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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 75-77

Tunica vaginalis flap in hypospadias repair: A preliminary experience

1 Assistant Professor, IGIMS, India
2 Professor & Head, IGIMS, India
3 Associate Professor, IGIMS, India
4 Additional Professor, IGIMS, India
5 Senior Resident, Dept. of Paediatric Surgery, IGIMS, India

Date of Submission09-Dec-2019
Date of Acceptance21-Feb-2020
Date of Web Publication16-Nov-2020

Correspondence Address:
Sandip K Rahu
Assistant Professor Dept. of Paediatric Surgery, IGIMS, Patna
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Source of Support: None, Conflict of Interest: None

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Aims and Objectives : To investígate the results of Hypospadias repair in patients having Tunica Vaginalis flap as a second layer after urethral reconstruction
Methods: A prospective study on all patients of Hypospadias who had Tunica Vaginalis used as a second layer after urethroplasty was conducted between 01.11.2017 to 31.10.2019. Data regarding nature of hypospadias, any previous surgery, duration of surgery and any postoperative complications were collected. Results collected were analyzed.
Results: A total of ten patients had the use of Tunica Vaginalis flap during surgery. Among these, 90% had proximal hypospadias and 10% had distal hypospadias. 50% patients (4/10 proximal & 1/10 distal) had this flap used in Redo-urethroplasty cases with 100% success. 40% cases had this flap used during primary urethroplasty, of which 50% cases had successful repair and other 50% had fistula formation. One patient who had Bracka-stage 2 surgery with this flap reported good cosmetic results.
Conclusion: Tunica Vaginalis Flap is a well vascularized, locally available flap that can be used in difficult cases of Hypospadias with tissue deficiency with good results and minimal complications.

Keywords: Distal; Flap; Hypospadias; Proximal; Tunica Vaginalis

How to cite this article:
Chaubey D, Rahu SK, Kumar V, Yadav R, Thakur VK, Hasan Z, Prasad R, Nitesh, Keshri R. Tunica vaginalis flap in hypospadias repair: A preliminary experience. J Indira Gandhi Inst Med Sci 2020;6:75-7

How to cite this URL:
Chaubey D, Rahu SK, Kumar V, Yadav R, Thakur VK, Hasan Z, Prasad R, Nitesh, Keshri R. Tunica vaginalis flap in hypospadias repair: A preliminary experience. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2021 Dec 6];6:75-7. Available from: http://www.jigims.co.in/text.asp?2020/6/1/75/300746

  Introduction Top

Hypospadias, being a reconstructive surgery, often leads to unsatisfactory results and urethrocutaneous fistula. Different modifications of the technique and flap cover have been described to lessen these complications. Several investigators have examined the role of Tunica Vaginalis (TV) flap in hypospadias repair[1],[2],[3]. We present our experience with the use of Tunica Vaginalis flap as a second layer after urethroplasty in Hypospadias surgery.

  Aims and Objectives Top

To investigate the results of Hypospadias repair in patients having TV flap as a second layer after urethral reconstruction.

  Materials and Methods Top

All patients of hypospadias, who had urethroplasty with vascularized TV flap as a second layer formed the study group. This was a prospective study conducted over a period of 2 years from 01.11.2017 to 31.10.2019 in the Department of Paediatric surgery, Indira Gandhi Institute of Medical Sciences, Patna. Wound infection, meatal stenosis and urethrocutaneous fistula were considered as treatment complications. Data regarding age of the patient, and number of previous surgeries, number and location of fistulae, status of urethral meatus, urethral caliber, surgery duration, post-operative complications and length of follow up were recorded. The need for reoperation was considered as failure. Data thus collected was analyzed.

  Technique of Raising Tunica Vaginalis Flap Top

Following the creation of neourethra by any of the means suitable for the anatomy of the individual’s phallus, TV flap was planned to be raised from one of the sides. Patient’s or his parent’s consent were taken for this beforehand. Then one of the testicles was brought out either through a transverse scrotal incision or via the same incision as for creating neourethra. The tunica vaginalis surrounding the testicle was incised and reconfigured as a flap [Figure 1]; it was then transferred to superimpose on the neourethra. The testicle was then returned to its native place in the scrotum. The scrotal incision was then closed. The penile shaft skin was rearranged and closed over the TV flap cover.
Figure 1: Left Tunica vaginalis flap for Hypospadias repair

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  Results Top

There were 10 patients in whom TV flap was used to superimpose over urethroplasty as second layer during this period. The age of these ten patients ranged from 2.5 years to 12 years (mean 5.6 years).

