Introduction
The average complication rate of primary hypospadias repair is reported to be approximately 42% for single-stage repair using a preputial island flap [1], with higher rates observed in proximal hypospadias [2]. The rate of additional procedures required after a planned two-stage repair of proximal hypospadias has been reported to range from 25% to 75%. Postoperative complications, such as ventral curvature and urethrocutaneous (UC) fistulae, often necessitate reconstruction with an initial skin graft and a second tubularization stage [3]. Severe penile scar contracture with recurrent UC fistula due to multiple failed proximal hypospadias repairs presents a significant reconstructive challenge because of extensive scar adhesion, contracture, soft tissue deficiency, and vascular insufficiency. Reuse of local flaps is often limited by soft tissue deficiency resulting from prior surgeries, while free flaps are less favorable due to their bulk and associated donor site morbidity.
We present a case of penile contracture deformity with a recurrent UC fistula successfully reconstructed using a two-stage approach. The first stage involved complete scar contracture release and full-thickness skin graft coverage, while the second stage included neourethral tubularization and bilateral advancement skin flap coverage. We also provide surgical tips for successful reconstruction. This retrospective study was approved by the Institutional Review Board of the University Hospital (No. KHUH 2025-02-029). Written informed consent was obtained from the participant’s legal guardian.
Case
The patient had previously undergone three proximal hypospadias repair procedures at another institute’s urology department. At 7 years of age, he received a cordectomy and preputial tubularized island flap as the initial operation. Four months later, a turnover flap combined with bilateral advancement flaps was performed to address a recurrent UC fistula. At age 8, a third operation was carried out using scrotal island and transposition flaps to correct both recurrent fistula and ventral penile curvature. Upon presentation to our department, the patient exhibited a fistula at the proximal penile shaft, accompanied by a diverticulum containing scrotal hair protruding through the fistula. Severe scar contracture and soft tissue deficiency had resulted in dense adhesion between the ventral glans and the fistula site. Given the complexity of the case, a two-stage surgical reconstruction was planned (Fig. 1).
After temporary cystostomy, complete contracture release and full-thickness skin graft coverage were performed as the first stage (Fig. 2). All scarred and contractured tissues extending from the normal urethral opening to the glans tip were released and excised until the penis achieved a straightened dorsal position under artificial erection with saline injection.
Contracture release was started by designing a zigzag pattern incision line along the lateral margins of the contracted scar and fistula (Fig. 2A). A local anesthetic mixture was injected into the scar tissue to facilitate dissection and minimize postoperative pain. The incision was then extended into the surrounding normal skin until the ventral glans, penile shaft, previous neourethra with diverticulum, and distal end of the normal urethra were fully exposed (Fig. 2B). At this stage, the skin incision was extended to the lateral midline of the penile shaft. Because additional skin release was necessary, further incisions were made in the proximal penile area, including the previous scrotal flap site.
An excisional release was then performed (Fig. 2C). The abnormal neourethra with a diverticulum was excised tangentially from Buck’s fascia, and when this was not intact or clear, from the tunica albuginea, preserving the distal end of the normal urethra. After excising scar tissue from the wound bed and tunica albuginea, the contracted tunica albuginea was further released through tangential scar excision and partial corporotomy while maintaining its continuity. The ventral glans was bilaterally divided along the midline to provide space for the neourethral opening. Bilateral subcutaneous release above Buck’s fascia was performed, particularly on the distal penile shaft. The distal opening of the normal urethra was widened using longitudinal mucosal incisions at the dorsal and ventral midlines to prevent constriction. Additional release was performed as needed until complete contracture release was confirmed as previously described. Traction sutures were placed at three sites from the glans to the pubic area to maintain full release of the ventral penis.
A 3×12-cm full-thickness skin graft was harvested from the hairless groin area and grafted onto the defect, extending from the glans tip to the proximal area, over which a tie-over dressing was applied (Fig. 2D). The graft was inserted into the dorsal and ventral incision gaps of the original urethra to cover the surrounding defects. Thin silastic drains were placed through the suture margins to prevent hematoma formation.
The tie-over dressing was removed on postoperative day 5, followed by continued compressive dressings with saline-moistened gauze until day 14. Graft sutures were removed on day 10. The traction sutures and temporary cystostomy were removed on day 14 to allow voiding through the ventral urethra. Compressive dressings were maintained for 2 months using surgical pads and tight elastic underwear to support dorsal extension.
