De-epithelialized overlap flap to secure urethroplasty in second stage hypospadias repair: Revisiting the Smith technique

Abstract Background: The application of a second layer between the neourethra and skin was a major contribution, which has improved the outcome of hypospadias repair. Here, we report our experience of revisiting the original Smith technique using a de-epithelialized overlap flap to support the urethroplasty in staged hypospadias repair. Methods: The study included primary cases of proximal hypospadias with significant chordee who underwent two-stage repair during the period 2016 through 2021. The ventral curvature was corrected at first stage by excision of the urethral plate, followed by covering the ventral shaft by skin flaps or inner preputial graft. The second stage (Thiersch -Duplay urethroplasty) was performed six months later. The de-epithelialized overlap flap (double breasting) technique was used to cover the neo-urethra in all cases, which was combined with a dartos scrotal flap to cover the proximal neourethra when indicated. Results: The study included 17 boys with proximal hypospadias who underwent two-stage repair. Follow up period after second stage ranged between 6 and 30 months (mean 19.7; median 18.5). Most complications were related to distal/glanular disruptions whether partial or complete (5 cases). One case developed a penoscrotal fistula that was closed surgically. Another case (belonging to the group which used preputial graft in the 1st stage) presented 21 months after the second stage with urethral stricture (penoscrotal). Conclusion: With the trend back to two-stage repairs for proximal hypospadias, applying the de-epithelialized double-breasting skin closure can offer a reliable second layer to support the neourethra along the penile shaft.