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MODEL
Journal of Pediatric Urology (2014) xx, 1e2
LETTER TO THE EDITOR
Re. ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’ Mollard et al. [1e3] proposed a revolutionary idea in treatment of patients with proximal hypospadias by the use of an onlay island flap [4] on a preserved urethral plate. But, the first release of chordee by mobilization of the urethral plate with resection of the underlying fibrous tissue was proposed by Koyanagui in 1983 [5]. Studies have shown with certainty that the mobilization of the urethral plate and resection of the underlying fibrous tissue gives a very low correction of the chordee (10 e20 ). And release of the skin and dartos fascia widely continued to upstream of the meatus provides an important correction of all curvature [6,7]. Thus, the essential factor responsible for formation of the curvature of the penis is the fibrosis present in the lateral areas and back of the urethral plate, and not the fibrous tissue present under the urethral plate [7]. These works clearly demonstrate that the blood supply of urethral plate remains good even with urethral mobilization from the corpora cavernosa. And I do not think that the separation of the urethral plate is responsible for the high rate of urethral stenosis reported by the author [8], but instead the use of fibrous tissue existing under the urethral plate in the creation of the neoure `tre, and Fig. 2 shows that the author has used in urethroplasty a very thin, nearly transparent wall, which corresponds to a fibrous tissue present under an urethral plate incised in the middle. This can result in exposure to stenosis. I think that the challenge in the proximal hypospadias repair remains the correction of the chordee. The author [8] showed no photographs taken during saline erection tests showing the chordee both before and after the urethral mobilization to confirm this hypothesis. Using a median incision added to the Duplay technique, Snodgrass delivered a technique to bring the urethral meatus to the apex of the glans, and thus achieve an excellent cosmetic appearance (the meatus was vertically oriented and normally positioned) with fewer fistulae. We
DOI of original j.jpurol.2013.12.004.
article:
http://dx.doi.org/10.1016/
started to use this technique early; however, the rate of stenosis encountered with this technique remains elevated for distal hypospadias [9]. These stenoses are sometimes difficult to treat. For Snodgrass, periodic neourethral calibration was routinely performed over 1 year postoperatively [10]. In our patients, regular calibration was practised using a catheter and feeding stent with the application of a local anaesthetic gel, once a week, for several months (sometimes for more than 2 years). This procedure is simple and relatively painless. However, it is difficult to practice given the large number of patients treated for distal hypospadias [9]. But, the fistulae are less frequent with the approach used by Snodgrass. This is because of the midline incision of the urethral plate, which lowers the tension on the edges of the sutures. The essential act in Mollard’s technique for release of the chordee is resection of the fibrous tissue present under the urethral mucosa and not urethral mobilization alone. And I think that the better results obtained with an onlay island flap compared with tubulization of the prepuce are a result of the ability to resect the poorly vascularized edges, because there is often an excess of prepuce, without the risk of proximal stricture and the presence of the solid floor made from the vestigial dysgenetic tissue from aplasia of the corpus spongiosium, termed the urethral plate [7]. The ideal solution would be to have a simple technique, which is easy to perform, can correct the deformity with few or no postoperative complications, and preserves the urogenital function of the penis. I think if the distal hypospadias is associated with a deep balanic groove, it should be corrected by the Duplay procedure, but when the groove is less deep or non-existent the Snodgrass technique can be used. But, I don’t think that this technique is a good indication for proximal hypospadias associated with chordee. Finally, it is difficult to keep a urinary stent 6Fr in a boy for 2 weeks as proposed by the author. After 5 days, the 6 Fr stent begins to close owing to a fibrin secreted by the bladder mucosa [6].
References [1] Mollard P, Mouriquand P, Felfela T. Nouvelle technique de traitement des hypospades avec coudure par utilisation du lambeau en onlay. Prog Urol 1991;1:305e11.
