Tunica Vaginalis Versus Dartos as Interposition Soft Tissue in Hypospadias Repair: A Systematic Review and Meta-analysis

A BSTRACT Hypospadias is one of the most common congenital anomalies of the male urethra, with urethrocutaneous fistula (UCF) being its most common postoperative complication. An interposition tissue layer is often used between the neourethra and skin to reduce the incidence of UCF. Dartos flap (DF) has traditionally been preferred, whereas the tunica vaginalis flap (TVF) has gained popularity for its robust vascularity. This systematic review and meta-analysis aimed to compare outcomes of TVF versus DF in primary hypospadias repair (TIP). PRISMA guidelines were followed. Randomized controlled trials (RCTs) comparing TVF and DF as interposition layers were identified through MEDLINE, Embase, Scopus, CENTRAL, trial registries, and Google Scholar. Inclusion criteria comprised children undergoing TIP with postoperative outcomes as variables. Risk of bias was assessed using the Cochrane RoB2 tool. Pooled analyses were performed using RevMan web. A fragility index (FI) was calculated for the primary outcome. Four RCTs, including 209 patients (TVF: 97, DF: 112), were included for analysis. UCF occurred in 9.28% in the TVF group versus 30.36% in the DF group. Pooled analysis favored TVF (risk ratio: 0.37; 95% confidence interval: 0.19–0.70, I ² = 0%). No significant differences were observed for meatal stenosis (MS) or penile torsion. The FI for UCF was 7, indicating moderate robustness. TVF significantly reduces UCF rates compared to DF in TIP with similar complication rates for MS and penile torsion. Considering the moderate fragility of the primary outcome UCF and limited data on secondary outcomes, more number of RCTs would be necessary to validate these findings.