Repair of hypospadias complications using the meatal based flap urethroplasty

Mathieu and Barcat repair with a V incision sutured meatoplasty for secondary hypospadias surgery

AIM

Today single-stage methods are more frequently selected for hypospadias repair than multistaged methods, but complications cannot always be avoided. We employed two kinds of meatal based flip-flap urethroplasty procedures for those with an unsuccessful primary hypospadias repair.

PATIENTS AND METHODS

From 1997 to 2005, a meatal based flip-flap urethroplasty was performed as a secondary hypospadias surgery on 17 patients. Basically we attempted the Mathieu repair, but when the wings of the glans were not generously widened and the urethral groove was not sufficiently deep we applied the Barcat procedure. While 11 patients were repaired with the Mathieu technique, six patients underwent the Barcat repair. The V incision sutured meatoplasty was added to obtain a natural ventral slit-like meatus.

RESULTS

Ten of the 11 patients who underwent the Mathieu repair had a good outcome, but one patient developed a urethrocutaneous fistula. None of the six patients repaired with the Barcat procedure encountered postoperative complications. Cosmetically, a vertical slit was constructed near the normal neomeatus with the Mathieu and V incision sutured (MAVIS) meatoplasty and the Barcat and V incision sutured (BAVIS) meatoplasty.

CONCLUSIONS

The Mathieu or the Barcat meatal based flip-flap urethroplasty procedure is feasible as a salvage surgery for those with relatively short urethral defects and adequate mobile ventral skin if an exact procedure is selected. Excellent cosmetic results could be obtained by adding the technique of V incision sutured meatoplasty.

Split onlay skin flap for the salvage hypospadias repair

PURPOSE

Following failed hypospadias repair absence of the penile foreskin, a shortage of ventral skin and residual chordee may all contribute to poor long-term results. We describe a technique called the split onlay skin (SOS) flap that has improved our surgical outcomes in boys requiring salvage hypospadias repair.

MATERIALS AND METHODS

The SOS flap uses a transverse island of penile shaft skin that is mobilized on its vascular pedicle and rotated into position to the ventrum of the penis at the site of the urethral defect. The flap is transected transversely, and half of the flap is used as an onlay to repair the urethra and the other half is used for additional skin coverage where needed on the penile shaft. We treated 11 boys 30 to 124 months old (mean age 60.3 months) who had a mean of 2 previous failed hypospadias repairs. All 11 boys presented with complex combinations of urethrocutaneous fistulas, stricture or urethral diverticula.

RESULTS

Of the 11 patients 6 (54.5%) had development of postoperative fistulas. Five of these fistulas were surgically closed with no further complications. One penoscrotal fistula closed spontaneously after 7 months. Mild chordee from contraction of the flap and a urethral diverticulum developed in 1 boy. At a mean followup of 24.5 months all patients, including those who underwent closure of the secondary fistula, were voiding well with excellent appearance.

CONCLUSIONS

In cases where little local tissue is present the SOS flap procedure is an excellent way to transfer healthy dorsal tissue to the ventrum for an onlay salvage urethroplasty while providing additional coverage of the urethral defect and a tension-free skin closure. Despite the high fistula rate we encountered following the initial SOS procedure, we endorse this technique because the transferred dartos provides additional tissue, which facilitates subsequent fistula repair. These boys can achieve a successful cosmetic result without incorporation of scrotal tissue or a free graft, which we believe leads to more predictable results.

Molecular biology of prostate cancer

Development of any cancer reflects a progressive accumulation of alterations in various genes. Oncogenes, tumour suppressor genes, DNA repair genes and metastasis suppressor genes have been investigated in prostate cancer. Here, we review current understanding of the molecular biology of prostate cancer. Detailed understanding of the molecular basis of prostate cancer will provide insights into the aetiology and prognosis of the disease, and suggest avenues for therapeutic intervention in the future.

Hypospadias

Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position anywhere along the penile shaft,scrotum, or perineum. Hypospadiology is an evolving and expanding discipline that remains at the forefront of pediatric surgical innovation. Although modern experiments have begun to yield a deeper understanding of the genetic, hormonal, and environmental basis of hypospadias, the quest for a surgical procedure that consistently results in a straight penis with a normally placed glanular meatus has challenged surgeons for over two centuries. This article focuses on the advances in the understanding of the etiology of hypospadias and the current approaches to the correction of hypospadias.

