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A Comparison of the Mustarde and Horton-Devine Flip-Flap Techniques of Hypospadias Repair
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-OD2'.2-53l/J /82/1341-0!03$02.0G/O THE J-GURNAL OF UROLOGY
Copyright© 1985 by Tfie V!illi2ms & '\Vilkin.s Co.
A COMPARISON OF THE MUSTARDE AND HORTON-DEVINE FLIPFLAP TECHNIQUES OF HYPOSPADIAS REPAIR IRA KLIMBERG
AND
R DIXON WALKER
From the Division of Urology, Department of Surgery, University of Florida, Gainesville, Florida
ABSTRACT
We compared the results and complications of the Horton-Devine flip-flap and Mustarde techniques for I-stage repair of distal hypospadias. Followup has been for at least 1 year so that longterm complications could be included. Urethral fistulas occurred in 6 of 20 patients treated with the Horton-Devine flip-flap and 3 of 20 who underwent the Mustarde repair. No strictures were noted with either procedure. In our opinion the meatus had a better configuration after the Mustarde repair. We conclude that the Mustarde procedure provides a more satisfying cosmetic and clinical result. Mustarde originally described a I-stage hypospadias repair for distal penile hypospadias with a meatal-based proximal penile skin flap.' The original Mustarde procedure resulted in frequent intraglandular or meatal stenosis. Later modifications by Mustarde included formation of a tube with the skin flap and placing it through a glans channel using a V glandular flap. 2 Belman placed the rolled tube through a glans channel without the V flap but with creation of a large meatus that would not constrict. 3 Devine and Horton developed the flipflap with a V-shaped glandular flap meatoplasty, which has some similarities to the Mustarde repair but enough differences to qualify as a separate technique. 4 We describe the results and complications of the HortonDevine flip-flap and Mustarde techniques (with modification as described by Belman) for a I-stage repair of distal hypospadias. MATERIALS AND METHODS
From 1980 through 1983, 40 consecutive patients with distal hypospadias underwent repair via the Horton -Devine flip- flap (group 1-20 patients seen during 1980 and 1981) and Mustarde techniques (group 2-20 patients seen from late 1981 through mid 1983). Patient age ranged from 16 months to 16 years, with a median age of 2. 75 years. Four patients in each group were more than 5 years old. All of the children were maintained on routine antibiotics for a minimum of 7 days postoperatively. Median age for the patients in groups 1 and 2 was 3.75 and 2.5 years, respectively. Hypospadias repair had been attempted previously in 1 child in each group. The urine was diverted in all patients (3 and 7, by open tube cystotomy, 3 and 7, respectively, percutaneous cystocatheter, and 14 and 6, respectively, by a urethral catheter). A urethral stent was used in 17 patients in group 1 and all patients in group 2. Postoperative hospital stay and urinary diversion ranged from 4 to 7 days in group 1 and 5 to 7 days in group 2, with 14 and 17 patients, respectively, having diversion for 7 days. Of the children in the Mustarde repair group 2 underwent additional operations at the time of the hypospadias repair (subcutaneous mastectomy in l and ureteral reimplantation in 1). RESULTS
The mean operative time was 75 minutes (78 minutes for the Horton-Devine flip-flap and 72 minutes for the Mustarde procedures). Urinary diversion with an open tube cystotomy lengthened either procedure by 30 minutes. Average estimated Accepted for publication February 22, 1985. Read at annual meeting of American Urological Association, New Orleans, Louisiana, May 6-10, 1984. 103
blood loss was 52 ml. (range 12 to 175 ml.) in group 1 and 40 ml. in group 2. Of the former patients 3 lost 100 ml. blood or more during the procedure, while none of the latter patients lost more than 90 ml. blood intraoperatively. Blood transfusion was not required in any patient. Complications were encountered in 8 patients (40 per cent) in group 1 and 5 (25 per cent) in group 2. Urethral fistulas developed in 6 (30 per cent) and 3 (15 per cent) patients, respectively, all of which were closed successfully in a second stage repair, often done as an outpatient procedure. Of the remaining patients in group 1 a glandular wound dehiscence resulted in a coronal meatus in 1, while epidermolysis of the glandular flap resulted in a meatal stenosis in 1. A small intraoperative urethral injury occurred in 1 patient during mobilization of the flap and the defect was treated successfully with a patch graft urethroplasty. Of the remaining 2 patients in group 2, 1 had a breakdown of the ventral glans with resultant meatal retraction, while hypertrophic scarring was noted along the penile suture line in a black child. No urethral strictures were noted with either procedure. The meatus had a more normal slit-like configuration after the Mustarde repair. In addition, this modification has improved upon the final appearance and conical shape of the glans (see figure). DISCUSSION
