ONE-STAGE REPAIR OF HYPOSPADIAS LOKA N. REDDY,
M.D.
From the Division of Plastic Surgery, New Jersey College of Medicine and Dentistry, Newark, New Jersey
ABSTRACT - A new one-stage procedure fin-repair of penile hypospadias is presented. Seventeen cases have been pe$ormed with minimum complications. The steps of the procedure are described.
Most surgical repairs for hypospadias involve two or three stages. This results in prolonged hospitalization and the risk of repeated anesthesia. A one-stage operation using only local tissues has been designed and is presented in this report. The average age for repair is eighteen months to four years, but operation at the age of two years is preferred for the following reasons: (1) In younger children healing processes are faster; (2) the development of the penis will be more normal; (3) parents and patient are relieved psychologically; and (4) the postoperative course is not complicated by erection as so often happens in older patients.
FIGURE
1.
Excision of chordee.
Operative Technique Release of chordee
and raising
of skin flaps
The external genitalia and pubic regions are prepared with betadine solution, and the penis is draped around with sterile towels. A 3-O silk suture is drawn through the tip of the glans penis for retraction of the penis upward during operation. The penis is held over the fingers displaying the ventral surface of the penis facing the surgeon. Two longitudinal, parallel skin incisions are made from coronal sulcus to just proximal to the hypospadiac meatus, the distance between the two incisions being about 3 to 4 mm. (Fig. 1). The incisions are deepened to the deep fascia. Presented at the New York Surgery, December, 1971.
UROLOGY
Regional
/ APRIL 1975 / VOLUME
Society
of Plastic
V. NUMBER 4
FIGURE 2. Reconstruction of urethra. (A) Development of lateral skin $ups; (B) two triangular areas denuded of epithelium for attachment of lateral flaps to glans penis.
475
FIGURE 3. Reconstruction of urethra. (A) Silastic catheter in place; (B) lateral flap sutured to glans penis; (C) approrimation of lateral jbps.
The dense fibrous bands along with the skin strip are dissected. All fibrous tissue distal to the urethral meatus must be removed down to the glistening tunica albuginea in the groove between the corpora cavernosum. Usually the fibrous tissue extends around and just proximal to the ectopic meatus, and this is also dissected. After this dissection, the ectopic urethra recedes further proximally, that is, a distal penile meatus becomes a middle penile meatus, and the middle penile meatus becomes a penoscrotal meatus. About 4 mm. lateral and parallel to the first two incisions, two additional skin incisions are made and their proximal ends formed with a curved incision just proximal to the hypospadiac meatus (Fig. 1). Thus, two lateral skin strips are formed (Fig. 2). These flaps are underminded to dissect fibrous tissue present beneath them. But the skin strips are not disturbed at their proximal and distal ends to maintain adequate blood supply. The previously mentioned measurements are a rough guide in the case of a child of three years of age, but the actual size of the skin strip depends on the size of the penis. We regard this excision of fibrous tissue an important step of the technique. Dissection is done with meticulous care, and every bit of fibrous tissue is scrupulously excised without impairing the blood supply of the flaps. It is important to handle the tissues gently to reduce the chance of fistula formation. Once the fibrous tissue is dissected completely, the penis becomes more supple and soft, and no more curvature is seen if the penis is left unsupported. Formation
of urethra
The lateral flaps or covering flaps are undermined subcutaneously, forming thick flaps so that the blood supply remains satisfactory (Fig. 2). A dorsal skin incision is made on the penis for
476
relaxation of the skin on the ventral surface. The extent of this incision proximally depends on the degree of hypospadias, for example, in proximal penile hypospadias the incision may be required well to the root of the penis, but in the case of a distal penile type just up to the middistance of the penis is sufficient. This incision aids in the mobilization of the lateral skin flaps while approximating outer edges and also relieves tension over the suture line. Even while suturing the skin edges there may not be any tension noticed; postoperatively, as a rule, edema will develop and exert pressure on the suture line. This should always be anticipated, and tension on suture lines must be scrupulously avoided. Care should be given not to injure the dorsal vein and artery. Complete relaxation of the flaps should be achieved before the covering flaps are sewn up to avoid the tearing of the skin. A useful test is to hold the flaps in the midline with the fingers and to observe their reaction on release; if they remain in position without springing apart, they should heal well.* A Silastic catheter is passed from the meatus to insure that no obstruction is present in the remaining proximal urethra, and the catheter is left indwelling for at least two days. Before suturing the skin flaps, absolute hemostasis should be adrenaline pack, thermal obtained, using cautery, and rarely ligation with 5-O plain catgut. The lateral flaps or covering flaps subcutaneously form thick flaps so that the blood supply remains satisfactory (Fig. 2). On the ventral surface of the glans or lateral to the fossa navicularis, when present, two triangular raw areas are made by excising the covering mucous membrane (Fig. 2). The apex of these areas should pass up to the tip of the *Crawford, J. Clin. Prac.
