OBJECTIVE To review our experience with tissue expanders for resurfacing the penis in selected cases of complex hypospadias repairs. MATERIALS AND METHODS We reviewed the medical records of 6 hypospadias male patients who underwent tissue expansion for phallic skin resurfacing. The patients ranged in age from 14-29 years of age at the time of placement of the tissue expander. All 6 patients had 5-8 failed surgeries and were "hypospadias cripples." In each case, the injection port was placed in the suprapubic area, whereas the tissue expander was placed under the skin on the dorsum of the penis. The tissue expanders were inflated slightly in the operating room and then subsequently at 2-week intervals over 12-16 weeks. At the point of maximum tissue expansion, the patients underwent reconstructive surgery and removal of the tissue expanders. RESULTS Successful tissue expansion occurred in all 6 patients. The patients then underwent penile skin flap reconstruction of their penises. Two patients developed minor complications (1 urethrocutaneous fistula, 1 meatal stenosis), which were successfully corrected. Long-term follow-up ranged from 1-22 years. Successful phallus resurfacing with penile skin was achieved in all 6 patients. CONCLUSION Patients who have undergone multiple attempted hypospadias repairs may lack a sufficient amount of healthy, unscarred penile skin for a successful outcome. These patients are therefore candidates for tissue expansion of the relatively normal skin usually found on the dorsum of the penis. In our experience, tissue expanders are a safe and effective method of acquiring genital skin for resurfacing in selected cases of hypospadias cripples and therefore should have a place in the surgical armamentarium of complex and redo-hypospadias repairs.

A technique is described for correction of distal hypospadias with minimal chordee by tubularizing the urethral plate. The key step is deep longitudinal incision of the plate, which allows for tubularization without the need for additional flaps. The resultant neourethra is functionally adequate and an excellent cosmetic result with a vertically oriented meatus is achieved. A total of 16 boys underwent the procedure with no case of meatal stenosis or fistula occurring during a median followup of 22 months.

PURPOSE: We report a multicenter experience using tubularized incised plate urethroplasty to correct distal hypospadias. MATERIALS AND METHODS: A total of 148 patients underwent repair by 6 pediatric urologists at different institutions in the United States and Europe. RESULTS: Tubularized incised plate repair created a functional neourethra with a vertically oriented meatus. Complications, including meatal stenoses and fistulas, occurred in 10 patients (7%). CONCLUSIONS: Tubularized incised plate urethroplasty can be performed in most cases of distal hypospadias. Cosmetic results are superior to those of other popular techniques.

Autologous buccal mucosa as a substitute for urethral epithelium was studied in 2 dogs and used in 6 patients with difficult urethral reconstruction problems. The indications for an operation in these patients were failed hypospadias repairs with limited skin in 3, severe structure disease after hypospadias repair in 1, a short urethra in 1 and epispadias in 1. Three urethral fistulas and 1 meatal stenosis occurred in 3 patients. No urethral stricture or diverticulum was noted, and the final outcome was good functionally and cosmetically in all patients. This technique is useful for urethral reconstruction when local skin is not available.

PURPOSE: We evaluated the impact of tubularized incised plate urethroplasty on primary and repeat hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all boys who underwent hypospadias repair at our institution during a recent 3-year period. The level of the hypospadias defect, technique of repair, primary repair versus reoperation, age at surgery and complications were recorded. RESULTS: A total of 520 hypospadias repairs were done from May 1996 through June 1999. We began to perform tubularized incised plate urethroplasty in November 1996. During the ensuing consecutive 32 months 181 primary and 25 repeat hypospadias repairs were done using this technique. Mean patient age at surgery was 22 months (range 3 months to 30 years). During the 6 months immediately before we began to use this method the Mathieu flip-flap procedure was the most commonly performed technique, accounting for 38% of all hypospadias repairs. In contrast, during the last 6 months reviewed tubularized incised plate urethroplasty accounted for 63% of all repairs, including 41 of 65 primary operations (63%) and 4 of 6 reoperations (67%), while no Mathieu procedures were performed. Postoperative followup was 6 to 38 months for tubularized incised plate repair. Overall meatal stenosis and a urethrocutaneous fistula developed in 1 and 14 boys, respectively (7% complication rate). CONCLUSIONS: Tubularized incised plate urethroplasty has become the preferred technique of primary and repeat hypospadias repair at our institution. The technique has few complications as well as proved success and versatility that continues to expand its applicability and popularity.

The MAGPI operation for the distal meatus has been a satisfactory operation both functionally and cosmetically. The complication rate is minimal. We therefore believe it is warranted in such cases, particularly to produce the esthetic appearance of a normal penis. We have found it to be a difficult operation to teach others except by demonstration, since we have not been very very successful in producing diagrams or photographs which convey the details of the technique adequately. It is therefore recommended that before this procedure is attempted, one should observe its performance by a surgeon who has mastered the technique.

Autologous buccal mucosa alone or combined with bladder mucosa was used as a free graft for urethral reconstruction in 8 patients with hypospadias. Of these patients 3 with medium penile hypospadias and chordee received a buccal mucosa graft alone and 5 with severe hypospadias received a combined buccal/bladder mucosa graft. Followup at 6 to 18 months showed no complications apart from a fistula in 1 patient with a buccal mucosa graft alone. Our initial results are encouraging. Buccal mucosa seems to be a good material for hypospadias repair.

PURPOSE: In select patients with hypospadias in whom genital skin is insufficient alternative tissues are needed for urethral reconstruction. Although skin and mucosal grafts may be used, they may increase hospitalization and morbidity. We explored the feasibility of using a bladder submucosal, collagen based inert matrix as a free graft substitute for urethral repair. MATERIALS AND METHODS: Four patients with a history of hypospadias underwent repeat hypospadias repair using a collagen based inert matrix for urethral reconstruction. The inert collagen matrix was trimmed to size as needed for each patient. The neourethra was created by anastomosing the matrix in an onlay fashion to the urethral plate with continuous 6-zero polyglactin sutures. The created neourethra size ranged from 5 to 15 cm. RESULTS: After a 22-month followup 3 of the 4 patients had a successful outcome in regard to cosmesis and function. One patient in whom a 15 cm. neourethra was created had a subglanular fistula. CONCLUSIONS: The use of a collagen inert matrix appears to be beneficial in patients who have undergone previous hypospadias repair and who may lack sufficient genital skin for reconstruction.