title: Two-stage hypospadias repair with a free graft for severe primary and revision hypospadias: A single surgeon's experience with long-term follow-up.
abstract: BACKGROUND
  Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation.
  
  
  OBJECTIVE
  To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up.
  
  
  METHODS
  Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n = 208): indications for a two-stage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n = 93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months.
  
  
  RESULTS
  For the primary repairs (n = 208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n = 93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8).
  
  
  CONCLUSIONS
  In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the two-stage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%.
  
  
  CONCLUSIONS
  The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity.
authors.affiliation: Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom. Electronic address: klmpfist@aol.com.
authors.forename: K L M
authors.initials: KL
authors.lastname: Pfistermüller
authors.affiliation: Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom.
authors.forename: S
authors.initials: S
authors.lastname: Manoharan
authors.affiliation: Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom.
authors.forename: D
authors.initials: D
authors.lastname: Desai
authors.affiliation: Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom.
authors.forename: P M
authors.initials: PM
authors.lastname: Cuckow
mesh_terms: D002648:Child; D002675:Child, Preschool; D005500:Follow-Up Studies; D006801:Humans; D007021:Hypospadias / Q000601:surgery*; D007223:Infant; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D013524:Surgical Flaps; D013997:Time Factors; D016896:Treatment Outcome; D014521:Urethra / Q000601:surgery*; D014563:Urodynamics / Q000502:physiology*; D013521:Urologic Surgical Procedures, Male / Q000379:methods*
keywords: Hypospadias; Long-term follow-up; Outcomes; Two-stage repair