Ventral rotational flap with dartos buttonhole modification

Objective Patients with bladder exstrophy - epispadias complex have a particularly high risk of penopubic scarring due to the multiple surgeries that they undergo. Penile skin coverage during epispadias repair can be particularly challenging in these patients. Surgical techniques for penile skin coverage during epispadias repair include Byar’s flap, the buttonhole technique, and the traditional ventral rotational flap. However, these methods do not achieve satisfactory cosmesis and can increase the risk of penile torsion. We aimed to assess whether the dartos buttonhole modification of the ventral rotational flap can provide adequate penile skin coverage and potentially minimize the risk of penile torsion. Patients and Surgical procedure In this video, we demonstrate the dartos buttonhole modification of the ventral rotational flap in three patients, one with isolated penile epispadias undergoing modified Cantwell-Ransley technique and two with classic bladder exstrophy, one undergoing one-stage radical soft tissue mobilization and the other undergoing redo radical soft tissue mobilization. Results The ventral rotational flap with dartos buttonhole modification was performed successfully in all three patients. Conclusions We report the feasibility of this modification, which may help circumvent many of the issues related to epispadias penile skin coverage witnessed in previously reported surgical techniques.