We compared the results and complications of 2 methods of 1-stage repair for distal hypospadias. There were no appreciable differences in the operative time, estimated intraoperative blood loss or transfusion requirements between the 2 groups. Data were insufficient to determine if the means or duration of urinary diversion, urethral stenting or use of postoperative antibiotics had any bearing on the surgical outcome. In our hands the Mustarde procedure appeared to produce a lower incidence of complications (25 versus 40 per cent) and urinary fistulas (15 versus 30 per cent) than the Horton-Devine flip-flap, although the differences were not statistically significant. The meatus had a more normal slit-like configuration after the Mustarde repair, whereas the Horton-Devine meatus tended to be gaping and triangular in shape. In addition, the Mustarde technique has resulted in an improved final appearance of the glans, with the minimization of glandular dissection and suture lines. We conclude that the Mustarde procedure provides a more satisfying cosmetic and clinical result in the repair of distal hypospadias. To date, we use the Mustarde technique for the repair of all cases of distal and mid penile hypospadias in which the proximal flap can be constructed so as not to involve skin that later
104
KLIMBERG AND WALKER
2. Mustarde, J. C.: Plastic Surgery in Infancy and Childhood, 2nd ed. New York: Churchill Livingstone, pp. 462-467, 1979. 3. Belman, A. B.: The modified Mustarde hypospadias repair. J. Urol., 127: 88, 1982. 4. Devine, C. J., Jr. and Horton, C. E.: Hypospadias repair. J. Urol., 118: 188, 1977.
EDITORIAL COMMENT
Glandular appearance after Mustarde repair
will be hair-bearing. We are modifying our technique continually, and currently use optical magnification, finer sutures and a reinforced suture line along the neourethra to increase the precision of the repair. The results in 11 patients treated by the Mustarde technique with these latest modifications have been excellent with no fistulas. Nevertheless, we do not expect that the operation will be free of complications but the incidence of complications should be less. The continued evolution in technique may account for the differences that we noted between the 2 procedures. REFERENCES
1. Mustarde, J. C.: One-stage correction of distal hypospadias: and
other people's fistulae. Brit. J. Plast. Surg., 18: 413, 1965.
The continuity of the development of the Devine and Horton flipflap operation was described in 1977. 1 We rarely find it necessary to do this operation at present if release of the chordee does not require an incision distal to the urethral meatus. In these cases, although our technique is different, it resembles that of Mathieu. In a series using the microscope and 7-zero to 9-zero polydioxanone sutures with Dr. David Gilbert, we did 49 without a complication, but now in 65 patients the complication rate is 8 per cent. This study presents the development of the technical ability of the authors. The 2 series are sequential and not parallel. The authors prefer the Mustarde technique but the statistics in the paper do not reflect any innate superiority of one procedure over the other. Charles J. Devine, Jr. Department of Urology Hague Medical Center Norfolk, Virginia 1. Devine, C. J., Jr. and Horton, C. E.: Chordee without hypospadias.
J. Urol., 110: 264, 1977.
REPLY BY AUTHORS Indeed, the reason for improved results probably is evolution of surgical technique rather than the inherent differences in the operations themselves. The surgeon should not be wed to 1 operation and, despite my preference for the Mustarde technique, I often incorporate "bits and pieces" from many different procedures (including the Horton-Devine flip-flap) to accomplish the desired end result.
