Byars two-stage procedure for hypospadias after urethral plate transection

Accepted Manuscript Byars two-stage procedure for hypospadias after urethral plate transection T. Yang , Y. Zou , L. Zhang , C. Su , Z. Li , Y. Wen PII:

S1477-5131(14)00149-1

DOI:

10.1016/j.jpurol.2014.05.002

Reference:

JPUROL 1705

To appear in:

Journal of Pediatric Urology

Received Date: 11 December 2013 Accepted Date: 15 May 2014

Please cite this article as: Yang T, Zou Y, Zhang L, Su C, Li Z, Wen Y, Byars two-stage procedure for hypospadias after urethral plate transection, Journal of Pediatric Urology (2014), doi: 10.1016/ j.jpurol.2014.05.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Byars two-stage procedure for hypospadias after urethral plate transection

Authors:

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T. Yanga, Y. Zoua, L. Zhanga, C. Sub, Z. Lia, Y. Wena

Affiliations: a

Guangzhou Women and Children’s Medical Center, Affiliated Women and Children's

Medical Center of Guangzhou Medical University, Guangzhou, China.

First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.

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Emails:

Corresponding author: Tianyou Yang

Department of Pediatric Surgery, Guangzhou Women and Children’s Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University,

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Guangzhou, China.

No: 9 Jinsui Road, Tianhe District, Guangzhou, 510623, China.

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Tel: +86-20-81886332

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Fax: +86-20-81886332.

E-mail: [email protected]

ACCEPTED MANUSCRIPT Summary Objective: To report on the outcomes of primary hypospadias repaired with the Byars two-stage procedure.

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Materials and Methods: Primary hypospadias repairs with the Byars two-stage procedure, between 2009 and 2012, were retrospectively reviewed. Medical charts were reviewed and analyzed. Follow up was at two weeks, three months, six months

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and one year after surgery. Complications, which included fistula, glans dehiscence,

were documented and analyzed.

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meatal stenosis, urethral stricture, diverticulum, recurrent penile curvature and others,

Results: One hundred and twenty-eight cases were included in the present study. The median follow up was 30 months (range 13 to 44 months). All flaps took successfully

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after the first stage. Overall complication rates were 11.8%. Complications included: seven cases of fistula; five glans dehiscence; two urethral strictures, which developed

recorded.

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after fistula repair; and one concealed penis. No recurrent penile curvature was

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Conclusions: The Byars two-stage procedure is an option for primary hypospadias when the urethral plate is transected. It had an 11.8% complication rate in this present study.

Keywords:

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ACCEPTED MANUSCRIPT Introduction The mainstay of hypospadias repair is to preserve the urethral plate and use it for urethral reconstruction. One-stage flaps and grafts, and two-stage flaps and grafts can

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be used to reconstruct the urethra if the urethral plate cannot be preserved [1-3]. The present study reports on the outcomes of a tertiary institution’s experiences with the Byars two-stage procedure for the repair of primary hypospadias after urethral plate

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transection. The Institutional Review Board of Guangzhou Women and Children’s

Materials and Methods

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Medical Center (Guangzhou, China) approved the present study.

People with primary hypospadias, who underwent a Byars two-stage repair after

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urethral plate transection by three experienced surgeons between 2009 and 2012, were identified. Medical charts were thoroughly reviewed and analyzed. Intraoperatively, all patients underwent a similar approach, which preserved the urethral plate for

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tubularized incised plate (TIP) or onlay preputial flap repair, unless urethral plate

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transection was performed to correct ventral penile curvature. The anatomical distribution of the hypospadiac meatus before degloving was progressively more severe in this patient cohort (Table 1).

Surgical procedure The first stage of the procedure begins with release of the preputial skin, which helps to correct some of the chordee. A U-shaped incision is made, extending along the edges of

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ACCEPTED MANUSCRIPT the urethral plate to healthy skin 2 mm proximal to the meatus, and then extended circumferentially around the coronal sulcus; the penile shaft is then completely degloved. If penile curvature remains, the urethral plate is transected and divided

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ventrally below the glans, midway between the tip of the glans and the urethral meatus. This then allows for thorough dissection of the distal spongiosum, which exposes the corpora on the ventral aspect of the penis. Further or persistent chordee is corrected by

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multiple transverse corporotomies (fairy cuts). Multiple transverse corporotomies

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include an incision at the point of the greatest curvature with another parallel incision. These incisions extend through the tunica albuginea without intentionally exposing the erectile tissue. Continuous bleeding may be encountered; electric cautery coagulation or interrupted suture can be used to stop bleeding. Once the penile curvature is

