Flip it to DIG it: Combining a reverse pedicle Dartos flap with a dorsal inlay graft.

INTRODUCTION: Re-do hypospadias repairs are technically challenging, requiring creative utilization of the limited and often scarred remaining tissues. We describe here a novel modification of the dorsal inlay graft, increasing the caliber of the urethral plate by repurposing the excised skin from a reverse pedicle Dartos flap.

CASE: The index patient is a four-year-old boy with a history of a tubularized incised plate (TIP) repair for distal hypospadias with subsequent recurrent urethrocutaneous fistula, referred after two failed primary fistula repairs and now presenting with recurrent coronal urethrocutaneous fistula and urethral stricture.

TECHNICAL APPROACH: After opening back to the level of the coronal urethrocutaneous fistula, the cut edges are matured. Lateral incisions for Thiersch-Duplay repair are extended proximally by a distance to match the planned length of the urethroplasty to ensure adequate coverage. A reverse pedicle Dartos flap is developed from here, saving the excised preputial skin for use as a graft. The dorsal urethral plate is deeply incised and the graft is quilted in, creating a well-grooved urethral plate fully surfaced over by the inlay graft. The added width allows the urethra to then be easily tubularized without tension and it is covered with the reverse pedicle flap as a barrier layer.

DISCUSSION: Re-do hypospadias repairs require an individualized intraoperative approach, taking into account the previous surgeries, current anatomy and quality of the remaining tissues. This approach combining a reverse pedicle Dartos flap with a dorsal inlay graft sourced from high-quality salvaged skin can be a valuable tool in re-do hypospadias cases with a paucity of skin.