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Pitfalls in Hypospadias Surgery Experience in Management of 200 Cases
Pediatrics 945
946
OUTPATIENT CATHETERLESS fODIFIED MATHIEU IIYPOSPADIAS REPAIR. Ronald Rabinowitz, Rochester, NY (Presentation to be made by Dr. Rabinowitz) Mathieu first reported his operation for single stage repair of distal hypospadias in 1928. Four years later, he published a more precise description of the procedure and reported on more than 40 boys with favorable results. Scattered reports in the literature attest to thes~ccess of this procedure. A ventral meatal based skin flap is elevated and any tissue causing chordee is excised. The flap is flipped to the distal tip of the glans and the lateral aspects of the flap are sutured to the medial or internal lips of paramedian balanic incisions. Postoperative catheterization has been reported to be maintained from 2 to 10 days. This has usually resulted in prolonged hospitalization or marked restriction of activity or immobilization at home or in the hospital. By performing the urethroplasty in a continous subcuticular fashion, a water tight closure is achieved. The lateral glans flaps are re-approximated over the neourethra without overlying suture lines, resulting in a rounded glans with a midglanular meatus. Penile nerve block is placed and a hypoallergenic transparent permeable dressing applied. Urinary diversion and catheter drainage are unnecessary. Over an 18 month period, 59 catheterless modified Mathieu procedures were performed, including 8 as secondary procedures. In 39, the procedure was performed as an outpatient; in the remaining 20, overnight hospitalization was planned for varying reasons (distance from hos pi ta 1 , prior surgery, medical problems, etc.). All boys were fully active the day of surgery. There was 1 flap retraction in a secondary repair and 7 with prominent skin tags of the meatus or skin coverage. The remaining 51 healed primarily. Voiding through the fresh repair is well tolerated and has not been a problem. There have been no instances of urinary retention, re-hospitalization, postoperative chordee, or urethral fistula. The cosmetic and functional results are exce 11 ent.
A SAFE ~ND EFFECTIVE PROCEDURE FOR BILATERAL REFLUX : THE SINGLE SUBMUCOSAL TRANSVERSAL TUNNEL ( SSTT). Gilbert Faure*, Jean, J. Rambeaud*, Charles Dufour*, Frederic Hosatte*, Jean.C. Mikaelian*, Grenoble, France. (Presentation to be made by Dr. Faure). Since its description by COHEN in .1971,. tbe antireflux procedure by transver~e. ureteral advancement seems to have been adopted by:_ the majority of urologists. We are using since 1975 a simplification of this procedure fa~ bilateral repair. Th~ necessity_ to create a submucosal tunnel for each of the two uret~rs seemed to. us· a·.bit excessive, especially in. smfl.llc Ch·ildren. Therefore, we have utilized a single submucosa1··transversal tunne·l created between the two ureter~l orifices. The ureters are parallel within the tunnel~ ~imply changing there arrival orifices. wich are secured without any resection with a continuous dexon suture. No· stents are necessary, in: the· ureteI'.s.,:A Foley catheter· is left for two day~. The _prpc~dure I'~presents a simpler method, with less surgical trauma to the bladder and· a shorter operatihg time genera11¥ less than 1 hour._ It can be used'' for duplicated~ ureters and for tailored megaureters. More than 350 patients have been~treated in our Department of Urology (720 ureters) with excellent results proved by I.V.P., echography and cystography. The very small morbidity rate, less than 2 per cent (ureteral stenosis or residual reflux) and the simplicity ci the method have made the S.S. T.'f. the 11 procedure of choice 11 for bilateral reimplantation.
947
948
HYPOSPADIAS REPAIR IN ADOLESCENTS. Moneer K. Hanna, New York, NY, (Presentation to be made by Dr, Hanna) Between January 1980 and January 1986, 48 adolescents and young adults were referred for hypospadias repair, The surgery was decJined in 5, Of the 43 patients who underwent surgical repair, 15 were circumcized during early childhood, 11 were hyupospadias cripples (more than two attempted repairs each), and 17 had intact foreskins, The surgical techniques included Free bladder mucosa graft (10), Freeskin graft (7), Preputal Island Flap ( 4), Flip Flap repair (12), Mustarde repair (9), and two stage repair using tissue expanders (1). Major complications including major break down and flap necrosis occurred in 2 patients. Minor com p1ications were: fistula (5), stri.cture (2) and additional skinplasty (6). In the finRl analysis 41/43 patients were corrected satisfactorily, A major problem postoperatively was frequent erections necessitaUng analgesics and sedaUves, anct may have contributed to several complications in this series. Also the hospital stay for this group was much longer than For younger children. It is concluded that all degrees of hypospadias should be repaired at a young age, as the abnormality becomes quite obtrusive with penile growth, Furthermore, hypospadias repair in the older patient is associated with high morbidity; it is therefore proposed that estrogen therapy may be instituted one week preoperativley to inhibit erecti.ons. H ypospadias cri.pples are best repaired by uUlizing a free bladder mucosa graft, which provides an excellent urethral substitute. Their chordee may be repaired by Nesbitt procedure, thus leaving the limited residual skin for resurfacing the penis. Nitroglycerine ointment to enhance the blood flow to these suboptimal quality flaps is also helpful.
