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Results of Complete Penile Disassembly for Epispadias Repair in 42 Patients
0022-5347/03/1705-1963/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 170, 1963–1965, November 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000092227.00999.a6
RESULTS OF COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR IN 42 PATIENTS HISHAM M. HAMMOUDA From the Pediatric Urology Division, Urology Department, Assiut University, Assiut, Egypt
ABSTRACT
Purpose: We evaluated the Mitchell complete penile disassembly technique for epispadias repair. Materials and Methods: A total of 42 males 1 month to 22 years old presented for repair of epispadias between 1998 and 2002. Cases were divided into 2 groups. Group 1 included 29 cases of complete epispadias as a component of bladder exstrophy, 8 with previous continent urinary diversion. Group 2 included 13 cases of epispadias alone (10 primary and 3 secondary). Of the 29 patients in group 1, 21 underwent complete penile disassembly as part of 1-stage primary closure of bladder exstrophy. Results: Mean followup was 37.5 months (range 6 to 52). Ischemic changes at the glans penis were observed in 5 cases during our initial experience. Ventral orthotopic meatus was observed in all 42 patients, conical glans in 40 (95.2%), straight shaft in 34 (81%) and urethral fistula in 1 (2.4%). There were no cases of dehiscence, meatal stenosis or urethral stricture. Erectile function was preserved in all patients. Conclusions: Complete penile disassembly is a safe procedure that can provide normalization of the urethra and penis together with satisfactory cosmetic and functional outcome. KEY WORDS: epispadias, penis
More than a century has passed since Cantwell stated that in all cases of reparative surgery in which the defect is congenital the aim of the surgeon should be to restore the parts to their normal relations as nearly as possible.1 Many techniques and their modifications have been described in trials to achieve those goals.2 Mitchell and Ba¨gli described their technique of complete penile disassembly for epispadias repair.3 Modifications of the original technique have also been described.4, 5 Debate exists concerning its outcome.6 The Cantwell-Ransley technique and its modifications were our previous procedures of choice. However, since 1998 the complete penile disassembly technique for epispadias repair has been the technique of choice at our institution. In this study we evaluated results of complete penile disassembly for epispadias repair. MATERIALS AND METHODS
A total of 42 epispadias repairs were done by the same surgeon between 1998 and 2002. Patients were 1 month to 22 years old (mean age 8.3 years). The cases were divided into 2 groups. Group 1 included 29 cases of complete epispadias as a component of bladder exstrophy, while group 2 included 13 cases of epispadias alone. Of group 1 patients 21 underwent complete penile disassembly as part of 1-stage primary closure of bladder exstrophy, while the remaining 8 were referred with some form of continent urinary diversion. Group 2 included 10 cases of complete penopubic incontinent epispadias and 3 cases of incomplete penile continent epispadias. Of the 13 cases in group 2, 10 were primary and 3 secondary. Patient characteristics are listed in table 1. The technique of complete penile disassembly was similar to that described previously (parts A to D of figure).2, 4, 6 Penile dissection is begun from the ventral aspect with preservation of the skin attachment of the urethral plate (urethral mesentery) in a plane directly on Buck’s fascia overlying the urethral wedge, then toward the medial side directly Accepted for publication June 13, 2003.
TABLE 1. Patient characteristics No. Pts/Total No. Mean age (range) (%) Group 1 (bladder exstrophy): Primary closure
29/42 (69) 21/29 (72.4)
Ureterosigmoidostomy Mainz II rectosigmoid pouch Charleston pouch Group 2 (epispadias alone): Incontinent epispadias (2 failed previous repairs) Continent epispadias (1 failed previous repair)
3/29 1/29 4/29 13/42 (31) 10/13 (76.9)
13 mos (12–18)
3/13 (23.1)
2.5 yrs (1–3)
3 mos (1–12) 16 yrs (12–22)
on the tunica albuginea overlying each corpus cavernosum. The level of separation proximally is extended up to the intersymphyseal ligament. The urethral plate is tubularized using interrupted absorbable sutures and secured to the tip of the glans, and meatoplasty is completed. Followup visits were scheduled at 3 months, and every 6 months thereafter. Cosmetic data were analyzed in terms of wound dehiscence, urethral fistula, urethral stricture, angle of the penis, shape of the glans, position, site and caliber of reconstructed external urethral meatus. Erectile function data were recorded. Function was suggested by observation of erections either by the parents in pediatric cases or by the patients themselves in adult cases. RESULTS
Ischemic changes at the glans penis in the form of immediate postoperative darkening of the skin were reported in 5 of the first 10 cases. Age of affected patients ranged from 1 month to 2 years. Followup at 3 months revealed that 2 cases resulted in the sloughing off of half the hemiglans, while the other 3 cases had a normal appearing glans (part E of figure). Mean followup after epispadias repair was 37.5 months (range 6 to 52). Results are listed in table 2.
