- Email: [email protected]
RESULTS OF 265 CONSECUTIVE PROXIMAL HYPOSPADIAS REPAIRS USING THE THIERSCH-DUPLAY PRINCIPLE
0022-5347/04/1726-2382/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 172, 2382–2383, December 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000143880.13698.ca
RESULTS OF 265 CONSECUTIVE PROXIMAL HYPOSPADIAS REPAIRS USING THE THIERSCH-DUPLAY PRINCIPLE SAMUEL A. AMUKELE, ADAM C. WEISER, JEFFREY A. STOCK
AND
MONEER K. HANNA*
From the Departments of Urology, Schneider Children’s Hospital, Long Island Jewish Medical Center, New Hyde Park (SAA, ACW, MKH) and New York Hospital-Weill Cornell Medical Center, New York, New York (MKH), and Children’s Hospital of New Jersey, Saint Barnabas Health Care System, Livingston, New Jersey (JAS, MKH)
ABSTRACT
Purpose: We review the evolution of the concept of tubularization of the urethral plate and our results in the repair of proximal hypospadias. Materials and Methods: A total of 281 children born with proximal hypospadias underwent Thiersch-Duplay urethroplasty with or without a midline incision of the urethral plate between 1989 and 1998. Followup data were available in 265 children. Results: Excellent functional and cosmetic results were achieved in 88.7% of the patients. The use of either a dartos or tunica vaginalis flap to waterproof the urethral suture line resulted in a decrease in the fistula rate from 17% to 1.8%. Conclusions: The principles of Thiersch-Duplay urethroplasty represent the basic foundation for surgical techniques that use the urethral plate to construct a urethral tube. The use of this principle in the repair of proximal hypospadias compares favorably with other methods. KEY WORDS: penis, reconstructive surgical procedures, hypospadias
In 1869 Thiersch tubularized the urethral plate to form a urethral canal in a child born with epispadias.1 In 1874 Duplay used the same principle, making 2 parallel incisions and tubularizing the urethral plate in a boy born with hypospadias.2 He observed that the catheter did not need to be covered entirely by skin to form a tube. Brown popularized this concept in 1949, when he described the buried skin strip method for hypospadias repair.3 Therefore, it is clear that the Thiersch-Duplay principles represent the earliest reported methods for formation of a urethral tube out of the urethral plate. Midline incision of the urethral plate was first reported by Reddy in 1975.4 He made this incision to excise the “fibrous” material in the midline, which was believed to be the cause of the chordee. He combined this incision with Thiersch-Duplay tubularization to correct hypospadias with chordee in 1 stage. Subsequently, Rich et al made a “relaxing” incision in the midline of the urethral plate to hinge the glans penis and create a slit-like meatus.5 Snodgrass subsequently popularized the tubularized incised plate (TIP) method.6 We have previously reported our experience with distal urethroplasty and glanduloplasty using the Thiersch-Duplay principle.7 Herein, we report our results with similar techniques in proximal hypospadias repair.