1477-5131/$36 ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.12.003
Please cite this article in press as: Acimi S, Re. ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.003
+
MODEL
2 [2] Mollard P, Mouriquand P, Felfela T. Application of the onlay island flap urethroplasty to penile hypospadias with severe chordee. Br J Urol 1991;68:317e9. [3] Mollard P, Castagnola C. Hypospadias: the release of chordee without dividing the urethral plate and onlay island flap (92 cases). J Urol 1994;152:1238e40. [4] Elder JS, Duckett JW, Snyder HM. Onlay island flap in the repair of mid and distal penile hypospadias without chordee. J Urol 1987;138:376e9. [5] Koyanagi T, Matsuno T, Nonomura K, Sakakibara N. Complete repair of severe penoscrotal hypospadias in 1 stage: experience with urethral mobilizationdwing flap-flipping urethroplasty and “glanulomeatoplasty”. J Urol 1983;130: 1150e3. [6] Acimi S, Boukli-Hacene A. Inte ´re ˆt de la mobilisation de la plaque ure ´trale dans la libe ´ration de la courbure qui accompagne les formes poste ´rieures d’hypospadias. Prog Urol 2005; 15:59e62. [7] Acimi S. Proximal hypospadias: effect of urethral plate mobilization on release of chordee. Urology 2012;80:894e8.
Letter to the Editor [8] Snodgrass WT, Granberg C, Bush NC. Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair. J Pediatr Urol 2013;9(6): 990e4. [9] Acimi S. Comparative study of two techniques used in distal hypospadias repair: tubularized incised plate (Snodgrass) and tubularized urethral plate (Duplay). Scand J Urol Nephrol 2011;45:68e71. [10] Snodgrass W. Does tubularized incised plate hypospadias repair create neourethral strictures? J Urol 1999;162:1159e61.
Smail Acimi Children’s Hospital of Canastel, University of Oran, Department of Pediatric Surgery, Canastel, Oran 31000, Algeria E-mail address: [email protected] 18 November 2013
Please cite this article in press as: Acimi S, Re. ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.003
MODEL
Journal of Pediatric Urology (2014) xx, 1e2
LETTER TO THE EDITOR
Re. ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’ Mollard et al. [1e3] proposed a revolutionary idea in treatment of patients with proximal hypospadias by the use of an onlay island flap [4] on a preserved urethral plate. But, the first release of chordee by mobilization of the urethral plate with resection of the underlying fibrous tissue was proposed by Koyanagui in 1983 [5]. Studies have shown with certainty that the mobilization of the urethral plate and resection of the underlying fibrous tissue gives a very low correction of the chordee (10 e20 ). And release of the skin and dartos fascia widely continued to upstream of the meatus provides an important correction of all curvature [6,7]. Thus, the essential factor responsible for formation of the curvature of the penis is the fibrosis present in the lateral areas and back of the urethral plate, and not the fibrous tissue present under the urethral plate [7]. These works clearly demonstrate that the blood supply of urethral plate remains good even with urethral mobilization from the corpora cavernosa. And I do not think that the separation of the urethral plate is responsible for the high rate of urethral stenosis reported by the author [8], but instead the use of fibrous tissue existing under the urethral plate in the creation of the neoure `tre, and Fig. 2 shows that the author has used in urethroplasty a very thin, nearly transparent wall, which corresponds to a fibrous tissue present under an urethral plate incised in the middle. This can result in exposure to stenosis. I think that the challenge in the proximal hypospadias repair remains the correction of the chordee. The author [8] showed no photographs taken during saline erection tests showing the chordee both before and after the urethral mobilization to confirm this hypothesis. Using a median incision added to the Duplay technique, Snodgrass delivered a technique to bring the urethral meatus to the apex of the glans, and thus achieve an excellent cosmetic appearance (the meatus was vertically oriented and normally positioned) with fewer fistulae. We
DOI of original j.jpurol.2013.12.004.