[Figure 2] summarizes the results of Tunica Vaginalis flap used for urethroplasty in our department.
Figure 2: Results of Tunica Vaginalis flap

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Most of these were Proximal Hypaospadias cases (9/10). Among these, 4 were Redo-urethroplasty cases wherein the child was operated earlier and had fistula after initial surgery. All these four fistula cases underwent fistula closure with Tunica vaginalis cover and had successful results in the postoperative period. In one patient of Penoscrotal hypospadias, TV flap was used after Bracka stage 2 procedure and this patient had cosmetic results with good flow rates on subsequent uroflowmetry. One patient had very small phallus with deficient urethral plate and small glans for which Duckett’s flap urethroplasty was done. This patient had postoperative infection and despite good TV flap cover, he had fistula. He is now waiting for redo surgery. Among other three patients in the proximal Hypospadias group who had wide urethral plate with deep glans groove, Tubularised Incised Plate (TIP) urethroplasty could be done with TV flap cover. Two of these three patients had successful repair with cosmetically pleasing glans in the postoperative period. One patient had fistula which was later repaired after eight months.

In one of the four patients who had primary repair, religious circumcision had been performed despite having proximal hypospadias. In this patient, Preputial tissue was deficient and so the only option in this patient was TV flap for interposition.

Only one patient with Distal Hypospadias needed TV flap during this period. This patient had earlier undergone TIP repair resulting in fistula formation in the subcoronal position and complete stenosis of the neourethra distal to it; this necessitated division of the previous neourethra and interposition of a graft from the phallic skin over the raw area (in Snodgraft fashion). Tubularisation was then done over a no. 7 Infant feeding tube. Because no other local tissue was available to cover this repair, right side’s TV flap was raised to cover this repair. Patient showed satisfactory healing with good stream from the neomeatus in the postoperative period after removal of the catheter.

Overall results of TV flap in this study showed around 80% success with fistula in only 2/10 (20%) of these patients. There was no remnant chordee or meatal stenosis in any of the patients. Two patients had some penile torsion (less than 15 degrees) towards the side from where the TV flap was raised. However, parents were satisfied with the cosmetic outcome given the fact that both these cases were of Proximal Hypospadias and so no further intervention was needed.

No significant complications except one scrotal haematoma (which resolved conservatively) were seen in the scrotum or the ipsilateral testis from where TV flap was raised.

  Discussion Top

Hypospadias surgery is a cosmetically and technically demanding surgery with variable fistula rates reported in several series.[4],[5],[6] This however varies depending on the anatomy of the native phallus, glans, urethral meatus/plate, presence or absence of chordee and presence of healthy tissue to be used to fashion repair. All these variables make hypospadias repair challenging so that no single technique is an answer to all the permutation and combination of variability of these parameters. This explains the numerous techniques with no single standard protocol for any particular anatomy.

However, once urethroplasty has been performed, most of the researchers agree to the need of a second covering layer which is well vascularized and locally available in abundance.[7],[8],[9],[10],[11] Dartos flap, use of Buck’s Fascia, local Spongiosal layer if available, Smith D flap[8], Belman flap[9], and Tunica vaginalis flap from one of the sides are the different options described in literature.[9],[10],[11], Although Dartos flap is the most widely used tissue for superimposition, many a times, it is unavailable due to tissue deficiency. This may commonly occur in failed cases where it has already been used during previous surgery or in proximal hypospadias where the length of the tissue needed far exceeds the length of the Dartos flap which is available. Finding any local tissue for cover in such cases is difficult and often not possible. TV which surrounds the testis is the next well vascularized tissue available in abundance. Also the vascularity of this tissue does not depend on the arterial supply of the phallus. So, this flap is an answer to all such situations where Dartos flap is either not available or is deficient.

TV flap has been reported to have several advantages including good vascularity, easy availability and not being affected by penile disorders.[11],[12],[13],[14] Nandoo Y. R. et. al. and Kirkali Z et. al. have reported the successful use of TV flap in their series.[11],[12],[13],[14],[15],[16]

In a comparative study by Dhua et.al., TV flap was seen to have an edge over Dartos fascia for soft tissue coverage of the neourethra.[11] They reported a fistula rate of 12% with Dartos fascia; while no fistula was reported with the use of TV flap.[11]

We have often observed that in a few patients of repair using Dartos Fascia, there is blackening and ischaemia of the rearranged skin used to cover the repair. This increases morbidity and causes undue anxiety even if it gets corrected on its own. Such conditions are rare with the use of TV flap.

