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Construction of Urethra in Hypospadias Using Vesical Mucosal Grafts
THE JOURNAL OF UROLOGY
Vol. 73, No. 2, February 1955 Printed in U.S.A.
CONSTRCCTION OF URETHRA IN HYPOSPADIAS USING VESICAL lVfCCOSAL GRAFTS VICTOR F. MARSHALL
AND
ROBERT lVI. SPELLMAN
Front the Departrnent of Siagery (Urnlogy) of the Cornell University Medical College and the Department of Surgery (Urology), James Buchanan Brady Foundation, of the New York Hospita?, New York, N. Y.
The presentation of another technique for the construction of a new urethra in cases of hypospadias seems justified by the reasonably satisfactory results that have been obtained in twenty-six cases. The mucosa of the urinary bladder appeared to be particularly suitable material. Certainly this mucosa is plentiful, easy to obtain and, in most cases, sterile. Surely it would not produce hair, and excoriation and desquamation from exposure to the urine would not be expected. Furthermore, bladder mucosa, being soft, pliable and elastic, might remain so after transplantation. In recent times we have favored the correction of the chordee after the method described by Nesbit 1 (fig. 1). This method limits the cutaneous scar tissue on the ventral surface to a small transverse area and provides excellent correction of the curvature. In December 1947 a segment of vesical mucosa was transplanted as a free tube graft about a splinting catheter through a subciltaneous tunnel in the ventral surface of the penis (J. S. NYH No. 482181). The proximal end of the graft was anastomosed to the partially amputated hypospadiac urethra in an end-to-end manner. Urinary diversion was supplied by cystostomy. The splinting catheter was removed on the seventeenth postoperative day and the supra.pubic tube the following day. The cystostomy opening closed at once and the patient voided without difficulty from the glandular meatus, without the presence of fistula or stricture. Memmelaar 2 also found that the bladder mucosa transplanted readily as a tube into a longitudinal incision on the ventral surface of the penis. The possibility of fistulas along the body of the graft would seem to be lessened by leaving the skin and subcutaneous tissues intact over this distance rather than performing the long, trough-like incision of l\;Iemmelaar. In fact, in our twenty-six consecutive cases in which the graft has been placed through a subcutaneous tunnel, not one fistula has developed along the body of the graft (exclusive of the ends of the graft). The possibility of bone formation was brought to our attention by the work of HuggiDs 3 • 4 and Copher. 5 • 6 • 7 These workers demonstrated that a flat piece of Read at annual meeting, American Urological Association, New York, N. Y. June 3, 1954. 1 Nesbit, R. M.: Plastic procedure for correction of hypospadias. J. Urol., 45: 699-702, 1941. 2 ]VIemmelaar, J.: Use of bladder mucosa in a one-stage repair of hypospadias. J. Urol., 58: 68-73, 1947. 3 Hug;gins, C. B.: The formation of bone under the influence of epithelium of the urinary tract. Arch. Surg., 22: 377-408, 1931. 4 Huggins, C. B.: Bone and calculi in the collecting tubules of the kidney. Arch. Surg., 27: 203-215, 1933. 335
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V. F. MARSHALL AND R. M. SPELLMAN
Fm. 1. Correction of chordee. A, B, C, method of developing and perforating dorsal skin flap following excision of ventral fibrous tissue. D, approximating skin edges. Note that linear ventral scar in skin is avoided. After Nesbit.