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completely corrected, the glans is prepared. The glans is divided deeply in the midline to the tip; following this midline split the glans is dissected laterally off the dome of the corpora cavernosum so that it is open like a book. The dorsal foreskin is unfolded and

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divided in the midline. The most-distal portion of the inner prepuce is rotated into the

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glanular cleft and sutured to the mucosa of the glans by interrupted stitches with 6-0 absorbable suture (Monosyn, Braun, Germany). A midline closure is then performed; the midline closures catch a small portion of the underlying tissue. This eliminates dead space and helps to create a groove in the preparation for the second stage. The preputial skin should be preserved as much as possible at this stage. The bladder is drained with a 6Fr/8Fr Foley catheter. Vaseline gauze dressing is placed around the penile shaft and the penis is wrapped with multiple layers of gauze to achieve uniform compression

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ACCEPTED MANUSCRIPT along the shaft. The second stage of the procedure is usually carried out six months later when complete healing has occurred (Fig. 1). A 6-0 absorbable suture (Monosyn) is placed

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through the tip of the glans as a traction suture. Incision lines are marked, designing a 12 to 15 mm-wide strip that extends from the ectopic meatus up to the six o’clock points of the proposed new meatus. The two wings of the glans are dissected laterally

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off the dome of the corpora cavernosum; extended dissection may be needed to achieve

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a tension-free approximation. In some cases, a midline incision of the grafted urethral plate may be needed to increase the diameter. A 6Fr/8Fr Foley catheter is inserted. An additional 6Fr feeding tube, prepared with several small lateral incisions, is inserted just into the native urethra to act as a drainage tube for the neourethra; its distal end is

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tied to the urinary catheter (Fig. 2). The strip is tubularized with 6-0 absorbable suture (Monosyn), by using an extraluminal inverting continuous method, reinforced with a few interrupted sutures. The penis is then degloved at the level of Buck’s fascia. A

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protective dartos fascia flap is placed over the entire suture line as a waterproofing layer.

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The dartos flap is taken from the adjacent penile skin or the scrotum. The glans spongiosum is reconstructed with 6-0 absorbable sutures (Monosyn), thereby completing closure of the glans wings below the meatus. Glansplasty is performed in two layers, the first is subepithelial and the second approximates the epithelium. Two or three stitches from the neomeatus to the corona are usually needed for glansplasty, depending on the size of the glans (Fig. 3). Glans epithelium and penile skin are sutured using simple interrupted 6-0 absorbable sutures. In rare cases of shortage of penile skin,

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ACCEPTED MANUSCRIPT part of the scrotal skin can be mobilized and advanced to cover the penile shaft. Pressure dressing is applied in a similar fashion to the first stage. The feeding tube remains in situ for three days to facilitate the drainage of the surgical wound. Urinary

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diversion is usually maintained for about two weeks. Patients had regular follow up in the clinic at two weeks, three months, six months and one year after surgery. Complications, including fistula, glans dehiscence, meatal

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stenosis, urethral stricture, diverticulum, recurrent penile curvature and others, were

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documented. Glans dehiscence was defined as a neourethral opening to the corona or more proximally (not glanular meatus). Meatal stenosis was a narrowing of the opening of the urethra at the external meatus. Ballooning of the urethra while voiding evidenced urethral diverticulum. Recurrent penile curvature was assessed by parental-reported

Results

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observation of the erect penis.

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One hundred and twenty-eight cases of primary hypospadias were included in this

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study. The median age at the first stage was 29 months (range 10 to 90 months) and 39 months (range 18 to 100 months) at the second stage. The median follow up was 30 months (range 13 to 44 months). Postoperative appearances after Stage II are shown in Figs 4 to 6.

Byars flaps were used in all 128 patients; all flaps took successfully after the first stage and no revisional surgery was required. There were 15 cases of complications in 13 patients, including: seven cases of fistula; five of glans dehiscence; two of urethral

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ACCEPTED MANUSCRIPT stricture, which developed after fistula repair; and one of concealed penis. Overall complication rates were 11.8% (Table 2). No recurrent penile curvature was recorded.

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Discussion The management of primary severe hypospadias remains challenging and disputable. Castagnetti’s opinion [4] on the management of primary severe hypospadias can be

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agreed with. If the urethral plate has been preserved, the two most popular alternatives

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for urethroplasty are TIP and onlay preputial flap repair. If the urethral plate has been transected, one-stage flaps and grafts, and two-stage flaps and grafts can be used to reconstruct the urethra. However, no consensus has been reached about when to transect the urethral plate. All patients in the present study underwent a similar

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intraoperative approach, whereby the urethral plate was preserved unless transection was performed to straighten penis. The Byars two-stage procedure was regularly performed after urethral plate transection.