padias and/or chordee, who were operated on during the same period. A total of 16 children were excluded because of inadequate followup and/or incomplete data. Of the 265 children included in the study the operative reports indicated that the meatus was mid or proximal in 128, penoscrotal in 74 and scrotal in 63. Urethroplasty was performed following correction of the chordee, confirmed by an artificial erection test. In a majority of cases the chordee was corrected by simple degloving of the skin and fascia. In 74 children the chordee was caused by corporeal disproportion and was corrected by the Nesbit procedure9 or tunica albuginea plication.10 Early in the series when the ventral meatus was thin and
METHODS
Before 1989 we repaired proximal hypospadias by either a free full thickness graft or an island skin flap in the form of a tube, or as an onlay as described by Duckett.8 We began to use the Thiersch-Duplay principle in 1989, and in selected cases of proximal hypospadias without significantly apparent chordee the urethral plate was tubularized. Subsequent to the Snodgrass report6 we extended the application of the TIP repair to the majority of children born with proximal hypospadias. A total of 281 children with proximal hypospadias underwent surgical repair using the Thiersch-Duplay method between 1989 and 1998. These cases were gleaned from our database, which listed 1,364 children with hypos-
a, 8Fr feeding tube is inserted to evaluate if meatus is hypoplastic, and ventral meatoplasty is performed (arrow). b, penile shaft is degloved, and artificial erection is produced to evaluate chordee. c, 2 wedges of glandular skin are excised and urethral plate is ready to be tubularized. d, first layer is tubularized with 7-zero polyglactin and second layer of subcuticular suture with 7-zero polydioxanone (not Accepted for publication July 2, 2004. * Correspondence: 935 Northern Blvd., Suite 303, Great Neck, shown). e, Byars flaps are rotated in to cover neourethra. f, appearance 6 months postoperatively. New York 11021 (e-mail: [email protected]). 2382
2383
PROXIMAL HYPOSPADIAS REPAIRS USING THIERSCH-DUPLAY PRINCIPLE Complications of 1-stage repair for proximal hypospadias References
No. Pts
Hypospadias Location
Chen et al14 Snodgrass and Lorenzo15
40 33
Mid shaft-perineal Mid shaft-scrotal
TIP TIP
Tunica albuginea plication Dorsal plication (18)
7 100 265
Penoscrotal Mid shaft-proximal Mid shaft, penoscrotal, scrotal
TIP TIP Thiersch-Duplay
None Not described Nesbit or tunica albuginea plication (74)
Palmer et al16 Cheng et al13 Present series
Repair Type
hypoplastic we opted for an island flap onlay. Subsequently, we performed ventral meatoplasty at the 6-o’clock position in conjunction with Thiersch-Duplay tubularization in 27 children (part a of figure). In all cases the urethral plate was tubularized in 2 layers. In 169 repairs waterproofing of the urethral suture line was achieved by either a flap of tunica vaginalis (40 patients) or dartos (129). The postoperative dressing was duoderm, and catheter drainage was maintained for 5 to 7 days in all cases. A representative case is illustrated in the figure. Preoperative adjunctive intramuscular testosterone (50 mg 3 to 4 weeks before repair) was given to children with a small phallus. The distribution was mid or proximal in 11 of 128, penoscrotal in 23 of 74 and scrotal in 41 of 63 patients. RESULTS
Followup data are available for 265 consecutive patients for a period of 2 to 11 years postoperatively (mean 7.5). Average age at repair was 7 months (range 6 to 11). A satisfactory outcome was achieved in 88.7% of patients. In these patients the meatus is terminal or glandular without chordee, and satisfactory cosmesis and normal voiding were observed by either parents or physician. The overall major complication rate was 11.3%, and included urethral stricture, urethrocutaneous fistula formation, urethral diverticulum, concealed penis and dehiscence (see table). Minor problems, including skin dimple, inclusion cyst and irregular meatus, occurred in 5 children, and all were subsequently repaired. Of the 16 fistulas 13 occurred in the first 96 patients when no waterproofing with either dartos or tunica vaginalis flap was done (13.5%). In contrast, only 3 fistulas occurred in the subsequent 169 patients where a dartos or tunica vaginalis flap was used (1.8%). Urethral diverticulum was noted in 2 of 3 children who had development of a meatal stricture. DISCUSSION
The aim of the surgeon in proximal hypospadias repair is to create a straight penis without chordee, a meatus at the tip of the glans penis, a neourethra of adequate caliber, normal voiding and penile cosmesis with minimal complications. Our policy is to repair perineoscrotal hypospadias with severe chordee due to corporeal disproportion in 2 stages, whereby dermal graft is used to correct the chordee and lengthen the ventral corporeal wall in the first stage.11 However, if the chordee is relatively mild (30 degrees or less), we have used the Nesbit procedure9 and more recently the Baskin modification10 to straighten the penis. Mild penoscrotal transposition was corrected by rotation of scrotal flaps and was combined with Thiersch-Duplay repair. In severe transposition we generally opted for a 2-stage repair, since in the majority of these cases the intrinsic chordee was caused by corporeal disproportion with a greater than 30-degree angle. In the past the urethral plate was considered to be the cause of chordee. It was often excised and the urethra was reconstructed with either a free skin graft or tubularized island flap. The recognition that chordee is often due to skin and fascial tethering resulted in more acceptance of the fact that the urethral plate has the potential of forming a urethral tube, a fact
Complications (No.)
