|Year : 2013 | Volume
| Issue : 1 | Page : 19-22
Proximal hypospadias repair with principles of progressive perineal urethroplasty
Altaf M Shaikh, Sunil M Mhaske, Pranav C Chhajed, Mohammad I Attar, Sanjay Swain, Sujata Patwardhan
Department of Urology, Seth G. S. Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||28-Aug-2013|
Altaf M Shaikh
Department of Urology, 8th Floor, MSB, KEM Hospital Campus, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct. Significant variability exists for preferred approaches of repair. Often combinations of procedures are required in staged manner. Here, we have combined steps of pelvic fracture urethral distraction defects (PFUDD) repair with tubularized incised plate procedure in a single stage.
Materials and Methods: A total of 8 patients consisting of 5 adults (mean age 20 years) and 3 children less than 3 years old that presented with proximal hyposphadias were included. All patients underwent degloving and progressive perineal approach as described by Webster for repair of PFUDD including mobilization of the entire bulbar urethra from the neomeatus to the membranous urethra with division of lateral attachments, division of attachment from perineal body and corporal separation. Mobilization of the urethral plate from the corpora cavernosa to the glans was carried out. The urethral plate was tubularized with a dorsal incision.
Results: The neomeatus was advanced by a distance of 2.5-3.8 cm in all eight patients. Dartos fascia was used in 5 adults and 1 child for cover. Two patients required a tunica vaginalis flap as dartos was tethered during the harvesting. Catheter drainage was 18 days on an average (14-21 days). Fistula (pinpoint) occurred in one adult, which healed with further catheter drainage. All the patients were voiding normally and satisfied in terms of cosmetic appearance. None of the patients had wound infection or total disruption, residual chordee, meatal stenosis or any erectile difficulties.
Conclusion: The steps of progressive perineal approach for repair of posterior urethral distraction defects if followed aids in achieving the goals of proximal hypospadias surgery in a single stage.
Keywords: Pelvic fracture urethral distraction defects, penoscrotal hypospadias, perineal urethroplasty, tubularized incised plate
|How to cite this article:|
Shaikh AM, Mhaske SM, Chhajed PC, Attar MI, Swain S, Patwardhan S. Proximal hypospadias repair with principles of progressive perineal urethroplasty. Arch Int Surg 2013;3:19-22
|How to cite this URL:|
Shaikh AM, Mhaske SM, Chhajed PC, Attar MI, Swain S, Patwardhan S. Proximal hypospadias repair with principles of progressive perineal urethroplasty. Arch Int Surg [serial online] 2013 [cited 2020 Aug 3];3:19-22. Available from: http://www.archintsurg.org/text.asp?2013/3/1/19/117133
| Introduction|| |
Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct. During the last 10 years, the approach to severe hypospadias has been controversial.  Approaches for severe hypospadias repair include the Asopa procedure, the Duckett repair, the Hodgson X and XX techniques, double island flap urethroplasty and 2-stage procedures.  Results are poorer and complications are greater in extensive procedures such as tube urethroplasty, compared to flaps and tubularized incised plate urethroplasy described by Snodgrass for distal hypospadias.  We have adopted the procedure of urethral mobilization by Webster and tubularized incised plate (TIP) procedure for patients with proximal hypospadias. In the process, we found that more proximal mobilization up to the triangular ligament, detachment of the urethra and its spongiosum from the perineal body and corporal separation, which are the steps for progressive perineal approach for repair of posterior urethral distraction defects, lead to better correction of chordee and more distal advancement of the neomeatus. Though, use of bulbar mobilization in repair of penoscrotal hypospadias is mentioned in the literature, techniques involving entire urethral mobilization and corporal separation have not been mentioned.  The objective of this study was to evaluate whether the neomeatus following repair of hypospadias can be advanced distally by utilizing steps of progressive perineal approach.
| Materials and Methods|| |
A total of 8 patients with penoscrotal hypospadias [Figure 1] consisting of 5 adults (mean age 20 years) and three children less than 3 years old were included in the study. All had normally descended testes and no associated anomalies. All patients have not been circumcised previously. Three adult patients and two of the children in this series were given local testosterone gel for local application for 3 months pre-operatively. One was given parenteral testosterone (this patient had androgen receptor insensitivity). Pre-operative urethroscopy revealed a prostatic utricle, which prevented proper catheterization in one patient.
