Detubularized pedicled vaginal onlay flap urethroplasty: a new method for hypospadias repair of ambiguous genitalia.

PURPOSE: We introduce the detubularized pedicled vaginal onlay flap urethroplasty for single stage repair in ambiguous genitalia with perineoscrotal hypospadias and accompanying vagina, and report its preliminary surgical outcome.

MATERIALS AND METHODS: A total of 10 children with severe perineoscrotal hypospadias and genital ambiguity presenting with vagina and urogenital opening underwent single stage reconstruction with vaginal onlay urethroplasty. Through the posterior sagittal or abdominoperineal approach the vagina was released and pulled out, with care taken to preserve its vascular pedicle. Two incisions were made along the lateral margins of the vagina, reaching each other on the upper surface of the vaginal base, converting the vagina into a longitudinal flap twice as long as its original length. The vagina was then trimmed and reconfigured into a suitable sized flap to cover the urethral plate and form a neourethra with the onlay technique. The onlay-tube-onlay technique was also used in 2 patients with insufficient urethral plate. In 5 cases severe ventral chordee was also corrected concurrently with free vaginal graft to the ventral corpus cavernosum without further dorsal plication.

RESULTS: The first 3 operations using the posterior sagittal approach failed due to improper surgical access, and the vagina was discarded. However, we achieved a satisfactory outcome with no failure after switching to an abdominoperineal approach. Immediate postoperative and short-term results revealed no urethrocutaneous fistula, urethral breakdown or necrosis at the distal end of the neourethra. Only 1 patient presented with severe mid shaft ring stricture, which required surgical revision.

CONCLUSIONS: Incorporating the vagina of intersex patients into urethroplasty using detubularized pedicled vaginal onlay flap seems to provide a safe and practical method to treat severe hypospadias with genital ambiguity. Short-term satisfactory results are achievable by choosing the proper surgical approach and preserving the vaginal blood supply. However, longer followup in a large series of patients is needed before applying this method to clinical practice.