UROLOGY
The management B. S.: 17: 273 (1963).
of hypospadias,
/ APRIL 1975 / VOLUME
Br.
V, NUMBER4
CORPUS CAVERNOSUM
SKIN STRIP I URETHRAL ROO LATERAL (URETHRAL
q FLAP FLOOR)
URf THRAL
glans; there must be an adequate strip of normal glans tissue left between them to avoid undue narrowing of the urethra which passes through the glans. The distal ends of the lateral skin flaps (Fig. 2, A’, A’) are sutured to these triangular raw areas with 4-O silk (Fig. 3). If any difficulty is encountered, the skin incision may be extended laterally around the coronal sulcus. The edges of the lateral covering flaps are approximated with continuous sutures of 5-O nylon. The sutures are placed subcutaneousLy from proximal to distal end of the penis. Thus, the two skin strips form the roof of the new urethra (Fig. 4). The skin tube is reconstructed almost to the tip of the penis, thereby improving the esthetic result (Fig. 3). It may be noted that the lower layer of sutures approximate the subcutaneous tissue 2 to 3 mm. from the free edge (Fig. 4). Finally, the second layer of sutures with 4-O nylon on an atraumatic needle is placed uniting the free edges. The sutures are placed quite close together while the penis is held straight by the
FIGURE 5. (A) Preoperative ten days after operation.
UROLOGY
and (B) postoperative
/ APRIL 1975 / VOLUME
V, NUMBER 4
CHANNEL
FIGURE 4. Transverse section of penis through reconstructed urethra. Note formation of new urethra from skin tube. Roof is formed from epithelial surface of buried skin strips and floor from raw surface of lateral skinjlups approximated by two layers of watertight sutures.
assistant. This layer is also continued to the tip of the glans penis. The new meatus should not be too narrow or too wide. The ends of the subcutaneous sutures must be separated and identified for easy removal on the tenth day. Comment In this technique we do not use any form of urinary diversion unlike other one-stage repair procedures. The patient passes urine from the second or third day when the catheter is removed (Fig. 5). This eliminates the chance of hematoma formation within the reconstructed urethra and also the chance of infection due to an indwelling catheter in the bladder and urethra. Our experience with a limited number (I7 cases) has convinced us that urinary diversion is not essential for healing process. The repair of hypospadias is completed in one operative procedure which saves at least one extra hospitalization, anesthesia, and surgery. In this
pictures
offive-year-old
patient.
Postoperative
view taken
477
technique only local tissues are used. The penile skin has peculiar features which are not found in skin from other parts of the body. This procedure does not require a free skin graft. This is a major advantage because with the use of free skin graft for reconstruction of the urethra, there is always a danger of stricture and hair growth. To some extent the same disadvantages apply to a tube graft. This procedure is based mainly on principles of the Dennis Brown technique. It had previously been proved in experiments on animals that if a strip of skin is buried under the skin flap and the space is maintained open for a certain period, the epithelium grows from the margin of the buried skin strip and forms an epithelial lined tube. Our clinical observation again confirms this fact, The complications encountered are of a minor nature and are easily corrected. The incidence of complications is no higher than other methods.
478
This technique can be used in all types of hypospadias. Let me emphasize again, that the complete and meticulous excision of fibrous tissue distal to the ectopic meatus is very important, and one must make sure that the curvature of the penis is fully corrected before reconstruction of the urethra. If this is not done properly, there is a chance of recurrence of the chordee with a poor result. The second most important factor to bear in mind during this part of the procedure is strict adherence to the fundamental principles of plastic surgery in handling the tissue. This will minimize the formation of hematoma, edema, fistula, stricture, and incomplete wound healing. 65 Bergen Street Newark, New Jersey 07107 ACKNOWLEDGMENT. Grateful thanks to B. Reddy, F.R.C.S., who guided the work; to Dr. Joseph J. Seebode, who reviewed the article; and Mr. Schwartz who provided the illustrations.
