The de-epithelialized flap and its influence on hypospadias repair

Post-urethroplasty complications in hypospadias repair: a systematic review and meta-analysis comparing polydioxanone and polyglactin sutures

Background

Polyglactin (PG) and polydioxanone (PDS) sutures are extensively used based on the surgeon's preference. The development of post-reconstruction urethrocutaneous fistula (UCF) is variably attributed to the choice of suture material for urethroplasty. This meta-analysis compares complications of hypospadias repair using PG and PDS sutures.

Methods

The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors conducted thorough searches in databases including MEDLINE, EMBASE, CENTRAL, Scopus, Google Scholar, and clinical trial registries. Outcome measures included UCF, meatal stenosis, wound infection, urethral stricture, glans dehiscence, and overall complications. Quantitative analysis was used with fixed or random-effect models to find the pooled risk ratio and I2 heterogeneity.

Results

The criteria for inclusion were met by five comparative studies with the inclusion of 1244 children altogether. Pooled analysis failed to show a statistically significant difference in the incidence of meatal stenosis, urethral stricture, wound infection, and total complications using PG and PDS sutures. However, it showed a reduction in the incidence of UCF with PDS suture hypospadias repairs (risk ratio=0.66, 95% CI 0.48 to 0.92).

Conclusions

PDS sutures are associated with decreased incidence of UCF than PG after hypospadias repair. The incidence of meatal stenosis, urethral stricture, wound infection, and total complications was not affected by the type of suture material used for repair.

Clinical implications

This meta-analysis suggests decreased incidence of UCF when PDS sutures are used for hypospadias repair which may impact the choice of suture material for repair.

PROSPERO registration number

CRD42023409710.

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

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 the second stage ranged between 6 and 30 months (mean 19.7; median 18.5). Post-operative complications were detected in 7 cases (41%). 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

Applying the de-epithelialized double-breasting skin closure can offer alternative second layer coverage for the neourethra along the penile shaft in staged repair of proximal hypospadias.

Retrograde urethrography in children: a decade of experience at a children's hospital

BACKGROUND

Retrograde urethrography (RUG) is a radiologic procedure that optimizes imaging evaluation of the urethra, particularly in settings of difficulty with micturition or urethral injury.

OBJECTIVE

To review our experience with RUG at a large pediatric radiology practice.

MATERIALS AND METHODS

We conducted a retrospective review of medical records and fluoroscopic images of RUGs performed from January 2010 to December 2020.

RESULTS

We identified 180 RUG exams (median frequency 17 exams per year), all in male children (median age 13 years). The most common indications were stricture (42%; n=76), postsurgical evaluation (34%; n=62) and trauma (16%; n=29). The most commonly used catheter was Foley (40%; n=72), with a median catheter size of 5 French (Fr) for infants younger than 1 year, 7 Fr for children ages 1-5 years and 8 Fr for children older than 5 years. About a third of the children (57; 32%) had combined voiding cystourethrography (VCUG)-RUG exams. Water-soluble contrast agent, either 17% or 43% Cysto-Conray, was used. Most RUG exams were normal (46%; n=83). The most common urethral pathology was stricture (30%; n=54), commonly involving a bulbar urethra (n=26). Urethral trauma was seen in 11 children (6%), 10 bulbar and 1 membranous. Most children with stricture were surgically treated (n=40; 74%), whereas most children with trauma were conservatively treated (n=8; 73%). The remaining diagnoses included diverticula, polyps, valves, fistulas and duplications, constituting <17% of our sample; most of these were surgically treated. Four exams (2%) were non-diagnostic. RUG showed 89% sensitivity and 97% specificity compared to cystourethroscopy/VCUG findings. Technical difficulties occurred in 14 (8%) children (e.g., pain or inappropriate catheter seal).

CONCLUSION

Our experience indicates that when catheterization techniques are properly tailored, RUG provides a useful and successful radiologic method of evaluating the pediatric male urethra.