vesical mucosa of a dog buried in connective tissue of certain locations routinely resulted in the transition of such connective tissue into actual bone. Forty-seven transplantations of free bladder mucosa were carried out by us in dogs. Fortythree of the grafts were transplanted successfully, i.e., they were "takes." Bone formation was induced only when the connective tissue was directly exposed to the mucosal surface. Actually the grafts, both here and in the human cases, consist not only of the transitional epithelium but also of some submucosa. If a tubular graft was transplanted with the transitional celled surface facing the lumen, and opening to the exterior, no bone formed in any case. Also, if a continuous cyst with the transitional celled surface inside was transplanted into a usual site for bone formation (just over the rectus sheath) no bone was found in any case. Contrariwise, if the transitional celled surface was placed on the out6 Copher, G. H. and Key, J. A.: Influence of bladder transplants on the healing of defects of bone. Arch. Surg., 29: 64--76, 1934. 6 Copher, G. H.: The influence of urinary bladder transplants on hyaline cartilage. Ann. Surg., 102: 927-939, 1935. 7 Copher, G. H.: The effect of urinary bladder transplants and extracts on the formation of bone (an experimental study). Ann. Surg. 108: 934--940, 1938.
HYPOSPADIAS
337
side of either the tube or cyst, i.e., in direct contact with the adjacent connective tissue, bone formation resulted routinely. Thus it seemed impossible that bone would form in the human so long as the mucosal surface faced the lumen and no bits of epithelium became buried against connective tissue ,vithout drainage to the exterior. 8 In twenty-six consecutive human cases in ,Yhich we have used vesical mucosal grafts for the construction of a new urethra, there has been no clinical evidence of bone formation. Encouraged by the results in the first case and supported by the findings in the animal experiments, twelve additional patients were operated on using this early technique. The patients ranged from six to thirty-seven years of age. The meatus was midshaft in two, penoscrotal in seven, and perineal in four. Three patients had had previous attempts to construct a urethra from skin. Although all grafts in this original series survived in their entirety and although no fistulas or strictures occurred along the body of the graft, the occurrence of complications at each end of the graft was not unusual. At the distal meatus four strictures occurred, but all were readily corrected by meatotomy. At the proximal end of the graft, i.e., at the juncture of the graft and the urethra, six fistulas occurred. One of these fistulas healed spontaneously within two weeks and the patient has had no other complications over the next three years (P. S. ::\:YH No. 323810). An almost microscopic fistula at the junctional area has remained unchanged over a 7-year period because the patient (C. S. NYH No. 428078) refused further treatment, having married and become a father during that time. On three patients, six surgical procedures successfully closed the fistula and these patients have now been followed for 3 years (H. W. No. 606254; R. W. No. 441552; R. W. No. 415856). The remaining patient with a fistula (R. 0. No. 430380) had the only large one at the junctional area and this resisted two premature attempts at surgical closure. Subsequently closure was accomplished by Mr. Denis Bmwne 9 using his technique. Four strictures occurred at the junctional area. One of these (M. M No. 597670) has been relieved for 3 years by one dilation under anesthesia. Another CW. M. No. 547377) has been relieved for 4 years following three dilations. A third patient with junctional stricture (W. B. Ko. 462847) has required no further therapy after two internal urethrotomies, the follow-up period now being 3 years since the last procedure. The fourth stricture occurred in a complicated case (R.H. No. 371016) in which six previous attempts to construct a urethra from the perineal meatus, using skin, had failed. Several remnants of skin tubes ·were excised at the mucosal grafting operation, but a stricture and the only diverticulum in this series developed at the junctional area. These were surgically corrected but urethral dilations have been required approximately every SL'{ to eight weeks over the succeeding four years, this being the only patient now receiving dilations. Another patient (C. K. No. 498513) had a peculiar, but fortunately transient, valve-like obstruction at the junctional area which was relieved following two apparently unrevealing endoscopic exami8 Marshall, V. F. and Spellman, R. M.: The use of bladder mucosa for the construction of a urethra in hypospadias. Scientific exhibit, Am. Ural. Ass'n., Atlantic City, 1952. 9 Browne, D.: Personal communication, 1954.
