{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T16:36:49Z","timestamp":1787071009610,"version":"build-2736575974"},"reference-count":21,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"2","license":[{"start":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T00:00:00Z","timestamp":1768953600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>\n                    A\n                    <jats:sc>BSTRACT<\/jats:sc>\n                  <\/jats:title>\n                  <jats:p>\n                    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\u20130.70,\n                    <jats:italic toggle=\"yes\">I<\/jats:italic>\n                    \u00b2 = 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.\n                  <\/jats:p>","DOI":"10.4103\/jiaps.jiaps_304_25","type":"journal-article","created":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T11:00:21Z","timestamp":1768993221000},"page":"145-150","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["Tunica Vaginalis Versus Dartos as Interposition Soft Tissue in Hypospadias Repair: A Systematic Review and Meta-analysis"],"prefix":"10.4103","volume":"31","author":[{"given":"Nitinkumar","family":"Borkar","sequence":"first","affiliation":[{"name":"Department of Paediatric Surgery, AIIMS, Raipur, Chhattisgarh, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charu","family":"Tiwari","sequence":"additional","affiliation":[{"name":"Department of Paediatric Surgery, AIIMS, Raipur, Chhattisgarh, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Prince","family":"Raj","sequence":"additional","affiliation":[{"name":"Department of Paediatric Surgery, AIIMS, Raipur, Chhattisgarh, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reyaz Ahmad","family":"Wani","sequence":"additional","affiliation":[{"name":"Department of Paediatric Surgery, AIIMS, Raipur, Chhattisgarh, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mustafa","family":"Azizoglu","sequence":"additional","affiliation":[{"name":"Department of Paediatric Surgery, Istanbul Esenyurt Necmi Kadioglu Hospital, Istanbul, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,1,21]]},"reference":[{"key":"R1-20260311","doi-asserted-by":"crossref","first-page":"482","DOI":"10.1016\/j.eururo.2019.06.027","article-title":"Hypospadias prevalence and trends in international birth defect 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Urol"},{"key":"R5-20260311","doi-asserted-by":"crossref","first-page":"392","DOI":"10.4103\/0970-1591.134234","article-title":"Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: A prospective study","volume":"30","author":"Bhat","year":"2014","journal-title":"Indian J Urol"},{"key":"R6-20260311","doi-asserted-by":"crossref","first-page":"2047","DOI":"10.1016\/S0022-5347(01)65432-6","article-title":"The dartos flap as an adjunct in preventing urethrocutaneous fistulas in repeat hypospadias surgery","volume":"156","author":"Churchill","year":"1996","journal-title":"J Urol"},{"key":"R7-20260311","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1097\/00005392-199502000-00061","article-title":"Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: An 8-year experience","volume":"153","author":"Snow","year":"1995","journal-title":"J Urol"},{"key":"R8-20260311","doi-asserted-by":"crossref","first-page":"90","DOI":"10.4103\/ajps.AJPS_93_20","article-title":"Evaluation of tunica vaginalis free graft as a better alternative to tunica vaginalis pedicled flap for providing waterproof cover in stage II hypospadias repair","volume":"18","author":"Tiwari","year":"2021","journal-title":"Afr J Paediatr Surg"},{"key":"R9-20260311","doi-asserted-by":"crossref","first-page":"16","DOI":"10.4103\/0971-9261.91080","article-title":"Soft tissue covers in hypospadias surgery: Is tunica vaginalis better than dartos flap?","volume":"17","author":"Dhua","year":"2012","journal-title":"J Indian Assoc Pediatr Surg"},{"key":"R10-20260311","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1007\/s00345-024-05419-x","article-title":"Tunica vaginalis or dartos as second layer coverage for distal and mid-shaft penile hypospadias, quo vadis?","volume":"43","author":"Ramez","year":"2025","journal-title":"World J Urol"},{"key":"R11-20260311","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1016\/S0022-5347(01)61824-X","article-title":"Penile torque after the use of tunica vaginalis blanket wrap as an aid in hypospadias repair","volume":"161","author":"Pattaras","year":"1999","journal-title":"J Urol"},{"key":"R12-20260311","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"R13-20260311","doi-asserted-by":"crossref","first-page":"451","DOI":"10.4103\/sja.sja_840_24","article-title":"Robvis Shiny App: A tool for risk of bias assessment","volume":"19","author":"Borkar","year":"2025","journal-title":"Saudi J Anaesth"},{"key":"R14-20260311","doi-asserted-by":"crossref","first-page":"310","DOI":"10.4103\/sja.sja_749_23","article-title":"Significance of fragility index in meta-analysis","volume":"18","author":"Borkar","year":"2024","journal-title":"Saudi J Anaesth"},{"key":"R15-20260311","doi-asserted-by":"crossref","first-page":"42","DOI":"10.4103\/ajps.AJPS_104_17","article-title":"A 1-year randomized controlled trial to compare the outcome of primary repair of hypospadias with vascular cover using tunica vaginalis flap with those using preputial dartos fascia","volume":"15","author":"Kurbet","year":"2018","journal-title":"Afr J Paediatr Surg"},{"key":"R16-20260311","first-page":"11","article-title":"Comparison of tunica vaginalis flap with dartos flap in reducing postoperative fistula after TIP","volume":"3","author":"Das","year":"2017","journal-title":"SAS J Surg"},{"key":"R17-20260311","doi-asserted-by":"crossref","first-page":"850","DOI":"10.18203\/2349-2902.isj20180433","article-title":"Outcome of standard tabularized incised plate urethroplasty repair using dartos flap and tunica vaginalis flap in of hypospadias cases","volume":"5","author":"Patel","year":"2018","journal-title":"Int Surg J"},{"key":"R18-20260311","doi-asserted-by":"crossref","first-page":"187","DOI":"10.4103\/0970-0358.163059","article-title":"Tunica vaginalis flap following 'tubularised incised plate'urethroplasty to prevent urethrocutaneous fistulaa","volume":"48","author":"Hamid","year":"2015","journal-title":"Indian J Plast Surg"},{"key":"R19-20260311","doi-asserted-by":"crossref","first-page":"1596","DOI":"10.1097\/01.ju.0000084661.05347.58","article-title":"Outcome analysis of tunica vaginalis flap for the correction of recurrent urethrocutaneous fistula in children","volume":"170","author":"Landau","year":"2003","journal-title":"J Urol"},{"key":"R20-20260311","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1016\/j.eururo.2015.12.047","article-title":"Algorithm for optimal urethral coverage in hypospadias and fistula repair: A systematic review","volume":"70","author":"Fahmy","year":"2016","journal-title":"Eur Urol"},{"key":"R21-20260311","doi-asserted-by":"crossref","first-page":"804","DOI":"10.1016\/j.jpurol.2012.10.022","article-title":"Tunica vaginalis flap is superior to inner preputial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias","volume":"9","author":"Babu","year":"2013","journal-title":"J Pediatr Urol"}],"container-title":["Journal of Indian Association of Pediatric 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History"}},{"value":"2025-11-11","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}