Optimizing neourethral coverage in urethroplasty for hypospadias with tunica vaginalis versus dartos fascia: A systematic review and meta-analysis

A BSTRACT Objectives: Hypospadias repair requires second-layer coverage to minimize complications. This study compares tunica vaginalis flap (TVF) and dartos fascia (DF) as second-layer materials in tubularized incised plate (TIP) urethroplasty, focusing on postoperative complications, functional outcomes, and cosmetic results to determine the superior option. Materials and Methods: Comparative studies on TVF versus DF in TIP urethroplasty were identified through five databases (PubMed, Scopus, ScienceDirect, Cochrane Library, and Google Scholar; January 2015–January 2025). A modified PICO framework guided the search, and risk of bias (RoB) was assessed using RoB 2 and ROBINS-I. Meta-analysis evaluated postoperative complications. Results: Ten studies comparing TVF and DF in TIP hypospadias repair were included in the study. TVF significantly reduced the risk of urethrocutaneous fistula (UCF) (risk ratios [RR] = 0.27; 95% confidence interval [CI]: 0.16–0.46; P < 0.00001), wound infection (RR = 0.40; 95% CI: 0.24–0.66; P = 0.0003), wound dehiscence (RR = 0.61; 95% CI: 0.38–0.98; P = 0.04), and penile skin necrosis (RR = 0.22; 95% CI: 0.06–0.73; P = 0.01), with minimal heterogeneity. No significant differences were found for meatal stenosis, urethral stricture, glans dehiscence, residual chordee, or torsion. Cosmetic outcomes slightly favored TVF, although assessment heterogeneity limited definitive conclusions. Functional outcomes were comparable between groups. Conclusion: Findings from this meta-analysis suggest that the tunica vaginalis flap may be associated with lower rates of selected postoperative complications, particularly UCF, wound infection, wound dehiscence, and penile skin necrosis, compared with dartos fascia in TIP hypospadias repair, whereas cosmetic and functional outcomes appear comparable between the two techniques.