Chordee Repairs (No.)
Fistula (5), meatal stenosis (4) Fistula (7), meatal stenosis (1), stricture (1), recurrent chordee (2), dehiscence (1) Fistula (1), glans dehiscence (1) Fistula (3), meatal stenosis (1) Fistula (16), stricture (3), diverticulum (2), major breakdown (2), concealed penis (7)
that Thiersch1 and Duplay2 realized more than a century ago. The addition of a midline relaxing incision allows for tensionfree ventral closure of the urethra. We believe that if the urethral groove and the glandular sulcus are deep, this relaxing incision of the urethral plate is unnecessary. In our early experience the presence of a thin and shiny meatal skin was considered a contraindication to tubularization of the urethral plate and prompted the use of an island skin flap onlay as described by Duckett.8 As our experience with Thiersch-Duplay has evolved, we have combined it with a ventral meatoplasty at the 6-o’clock position. The dartos or tunica vaginalis flap provides excellent support to the suture line, especially when ventral meatoplasty is contemplated.12 The routine use of the dartos or tunica vaginalis flap to waterproof the suture line has resulted in a significant decrease in our urethral fistula rate from 17% to 1.8%. The experience of Cheng et al also supports this notion.13 In conclusion, tubularization of the urethral plate should be included in the armamentarium of proximal hypospadias repair. This series and others support this concept (see table). REFERENCES
1. Thiersch, C.: Uber die Entstehungweise und operative Behandlung des Epispadie. Arch Heilkd, 10: 20, 1869 2. Duplay, S.: De l’hypospadias perineo-scrotal et de son traitement chirugical. Arch Gen Med, 513: 657, 1874 3. Brown, D.: An operation for hypospadias. Proc R Soc Med, 41: 466, 1949 4. Reddy, L. N.: One-stage repair of hypospadias. Urology, 5: 475, 1975 5. Rich, M. A., Keating, M. A., Synder, H. M. and Duckett, J. W.: Hinging the urethral plate in hypospadias meatoplasty. J Urol, 142: 1551, 1989 6. Snodgrass, W.: Tubularized, incised plate urethroplasty for distal hypospadias. J Urol, 151: 464, 1994 7. Stock, J. A. and Hanna, M. K.: Distal urethroplasty and glanuloplasty procedure: results of 512 repairs. Urology, 49: 449, 1997 8. Duckett, J. W., Jr.: Transverse preputial island flap technique for repair of severe hypospadias. Urol Clin North Am, 7: 423, 1980 9. Nesbit, R. M.: Operation for correction of distal penile ventral curvature with or without hypospadias. J Urol, 97: 720, 1967 10. Baskin, L. S. and Duckett, J. W.: Dorsal tunica albuginea plication for hypospadias curvature. J Urol, 151: 1668, 1994 11. Gershbaum, M. D., Stock, J. A. and Hanna, M. K.: A case for 2-stage repair of perineoscrotal hypospadias with severe chordee. J Urol, 168: 1727, 2002 12. Snow, B. W., Cartwright, P. C. and Unger, K.: Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: an 8-year experience. J Urol, 153: 472, 1995 13. Cheng, E. Y., Vemulapalli, S. N., Kropp, B. P., Pope, J. C., IV, Furness, P. D., III, Kaplan, W. E. et al: Snodgrass hypospadias repair with vascularized dartos flap: the perfect repair for virgin cases of hypospadias? J Urol, 168: 1723, 2002 14. Chen, S. C., Yang, S. S. D., Hsieh, C. H. and Chen, Y. T.: Tubularized incised plate urethroplasty for proximal hypospadias. BJU Int, 86: 1050, 2000 15. Snodgrass, W. T. and Lorenzo, A.: Tubularized incised-plate urethroplasty for proximal hypospadias. BJU Int, 89: 90, 2002 16. Palmer, L. S., Palmer, J. S., Franco, I., Friedman, S. C., Kolligian, M. E., Gill, B. et al: The “long Snodgrass”: applying the tubularized incised plate urethroplasty to penoscrotal hypospadias in 1-stage or 2-stage repairs. J Urol, 168: 1748, 2002
Vol. 172, 2382–2383, December 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000143880.13698.ca
RESULTS OF 265 CONSECUTIVE PROXIMAL HYPOSPADIAS REPAIRS USING THE THIERSCH-DUPLAY PRINCIPLE SAMUEL A. AMUKELE, ADAM C. WEISER, JEFFREY A. STOCK
AND
MONEER K. HANNA*
From the Departments of Urology, Schneider Children’s Hospital, Long Island Jewish Medical Center, New Hyde Park (SAA, ACW, MKH) and New York Hospital-Weill Cornell Medical Center, New York, New York (MKH), and Children’s Hospital of New Jersey, Saint Barnabas Health Care System, Livingston, New Jersey (JAS, MKH)
