake in the preputial flap decreased with increasing manipulation and mobilization of the flap. ICG was able to detect changes to flap perfusion which were not able to be seen with the naked eye. Reliance on surgeon's subjective assessment of flap perfusion may be inadequate and ICG could provide a useful tool for surgeons to improve preputial flap outcomes. ICG may also enhance the learning experience for trainees and early career urologists in these complex surgeries.

Evaluation of double faced transverse preputial (onlay) island flap for hypospadias repair in pediatrics: a randomized controlled study.

BACKGROUND: The preputial onlay island flap technique has been popularized for hypospadias repair as a result of offering a consistent combination of acceptable functional and cosmetic results. Like other techniques, urethrocutaneous fistulae and stricture continues to be the most common complications, in addition to other complications, which could be attributed to the compromise in flaps vascularity. Some authors describe a technique that resolves some of these problems by combining the unique benefits of the double faced preputial flaps. THE AIM OF THIS STUDY: - to evaluate double faced preputial onlay island flap technique for complications rate, outcomes of surgical procedure, and cosmetic results in comparison to transverse inner preputial flap technique. PATIENTS AND METHODS: This was a prospective randomized controlled study that included 68 patients with anterior, mid-penile, and posterior penile hypospadias, with shallow and narrow urethral plate of size less than 6 mm, who underwent single-stage repair using preputial flaps, conducted at the department of pediatric surgery (Al-Azhar University, Cairo, Egypt), between May 2019 and October 2021, to evaluate double faced transverse preputial onlay island flap technique. Thirty-four patients underwent double faced transverse preputial onlay island flap (group A) and another 34 patients underwent inner transverse preputial onlay island flap (control group) (group B). The follow-up period ranged from 12 to 26 months. RESULTS: The overall complication rate was 20.5% (14 of 68 children). Complications developed in 5 cases (14.7%) in group A who underwent double face onlay island flap (2 glannular dehiscence, 1 penile rotation, 1 fistula, and 1 diverticulum), as opposed to 9 patients in group B (26.4%) who underwent transverse inner preputial flap (3 developed glannular dehiscence, 2 skin flap necrosis, 3 fistulae, and 1 diverticulum). After management of the complications, all patients had good surgical outcomes with satisfactory cosmetic results. CONCLUSION: Double faced transverse preputial onlay island flap is an alternative option to reconstruct narrow urethral plate hypospadias. So that double faced transverse preputial onlay island flap technique appears to achieve satisfactory surgical outcomes with lower complication rate.

Modified double face preputial flap urethroplasty for single-stage repair of proximal hypospadias.

Background: There is an ongoing pursuit to decrease complications of hypospadias surgery. We studied a modification to the double onlay preputial island flap, whereby an additional tunica vaginalis layer was used. Aims: We aim to study the efficacy, complication rates and outcomes of the modified double onlay urethroplasty technique. Materials and Methods: This study adopts an observational consecutive study design. From 2014 to 2019 the modified preputial double onlay urethroplasty technique was used in 30 patients. Selection criteria was severe hypospadias operated on using the technique studied in a single stage procedure. We excluded perineal hypospadias, cripple hypospadias, and combined procedures. The operative technique used involved a layer of preputial flap for the neourethra followed by a layer of tunica vaginalis followed by another preputial flap layer over the ventral penile skin defect. Results: Patients were followed up for a mean of 2.04 years. There were 11 (36.67%) complications. Urethrocutaneous fistulas occurred in 3 patients (10%). There were 3 cases (10%) of glanular dehiscence and 1 (3.3%) diverticulum. No correlation was found between operative age, hypospadias type, or chordee approach and complications. Short second surgeries were needed in 7 patients (23.3%). Conclusion: The modified technique used in this study yielded good cosmetic and functional results. Complication rates were in line with the lower ranges reported by the literature for the standard double onlay preputial flap technique.

Repair of distal hypospadias by construction of neourethra from augmented urethral plate with two lateral strips of glans skin and coverage with dartos flap followed by skin closure with preputial flap: single center series.