Biologic adjuvant urethral coverings for single-stage primary hypospadias repairs: A systematic review and pooled proportional meta-analysis of postoperative urethrocutaneous fistulas

BACKGROUND

The use of barrier layers between the neourethra and skin is associated with lower rates of post-operative urethrocutaneous fistula (UCF) following hypospadias surgery. Recent studies have evaluated the ability of biologic adjuvant urethral coverings (BAUCs) - namely acellular matrix (AM), tissue adhesives (TAs), and autologous platelet-rich plasma or fibrin (PRP/PRF) - to prevent wound complications following hypospadias surgery. In general, however, these studies are small and conducted at single institutions.

OBJECTIVE

To assess the effect of BAUCs on the rate of UCF following single-stage primary hypospadias repair.

METHODS

We conducted a systematic review of studies reporting the rate of postoperative UCF in pediatric patients undergoing single-stage, primary hypospadias repairs using either AM, TA, or PRP/PRF as a layer interposed between the neourethra and skin. We then performed a pooled proportional meta-analysis of post-operative UCF. Patients within each study who underwent comparable surgery but did not receive a BAUC were used as controls.

RESULTS

10 studies were included in our review. The meta-analysis included 280 patients from 7 studies who underwent hypospadias repairs with BAUCs. The pooled incidence of UCF was 10% (95% CI 6-14%). Mean follow-up ranged 5-23.5 months in the 5/7 studies reporting specific durations, and ≥6 month and 14-30 months, respectively, in the other two studies. Patients in whom a BAUC was used had significantly lower odds of UCF than control patients (OR 0.39, 95% CI 0.24-0.64, p = 0.0002). In subgroup analyses, significant superiority held for AM and TA; proximal or penoscrotal cases; transverse preputial island flap (TPIF) technique; when both cases and controls had local flaps; and when neither cases nor controls had flaps.

DISCUSSION

The use of BAUCs was associated with decreased rates of post-operative UCF in single-stage primary hypospadias repairs and may be most beneficial in more severe cases and when used in addition to local flaps or when using a flap is not possible. In 2/3 studies of PRP/PRF and 2/4 studies of tubularized incised plate (TIP) technique, dartos flaps were used in controls but not BAUC patients, which may explain the lack of benefit demonstrated for these subgroups. This meta-analysis is limited by the quality of evidence in the included studies, which are not uniformly randomized. Furthermore, the follow-up durations and methods for assessing complications are not standardized between included studies.

CONCLUSION

The meta-analysis herein suggests that using BAUCs may reduce UCF rates following hypospadias surgery. Rigorous prospective evaluation is needed to validate this benefit.

A simple technique to repair distal and mid-shaft hypospadias using a de-epithelialized Byars' flap

OBJECTIVE

To describe standard and modified de-epithelialized Byars' flap techniques in tubularized incised plate urethroplasty and evaluate postoperative outcomes.

METHODS

We retrospectively evaluated data for 404 primary hypospadias repair patients who underwent standard (Group A) or modified (Group B) urethroplasty between January 2016 and 2021. Group B's data were analyzed to evaluate whether our modified technique was effective for all hypospadias types.

RESULTS

There was no difference in the ratio of different hypospadias types between Groups A (n = 145) and B (n = 259). Median follow-up duration was 35 months. Fistula occurred in 19 patients in Group A and 12 in Group B (statistically significant difference). The total complication rate was statistically significantly different between the groups. In Group B, 3/142 patients with distal hypospadias developed urethrocutaneous fistula vs 4/95 with mid-shaft hypospadias and 5/22 with proximal hypospadias. No difference was noted between the distal and mid-shaft groups. Significant differences were observed when comparing distal and mid-shaft groups with the proximal group; total complication rates were similar. Glans dehiscence and meatal stenosis rates were similar between Groups A and B, and among the hypospadias phenotypes.

CONCLUSION

Our modified procedure is simple to perform and yields excellent results in distal and mid-shaft hypospadias repair.

Novel use of Asopa technique for penile urethrocutaneous fistula repair

PURPOSE

To evaluate the feasibility of ventral urethrotomy, dorsal inlay (Asopa) technique in management of urethrocutaneous fistula. The Asopa technique has been employed for management of urethral stricture repair but has not been described in adult penile urethrocutaneous fistula.