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The reported overall complication rates of the two-stage procedure with free graft for

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primary severe hypospadias were between 12.3% and 18% [5,6]. The overall complication rates after the Byars two-stage procedure in this cohort were 11.8%, which was no less than the two-stage procedure with free graft. Three experienced surgeons, who had specialized in pediatric urology for more than 10 years, performed all surgeries in the present study. The experience of surgeon is considered to be an important factor, which can significantly influence the success rate of hypospadias repair; low surgeon-volume independently increases the risk of fistula, stricture or

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ACCEPTED MANUSCRIPT diverticulum development [7-9]. Proficiency and experience may be one of the important factors that contributed to the high success rates in the present study. Fistula was the most-common complication in this cohort (5.5%). However, Wray et

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al. [10] reported a rate of 22% for fistula formation after the Byars two-stage procedure. In this study, hypospadias were repaired by a considerable number of residents and attending surgeons during four decades [10]. The different experience of the surgeons

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may influence the success rate of hypospadias repair, which may also explain the

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different fistula formation rate between these two studies. Moreover, in the present study, a dartos fascia flap was mobilized and placed over the neourethra as a waterproofing layer, which can significantly decrease fistula formation [11]. Additionally, a feeding tube was used to further drain the surgical wound, as keeping

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the suture lines dry in the early postoperative period is generally considered to be a key factor for appropriate healing [11]. However, no control study was conducted to prove the use of an additional feeding tube.

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Glans dehiscence occurred in 3.9% of patients, which was similar to the 5%

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occurrence rate after the Bracka two-stage procedure [12]. In the present study, urethral stricture was another concern, especially for those who had been incised in the grafted urethral plate. However, only two patients developed urethral stricture after fistula repair. Urethral stricture most commonly occurs at the level of the original meatus. Creation of an end-to-end anastomosis is considered to be a predisposing factor, which is already avoided in the Byars two-stage procedure. Surprisingly, no meatal stenosis and diverticulum were documented in the present study. Prevention of meatal stenosis

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ACCEPTED MANUSCRIPT can be achieved by generously incising ventrally and laterally along both sides of the site proposed for neourethral formation. Diverticulum may be caused by distal obstruction or poor support of the reconstructed urethra. A causal association between

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distal stricture and diverticula has been previously proposed [13-15], which may explain why there were no diverticula in the present study, as no meatal stenosis developed.

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Penile curvature resulting from chordee could be challenging for hypospadias repair.

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Currently, there is no consensus as to how chordee should be managed. In the past, many surgeons have believed that the urethral plate does not often contribute to chordee, however, as the severity of curvature increased, division of the urethral plate became the most-common intervention and the ventral approach seemed to be useful in

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more-severe chordee [16,17]. In this cohort, persistent penile curvature after degloving was approached ventrally, including transection of the urethral plate and fairy cuts. Snodgrass et al. [18] also reported on the effectiveness of multiple transverse incisions

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without graft to correct penile curvature > 30 after penile degloving. Unfortunately, no

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specific data regarding the degree of penile curvature corrected by fairy cut was recorded in the present study’s reviewed charts. Dorsal plication was not necessary after fairy cuts and was not performed in the present study. No recurrent penile curvature was observed during short-term follow up in this cohort. Abnormal spraying streams can be seen after both one-stage and two-stage techniques [2]. Lam et al. [14] report that 40% of patients who underwent two-stage repair had minor spraying of stream after puberty, but all stood to void. Unfortunately,

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ACCEPTED MANUSCRIPT no such complete information was documented in this retrospective study, but definitely needs to be addressed in future follow up. Quantitative data regarding penile curvature before and after fairy cut was not recorded in the reviewed charts and the

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long-term consequences of fairy cuts were not available. Moreover, the objective assessment of cosmetic and functional outcomes was not available. Further

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investigation and long-term follow up is therefore needed.

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Conclusions

The Byars two-stage procedure is an option for primary hypospadias when the urethral plate is transected. In the present study it had a complication rate of 11.8%. However,

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long-term follow up is needed to address the consequences beyond puberty.

Acknowledgements The authors’ declare that the submitted manuscript does not contain previously

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ACCEPTED MANUSCRIPT published material, and are not under consideration for publication elsewhere. Each author has made an important scientific contribution to the study and is thoroughly familiar with the primary data. All authors listed have read the complete manuscript

without fabrication, fraud or plagiarism.

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Conflict of Interest

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and have approved submission of the paper. The manuscript is truthful original work

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None declared.

