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Borgognone A, Santi GD, Baffigo G, Capobianco SV, Goletti S. Is a pedicular flap coupled to the double turnover flaps urethroplasty suitable for urethral-perineal reconstruction? Considerations about a relapsing urethral-cutaneous fistula condition. JPRAS Open 2023; 38:91-97. [PMID: 37745010 PMCID: PMC10514385 DOI: 10.1016/j.jpra.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Background: This study highlights the effectiveness, in one surgical stage, of two combined local techniques for perineal fistula repair in a patient with spinal cord injury: the " Turn over flaps urethroplasty" and the "Pedicular fasciocutaneous flap" from the inferior gluteal fold. Unlike the traditional Perforator flap, we harvested a Pedicular flap; by definition, this is a flap with a narrow diffuse microvascular supply aimed in our case at shielding the neourethra and substituting the remaining scarred perineum. Method: The urethroplasty technique adopted, the 'Double turn over flaps urethroplasty', has been based on sculpting two opposing local cutaneous flaps circumscribing the fistulous cutaneous openings. Eventually, the neourethra continuity has been re-established by turning over both flaps and making them meet medially. The dimension and thickness of the "Pedicular fasciocutaneous flap", have been considered to prevent any damage to the urethroplasty and at the same time to replace all the debrided scarred perineal tissue. Results: The follow-up confirmed a well-consolidated supple perineal area and a competent neourethra. Conclusions: The "Pedicular flap" is by definition a random vascular flap nourished through a narrow pedicle, not based on a single perforator but only on a diffuse, spread micro-perforators. When associated with the double "Turn over flaps urethroplasty", it represents a possible alternative to achieve satisfactory results for those physical and psychological challenges encountered in the treatment of recurrent urethral fistula of the perineum in a patient with spinal cord injury.
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Affiliation(s)
- Alessandro Borgognone
- Operative Unit of Plastic Surgery and Burns, S. Eugenio – C.T.O. Hospital, Rome, Italy
| | - Giancarlo Delli Santi
- Operative Unit of Plastic Surgery and Burns, S. Eugenio – C.T.O. Hospital, Rome, Italy
| | - Giulio Baffigo
- Operative Unit of Neuro- Urology, S. Eugenio – C.T.O. Hospital, Rome, Italy
| | | | - Stefania Goletti
- Operative Unit of Radiology, S. Eugenio – C.T.O. Hospital, Rome, Italy
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Meng W, Jiang Z, Wang J, Chen X, Chen B, Cai B, Zhou Y, Ma L, Guan Y. Inhibition of urethral stricture by a catheter loaded with nanoparticle/ pirfenidone complexes. Front Bioeng Biotechnol 2023; 11:1254621. [PMID: 37954024 PMCID: PMC10639154 DOI: 10.3389/fbioe.2023.1254621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/13/2023] [Indexed: 11/14/2023] Open
Abstract
Background: Urethral strictures are common injurious conditions of the urinary system. Reducing and preventing urethral strictures has become a hot and challenging topic for urological surgeons and related researchers. In this study, we developed a catheter loaded with nanoparticle/pirfenidone (NP/PFD) complexes and evaluated its effectiveness at inhibiting urethral stricture in rabbits, providing more references for the clinical prevention and reduction of urethral stenosis. Methods: Twelve adult male New Zealand rabbits were selected and divided into the following four groups in a ratio of 1:1:1:1 using the random number table method: Group A, sham; Group B, urethral stricture (US); Group C, US + unmodified catheter; and Group D, US + NP/PFD catheter. On the 30th day after modelling, retrograde urethrography was performed to evaluate urethral stricture formation, and histopathological examination was performed on the tissues of the corresponding surgical site. Meanwhile, changes in the expression level of Transforming growth factor β1 (TGF-β1) in the tissues were detected by immunohistochemistry. Results: The NP/PFD complexes adhered uniformly to the catheter surface. They remained on the surface of the catheter after insertion into the urethra. In addition, the NP/PFD complexes spread into the urethral epithelium 2 weeks after surgery. Ultimately, urethral strictures were significantly reduced with the placement of the NP/PFD complex catheter. Conclusion: Our catheter loaded with NP/PFD complexes effectively delivered PFD to the urethral epithelium through continuous local delivery, thereby reducing fibrosis and stricture after urethral injury, which may be associated with the inhibition of TGF-β1 expression.