METHODS

This is a retrospective review of IRB-approved databases of patients undergoing urethral reconstruction from two urologic reconstruction units. In this technique, the fistulous tract is circumscribed and excised, leaving a larger ventral urethral defect with healthy edges. The ventral-sagittal urethrotomy is extended, a dorsal urethrotomy made, and a graft inlaid dorsally to augment the urethral caliber prior to tension-free closure of the ventral urethrotomy.

RESULTS

From 2010 to 2019, ten patients underwent repair of urethrocutaneous fistula using the Asopa technique. Median patient age was 33.5 years (IQR 35.5). All fistulae involved penile urethra, eight had concomitant adjacent urethral stricture. Five patients failed prior hypospadias repair, three developed fistulae after surgery for penile urethral stricture, and two developed fistulae after extensive debridement (hidradenitis and Fournier's gangrene). Of these ten patients, oral mucosa graft was used in nine and preputial graft in one to augment the urethra. At median follow-up of 50.5 months (IQR 26.5), 80% (8/10) of patients demonstrated durably patent urethra, with no recurrence of fistula.

CONCLUSION

The Asopa technique is an established option for augmenting urethral caliber for urethral stricture disease. We demonstrate in our series that this technique can be applied to patients with urethrocutaneous fistulae.

Gas (Oxygen) insufflation: A new technique for the visualization of the operative field during hypospadias surgery

OBJECTIVE

Maintaining a bloodless operative field is a crucial step in achieving success and reducing complications in hypospadias surgery. So, far, the most harmless and least damaging technique in terms of penile tissue oxygenation during hemostasis has not still been defined. We aimed to present our new technique of gas (oxygen) insufflation for better visualization of the operative field, and to compare this with the control group, where a wet sponge was used for hemostasis.

MATERIAL AND METHODS

A total of 28 patients with primary distal hypospadias who were treated with modified tubularized incised plate urethroplasty (TIPU) repair between March 2017 and October 2018 were evaluated prospectively. The patients were divided randomly into two groups. While only a wet sponge was used to clean hemorrhagic area in the control group (group I) (n=12), gas (oxygen) insufflation was used to visualize the operative field during the operation in the patient group (group II) (n=16). The patients' ages, operation time, follow-up durations, and postoperative complications were documented and statistically compared.

RESULTS

The mean ages and follow-up durations of both groups were found to be similar. The operation time was statistically shorter in group II than in group I (p=0.01). Eight patients (66.7%) in group I showed a complication, while 2 patients (12.5%) in group II showed a complication (p=0.005).

CONCLUSION

The gas (oxygen) insufflation technique provides good visualization during the dissection step of hypospadias surgery and results in better postoperative outcomes. Therefore, we think that this technique can be preferred as an alternative method for the visualization of the operative field in hypospadias surgery.

Tourniquet and adrenaline use in hypospadias surgery: a survey on the current practice in Turkey

OBJECTIVE

Aim of the study is to determine the hemostatic techniques among pediatric urologists in Turkey.

MATERIAL AND METHODS

Questionnaire forms were sent to 459 pediatric urologist by e-mail.

RESULTS

Ninety eight of 459 participants answered the questionnaire forms. Eighty-one (84.4%) of the participants were using tourniquet. The participants who didn't use tourniquet stated their justifications as follows: lack of need (n=10: 66.7%), development of edema, ischemia, delay of wound-graft healing and fistula risk (n=5: 33.3%). The indications of tourniquet use were stated as follows: penile (91.4%: n=74), distal (72.8%: n=59), penoscrotal (55.6%: n=45) hypospadias; fistula repair (33.3%: n=27), cripple hypospadias (33.3%: n=27), repair with flaps (30.9%: n=25), repair with grafts (27.2%: n=22), and isolated penile curvature (21%: n=17). Most commonly used tourniquet material (49.9%) was latex glove. Erection test was applied by 43.8% of participants. Scalp vein set was the most commonly (54.8%) used injector during erection test. Only 9.4% of participants were using adrenaline. Adrenaline dosages used at 1/100.000 dilution by 55.6%, lidocaine with 1/100.000 adrenaline by 44.4% of participants.

CONCLUSION

Beside a few experimental ones there is a paucity of studies that can serve as a guideline for using these techniques in the literature. There is a necessity of realizing prospective, randomized studies with long-term follow up to evidence that postoperative complications could develop secondary to hemostatic techniques and also to facilitate safe use of these techniques.