ABSTRACT
Purpose: We review the evolution of the concept of tubularization of the urethral plate and our results in the repair of proximal hypospadias. Materials and Methods: A total of 281 children born with proximal hypospadias underwent Thiersch-Duplay urethroplasty with or without a midline incision of the urethral plate between 1989 and 1998. Followup data were available in 265 children. Results: Excellent functional and cosmetic results were achieved in 88.7% of the patients. The use of either a dartos or tunica vaginalis flap to waterproof the urethral suture line resulted in a decrease in the fistula rate from 17% to 1.8%. Conclusions: The principles of Thiersch-Duplay urethroplasty represent the basic foundation for surgical techniques that use the urethral plate to construct a urethral tube. The use of this principle in the repair of proximal hypospadias compares favorably with other methods. KEY WORDS: penis, reconstructive surgical procedures, hypospadias
In 1869 Thiersch tubularized the urethral plate to form a urethral canal in a child born with epispadias.1 In 1874 Duplay used the same principle, making 2 parallel incisions and tubularizing the urethral plate in a boy born with hypospadias.2 He observed that the catheter did not need to be covered entirely by skin to form a tube. Brown popularized this concept in 1949, when he described the buried skin strip method for hypospadias repair.3 Therefore, it is clear that the Thiersch-Duplay principles represent the earliest reported methods for formation of a urethral tube out of the urethral plate. Midline incision of the urethral plate was first reported by Reddy in 1975.4 He made this incision to excise the “fibrous” material in the midline, which was believed to be the cause of the chordee. He combined this incision with Thiersch-Duplay tubularization to correct hypospadias with chordee in 1 stage. Subsequently, Rich et al made a “relaxing” incision in the midline of the urethral plate to hinge the glans penis and create a slit-like meatus.5 Snodgrass subsequently popularized the tubularized incised plate (TIP) method.6 We have previously reported our experience with distal urethroplasty and glanduloplasty using the Thiersch-Duplay principle.7 Herein, we report our results with similar techniques in proximal hypospadias repair.
padias and/or chordee, who were operated on during the same period. A total of 16 children were excluded because of inadequate followup and/or incomplete data. Of the 265 children included in the study the operative reports indicated that the meatus was mid or proximal in 128, penoscrotal in 74 and scrotal in 63. Urethroplasty was performed following correction of the chordee, confirmed by an artificial erection test. In a majority of cases the chordee was corrected by simple degloving of the skin and fascia. In 74 children the chordee was caused by corporeal disproportion and was corrected by the Nesbit procedure9 or tunica albuginea plication.10 Early in the series when the ventral meatus was thin and
METHODS
Before 1989 we repaired proximal hypospadias by either a free full thickness graft or an island skin flap in the form of a tube, or as an onlay as described by Duckett.8 We began to use the Thiersch-Duplay principle in 1989, and in selected cases of proximal hypospadias without significantly apparent chordee the urethral plate was tubularized. Subsequent to the Snodgrass report6 we extended the application of the TIP repair to the majority of children born with proximal hypospadias. A total of 281 children with proximal hypospadias underwent surgical repair using the Thiersch-Duplay method between 1989 and 1998. These cases were gleaned from our database, which listed 1,364 children with hypos-