UROLOGY
/ APRIL1975 / VOLUMEV,
NUMBER4
M.D.
From the Division of Plastic Surgery, New Jersey College of Medicine and Dentistry, Newark, New Jersey
ABSTRACT - A new one-stage procedure fin-repair of penile hypospadias is presented. Seventeen cases have been pe$ormed with minimum complications. The steps of the procedure are described.
Most surgical repairs for hypospadias involve two or three stages. This results in prolonged hospitalization and the risk of repeated anesthesia. A one-stage operation using only local tissues has been designed and is presented in this report. The average age for repair is eighteen months to four years, but operation at the age of two years is preferred for the following reasons: (1) In younger children healing processes are faster; (2) the development of the penis will be more normal; (3) parents and patient are relieved psychologically; and (4) the postoperative course is not complicated by erection as so often happens in older patients.
FIGURE
1.
Excision of chordee.
Operative Technique Release of chordee
and raising
of skin flaps
The external genitalia and pubic regions are prepared with betadine solution, and the penis is draped around with sterile towels. A 3-O silk suture is drawn through the tip of the glans penis for retraction of the penis upward during operation. The penis is held over the fingers displaying the ventral surface of the penis facing the surgeon. Two longitudinal, parallel skin incisions are made from coronal sulcus to just proximal to the hypospadiac meatus, the distance between the two incisions being about 3 to 4 mm. (Fig. 1). The incisions are deepened to the deep fascia. Presented at the New York Surgery, December, 1971.
UROLOGY
Regional
/ APRIL 1975 / VOLUME
Society
of Plastic
V. NUMBER 4
FIGURE 2. Reconstruction of urethra. (A) Development of lateral skin $ups; (B) two triangular areas denuded of epithelium for attachment of lateral flaps to glans penis.
475
FIGURE 3. Reconstruction of urethra. (A) Silastic catheter in place; (B) lateral flap sutured to glans penis; (C) approrimation of lateral jbps.
The dense fibrous bands along with the skin strip are dissected. All fibrous tissue distal to the urethral meatus must be removed down to the glistening tunica albuginea in the groove between the corpora cavernosum. Usually the fibrous tissue extends around and just proximal to the ectopic meatus, and this is also dissected. After this dissection, the ectopic urethra recedes further proximally, that is, a distal penile meatus becomes a middle penile meatus, and the middle penile meatus becomes a penoscrotal meatus. About 4 mm. lateral and parallel to the first two incisions, two additional skin incisions are made and their proximal ends formed with a curved incision just proximal to the hypospadiac meatus (Fig. 1). Thus, two lateral skin strips are formed (Fig. 2). These flaps are underminded to dissect fibrous tissue present beneath them. But the skin strips are not disturbed at their proximal and distal ends to maintain adequate blood supply. The previously mentioned measurements are a rough guide in the case of a child of three years of age, but the actual size of the skin strip depends on the size of the penis. We regard this excision of fibrous tissue an important step of the technique. Dissection is done with meticulous care, and every bit of fibrous tissue is scrupulously excised without impairing the blood supply of the flaps. It is important to handle the tissues gently to reduce the chance of fistula formation. Once the fibrous tissue is dissected completely, the penis becomes more supple and soft, and no more curvature is seen if the penis is left unsupported. Formation
of urethra
The lateral flaps or covering flaps are undermined subcutaneously, forming thick flaps so that the blood supply remains satisfactory (Fig. 2). A dorsal skin incision is made on the penis for
476
relaxation of the skin on the ventral surface. The extent of this incision proximally depends on the degree of hypospadias, for example, in proximal penile hypospadias the incision may be required well to the root of the penis, but in the case of a distal penile type just up to the middistance of the penis is sufficient. This incision aids in the mobilization of the lateral skin flaps while approximating outer edges and also relieves tension over the suture line. Even while suturing the skin edges there may not be any tension noticed; postoperatively, as a rule, edema will develop and exert pressure on the suture line. This should always be anticipated, and tension on suture lines must be scrupulously avoided. Care should be given not to injure the dorsal vein and artery. Complete relaxation of the flaps should be achieved before the covering flaps are sewn up to avoid the tearing of the skin. A useful test is to hold the flaps in the midline with the fingers and to observe their reaction on release; if they remain in position without springing apart, they should heal well.* A Silastic catheter is passed from the meatus to insure that no obstruction is present in the remaining proximal urethra, and the catheter is left indwelling for at least two days. Before suturing the skin flaps, absolute hemostasis should be adrenaline pack, thermal obtained, using cautery, and rarely ligation with 5-O plain catgut. The lateral flaps or covering flaps subcutaneously form thick flaps so that the blood supply remains satisfactory (Fig. 2). On the ventral surface of the glans or lateral to the fossa navicularis, when present, two triangular raw areas are made by excising the covering mucous membrane (Fig. 2). The apex of these areas should pass up to the tip of the *Crawford, J. Clin. Prac.
