Journal of Pediatric Urology (2011) 7, 305e309

Z-plasty for sculpturing of the bifid scrotum in

severe hypospadias associated with penoscrotal
transposition
Ibrahim Mokhless a, Mohamed Youssif a,*, Marwan Eltayeb a, Moneer Hanna b

a
Faculty of Medicine, Section of Pediatric Urology, Department of Urology, Main University Hospital,
University of Alexandria, Alexandria, Egypt
b
New York Presbyterian Weill Cornell Medical Center, NY, USA

Available online 27 April 2011

KEYWORDS Abstract Purpose: Bifid scrotum is usually associated with scrotal and perineal hypospadias.
Scrotoplasty; Conventional surgical repair involves rotation of two scrotal flaps, joining them in the midline,
Hypospadias; and vertical skin closure. Dimpling of skin can occur, resulting in suboptimal aesthetic results.
Bifid scrotum We describe a technique whereby the bifid scrotum is rebuilt and contoured using single or
multiple Z-plasties.
Methods: We repaired 43 children with scrotal, penoscrotal or perineal hypospadias and
varying degrees of bifid scrotum. Age range was 5 monthse18 years. Patients were divided into
three groups: I) 26 children with primary perineoscrotal hypospadias who underwent two-stage
hypospadias repair and had a Z-scrotoplasty during either the first or second stage repair; II) 11
children who had previous hypospadias surgery with vertical closure of scrotum, and who
underwent secondary Z-scrotoplasty; III) 6 children with primary posterior hypospadias who
had their scrotum repaired with midline vertical closure, serving as control.
Results: 24 children in Group I and all patients in Group II achieved excellent aesthetic results,
with rounded scrotum, no midline dimpling and no major complications. Midline dimple was
encountered in 4 patients in Group III.
Conclusions: In repairing bifid scrotum associated with hypospadias, the principle of Z-plasty
can be incorporated in scrotal contouring. This elongates, relaxes and interrupts the longitu-
dinal tension of the midline closure. Multiple Z-plasties avoid contracture and scar formation,
which are apt to result in recurrence of bifid scrotum.
2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Pediatric Urology Unit, Department of Urology, University of Alexandria School of Medicine, Alexandria, Egypt.
Tel./fax: 00 203 4860029.
E-mail address: dr.youssif@gmail.com (M. Youssif).

1477-5131/$36 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpurol.2011.02.023
306
Figure 1 Different types of bifid scrotum. A) bifid scrotum with perineal hypospadias, B) incomplete penoscrotal transposition,
C) recurrent scarred bifid scrotum.
Introduction
Bifid scrotum is usually associated with scrotal and perineal
hypospadias. The penoscrotal transposition in these cases
may be partial or complete. In the incomplete or partial
type, which is less severe but more common than the
complete type, the penis lies in the middle of the scrotum.
Surgical treatment is based on the severity of transposition
and associated hypospadias. The ideal approach for repair
of severe proximal hypospadias with incomplete peno-
scrotal transposition and bifid scrotum is still controversial.
There are a number of approaches for surgical correction of
transposition. Conventional surgical repair includes rota-
tion of two scrotal flaps, joining them in the midline, and
vertical skin closure [1]. Other surgical techniques include
reorienting the scrotum inferiorly with limited rotation
flaps [2], inguinal based groin flaps [2] and transposition of
the penis superiorly in a planned two-stage approach [3,4].
Other authors have reported on incorporating urethroplasty
and transposition in a single-stage procedure particularly if
the Koyanagi procedure is used [5e8]. Reconstruction of
transposition prior to the management of hypospadias will
give more satisfying results since the scrotum is placed in
its true anatomical position. The penile body also becomes
more prominent with an acceptable appearance that in
turn affects the final outcome after hypospadias surgery.
The two-stage repair for severe proximal hypospadias has
gained wide popularity due to its lower complication rates
[9e11]. But dimpling of the skin in the midline of the
scrotum can occur, resulting in suboptimal aesthetic
results.
Z-plasty is a plastic surgery technique used to improve
the functional and cosmetic appearance of scars. It
involves the creation of two triangular flaps of equal
dimensions that are then transposed. For a basic Z-plasty,
the triangular flaps are created using an angle of 60 .