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Affiliation(s)
- Wei Meng
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Zhaosheng Jiang
- Department of Urology, Nantong TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Nantong, China
| | - Jiahao Wang
- Department of Urology, Wuxi Hospital Affiliated to the Nanjing University of Chinese Medicine, Wuxi, China
| | - Xiaohua Chen
- Department of Imaging, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Bo Chen
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Bo Cai
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Youlang Zhou
- Research Central of Clinical Medicine, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Limin Ma
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yangbo Guan
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
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Histological Comparison of Buccal and Lingual Mucosa Grafts for Urethroplasty: Do They Share Tissue Structures and Vascular Supply? J Clin Med 2022; 11:jcm11072064. [PMID: 35407672 PMCID: PMC8999541 DOI: 10.3390/jcm11072064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/30/2022] [Accepted: 04/03/2022] [Indexed: 01/08/2023] Open
Abstract
Comparable outcomes were published using a buccal mucosa graft (BMG) from the cheek and a lingual mucosa graft (LMG) from the sublingual area, for urethral augmentation or substitution. To date, no histological comparison between both grafts has been conducted. We histologically assessed BMG and LMG harvested during urethral surgeries, aiming to compare graft properties and vascular support. We conducted a prospective single cohort study, including oral mucosa urethroplasty patients. During surgery, graft dimensions and donor sites were collected, and a 0.5 × 0.5 cm sample was obtained from the prepared graft. Formalin-fixed paraffin-embedded samples were sliced at 4 micrometres (µm) and hematoxylin-eosin stained. Using a telepathology tool, all slides were digitalized and measured from 10× to 40× magnification. In each graft, global and individual layers thicknesses were assessed, including vascular density and area. Descriptive and comparative (parametrical and non-parametrical) statistical analysis occurred. We collected 57 grafts during 33 urethroplasties, with 30 BMG and 22 LMG, finally, included. The mean age was 56.6 (SD 15.2) years, and the mean graft length was 5.8 (SD 1.7) cm and the width was 1.7 (SD 0.4) cm. The median graft thickness was 1598.9 (IQR 1200–2100) µm, the mean epithelium layer was 510.2 (SD 223.7) µm, the median submucosa was 654 (IQR 378–943) µm. the median muscular was 477.6 (IQR 286–772) µm, the median vascular area was 5% (IQR 5–10), and the median adipose tissue area was 5% (IQR 0–20). LMG were significantly longer and narrower than BMG. Total graft thickness was similar between LMG and BMG, but the epithelium and submucosa layers were significantly thinner in LMG. The muscular layer was significantly thicker in LMG. Vascular density and vascular areas were not significantly different between both types of grafts. LMG showed significantly less adipose tissue compared with BMG. Our findings show LMG and BMG for urethroplasty surgeries share the same thickness and blood supply, despite having significantly different graft sizes as well as mucosal and submucosal layers thickness.
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Abramowitz D, Sam AP, Pachorek M, Ruel N, Martins F, Angulo J, Simhan J, Li E, Nikolavsky D, Policastro C, Ramirez-Perez E, Burks F, Shetty Z, Venkatesan K, Hunter C, Gallegos M, Foreman J, Pariser J, Kasabwala K, Lopez D, Macdonald S, Warner J. Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes. Int J Urol 2022; 29:376-382. [PMID: 35118726 DOI: 10.1111/iju.14786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 12/08/2021] [Accepted: 12/22/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Penile urethral stricture disease not associated with hypospadias is rare, and there is a wide range of commonly used surgical repair techniques for this disease. We sought to compile a multi-institutional database of patients who had surgical correction of strictures in the penile urethra not limited to the meatus, and who had no history of hypospadias, for analysis using the Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology classification system. METHODS A retrospective database from 13 institutions was compiled of patients who had undergone surgical correction of Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology urethral stricture segments S2b/S2c and excluding E5, with a minimum follow-up time of 4 months. Failure was defined as cystoscopically confirmed recurrence of a stricture measuring less than 16-Fr. RESULTS We analyzed 222 patients with a median age of 57 years and a follow-up of 49 months. The overall surgical success rate was 80.2%. On multivariate analysis, the two variables identified that were predictive of surgical success were stricture length ≤2 cm as well as use of a buccal mucosa graft as compared to use of a fasciocutaneous flap, which had success rates of 83% and 52%, respectively (P = 0.0004). No statistically significant differences were found based on incisional approach or surgical technique, nor were outcomes different based on etiology or preoperative patient demographics. CONCLUSIONS Surgical repair of penile urethral strictures of non-hypospadiac origin have a favorable overall success rate, at 80.2%. Regardless of incisional approach or surgical technique, all operations appear to have similar outcomes other than repairs using fasciocutaneous flap, which were statistically less successful than those using buccal mucosa graft.
