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This is a study to review the local experience with the use of TPIPF in the repair of failed hypospadias in order to improve the results in the future. A total Number of 20 cases of failed Hypospadias was repaired during the period between 2001-2009 done in the public and private hospitals in Tikrit and Basrah. The repair was accomplished via Duckett method (transverse preputial island pedicle flap). The medical and operative records of each patient were registered and followed for 6 months. The success rate was 47% (9 patients). The complication rate was 55% in which urethro-cutaneous fistula was the commonest in 32% of the cases, meatal stenosis in 16%, urethral stricture in 10% and breakdown of the tube in 5%. In conclusion, TPIPF remains a viable option in the management of failed hypospadias especially in the proximal type, the complications can be avoided by using the magnification loupes with perfect surgical technique and mandatory proximal urinary diversion. Introduction he hypospadiology is rapidly expanding based on simple facts that none of the current methods of urethroplasty have been proved superior to the others in terms of achieving the goals of excellent functional and cosmetic results 1 . John W. Duckett, defines hypospadiology as" the-in-depth study of the art and science of the surgical correction of hypospadias 2 . The TPIPF for hypospadias was originally advocated by Asopa 3 . but Duckett developed and popularized it 4,5 . This is mainly because it can be applied to anterior, midand posterior penile hypospadias associated with or without chordee. The preputial skin, with its accompanying superficial fascia and vessels, is ideal for the construction of flaps for hypospadias repair 6 . It is relatively thin and pliable; it has good blood supply that can be mobilized as pedicle. It also tolerates prolonged contact with urine better than any tissue other than bladder mucosa 7 . Correction of a repeatedly failed hypospadias repair is a surgical challenge because the repair is done using surgically damaged tissues which may be inadequate for the repair. The correction of a hypospadias repair may be very similar to a primary repair, but it can be also be difficult because of the badly vascularized tissues at the repair site 8 . Patients and Methods This is a retrospective study of 20 cases of failed repaired hypospadias with intact prepuce (midand proximal penile) managed with TPIPF between 2001 to 2009 and operated upon by the same urologist. The case notes were recorded as follows: age of patient, type of hypospadias, presence or absence of chordee, use of stent, making of urinary diversion and duration, history of T Transverse Preputial Island Pedicle Flap (TPIPF) In Treatment of Failed Hypospadias Repair Safaa. A. Mohssin Bas J Surg, September, 17, 2011 76 previous repair, complications after repair (bleeding, meatal stenosis, urethro-cutaneous fistula, infection, urethral diverticulum, urethral stricture and breakdown of the repair). All cases were followed for 6 months Surgical technique The applied technique is as described by duckett 4,5 . Optical magnification was not used because operative microscope and loupe were not available in the centers were the study has been done. 3\0 silk traction suture were applied to the dorsum of the glans penis and artificial erection was induced by injection of 1015 ml of normal saline by a butterfly needle in each corpus cavernosum to diagnose and assess severity of chordee. A circumferential incision is made proximal to the corona and hypospadias orifice. The urethra and shaft skin were dissected free of corpora cavernosa to release the chordee tethering. An artificial erection is induced again to reassess the chordee. The native urethra was brought to comfortable position without tension on the shaft and fixed by 5\0 vicryl suture to the tunica albugina. A transverse island from inner layer of prepuce was outlined and dissected with the distance equal to or slightly longer than that between hypospadias orifice and the tip of glans as measured with a strip of suture, the width was measured subjectively based on the age of the patient. The flap was dissected with its axial vascular pedicle which was mobilized proximally to an extent that allowed ventral transposition of the flap with no tension. The islands flap was tabularized such that it was slightly loose around a suitable sized stent using subcuticular and 2nd interrupted layer by 5\0 PDS suture. The neo-urethra was transported ventrally and anastomosed to the native urethra using 5\0 interrupted vicryl suture. A glans channel was constructed by excising central core of glandular tissue to the level that make the glandular edges cover the neourethra which was brought through the glans and the glandular edges sutured by 4\0 dexon (mattress). The dorsal layer of prepuce was transported ventrally and the repair covered with skin as cosmetically as possible. Perineal urethrostomy catheter of 10-14Fr. was placed as proximal urinary diversion and kept in situ for 14-21 days and the stent in the flap left in situ (neo-urethra) for 10-14 days. Picture 1: Delineation of the flap

TRANSVERSE PREPUTIAL ISLAND PEDICLE FLAP (TPIPF) IN TREATMENT OF FAILED HYPOSPADIAS REPAIR: PERSONAL EXPERIENCE