title: Unexpected outcome of a modification of Bracka repair for proximal hypospadias: High incidence of diverticula with flaps.
abstract: BACKGROUND
  Various graft and flap techniques have been proposed for urethral reconstruction in proximal hypospadias repair. The Bracka repair involving the transfer of inner prepuce like a Wolfe graft mostly results in satisfactory results besides a high fistula rate.
  
  
  OBJECTIVE
  The aim was to decrease the high fistula rate with Bracka repair; we wanted to use the advantages of vascularized skin in the Bracka method. The aim of this study was to evaluate our results with this modification.
  
  
  METHODS
  Our modification involves using a flap instead of a graft. In the first stage, chordee was corrected by transection of the urethral plate and dorsal midline plication when necessary. Instead of a graft as suggested by Bracka, inner preputial skin with ample blood supply was transferred and stitched to the denuded ventral penile surface. In the second stage after 6 months, this flap was tubularized in the Thiersch-Duplay fashion. Hospital records of patients who had undergone two stage modified Bracka repair between June 2007 and July 2012 were reviewed, including complaints, complications, and need for interventions.
  
  
  RESULTS
  Thirty-eight patients had undergone this operation. Four patients were lost to follow-up. The main complaint was obstructed urinary flow. Voiding symptoms were first attributed to urethral stenosis, but were, however, found to be due to diverticulum and vortex of the urine in the dilated urethra. Twenty-one patients (61%) had voiding problems and 10 patients (29%) had urinary tract infections. Fistula was observed in 23 and diverticula were observed in 24 patients. Of these, 16 patients had both fistula and diverticula. Only two patients (5%) were free of complications and totally satisfied with the operation, and 23 of the 34 patients had complications requiring intervention (Figure).
  
  
  CONCLUSIONS
  Inner preputial flaps used in proximal hypospadias repairs are prone to diverticula formation. They become redundant in time requiring reoperation, thus decreasing the success rate. Careful fixation of the flap to the corpora and allowing time for additional attachment of the urethral plate substitution through fibrotic activity could not overcome this complication.
  
  
  CONCLUSIONS
  Our modification of the Bracka technique using a flap for the plate resulted in a high rate of complications (in particular diverticulum formation) and was therefore abandoned. We recommend careful use of flaps in hypospadias surgery and long-term follow-up studies to evaluate actual functional and cosmetic results.
authors.affiliation: Ege University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Izmir, Turkey.
authors.forename: Sibel
authors.initials: S
authors.lastname: Tiryaki
authors.affiliation: Ege University, Faculty of Medicine, Department of Pediatric Surgery, Izmir, Turkey.
authors.forename: Vüsalə
authors.initials: V
authors.lastname: Ələkbərova
authors.affiliation: Ege University, Faculty of Medicine, Department of Pediatric Surgery, Izmir, Turkey.
authors.forename: Zafer
authors.initials: Z
authors.lastname: Dokumcu
authors.affiliation: Marmara University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Istanbul, Turkey.
authors.forename: Raziye
authors.initials: R
authors.lastname: Ergun
authors.affiliation: Ege University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Izmir, Turkey.
authors.forename: Ali
authors.initials: A
authors.lastname: Tekin
authors.affiliation: Ege University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Izmir, Turkey.
authors.forename: Ismail
authors.initials: I
authors.lastname: Yagmur
authors.affiliation: Ege University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Izmir, Turkey.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Ulman
authors.affiliation: Ege University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Izmir, Turkey. Electronic address: ali.avanoglu@gmail.com.
authors.forename: Ali
authors.initials: A
authors.lastname: Avanoglu
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004240:Diverticulum / Q000453:epidemiology*; D006801:Humans; D007021:Hypospadias / Q000473:pathology / Q000601:surgery*; D015994:Incidence; D007223:Infant; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013524:Surgical Flaps; D016896:Treatment Outcome; D014522:Urethral Diseases / Q000453:epidemiology*; D013521:Urologic Surgical Procedures, Male / Q000379:methods
keywords: Bracka repair; Diverticulum; Flap; Graft; Proximal hypospadias; Two-stage repair