In our study, TV flap led to successful repair in 80% patients with low fistula rate (20%) cases. All these cases were complicated cases (either proximal hypospadias or previously failed repair). This suggests that TV flap has advantages to be used in such difficult situations where deficiency of local phallic tissue is present.

Several local complications of TV flap have been reported including scrotal haematoma, scrotal abscess, ascent of ipsilateral testis or its torsion, damage to Vas deferens and vascular supply of the ipsilateral testis[17]. However, we believe that all these complications can be avoided by meticulous dissection and raising of TV flap and ensuring proper haemostasis and return of testis to its native scrotal position. We, therefore, seldom had any such complications in our study except in one case where scrotal haematoma was conservatively managed.

We had one patient in the primary surgery group who had a religious circumcision despite having proximal hypospadias. In such situations, where Preputial tissue is unavailable, TV flap remains a good alternative for interposition between neourethra and skin. We believe that in developing countries, this scenario becomes a special indication for the use of TV flap.

  Conclusion Top

Tunica Vaginalis flap is a locally available, vascular option to strengthen urethroplasty as a second layer with minimal complications and good results.

  Limitations of the Study Top

The number of patients included in this study is small with a short follow-up. A larger comparative study with other flap techniques done in a similar manner would provide stronger evidence in favor of the TV flap.

Conflict of Interest: None declared

Source of support: None declared

  References Top

TavakkoliTabassi K, Mohammadi S. Tunica vaginalis flap as a second layer for tubularized incised plate urethroplasty. Urol J.2010; 7:2547  Back to cited text no. 1
Snow BW, Cartwright PC, Unger K. Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: an 8-year Journal of Urology.1995; 153:472- 3.  Back to cited text no. 2
Hamid R, Baba AA, Shera A, Ahmad S. Tunica vaginalis flap following ' Tubularised Incised Plate’ urethroplasty to prevent urethrocutaeousfustulaa. Indian J Plast Surg.2015; 48:187- 91.  Back to cited text no. 3
Horton C.E., Devine C.J., Graham J.K. Fistulas of the penile urethra. Plast Reconstr Surg. 1980;66:407-18.  Back to cited text no. 4
Castagne^ M., El-Ghoneimi A. Surgical management of primary severe hypospadias in children: systematic 20 years review. J Urol. 2010;184:1469-74  Back to cited text no. 5
Retìk A.B., Baur S.B., Mandell J., Peters C.A., Colodry A., Atala A. Management of severe hypospadias with a 2-stage repair. J Urol. 1994;152:749-52.  Back to cited text no. 6
Mustafa M, Wadie BS, Abol-Enein H. Dorsal dartos flap in Snodgrass hypospadias repair: how to use it? Urol Int. 2008;81:215-7.  Back to cited text no. 7
Smith D. A de-epithelialised overlap flap technique in the repair of hypospadias. Br J PlastSurg 1973;26:106-14  Back to cited text no. 8
Belman AB. De-epithelialized skin flap coverage in hypospadias repair. J Urol 1988;140:1273.  Back to cited text no. 9
Bhat A, Sabharwal K, Bhat M, Saran R, Singla M, Kumar V. Outcome of Tubularized incised plate urethroplasty with spongioplasty alone as additìonal tìssue cover: A prospectìve study. Indian J Urol 2014;30:392-7  Back to cited text no. 10
Dhua AK, Aggarwal SK, Sinha S, Ratan SK. Soft tissue covers in hypospadias surgery: Is tunica vaginalis better than dartos flap? J Indian AssocPediatr Surg. 2012 ;17:16-9.  Back to cited text no. 11
Baba AA, Wani SA, Bhat NA, Mufti GN, Lone TN, Nazir S. Buck’s fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome. J Pediatr Urol. 2017 ;13:633.  Back to cited text no. 12
Snow B.W. Use of tunica vaginalis to prevent fistulas in hypospadias surgery. J Urol. 1986;138: 861-3.  Back to cited text no. 13
Kadian YS, Singh M, Rattan KN. The role of tunica vaginalis flap in staged repair of hypospadias. Asian J Urol. 2017;4:107-10.  Back to cited text no. 14
Nandoo Y.R. Role of tunica vaginalis interpositìon layer in hypospadias surgery. Indian J Plast Surg. 2006;39:15-6.  Back to cited text no. 15
Kirkali Z. Tunica vaginalis: an aid in hypospadias surgery. Br J Urol. 1990;65:530-2.  Back to cited text no. 16
Paltaras J.G., Rushton H.G. Penile torgue after the use of tunica vaginalis blanket wrap as an aid in hypospadias repair. J Urol. 1999;161:934-5.  Back to cited text no. 17


  [Figure 1], [Figure 2]


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