Sensory innervation of normal and hypospadiac prepuce: possible implications in hypospadiology

Sensory innervation of the skin influences wound healing through the release of neuropeptides from the nerve endings. The purpose of this study was to investigate the differences in the sensory innervation of the normal and the hypospadiac prepuce. The prepuce from 10 healthy children undergoing routine circumcision and 10 age-matched children undergoing hypospadias repair were submitted for immunohistochemistry, using antibodies against protein gene product (PGP) 9.5, calcitonin gene-related peptide (CGRP), and substance P (SP). The hypospadiac prepuce was found to be hypo-innervated for PGP 9.5 and CGRP positive nerves when compared with the normal prepuce ( p<0.05). The number of SP-positive nerves were increased in the hypospadiac prepuce, but not to statistical significance ( p=0.06, confidence interval >95%). There may be differences in the sensory innervation of the normal and hypospadiac prepuce. These differences in tissue environment may partly explain the postoperative edema, poor wound healing leading to urethrocutaneous fistula (UF), and increased analgesia requirements in patients undergoing hypospadias surgery.

Management of urethrocutaneous fistula after hypospadias repair: 10 years' experience

OBJECTIVES

To report the outcome of managing urethrocutaneous fistula after hypospadias repair over 10 years.

PATIENTS AND METHODS

Forty-seven patients (mean age 7.6 years, range 2-18) underwent repair of 57 urethrocutaneous fistulae after hypospadias surgery. The fistula was single in 37 patients and multiple in 10; 42 fistulae were small (< 4 mm) and 15 large (> 4 mm). Twenty-one fistulae were at the corona, 15 at the anterior shaft, 16 at the mid-shaft and five were penoscrotal. The interval between primary hypospadias repair and the first attempt at fistula repair was 6-12 months. Small fistulae were repaired using a multilayer simple closure technique, and large fistulae repaired using rotational and advancement skin flaps. Suprapubic urinary diversion was used in all patients with large fistulae or small multiple fistulae (25 patients); an overnight urethral catheter was used in the remaining patients.

RESULTS

Simple closure was successful in 30 of 42 small fistulae (71%); eight were successfully closed by secondary closure, while four needed a third closure. Rotational and advancement skin flaps were successful in 13 of 15 large fistulae; one required secondary flap repair and one was closed simply. Most recurrences (78%) were of coronal fistulae; there was recurrence in four of 25 (16%) patients in whom suprapubic diversion was used, in contrast to 10 of 22 (45%) with no suprapubic diversion.

CONCLUSIONS

Although simple closure of a fistula is easy and not time-consuming it is followed by a significantly higher rate of recurrence than when skin flaps are used. Rotational and advancement flaps are the optimal methods for repairing fistulae after hypospadias, particularly for large and coronal fistulae. Thus, the appropriate indication for simple closure is small fistulae at the penile shaft. Suprapubic diversion is important in those with large or multiple fistulae.

Tubularized incised-plate urethroplasty for secondary hypospadias surgery

PURPOSE

Reoperation for failed hypospadias has been considered to be seriously bothersome because abundant penile skin does not tend to remain for urethroplasty or for penile shaft skin coverage. In this study, the tubularization of incised urethral plate was employed for those who had no excessive penile skin after failure of hypospadias repair.

METHODS

Five patients with hypospadias underwent tubularized incised-plate urethroplasty as salvage surgery. The surgical techniques necessary for the performance of the reoperation were not different from those for the primary repair. The urethral plate was incised sufficiently deeply in its midline from the tip of the glans to the regressed meatus. The incised urethral plate was tubularized without tension over a catheter of an appropriate size.

RESULTS

Four of those who underwent secondary tubularized incised-plate urethroplasty were successfully repaired without complications. A urethrocutaneous fistula occurred at the corona in the remaining patient.

CONCLUSIONS

The absence of preputial skin in reoperative cases makes tubularized incised-plate urethroplasty the ideal option, although the series was small and postoperative duration is still short. In addition, this procedure can give excellent functional and cosmetic results even in patients who require revisional hypospadias surgery.

Primary and salvage urethroplasty using Mathieu meatal-based flip-flap technique for distal hypospadias

BACKGROUND

Numerous surgical procedures have been attempted for correction of distal hypospadias. The Mathieu procedure was employed in this study for secondary cases as well as primary cases.

METHODS

The length of the skin flap is determined by measuring the distance from the meatus to the glans tip and then the ventral meatal-based skin flap is incised. The proximal skin flap is flipped and anastomosed to the distal urethral plate. Additionally, subcutaneous tissue of the flipped flap is sutured to cover the original suture lines completely.

