Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2012  |  Volume : 17  |  Issue : 3  |  Page : 142--143

Authors' reply

Anjan K Dhua, Satish K Aggarwal, Shandip Sinha, Simmi K Ratan 
 Department of Pediatric Surgery, Maulana Azad Medical College, Delhi, India

Correspondence Address:
Anjan K Dhua
Department of Pediatric Surgery, Maulana Azad Medical College, Delhi - 110 002

How to cite this article:
Dhua AK, Aggarwal SK, Sinha S, Ratan SK. Authors' reply.J Indian Assoc Pediatr Surg 2012;17:142-143

How to cite this URL:
Dhua AK, Aggarwal SK, Sinha S, Ratan SK. Authors' reply. J Indian Assoc Pediatr Surg [serial online] 2012 [cited 2020 Feb 24 ];17:142-143
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We thank Dr. Chandrasekharam and Dr. Jayaram for their interest [1] and comments on our article. [2] They suggest that the better results of tunica vaginalis flap (TVF) soft tissue cover in our series may be a reflection of the surgeon's experience (learning curve) rather than the change in technique. To support their contention they cite Horowitz and Salzhauer's article, [3] which reports 5 years' experience of a pediatric urologist immediately after 2 years fellowship training in Pediatric Urology. Their fistula rate declined from 23% in the 1st year to 6% in the 5 th year; interestingly, a relative plateau reached in the 3 rd year, suggesting thereby that the learning curve effect did not matter beyond 3 years. In our study, all the operations were performed by the same senior author (SKA) who has nearly 20 years of experience in a busy government teaching hospital with abundant case load. During the period of surgery on retrospective controls he already had acquired more than 15 years of experience after his training. This is well beyond the suggested learning curve for hypospadias operation (3-5 years). Therefore, it is logical to conclude that relatively better results with tunica vaginalis were because of the technique rather than the learning curve effect.

Furthermore, Horowitz and Salzhauer have used different surgical techniques during the last 3 years of the study. This alone could be responsible for better results. These authors themselves admit that the technical modifications during the last 3 years of the study may well have contributed to better results. Snodgrass, in his letter to editor, [4] in response to Horowitz and Salzhauer's article has also echoed the same view.

In a review of literature on tubularized incised plate urethroplasty for distal hypospadias, Braga et al. concluded that the acceptable complication rate with the available techniques is below 10%. [5] Much lower complications have been reported with the use of TVF in primary cases. Snodgrass, a world authority on hypospadias, observed zero fistulas in 14 consecutive cases of proximal hypospadias treated by a double-layered urethroplasty and tunica vaginalis cover. [6] Chatterjee et al., while describing a comparison of dartos (20 cases) and TVF (29 cases) in primary repair of hypospadias, reported zero fistula rate with TVF as opposed to 15% in dartos group. [7]

We have not underestimated the role of dartos cover. In our series, statistical difference may not be evident between the 2 groups, dartos and TVF; however, in absolute terms the complication of skin necrosis in 3 cases was seen only in the dartos group. In the TVF group no complication was seen. Raising dartos flap does pose vascularity problems to the remaining skin, which may have to be used for ventral skin cover. TVF is free from this complication as the entire dartos is left with the skin.

Although the vas and vessels are at a small risk for damage during inguinal hernia repair, the same does not apply to the technique of harvesting the TVF. In hernia the sac is intimately related to the cord structures at the neck of the sac and immediately beyond. While raising the TVF the dissection is much distal-directly over the testis where the tunica vaginalis surrounds the testis and not the vas and vessels. The upward dissection of the flap is also away from the vas and vessels. Therefore, the 2 operations cannot be compared with this complication. Furthermore, no such complication has been reported during the harvest of the TVF.

Historically, TVF was described for redo cases, but with the realization of its potential, it has been used in primary cases also. [6],[7],[8],[9] The whole evolution of hypospadias surgery has been through newer techniques and modifications thereof. Another such example is the use of free graft to cover the raw area created by the dorsal incision in the urethral plate. It was started in redo cases but gradually it is being used for primary cases as well. [10] It is a constantly changing world and hypospadiologists cannot be dogmatic about techniques and their modifications.


1Chandrasekharam VV, Jayaram H. Soft tissue covers in hypospadias surgery: Is tunica vaginalis better than dartos flap? J Indian Assoc Pediatr Surg 2012;17:141.
2Dhua AK, Aggarwal SK, Sinha S, Ratan SK. Soft tissue covers in hypospadias surgery: Is tunica vaginalis better than dartos flap? J Indian Assoc Pediatr Surg 2012;17:16-9.
3Horowitz M, Salzhauer E. The 'learning curve' in hypospadias surgery. BJU Int 2006;97:593-6.
4Snodgrass WT. The "learning curve" in hypospadias surgery. BJU Int 2007;100:217.
5Braga LH, Lorenzo AJ, Pippe Salle JL. Tubularized incised plate urethroplasty for distal hypospadias: A literature review. Indian J Urol 2008;24:219-25.
6Snodgrass WT. Editorial comment. J Urol 2007;178:1456.
7Chatterjee US, Mandal MK, Basu S, Das R, Majhi T. Comparative study of dartos fascia and tunica vaginalis pedicle wrap for the tubularized incised plate in primary hypospadias repair. BJU Int 2004;94:1102-4.
8Tavakkoli Tabassi K, Mohammadi S. Tunica vaginalis flap as a second layer for tubularized incised plate urethroplasty. Urol J 2010;7:254-7.
9Handoo YR. Role of tunica vaginalis interposition layer in hypospadias surgery. Indian J Plast Surg 2006;39:152-6.
10Asanuma H, Satoh H, Shishido S. Dorsal inlay graft urethroplasty for primary hypospadias repair. Int J Urol 2007;14:43-7.