a, 8Fr feeding tube is inserted to evaluate if meatus is hypoplastic, and ventral meatoplasty is performed (arrow). b, penile shaft is degloved, and artificial erection is produced to evaluate chordee. c, 2 wedges of glandular skin are excised and urethral plate is ready to be tubularized. d, first layer is tubularized with 7-zero polyglactin and second layer of subcuticular suture with 7-zero polydioxanone (not Accepted for publication July 2, 2004. * Correspondence: 935 Northern Blvd., Suite 303, Great Neck, shown). e, Byars flaps are rotated in to cover neourethra. f, appearance 6 months postoperatively. New York 11021 (e-mail: [email protected]). 2382
2383
PROXIMAL HYPOSPADIAS REPAIRS USING THIERSCH-DUPLAY PRINCIPLE Complications of 1-stage repair for proximal hypospadias References
No. Pts
Hypospadias Location
Chen et al14 Snodgrass and Lorenzo15
40 33
Mid shaft-perineal Mid shaft-scrotal
TIP TIP
Tunica albuginea plication Dorsal plication (18)
7 100 265
Penoscrotal Mid shaft-proximal Mid shaft, penoscrotal, scrotal
TIP TIP Thiersch-Duplay
None Not described Nesbit or tunica albuginea plication (74)
Palmer et al16 Cheng et al13 Present series
Repair Type
hypoplastic we opted for an island flap onlay. Subsequently, we performed ventral meatoplasty at the 6-o’clock position in conjunction with Thiersch-Duplay tubularization in 27 children (part a of figure). In all cases the urethral plate was tubularized in 2 layers. In 169 repairs waterproofing of the urethral suture line was achieved by either a flap of tunica vaginalis (40 patients) or dartos (129). The postoperative dressing was duoderm, and catheter drainage was maintained for 5 to 7 days in all cases. A representative case is illustrated in the figure. Preoperative adjunctive intramuscular testosterone (50 mg 3 to 4 weeks before repair) was given to children with a small phallus. The distribution was mid or proximal in 11 of 128, penoscrotal in 23 of 74 and scrotal in 41 of 63 patients. RESULTS
Followup data are available for 265 consecutive patients for a period of 2 to 11 years postoperatively (mean 7.5). Average age at repair was 7 months (range 6 to 11). A satisfactory outcome was achieved in 88.7% of patients. In these patients the meatus is terminal or glandular without chordee, and satisfactory cosmesis and normal voiding were observed by either parents or physician. The overall major complication rate was 11.3%, and included urethral stricture, urethrocutaneous fistula formation, urethral diverticulum, concealed penis and dehiscence (see table). Minor problems, including skin dimple, inclusion cyst and irregular meatus, occurred in 5 children, and all were subsequently repaired. Of the 16 fistulas 13 occurred in the first 96 patients when no waterproofing with either dartos or tunica vaginalis flap was done (13.5%). In contrast, only 3 fistulas occurred in the subsequent 169 patients where a dartos or tunica vaginalis flap was used (1.8%). Urethral diverticulum was noted in 2 of 3 children who had development of a meatal stricture. DISCUSSION
The aim of the surgeon in proximal hypospadias repair is to create a straight penis without chordee, a meatus at the tip of the glans penis, a neourethra of adequate caliber, normal voiding and penile cosmesis with minimal complications. Our policy is to repair perineoscrotal hypospadias with severe chordee due to corporeal disproportion in 2 stages, whereby dermal graft is used to correct the chordee and lengthen the ventral corporeal wall in the first stage.11 However, if the chordee is relatively mild (30 degrees or less), we have used the Nesbit procedure9 and more recently the Baskin modification10 to straighten the penis. Mild penoscrotal transposition was corrected by rotation of scrotal flaps and was combined with Thiersch-Duplay repair. In severe transposition we generally opted for a 2-stage repair, since in the majority of these cases the intrinsic chordee was caused by corporeal disproportion with a greater than 30-degree angle. In the past the urethral plate was considered to be the cause of chordee. It was often excised and the urethra was reconstructed with either a free skin graft or tubularized island flap. The recognition that chordee is often due to skin and fascial tethering resulted in more acceptance of the fact that the urethral plate has the potential of forming a urethral tube, a fact
Complications (No.)
