Perineal hypospadias: the Bilateral Based (BILAB) skin flap technique

The urethral plate and the underlying tissue; a histological and histochemical study

OBJECTIVE

To examine the urethral plate and the underlying tissues in children with proximal hypospadias associated with severe chordee.

MATERIALS AND METHODS

The urethral plate and the underlying tissue specimens were excised to correct severe chordee in 17 children with proximal and perineal hypospadias with severe chordee. The median age was 20 months (range 8-36). Sections samples were marked and examined from proximal to distal. Specimens were examined histologically using hematoxylin-eosin (H/E) and Elastic van Gieson (EvG) stain. Histochemical examination was also performed using smooth muscle actin (SMA) and factor 8 antibodies. For control, samples from four patients with hypoplastic urethra proximal to the meatus including the hypoplastic segments until the normal urethra were taken. In addition, the urethra of an adult patient with penile tumor was used as control.

RESULTS

The average size of the 17 tissue samples was 0.5 cm × 0.5 cm x 0.3 cm in depth. There was a common pattern that was seen in all the 17 specimens with a variable degree of expression. H/E staining showed that the epithelial lining changed from pseudostratified epithelium at the proximal intact urethra to non-keratinized stratified squamous epithelium at the urethral meatus to keratinized stratified squamous epithelium distally at the urethral plate level. EvG staining showed overall very few elastic fibres that increased slightly in the distal urethral plate. SMA staining showed a circular pattern of smooth muscle cells in the proximal intact urethra that changed to a U-shaped pattern at the level of the meatus, to a triangle shaped pattern just distal to the meatus. The distal urethral plate showed an irregular, disorganized rather flat pattern of the smooth muscles. Factor 8 antibodies staining the blood spaces revealed dysplastic unorganized large blood sinusoids underneath the urethral plate that were different from normal capillaries surrounding the proximal urethra.

CONCLUSION

The urethral plate and the underlying tissues in patients with severe chordee have different structure from normal urethra as compared to available literature and the adult control patient. The lack of elastic fibres may help to explain the rigidity of the ventral penis causing chordee. The disorganized irregular distribution of the smooth muscle fibres is suggestive of the hypoplastic corpus spongiosum. The abnormal large blood sinusoids may explain the poor healing quality of the ventral penis in patients with perineal and proximal patients associated with severe chordee. This may explain persistent/recurrent chordee observed later in those patients with severe chordee when dorsal plication is used. The study also supports the recent trend of 2 stage procedure as a plan of management for patients with proximal and perineal hypospadias with severe chordee and excision of all the dysplastic tissues during the first operation.

What are the factors affecting glanular dehiscence after hypospadias surgery?

BACKGROUND

Glanular dehiscence (GD) is one of the main complications after hypospadias surgery. There is a limited number of publications regarding GD in the literature.

OBJECTIVE

The aim of this work is to reveal the factors that affect GD after a literature review.

EVIDENCE ACQUISITION

A literature search for relevant articles was performed in database using the search term glans dehiscence without setting date range limit or any other limits. All articles related to GD after hypospadias surgery were included in this study. After collecting the information from full text articles, 71 articles were included in this systematic review. In these studies, localization of hypospadic meatus, type of surgery, and other clinical data which were thought to behave as risk factors for GD were obtained. Chi-Square test was used to evaluate the differences between the parameters, where p < 0.05 was taken as statistically significant.

RESULTS

After evaluating the 71 articles that met the inclusion criteria, 309 cases (3.48%) of GD after 8858 hypospadias repairs were obtained in this review. GD rates were found significantly high for proximal hypospadias (5%), two-stage hypospadia repairs (5%) and re-do hypospadias repair (8.75%) (p = 0.002, 0.022, and 0.004, respectively). Glans width <14 mm, urethral plate (UP) width <7 mm, hypospadias surgeries performed before 6 months of age and after puberty, and caudal block anesthesia increased the rate of GD.

