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A Urethral Lengthening Procedure for Epispadias and Exstrophy
0022-5347/80/1234-0544$02.00/0 Vol. 123, April
THE JOURNAL OF UROLOGY
Printedi.n U.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
A URETHRAL LENGTHENING PROCEDURE FOR EPISPADIAS AND EXSTROPHY JOHN K. LATTIMER
AND
MICHAEL T. MACFARLANE
From the Pediatric Urological Service, Squier Urological Clinic, Columbia Presbyterian Medical Center, New York, New York ABSTRACT
A procedure to lengthen the urethra is described, which involves the tubularization of the top layer of the foreskin, maintains a good vascular supply and requires only 1 anastomosis. The short natural urethra, with whatever functional capability it may have, also is tubularized and dropped back to form the proximal urethral segment. This technique has worked well and gives a satisfactory cosmetic result. An upward or reverse chordee is a universal problem in patients with penile epispadias. It results from the shortness, the dorsal position and the less elastic nature of the urethral component of the epispadiac penis. The most common surgical treatment for epispadias has been to roll the urethra into a tube, burying it between the 2 lateral corpora cavemosa and then joining the skin over the corpora without lengthening the urethral component. The result is that upon erection the shorter, less elastic urethral component will not stretch enough and the penis will curl sharply upward, to be pressed tightly against the abdominal wall. If this reverse chordee, which is so markedly exaggerated upon erection, is not corrected sexual functioning (penetration) by the penis will be limited, if not impossible, in most cases. If there is a longitudinal scar on the dorsum of the penile skin from a previous operation this inelastic scar will provide an additional reason for the persistence of the reverse chordee with erection. Many attempts at revision to release the chordee have been directed at removing only the superficial scar tissue on the dorsum of the penis. This method will give some relief but it usually fails to correct the chordee fully. The universal presence of a short, inelastic urethra running along the dorsum of the penis has been the principal cause of the persistence of chordee in our patients with epispadias. In 1954 we developed a technique based on a combination of procedures favored years ago by Hinman1 and others. The short urethral plate is released, which allows the rest of the penis to drop downward. We then lengthen the short urethra by adding a tube of preputial skin, which is still attached at the distal end, for viability. This permits the original urethral strip not only to be dropped back but to be saved in toto and intact by rolling it into a thick-walled tube of appropriate size in the difficult area toward the base of the newly formed penis. We have performed this technique since 1954 on new cases and also have used it for revision of previous repairs. In the latter case the procedure is similar, although it is essential that the patients have not been circumcised previously. TECHNIQUE
The flat strip (plate or tongue) of obvious urethral tissue on the top of the epispadiac penis is outlined with a skin pencil. A thick, square-tipped, flat slab of tissue is made with a sharp knife, which is freed from the tip of the penis back to the level where the ducts of Cowper's glands Inight be anticipated to be entering the urethra. This tongue of tissue usually is shorter than the lateral corpora cavernosa and, when it is freed from them, the lateral corpora can hang down over the scrotum in a more pendulous configuration. An incision is made between the Accepted for publication June 18, 1979. Supported in part by the Reed M. Chambers Medical Research Gift. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1979.