A straight midline incision or inverted U or lambda incision was made in the perineum similar to approach to the posterior urethra in pelvic fracture urethral distraction defect (PFUDD) repair. An inverted U shaped incision is made encircling the meatus to the corona, preserving urethral plate the width preferably inclusive of adjacent penile skin, which was kept 3 cm in adults and then extending circumferentially around the corona.
Correction of chordee
The correction of chordee was achieved by one or more of the following manoeuvres:
- Degloving of penile skin.
- Mobilization of the entire bulbar urethra from the neomeatus to the membranous urethra, division of lateral attachments, division of attachment from perineal body and corporal separation [Figure 2].
- Mobilization of the urethral plate from the corpora cavernosa to the glans and fixation to corpora cavernosa [Figure 3].
- The option of Nesbit plication sutures was used in one patient.
|Figure 2: Bulbar urethral mobilization up to membranous urethra, with division of lateral attachments, from perineal body and corporal separation|
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|Figure 3: Mobilization of the urethral plate from the corpora cavernosa to the glans and fixation to corpora cavernosa|
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Division of the urethral plate was not required in any patient. Two of the children required dorsal inlay buccal mucosa graft as their urethral plate width was inadequate for tubularization. Correction of chordee was confirmed by Gitti's manoeuvre intra operatively.  The distance between the neomeatus and ideal glanular site of external urinary meatus was measured pre and post-operatively. The urethral plate was tubularized with a dorsal incision as described by Snodgrass.  Polyglactin 6-0 was used to close the urethra in subcuticular single layer over a 6-14 F catheter depending upon the patient's age. Spongioplasty was performed in all patients. Dartos flap was used in six patients and tunica vaginalis in two patients to cover the entire neourethra. Glanuloplasty by mobilization of glans wings was carried out in all cases. Skin was closed by interrupted sutures and normal dressing was applied. All patients received amoxicillin - clavulinic acid, (25 mg/5 mg/kg) every 8 h intravenously for 5 days. Urethral catheter was removed after 14-21 days. Follow-up was initially every week for 3 months and then 6 monthly for 2 years. The repair was assessed for shape of meatus, voiding pattern, presence of fistula, chordee, and early morning erections in children and erectile dysfunction in adults.
| Results|| |
All patients had a severe chordee at presentation, which was corrected by simple degloving, urethral mobilization and corporal separation. One child required two Nesbit sutures for penile straightening. The neomeatus was advanced by a distance of 2.5-3.8 cm in all 8 patients. Dartos fascia was used in 5 adults and 1 child. Two patients required a tunica vaginalis flap as dartos was tethered during harvesting and was not of good quality. Catheter drainage was 18 days on an average (14-21 days). Fistula (pinpoint) occurred in one adult, which healed with further catheter drainage. All patients were satisfied in terms of cosmetic appearance and act of micturation. None of the patients had wound infection or total disruption, residual chordee or meatal stenosis. None of the adults reported any erectile difficulties or absence of early morning erections in children. The mean operation time was 2.3 h.
| Discussion|| |
Due to the severity of these abnormalities, proximal hypospadias often requires more extensive reconstruction in order to achieve an anatomically and functionally successful result.  TIP and urethral mobilization have resolved the problem of chordee correction. , Webster and Ramon  has described a progressive perineal approach for an end to end anastamotic urethroplasty for patients with posterior urethral distraction defects. Mollard and Castagnola  have documented the increase in length of the urethra, which can be achieved by urethral mobilization up to the membranous urethra, division of lateral attachments, division of attachment from perineal body and corporal separation. The increase in length is approximately up to 4-5 cm.
Applying the same principles of progressive perineal approach to proximal hypospadias surgery has helped in correcting chordee better and advancing the meatus (neomeatus) to a position 2.5-3.8 cm nearer the glans. The gain in urethral length will minimize the length of urethra, which needs to be reconstructed.