CONCLUSIONS

The rate of GD increases after proximal, cripple and staged hypospadias surgeries, a glans width <15 mm and UP width <8 mm, postpubertal surgeries, and caudal anesthesia use during surgery.

Ano-Scrotal Distance (ASD) : Is it a marker for the severity of chordee?

OBJECTIVE

To evaluate the relation between ASD and the severity of chordee and hypospadias in a referral center.

METHODS

The distance between the anal verge and proximal scrotal edge (ASD) was measured in hypospadias patients between 6 and 18 months between 2016 and 2020 in the operating room under anaesthesia. Patients older than 36 months and younger than 6 months were excluded. The patients were classified according to meatus into: Grade I (glandular or chordee without hypospadias), II (distal), III (proximal) and IV (perineal). Chordee was assessed by erection test and classified into 2 groups; Group I: no chordee or mild chordee <30 and Group II: with severe chordee >30. Short ASD was defined as ≤ 2.0 cm.

RESULTS

817 boys were included. The patients were classified according to the hypospadias grades I (180 pt), II (415 pt), III (120 pt) and IV (102 pt). The median ASD for group I was 3.07 cm (range 1.0-5.5), for group II 3.10 cm (range 1.5-5.0), for group III 2.40 cm (range 1.5-54.5) and for group IV 2.10 cm (range 1.0-3.5). The average ASD of the patients in Grade III and IV (2.26 cm) was significantly shorter than the average ASD of the patients in Grade I and II (3.09 cm) (p < 0.05). 184 patients had an ASD ≤2.0 cm. 38% of patients with glanular hypospadias (grade I) with ASD ≤ 2.0 cm had severe chordee.

CONCLUSION

This study shows that short ASD is a helpful marker of the severity of chordee and hypospadias. Patients with glanular hypospadias and short ASD have 38% chance of having severe chordee.

Recurrent chordee in 59 adolescents and young adults following childhood hypospadias repair

BACKGROUND

As children transition to adolescence, penile curvature may recur several years, sometimes, decades later. Herein we review our experience with a group of symptomatic patients, their surgical repairs and outcome.

MATERIAL & METHODS

Reviews were done on the charts of 59 symptomatic adolescents aged 14-21 years who presented with recurrent penile curvature, causing either sexual dysfunction or significant deformity and had undergone surgical correction between 2000 and 2017. Their initial hypospadias repairs were: TIP & dorsal midline plication (28), Tiersch-Duplay (T-D) urethroplasty and Nesbit dorsal repair [9], prepuce mucosal island onlay and Nesbit repair [6], Two-stage Byar repair and ventral dermal graft (3 patients). 13/59 patients were repaired elsewhere, and their records were unavailable. Surgical correction included one stage dorsal replication and skin detethering (32patients), one-stage urethral mobilization and corporal/dermal grafts (12patients), staged corporal/dermal graft and skin coverage followed by urethroplasty (Grafted TIP) 8-12 months later (15patients), and 11/59 had urethral fistula, which were repaired concomitantly.

RESULTS

55 out of 59 patients were followed up for 6-48 months (median 30 months) by periodic office visits, and 2-4 weeks in 4 patients whose subsequent follow up was by email. Of the 55 patients, 53 healed well, and 2patients developed wound breakdown and scarring, which resulted in mild recurrent curvature but to a lesser degree than preoperatively. The other 4 patients who corresponded by email were pleased with the surgical outcome. Of the total 59 patients, 28 reported satisfactory sexual activity. None of the patients who had corporal/dermal grafts reported erectile abnormalities.

CONCLUSIONS

Recurrent curvature in adolescents following hypospadias repair, may be caused by peri-urethral and skin fibrosis and/or disproportionate growth of the relatively hypoplastic ventral corporal wall or the reconstructed urethra. Surgical correction of symptomatic patients by dorsal shortening or ventral lengthening procedures depends on the degree of curvature following skin degloving of the penis. We have been recommending to parents of children born with proximal hypospadias who had what appeared to be a good surgical result to follow up after puberty.