1963
1964
COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR
A, epispadias as part of bladder exstrophy. Urethral plate is marked with methylene blue pen. B, urethral plate is dissected from corpora cavernosa. C, complete disassembly into 2 corporeal bodies with hemiglans and urethral plate. D, reassembly of urethra and corpora cavernosa with hemiglans. E, conical glans with ventral orthotopic urethra 2 years after epispadias repair.
DISCUSSION
The 2 corporeal bodies are supplied by deep penile arteries, which are terminal branches of the internal pudendal artery within the Alcock canal. Additional pudendal branches, the dorsal arteries of the paired neurovascular bundles, supply the glans penis. Therefore, it is possible to disassemble the epispadiac penis based on this constant vascular supply. Approaches that maintain the distal fixation point of the urethral plate to the dorsal glans make glans repair and true ventralization of the urethra difficult.3 Preservation of the attachment of the urethra to the glans is not mandatory to preserve vasculature according to some authors, while others disagree.3–5, 7 Ischemic changes are iatrogenic and may result from injury of the corporeal artery, which occurs if the dissection goes through the incorrect plane. We emphasize the great benefit of beginning the dissection on the ventral and medial aspect of the corporeal bodies to maintain the correct plane on Buck’s fascia between the urethral plate and corporeal bodies.3 Also, ischemia may be induced by using thick, extra number sutures, or taking large tissue bites to join the corpora cavernosa together. Great care should be taken, especially in infants and young children, to prevent any ischemic changes. Preservation of urethral plate mesentery may be beneficial for its vasculature.
TABLE 2. Results of complete penile disassembly repair of epispadias Results Dehiscence Urethral fistula Urethral stricture Conical glans Straight shaft Downward angle Urethral meatus: Meatal stenosis Ventral orthotopic Preserved erectile function * Pinhole coronal urethral fistula was successfully closed.
No. Pts (%) 0 1 (2.4)* 0 40 (95.2) 34 (81) 8 (19)
We believe that complete penile disassembly can provide normalization of the reconstructed urethra in terms of ventral transposition, straight course, dorsal protection of suture line by the corpora cavernosa and orthotopic position. All these factors contribute to the low fistula rate after total penile disassembly in comparison to other techniques. Fistula rate after the modified Cantwell-Ransley technique ranges from 5.5% to 42%,3, 5, 7–10 while it was 2.4% in the current study after complete disassembly. Hypospadiac position of reconstructed urethra may be due to either shortening of the urethra, which can be prevented by suturing the urethra using interrupted sutures,11 or urethral retraction, which can be managed by proper fixation to the glans and corpora cavernosa. This complication was recorded in 3 of 10 patients by Mitchell and Ba¨gli3 but it was not observed in our series, similar to others.5, 7 We disagree with Gearhart that complications of complete primary repair are more difficult not only because of loss of penile skin, but also because of loss of the urethral closure.6 Gearhart reported 2 cases with loss of urethra and penile skin, and 1 with loss of urethra and impassable urethral stricture out of 7 males referred after complete primary repair for bladder exstrophy.6 Wound dehiscence was not observed in our series, similar to others,3, 5 although it was noted in 1 of 17 patients in a single series.7 Corporeal rotation with corporotomy and cavernocavernostomy for correction of dorsal curvature necessitate mobilization of neurovascular bundles.12–16 Corporeal rotation with corporotomy and cavernocavernostomy and mobilization of neurovascular bundles are not necessary with the complete disassembly technique. However, ventral corporeal plication for correction of dorsal curvature is a valid option. Avoidance of neurovascular mobilization helps to preserve erectile function after epispadias repair. Erectile function was preserved in this series, as in others.7 CONCLUSIONS
0 42 (100) 42 (100)
We report our experience with complete penile disassembly for repair of epispadias in 42 patients. We believe that this technique could provide normalization of the urethra and
1965
COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR
penis in addition to excellent cosmetic and functional outcome. It is a safe procedure while being a formidable challenge. REFERENCES
