Fistula advancement operation in the treatment of selected cases of persistently recurrent urethrocutaneous fistula following distal penile hypospadias repair

Urethral advancement in hypospadias with a distal division of the corpus spongiosum: outcome in 158 cases

OBJECTIVE

Outcome of urethral mobilization and advancement (Koff procedure) in hypospadias with a distal division of the corpus spongiosum and redo cases with distal urethral failure.

MATERIALS AND METHODS

From January 1999 to November 2012, 158 children with a distal hypospadias (115 primary cases and 43 redo cases) underwent surgical repair using the Koff technique with a median age at surgery of 21 months (range, 12-217 months).

RESULTS

Mean follow-up was 19 months (median, 14 months). Thirty patients (19%) presented with a complication (13.9% in primary cases and 32.5% in redo surgery) mostly at the beginning of our experience. Meatal stenosis was the most common one (3.5% in primary case, 6% overall). Ventral curvature (>10°), which is considered as a possible long-term iatrogenic complication of the Koff procedure, was not found in patients with fully grown penis except in one redo patient who had, retrospectively, an inadequate indication for this type of repair. Of 158 patients, 33 reached the age of puberty (>14 years old) with a mean follow-up of 34 months, only one presented with a significant ventral curvature.

CONCLUSION

Urethral mobilization and advancement is a reasonable alternative for anterior hypospadias and distal fistula repair in selected cases. It has two major advantages compared to other techniques: it avoids any urethroplasty with non-urethral tissue and eliminates dysplastic tissues located beyond the division of the corpus spongiosum, which may not grow at the same pace as the rest of the penis. Significant iatrogenic curvature in fully grown penis is not supported by this series.

Urethral advancement for recurrent distal hypospadias fistula treatment

Hypospadias fistula may be persistently recurrent in some patients. In distal hypospadiac fistula cases, carrying the fistulous opening to the glans tip may be possible with extensive urethral mobilization and advancement. In 9 patients who were operated for urethrocutaneous fistula, we used the urethral advancement technique. Patient ages ranged from 5 to 14 years (mean, 8 years). In all of the cases, the urethra was mobilized proximally to at least penoscrotal junction, and in some cases, the bulbar urethra was mobilized partially. Follow-up ranged from 6 months to 16 months. In all but 1 child, a straight penis with the neomeatus at the glans tip was maintained without any urethrocutaneous fistula. In 1 child, chordee, which was already present, could not be prevented.Urethral advancement technique may effectively solve the problem of persistently recurrent hypospadias fistula. We recommend the technique to plastic surgeons' armamentarium.

Marzouk skin tag two-stage urethroplasty for the repair of complex cases of hypospadias

BACKGROUND

Cases of hypospadias with severe chordee and deficient skin, as well as those for re-do hypospadias or fistula repair, are considered complex cases. Depending on the degree of complexity of the defect, a two-stage procedure may still be advisable. The present paper describes the so-called Marzouk skin tag urethroplasty as a new two-stage procedure advisable for use in such difficult cases.

METHODS

The Marzouk skin tag urethroplasty procedure was performed on 16 complex cases. The first stage consists of urethral mobilization plus the double-buttonhole procedure (designed by the author) to form a midline ventral skin tag proximal to an advanced hypospadiac orifice. This skin tag is fashioned, 6 months later, by the author's special techniques (type I in 12 patients and type II in four patients) to form the neourethral tube and its coverage with minimal dissection.

RESULTS

The operation resulted in a straight penis with neomeatus at the glans top in all 16 cases without significant complications. Both type I and II procedures give good functional results. The type I procedure has a superior cosmetic result. The follow-up period ranged from 4 to 8 months.

CONCLUSIONS

The double-buttonhole modification can solve the problem of deficient skin and simplify a safe second-stage procedure. The Marzouk skin tag operation (types I and II) can be an additional option to be used when indicated.