There would appear to be no other reports in the English language literature about the success of STR for improving post-salvage repair outcome and preventing PUC. Nguyen and Snodgrass reported 7/31 salvage tubularized incised plate UP patients developed dehiscence (n=2), large fistula (n=1), and small fistula (n=4) to give a complication rate of 22.6% ; Emir and Erol reported complications in 14/55 salvage Mathieu UP patients to give a complication rate of 25.6% , and Joseph et al reported complications in 6/11 tunica vaginalis onlay flap salvage UP in 10 boys and 1 adult to give a complication rate of 54.5% . In contrast, in a previous study that introduced the CHARGE technique used in this series, there were no PUC documented in 39 cases  and in this series, no PUC have developed to date in any of the 8 cases after mean follow-up after salvage UP of 3.9±1.2 years (range: 1.6 to 6.4 years). Given the fact that in a previous study by colleagues of the authors of this series, PUC were noted to develop after a mean of 0.7±0.2 years , more than enough time (mean of 3.9 years) has passed for complications to develop, so STR would appear to have prevented PUC in cases at greater risk for their development.
Despite reports of several techniques for reconstructing the urethra during salvage surgery for hypospadias [1-7] the reasons why redo surgery and salvage surgery for failed hypospadias remain so particularly challenging are because scar tissue and poor perfusion hamper recovery , contributing to poor outcome and further PUC. During salvage hypospadias surgery, thin, under-perfused tissue of poor flexibility and vascularity tends to leak when sutured because it lacks resilience giving rise to delayed wound healing, infection, and urethrocutaneous fistula formation. CHARGE very effectively improves the thickness, flexibility and vascularity of the urethral plate contributing to better outcome and preventing PUC and is highly recommended for salvage hypospadias surgery. Similarly, NUC is acknowledged as a procedure for preventing postoperative urethrocutaneous fistula [12-14] and in a previous report, the value of a variety of tissues such as foreskin connective tissue, pedicled external spermatic fascia, and tunica vaginalis flap for reinforcing the neourethra during both single- and multi-stage repair of hypospadias urethrocutaneous fistula were discussed
In the cases CHARGE was used in this series (cases 1, 2, 3, and 4; see Figure 2), the skin and subcutaneous tissues were noted to be thick and well perfused when the next procedure was performed (Figure 3); a distinct advantage because during surgery for failed hypospadias repair, the scarred urethral plate, even the neourethra created previously may require revision or removal and working with thin tissue with compromised perfusion is extremely difficult.
While each case of failed hypospadias is unique with a spectrum of compromising factors, CHARGE and NUC are of practical value because they can be applied during all cases requiring salvage surgery. Harvesting tissue for STR may seem daunting because damage from previous surgery causes scarring, poor vascular perfusion, and poor flexibility, but NUC was performed readily by making an incision in the scrotum to harvest intra-scrotal tissue, especially intra-scrotal fat tissue, that provided a thick, well perfused layer of tissue with good flexibility to support the new neourethra physically, and improve perfusion/vascularity. It was easy to harvest, had a good blood supply, and could reach the distal neourethra.
While this study has limitations because it is retrospective and was performed at a single center with only a very small number of subjects and large variation in morbidity (types of hypospadias, types of previous surgery, and indications for salvage surgery), this series demonstrated that STR is beneficial for successful salvage hypospadias surgery and preventing PUC. Longer term follow-up will confirm the efficacy of STR for preventing PUC and a larger study will reinforce the indications for STR. In fact, STR could have potential to be incorporated routinely to improve outcome and prevent PUC in all hypospadias cases.