a perfect hypospadias repair is supposed to return urethral continuity with sufficient caliber , eradicate phallus curvature , and supply an acceptable appearance with low complications .
in this study we are planning to assess objectively this skillful technique for complications such as fistula , dehiscence , recurrent ventral curvature , meatal stenosis , diverticulum and urethral stricture .
from june 2012 to december 2013 onlay island flap was performed to repair hypospadias with shallow urethral plate measuring less than 6 millimeter .
island flap onlay urethroplasty was performed based on the unique introduction by duckett ( 1 ) . in all cases glans penis
is injected with 1:200,000 epinephrine at the incision sites , by using 2.5  magnifying loupe for most cases .
ventral skin was incised with a u - shaped incision that preserved the urethral plate ( figure 1 ) .
subsequently , an artificial erection was performed to notice remaining ventral curvature , which if present , was straightened by nesbit s dorsal plication with 4.0 prolen at the 12 oclock position .
cases with severe chordee that needed transect urethral plate underwent inlay genital graft from scrotal skin and onlay island flap urethroplasty was performed 6 months later . then a rectangular flap 1 cm longer than the length of the urethral plate was harvested from the dorsal inner prepuce ventrally rotated and anastomosed to the urethral plate with a 6-o polydioxanone running suture over an 8 fr silastic foley catheter ( figure 2 ) and a vascular pedicle flap was used to cover the suture line .
two lateral incisions were made along the urethral plate with deep dissection into the glanular wings except in cases with very small glans .
after glansplasty the penile shaft skin was closed with a midline suture or with a transverse island skin flap in cases of significant ventral skin deficiency according to surgeon s preference ( figure 3 ) . in cases with very small glans , urethroplasty was performed without glansplasty .
the dressing was changed on day 2 post surgery and catheter removed on day 7 .
children under 2 years of age had a double nappy whereas older children had a collecting bag .
patients were visited at the time of catheter removal 2 weeks and then at 1 , 3 , 6 and 12 months postoperative .
regular weekly meatal dilatation was used only in patients with voiding difficulty that had an obvious tendency to stenosis and a narrow stream on visual observation .
type of hypospadiasis , type of ventral curvature repair , complication rate such as fistula , dehiscence , recurrent ventral curvature , meatal stenosis , diverticulum and urethral stricture , management of complications and number of reoperations were analyzed .
data were collected and processed using the commercially available software package ( spss-20 for windows ) .
twenty three patients with mean age of 30 ( range 10 - 60 ) months underwent onlay island flap repair ; all had a shallow urethral plate < 6 mm , 3 had a very small glans , and 18 had chordee .
meatus was located in distal shaft in 5 cases , mid shaft in 8 , proximal in 6 and penoscrotal type in 4 patients .
the flap was sutured completely to the urethral plate , except in the mentioned 3 cases that was left 1 cm distal to the tip of the glans , which was sutured to the edges of the glandular wings .
glansplasty was performed in all cases , except in mentioned 3 cases that were left 1 cm distal to the tip of the glans , which was sutured to the edges of the glandular wings .
chordee was corrected with nesbit s dorsal plication in 16 cases . in 2 cases with severe chordee ,
the urethral plate was transected first , then underwent inlay genital graft from scrotal skin and onlay island flap urethroplasty was performed 6 months later .
following onlay flap repair 3 ( 13% ) boys had fistula ( one in distal shaft and two in midshaft ) , of whom one case with distal fistula is under observation , while other 2 cases were repaired surgically without further complications .
all cases that had glansplasty have acceptable voiding and satisfactory cosmetic esthetic result and appearance , except 3 patients who had no glansplasty .
it necessitates the construction of a straight penis , with an acceptable caliber of neourethra that ends in a natural slit - like meatus ( 2 ) . in hypospadias repair ,
there are many different techniques and modifications . technique of repair is based on a number of variants such as degree of curvature , site of meatus , width of urethral plate and surgeon favorite . in onlay flap repair
careful protection of the vasculature of the flap and prevention of overlapping suture lines generate a waterproof closure with minimum risk of postoperative fistula . tubularized incised plate ( tip )
is a common operation in hypospadias reconstruction , but our experience shows that risk of stricture and fistula in this method is relatively high and needs acceptable width of urethral plate for urethroplasty . however in sozubir s et al.s study ,
complications after tip repair were equivalent to other current repairs , and with caution in technical details these complications could be decreased .
the mentioned authors believed that this procedure regularly will generate a vertical meatus , and result in a normal aesthetic outcome ( 3 ) .
the main complication in their patients was fistula . despite the use of a dartos flap in all cases , fistula occurred in 5% of distal and 19% of proximal repairs ( 4 ) .
they used tubularized incised - plate urethroplasty for hypospadias reoperation but when it was employed in proximal hypospadias , they encountered a complication rate of 33% with 21% incidence of fistula and persistent chordee in some patients ( 4 ) . in our study
we had fistula in 3 ( 13% ) boys ( one in distal shaft and two in midshaft ) .
a large multicenter series of patients with both distal and proximal hypospadias performed tip repair with less than 1% occurrence of fistulas . they approximated the corpus spongiosum over the neourethra during proximal repair and protected neouretra with dartos layer and glans wings . in recent study the only parameter for selection of patients was urethral plate diameter less than 6 millimeter and type of hypospadias was not an effective factor .