Problems of corporal separation include trauma to the corpora cavernosa and deep dorsal vein, which is just between the corpora. However, with careful sharp dissection and practice this concern can be easily dismissed. The other concern of excessive urethral mobilization would be injury to the urethral blood supply. Retrograde blood supply through glans is adequate for urethra if antegrade blood supply is jeopardized after primary surgery. However, the blood supply will be compromised in patients who have undergone previous urethral surgery for hypospadias repair or stricture disease of the urethra.
We have not adopted this technique in patients that have had previous hypospadias repair because of this concerns though re-do urethroplasty can be done using the same principles after a period of 1 year. Fistulas are the more frequent of these complications occurring in less than 5% of anterior cases, but up to 50% in posterior cases.  In our series, it was seen in 12.5% of patients.
Advantages of the procedure include the use of native urethra for repair without the addition of any substitution such as buccal mucosa, prepuitial mucosa or skin. However, in two of our patients we utilized the buccal mocosa as the distal urethral plate was narrow. The results of substitution urethroplasty are always inferior to utilization of normal urethral mucosa, in addition the urethral incision with its known complications are avoided. The procedure does involve extensive dissection and prolonged operative time with an average of 2 h and 30 min.
The procedure is completed in a single stage and the attendant complications of repeated surgeries are avoided. It helps in better correction of chordee as up to 3 cm of urethral length is gained and chordee due a short urethral length is addressed easily. Our institution being a tertiary trauma center, we frequently utilize progressive perineal approach for PFUDD repair and are conversant with the technique. It can be easily learnt as all hypospadias surgeons are familiar with reconstructive surgery of the urethra. This manoeuvre is freuquently utilized by urethroplasy surgeons to gain additional length. Further study involving more patients will support the application of this approach to patients with proximal hypospadias. The current standard of care for hypospadias repair includes not only a functional penis adequate for sexual intercourse and urethral reconstruction offering the ability to stand to urinate, but also a satisfactory cosmetic result [Figure 4], which we are able to achieve in a single stage with a minimal morbidity. 
The procedure can be performed in adults and children with similar ease with minimal complications. It will be necessary to follow-up these children until puberty to note the changes with an increase in penile size.
In conclusion, the steps of progressive perineal approach for repair of posterior urethral stricture if followed leads to better correction of chordee and more distal advancement of the neomeatus. Repair of proximal hypospadias is still one of the most challenging surgery and newer innovations continue to be proposed. Whether the newer modification stands the test of time remains to be proved.
| Acknowledgments|| |
Prof. Amilal Bhat, Department of Urology, S. P. Medical College Bikaner, Rajasthan, India.
| References|| |
|1.||DeFoor W, Wacksman J. Results of single staged hypospadias surgery to repair penoscrotal hypospadias with bifid scrotum or penoscrotal transposition. J Urol 2003;170:1585-8. |
|2.||Retik AB, Borer JG. Hypospadias. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, editors. Campbell's Urology. 8 th ed. Philadelphia: WB Saunders Co.; 2002. p. 2302-033. |
|3.||Retik AB, Atala A. Complications of hypospadias repair. Urol Clin North Am 2002;29:329-39. |
|4.||Snodgrass WT, Lorenzo A. Tubularized incised-plate urethroplasty for proximal hypospadias. BJU Int 2002;89:90-3. |
|5.||Kraft KH, Shukla AR, Canning DA. Proximal hypospadias. Scientific World Journal 2011;11:894-906. |
|6.||Snodgrass W, Yucel S. Tubularized incised plate for mid shaft and proximal hypospadias repair. J Urol 2007;177:698-702. |
|7.||Bhat A. Extended urethral mobilization in incised plate urethroplasty for severe hypospadias: A variation in technique to improve chordee correction. J Urol 2007;178:1031-5. |
|8.||Webster GD, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: Experience with 74 cases. J Urol 1991;145:744-8. |
|9.||Mollard P, Castagnola C. Hypospadias: The release of chordee without dividing the urethral plate and onlay island flap (92 cases) J Urol 1994;152:1238-40. |
|10.||Aigrain Y, Cheikhelard A, Lottmann H, Lortat-Jacob S. Hypospadias: Surgery and complications. Horm Res Paediatr 2010;74:218-22. |
|11.||Hayashi Y, Kojima Y. Current concepts in hypospadias surgery. Int J Urol 2008;15:651-64. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]