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V. F. MARSHALL AND R. M. SPELLMAN
nations. Four years later the patient has an occasional dribble but has a good stream, clear urine, and no evidence of stricture or fistula. Severe bladder spasms occurred in one patient (A. K. No. 389920) with an hysterical type of personality, so that it was necessary to make a perineal urethrostomy which is his present functioning meatus, although a mucosal-lined urethra is present from the urethrostomy to the glans. Thus, nine of the original thirteen patients now have achieved a satisfactory result. By satisfactory result is meant that the penis is straight, there are no fistulas or strictures, the meatus is at or on the glans, the urethra is without hair, the stream is good, and the urine is clear. To this group may be added the case of R. 0. whose fistula was subsequently closed by the Denis Browne procedure. Three unsatisfactory results are in the patient who will not permit closure of his minute fistula, the patient requiring dilations, and the patient currently with the urethrostomy. The follow-up period varies from three years to over seven years in these cases. Although most of the complications were fairly readily and apparently permanently overcome, it became apparent that an improved method for managing the ends of the grafts was highly desirable, since all of the difficulties had occurred either at the junctional area or at the new meatus. In the early technique the original urethra and the graft were anastomosed end-to-end and this anastomosis was situated in a potentially large dead space. Perhaps also, the graft at the anastomotic site was not sufficiently supported by immediately adjacent tissues. Furthermore, the suture line of the skin was immediately over the anastomosis, thus encouraging fistula formation. At the distal or glandular end of the graft even a slight slough at the skin edge would leave a contracting ring of fibrous tissue which might result in stricture. Bearing these considerations in mind, the following technique was devised and has now been applied in another thirteen consecutive cases. After the elapse of approximately six months from the time of chordee correction the second stage of the program is undertaken (figs. 2 and 3). The anesthetized patient is placed in a semi-lithotomy position with the buttocks elevated and slightly protruding over the end of the table. The field is prepared from
A
·... _,.. __
~--____ r_ !__ ~---~-
Fw. 2. Improved technique. A, suprapubic dissection of vesical mucosa from distended bladder wall. B, excision of mucosal and submucosal segment.
339
HYPOSP ADIAS
C
u H
Fw. 3. A and B, opening of perineum and urethral floor. C and D, excision of mucosal patch in urethral roof and removal of small patch of skin from glans. E and F, development of submucous tunnel (between corpora cavernosa and skin). G and H, graft in place with proximal edge sutured to mucosal opening previously made, D, as splinting catheter is passed into bladder. I, J, K, excising excess mucosa except that necessary for a side-toside closure. Eversion and suturing of graft on glans. L, cross section showing splint, graft, perineal closure and cystostomy tube.
above the umbilicus to well below the hypospadiac meatus. A catheter is inserted into the bladder which is distended with saline. The anterior bladder wall is exposed through the usual suprapubic incision. By sharp and blunt dissection a line of cleavage between the mucosa (with submucosa) and the muscularis is developed. This is usually easier than excising an oblong, full thickness segment
340
V. F. MARSHALL AND R. M. SPELLMAN
of the bladder wall, pinning it to a board and dissecting the mucosa and submucosa off the muscle layer. This mucosal and submucosal graft tissue has surprising strength and is quite elastic. We have always obtained more than needed by excising the estimated length required and a width of about two centimeters from the distended bladder. A cystostomy catheter is placed, the inner end of the transurethral catheter (used to distend the bladder) brought out beside it, and the wound closed in routine fashion. The graft is stabilized by pinning it with fine needles to a moistened board. A latex catheter, usually 12F for children but larger for adults, is placed over the mucosal side of the rectangular strip of tissue to be grafted. The graft is made into a tube over the catheter by loose approximation with a continuous 6-0 atraumatic chromic catgut suture. Extraneous tissue adherent to the graft and irregularities are carefully trimmed away. At all times the graft is kept moist with warm saline. A ventral midline incision of three or more centimeters is then made from the hypospadiac meatus backward through the skin, connective tissue of the perineum, and urethral floor. The inlying catheter is retracted toward the rectum, thus providing exposure of the mucosal roof of the natural urethra in its distal three or more centimeters. A circular or diamond-shaped piece of mucosa in the roof of the