1. Cantwell, F. V.: Operative treatment of epispadias by transplantation of the urethra. Ann Surg, 22: 689, 1895 2. Ransley, P. G., Duffy, P. G. and Wollin, M.: Bladder exstrophy closure and epispadias repair. In: Rob and Smith’s Operative Surgery—Pediatric Surgery, 4th ed. Edited by L. Spitz and H. H. Nixon. Boston: Butterworths, p. 620, 1988 3. Mitchell, M. E. and Ba¨ gli, D. J.: Complete penile disassembly for epispadias repair: the Mitchell technique. J Urol, 155: 300, 1996 4. Perovic, S. V., Vukadinovic, V., Djordjevic, M. L. J. and Djakovic, N. G.: Penile disassembly technique for epispadias: variants of technique. J Urol, 162: 1181, 1999 5. Caione, P. and Capozza, N.: Evolution of male epispadias repair: 16-year experience. J Urol, 165: 2410, 2001 6. Gearhart, J. P.: Complete repair of bladder exstrophy in the newborn: complications and management. J Urol, 165: 2431, 2001 7. Zaontz, M. R., Steckler, R. E., Shortliffe, L. M. D., Kogan, B. A., Baskin, L. and Tekgul, S.: Multicenter experience with the Mitchell technique for epispadias repair. J Urol, 160: 172, 1998 8. Lottmann, H. B., Yaqouti, M. and Melin, Y.: Male epispadias repair: surgical and functional results with the CantwellRansley procedure in 40 patients. J Urol, 162: 1176, 1999 9. Surer, I., Baker, L. A., Jeffs, R. D. and Gearhart, J. P.: The modified Cantwell-Ransley repair in exstrophy and epispadias: ten years experience. J Urol, 164: 1040, 2000 10. Surer, I., Baker, L. A., Jeffs, R. D. and Gearhart, J. P.: Combined bladder neck reconstruction and epispadias repair for exstrophy-epispadias complex. J Urol, 165: 2425, 2001 11. Pipi-Salle, J. L. and Chan, P. T.: One stage bladder exstrophy and epispadias repair in newborn male. Can J Urol, 6: 757, 1999 12. Kajbafzadeh, A. M., Duffy, P. G. and Ransley, P. G.: The evolution of penile reconstruction in epispadias repair: a report of 180 cases. J Urol, 154: 858, 1995 13. Woodhouse, C. R. J. and Kellett, M. J.: Anatomy of the penis and its deformities in exstrophy and epispadias. J Urol, 132: 1122, 1984 14. Koff, S. A. and Eakins, M.: The treatment of penile chordee using corporal rotation. J Urol, 131: 931, 1984 15. Hurwitz, R. S., Woodhouse, C. R. J. and Ransley, P.: The anatomical course of the neurovascular bundles in epispadias. J Urol, 136: 68, 1986 16. Gearhart, J. P., Leonard, M. P., Burgers, J. K. and Jeffs, R. D.: The Cantwell-Ransley technique for repair of epispadias. J Urol, 148: 851, 1992 EDITORIAL COMMENTS This is an impressive series of penile disassembly by a single surgeon. I am intrigued by the notion of maintaining the attachment
of the urethral plate to the ventral penile skin, “the urethral mesentery.” This is a modification of the Mitchell technique and may be significant. It may explain why there were no hypospadiac meatuses in the 42 patients, and I shall use this surgical tip in the future. However, there were ischemic changes in 5 patients, and there is an important message, that there is a learning curve, and it is not a technique for the “occasional” surgeon. Moneer K. Hanna Great Neck, New York The author should be congratulated for this impressive review of the results of 42 penile reconstructions in 2 groups of patients with bladder exstrophy and epispadias using the Mitchell disassembly technique. Correction of the dorsal curvature of the penis in the Mitchell technique implies some degree of derotation of the corpora cavernosa, and the complete disassembly certainly allows this without dissecting the neurovascular bundles. What is the point of separating the corpora cavernosa if they are not derotated? The problems met by other surgeons (including myself) with the disassembly technique are not with the blood supply of the corpora cavernosa but the blood supply of each hemiglans and distal urethral plate, which may not be as symmetrical as expected. The central artery of both corpora cavernosa remains safe during this dissection, whereas the neurovascular bundles can be injured. I am not convinced that the midline is always the surgeon’s best friend. This is the reason why I still favor the Cantwell-Ransley procedure, which does not jeopardize the blood supply of the glans and allows a dangling penis with a ventral urethra. Considering the large experience of this author, it would be instructive to have his experience with the Cantwell-Ransley technique and compare it to the Mitchell procedure he has used since 1998. Although the Mitchell and the Cantwell-Ransley techniques have been a major step forward in penile reconstruction in these 2 groups of patients, I would not say that these procedures can provide normalization