The second stage operation was performed 6 months after the first stage and involved neourethral tubularization and bilateral advancement skin flap coverage (Fig. 3). The neourethral lining was designed on the grafted skin, 2 cm in width, as to be wider than the circumference of a 16 Fr Foley catheter (Fig. 3A). After incising the skin, subcutaneous dissection was performed up to both lateral midlines of the penis, preserving Buck’s fascia and subcutaneous tissue for adequate blood supply (Fig. 3B). A 16 Fr Foley catheter was placed over the grafted skin and inserted through the proximal previous urethral opening, after which neourethral tubularization was performed by rolling up and closing the incised and dissected skin graft over the Foley catheter with 6-0 Vicryl buried-knot vertical mattress sutures, followed by approximation of the subcutaneous tissue or Buck’s fascia as a second layer with 5-0 Vicryl (Fig. 3C). Bilateral skin flaps were advanced to the midline and Z-plasty was performed on the proximal penis to prevent ventral scar contraction. The flaps were closed with 5-0 Vicryl subcutaneous and 6-0 nylon skin sutures (Fig. 3D). A mildly compressive dressing using a surgical pad was applied, and as with the first stage, the patient was instructed to wear tight underwear over the surgical pad for 2 months to maintain dorsal penile extension. The Foley catheter was removed on postoperative day 14, allowing self-voiding.
No wound complications such as wound dehiscence, infection, partial necrosis, or urinary leakage were observed (Fig. 4). At 1-year follow-up via phone call, the patient claimed no issues with voiding, penile curvature, or erection and reported high satisfaction with both functional and aesthetic outcomes.
Discussion
Hypospadias, the most common congenial anomaly of the penis, is characterized by an ectopic location of the urethral meatus proximal to the normal location. Initial surgery is associated with a 10% early complication rate and significant higher long-term complication rates. Repeated unsuccessful hypospadias repairs result in progressive scarring, vascular compromise, and soft tissue insufficiency. In such complex cases, extensive scar resection, major tissue rearrangements, and meticulous reconstruction are required to achieve a straight phallus with normal urinary and sexual function while ensuring a cosmetically favorable appearance [4].
This case demonstrates the utility of a two-stage reconstruction approach involving skin grafting, tubularization of the graft, and bilateral advancement flaps, particularly when local or free flaps are not viable options. We emphasize the importance of complete and meticulous release of scar contracture, ensuring adequate soft tissue coverage of the ventral penis, and maintaining sustained dorsal extension—potentially for up to 2 months—for optimal outcomes with this technique. Through extensive resection of scar tissue, penile scar contracture was completely released from the normal urethral opening to the glans tip, while still preserving continuity of the tunica albuginea, in a manner analogous to contracture release in the finger. To optimize soft tissue supply for successful second stage reconstruction, a single sheet of wide full-thickness skin graft harvested from the hairless groin area provided an optimal urethral lining with an unscarred even surface. For complex penile and urethral reconstructions, a wide full-thickness skin graft offers more advantages than regional [5] or free flaps [6], which are associated with disadvantages such as unnatural penile appearance and sexual dysfunction due to flap bulkiness and donor site morbidity.
In the first stage, comprehensive perioperative management, including prolonged penile dorsal extension, marginal silastic drain insertion, tie-over dressing, and continuous saline-moistened gauze compression, ensured optimal graft integration. Long-term maintenance of compressive dressings with the penis in dorsal extension proved effective in preventing ventral contractions.
To prevent wound complications at the suture sites during neourethral tubularization, two key surgical strategies were employed. First, the width of the grafted skin for the neourethra was intentionally designed to exceed the circumference of the Foley catheter. Second, a two-layer closure was performed: superficial skin closure was combined with tension-free central approximation of Buck’s fascia. These measures helped preserve adequate blood supply from Buck’s fascia and supported optimal wound healing. Additionally, maintaining dorsal penile extension for 2 months allowed the surgical scar to mature and achieve maximal tensile strength.
A severe penile contracture with a recurrent UC fistula was successfully reconstructed using a two-stage approach based on established surgical principles. The procedure resulted in favorable functional and aesthetic outcomes free of complications and contributed to improved psychological well-being and quality of life for the patient.
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