( 6 ) in a single - center experience with 500 cases reported tip procedure as a reliable technique for management of both distal and proximal hypospadias in both primary and re - operative cases with a small rate of complications but urethral plate diameter was not mentioned .
postoperative meatal / neourethral stenosis after tip is common , so shimotakahara ( 7 ) collected a dorsal inlay graft from the inner prepuce and sutured to midline incision of the urethral plate . in our study 2 cases with severe chordee needed to transect urethral plate who underwent inlay genital graft from scrotal skin and onlay island flap urethroplasty was performed 6 months later and both cases had acceptable results .
although tip urethroplasty is a choice procedure in distal penile hypospadias for some surgeons , some others prefer to use onlay flap technique , particularly in cases of a small phallus with narrow plate or conical glans , which create tubularization difficult ( 7 ) . in 1987 , elder ( 8) reported the first one - stage hypospadias repair using an onlay island flap , although the preputial island flap had long been done previously .
( 9 ) evaluated the consequences of using a distally folded onlay flap in the repair of distal penile hypospadias in 36 patients , they had only two urethrocutaneous fistulas , and they used onlay flap for distal type . in our study
( 10 ) had a studied forty five boys with similar mid - penile hypospadias deformities and designed a comparative study between tip and onlay preputial island flap and found no differences between the two techniques .
leslie et al . ( 12 ) used tunica vaginalis graft plus onlay preputial island flap in urethral reconstructive surgery in rabbits in one - stage for complex hypospadias with divided urethral plate .
( 13 ) compared three different urethroplasty techniques ( onlay , buccal mucosa , koyanagi type i ) in severe hypospadias .
fistula occurred in 15% in onlay group ; 32% in buccal mucosa group , and 19.2% in koyanagi cases .
patel et al . ( 14 ) introduced a technique called the split onlay skin flap , which had fistula in 6 patients .
snodgrass ( 16 ) reported most of urethral complications are diagnosed at the rst postoperative visit or within the rst year after reconstruction .
glans dehiscence is usually apparent by 2 months , whereas most stulas and other complications are found after 6 months .
in our experience with 23 patients the onlay flap hypospadias repair provided excellent cosmetic and functional results .
the overall complication rate as well as the rate of postoperative urethrocutaneous fistula was minimal and compares favorably with rates reported by other authors , but need more long postoperative surveillance .
 background : hypospadias is one of the most common congenital genital anomalies in males that necessitates to be operated early in infancy ( when 6 to 9 months old ) . on the other hand , hypospadias is a challenging field of pediatric urology with multiple reconstruction techniques . a perfect hypospadias repair is supposed to return urethral continuity with sufficient caliber , eradicate phallus curvature , and supply an acceptable appearance with low complications.objectives:this study aimed to evaluate the outcomes of using onlay island flap technique in the repair of hypospadias with shallow urethral plate.patients and methods : in this prospective study within june 2012 to december 2013 , we performed onlay island flap procedure to repair hypospadias with shallow urethral plate measuring less than 6 millimeter . 
 this technique was selected for all types of hypospadiasis except subcoronal type . 
 nesbit s dorsal plication procedure was established for chordee . in cases with very small glans , 
 urethroplasty was performed without glansplasty.results:twenty three patients with mean age of 30 ( range 10 - 60 ) months underwent onlay island flap repair ; all had a shallow urethral plate < 6 mm , 3 had a very small glans , and 18 had chordee . 
 meatus was located in distal shaft in 5 cases , mid shaft in 8 , proximal in 6 and penoscrotal type in 4 patients . 
 chordee was corrected with nesbit s dorsal plication in 16 cases . 
 complications were : meatal stenosis in 2 cases and urethrocutaneous fistula in 2 patients , all of which were repaired surgically . 
 mean follow up time was 13 ( 3 - 20 ) months . 
 all cases that had glansplasty have excellent esthetic appearance.conclusions:this technique offers acceptable results regarding meatal stenosis , urethrocutaneous fistula and esthetic outcome . 
1. Background
2. Objectives
3. Patients and Methods
4. Results
5. Discussion
5. 1. Conclusion