Original Article Tunica vaginalis flap cover in hypospadias cripple following Bracka's stage 1 using buccal mucosal graft: A reliable option than simple Theirsch duplay urethroplasty N. Sharma, M. Bajpai, S. S. Panda, A. Singh Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India Abstract. Objective: Objective of this study was to assess the significance of tunica vaginalis flap cover in cases of proximal penile hypospadias cripples managed by staged repair on Bracka's principle. This retrospective study included cases Methods: of proximal penile hypospadias cripples managed on Bracka's principle using buccal mucosa graft. Second surgery was on Theirsch duplay principle. Group I included cases with tunica vaginalis flap reinforcement, Group using dartos cover. All cases II were managed by a uniform protocol. Outcome was assessed at day 10 after stent removal and at first follow up. Urethroplasty was considered successful in case with no leak. P value < 0.05 was considered significant. Out of 42 cases, 18 cases in Results: group I and 24 cases in group formed the study group. Mean age at hypospadias repair was 4.2 ± 0.9 years (range1.1 – 5.2 II years) and 4.1 ± 0.7 years (range1.3- 5.6 years) in group I and respectively. Leak at the time of stent removal was present in II 1/18(5.57%) and 4/24(16.67%) cases in group I and (p=0.04). Leak at the time of first follow up was present in 1/18(5.55%) and II 5/24(20.83%) cases in group I and (p=0.03). Complete disruption of urethroplasty was present in 1/18(5.57%) and 2/24(8.83%) II cases in group I and group (p=0.1). The overall success rate in group I and was 15/18(83.83%) and 13/24(54.16%) (p=0.01). II II Conclusions: Tunica vaginalis flap reinforcement in cases of proximal penile hypospadias cripples is a viable and reliable option. Key words: Bracka's principle, Dartos flap, Fistula, Proximal penile hypospadias cripples, Tunica vaginalis flap Introduction Hypospadias is one of the common congenital anomaly of urethra with a reported incidence of 1 in 300. Management [1] of proximal penile hypospadias offers a technical challenge to the operating surgeon. This challenge is both in terms of cosmesis and association with a high fistula rate. A number of techniques have been described. We tried to compare the results of management of proximal penile hypospadias cripples managed by staged repair on Bracka's principle using tunica vaginalis flap reinforcement and the use of dartos flap. Objective of this study was to assess the significance of tunica vaginalis flap cover in cases of proximal penile hypospadias cripples managed by staged repair on Bracka's principle. _______________________________________________ Copyright and reprint request: Prof. M. Bajpai, , h, PhD, , , National Board, Fulbright Scholar, MS MC FRCS FNAMS Professor, Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India. Website: http://www.paediatric-urologyonline.org; e-mail: bajpai2@hotmail.com; phone no.: +91-11-26593555; mob. no.: +91-981-802-5584. Materials and Methods This was a retrospective analysis. Case records of cases of proximal penile hypospadias cripples between January 2007 and May 2013 were analyzed. Hypospadias cripple was defined as cases of hypospadias with at least two prior attempts of urethroplasty but presenting with complete dehiscence. Those cases that were managed with staged repair on Bracka's principle using buccal mucosa graft followed by urethroplasty on Theirsch-duplay principle at least 6 months after the initial procedure were included. All the cases were operated by a single senior surgeon experienced in harvesting buccal mucosa graft, tunica vaginalis flap and applying it and also in other techniques of application of second layer over urethroplasty. These cases were divided into two groups. Group I included cases with tunica vaginalis flap reinforcement and Group (Fig. 1 A, B) II using dartos cover. All the cases were managed by a uniform protocol using 6-0 interrupted sutures for urethroplasty PDS and 5-0 vicryl for flap reinforcement followed by compression dressing for 4 days. Dressing was removed on 12 Urology, — , , Journal of Progress in Paediatric May Aug 2013 Vol 16 Issue 1