The Megameatus, Intact Prepuce Variant of Hypospadias: Use of the Inframeatal Vascularized Flap for Surgical Correction

INTRODUCTION

The megameatus intact prepuce (MIP) variant of hypospadias is a rare variant of hypospadias that is diagnosed either early at the time of circumcision or later as the foreskin is retracted. The true incidence of the anomaly is difficult to determine precisely as some patient never come to medical attention but is felt to under 5% of all cases of hypospadias. The purposes of this study are to review the embryology and clinical findings of MIP and then, in light of a personal experience, present a series of patients evaluated for MIP who were treated with a modification of the Mathieu technique.

MATERIALS AND METHODS

A PubMed search of all articles in the MIP variant of hypospadias was carried out followed by an exhaustive review of the literature. The charts of all patients evaluated and treated at Boston Children's Hospital by MC between 2007 and 2017 were reviewed retrospectively. The patients were divided into two groups: those who underwent the standard procedure and those who underwent a repair using a modification of the Mathieu procedure using an inframeatal flap.

RESULTS

The embryologic explanation of the MIP variant is not clear but failure of the distal, glanular portion of the urethra to tubularize results in spectrum of abnormality characterized by a deep glanular groove and an abnormal opening of the urethra anywhere from the mid-glans to a subcoronal location. Surgical repair is complicated by a wide distal urethra which may be injured if not properly identified. Overall good outcomes were noted with one patient experiencing a urethra cutaneous fistula in the first group and one patient having a mild glans dehiscence in the second.

CONCLUSION

The MIP variant of hypospadias is a rare variant of hypospadias that presents as a spectrum of urethral anomaly. Surgical repair may not always be necessary but if surgical repair is carried out, the Mathieu technique modification may offer better anatomic delineation of the urethra and will provide an extra layer of tissue to cover the reconstructed urethra. Low complication rates should be expected with adequate functional outcome such as a normal urinary stream. In addition, criteria for selecting patients for surgical repair are provided.

A comparison between tourniquet application and epinephrine injection for hemostasis during hypospadias surgery: The effect on bleeding and postoperative outcome

OBJECTIVE

To compare tourniquet application and epinephrine injection for hemostasis during hypospadias surgery in terms of bleeding and complications.

METHODS

Between April 2013 and September 2014, patients who were admitted for hypospadias repair were divided by random allocation into either a diluted epinephrine injection (DE) group or tourniquet application (T) group for hemostasis during the procedure. In the T group, a rubber band was applied at the base of the penis after skin dissection, and in the DE group, epinephrine 1/100,000 was injected along the incision lines. The patients' ages, urethral defect lengths, pre-operative, intraoperative and postoperative variables were compared between the two groups.

RESULTS

A total of 70 patients (35 in each group) were enrolled into the study. The mean ages and preoperative variables were not significantly different. Average blood loss was 23.51 ± 15.36 cc in the tourniquet group and 15.99 ± 10.00 cc in the epinephrine group, and was significantly higher in tourniquet group (P = 0.022); however, the mean operative time was not significantly different. Postoperative complications, described as Clavian classification, were reported in eight patients (23%) in the T group and 10 patients (30%) in the DE group, which was not significantly different.

CONCLUSION

Epinephrine injections minimize operative bleeding without significant harmful effects on postoperative outcomes; therefore, it could be considered to be a safe and effective method for preparation of a bloodless field during hypospadias surgery.

Preliminary experience with the use of an autologous platelet-rich fibrin membrane for urethroplasty coverage in distal hypospadias surgery

OBJECTIVE

Platelet-rich fibrin (PRF) has been shown to have structural and biological properties that promote tissue healing. This prospective study evaluated the feasibility, safety, and efficiency of using autologous PRF membrane for urethroplasty coverage in distal hypospadias.

MATERIALS AND METHODS

We prospectively included 33 patients with distal hypospadias operated on between June 2010 and September 2011. Urethroplasties were performed using the Duplay technique. During surgery, 5-10 ml of patient's blood was collected and immediately centrifuged. A PRF clot was transformed into a dense fibrin membrane with a particular cell content and architecture. This membrane was applied and sutured over the urethroplasty. The perioperative course and complications were recorded. Outcomes were compared with those in a control group of children undergoing the same procedure, but with another mean of coverage.