Perineal hypospadias: back to the future Chordee Excision & Distal Urethroplasty

PURPOSE

Perineal hypospadias correction has swung from two-stage repair in the 1960s to one-stage repair in the 1980s and back to two-stage repair in the 2000s. The author's experience with a technique in which Chordee Excision and Distal Urethroplasty (CEDU) was performed at the first operation leaving a 1-cm segment as perineal urethrotomy to be reconstructed at the second operation is presented.

PATIENTS AND METHODS

Between January 2013 and December 2016, the CEDU technique was performed in 63 patients with perineal hypospadias. The records of 59 patients who maintained regular follow-up were reviewed. The principle is to excise the hypoplastic urethral plate, atretic corpus spongiosum, and longitudinal layer of tunica albuginea; split the glans in the midline; and reconstruct a healthy urethral plate using preputial and lateral skin flaps to the tip of the glans. Distal urethroplasty was performed leaving 1 cm at the proximal end to be reconstructed 3-6 months later. This principle was used by Duplay in the 1880s. Patient age ranged between 6 months and 2 years (mean 8 months). All the patients had perineal hypospadias and bifid scrotum with severe deep chordee. Follow-up period ranged from 17 to 53 months (mean 36). A transurethral Silastic catheter was inserted for 4 days. Three months later, the remaining 1 cm of the new urethra was reconstructed, and final adjustment of the glans and foreskin was performed.

RESULTS

Satisfactory results were obtained in 54 patients (90%). Three children experienced glans dehiscence that was corrected in the second stage, one child developed fistula after the second operation, and one developed diverticulum. The fistula and diverticulum were corrected at the third operation successfully.

DISCUSSION

It was necessary in this series to divide the urethral plate and excise the hypoplastic corpus spongiosum and the outer longitudinal layer of tunica albuginea to correct the associated deep chordee. The lateral skin flaps receive double blood supply from the base of the penis and the preputial vessels. This natural urinary diversion allows early removal of the catheter, reduces the discomfort of the patient, and allows the new urethra to heal without urine irritation for 3 months. Long-term follow-up for 15 years is necessary to assess the technique objectively.

CONCLUSIONS

The CEDU technique diverts urine away from the site of urethroplasty for 3 months without a catheter. It reduces the hospital stay and patient discomfort. It produces satisfactory results and has become a the standard technique in perineal hypospadias.

History of hypospadias: Lost in translation

The evolution of hypospadias surgery can be classified under 3 periods that were closely related to advances in surgical instruments, introduction of anesthesia, and newer suture materials. Stretching dominated the early period, tunneling during the Middle Ages, and flaps during the modern period. Suture materials have included at various time silver wires, horsehair, and stainless steel. Examination and translation of the original manuscripts showed that Galen recommended stretching and suturing of glanular hypospadias and not amputation or partial penectomy as has been currently reported. The term chordee was first introduced in the 18th century in relation to gonorrhea and was defined as "painful imperfect erection of the penis during gonorrhea, with downward incurvation." This was a common complication of gonorrhea before the introduction of antibiotics. Mettauer, Duplay, Mayo, and others used the terms incurvation, ventral deformity, ventral curvature, and others. Clinton Smith in 1938 was the first surgeon to use the term congenital chordee in direct relation to hypospadias. The use of prepuce for urethroplasty, popular now, was first reported by Liston in 1838, Rochet in 1899, Russell in 1900, and Mayo in 1901. The two stage repair performed in the early 20th century differed from that in the early 21st century in that urethroplasty was performed in the first stage and only anastomosis to the original meatus was performed in the second stage. The two-stage repair, currently known as Bracka's two-stage repair, was first described in 1962 by Cloutier. The use of the urethral plate in epispadias was first described by Liston in 1838, Thiersch in 1869 and by Anger & Duplay in hypospadias in 1874. Partially epithelialized urethroplasty using the urethral plate was described by Duplay in 1880, Russell 1915, Denis Browne 1940, Reddy 1975, Orkiszewski 1987, Rich 1989, and Snodgrass in 1994.

LEVEL OF EVIDENCE

V.