Theoretically, this angle can lengthen a contracted scar
by about 75% and reorient the direction of the central
Table 1 Type of hypospadias, timing and type of scrotoplasty.
Type of hypospadias Total number of cases Primary scrotoplasty
Perineo-scrotal 28 22
Penoscrotal 3 e
Perineal 12 7 5
Total 43 29
I. Mokhless et al.
wound by 90 [12]. In practise, the lengthening and
reorientation will be less, owing to increased wound
tension. Herein, we describe a surgical technique
whereby the bifid scrotum is rebuilt and contoured using
single or multiple Z-plasties.
Materials and methods
Forty-three patients with perineoscrotal and scrotal hypo-
spadias and severe chordee, and variable degrees of
incomplete scrotal transposition or post surgical scrotal
scarring (Fig. 1), were included in the study (Table 1). Their
ages ranged between 5 months and 18 years (mean 4
years). The study was performed as a collaborative work
between two institutions, and the patients were random-
ized into three groups. Group I included 26 children with
primary perineoscrotal hypospadias who underwent two-
stage hypospadias repair and had a Z-scrotoplasty during
either the first or second stage. Group II included 11 chil-
dren who had previous hypospadias surgery with vertical
closure of scrotum and persistent bifid scrotum. This group
underwent secondary Z-scrotoplasty. Group III included 6
children with primary posterior hypospadias who had
undergone midline vertical closure, serving as the control.
In patients with a small sized phallus and glans, topical
testosterone cream was applied before surgery twice daily
for 1 month to achieve penile lengthening without any
secondary effects on the hypothalamus-pituitary-testicular
axis. In the case of penoscrotal transposition with peno-
scrotal hypospadias, the first-stage procedure was similar
to that described by Glenn and Anderson [1] with complete
mobilization of the two halves of the scrotum as rotational
advancement flaps with relocation of the scrotal
compartment in a normal position. At the same time,
release of the chordee was achieved. In cases with asso-
ciated scrotal or perineal hypospadias with bifid scrotum,
the initial stage differed from the GlennAnderson
Secondary scrotoplasty Type of repair
Vertical Z-plasty
Single Multiple
6 4 e 24
3 e e 3
2 3 7
14 6 3 34
Z-plasty for sculpture of bifid scrotum
Figure 2 The Z-scrotoplasty procedure. A, initial stay suture and drawing lines. B, single and C, multiple Zs.
description in that the incision was made proximally or
behind the meatus to allow formation of a ThierschDuplay
skin tube, and transforming a scrotal or perineal hypospa-
dias into a penoscrotal hypospadias. The chordee was
corrected by excessive release of dysplastic tissues. Arti-
ficial erection was performed to ensure a straight penis.
Tunica albuginea plication corporoplasty was performed if
mild chordee persisted. In the case of a small penis or
corporal defect with severe angulations (>60 ), a ventral
dermal or buccal mucosa free graft [13] was applied. The
suspensory ligament was released to increase the length of
307
the exposed penis along with tacking of the corpora to
penopubic skin. An indwelling silicon Foley catheter was
used, and was removed after 7 days. After completion of
the first stage, Z-plasty was performed in association with
the second stage repair to preserve flap vasculature.
During the second stage, the operative principle of Z-plasty
[12] is based on a technique to achieve a normal anatomic
scrotum. Stay sutures of 6-0 polyglycolic acid (Vicryl) were
placed at the glans, the penoscrotal junction and the distal
edge of the bifid scrotum at the perineum. Marking lines
were drawn at the edges, the scrotum midline or scrotal
308
Figure 3 The surgical steps of Z-scrotoplasty. A) drawing the flap lines, B) dissection of flaps and their transposition,
C) appearance of scrotum after completion of the procedure.
scar. Single or multiple parallel staggered cuts were made
at each end of the scrotum midline. The side arms of the
cuts were exactly equal in length to the central scar lines
and had precisely the same angles to form the Zs. Full
thickness skin incisions were made creating triangular flaps
of equal size and shape. Adequate undermining of
surrounding tissues was performed to achieve proper
mobilization of the flaps (Figs. 2 and 3). Scrotal Z flaps
angles ranged from 45 to 60 depending on local anatomy.