References [1] Springer A, Krois W, Horcher E. Trends in hypospadias surgery: results of a

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ACCEPTED MANUSCRIPT worldwide survey. Eur Urol. 2011;60(6):1184-89. [2] Gershbaum MD, Stock JA, Hanna MK. A case for 2-stage repair of perineoscrotal hypospadias with severe chordee. J Urol. 2002;168(4 Pt 2):1727-28; discussion 1729.

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[3] Tan YW, Patel N, Scarlett A, Clibbon J, Kulkarni M, Mathur A. Bracka's staged repair of proximal hypospadias--revisiting a versatile technique. J Pediatr Urol. 2012;8(1):108, 108e1.

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[4] Castagnetti M, El-Ghoneimi A. Surgical management of primary severe

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hypospadias in children: systematic 20-year review. J Urol. 2010;184(4):1469-74. [5] Johal NS, Nitkunan T, O'Malley K, Cuckow PM. The two-stage repair for severe primary hypospadias. Eur Urol. 2006;50(2):366-71.

[6] Price RD, Lambe GF, Jones RP. Two-stage hypospadias repair: audit in a district

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general hospital. Br J Plast Surg. 2003;56(8):752-58.

[7] Chrzan R, Dik P, Klijn AJ, de Jong TP. Quality assessment of hypospadias repair with emphasis on techniques used and experience of pediatric urologic surgeons.

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Urology. 2007;70(1):148-52.

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[8] Horowitz M, Salzhauer E. The 'learning curve' in hypospadias surgery. BJU Int. 2006;97(3):593-96.

[9] Frimberger D, Campbell J, Kropp BP. Hypospadias outcome in the first 3 years after completing a pediatric urology fellowship. J Pediatr Urol. 2008;4(4):270-74. [10] Wray RC Jr, Ribaudo JM, Weeks PM. The Byars hypospadias repair. A review of 253 consecutive patients. Plast Reconstr Surg. 1976;58(3):329-31. [11] Castagnetti M, El-Ghoneimi A. The influence of perioperative factors on primary

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ACCEPTED MANUSCRIPT severe hypospadias repair. Nat Rev Urol. 2011;8(4):198-206. [12] Johal NS, Nitkunan T, O'Malley K, Cuckow PM. The two-stage repair for severe primary hypospadias. Eur Urol. 2006;50(2):366-71.

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[13] Retik AB, Atala A. Complications of hypospadias repair. Urol Clin North Am. 2002;29(2):329-39.

[14] Lam PN, Greenfield SP, Williot P. 2-stage repair in infancy for severe hypospadias

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with chordee: long-term results after puberty. J Urol. 2005;174(4 Pt 2):1567-72;

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discussion 1572.

[15] Snyder CL, Evangelidis A, Snyder RP, Ostlie DJ, Gatti JM, Murphy JP. Management of urethral diverticulum complicating hypospadias repair. J Pediatr Urol. 2005;1(2):81-3.

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[16] Bologna RA, Noah TA, Nasrallah PF, McMahon DR. Chordee: varied opinions and treatments as documented in a survey of the American Academy of Pediatrics, Section of Urology. Urology. 1999;53(3):608-12.

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[17] Steven L, Cherian A, Yankovic F, Mathur A, Kulkarni M, Cuckow P. Current

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practice in paediatric hypospadias surgery; a specialist survey. J Pediatr Urol. 2013;9(6 Pt B):1126-30.

[18] Snodgrass W, Prieto J. Straightening ventral curvature while preserving the urethral plate in proximal hypospadias repair. J Urol. 2009;182(4 Suppl):1720-25.

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ACCEPTED MANUSCRIPT Figure legends Fig. 1: Appearance after Stage I. Fig. 2: The feeding tube just enters the native urethra.

Fig. 4: Postoperative appearance, two weeks after Stage II. Fig. 5: Postoperative appearance, six months after Stage II.

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Fig. 6: Postoperative appearance, one year after Stage II.

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Fig. 3: The ventral aspect of the penis after glansplasty.

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ACCEPTED MANUSCRIPT Table 1: Anatomical location of the hypospadiac meatus before chordee correction Number of patients (%) －

Coronal

5 (3.9%)

Penile shaft

8 (6.3%)

Penoscrotal

97 (75.8%)

Perineal

18 (14.0%)

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Glanular

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Location

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ACCEPTED MANUSCRIPT Table 2: Complications encountered after the second stage. Number of patients (%)

Fistula

7 (5.5%)

Glans dehiscence

5 (3.9%)

Urethral stricture

2 (1.6%)

Concealed penis

1 (0.8%)

Total complications

15 (11.8%)

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Complications

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