article:
http://dx.doi.org/10.1016/
started to use this technique early; however, the rate of stenosis encountered with this technique remains elevated for distal hypospadias [9]. These stenoses are sometimes difficult to treat. For Snodgrass, periodic neourethral calibration was routinely performed over 1 year postoperatively [10]. In our patients, regular calibration was practised using a catheter and feeding stent with the application of a local anaesthetic gel, once a week, for several months (sometimes for more than 2 years). This procedure is simple and relatively painless. However, it is difficult to practice given the large number of patients treated for distal hypospadias [9]. But, the fistulae are less frequent with the approach used by Snodgrass. This is because of the midline incision of the urethral plate, which lowers the tension on the edges of the sutures. The essential act in Mollard’s technique for release of the chordee is resection of the fibrous tissue present under the urethral mucosa and not urethral mobilization alone. And I think that the better results obtained with an onlay island flap compared with tubulization of the prepuce are a result of the ability to resect the poorly vascularized edges, because there is often an excess of prepuce, without the risk of proximal stricture and the presence of the solid floor made from the vestigial dysgenetic tissue from aplasia of the corpus spongiosium, termed the urethral plate [7]. The ideal solution would be to have a simple technique, which is easy to perform, can correct the deformity with few or no postoperative complications, and preserves the urogenital function of the penis. I think if the distal hypospadias is associated with a deep balanic groove, it should be corrected by the Duplay procedure, but when the groove is less deep or non-existent the Snodgrass technique can be used. But, I don’t think that this technique is a good indication for proximal hypospadias associated with chordee. Finally, it is difficult to keep a urinary stent 6Fr in a boy for 2 weeks as proposed by the author. After 5 days, the 6 Fr stent begins to close owing to a fibrin secreted by the bladder mucosa [6].
References [1] Mollard P, Mouriquand P, Felfela T. Nouvelle technique de traitement des hypospades avec coudure par utilisation du lambeau en onlay. Prog Urol 1991;1:305e11.
1477-5131/$36 ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.12.003
Please cite this article in press as: Acimi S, Re. ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.003
+
MODEL
2 [2] Mollard P, Mouriquand P, Felfela T. Application of the onlay island flap urethroplasty to penile hypospadias with severe chordee. Br J Urol 1991;68:317e9. [3] Mollard P, Castagnola C. Hypospadias: the release of chordee without dividing the urethral plate and onlay island flap (92 cases). J Urol 1994;152:1238e40. [4] Elder JS, Duckett JW, Snyder HM. Onlay island flap in the repair of mid and distal penile hypospadias without chordee. J Urol 1987;138:376e9. [5] Koyanagi T, Matsuno T, Nonomura K, Sakakibara N. Complete repair of severe penoscrotal hypospadias in 1 stage: experience with urethral mobilizationdwing flap-flipping urethroplasty and “glanulomeatoplasty”. J Urol 1983;130: 1150e3. [6] Acimi S, Boukli-Hacene A. Inte ´re ˆt de la mobilisation de la plaque ure ´trale dans la libe ´ration de la courbure qui accompagne les formes poste ´rieures d’hypospadias. Prog Urol 2005; 15:59e62. [7] Acimi S. Proximal hypospadias: effect of urethral plate mobilization on release of chordee. Urology 2012;80:894e8.
Letter to the Editor [8] Snodgrass WT, Granberg C, Bush NC. Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair. J Pediatr Urol 2013;9(6): 990e4. [9] Acimi S. Comparative study of two techniques used in distal hypospadias repair: tubularized incised plate (Snodgrass) and tubularized urethral plate (Duplay). Scand J Urol Nephrol 2011;45:68e71. [10] Snodgrass W. Does tubularized incised plate hypospadias repair create neourethral strictures? J Urol 1999;162:1159e61.
Smail Acimi Children’s Hospital of Canastel, University of Oran, Department of Pediatric Surgery, Canastel, Oran 31000, Algeria E-mail address: [email protected] 18 November 2013
Please cite this article in press as: Acimi S, Re. ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.003