of the penis. Pierre D. E. Mouriquand Department of Paediatric Urology Debrousse Hospital Lyon Cedex France REPLY BY AUTHOR Debate concerning the importance of complete separation of corpora was addressed to in the introduction (reference 1 in article), and the concept of corporeal separation was resolved (references 3 to 5 and 7 in article). It provides many advantages rather than corporeal derotation, such as additional geometric degree of freedom to the repair, ventralization of the urethra and protection of the urethral suture line against corporeal bodies (reference 3 in article). The problem with the blood supply of each hemiglans can be avoided by ventral dissection on Buck’s fascia overlying the urethral plate together with overlying corpus spongiosum (urethral wedge) and then toward the medial side directly on the tunica albuginea overlying each corpus, so that the neurovascular bundle is protected. I believe that the midline is a good friend. The Cantwell-Ransley technique has been evaluated in many series (references 8 to 10 in article).
Vol. 170, 1963–1965, November 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000092227.00999.a6
RESULTS OF COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR IN 42 PATIENTS HISHAM M. HAMMOUDA From the Pediatric Urology Division, Urology Department, Assiut University, Assiut, Egypt
ABSTRACT
Purpose: We evaluated the Mitchell complete penile disassembly technique for epispadias repair. Materials and Methods: A total of 42 males 1 month to 22 years old presented for repair of epispadias between 1998 and 2002. Cases were divided into 2 groups. Group 1 included 29 cases of complete epispadias as a component of bladder exstrophy, 8 with previous continent urinary diversion. Group 2 included 13 cases of epispadias alone (10 primary and 3 secondary). Of the 29 patients in group 1, 21 underwent complete penile disassembly as part of 1-stage primary closure of bladder exstrophy. Results: Mean followup was 37.5 months (range 6 to 52). Ischemic changes at the glans penis were observed in 5 cases during our initial experience. Ventral orthotopic meatus was observed in all 42 patients, conical glans in 40 (95.2%), straight shaft in 34 (81%) and urethral fistula in 1 (2.4%). There were no cases of dehiscence, meatal stenosis or urethral stricture. Erectile function was preserved in all patients. Conclusions: Complete penile disassembly is a safe procedure that can provide normalization of the urethra and penis together with satisfactory cosmetic and functional outcome. KEY WORDS: epispadias, penis
More than a century has passed since Cantwell stated that in all cases of reparative surgery in which the defect is congenital the aim of the surgeon should be to restore the parts to their normal relations as nearly as possible.1 Many techniques and their modifications have been described in trials to achieve those goals.2 Mitchell and Ba¨gli described their technique of complete penile disassembly for epispadias repair.3 Modifications of the original technique have also been described.4, 5 Debate exists concerning its outcome.6 The Cantwell-Ransley technique and its modifications were our previous procedures of choice. However, since 1998 the complete penile disassembly technique for epispadias repair has been the technique of choice at our institution. In this study we evaluated results of complete penile disassembly for epispadias repair. MATERIALS AND METHODS
A total of 42 epispadias repairs were done by the same surgeon between 1998 and 2002. Patients were 1 month to 22 years old (mean age 8.3 years). The cases were divided into 2 groups. Group 1 included 29 cases of complete epispadias as a component of bladder exstrophy, while group 2 included 13 cases of epispadias alone. Of group 1 patients 21 underwent complete penile disassembly as part of 1-stage primary closure of bladder exstrophy, while the remaining 8 were referred with some form of continent urinary diversion. Group 2 included 10 cases of complete penopubic incontinent epispadias and 3 cases of incomplete penile continent epispadias. Of the 13 cases in group 2, 10 were primary and 3 secondary. Patient characteristics are listed in table 1. The technique of complete penile disassembly was similar to that described previously (parts A to D of figure).2, 4, 6 Penile dissection is begun from the ventral aspect with preservation of the skin attachment of the urethral plate (urethral mesentery) in a plane directly on Buck’s fascia overlying the urethral wedge, then toward the medial side directly Accepted for publication June 13, 2003.
