Ventral dartos fascia flap as a third interposition layer in tubularized incised plate urethroplasty for distal hypospadias: a prospective study of 52 cases.

BACKGROUND

Tubularized incised plate (TIP) urethroplasty is the preferred technique for distal hypospadias repair, but urethrocutaneous fistula and glanular torsion remain significant complications. Vascularised tissue interposition between the neourethra and skin reduces these risks. Dorsal dartos flaps risk penile torsion through asymmetric traction, and tunica vaginalis flaps carry scrotal haematoma risk. The ventral dartos fascia flap offers a potentially superior alternative.

METHODS

A single-centre, prospective observational study enrolled 52 male patients (age 8 months-28 years; mean 4.92 ± 7.48 years) with distal hypospadias undergoing TIP urethroplasty with ventral dartos fascia flap interposition (May 2022-February 2024). Patients with proximal hypospadias, severe chordee, or associated penile anomalies were excluded. Primary outcomes were meatal configuration, urinary stream, penile alignment, and complications. Minimum follow-up was 12 months.

RESULTS

Forty-nine patients (94.2%) underwent primary repair, and 3 (5.8%) underwent revision repair. Mean operative time was 95.3 ± 5.8 min. All 52 patients (100%) achieved straight penile erection. A slit-like neomeatus was achieved in 46 patients (88.5%); 36 (69.2%) demonstrated a straight urinary stream, and 16 (30.8%) a functionally adequate standing stream. Urethrocutaneous fistula occurred in 2 patients (3.8%), both managed by secondary repair. No penile torsion, meatal stenosis, urethral stricture, or preputial oedema occurred.

CONCLUSIONS

The ventral dartos fascia flap is a safe, reproducible third interposition layer in TIP urethroplasty for distal hypospadias. By preserving dorsal tissue and avoiding asymmetric rotational forces, it was associated with a low fistula rate (3.8%) and no observed penile torsion, representing a promising alternative to dorsal dartos and tunica vaginalis coverage.

LEVEL OF EVIDENCE: Level IV, therapeutic study.