Chordee Repairs (No.)
Fistula (5), meatal stenosis (4) Fistula (7), meatal stenosis (1), stricture (1), recurrent chordee (2), dehiscence (1) Fistula (1), glans dehiscence (1) Fistula (3), meatal stenosis (1) Fistula (16), stricture (3), diverticulum (2), major breakdown (2), concealed penis (7)
that Thiersch1 and Duplay2 realized more than a century ago. The addition of a midline relaxing incision allows for tensionfree ventral closure of the urethra. We believe that if the urethral groove and the glandular sulcus are deep, this relaxing incision of the urethral plate is unnecessary. In our early experience the presence of a thin and shiny meatal skin was considered a contraindication to tubularization of the urethral plate and prompted the use of an island skin flap onlay as described by Duckett.8 As our experience with Thiersch-Duplay has evolved, we have combined it with a ventral meatoplasty at the 6-o’clock position. The dartos or tunica vaginalis flap provides excellent support to the suture line, especially when ventral meatoplasty is contemplated.12 The routine use of the dartos or tunica vaginalis flap to waterproof the suture line has resulted in a significant decrease in our urethral fistula rate from 17% to 1.8%. The experience of Cheng et al also supports this notion.13 In conclusion, tubularization of the urethral plate should be included in the armamentarium of proximal hypospadias repair. This series and others support this concept (see table). REFERENCES
1. Thiersch, C.: Uber die Entstehungweise und operative Behandlung des Epispadie. Arch Heilkd, 10: 20, 1869 2. Duplay, S.: De l’hypospadias perineo-scrotal et de son traitement chirugical. Arch Gen Med, 513: 657, 1874 3. Brown, D.: An operation for hypospadias. Proc R Soc Med, 41: 466, 1949 4. Reddy, L. N.: One-stage repair of hypospadias. Urology, 5: 475, 1975 5. Rich, M. A., Keating, M. A., Synder, H. M. and Duckett, J. W.: Hinging the urethral plate in hypospadias meatoplasty. J Urol, 142: 1551, 1989 6. Snodgrass, W.: Tubularized, incised plate urethroplasty for distal hypospadias. J Urol, 151: 464, 1994 7. Stock, J. A. and Hanna, M. K.: Distal urethroplasty and glanuloplasty procedure: results of 512 repairs. Urology, 49: 449, 1997 8. Duckett, J. W., Jr.: Transverse preputial island flap technique for repair of severe hypospadias. Urol Clin North Am, 7: 423, 1980 9. Nesbit, R. M.: Operation for correction of distal penile ventral curvature with or without hypospadias. J Urol, 97: 720, 1967 10. Baskin, L. S. and Duckett, J. W.: Dorsal tunica albuginea plication for hypospadias curvature. J Urol, 151: 1668, 1994 11. Gershbaum, M. D., Stock, J. A. and Hanna, M. K.: A case for 2-stage repair of perineoscrotal hypospadias with severe chordee. J Urol, 168: 1727, 2002 12. Snow, B. W., Cartwright, P. C. and Unger, K.: Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: an 8-year experience. J Urol, 153: 472, 1995 13. Cheng, E. Y., Vemulapalli, S. N., Kropp, B. P., Pope, J. C., IV, Furness, P. D., III, Kaplan, W. E. et al: Snodgrass hypospadias repair with vascularized dartos flap: the perfect repair for virgin cases of hypospadias? J Urol, 168: 1723, 2002 14. Chen, S. C., Yang, S. S. D., Hsieh, C. H. and Chen, Y. T.: Tubularized incised plate urethroplasty for proximal hypospadias. BJU Int, 86: 1050, 2000 15. Snodgrass, W. T. and Lorenzo, A.: Tubularized incised-plate urethroplasty for proximal hypospadias. BJU Int, 89: 90, 2002 16. Palmer, L. S., Palmer, J. S., Franco, I., Friedman, S. C., Kolligian, M. E., Gill, B. et al: The “long Snodgrass”: applying the tubularized incised plate urethroplasty to penoscrotal hypospadias in 1-stage or 2-stage repairs. J Urol, 168: 1748, 2002