2 lateral corpora down to the skin of the underside of the penis. The glans is divided in the Inidline almost but not completely down to its ventral margin, leaving enough of a lower rim of glans to permit the new meatus to be at the tip of the glans rather than at its lower margin. It is easy to go too far with this incision in the glans and one has to be careful at this point not to divide the glans completely. A traction suture or tiny clamp is put on each of the 2 corners of the foreskin at its distal margin and on each side of the Inidline about 15 mm. apart. The foreskin is then stretched downward so that the prepuce is a flat tongue of tissue, extending from the lower lip of the glans (fig. 1, A). An incision is made transversely across the foreskin just at the lower edge of the glans but only through the top layer of the foreskin, leaving the lower (outer) layer intact. This transverse incision is usually about 1½ to 2 cm. wide. Two vertical incisions are then made at right angles to this transverse incision, 1 at each lateral margin of the preputial flap, continuing towards the 2 distal stay sutures and usually about 2 cm. long. Again, these incisions are made through only the top layer of the prepuce. This outlines a rectangle of skin on the top surface of the foreskin, which can now be freed on 3 sides, namely the 2 lateral sides and the cephalad side of the rectangle. The upper surface of this rectangle can then be undermined and freed from the lower layer of the foreskin by blunt dissection and the resulting rectangle can be rolled into a tube (fig. 1, B). The cephalad end of this tube can then be pulled up the Inidline of the penis and anastomosed to the tubularized proximal urethra made from the original tongue of urethral tissue, which has now retracted almost back to the bladder neck as the penis assumes a pendulous position (fig. 2, A). A catheter or open sump tube of appropriate (small) size is left in the urethra or brought out suprapubically as a cystotomy to prevent any possibility of extravasation through the new anastomosis. The lateral corpora are closed together over the new urethra and the skin is closed down the dorsum of the penis, preferably in a "Z" configuration with overlapping skin flaps (fig. 2, B). In this way a pedicled tube of distal urethra is created, which is still attached to the foreskin at its tip and reaches from the tip of the penis up its center to join the tubularized intact natural or regular urethra to which it is anastomosed. In many cases there is so much skin that the tube is too long, even after creating an anastomosis free of tension. We leave the tube long and at a later stage the pedicle attachment at the tip of the penis is divided and any excess skin is trimmed away. A sound is passed to test for stricture and a urethral pressure profile can be done. DISCUSSION
This technique has a number of advantages over others that we have used to lengthen the urethra. One alternative procedure we have tried is to use a free skin graft, which is tubularized over a stent and interposed in the Inid shaft of the urethra just
544
URETHRAL LENGTHENING PROCEDURE FOR EPISPADIAS AND EXSTROPHY
B
545
'\'\
( \.
FIG. 1. A, rectangular skin flap incised on 3 sides from stretched out prepuce, B, rectangular flap is freed from lower layer of foreskin and rolled into tube.
B
FIG. 2. A, cephalad end of tube is anastomosed to proximal urethra. B, lateral corpora are closed together and skin is closed down dorsum penis.
distal to the verumontanum. This technique not only carries with it some risk of sloughing or later fibrosis and contracture of the free graft but it entails 2 anastomoses, doubling the chances of stricture or fistula. There also is the possibility of a mi.d urethral fusiform dilated segment owing to the looser nature of the interposed skin. Another technique that can be used (in older patients only) to add skin and to lengthen the dorsum of the penis is to bury the penis under a transverse bridge of upper scrotal skin, later to be freed in a second stage. This technique cannot be used in young exstrophy patients because, as we have indicated, many male exstrophy patients have an underdeveloped scrotum that does not enlarge enough to become a pendulous structure until sometime after puberty. 2 It is not wise to compromise what little scrotum these boys have while they are still young and the scrotum is still growing. In those patients who have a well developed scrotum this technique is a viable alternative. Still other techniques use Y-V incisions to lengthen the dorsal urethral strip, with resultant narrowing of the strip, or use strips of the thin, shiny skin alongside the bladder to splice out the urethra. These procedures scar the urethra more than the technique described herein. Our technique, which tubularizes the attached foreskin, per-
mits good blood supply to be maintained, minimizing the sibility of sloughing or contracture. In addition, this requires only 1 anastomosis located in the mid (straight) of the penis, thus lessening the chances of anastomotic down. It permits a more normal relocation of the meatus at the tip of the glans and slightly on its ventral surface. The urethxa is lengthened with copious viable skin, permitting the penis to drop down to a pendulous configuration free of upward or reverse chordee even during erection. The patient's own natural urethral tissues are preserved in a single unit to form a urethral segment made of the type of urethral tissue have some inherent tone and, thus, contribute to holding urine at some later date. Tubes made entirely of skin will never have this helpful elastic property and are best used for the distal portions of the reconstructed urethra. This technique has worked well for us. REFERENCES 1. Hinman, F., Jr.: A method of lengthening and repairing the penis
in exstrophy of the bladder. J. Urol., 79: 237, 1958. 2. Lattimer, J. K., Puchner, P. J., Hensle, T. W. and Macfarlane, M. T.: Delayed development of the scrotum in exstrophy. J. Urol., 121: 339, 1979.