RESULTS

With a median follow-up of 8 months (range, 6-18 months), urethral fistula occurred in 2/33 patients. No other complication was noted. No complication related to the blood sampling was reported. There was no statistically significant difference with the control group (p = 0.65).

CONCLUSION

The PRF patch seems to be a safe and efficient covering technique. Thus, procedure is an additional approach to coverage for hypospadias surgery, and may help to reduce the incidence of postoperative complications when coverage healthy tissue is not available.

Management of urethrocutaneous fistula after hypospadias surgery - An experience of thirty-five cases

Introduction:

The commonest complication following hypospadias repair is occurrence of urethrocutaneous fistula. The smaller fistulas (<2 mm) are easier to close with a simple closure whereas larger ones (>2 mm) with good vascular surrounding skin require a local skin flap closure for avoiding overlapping suture lines. For the recurrent/larger fistulas with impaired local surrounding skin - incidence of recurrence is significantly reduced by providing a waterproofing interposition layer.

Aims:

To study the effect of size, location, number of fistulas and surrounding tissues in selecting the procedure and its outcome. To identify various factors involved in the recurrence and to formulate a management in the cases where recurrence has occurred.

Patients and Methods:

This study of 35 cases of urethrocutaneous fistula repair was done from July 2006 to May 2009 to achieve better results in fistula management following hypospadias surgery.

Statistical analysis used:

X² test and Fisher's exact test.

Results:

The overall success rate for fistula repair at first attempt was 89% with success rates for simple closure, layered closure and closure with waterproofing layer being 77%,89% and 100%, respectively. The second attempt success rate at fistula repair for simple closure and closure with waterproofing layer were 33% and 100%, respectively. At third attempt the two recurrent fistulas were managed by simple closure with a waterproofing interposition layer with no recurrence. All the waterproofing procedures in this study had a success rate of 100%.

Conclusions:

The treatment plan for a fistula must be individualized based on variables which has an effect on the outcome of repair and to an extent dictates the type of repair to be performed. The significantly improved success rates with the addition of a waterproofing layer suggests the use of this interposition layer should be done at the earliest available opportunity to prevent a reccurence rather than to reserve it for future options.

Subcutaneous frenulum flap (SCUFF) for iatrogenic or primary megameatus and reoperative hypospadias repair

OBJECTIVES

Megameatus, whether primary or iatrogenic, can be managed by one of several tubularization techniques. Repair after prior circumcision or after failed hypospadias repair can occasionally be challenging because of the lack of local vascularized tissues. The use of an inferiorly based frenulum flap as a buttressing layer for these unusual repairs is described.

METHODS

An inferiorly based island flap of frenulum skin is de-epithelialized and advanced over the urethral repair.

RESULTS

The procedure has been used in 5 cases: two reoperative hypospadias repairs, one primary megameatus repair, and two repairs of traumatic fistula/megameatus after circumcision. Overall, the cosmetic results were excellent, with one postoperative fistula.

CONCLUSIONS

This is a straightforward technique providing added vascularity in these relatively unusual cases in which a dorsal or meatal-based flap is not convenient or feasible.

A comprehensive analysis of a tubularized incised plate hypospadias repair

OBJECTIVES

To critically evaluate my experience using a modified tubularized incised plate (TIP) hypospadias repair.

METHODS

Sixty-four boys, 7 months to 11 years old (mean age 22.9 months), underwent a TIP urethroplasty by a single pediatric urologist for primary hypospadias. The hypospadias defects included 53 distal and 11 midshaft. The incision of the urethral plate was always deep and proximal but never extended the entire length of the plate. In 25 cases (39%), the incision was less than one half the length of the urethral plate. A two-layer urethroplasty was always obtained. A vascularized subcutaneous pedicle was always placed onto the urethroplasty. This pedicle was ventrally based in 56 of the repairs (87.5%). Postoperative urethral stents were not used in 52 boys (81.3%), including 7 with midshaft repairs. All children were scheduled for a postoperative evaluation at 1 month. A confidential phone survey was later conducted by someone other than the surgeon. The parents were asked if they were satisfied or dissatisfied with the direction and caliber of the urinary stream, chordee correction, and overall general appearance.

