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Bizic et al. Plast Aesthet Res 2022;9:14 https://dx.doi.org/10.20517/2347-9264.2021.102 Page 3 of 12

penile curvature and maximal straightening and lengthening of the penis, while the second stage included
penile urethra reconstruction using buccal mucosa graft or hairless penile skin flap in combination with
scrotal skin flap, or tubularization of the penile skin flap. Patients were instructed to perform either
electrolysis or laser epilation on the marked area of the scrotum for permanent hair removal before second
stage of epispadias repair. Prior to the inclusion in the study, all patients and/or their legal guardians gave
their written consent to study participation and permission to have their genitalia photographed
anonymously.

The patients from Group A were divided into three subgroups according to epispadias severity: penopubic
epispadias (Group A1, two patients), midshaft penile epispadias (Group A2, nine patients), and distal penile
(glanular) epispadias (Group A3, seven patients).

All patients underwent preoperative evaluation and physical examination. In all patients, the surgery was
performed in general anesthesia. In patients in Group A, caudal analgesia was additionally administered
while epidural catheter was used in older patients. Intravenous antibiotic therapy was administered
preoperatively, according to the patient’s weight.

Operative technique
The patient was placed in a supine position. In all patients from Group A, the penile disassembly technique
was used with the aim to restore all penile entities in a one-stage procedure [Figure 1A]. The stay suture was
placed on each hemiglans carefully to avoid injuring the urethral plate. A circumcision line incision was
made ventrally and a periurethral incision was made dorsally, with careful mobilization of the urethral plate.
In penopubic epispadias, a suprapubic incision was made with the simultaneous bladder neck
reconstruction to achieve continence. The urethral plate was carefully dissected from the corpora cavernosa,
[5]
together with the Buck’s fascia to ensure blood supply and to avoid injury of the urethral plate . Distal
attachment of the urethral plate to the glans was preserved . The neurovascular bundles were carefully
[1]
mobilized together with each hemiglans. Corpora cavernosa were detached completely from the glans and
totally freed to their attachments on the pubic bones [Figure 1B]. The dorsal curvature was then repaired
using a graft if severe to prevent penile shortage. The corpora cavernosa were derotated and approximated
in the midline dorsally [Figure 1C]. The dissected urethral plate was then transposed ventrally and fixed to
the corpora cavernosa [Figure 1D]. The ventrally positioned urethral plate was then tubularized over a
silicone Foley catheter 6-8 Ch (depending on the patient’s age). In cases where the urethral plate is short and
anticipated to present a limiting factor for penile lengthening and straightening, it should be transected and
[1]
transposed ventrally and tubularized and fixed to the corpora cavernosa to prevent retraction .
Hemiglanses were reshaped to have a conical appearance and fixed to the corpora cavernosa using a U
suture. Neurovascular bundles were joined on the dorsal side of the penis, establishing normal anatomical
relations of all penile entities [Figure 1E]. The gap between the upper and lower parts of the urethra could
[1]
be reconstructed using rotational preputial flap if suitable anatomy is present [Figure 1F]. Urethroplasty was
then completed by anastomosis between the tubularized urethra proximally and preputial flap distally over
the urethral stent or catheter [Figure 1G]. The penile shaft was reconstructed using available skin
[Figure 1H]. A suprapubic catheter was introduced into the bladder for two weeks. Oxybutynin was
administered for prevention of bladder spasms. Elastic-adhesive compression dressing was placed around
the penis to prevent swelling and subsequent lymphedema. In two patients who had cryptorchidism,
orchiopexy was simultaneously performed.

In all patients from Group B, isolated redo epispadias repair was performed as a two-stage surgery
[Figure 2A]. The patient was also placed in a supine position. Circumcision incision was made and penile