The scrotal flaps were transposed around each other,
changing the direction of the midline, and resulting in
lengthening and interruption of longitudinal tension. Flaps
were held in place with anchoring stitches. Skin closure
was performed with 6/0 polyglycolic acid (Vicryl), trans-
verse mattress or interrupted sutures. In severe pathology,
multiple Z flaps are used and fashioned to achieve a round
scrotum. Pressure dressing was applied over the wound.
Outcome and complications were compared between the
three groups.
Results
Follow up ranged from 6 months to 3 years. No major
complications were encountered. Multiple Zs (two or
more) were performed in 34 cases; a single Z was per-
formed in 3 cases. In Group I (new cases), 24 of the 26
patients and in Group II (redo cases) all 11 patients ach-
ieved excellent aesthetic results, with rounded scrotum
and no midline dimpling (Fig. 4). A midline dimple was
encountered in 4 of the 6 studied patients in Group III who
Figure 4 Postoperative appearance of scrotum after Z-plasty. A) Early, B) Late. Notice the rounded contour of the scrotum.
I. Mokhless et al.
had undergone the vertical midline closure technique
(Table 2). Patients were further evaluated according to the
general look, on the opinion of the attending physicians.
Multiple Zs were used in extreme cases of bifid scrotum
and in severe scrotal scarring. Multiple Zs showed superior
cosmetic results to a single Z; it is observed that the more
Zs done the better the cosmetic results.
Discussion
Bifid scrotum seldom occurs as an isolated defect but is not
rare in severe hypospadias without transposition. Peno-
scrotal transposition accurately describes an improper
anatomical relationship between the penis and the
scrotum. Classically, the scrotum is viewed as being
improperly positioned in reference to the penis. Virtually
all surgical approaches to penoscrotal transposition focus
on correcting this scrotal pathology. The etiology of
penoscrotal transposition remains uncertain. Bifid scrotum,
which is invariably associated with incomplete trans-
position, has been well established as a phenotype of the
partial androgen insensitivity syndrome [6]. This syndrome
occurs in various degrees and is caused by mutations in the
androgen receptor gene.
The ideal approach for severe proximal hypospadias and
bifid scrotum is complex and still controversial. Penoscrotal
transposition associated with hypospadias and bifid scrotum
is treated most frequently in a multistage operation. Various
different techniques have been described in the literature
for two-stage repair. Stage one of the procedure involves the
Z-plasty for sculpture of bifid scrotum
Table 2 Outcome in different groups.
Group No. of Rounded scrotum Midline dimple
cases (no midline dimple)
I 26 24 2 morbidity and good aesthetic results. Both parents and
II 11 11 e surgeons were satisfied with the scrotal appearance after Z-
III 6 2 4 plasty. Long-term follow up is needed to further document
correction of penoscrotal transposition and bifid scrotum.
Stage two involves the creation of a neourethra. Various
techniques of scrotoplasty have been reported, to incorpo-
rate scrotal skin and overcome this congenital deficiency.
The scrotal transposition technique was described initially by
Glenn and Anderson [1] and Ehrlich and Scardino [4] in
penoscrotal transposition and bifid scrotum. They performed
the scrotoplasty by creating two large scrotal flaps and
rotating them inferiorly underneath the penis. The bifid
scrotum was reconstructed by excising the midline scrotal
tissue and bringing the scrotal halves together in the midline.
In scrotal or perineal hypospadias with bifid scrotum the
procedure differs from that depicted by Glenn and Anderson
[1] in one important aspect. According to the Thiersch
Duplay technique, it is possible to use the smooth hairless
epithelium that lies between the two parts of the scrotum.
This allows positioning of the new meatus far more distally,
facilitating a less complex and shorter second-stage repair.
But on several occasions dimpling of the scar in the midline of
the scrotum has occurred [2]. Others have placed the penis
anterior to the scrotum through a subcutaneous tunnel
[4,15]. But actually this may be the reverse of what should be
done: the problem lies in the scrotum and it needs correction
rather than just changing the position of the penis.
