and functional results using this technique have been satis-factory.

Recently we switched to the Koyanagi procedure with en-couraging early results. The initial report in 1984 described aparameatal based preputial flap for the correction of proxi-mal hypospadias,8 which was a modification of the previouslydescribed 1-stage technique.9 Initial series treated with theKoyanagi repair had high complication rates. Glassberg et alreported a complication rate of 50% in 14 boys,10 and thelargest and most recent series presented by Koyanagi et al of70 patients had a complication rate of 47%.11 However, morerecent series treated with a modification of this techniquehave had lower complication rates of 17% to 20%.12, 13 Thehigher success rate is believed to reflect preservation of thelateral blood supply to the skin flaps and not to rely entirelyon the microvasculature emanating from the region of theurethral meatus and its surrounding corpus spongiosum.12

The timing of the repair of a penoscrotal transpositionaccompanied by proximal hypospadias is another area ofcontroversy. Mobilization of the scrotal flaps was thought topotentially compromise the vasculature to the dorsal penileskin and pedicle tube graft.10 Pinke et al suggested stagingthe urethroplasty and correction of the transposition due to a70% overall complication rate.14 Our experience indicatesthat combining the procedure does not lead to an unaccept-ably high complication rate. Further experience with themodified Koyanagi technique that bases the urethral bloodsupply on parameatal skin flaps rather than a dorsal prepu-tial tube graft may lead to a lower incidence of complications.

CONCLUSIONS

We believe that a single staged repair can be safely andeffectively performed even in patients with the most severeproximal hypospadias accompanied by penoscrotal transpo-sition and/or bifid scrotum. The Hodgson XX and Koyanagirepairs are excellent techniques with relatively low compli-cation rates in more recent series. Pediatric urologists shouldcontinue to use these techniques in their hypospadias arma-mentarium and strive to perfect a single stage approach tosevere hypospadias.

REFERENCES

1. Bracka, A.: Hypospadias repair: the two-stage alternative. Br JUrol, suppl., 76: 31, 1995

2. Greenfield, S. P., Sadler, B. T. and Wan, J.: Two-stage repair forsevere hypospadias. J Urol, 152: 498, 1994

3. Glenn, J. F. and Anderson, E. E.: Surgical correction of incom-plete penoscrotal transposition. J Urol, 110: 603, 1973

4. Ehrlich, R. M. and Scardino, P. T.: Surgical correction of scrotaltransposition and perineal hypospadias. J Pediatr Surg, 17:175, 1982

5. Retik, A. B., Bauer, S. B., Mandell, J., Peters, C. A., Colodny, A.and Atala, A.: Management of severe hypospadias with a2-stage repair. J Urol, 152: 749, 1994

6. Wacksman, J.: Use of the Hodgson XX (modified Asopa) proce-dure to correct hypospadias with chordee: surgical techniqueand results. J Urol, 136: 1264, 1986

7. Ellsworth, P. I., Barraza, M. A. and Stevens, P. S.: ModifiedASOPA procedure (Hodgson XX) achieves the goals of hypos-padias repair. J Pediatr Surg, 31: 917, 1996

8. Koyanagi, T., Nonomura, K., Gotoh, T., Nakanishi, S. andKakizaki, H.: One-stage repair of perineal hypospadias andscrotal transposition. Eur Urol, 10: 364, 1984

9. Koyanagi, T., Matsuno, T., Nonomura, K. and Sakakibara, N.:Complete repair of severe penoscrotal hypospadias in 1 stage:experience with urethral mobilization, wing flap-flipping ure-throplasty and “glanulomeatoplasty.” J Urol, 130: 1150, 1983

10. Glassberg, K. I., Hansbrough, F. and Horowitz, M.: TheKoyanagi-Nonomura 1-stage bucket repair of severe hypospa-dias with and without penoscrotal transposition. J Urol, 160:1104, 1998

11. Koyanagi, T., Nonomura, K., Yamashita, T., Kanagawa, K. andKakizaki, H.: One-stage repair of hypospadias: is there nosimple method universally applicable to all types of hypospa-dias? J Urol, 152: 1232, 1994

12. Emir, H., Jayanthi, V. R., Nitahara, K., Danismend, N. and Koff,S. A.: Modification of the Koyanagi technique for the singlestage repair of proximal hypospadias. J Urol, 164: 973, 2000

13. Sugita, Y., Tanikaze, S., Yoshino, K. and Yamamichi, F.: Severehypospadias repair with meatal based paracoronal skin flap:the modified Koyanagi repair. J Urol, 166: 1051, 2001

14. Pinke, L. A., Rathbun, S. R., Husmann, D. A. and Kramer, S. A.:Penoscrotal transposition: review of 53 patients. J Urol, 166:1865, 2001

EDITORIAL COMMENT

This report challenges the prevalent majority opinion among ex-perienced pediatric urologists who favor a 2-stage procedure in thesesevere cases of hypospadias with penoscrotal transposition. The factthat these authors have switched to the Koyanagi procedure despitetheir claim of good success with the Hodgson XX operation is reveal-ing. Although they did achieve an excellent result in the last 3patients using the Koyanagi procedure, Koyanagi himself in a muchlarger series of 70 patients had a 47% complication rate (reference 11in article).

Despite this critical commentary, I would like to take this oppor-tunity to congratulate these authors on their success and wouldencourage other young innovative pediatric urologists to continuetheir work in pursuit of a single stage procedure that would achievepredictable functional and cosmetic results in these unfortunatechildren. A published report such as this will encourage furtherresearch in this direction.

Selwyn B. LevittDivision of Pediatric UrologySchneider Children’s HospitalLong Island Jewish and Northshore Medical Center and

Westchester Medical CenterNew York, New York

Complications of single staged repairs for proximal hypospadias

References Technique No.Pts

MosFollowup

%Complications

Wacksman6 Hodgson XX 37 — 11Koyanagi et al11 Koyanagi 70 — 47Ellsworth et al7 Hodgson XX 12 26 25Glassberg et al10 Koyanagi 14 — 50Emir et al12 Modified Koyanagi 20 34 20Sugita et al13 Modified Koyanagi 151 72 17Present series Hodgson/Koyanagi 20 23 20

HYPOSPADIAS WITH BIFID SCROTUM OR PENSCROTAL TRANSPOSITION1588