TABLE 1. Patient characteristics No. Pts/Total No. Mean age (range) (%) Group 1 (bladder exstrophy): Primary closure
29/42 (69) 21/29 (72.4)
Ureterosigmoidostomy Mainz II rectosigmoid pouch Charleston pouch Group 2 (epispadias alone): Incontinent epispadias (2 failed previous repairs) Continent epispadias (1 failed previous repair)
3/29 1/29 4/29 13/42 (31) 10/13 (76.9)
13 mos (12–18)
3/13 (23.1)
2.5 yrs (1–3)
3 mos (1–12) 16 yrs (12–22)
on the tunica albuginea overlying each corpus cavernosum. The level of separation proximally is extended up to the intersymphyseal ligament. The urethral plate is tubularized using interrupted absorbable sutures and secured to the tip of the glans, and meatoplasty is completed. Followup visits were scheduled at 3 months, and every 6 months thereafter. Cosmetic data were analyzed in terms of wound dehiscence, urethral fistula, urethral stricture, angle of the penis, shape of the glans, position, site and caliber of reconstructed external urethral meatus. Erectile function data were recorded. Function was suggested by observation of erections either by the parents in pediatric cases or by the patients themselves in adult cases. RESULTS
Ischemic changes at the glans penis in the form of immediate postoperative darkening of the skin were reported in 5 of the first 10 cases. Age of affected patients ranged from 1 month to 2 years. Followup at 3 months revealed that 2 cases resulted in the sloughing off of half the hemiglans, while the other 3 cases had a normal appearing glans (part E of figure). Mean followup after epispadias repair was 37.5 months (range 6 to 52). Results are listed in table 2.
1963
1964
COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR
A, epispadias as part of bladder exstrophy. Urethral plate is marked with methylene blue pen. B, urethral plate is dissected from corpora cavernosa. C, complete disassembly into 2 corporeal bodies with hemiglans and urethral plate. D, reassembly of urethra and corpora cavernosa with hemiglans. E, conical glans with ventral orthotopic urethra 2 years after epispadias repair.
DISCUSSION
The 2 corporeal bodies are supplied by deep penile arteries, which are terminal branches of the internal pudendal artery within the Alcock canal. Additional pudendal branches, the dorsal arteries of the paired neurovascular bundles, supply the glans penis. Therefore, it is possible to disassemble the epispadiac penis based on this constant vascular supply. Approaches that maintain the distal fixation point of the urethral plate to the dorsal glans make glans repair and true ventralization of the urethra difficult.3 Preservation of the attachment of the urethra to the glans is not mandatory to preserve vasculature according to some authors, while others disagree.3–5, 7 Ischemic changes are iatrogenic and may result from injury of the corporeal artery, which occurs if the dissection goes through the incorrect plane. We emphasize the great benefit of beginning the dissection on the ventral and medial aspect of the corporeal bodies to maintain the correct plane on Buck’s fascia between the urethral plate and corporeal bodies.3 Also, ischemia may be induced by using thick, extra number sutures, or taking large tissue bites to join the corpora cavernosa together. Great care should be taken, especially in infants and young children, to prevent any ischemic changes. Preservation of urethral plate mesentery may be beneficial for its vasculature.