UROLOGY
The management B. S.: 17: 273 (1963).
of hypospadias,
/ APRIL 1975 / VOLUME
Br.
V, NUMBER4
CORPUS CAVERNOSUM
SKIN STRIP I URETHRAL ROO LATERAL (URETHRAL
q FLAP FLOOR)
URf THRAL
glans; there must be an adequate strip of normal glans tissue left between them to avoid undue narrowing of the urethra which passes through the glans. The distal ends of the lateral skin flaps (Fig. 2, A’, A’) are sutured to these triangular raw areas with 4-O silk (Fig. 3). If any difficulty is encountered, the skin incision may be extended laterally around the coronal sulcus. The edges of the lateral covering flaps are approximated with continuous sutures of 5-O nylon. The sutures are placed subcutaneousLy from proximal to distal end of the penis. Thus, the two skin strips form the roof of the new urethra (Fig. 4). The skin tube is reconstructed almost to the tip of the penis, thereby improving the esthetic result (Fig. 3). It may be noted that the lower layer of sutures approximate the subcutaneous tissue 2 to 3 mm. from the free edge (Fig. 4). Finally, the second layer of sutures with 4-O nylon on an atraumatic needle is placed uniting the free edges. The sutures are placed quite close together while the penis is held straight by the
FIGURE 5. (A) Preoperative ten days after operation.
UROLOGY
and (B) postoperative
/ APRIL 1975 / VOLUME
V, NUMBER 4
CHANNEL
FIGURE 4. Transverse section of penis through reconstructed urethra. Note formation of new urethra from skin tube. Roof is formed from epithelial surface of buried skin strips and floor from raw surface of lateral skinjlups approximated by two layers of watertight sutures.
assistant. This layer is also continued to the tip of the glans penis. The new meatus should not be too narrow or too wide. The ends of the subcutaneous sutures must be separated and identified for easy removal on the tenth day. Comment In this technique we do not use any form of urinary diversion unlike other one-stage repair procedures. The patient passes urine from the second or third day when the catheter is removed (Fig. 5). This eliminates the chance of hematoma formation within the reconstructed urethra and also the chance of infection due to an indwelling catheter in the bladder and urethra. Our experience with a limited number (I7 cases) has convinced us that urinary diversion is not essential for healing process. The repair of hypospadias is completed in one operative procedure which saves at least one extra hospitalization, anesthesia, and surgery. In this
pictures
offive-year-old
patient.
Postoperative
view taken
477
technique only local tissues are used. The penile skin has peculiar features which are not found in skin from other parts of the body. This procedure does not require a free skin graft. This is a major advantage because with the use of free skin graft for reconstruction of the urethra, there is always a danger of stricture and hair growth. To some extent the same disadvantages apply to a tube graft. This procedure is based mainly on principles of the Dennis Brown technique. It had previously been proved in experiments on animals that if a strip of skin is buried under the skin flap and the space is maintained open for a certain period, the epithelium grows from the margin of the buried skin strip and forms an epithelial lined tube. Our clinical observation again confirms this fact, The complications encountered are of a minor nature and are easily corrected. The incidence of complications is no higher than other methods.
478
This technique can be used in all types of hypospadias. Let me emphasize again, that the complete and meticulous excision of fibrous tissue distal to the ectopic meatus is very important, and one must make sure that the curvature of the penis is fully corrected before reconstruction of the urethra. If this is not done properly, there is a chance of recurrence of the chordee with a poor result. The second most important factor to bear in mind during this part of the procedure is strict adherence to the fundamental principles of plastic surgery in handling the tissue. This will minimize the formation of hematoma, edema, fistula, stricture, and incomplete wound healing. 65 Bergen Street Newark, New Jersey 07107 ACKNOWLEDGMENT. Grateful thanks to B. Reddy, F.R.C.S., who guided the work; to Dr. Joseph J. Seebode, who reviewed the article; and Mr. Schwartz who provided the illustrations.
UROLOGY
/ APRIL1975 / VOLUMEV,
NUMBER4
