Comparative analysis of longitudinal dorsal and lateroventral dartos flap in complications prevention in surgical treatment of distal and midshaft hypospadias using snodgrass technique

Background: Hypospadias is the most common congenital anomalies of the male genitalia. Objective: The objective of this study was to assess the role of longitudinal dorsal and lateroventral dartos flap for prevention of complications in surgical treatment of distal and midshaft hypospadias using Snodgrass technique. Material and methods: The study was conducted as a prospective, controlled, open study and included 116 boys of age 11 months to 7 years, with distal and midshaft hypospadias. The patients were divided into two groups, Group A and Group B, with 40 patients each, and a control group, Group C with 36 patients. A preoperative protocol was completed before the patients underwent surgical treatment applying Snodgrass technique. In Group A longitudinal dorsal flap was prepared by deepithelization of hipospadiac prepuce and dorsal penile shaft skin, using the "button-holed" maneuver, hence covering neourethra. In Group B in order to cover neourethra, lateroventral subcutaneous flap was prepared by deepithelization of lateral penile shaft skin and prepuce, whereas no flap was used in the control Group C. Postoperative complications, in particular appearance of urethtrocutaneous fistula were analyzed in follow-up periods of 1, 3 and 6 months. Results: In Group C where no flap was used, the occurrence of fistula was 16,7% with a statistically significant difference (p=0,007) to Group A and Group B where secondary dartos flap was used. Also it was found a statistically significant difference in postoperative penile torsion, more frequent in Group B where lateroventral flap was used in contrast to Group A, where longitudinal dorsal flap dartosa was used (p=0,04). No statistically significant differences were found among the groups when stenosis of the meatus, urethral stricture, oedema, bleeding, hematoma, and other complications were assessed. The overall success rate of surgery in Group A was 96,2%, in Group B 94,1%, and in Group C 86,1%. Conclusion: Based on this study, the following conclusions were made: a) the use of longitudinal dorsal subcutaneous flap and lateroventral subcutaneous flap in surgical treatment of distal and midshaft hypospadias using Snodgrass technique provides a maximum prevention of fistula formation; b) longitudinal dorsal subcutaneous flap is compatible with the anatomical longitudinal direction of the penis, therefore it prevents postoperative penile torsion; c) lateroventral subcutaneous flap provides additional support for prevention of fistula formation, but it may cause postoperative penile torsion; d) Snodgrass urethroplasty represents a versatile, simple, and a single-stage technique in surgical treatment of distal and midshaft hypospadias, with minimal postoperative complications rate and excellent functional and cosmetic result