With the improvements in techniques of hypospadias
repair and increased patient expectation of better cosm-
esis, alternative procedures with superior outcomes should
be investigated. Z-plasty is a standardized plastic surgical
technique used to improve the function and cosmetic
appearance of scars; it involves the creation of two flaps of
equal dimensions, which are transposed and rotated. With
angles of 60 , Z flaps achieved a 75% gain in length; with 45-
degree angles, the length gain was 50% [14]. Perovic and
Vukadinovic [6] recommended single-stage repair of peri-
neoscrotal transposition for reconstruction of the bifid
scrotum, and reported excision of the thin and hairless skin
in the midline to avoid middle groove formation. They also
performed Z-plasty to reconstruct the scrotum. Mori and
Ikoma [16] reported 20 cases of perineoscrotal trans-
position; they performed an inverted U skin incision around
the scrotal skin and the base of the penis. Scrotal flaps were
mobilized beneath the penis and sutured in a straight line
or Z form. We utilized the principle of Z-plasty to improve
the cosmetic outcome of the scrotum.
Our results favour the utilization of Z-plasty in scarred
scrotum and primary surgery, particularly in severe scrotal
transposition and extreme bifid scrotum. The procedure
can be performed with first or second stage repair
according to individual case variation or surgeons
309
preference. The penoscrotal angle looks sharper and better
defined if Z-plasty is performed. There was a more rounded
appearance of the scrotum in groups I and II than in control
group III. The procedure is easy to perform with minimal
the success of the procedure.
Conclusion
In repairing bifid scrotum associated with hypospadias, the
principle of Z-plasty can be incorporated in scrotal con-
touring. It elongates, relaxes and interrupts the longitu-
dinal tension of the midline closure. There are advantages
to multiple small Z-plasties over one large Z-plasty, as they
avoid contracture and scar formation which are apt to
result in recurrence of the bifid scrotum.
References
[1] Glenn JF, Anderson EE. Surgical correction of incomplete
penoscrotal transposition. J Urol 1973;110:603.
[2] Pinke LA, Rathbun SR, Husmann DA. Penoscrotal transposition:
review of 53 patients. J Urol 2001;166:1865.
[3] Levy J, Darson M, Bite U. Modified pudendal-thing flap for
penoscrotal transposition. Urology 1997;50:597.
[4] Kolligian ME, Franco I, Reda EF. Correction of penoscrotal
transposition: a novel approach. J Urol 2000;164:994.
[5] Koyanagi T. Repair of severe proximal hypospadias associated
with bifid scrotum. Int Urol Nephrol 1984;16(2):115.
[6] Perovic S, Vukadinovic V. Penoscrotal transposition with
hypospadias: 1-stage repair. J Urol 1992;148:1510.
[7] Glassberg K, Hansbrough F, Horowitz M. The Koyanangi-Non-
omura 1-stage bucket repair of severe hypospadias with and
without penoscrotal transposition. J Urol 1998;160:1104.
[8] De Foor W, Wacksman J. Results of single staged hypospadias
surgery to repair penoscrotal hypospadias with bifid scrotum
or penoscrotal transposition. J Urol 2003;170:1585.
[9] Gershbaum MD, Stock JA, Hanna MK. A case for 2-stage repair
of perineoscrotal hypospadias with severe chordee. J Urol
2002;168:1727.
[10] Arena F, Romeo C, Manganaro A, Arena S. Surgical correction
of penoscrotal transposition associated with hypospadias and
bifid scrotum; our experience of two-stage repair. J Pediatr
Urol 2005;1:289.
[11] Bracka A. Hypospadias repair: the two-stage alternative. Br J
Urol 1995;76:31.
[12] Slam GA, Amin P. The basic Z-plasty. Amer Fam Physician
2003;67:11.
[13] Mokhless IA, Youssif ME, Orabi SS. Corporal body grafting using
buccal mucosa in posterior hypospadias with severe curva-
ture: a prospective study. J Urol 2009;182(4):1726.
[14] Ehrlich RM, Scardino PT. Surgical correction of scrotal trans-
position and perineal hypospadias. J Pediatr Surg 1982;
17:175.
[15] Cohen-Addad N, Zarafu IW, Hanna MK. Complete penoscrotal
transposition. Urology 1985;26:149.
[16] Mori Y, Ikoma F. Surgical correction of incomplete penoscrotal
transposition with hypospadias. J Pediatr Surg 1982;21:46.