.,. _-, ... _- .. _.--_.--·
-OD2'.2-53l/J /82/1341-0!03$02.0G/O THE J-GURNAL OF UROLOGY
Copyright© 1985 by Tfie V!illi2ms & '\Vilkin.s Co.
A COMPARISON OF THE MUSTARDE AND HORTON-DEVINE FLIPFLAP TECHNIQUES OF HYPOSPADIAS REPAIR IRA KLIMBERG
AND
R DIXON WALKER
From the Division of Urology, Department of Surgery, University of Florida, Gainesville, Florida
ABSTRACT
We compared the results and complications of the Horton-Devine flip-flap and Mustarde techniques for I-stage repair of distal hypospadias. Followup has been for at least 1 year so that longterm complications could be included. Urethral fistulas occurred in 6 of 20 patients treated with the Horton-Devine flip-flap and 3 of 20 who underwent the Mustarde repair. No strictures were noted with either procedure. In our opinion the meatus had a better configuration after the Mustarde repair. We conclude that the Mustarde procedure provides a more satisfying cosmetic and clinical result. Mustarde originally described a I-stage hypospadias repair for distal penile hypospadias with a meatal-based proximal penile skin flap.' The original Mustarde procedure resulted in frequent intraglandular or meatal stenosis. Later modifications by Mustarde included formation of a tube with the skin flap and placing it through a glans channel using a V glandular flap. 2 Belman placed the rolled tube through a glans channel without the V flap but with creation of a large meatus that would not constrict. 3 Devine and Horton developed the flipflap with a V-shaped glandular flap meatoplasty, which has some similarities to the Mustarde repair but enough differences to qualify as a separate technique. 4 We describe the results and complications of the HortonDevine flip-flap and Mustarde techniques (with modification as described by Belman) for a I-stage repair of distal hypospadias. MATERIALS AND METHODS
From 1980 through 1983, 40 consecutive patients with distal hypospadias underwent repair via the Horton -Devine flip- flap (group 1-20 patients seen during 1980 and 1981) and Mustarde techniques (group 2-20 patients seen from late 1981 through mid 1983). Patient age ranged from 16 months to 16 years, with a median age of 2. 75 years. Four patients in each group were more than 5 years old. All of the children were maintained on routine antibiotics for a minimum of 7 days postoperatively. Median age for the patients in groups 1 and 2 was 3.75 and 2.5 years, respectively. Hypospadias repair had been attempted previously in 1 child in each group. The urine was diverted in all patients (3 and 7, by open tube cystotomy, 3 and 7, respectively, percutaneous cystocatheter, and 14 and 6, respectively, by a urethral catheter). A urethral stent was used in 17 patients in group 1 and all patients in group 2. Postoperative hospital stay and urinary diversion ranged from 4 to 7 days in group 1 and 5 to 7 days in group 2, with 14 and 17 patients, respectively, having diversion for 7 days. Of the children in the Mustarde repair group 2 underwent additional operations at the time of the hypospadias repair (subcutaneous mastectomy in l and ureteral reimplantation in 1). RESULTS
The mean operative time was 75 minutes (78 minutes for the Horton-Devine flip-flap and 72 minutes for the Mustarde procedures). Urinary diversion with an open tube cystotomy lengthened either procedure by 30 minutes. Average estimated Accepted for publication February 22, 1985. Read at annual meeting of American Urological Association, New Orleans, Louisiana, May 6-10, 1984. 103
blood loss was 52 ml. (range 12 to 175 ml.) in group 1 and 40 ml. in group 2. Of the former patients 3 lost 100 ml. blood or more during the procedure, while none of the latter patients lost more than 90 ml. blood intraoperatively. Blood transfusion was not required in any patient. Complications were encountered in 8 patients (40 per cent) in group 1 and 5 (25 per cent) in group 2. Urethral fistulas developed in 6 (30 per cent) and 3 (15 per cent) patients, respectively, all of which were closed successfully in a second stage repair, often done as an outpatient procedure. Of the remaining patients in group 1 a glandular wound dehiscence resulted in a coronal meatus in 1, while epidermolysis of the glandular flap resulted in a meatal stenosis in 1. A small intraoperative urethral injury occurred in 1 patient during mobilization of the flap and the defect was treated successfully with a patch graft urethroplasty. Of the remaining 2 patients in group 2, 1 had a breakdown of the ventral glans with resultant meatal retraction, while hypertrophic scarring was noted along the penile suture line in a black child. No urethral strictures were noted with either procedure. The meatus had a more normal slit-like configuration after the Mustarde repair. In addition, this modification has improved upon the final appearance and conical shape of the glans (see figure). DISCUSSION