INTRODUCTION: Hypospadias is one of the most common anomalies in boys. Many surgical techniques for reconstruction of distal hypospadias have been described, each method having a different success rate. Our objective in this study is the assessment of the surgical technique for repair of distal hypospadias by construction of a neourethra from the augmented urethral plate with two lateral strips of glanular skin, coverage with a dartos flap, and followed by skin closure with preputial skin flap. MATERIAL AND METHODS: From March 2016 to November 2018, repair of distal hypospadias was performed in 56 children with a mean age of 3.2 years (range 2 to 8 years old). Minimum follow-up was 12 months, maximum up to 24 months. Success was defined by cosmetic appearance of the penis, parent perception of penile appearance, and urinary function. Uroflowmetry was done in 22 children at the 12 months follow-up. Parents evaluation of procedure was done by questionnaire using the pediatric penile perception score (PPPS). RESULTS: The results were successful with straight penile shaft, conical glans, slit-like meatus located at the tip of the glans, with no rotation, and normal micturition. Five children had urethrocutaneous fistula (8.9%) that were treated with simple closure. Parents reported 'very satisfactory' (98.2%) and 'satisfactory' (1.8%). CONCLUSIONS: The described technique of repair of distal hypospadias in children with different variants of urethral plate width and glans size showed good results, both operator's and parent's perception of the results being very satisfactory. This technique is categorised stage 2a in the IDEAL (Idea, Development, Evaluation, Assessment, and Long-term study) staging system for surgical innovations.

Vaginoplasty Modifications to Improve Vulvar Aesthetics.

Improvements to vulvar aesthetics, particularly the clitoral complex and labia minora reconstruction, are difficult and remain the challenge of genital reconstructive surgeons. Various modifications of penile inversion technique have been introduced to improve vulvar aesthetics in recent years. Generally penile inversion vaginoplasty leaves limited penile tissue to reconstruct the natural labia minora. This article describes improvements made to overcome substantial limitations of the widely used traditional penile inversion vaginoplasty technique, with emphasis on creating a realistic vulvar aesthetic appearance in all respects, without compromising sexual sensation or vaginal depth.

A novel technique to construct a neo-scrotum out of preputial skin for agenesis and underdeveloped scrotum.

INTRODUCTION: Congenital scrotal agenesis (CSA) is an extremely rare condition with fewer than 10 cases reported in the literature. These patients are often further complicated by undescended testicles as well as systemic developmental disorders. Herein, we report our experience and an innovative surgical technique for creation of a neo-scrotum in three children. MATERIALS AND METHODS: We evaluated the records of three children in our database who were labeled as having an absent (1 patient) or severely underdeveloped scrotum (2 patients). Patients were aged 6, 14, and 16 months. All patients were uncircumcised, and the decision was made to create a neo-scrotum using the foreskin. The prepuce was harvested on a pedicle of dartos and transposed over the perineal cleft to create a neo-scrotal pouch. The flap was allowed to heal for 12-14 weeks, at which time the orchidopexy was performed. RESULTS: The follow-up to the surgery was 5 years, 3 years, and 6 months, respectively. There were no instances of flap necrosis, dehiscence, or wound infection. The three children had a capacious, aesthetically pleasing scrotal sac, which in all cases accommodated both testicles. CONCLUSION: In our experience, a well-vascularized preputial skin flap rotated to the perineum based on its ventral dartos pedicle provides an excellent source of tissue for creation of a neo-scrotum. We believe that the esthetic outcome of our technique rivals that of other reported techniques.

Results of Onlay Preputial Flap Urethroplasty for the Single-Stage Repair of Mid- and Proximal Hypospadias.