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Affiliation(s)
| | | | | | - Nora Ruel
- Department of Biostatistics, City of Hope Medical Center, Duarte, CA, USA
| | | | - Javier Angulo
- Universidad Europea: Universidad Europea de Madrid SLU, Madrid, Spain
| | - Jay Simhan
- Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - Eric Li
- Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - Dmitriy Nikolavsky
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Connor Policastro
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | | | | | | | | | - Craig Hunter
- Urology Specialists of Nevada, Las Vegas, NV, USA
| | - Maxx Gallegos
- University of New Mexico Health Sciences Center, Santa Fe, NM, USA
| | - Jordan Foreman
- University of New Mexico Health Sciences Center, Santa Fe, NM, USA
| | | | | | - Damian Lopez
- Hospital Regional Licenciado Adolfo Lopez Mateos, Mexico City, Mexico
| | - Susan Macdonald
- Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
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Chandrasekharam VVS, Babu R. Single-Stage Versus Two-Stage Repair for Late Hypospadias Urethral Strictures in Adults: a Systematic Review of Incidence and Meta-analysis of Results. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Anterior Urethroplasty for the Management of Urethral Strictures in Males: A Systematic Review. Urology 2021; 159:222-234. [PMID: 34537198 DOI: 10.1016/j.urology.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/19/2021] [Accepted: 09/02/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify the currently utilised techniques of anterior urethroplasty described in literature for treatment of urethral strictures, assess the effectiveness of the identified techniques based on re-stricture and complication rates, evaluate, and suggest treatment options based on current evidence for urethral strictures at different locations and of different lengths. METHODS A systematic review of the MEDLINE, EMBASE, Scopus and Cochrane Library databases from conception up to September 2020 was performed. Primary outcomes included success rates measured via re-stricture rates and the post-operative maximum urinary flow rate (Qmax). Secondary outcomes included patient reported complication rates. RESULTS A total of 52 papers, including 7 RCTs, met the inclusion criteria. Forty studies described the use of free graft urethroplasty with a median success rate of 86.5% (IQR = 8.1). The best outcomes were found in dorsal onlay buccal mucosa grafting in the penile urethra (86.6%). Twelve described the use of pedicled flap urethroplasty with a median success rate of 76% (IQR = 14.4). Excision and Primary Anastomosis results were reported in 5 studies and showed an overall highest success rate of 89.7% (IQR = 7.0) but involved the shortest strictures of median lengths of 2.1 cm (IQR = 0.48). CONCLUSION Graft urethroplasty showed optimal outcomes when utilised in penile and bulbar strictures, with dorsal onlay buccal mucosa grafting presenting with the largest evidence base and best outcomes overall. Flap urethroplasty had the highest success rates in panurethral and bulbar strictures, while anastomotic urethroplasty had the greatest success in bulbar and penobulbar strictures.
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Vetterlein MW, Fisch MM, Zumstein V. Update on the management of penile and meatal strictures. Curr Opin Urol 2021; 31:493-497. [PMID: 34224436 DOI: 10.1097/mou.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Treatment of penile and distal urethral strictures including the fossa navicularis and the meatus remains challenging due to their adverse etiology and lack of ventral tissue support. In this contemporary review, we summarize the available evidence and recent advancements in reconstructive techniques. RECENT FINDINGS Over the last years, several refinements of already established techniques have been added to the reconstructive armamentarium in the management of penile urethral strictures. These include the single-stage combination of flap and graft, the additional use of tissue glue, or an optimized single-stage tubularization using a free graft. SUMMARY There is a shift toward an increased use of single-stage procedures even in complex strictures of the penile and distal urethra. This is reflected by advancements and refinements in operative techniques. Nonetheless, staged urethroplasty remains a cornerstone of curative management in such patients with durable success rates. Future research should focus on identifying distinct patient and stricture characteristics to determine the individual therapeutic approach with optimal functional outcomes.
