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The value of double dartos flaps to protect tubularized incised plate urethroplasty

Mohamed Ramadan Abdallah¹, Mohamed Ibrahim Naga², Ashraf A. Alnosair², Ahmed H. Al-Salem²
¹Pediatric Surgery Unit, Sohag Faculty of Medicine, Sohag, Egypt
²Department of Pediatric Surgery, Maternity and Children Hospital, Dammam, Saudi Arabia



Background: The TIP procedure has become the procedure of choice to repair a variety of hypospadias without chordee. The TIP procedure was however associated with a relatively high incidence of fistula and a variety of techniques were adopted in an attempt to reduce this. This is a review of our experience with TIP procedure and protective double dartos flaps.

Methods: Over a 6-year period (June 2008- June 2013), 98 children with hypospadias underwent TIP urethroplasty with double dartos flaps. Their records were reviewed for type of hypospadias, technique of repair, hospital stay and complications.

Results: 98 children with hypospadias (44 coronal, 29 subncoronal, 5 distal penile, 7 mid-penile and 3 proximal penile) had TIP repair which was reinforced with double dartos flaps. Their age at the time of repair ranged from 5 month -7 years and 3 months (mean 2.4 years). On follow-up ranging from 9 months-2 years (mean 1.5 years), 3 (3.1%) developed fistula and 2 (2%) developed mild meatal stenosis that responded to dilatation.

Conclusions: TIP urethroplasty with double dartos flaps is safe and simple single-stage operation in the management of different types of hypospadias without chordee. It has good functional and cosmetic outcome and low complication rates.

Key words: hypospdias, urethroplasty, tubularized incised urethroplasty, Dartos flap, fistula, stenosis



Ahmed H. Al-Salem
P. O. Box 61015
Qatif 31911
Saudi Arabia
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The aim of hypospadias repair is to achieve a good urinary stream through a normal looking penis with a good size and site urethral meatus. The TIP has become the procedure of choice to repair all types of hypospadias without chordee [1, 2, 3]. The initial results of the TIP procedure were good but continued to have a relatively high incidence of urethral fistula ranging from 10-20% [1, 2, 4, 5, 6, 7, 8, 9, 10, 11]. A variety of techniques were used to try and reduce the relatively high incidence of urethral fistula [12, 13, 14, 15]. This is a report of our experience with TIP procedure that is reinforced using double dartos flaps for the management of different types of hypospadias.

Patients and methods

Over a period of 6-year (June 2008- June 2013), 98 children with hypospadias underwent TIP urethroplasty with double dartos flaps. In all, the urethroplasty was done using a slight modification of TIP as described below. A size 6.0 vicryle sutures were used for the urethroplasty. The datos flap was dissected and divided in the midline, one on each side. The two flaps were sutured on each other. A size 8 Foley’s catheter was used in all of them and this was left indwelling for one week. A bandage dressing was used in all of them and all were covered with antibiotics till the catheter was removed.

Surgical technique (Figures 1, 2, 3 and 4): The foreskin is retracted and a circular incision is made on the dorsal aspect of the penis about 0.5 cm distal to the glans penis (Figures 1a and 1b).

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Figure 1a and 1b: Clinical photographs showing subcoronal hypospadias. Note the good deep urethral plate. Note also the incision which encircled the urethral meatus

This is continued ventrally to encircle the urethral meatus. This is deepened and the penis is degloved. The dartos flap is prepared at this stage starting from the end of the foreskin and only a thin layer is dissected to preserve the skin in case a Bayer’s flap is required to cover skin defects ventrally (Figure 2a). Once the dartos flap is dissected and sufficient length is obtained, the flap is divided in the midline (Figure 2b).

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Figure 2a and 2b: Clinical photographs showing the already dissected dartos flap from the prepuce skin that was divided in the midline.

At the end two dartos flaps are ready, one on each side. At this stage, a tourniquet is applied to minimize blood loss. The urethroplasty is made by incising the urethral plate on each side all the way up to the tip of the future external urethral meatus (Figure 3).

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Figure 3: Clinical photograph showing the already performed urethroplasty using interrupted subcuticular 6.0 vicryle sutures. Note the tourniquet used at this stage and a size 8 Foley’s catheter. Note the external urethral meatus surrounded by normal glans skin to avoid stenosis.

This is dissected to mobilize the urethral plate and the urethral plate is incised in the midline. The new urethra is made over a size 8 Foley’s catheter using 6.0 subcuticular vicryle sutures. We use interrupted rather than continuous subcuticular sutures. This makes approximation of sutures more accurate. We start suturing from the future meatus distally and move proximally and the first stich is inserted just prior to the tip of the new urethra. This leads to folding of the most distal part of the glans and the whole new meatus is lined by normal glans skin. This is an important point in reducing the incidence of meatal stenosis. The two dartos flaps are then sutured to cover the new urethra, one on each side to have a double dartos cover (Figures 4a and 4b).

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Figure 4a and 4b: Clinical photographs showing the double dartos flaps already sutured and the two wings of glans sutured together.

The glans is sutured using a single layer of vicryle 5.0. Circumscion is done and dressing is applied using a bandage to avoid postoperative hematoma and edema (Figures 5a, 5b and 5c).

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Figures 5a, 5b and 5c: Clinical photographs showing the completed urethroplasty and the dressing applied.