PITFALLS IN HYPOSPADIAS SURGERY EXPERIENCE IN MANAGEMENT OF
200 CASES. umesh B. Patil, 'Syracuse, NY (Presentation to be made by Dr. Patil) Surgical management of Hypospadias anomaly requires specialized skills and experience. The hypospadias anomaly presents not as a single entity but with many variations. Hence, the pitfalls are likely to occur in proper selection and executing an appropriate procedure. Surgeons from many lands have been attempting to correct the hypospadias anomaly for over 200 years. However, since the late 1960 's, many new surgical techniques have been developed in various parts of the world. In utilizing these new techniques, we can avoid potential serious preventable complications. In this presentation we wish to highl.ight the various aspects of hypospadias surgery which are potential sources of difficulties to the surgeon with long-term complications in the child, In our experience of treating 200 patients during 1980-1986, we have encountered 45 patients which presented to us with serious complications such as multiple fistulae, persistent chordee, meat us stenosis and in 3 cases of total loss of neourethra. Most of these are preventable complications. Hence, we have utilized various technical refinements to avoid such pitfalls in all remaining 155 patients. We classify the surgical procedure into six different steps. These are correction of chordee, assessment of site of meatus to plan construction of neourethra, fixation of neourethra to the corpus, assessment of the available foreskin, placement of the meat us on the glans penis based on the shape and size of the glans, and finally skin coverage of the phallus. Methods of drainage of urine and type of surgical dressings to be placed have been simplified to facilitate easier postoperative care of the patients at home. We follow our patients for a minimum period of 4 to 5 years with uroflok'metry. Our long-term results are encouraging with overall complication rates of 10%. Hence, with these precautions, we feel that pitfalls in hypospadias surgery can be minimized with excellent postop longterm results.
340A
946
OUTPATIENT CATHETERLESS fODIFIED MATHIEU IIYPOSPADIAS REPAIR. Ronald Rabinowitz, Rochester, NY (Presentation to be made by Dr. Rabinowitz) Mathieu first reported his operation for single stage repair of distal hypospadias in 1928. Four years later, he published a more precise description of the procedure and reported on more than 40 boys with favorable results. Scattered reports in the literature attest to thes~ccess of this procedure. A ventral meatal based skin flap is elevated and any tissue causing chordee is excised. The flap is flipped to the distal tip of the glans and the lateral aspects of the flap are sutured to the medial or internal lips of paramedian balanic incisions. Postoperative catheterization has been reported to be maintained from 2 to 10 days. This has usually resulted in prolonged hospitalization or marked restriction of activity or immobilization at home or in the hospital. By performing the urethroplasty in a continous subcuticular fashion, a water tight closure is achieved. The lateral glans flaps are re-approximated over the neourethra without overlying suture lines, resulting in a rounded glans with a midglanular meatus. Penile nerve block is placed and a hypoallergenic transparent permeable dressing applied. Urinary diversion and catheter drainage are unnecessary. Over an 18 month period, 59 catheterless modified Mathieu procedures were performed, including 8 as secondary procedures. In 39, the procedure was performed as an outpatient; in the remaining 20, overnight hospitalization was planned for varying reasons (distance from hos pi ta 1 , prior surgery, medical problems, etc.). All boys were fully active the day of surgery. There was 1 flap retraction in a secondary repair and 7 with prominent skin tags of the meatus or skin coverage. The remaining 51 healed primarily. Voiding through the fresh repair is well tolerated and has not been a problem. There have been no instances of urinary retention, re-hospitalization, postoperative chordee, or urethral fistula. The cosmetic and functional results are exce 11 ent.