TABLE 2. Results of complete penile disassembly repair of epispadias Results Dehiscence Urethral fistula Urethral stricture Conical glans Straight shaft Downward angle Urethral meatus: Meatal stenosis Ventral orthotopic Preserved erectile function * Pinhole coronal urethral fistula was successfully closed.
No. Pts (%) 0 1 (2.4)* 0 40 (95.2) 34 (81) 8 (19)
We believe that complete penile disassembly can provide normalization of the reconstructed urethra in terms of ventral transposition, straight course, dorsal protection of suture line by the corpora cavernosa and orthotopic position. All these factors contribute to the low fistula rate after total penile disassembly in comparison to other techniques. Fistula rate after the modified Cantwell-Ransley technique ranges from 5.5% to 42%,3, 5, 7–10 while it was 2.4% in the current study after complete disassembly. Hypospadiac position of reconstructed urethra may be due to either shortening of the urethra, which can be prevented by suturing the urethra using interrupted sutures,11 or urethral retraction, which can be managed by proper fixation to the glans and corpora cavernosa. This complication was recorded in 3 of 10 patients by Mitchell and Ba¨gli3 but it was not observed in our series, similar to others.5, 7 We disagree with Gearhart that complications of complete primary repair are more difficult not only because of loss of penile skin, but also because of loss of the urethral closure.6 Gearhart reported 2 cases with loss of urethra and penile skin, and 1 with loss of urethra and impassable urethral stricture out of 7 males referred after complete primary repair for bladder exstrophy.6 Wound dehiscence was not observed in our series, similar to others,3, 5 although it was noted in 1 of 17 patients in a single series.7 Corporeal rotation with corporotomy and cavernocavernostomy for correction of dorsal curvature necessitate mobilization of neurovascular bundles.12–16 Corporeal rotation with corporotomy and cavernocavernostomy and mobilization of neurovascular bundles are not necessary with the complete disassembly technique. However, ventral corporeal plication for correction of dorsal curvature is a valid option. Avoidance of neurovascular mobilization helps to preserve erectile function after epispadias repair. Erectile function was preserved in this series, as in others.7 CONCLUSIONS
0 42 (100) 42 (100)
We report our experience with complete penile disassembly for repair of epispadias in 42 patients. We believe that this technique could provide normalization of the urethra and
1965
COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR
penis in addition to excellent cosmetic and functional outcome. It is a safe procedure while being a formidable challenge. REFERENCES
1. Cantwell, F. V.: Operative treatment of epispadias by transplantation of the urethra. Ann Surg, 22: 689, 1895 2. Ransley, P. G., Duffy, P. G. and Wollin, M.: Bladder exstrophy closure and epispadias repair. In: Rob and Smith’s Operative Surgery—Pediatric Surgery, 4th ed. Edited by L. Spitz and H. H. Nixon. Boston: Butterworths, p. 620, 1988 3. Mitchell, M. E. and Ba¨ gli, D. J.: Complete penile disassembly for epispadias repair: the Mitchell technique. J Urol, 155: 300, 1996 4. Perovic, S. V., Vukadinovic, V., Djordjevic, M. L. J. and Djakovic, N. G.: Penile disassembly technique for epispadias: variants of technique. J Urol, 162: 1181, 1999 5. Caione, P. and Capozza, N.: Evolution of male epispadias repair: 16-year experience. J Urol, 165: 2410, 2001 6. Gearhart, J. P.: Complete repair of bladder exstrophy in the newborn: complications and management. J Urol, 165: 2431, 2001 7. Zaontz, M. R., Steckler, R. E., Shortliffe, L. M. D., Kogan, B. A., Baskin, L. and Tekgul, S.: Multicenter experience with the Mitchell technique for epispadias repair. J Urol, 160: 172, 1998 8. Lottmann, H. B., Yaqouti, M. and Melin, Y.: Male epispadias repair: surgical and functional results with the CantwellRansley procedure in 40 patients. J Urol, 162: 1176, 1999 9. Surer, I., Baker, L. A., Jeffs, R. D. and Gearhart, J. P.: The modified Cantwell-Ransley repair in exstrophy and epispadias: ten years experience. J Urol, 164: 1040, 2000 10. Surer, I., Baker, L. A., Jeffs, R. D. and