RESULTS

The Mathieu urethroplasty was successful in one stage in 13 of the 16 primary repair cases (81%). Twelve of the 13 (92%) who underwent a secondary Mathieu procedure were successfully repaired with no problems. An overall success rate of 86% was achieved at the first operation for both primary and secondary cases. In the remaining 14% of the cases, success was achieved with only one additional procedure.

CONCLUSIONS

The Mathieu flip-flap procedure is feasible for relatively short urethral defects if the ventral penile skin demonstrates adequate mobility and there is no chordee. Even in patients who require revisional hypospadias surgery, the Mathieu procedure can give excellent functional and cosmetic results.

Repair of hypospadias complications using the previously utilized urethral plate

OBJECTIVES

To review our results of patients who underwent repeat hypospadias surgery using local skin flaps with preservation of the urethral plate.

METHODS

We retrospectively reviewed the medical records of all patients who underwent a reoperative hypospadias repair using the urethral plate between 1988 and 1996. A total of 53 patients were identified who developed either a large fistula (47 patients) or severe stricture (6 patients) after the initial repair. Seventeen patients underwent a repeat Mathieu flip-flap and 36 an onlay flap. The mean age at the time of surgery was 5.2 years (range 1 to 27). The mean duration of follow-up was 17 months (range 6 to 108).

RESULTS

The initial failed hypospadias repair was corrected with a single procedure in 44 (83%) of the 53 patients. The 9 patients who had further complications required 17 additional procedures. A meatal-based flap had been used in 4 of these patients and an onlay flap in 5. Three of the 9 patients who had further complications presented with urethral strictures after the previous repair.

CONCLUSIONS

Fistula and stricture are common complications of hypospadias surgery. The use of the urethral plate in primary repairs has helped decrease the complication rate. We report the effectiveness of using local skin flaps and preserving the urethral plate in complex reoperative hypospadias surgery. These techniques were successful in 83% of these challenging patients. Patients with stricture after hypospadias surgery are at increased risk of further complications.

An axially vascularized meatal-based flap for the repair of hypospadias

OBJECTIVES

To report the initial experience of hypospadias repair using an axially vascularized meatal-based skin flap.

PATIENTS AND METHODS

Twenty-six children aged 2-5.5 years with subcoronal hypospadias underwent the procedure: three were circumcised and three had recurrent hypospadias. The neourethra was constructed using a meatal-based flap extending obliquely from the hypospadiac orifice towards the prepuce or its remnants. The flap was supplied axially by the ventrolateral branch of the superficial external pudendal artery. The vascular pedicle was dissected and mobilized to allow tensionless reflection of the flap ventrally to be sutured to the urethral plate.

RESULTS

Functional and cosmetic success was achieved in 25 of the patients (96%). Haematoma and disruption of the flap occurred in one patient, who underwent re-operation, and slight and insignificant meatal retraction occurred in another child.

CONCLUSIONS

The procedure confirmed the technical feasibility of creating an axially vascularized meatal-based flap. The oblique orientation of the flap permits it to be obtained from well-developed skin. Continuity of the oblique flap with the urethral plate reduces the total length of suture lines and minimizes the possibility of fistula formation.

The extended Mathieu procedure in coronal, distal penile, and midshaft hypospadias repair

The Mathieu procedure was adequately modified for glanular, coronal, and midshaft hypospadias variants with chordee and/or urethral hypoplasia in order to anatomically reconstruct the penis. A total of 129 patients aged 12 months to 22 years with coronal (35.7%), distal penile (51.9%), and midshaft (12.4%) hypospadias were operated upon. Chordee was found in 33.3% and distal urethral hypoplasia in 15.5% of the patients. The ventral flap was based anatomically on the external meatus, the glans was made pyramidal with an apical external meatus, the prepuce was resutured, and the neurethra was buried deeply within the glans. In patients with distal urethral hypoplasia the external meatus was incised proximally; in chordee the urethral plate was mobilized off the corpora cavernosa. Fistulas were uncommon (3.4%) in the primarily operated patients. The external meatus was always apical, and no stenosis was demonstrated at follow-up. The prepuce was reconstructed in 71.5% of patients. The extended Mathieu procedure appears recommendable for all coronal, distal penile, and midshaft variants regardless of associated anomalies of the penis. It also seems suitable for secondary repairs. The prepuce can be reconstructed in the majority of patients. The complication rate is significantly low compared to other methods, and the extended Mathieu operation is a good teaching tool with a high success rate and versatility.