Editorial comment

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The authors should be congratulated for this very clear and honest review of a series of urethroplasties in primary cases and reoperative cases. It is surprising that so many onlay urethroplasties in the reoperative cases were performed, because the foreskin is usually no longer available in these patients. This is probably why so few series have been published on the use of onlay urethroplasty as a salvage procedure. In addition to the presence of scarred tissues, it is likely that the difference in the fistula rate between the two groups is explained by the defective “healing abilities” of the tissues forming the ventral aspect of the penis, especially in the most severe cases. It seems that in this series of patients very few had chordee after degloving the penis. In my experience, onlay urethroplasty is usually performed in primary cases with a proximal division of the corpus spongiosum (ie, severe hypospadias with chordee); therefore, correction of chordee is common in this group of patients and includes (a) degloving of the penis, (b) untethering of the urethral plate from the ventral aspect of the corpora, and (c) in rare cases (less than 5%), dorsal plication of the corpora. I am, therefore, surprised that the authors state that “In proximal cases, the onlay transverse preputial island flap is a good alternative when chordee is not present,” because almost all of our cases required correction of chordee before onlay urethroplasty.

The conclusion of this report confirms that distal hypospadias (ie, distal division of the corpus spongiosum) and primary cases get better results than hypospadias cripple and those with a proximal division of the corpus spongiosum.