AIMS: To report current results of preputial flap onlay urethroplasty using the principle of the total preputial flap (TPF) for the one-stage repair of mid- and proximal hypospadias. METHODS: This study was a retrospective chart review of patients in a prospectively kept database of all hypospadias operations performed at two institutions from January 1 2011 to August 2017. Inclusion criteria: all patients who underwent hypospadias repair using a preputial only flap urethroplasty based on the principle of the TPF. Demographic data, duration of follow-up, complications, and reoperations were recorded. A successful result was considered to be a straight penis, a glanular meatus, and absence of voiding symptoms. Whenever possible an uroflow was obtained during the follow-up visits. RESULTS: Forty-nine children met the inclusion criteria. All patients had marked penile curvature. Three patients had chromosomal abnormalities. The mean age at the time of surgery was 22 months (11-110) and the mean duration of follow-up 23.4 months (1-79). In 48 cases, the urethral plate could be preserved without dividing it. The penile curvature was corrected with chordectomy alone in 10 patients, 38 required a dorsal plication of the tunica albuginea, and 1 required an additional ventral dermal graft. In 38 patients (77.5%), the initial operation was successful, and no further operations were needed. There were eight urethrocutaneous fistulas, three dehiscences of the glans approximation. One patient suffered a wound infection and partial loss of the flap. CONCLUSION: One-stage repair of mid- and proximal hypospadias preserving the urethral plate and using a TPF for the urethroplasty and coverage of the ventral penis is successful in 77.5% of cases. Complications in the remaining patients were easily managed or did not require treatment. Compared to a planned two-stage approach, the technique described in this report resulted in significantly fewer procedures till complete resolution of the problem.

Preputial flap as an adjunct to groin flap for the coverage of electrical burns in the hand.

High voltage electrical contact to hand result in injuries at multiple levels that may require more than a single flap for effective coverage. We present here a simple technique to utilise preputial flap as an adjunct to groin flap in cases where simultaneous coverage was required at more than one site in hands. In the past two years, 15 patients with unilateral involvement of hands due to electrical contact injury underwent this procedure. In addition to a comfortable position of the hand, stable and purposeful coverage at the wrist and various areas of hands was achieved in all the patients and none had flap failure. Minor complications related to penile erection were encountered that resulted in partial wound dehiscence that was managed with resuturing, pain relief and temporary suppression of erection. In our opinion, preputial flap is a good addition in our armamentarium to be used alongside groin flap for effective coverage of more than a single site requiring flap cover in electric injuries of the hand.

Total preputial flap: a reliable and versatile technique for urethral and penile reconstruction.

We revisit the technique of total preputial flap (TPF) and its application for urethroplasty, penile skin coverage of both and present our results in 43 patients (41 hypospadias, 2 epispadias). There were no instances of flap necrosis. In patients without prior attempts at reconstruction (n = 36), we observed four urethrocutaneous fistulas. TPF allowed the repair of cases of proximal hypospadias in one stage with an acceptable complication rate.

Glans-reconstruction with preputial flap is superior to primary closure for post-surgical restoration of male sexual function in glans-preserving surgery.

We conducted this study to investigate whether glans-reconstruction with preputial flap would be more helpful for post-operative restoration of patients' sexual potency than primary closure. From 2007 to 2013 at four centres, 46 cases reconstructed with preputial flap and 59 with primary closure were selected for the investigation from 142 consecutive cases of superficial glans cancer, with the largest diameter of lesion ≤2.5 cm, who undergoing glans-preserving surgery (GPS). Subjective evaluation for patients' sexual performance was investigated using the International Index of Erectile Function-15. Objective evaluation was carried out by the Audio Visual Sexual Stimulation test with RigiScan-Plus. The degree of satisfaction for penile appearance and patients' confidence and partners' acceptability for intercourse were evaluated by 5-point scales. Patients with preputial flap reconstruction showed significant better performance in three domains (orgasmic function, intercourse satisfaction and overall satisfaction, all p < 0.05) and significantly higher ratios of appearance satisfaction (78.3% vs. 57.6%, p = 0.026) and intercourse confidence (69.6% vs. 49.2%, p = 0.035) compared with those undergoing primary closure at post-operative month 6 ends. Their sexual partners in the preputial flap group also exhibited significantly higher ratios of appearance satisfaction than in the primary closure group (67.4% vs. 42.4%, p = 0.011). Reconstruction with preputial flap contributes to a more acceptable cosmetic appearance of the penis and minimizes post-operative negative psychological impediments. Patients can benefit more from reconstruction with preputial flap than primary closure. Glans-reconstruction with preputial flap should be considered the primary reconstruction technique in GPS.