THE JOURNAL OF UROLOGY
Printedi.n U.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
A URETHRAL LENGTHENING PROCEDURE FOR EPISPADIAS AND EXSTROPHY JOHN K. LATTIMER
AND
MICHAEL T. MACFARLANE
From the Pediatric Urological Service, Squier Urological Clinic, Columbia Presbyterian Medical Center, New York, New York ABSTRACT
A procedure to lengthen the urethra is described, which involves the tubularization of the top layer of the foreskin, maintains a good vascular supply and requires only 1 anastomosis. The short natural urethra, with whatever functional capability it may have, also is tubularized and dropped back to form the proximal urethral segment. This technique has worked well and gives a satisfactory cosmetic result. An upward or reverse chordee is a universal problem in patients with penile epispadias. It results from the shortness, the dorsal position and the less elastic nature of the urethral component of the epispadiac penis. The most common surgical treatment for epispadias has been to roll the urethra into a tube, burying it between the 2 lateral corpora cavemosa and then joining the skin over the corpora without lengthening the urethral component. The result is that upon erection the shorter, less elastic urethral component will not stretch enough and the penis will curl sharply upward, to be pressed tightly against the abdominal wall. If this reverse chordee, which is so markedly exaggerated upon erection, is not corrected sexual functioning (penetration) by the penis will be limited, if not impossible, in most cases. If there is a longitudinal scar on the dorsum of the penile skin from a previous operation this inelastic scar will provide an additional reason for the persistence of the reverse chordee with erection. Many attempts at revision to release the chordee have been directed at removing only the superficial scar tissue on the dorsum of the penis. This method will give some relief but it usually fails to correct the chordee fully. The universal presence of a short, inelastic urethra running along the dorsum of the penis has been the principal cause of the persistence of chordee in our patients with epispadias. In 1954 we developed a technique based on a combination of procedures favored years ago by Hinman1 and others. The short urethral plate is released, which allows the rest of the penis to drop downward. We then lengthen the short urethra by adding a tube of preputial skin, which is still attached at the distal end, for viability. This permits the original urethral strip not only to be dropped back but to be saved in toto and intact by rolling it into a thick-walled tube of appropriate size in the difficult area toward the base of the newly formed penis. We have performed this technique since 1954 on new cases and also have used it for revision of previous repairs. In the latter case the procedure is similar, although it is essential that the patients have not been circumcised previously. TECHNIQUE
The flat strip (plate or tongue) of obvious urethral tissue on the top of the epispadiac penis is outlined with a skin pencil. A thick, square-tipped, flat slab of tissue is made with a sharp knife, which is freed from the tip of the penis back to the level where the ducts of Cowper's glands Inight be anticipated to be entering the urethra. This tongue of tissue usually is shorter than the lateral corpora cavernosa and, when it is freed from them, the lateral corpora can hang down over the scrotum in a more pendulous configuration. An incision is made between the Accepted for publication June 18, 1979. Supported in part by the Reed M. Chambers Medical Research Gift. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1979.
