Repair of posterior hypospadias with severe chordee: Miopti

Generally the success rate of OIF (onlay island flap) is superior to TPIF (tubularized preputial island flap). However OIF need mandatory two separate suture lines in making urethra and can not be applied in cases having severe chordee. We modified OIF and TPIF, and developed MIOPTI (meatal island onlay proximal tubularized island flap). Ventral penile skin is incised transversally at 5-10mm proximal to the border of glans, carried vertically, and ext-ended in circumferential fashion at the coronal sulcus. Chordee including the proximal urethral plate is removed. Rectangular vascularized flap is made on the dorsal skin and tubed except the distal 15-20mm reserved for distal onlay reconstruction. The proximal end of the tube is anastomosed to the original urethra. Two longitudinal parallel incisions are made on the glandular groove, and the distal opened part of tube is anastomosed to thus formed glandular urethral plate. In cases when vascularized flap is not sufficient in length to make urethra, the scrotal or perineal skin is also tubed, anastomosed to the proximal end of tube, and the vascularity is reinforced by wrapping with tunica vaginalis flap. If necessary, penoscrotal interposition is corrected in the same stage. MIOPTI technique was performed in 45 patients (mean age 1.9 years) where 11 were proximal penile, 20 penoscrotal, 10 scrotal and 4 perineal hypospadias. In 22 patients, glandular urethral plate was used, in 23 patients both glandular urethral plate and tunica vaginalis flap were used. Penoscrotal interposition was simultaneously corrected in 5 penoscrotal, 10 scrotal and 4 perineal hypospadias. Short-term complications were mild urethrocutaneous fistula in 3 cases. All patients have good cosmetic and functional results at 6 months followup. MIOPTI can offer the advantages 1) prevent meatal stricture, 2) avoid urethrocutaneous fistula caused by meatal stricture, compared to TPIF, 3) decrease the number of suture lines, 4) completely remove chordee, compared to OIF, 5) obtain the distal urethral shape similar to normal fossa navicularis. And the combined use of tunica vaginalis flap could improve the vascularity of the proximal circumferential anastomotic site and promise high success rate in severe hypospadias with penoscrotal interposition.