A SAFE ~ND EFFECTIVE PROCEDURE FOR BILATERAL REFLUX : THE SINGLE SUBMUCOSAL TRANSVERSAL TUNNEL ( SSTT). Gilbert Faure*, Jean, J. Rambeaud*, Charles Dufour*, Frederic Hosatte*, Jean.C. Mikaelian*, Grenoble, France. (Presentation to be made by Dr. Faure). Since its description by COHEN in .1971,. tbe antireflux procedure by transver~e. ureteral advancement seems to have been adopted by:_ the majority of urologists. We are using since 1975 a simplification of this procedure fa~ bilateral repair. Th~ necessity_ to create a submucosal tunnel for each of the two uret~rs seemed to. us· a·.bit excessive, especially in. smfl.llc Ch·ildren. Therefore, we have utilized a single submucosa1··transversal tunne·l created between the two ureter~l orifices. The ureters are parallel within the tunnel~ ~imply changing there arrival orifices. wich are secured without any resection with a continuous dexon suture. No· stents are necessary, in: the· ureteI'.s.,:A Foley catheter· is left for two day~. The _prpc~dure I'~presents a simpler method, with less surgical trauma to the bladder and· a shorter operatihg time genera11¥ less than 1 hour._ It can be used'' for duplicated~ ureters and for tailored megaureters. More than 350 patients have been~treated in our Department of Urology (720 ureters) with excellent results proved by I.V.P., echography and cystography. The very small morbidity rate, less than 2 per cent (ureteral stenosis or residual reflux) and the simplicity ci the method have made the S.S. T.'f. the 11 procedure of choice 11 for bilateral reimplantation.
947
948
HYPOSPADIAS REPAIR IN ADOLESCENTS. Moneer K. Hanna, New York, NY, (Presentation to be made by Dr, Hanna) Between January 1980 and January 1986, 48 adolescents and young adults were referred for hypospadias repair, The surgery was decJined in 5, Of the 43 patients who underwent surgical repair, 15 were circumcized during early childhood, 11 were hyupospadias cripples (more than two attempted repairs each), and 17 had intact foreskins, The surgical techniques included Free bladder mucosa graft (10), Freeskin graft (7), Preputal Island Flap ( 4), Flip Flap repair (12), Mustarde repair (9), and two stage repair using tissue expanders (1). Major complications including major break down and flap necrosis occurred in 2 patients. Minor com p1ications were: fistula (5), stri.cture (2) and additional skinplasty (6). In the finRl analysis 41/43 patients were corrected satisfactorily, A major problem postoperatively was frequent erections necessitaUng analgesics and sedaUves, anct may have contributed to several complications in this series. Also the hospital stay for this group was much longer than For younger children. It is concluded that all degrees of hypospadias should be repaired at a young age, as the abnormality becomes quite obtrusive with penile growth, Furthermore, hypospadias repair in the older patient is associated with high morbidity; it is therefore proposed that estrogen therapy may be instituted one week preoperativley to inhibit erecti.ons. H ypospadias cri.pples are best repaired by uUlizing a free bladder mucosa graft, which provides an excellent urethral substitute. Their chordee may be repaired by Nesbitt procedure, thus leaving the limited residual skin for resurfacing the penis. Nitroglycerine ointment to enhance the blood flow to these suboptimal quality flaps is also helpful.
PITFALLS IN HYPOSPADIAS SURGERY EXPERIENCE IN MANAGEMENT OF
200 CASES. umesh B. Patil, 'Syracuse, NY (Presentation to be made by Dr. Patil) Surgical management of Hypospadias anomaly requires specialized skills and experience. The hypospadias anomaly presents not as a single entity but with many variations. Hence, the pitfalls are likely to occur in proper selection and executing an appropriate procedure. Surgeons from many lands have been attempting to correct the hypospadias anomaly for over 200 years. However, since the late 1960 's, many new surgical techniques have been developed in various parts of the world. In utilizing these new techniques, we can avoid potential serious preventable complications. In this presentation we wish to highl.ight the various aspects of hypospadias surgery which are potential sources of difficulties to the surgeon with long-term complications in the child, In our experience of treating 200 patients during 1980-1986, we have encountered 45 patients which presented to us with serious complications such as multiple fistulae, persistent chordee, meat us stenosis and in 3 cases of total loss of neourethra. Most of these are preventable complications. Hence, we have utilized various technical refinements to avoid such pitfalls in all remaining 155 patients. We classify the surgical procedure into six different steps. These are correction of chordee, assessment of site of meatus to plan construction of neourethra, fixation of neourethra to the corpus, assessment of the available foreskin, placement of the meat us on the glans penis based on the shape and size of the glans, and finally skin coverage of the phallus. Methods of drainage of urine and type of surgical dressings to be placed have been simplified to facilitate easier postoperative care of the patients at home. We follow our patients for a minimum period of 4 to 5 years with uroflok'metry. Our long-term results are encouraging with overall complication rates of 10%. Hence, with these precautions, we feel that pitfalls in hypospadias surgery can be minimized with excellent postop longterm results.
340A