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Affiliation(s)
- Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit M Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Zumstein
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
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Esperto F, Verla W, Ploumidis A, Barratt R, La Rocca R, Lumen N, Yuan Y, Campos-Juanatey F, Greenwell T, Martins F, Osman N, Riechardt S, Waterloos M, Dimitropoulos K. What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review. World J Urol 2021; 40:393-408. [PMID: 34448008 DOI: 10.1007/s00345-021-03803-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given. MATERIALS AND METHODS To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed. RESULTS Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL. CONCLUSIONS The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.
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Affiliation(s)
- Francesco Esperto
- Department of Urology, Campus Biomedico University of Rome, Via Álvaro Del Portillo, 200 00128, Rome, Italy.
| | - Wesley Verla
- Division of Urology, Gent University Hospital, Gent, Belgium
| | | | - Rachel Barratt
- Department of Urology, University College London Hospital, London, UK
| | - Roberto La Rocca
- Department of Urology, University of Naples Federico II, Naples, Italy
| | - Nicolaas Lumen
- Division of Urology, Gent University Hospital, Gent, Belgium
| | - Yuhong Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | | | - Tamsin Greenwell
- Department of Urology, University College London Hospital, London, UK
| | - Francisco Martins
- Department of Urology, Santa Maria University Hospital, University of Lisbon, School of Medicine, Lisbon, Portugal
| | - Nadir Osman
- Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Evaluation of the Extent of Primary Buccal Mucosal Graft Contracture in Augmentation Urethroplasty for Stricture Urethra: A Prospective Observational Study at a Tertiary Healthcare Centre. Adv Urol 2021; 2021:9913452. [PMID: 34341663 PMCID: PMC8325577 DOI: 10.1155/2021/9913452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/18/2021] [Accepted: 07/15/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Buccal mucosal graft (BMG) urethroplasty is considered as gold standard in the treatment of urethral stricture disease. The successful outcome after BMG urethroplasty varies between 66 and 99%. One of the possible causes for failure is BMG contracture. Primary BMG contracture rate is poorly understood and unreported. The present study aimed to evaluate the extent of contracture of buccal mucosa immediately after harvesting. Materials and Methods This was a prospective observational study conducted in the Department of Urology at our institute between January 2016 and December 2019. All patients with urethral stricture disease undergoing BMG urethroplasty for the first time were enrolled in the study after obtaining informed consent. Demographic and patient clinical profile was noted. Based on the intraoperative urethral stricture size, the preharvest graft was marked on the buccal mucosa and the size was calculated. Postharvest unstretched size of the graft was measured immediately after graft removal from the oral cavity. Alteration in BMG size was analysed using paired t-test. Results Forty-four patients were included in the study. Mean age of the patient was 53.6 years. Mean stricture length was 7.45 cm (range 4–12 cm). Mean pre- and postharvest BMG size was 8.3 × 1.5 cm and 7.6 × 1.3 cm, respectively. There was a 8.4% decrease in length and 9.5% decrease in width of the buccal mucosal graft. Conclusion Primary buccal mucosal graft contracture is around 8.4% in length and 9.5% in width. It would be better to mark wider than necessary while harvesting buccal mucosa so that tension-free anastomosis is performed.
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Andrich DE. Introduction to the 12 th Genitourinary Reconstructive Surgeons (GURS)-Masterclass special issue. Asian J Androl 2021; 22:123. [PMID: 32098933 PMCID: PMC7155791 DOI: 10.4103/aja.aja_147_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Daniela E Andrich
- Reconstructive Urology Unit, Institute of Urology, University College London Hospitals, London W1G 8PH, UK
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Long-Term Undesirable Consequences of Penile Skin Island Flap to Correct Penoescrotal Transposition: A Case Report and Review of Literature. Case Rep Urol 2021; 2021:6656540. [PMID: 33505761 PMCID: PMC7815407 DOI: 10.1155/2021/6656540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/05/2021] [Indexed: 11/18/2022] Open
Abstract
Hypospadias is a congenital malformation of the male lower urinary tract, consisting of a ventral urethral opening proximal to the glans penis. This condition is corrected surgically in the paediatric age, with a great variety of techniques available. Traditionally, a tubularized genital skin was used for one- or two-stage repairs. Nowadays, the tendency is to use preputial or oral mucosa grafts, dorsally located, to avoid diverticula formation and prevent hair growth in the neourethra. We present a case of a patient born with proximal hypospadias with penoscrotal transposition, surgically corrected in his childhood, using dorsal penile skin island flap. The patient is referred to urology consultation in his adulthood for a weak urinary stream, recurrent infections, and a large amount of hair exiting through the urethral meatus.
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