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Abstract
Treatment of failed hypospadias can be challenging because of significant scaring and paucity of genital skin; thus, leaving the surgeon with less than ideal material with which to reconstruct the patient.
Initial examination of these patient usually guides our decision of which salvage technique could be used. However final decision is usually made intra-operatively after taking into consideration the amount and location of scarring, the availability and quality of penile skin and quality of urethral plate.
General principles of hypospadias repair should be followed including, minimal use of cautery, avoidance of tension, use of well vascularized tissue, closure in as many as possible, the use of loupe magnification and identification and relief of any obstruction.
Although the principles of repeat surgery are very similar to those of primary surgery. No definite guidelines can be given. The surgical strategy is aiming at multiple goals including orthoplasty (penile straightening), urethroplasty, glanuloplasty, meato-plasty, scrotoplasty and skin coverage.
The corner stone in redo hypospadias repair is the step of urethroplasty (neourethral formation) which may be performed in one or two stages:
One stage repair:
If the urethral plate is presented wide enough, tubularization of the urethral plate is in Thiersch-Duplay technique. When the plate is narrow, Snodgrass withits posterior incision provides a chance for tubularization.
The Snodgrass can be applied in both distal and proximal anomalies. If the urethral plate is so narrow or cannot be used then repair using genital tissue should be planned.
The tissue should be as close as possible to the urethral defect; it should have no or very little scarring and preferably have a mucosal surface instead of skin and it should be easily mobilized. Meatal based, onlay island or tubularized flaps can be used for urethral reconstruction. If the urethral plate is absent and penile skin is not appropriate, tunica vaginalis can be the alternative. Buccal mucosa is readily available as a free flap if the urethral plate and genital tissues not available.