Surgery is the standard treatment for hypospadias. It is a difficult surgery, with a multitude of techniques described. The posterior forms of hypospadias require the most complex techniques with a higher risk of complications [6. To improve the results, some authors opt for two-stage techniques [3, 7]. These would reduce the rate of infection and failure due to flap necrosis or suture disunion [3]. Zheng et al. [7] recommend two-stage urethroplasty in posterior forms with severe curvature after excision of the urethral plate, because they believe that this avoids the frequent urethral stenosis that occurs with single-stage urethroplasty. Bankole Sapin et al. [3] found a complication rate of 26% for two-stage surgery and 37% for one-stage surgery. However, the anesthetic risk and the additional financial costs generated by this technique are not negligible [8]. The Bracka technique is the most successful in this indication [8]. The choice of the DUCKETT's one-step technique [2] in our series was guided by the need to excise the urethral plate as part of the orthoplasty, the presence of a posterior preputial apron, but also because of the good mastery of the technique in our center. Added to this, the financial reasons and the problem of follow-up. For some authors [9], single-stage urethroplasty offers good results, especially for very young patients. While others, such as Bankole Sapin R et al. [3], believe that it is more likely to have complications. Complications of hypospadias surgery are particularly common in developing countries [3, 10]. Several factors may explain this phenomenon: the unavailability of adequate equipment (magnifying glasses, fine threads and microsurgical instruments in particular), the problem of post-operative care often entrusted to non-specialist nurses and the variability of the operators. Lower complication rates are noted by other authors, especially in Western countries [6, 11]. The main complications of hypospadias surgery reported in the literature are wound infection, flap necrosis, urethro-cutaneous fistula, and neo-urethral or neo-meatus stenosis [3, 10,11,12,13]. Wound infection was the most common early complication in this series, probably due to the poor conditions in which post-operative care was carried out, but also due to the hot and dry tropical climate. The use of two-stage surgery could in some cases minimize this complication rate. These infections are promoted to the failure of the repair by the sutures being loosened or by flap necrosis [14]. Flap necrosis can also be the consequence of poor dissection and devascularisation of the flap. Diallo et al. [10] reported 15% flap necrosis and suture disunion. No cases of flap necrosis were reported in this series. Urethro-cutaneous fistula was present in 2.4% of the cases in our series. Other authors reported varying frequencies ranging from 7.9% to 25% of cases depending on the series [3, 10, 11]. Prevention of this fistula can be achieved by interposing a secondary layer between the flap and the skin [15]. It is advisable to put in intermediate layers to minimize the risk of fistula [16]. The low rate of fistulas in this series may be due to this procedure being performed in most patients. The secondary treatment of this fistula is usually easy, but there is a risk of failure depending on the size of the fistula, the number of fistulas and the experience of the surgeon [14]. However, the age of the fistula, its location, and the length of the neo-urethra do not seem to influence the results [14]. Urethral stenosis is usually the result of devascularization of the stenotic area in the case of tension anastomosis, with a higher risk of wound infection [10]. The urethral stenosis rate is variable according to the literature. The rate was high in the series of Akbiyik et al. [12] who reported a 27.5% stenosis rate, while Mosharafa et al. [6] reported only 0.9% urethral meatus stenosis. Finally, the rate of unintrusive residual penile curvature (5%) was lower than that reported by Diallo et al. [10]. In total, the success rate of the DUCKETT technique was 63% after treatment of complications. The rate of good results depends, among other things, on the technique, the operator's experience, the type of hypospadias, and the presence and severity of the curvature [16]. Diallo et al. [10] in Guinea, after a 3–22 month follow-up, reported 61.7% good results for all techniques and all forms of hypospadias. While Diao et al. [13] in Senegal reported 62.5% good results for all previous forms of hypospadias, all techniques combined. Other, mainly western authors such as Dewan et al. [17] report better success rates with the Duckett technique after a single treatment (66.6% success rate out of 190 hypospadias treated). Similarly, Zheng et al. [15] reported only 24% complications after a first treatment with a pedicled preputial flap. According to them, the failure rate is higher with the Duckett procedure for recurrent hypospadias. The poor prognosis risk factors were advanced age at the time of surgery, the absence of an additional layer, and tissue fibrosis [15]. Lyu et al. [18], comparing the tubulated Duckett preputial flap with the untubulated Onlay patch flap, noted a higher rate of fistulas and stenosis with the DUCKETT procedure.
