The introduction of an intermediate layer in urethroplasty has significantly reduced the formation of urethrocutaneous fistulas (UCF). Durhan Smith was the first to introduce an interposition layer between the neourethra and the cutaneous sutures. Various types of waterproofing layers have been explored over the years, including Snow et al., tunica vaginalis wrap, Reticketal et al., dorsal prepuce flap, Motiwala dartos flap, and Yamakatasupermatic fascia flap [6,7,8,9]. These authors emphasized that the primary change in technique was the use of a waterproof barrier layer. The quest to reduce complications post-urethroplasty, especially UCF, persists. Thus, we compared the dorsal subcutaneous flap with a novel approach: Buck’s fascia closure over the neourethra.

Some scholars have proposed the concept of using Buck’s fascia coverage to restore the normal anatomy of the penis. This material possesses a tough texture and provides clear coverage, with the capability to significantly reduce urethral tension and the incidence of urethral fistula [4, 10]. It also maintains anatomical integrity from the two flanks of the head of the penis as a whole, preserving tissue continuity at the coronal sulcus and contributing to the inhibition of coronal fistula occurrence [5]. Buck’s fascia (the deep fascia of the penis) anteriorly splits to cover the corpus spongiosum. It can be easily identified over the spongiosum, traced distally, and brought to the midline over the neourethra. We used this layer to cover the neourethra without suturing the corpus spongiosum, as suturing the corpus spongiosum could potentially interfere with vascularity. This fascia is readily available in all cases and does not require repeat dissection. It provides a smooth covering for the neourethra.

As demonstrated in our series, the Buck’s fascia repair is significantly less time-consuming as it requires minimal dissection. The operative time was significantly lower in group ‘A’, similar to the results by Zhou et al. &Albilyosar A et al. [5, 11]. Early post-operative issues such as glanular edema, hematoma, and infection were significantly less frequent than with the dartos flap barrier. This observation may be attributed to the shorter operative time, minimal dissection of glanular wings, and the absence of the need to separate the dartos flap from the skin. As described in our procedure, the spongiosum remains undisturbed while waterproofing with Buck’s fascia, which may further reduce the chances of edema and hematoma.

Given that the primary objective of urethroplasty is to decrease the occurrence of UCF, many authors are actively searching for an ideal interposition barrier. The incidence of UCF was significantly lower with Buck’s fascia than with the dartos flap procedure. In a multicenter Chinese study by Yin Zhang et al., the incidence of complications included fistulas (5.2%), dehiscence (0.6%), strictures (1.6%), and diverticula in (0.7%) of cases [4]. The rate of complications was consistent with the results of our study. In a study conducted by Zhou Qian et al., compared the surgical outcomes of Buck’s fascia and Dartos fascia, revealing a lower incidence of urethral fistula (9.4%) with Buck’s fascia coverage compared to Dartos fascia coverage (29.8%). The odds of urethral fistula were reduced by 5.1-fold (95% CI 1.09–25, P < 0.05) with the use of Buck’s fascia [5]. The results of our study was almost same in terms of reduction in the rate of fistula formation. Snow Cartwright described the use of TVF as a waterproof layer over the neourethra [12]. The dorsal subcutaneous flap by Retiket and TVF (TVF) has been described as a vascular flap with simpler techniques and lower complication rates in urethroplasty [7]. As observed from one study, application of Buck’s fascia had a low UCF formation rate compared to the dartos flap and all other interposition layers described in the literature. The incidence of UCF in our series was 2.8%, well below the accepted standard of approximately 5% for anterior hypospadias, as reported by many authors like Keays MA et al. ,AmilBhatet al. &Bhat A, Mandal AK et al. [13,14,15], who used Bucks fascia as the intermediate barrier in urethroplasty. A Chinese multicenter study revealed a 4.9% incidence of urethral fistula with the application of Buck’s fascia coverage in TIPU, strongly validating the effectiveness of this method. The incidence of urethral fistula (9.4%) with Buck’s fascia coverage in a study by Zhou Qian et al. Comparing the result of our study the rate of fistula formation was slightly less than that observed byZhang, Y&Zhou Qian et al.

Meatal stenosis was higher in group ‘B’ (2.35% of cases in Group ‘A’and 10% in Group‘B’). We hypothesize that this observation could be due to the need for slightly more mobilization of the glanular wings to accommodate the dartos fascia. The significantly lower rate of meatal stenosis in Buck’s fascia repair could be attributed to glanuloplasty without extensive mobilization of the glanular wings and less interference with blood supply. Previously, glanular wingless procedures have been used in GAP procedures with excellent results [16]. Meatal stenosis was reported in 1.6% and 3% by authors like Yin Zhang et al. and Qian Zhou et al. respectively, this observation was consistent with our results [4, 5]. Preventive strategies for pediatric surgery of meatal stenosis include UP incision, not extending too distally, and not suturing the neourethra to the glanular wings. Both of these preventive measures were adopted in our techniques. The limitations of this study are as follows: First, despite the high level of experience possessed by both operators in hypospadias surgery, the intricacies of their surgical techniques and potential measurement bias could still impact the study’s outcome. Second, patients had short- to medium-term follow-up results provided, and there is no literature reporting the long-term efficacy of Buck’s fascia repair. Therefore, further follow-up must be conducted in the future to supplement the long-term efficacy of Buck’s fascia repair.