Dual Urethral plate substitution in staged hypospadias repair: flap for the shaft and graft for the glans

Background: Regarding proximal hypospadias, there is worldwide trend back to two-stage repairs that involve transection of the urethral plate to prevent recurrence of chordee. However, there is an ongoing debate on the best urethral substitute: flaps versus grafts. Case presentation: We present two primary cases of penoscrotal hypospadias who underwent two-stage repair while applying a modification of combined urethral plate substitution (flap + graft) during the first stage of repair. Skin flaps with its reliable blood supply provides a secure coverage for the penile shaft, while the thinner inner preputial graft is more suitable for the glans. The first boy was 42-month-old, while the second was 14-month-old at time of the first stage. Both cases had a straight penis with no residual chordee at follow up (6 months). Both were urinating freely (with no strictures) through a distal meatus. The site of the meatus was glanular in the first case, while it was distal penile (sub-coronal) in the second case. Conclusion: The technique described in this report does not represent significant deviation from the standard/current practice for performing two-stage repair. Revisiting the buttonholing technique to re-cover the ventral shaft provides a smooth urethral plate for tubularization at second stage avoiding midline scars of the more popular Byars technique. Concomitant grafting of the under-surface of the glans represents the main modification to the standard flap technique aiming to facilitate glanular closure at the second stage.