98 children with hypospadias had TIP repair which was reinforced with double dartos flaps. Their age at the time of repair ranged from 5 month -7 years and 3 months (mean 2.4 years). The distribution of hypospadias according to site was as follows: 44 coronal, 29 subcoronal, 5 distal penile, 7 mid-penile and 3 proximal penile. On follow-up ranging from 9 months-2 years (mean 1.5 years), 3 (3.1%) developed fistula and 2 (2%) developed mild stenosis that responded to dilatation.


Hypospadias is a common congenital defect with an incidence of 0.8-8.2 per 1000 live male births with an average of 3.2 per 1000 live male birth [16]. The abnormal urethral meatus can be located anywhere from the glans to the perineum but in the majority of cases (>80%), the urethral opening is located distal to the midshaft of the penis. There are several techniques to repair hypospadias. In 1994, Snodgrass introduced the TIP (Tubularized Incised Plate) urethroplasty to correct distal penile hypospadias has revolutionized the surgical management of hypospadias and since then it has become the most popular procedure to repair hypospadias [1]. This is attributed to its low complication rate, good cosmetic result, and technical simplicity. The incised urethral plate increase the caliber of the new urethra without compromising the blood supply of the urethral plate. This heals by reepitheliaIization and without fibrosis. The indications for TIP urethroplasty has extended and currently the TIP urethroplasty is used for all types of hypospadias with a good urethral plate of adequate width and no or minimal chordee. The TIP procedure can be used also for redo urethroplasties and the contraindications to TIP urethroplasty include severe chordee, previous resection of the urethral plate and scarring of the urethral palate.

Metal stenosis is one of the known complications of the TIP urethroplasty. The incidence of meatal stenosis is however variable ranging from 0% to 14% [1, 4, 8, 12, 13, 14, 15]. Elbarky, advocated regular urethral calibration in all the patients after the TIP urethroplasty [20]. Meatal stenosis was seen in 2% of our patients and we like others feel that regular calibration is painful and unnecessary [21]. We feel the site of insertion of the first stich in the urethroplasty is important. This is inserted just before the tip of the new urethra which leads to out folding of the glans skin resulting in a urethral tip that is lined by normal glans skin which reduces the incidence of meatal stenosis. The edge of this out folded part are sutured to the wings of the glans which further widen the new external urethral meatus. Tubularizing the urethral plate too far distally can cause narrowing of the external urethral meatus even in the absence of scarring.

We use a Foley’s catheter rather than a urethral stent. The Foley’s catheter has a balloon which prevent its inadvertent removal and also prevent forceful urination against the urethroplasty. The use of a Foley’s catheter also avoid taking a stitch at the dorsal aspect of the glans to fix the stent which can leave a permanent mark on the dorsum of the glans.

Another common complication of urethroplasty is urethrocutaneous fistula. The incidence of urethrocutaneous fistula is variable ranging from 0%- 21% (mean 5.9%) [1, 2, 4, 5, 6, 7, 8, 9, 10, 11]. Several factors contribute to fistula formation. These include the surgical technique used to repair hypospadias, the site of urethral fistula, the surgeon experience, the patient age at the time of urethroplasty, delicate tissue handling, and the use of dartos flaps for urethroplasty coverage. The TIP urethroplasty is known to be associated with a relatively low incidence of urethrocutaneous fistula. In the past, the TIP urethroplasy was associated with a high fistula rate (14%) but this decreased to about 5% following the use of a dartos flap [22, 23, 24, 25]. Snodgrass has reported that his fistula rate reduced from 33 to 11% when performing two-layer urethroplasty in proximal hypospadias [26]. According to Snodgrass’s experience, the fistula rate reduced to almost 0% when in addition to two-layer neourethra closure, the urethroplasty was covered with a tunica vaginalis flap instead of a dartos flap [27]. Cheng et al, reported <1% complication rate for distal hypospadias in more than 400 patients and have suggested a two layer closure of the neourethra to minimize the fistula rate [28]. Closure of the first layer is done in a running subcuticular fashion with efforts made to invert the epithelium completely. The second layer incorporates the carefully preserved periurethral vascularized tissue.

In our series, 3 (3.1%) developed urethrocutaneous fistula. We feel the reason for this low fistula is the use of double dartos flaps to cover the neourethra. A single layer of dartos flap was used to cover the neourethra but this was associated with a slightly higher incidence of urethrocutaneous fistula. We do not use a tunica vaginalis flap as suggested by Snodgrass. We feel that a dartos flap is readily available and easily harvested and transferred ventrally.

Since most of the patients with midshaft and proximal hypospadias have a supple urethral plate, a midline incision consistently widens the plate and enables tubularisation. This makes TIP urethroplasty a versatile technique in repairing the proximal hypospadias as well [29, 30]. We have expanded the use of TIP urethroplasty to include those with midshaft and proximal hypospadias. We feel the two contraindications to TIP urethroplasty are the presence of severe chordee requiring plate excision to straighten the penis and an unhealthy urethral plate that appears thin or is insufficiently widened after incision.

In conclusion, TIP urethroplasty should be the procedure of choice to correct distal hypospadias and can be used to correct cases of midshaft and proximal hypospadias without chordee. It is a simple procedure that gives excellent functional and cosmetic results. It is associated with a fairly low rate of complications. The incidence of urethrocutaneous fistula can be reduced by using a double dartos flaps harvested from the foreskin and transferred ventrally.




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