الفهرس 
Review of literatureOnly 14 pages are availabe for public view
 |  | from | 131 |  |  |
| | | from | 131 | | |
Abstract
The spectrum of hypospadias anomalies includes an abnormal urethral opening, chordee (ventral curvature of the penis), an incomplete prepuce, rotation of the penis, abnormal raphe, and disorganised corpus spongiosum and penile fascia.Worldwide, hypospadias surgery is known to be challenging and technically demanding[31] . Hypospadias is the most frequent congenital urological anomaly, occurring in 1–3 per 1,000 live births. The incidence varies geographically from 1.2 per 1,000 live births in Egypt to 3.9 per 1,000 live births in the United States. Reports have suggested that the prevalence of hypospadias varies across different races, being highest among caucasians, less in Hispanics, and least in blacks[31]. The different degrees of hypospadias require different operations, have different complication rates, and have different prognoses[31]. The primary goal of hypospadias surgery is to have a good functioning penis. This means ensuring that the penis is straight and that the child can micturate from the tip of the penis in a straight adequately wide stream of urine. The second important goal is for the penis to have a normal or near-normal appearance with a slit-like meatus at the tip of the glans[35]. More than 300 methods are described for hypospadias correction. This is partly because of the wide spectrum of hypospadias presentations and partly because no single method produces 100% satisfactory results. In general, the surgeon should use the technique that is suitable for the patient and with which he is most conversant. The best operation for hypospadias correction is the operation that brings the best results. In addition, the surgeon should not shorten an already short penis. In other words, the surgeon needs to master several techniques to use in different situations[48]. In 1994, Snodgrass described the tubularised incised plate (TIP) for repair of hypospadias as a mean to widen and improve mobilization of the urethral plate when performing a Thiersch-Duplay urethroplasty. Since that time many reports have been published describing the success of this modified procedure to repair distal hypospadias lesions. As a result of the popularity of this procedure, many other used techniques such as Mathieu or Transverse Island only, for distal hypospadias will probably be used less and less[69]. Given the relative simplicity of the operative concept, low complication rate and good cosmetic result in distal hypospadias, the tubularised incised plate procedure has been progressively applied to more proximal defects[70]. Two contraindications to TIP hypospadias repair are severe chordee, which requires plate excision to straighten the penis, and an unhealthy urethral plate that appears thin or is insufficiently widened after incision[59]. TIP urethroplasty is a versatile procedure with no more complications than other procedures used in hypospadias surgery. However, its widespread acceptance has arisen from the observation that tubularization of the urethral plate most reliably creates a vertical slit-like neomeatus. Consequently, currently it is the goal of hypospadias repair both to restore good function and normal appearance to the penis[74]. In their review article, Baskin and Ebbers referred to the importance of skin coverage by counting it as one of five sequential steps for the successful repair of hypospadias[7]. This has also been considered by Duckett, who mentioned that one of four goals in the one-stage repair of hypospadias is to cover the penis with skin that is pliable, elastic and symmetrical and preferably non-hair-bearing[8]. The prepuce is an important source of tissues that can be used in different ways in the repair of hypospadias: (1) neo-urethral reconstruction, (2) providing a barrier layer to cover the repair, or (3) providing skin cover to the ventral shaft. Unfortunately, each patient has only one dorsal prepuce, usually serving one function in the repair[11]. Many reports have emphasized the importance of the barrier layer covering the repair before skin closure. In proximal hypospadias repair, a TIP urethroplasty has the advantage of sparing the prepuce which can provide the dartos flap to be used as a barrier. However, this may jeopardize the blood supply of the dorsal skin flaps. In minor forms of hypospadias, these nonviable skin flaps may be considered excess and can be excised; however, in more severe forms these flaps are needed to reconstruct the deficient ventral penile skin.[76]. In Byars’ technique, a wide dartos flap is dissected from the prepuce and dorsal skin to cover the urethroplasty. Next a vertical relaxing incision of the dorsal preputial skin is then followed by ventral midline skin closure simulating the median raphe with continuous running sutures[79]. Skin complication following dorsal dartos flap dissection from the whole prepuce:(A) ischemic ventral skin; (B) healing by secondary epithelialization with mild scaring and subsquent cordee[11]. In modified Byars’ technique, before dissection of the dorsal dartos flap, the prepuce is gently stretched and incised vertically into two halves. The dartos flap is dissected from one half of the prepuce and brought ventrally around the side of the penile shaft to cover the urethroplasty, leaving the other preputial half with intact vascularity to reconstruct the ventral shaft skin. [11]. Here in our study, we noticed a strikingly high incidence of skin complications on using the conventional dorsal dartos flap from the whole prepuce (Byars flap) for covering the TIP urethroplasty. Skin complications occurred in 7 patients (35%), flap necrosis in 5 patients (25%), and development of urethero-cutaneous fistula in 4 patients (20%). But when using a modified approach combining TIP urethroplasty with modified Byars‘ flaps, we notice that the complication rate was much declined; skin complications occurred in 1 patient (5%), flap necrosis in 2 patients (10%), and development of urethero-cutaneous fistula in 1 patient (5%). In the absence of contraindications to a TIP urethroplasty (unhealthy plate, severe chordee)[59], the modified Byars technique combined with TIP described in this study can be used for distal and mid-penile hypospadias that are associated with deficient ventral shaft skin. The cosmetic outcome appears well accepted although being suboptimal in lacking a median raphe. However, this technique helps to avoid skin complications (sloughing and scaring) owing to the reliable vascularity of the skin flap used to cover the shaft ventrum. Penile torsion is prevented by the balance created from rotating a flap on either side of the penis. Also, we have noticed decrease in the urethrocutaneous fistulae, this might be explained by the skin closure being shifted laterally away from the urethral suture line, adding extra security to the barrier layer. Conclusion: TIP urethroplasty is a good procedure with no more complications than other procedures used in hypospadias surgery for distal and midshaft hypospadias. The modified Byars‘ flaps technique is a useful method for skin closure in the repair of distal-shaft and mid-penile hypospadias with deficient ventral skin, with fewer complications than original Byars‘ flap technique, and accepted cosmetic outcome. This approach maximizes the utilization of the prepuce in the repair by providing a barrier layer for the urethroplasty from one preputial half, and a well-vascularized skin flap to cover the ventral shaft from the other half.