Two-stage graft urethroplasty for proximal and complicated hypospadias in children: A retrospective study

INTRODUCTION

Although two-stage graft urethroplasty is widely used, the literature regarding the complication rates and functional characteristics of reconstructed neourethra is relatively modest.

OBJECTIVES

The aim was to analyze the complication rates and uroflow data of boys who have previously undergone a two-stage graft urethroplasty procedure for proximal and complicated hypospadias.

PATIENTS AND METHODS

We retrospectively reviewed the clinical outcomes of 52 boys with proximal (n = 44) and complicated (n = 8) hypospadias who underwent two-stage graft urethroplasty repair (median age of 15 months and 3 years respectively) between 2004 and 2015. Fifteen toilet-trained boys without fistulas underwent uroflowmetry. The uroflow data were plotted on age-volume-dependent normograms with normal controls. The median follow-up was 34 months (8 months-8 years).

RESULTS AND COMPLICATIONS

Complications were identified in three patients (6%) after the first stage (i.e. contracture of the graft) and in 20 patients (38.4%) after the second stage, including meatal stenosis (n = 8, 15.3%), urethral stricture (n = 4, 7.6%), urethrocutaneous fistula (n = 8, 15.3%), glandular dehiscence (n = 1, 1.9%), and diverticulum (n = 1, 1.9%). The patients with failed hypospadias experienced fewer complications than those who underwent the two-stage procedure for primary repair (25% and 45%, respectively). The reoperation rate was 36.8%. Eleven of the 15 toilet-trained boys were asymptomatic but exhibited flow rates below the normal range (median Q_max = 7 mL/s, range 3.5-16.7). Only one of the boys with a low flow rate was confirmed to have urethral stenosis under general anesthesia.

DISCUSSION

In our study, primary hypospadias repair requiring urethral plate transection elicited worse outcomes than those observed in the prior failed hypospadias cases. However, because of our study's retrospective design, we were unable to accurately assess the initial position of the meatus in the redo hypospadias cases. Our data also demonstrated that the majority of cases without any voiding symptoms exhibited flow rates that were below the normal range despite no urethral stricture under general anesthesia. These findings indicate that urethras reconstructed via two-stage graft urethroplasty repair are not functionally equivalent to normal urethras, at least prior to puberty.

CONCLUSION

Two-stage graft urethroplasty repair was successful in 62% of cases after the second-stage procedure, but one-third of the boys required a reoperation after the two-stage planned repair. We demonstrated that although we used a urethral tissue substitute, the urine flow patterns of the patients without strictures were abnormal.

Staged segmental urethroplasty for scrotal/perineal hypospadias: a new concept

PURPOSE

We report the efficacy of staged segmental urethroplasty (SSUP) versus non-staged urethroplasty (NSUP) for treating scrotal/perineal hypospadias (SPH).

METHODS

Between 1997 and 2015, 29 SPH patients underwent UP (SSUP: n = 15; NSUP: n = 14). Incidences of urethrocutaneous fistula (UF), stenosis of the neourethra (SNU), diverticula formation, and residual chordee (RC) were compared. Differences were statistically significant if p < 0.05.

RESULTS

The difference in mean age at NSUP (3.2 ± 1.3 years) and at the final stage of SSUP (5.5 ± 2.4 years) was significant (p < 0.05). Mean operative times for NSUP and SSUP (total for all stages) were not significantly different (231.5 ± 117.5 versus 272.5 ± 99.4 min); however, the incidence of postoperative complications was significantly less in SSUP (n = 1; UF) compared with NSUP (n = 6; 2 cases of UF, 3 cases of SNU, and 1 case of RC; (p < 0.05). Mean follow-up was significantly shorter in SSUP; 1.4 ± 1.2 years versus 7.0 ± 4.5 years in NSUP (p < 0.05).

CONCLUSION

SSUP would appear to be effective for treating SPH because of a significantly lower incidence of UF, SNU and RC during the first postoperative year, the period when complications have been reported to arise most frequently.