Looking beyond the dartos fascia and tunica vaginalis: reviewing the stance of common adjuvant covering biomaterials in hypospadiology.

Hypospadias, one of the commonest congenital anomalies in boys, can have a spectrum of clinical presentation based on the location of the meatus and the presence of chordee. The surgical repair of hypospadias involves great precision, especially in proximal varieties and redo/complex cases of hypospadias. Hypospadiologists have put in tremendous efforts to improve the outcomes of these children. The utilization of adjuvant biomaterials is one such effort that has gained significant attention over the recent years. Biomaterials are used to cover the urethral suture line in instances where the ideal covering agents (dartos fascia and tunica vaginalis) are unavailable. We reviewed the mechanism of action, current stance, and advantages/disadvantages of three commonly used adjuvant agents, i.e. autologous platelet concentrates, tissue glues, and acellular dermal matrixes. Although individual studies have highlighted the therapeutic benefits of these adjuvants, the available literature has a limited level of evidence. Moreover, it is believed that the application procedure of these covering agents needs to be scrutinized in future studies. In addition, it is suggested that the application of any covering agent right up to the meatus is non-anatomical and redundant. Well-designed randomized controlled trials with a uniform application procedure and comparing different covering agents need to be conducted in the future before any definite conclusion is drawn.