We compared the results and complications of 2 methods of 1-stage repair for distal hypospadias. There were no appreciable differences in the operative time, estimated intraoperative blood loss or transfusion requirements between the 2 groups. Data were insufficient to determine if the means or duration of urinary diversion, urethral stenting or use of postoperative antibiotics had any bearing on the surgical outcome. In our hands the Mustarde procedure appeared to produce a lower incidence of complications (25 versus 40 per cent) and urinary fistulas (15 versus 30 per cent) than the Horton-Devine flip-flap, although the differences were not statistically significant. The meatus had a more normal slit-like configuration after the Mustarde repair, whereas the Horton-Devine meatus tended to be gaping and triangular in shape. In addition, the Mustarde technique has resulted in an improved final appearance of the glans, with the minimization of glandular dissection and suture lines. We conclude that the Mustarde procedure provides a more satisfying cosmetic and clinical result in the repair of distal hypospadias. To date, we use the Mustarde technique for the repair of all cases of distal and mid penile hypospadias in which the proximal flap can be constructed so as not to involve skin that later
104
KLIMBERG AND WALKER
2. Mustarde, J. C.: Plastic Surgery in Infancy and Childhood, 2nd ed. New York: Churchill Livingstone, pp. 462-467, 1979. 3. Belman, A. B.: The modified Mustarde hypospadias repair. J. Urol., 127: 88, 1982. 4. Devine, C. J., Jr. and Horton, C. E.: Hypospadias repair. J. Urol., 118: 188, 1977.
EDITORIAL COMMENT
Glandular appearance after Mustarde repair
will be hair-bearing. We are modifying our technique continually, and currently use optical magnification, finer sutures and a reinforced suture line along the neourethra to increase the precision of the repair. The results in 11 patients treated by the Mustarde technique with these latest modifications have been excellent with no fistulas. Nevertheless, we do not expect that the operation will be free of complications but the incidence of complications should be less. The continued evolution in technique may account for the differences that we noted between the 2 procedures. REFERENCES
1. Mustarde, J. C.: One-stage correction of distal hypospadias: and
other people's fistulae. Brit. J. Plast. Surg., 18: 413, 1965.
The continuity of the development of the Devine and Horton flipflap operation was described in 1977. 1 We rarely find it necessary to do this operation at present if release of the chordee does not require an incision distal to the urethral meatus. In these cases, although our technique is different, it resembles that of Mathieu. In a series using the microscope and 7-zero to 9-zero polydioxanone sutures with Dr. David Gilbert, we did 49 without a complication, but now in 65 patients the complication rate is 8 per cent. This study presents the development of the technical ability of the authors. The 2 series are sequential and not parallel. The authors prefer the Mustarde technique but the statistics in the paper do not reflect any innate superiority of one procedure over the other. Charles J. Devine, Jr. Department of Urology Hague Medical Center Norfolk, Virginia 1. Devine, C. J., Jr. and Horton, C. E.: Chordee without hypospadias.
J. Urol., 110: 264, 1977.
REPLY BY AUTHORS Indeed, the reason for improved results probably is evolution of surgical technique rather than the inherent differences in the operations themselves. The surgeon should not be wed to 1 operation and, despite my preference for the Mustarde technique, I often incorporate "bits and pieces" from many different procedures (including the Horton-Devine flip-flap) to accomplish the desired end result.