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Page 8 of 12 Dávila et al. Plast Aesthet Res 2022;9:31 https://dx.doi.org/10.20517/2347-9264.2021.133

[33]
satisfactory results in the most severe forms of hypospadias. In 2001, Morey published his first experience
with a similar procedure.

Staged techniques
The best application of these techniques is in men who have failed hypospadias surgical attempts, with a
deficient or densely fibrotic urethral plate, or in the presence of LS. These techniques are usually regarded as
more adaptable compared to flap procedures and are especially favored in the presence of LS. In 1995,
Bracka initiated a modern era of staged urethral reconstruction by describing a versatile approach to
[34]
difficult anterior urethral reconstructions . In his procedure, the diseased urethra is completely removed,
and the urethral plate is covered by an onlay graft of oral mucosa.

To the penile urethra and bulbar urethra
Dorsal graft with ventral penile skin flap
In 2001, Morey introduced the principle of augmentation urethroplasty combining OMG and penile
cutaneous flap. He reported salvage of the urethral plate using a dorsal OMG combined with a flap of
[33]
ventral penile skin in men with complex strictures involving the penile urethra . In the initial use of this
new procedure (with mean follow-up to 2.1 years), all four patients voided well and needed no further
intervention. Similarly, Erickson et al. described a single-stage procedure in 14 men with anterior urethral
[35]
strictures using this combination of dorsal onlay OMG with a ventral fasciocutaneous flap.

The average length of the urethral strictures in his patient population was 9.75 cm with 12 (12/14; 85%)
strictures found in the penobulbar segment. At a median follow-up of 2.5 years, the authors published an
overall urethral patency rate of 78% (11/14 patients), although two of these patients (14%) needed an
additional intraluminal maneuver to attain a fairly good urethral caliber. Individuals with longer strictures
seemed to have a higher risk of restricture (12.8 cm vs. 8.7 cm). A similar experience was reported by
Gelman and Sohn when applying this combination of dorsal oral graft with a ventral penile fasciocutaneous
[31]
flap in distal obliterative strictures . Although stricture length was not specified by the authors, various
sizes of OMGs were employed (range, 2-6.5 cm) with all strictures detected in the penile urethra. All 12
patients had good urethral patency on three-month postoperative follow-up cystoscopy and all voided well
at a mean 39-month follow-up.

Dorsal graft with ventral penile skin flap in proximal hypospadias surgery
Surgical reconstruction of proximal hypospadias implies rectifying different basic elements of the
hypospadias complex to optimize long-term success, both functionally and cosmetically. These elements
include ventral penile chordee, proximal implantation of the urethral meatus, ventral skin shortage, atypical
glans morphological appearance, abnormal division of the corpus spongiosum, penile rotation, and
penoscrotal transposition [Figure 6]. In some cases, there is not enough foreskin or penile skin tissue for
surgery, so the choice of the technique will depend on the surgeon’s preference. Staged repairs aim at the
initial rectification of ventral chordee with the fashioning of a new urethral plate using preputial/penile skin
flap or OMG and followed by urethral reconstruction in the next stage [34-36] . A recently described technique
[32]
by Djordjevic et al. used the combination of a longitudinal dorsal island skin flap and OMG [Figure 7].
They employed this surgical procedure in children with hypospadias. Seventeen patients, aged less than two
years old, received this single-stage operation for severe hypospadias (13 penoscrotal and 4 scrotal). This
technique involved a combination of a dorsal OMG with a ventrally applied dorsal island penile cutaneous
flap. Functional and cosmetic success was achieved in 14 patients (82%) at a mean follow-up of 25 months.
Complications occurred in the remaining three patients, specifically urethral fistulation and distal urethral
stricture (18%) .
[32]