Gearhart, J. P.: Combined bladder neck reconstruction and epispadias repair for exstrophy-epispadias complex. J Urol, 165: 2425, 2001 11. Pipi-Salle, J. L. and Chan, P. T.: One stage bladder exstrophy and epispadias repair in newborn male. Can J Urol, 6: 757, 1999 12. Kajbafzadeh, A. M., Duffy, P. G. and Ransley, P. G.: The evolution of penile reconstruction in epispadias repair: a report of 180 cases. J Urol, 154: 858, 1995 13. Woodhouse, C. R. J. and Kellett, M. J.: Anatomy of the penis and its deformities in exstrophy and epispadias. J Urol, 132: 1122, 1984 14. Koff, S. A. and Eakins, M.: The treatment of penile chordee using corporal rotation. J Urol, 131: 931, 1984 15. Hurwitz, R. S., Woodhouse, C. R. J. and Ransley, P.: The anatomical course of the neurovascular bundles in epispadias. J Urol, 136: 68, 1986 16. Gearhart, J. P., Leonard, M. P., Burgers, J. K. and Jeffs, R. D.: The Cantwell-Ransley technique for repair of epispadias. J Urol, 148: 851, 1992 EDITORIAL COMMENTS This is an impressive series of penile disassembly by a single surgeon. I am intrigued by the notion of maintaining the attachment
of the urethral plate to the ventral penile skin, “the urethral mesentery.” This is a modification of the Mitchell technique and may be significant. It may explain why there were no hypospadiac meatuses in the 42 patients, and I shall use this surgical tip in the future. However, there were ischemic changes in 5 patients, and there is an important message, that there is a learning curve, and it is not a technique for the “occasional” surgeon. Moneer K. Hanna Great Neck, New York The author should be congratulated for this impressive review of the results of 42 penile reconstructions in 2 groups of patients with bladder exstrophy and epispadias using the Mitchell disassembly technique. Correction of the dorsal curvature of the penis in the Mitchell technique implies some degree of derotation of the corpora cavernosa, and the complete disassembly certainly allows this without dissecting the neurovascular bundles. What is the point of separating the corpora cavernosa if they are not derotated? The problems met by other surgeons (including myself) with the disassembly technique are not with the blood supply of the corpora cavernosa but the blood supply of each hemiglans and distal urethral plate, which may not be as symmetrical as expected. The central artery of both corpora cavernosa remains safe during this dissection, whereas the neurovascular bundles can be injured. I am not convinced that the midline is always the surgeon’s best friend. This is the reason why I still favor the Cantwell-Ransley procedure, which does not jeopardize the blood supply of the glans and allows a dangling penis with a ventral urethra. Considering the large experience of this author, it would be instructive to have his experience with the Cantwell-Ransley technique and compare it to the Mitchell procedure he has used since 1998. Although the Mitchell and the Cantwell-Ransley techniques have been a major step forward in penile reconstruction in these 2 groups of patients, I would not say that these procedures can provide normalization of the penis. Pierre D. E. Mouriquand Department of Paediatric Urology Debrousse Hospital Lyon Cedex France REPLY BY AUTHOR Debate concerning the importance of complete separation of corpora was addressed to in the introduction (reference 1 in article), and the concept of corporeal separation was resolved (references 3 to 5 and 7 in article). It provides many advantages rather than corporeal derotation, such as additional geometric degree of freedom to the repair, ventralization of the urethra and protection of the urethral suture line against corporeal bodies (reference 3 in article). The problem with the blood supply of each hemiglans can be avoided by ventral dissection on Buck’s fascia overlying the urethral plate together with overlying corpus spongiosum (urethral wedge) and then toward the medial side directly on the tunica albuginea overlying each corpus, so that the neurovascular bundle is protected. I believe that the midline is a good friend. The Cantwell-Ransley technique has been evaluated in many series (references 8 to 10 in article).