RESULTS

The clinical evaluation was performed in 54 boys (84.7%) not earlier than 1 month after the repair. The examination revealed a conical glans, slit meatus, circumferential mucosal collar, and a straight phallus in all cases. No cases of fistula, stricture, or dehiscence occurred. A follow-up phone survey 3 to 43 months (mean 21 months) postoperatively was obtained from the parents of 40 patients. Without exception, the parents were satisfied with the urinary stream, chordee correction, and overall appearance.

CONCLUSIONS

Without incising the entire urethral plate and stenting the repair, a TIP urethroplasty can still be expected to provide excellent results when correcting distal and midshaft hypospadias. Parents were satisfied with the long-term cosmetic and functional results obtained with a TIP urethroplasty.

Tubularized incised plate urethroplasty for proximal hypospadias

OBJECTIVE

To review our experience of using the tubularized incised plate (TIP) urethroplasty (useful in the treatment of distal hypospadias) to treat proximal hypospadias.

MATERIALS AND METHODS

From March 1997 to March 2000 primary repairs were carried out on 40 boys (mean age 4.5 years) with proximal hypospadias. After degloving the penile skin the meatus was at the mid-shaft in 10 boys, at the proximal penile shaft in 11, at the penoscrotal junction in 16, at the scrotum in two and at the perineum in one. The 21 patients with a mid or proximal shaft meatus were categorized as having mid-shaft and the other 19 as having posterior hypospadias. Tunica albuginea plication (TAP) was used to correct residual ventral curvature. The method of urethroplasty was adapted from that described by Snodgrass. The key step of the TIP repair is a midline incision of the urethral plate; a subcutaneous tissue flap dissected from the inner prepuce is used to cover the neourethra. An 8 or 10 F nasogastric tube is used as a urethral stent and removed 7 or 8 days after surgery. Follow-up endoscopy and urethral sounding were carried out in 17 of the patients aged < 6 years; the mean follow-up was 12.5 months.

RESULTS

TAP was used to correct penile curvature in nine (23%) of the patients. Excluding stenosis, the TIP repair was successful in 20 (90%) of those with mid-shaft and in 16 of the 19 with posterior hypospadias; for all complications the respective rates were 19 of 22 and 15 of 19. The overall success rate was 88% for all 40 patients with proximal hypospadias; a urethrocutaneous fistula occurred in two of those with mid-shaft and three of those with posterior hypospadias. Urethral meatal stenosis occurred in four (12%) of the patients (two in each group); two were associated with a fistula and the other two had only mild meatal stenosis. The overall complication rate was 17.5% (three and four in the mid and the posterior hypospadias groups, respectively). The meatal stenosis was managed by simple dilatation in three and meatoplasty in one patient. Endoscopically, the mucosa of neourethra was pink and smooth in all 17 patients assessed. The calibre of all 17 neourethra was > or = 8 F and in 13 was > or = 10 F.

CONCLUSION

TIP repair is a reliable method for treating both mid-shaft and posterior hypospadias.

An investigation into the role of waterproofing in a two-stage hypospadias repair

In our unit a two-stage procedure, using a full thickness preputial graft, has been adopted as the method of choice for the repair of hypospadias proximal to the coronal sulcus. In 1993 an audit was undertaken to establish our complication rate for this procedure. Twenty-two consecutive patients who completed a two-stage repair between January 1988 and December 1993 were studied. An unacceptably high fistula rate was identified (63%, 14/22 cases). Consequently our technique was modified by transposing a vascularised flap of preputial areolar tissue over the urethral suture line, at the time of urethroplasty. A second group of 22 consecutive patients, operated upon between January 1994 and July 1997, were subsequently investigated and a dramatic improvement in the fistula rate was demonstrated (4.5%, 1/22 cases). These cases represent a subgroup of almost 200 cases, which the senior author has managed over the last 10 years. The senior author undertook or supervised the surgery in all 44 cases, which were the focus of this study, and the introduction of a waterproofing layer represents the only change in technique.