2 lateral corpora down to the skin of the underside of the penis. The glans is divided in the Inidline almost but not completely down to its ventral margin, leaving enough of a lower rim of glans to permit the new meatus to be at the tip of the glans rather than at its lower margin. It is easy to go too far with this incision in the glans and one has to be careful at this point not to divide the glans completely. A traction suture or tiny clamp is put on each of the 2 corners of the foreskin at its distal margin and on each side of the Inidline about 15 mm. apart. The foreskin is then stretched downward so that the prepuce is a flat tongue of tissue, extending from the lower lip of the glans (fig. 1, A). An incision is made transversely across the foreskin just at the lower edge of the glans but only through the top layer of the foreskin, leaving the lower (outer) layer intact. This transverse incision is usually about 1½ to 2 cm. wide. Two vertical incisions are then made at right angles to this transverse incision, 1 at each lateral margin of the preputial flap, continuing towards the 2 distal stay sutures and usually about 2 cm. long. Again, these incisions are made through only the top layer of the prepuce. This outlines a rectangle of skin on the top surface of the foreskin, which can now be freed on 3 sides, namely the 2 lateral sides and the cephalad side of the rectangle. The upper surface of this rectangle can then be undermined and freed from the lower layer of the foreskin by blunt dissection and the resulting rectangle can be rolled into a tube (fig. 1, B). The cephalad end of this tube can then be pulled up the Inidline of the penis and anastomosed to the tubularized proximal urethra made from the original tongue of urethral tissue, which has now retracted almost back to the bladder neck as the penis assumes a pendulous position (fig. 2, A). A catheter or open sump tube of appropriate (small) size is left in the urethra or brought out suprapubically as a cystotomy to prevent any possibility of extravasation through the new anastomosis. The lateral corpora are closed together over the new urethra and the skin is closed down the dorsum of the penis, preferably in a "Z" configuration with overlapping skin flaps (fig. 2, B). In this way a pedicled tube of distal urethra is created, which is still attached to the foreskin at its tip and reaches from the tip of the penis up its center to join the tubularized intact natural or regular urethra to which it is anastomosed. In many cases there is so much skin that the tube is too long, even after creating an anastomosis free of tension. We leave the tube long and at a later stage the pedicle attachment at the tip of the penis is divided and any excess skin is trimmed away. A sound is passed to test for stricture and a urethral pressure profile can be done. DISCUSSION
This technique has a number of advantages over others that we have used to lengthen the urethra. One alternative procedure we have tried is to use a free skin graft, which is tubularized over a stent and interposed in the Inid shaft of the urethra just
544
URETHRAL LENGTHENING PROCEDURE FOR EPISPADIAS AND EXSTROPHY
B
545
'\'\
( \.
FIG. 1. A, rectangular skin flap incised on 3 sides from stretched out prepuce, B, rectangular flap is freed from lower layer of foreskin and rolled into tube.
B
FIG. 2. A, cephalad end of tube is anastomosed to proximal urethra. B, lateral corpora are closed together and skin is closed down dorsum penis.
distal to the verumontanum. This technique not only carries with it some risk of sloughing or later fibrosis and contracture of the free graft but it entails 2 anastomoses, doubling the chances of stricture or fistula. There also is the possibility of a mi.d urethral fusiform dilated segment owing to the looser nature of the interposed skin. Another technique that can be used (in older patients only) to add skin and to lengthen the dorsum of the penis is to bury the penis under a transverse bridge of upper scrotal skin, later to be freed in a second stage. This technique cannot be used in young exstrophy patients because, as we have indicated, many male exstrophy patients have an underdeveloped scrotum that does not enlarge enough to become a pendulous structure until sometime after puberty. 2 It is not wise to compromise what little scrotum these boys have while they are still young and the scrotum is still growing. In those patients who have a well developed scrotum this technique is a viable alternative. Still other techniques use Y-V incisions to lengthen the dorsal urethral strip, with resultant narrowing of the strip, or use strips of the thin, shiny skin alongside the bladder to splice out the urethra. These procedures scar the urethra more than the technique described herein. Our technique, which tubularizes the attached foreskin, per-
mits good blood supply to be maintained, minimizing the sibility of sloughing or contracture. In addition, this requires only 1 anastomosis located in the mid (straight) of the penis, thus lessening the chances of anastomotic down. It permits a more normal relocation of the meatus at the tip of the glans and slightly on its ventral surface. The urethxa is lengthened with copious viable skin, permitting the penis to drop down to a pendulous configuration free of upward or reverse chordee even during erection. The patient's own natural urethral tissues are preserved in a single unit to form a urethral segment made of the type of urethral tissue have some inherent tone and, thus, contribute to holding urine at some later date. Tubes made entirely of skin will never have this helpful elastic property and are best used for the distal portions of the reconstructed urethra. This technique has worked well for us. REFERENCES 1. Hinman, F., Jr.: A method of lengthening and repairing the penis
in exstrophy of the bladder. J. Urol., 79: 237, 1958. 2. Lattimer, J. K., Puchner, P. J., Hensle, T. W. and Macfarlane, M. T.: Delayed development of the scrotum in exstrophy. J. Urol., 121: 339, 1979.