urethra at least one centimeter proximal to the mucocutaneous junction is then excised. The diameter of this bit of mucosa removed is intended to be slightly larger than the diameter of the splinting catheter to be used. The skin is superficially removed for a radius of five or six millimeters about the urethral dimple on the glans. A sharp-pointed blade (No. 11, Bard-Parker) on a narrow handle is introduced at the most proximal edge of the prepared opening in the roof of the urethra. The knife is carefully passed subcutaneously along the ventral surface of the penis and out through the center of the prepared area in the glans, taking care not to buttonhole the skin or pass into the corpora cavernosa. The handle of the knife is grasped with a small clamp and the latter is guided through the tunnel. The tip of the splinting catheter and the graft are grasped with this clamp and drawn through the tunnel. Any damaged bits of the end of the graft are carefully excised. The graft is grasped on its most distal or glandular end with a small clamp and the well moistened splinting catheter is pulled through this mucosal sleeve toward the bladder for fifteen or twenty centimeters. The proximal end of the splinting catheter is now held upward for exposure, so one half of the circumference of the proximal end of the graft can be approximated to the mucosal edge of the proximal aspect of the diamondshaped defect with 6-0 catgut sutures. The tip of the splinting catheter is next attached to the perineal end of the transurethral catheter and is introduced into the bladder and out the cystostomy opening by simple traction. The remaining circumference of the juncture of the graft and the urethra is then approximated. The incision in the natural urethra now appears similar to the usual external urethrostomy. The excess mucosa of this area is excised and the ventral urethral mucosa is closed over the splinting catheter with a continuous 6-0 atraumatic chromic catgut suture. The remainder of the perineal defect is closed in layers with interrupted 4-0 atraumatic chromic sutures. Both ends of the splinting
HYPO SP ADIAS
341
catheter are joined over the anterior abdominal wall and secured to the cystostomy tube. After excising excess graft at the distal glandular end, the tissue is fanned out over the prepared raw area and attached there with interrupted single sutures of 4-0 plain catgut. A saline soaked gauze is placed over the glans and kept moist for the next four to five days. No other dressings are applied except about the cystostomy wound. Penile edema which may be quite marked usually subsides by the fifth day. A mild degree of ecchymosis is common but actual hematoma formation has been rare, due no doubt to avoiding the corpora when making the subcutaneous tunnel. The cystostomy tube is kept open at all times and is only irrigated on indication. The patient is kept in bed for the first three or four days and then mobilized. Prophylactic antibiotics are administered. According to the appearance of the operative area, the splinting catheter is removed between the seventh and tenth days. After twenty-four to forty-eight hours the cystostomy tube is clamped and the patient is allowed to void. As a rule there is dysuria and often it is necessary to reopen the cystostomy tube for another 24 hours. If all is then satisfactory the cystostomy tube is removed. Many of the complications in this series, and in the earlier series, can be attributed directly to anxious early instrumentation. Occasionally the anterior meatus may require a very gentle dilation, but otherwise it is best to forego all instrumentation for at least two weeks, even to the extent of replacing the cystostomy tube if needed. After the patient is voiding well he is discharged to be followed. Excretory urograms have been routinely employed as a follmv-up procedure and often an atraumatic voiding urethrogram can be obtained after the pyelogram when concentrated intravenous media (70 per cent urokon) are used. This improved technique has now been applied to thirteen consecutive patients ranging in age from four to thirty-one years. The meatus was midshaft in one, penoscrotal in five, and perineal in seven. There was one complete failure which yielded to a repetition of the technique: J.P. (NYH No. 70035), a 31year-old white man ,vith a perineal hypospadias, had had at least twelve unsuccessful attempts to form a urethra from skin. On the third postoperative day the splinting catheter was inadvertently disturbed and presumably the graft was damaged. Eventually there was no demonstrable mucosa persisting. Two months later the procedure was repeated and the patient, for the first time, voids from a glandular meatus without a fistula. However, there is a stricture at the meatus and in spite of two meatotomies the patient dilates his urethra with a bougie as necessary to maintain a good stream. In addition to this meatal stricture there were three others, all yielding satisfactorily to one meatotomy each (A. K. No. 465673; A. C. No. 643942; and J.P. No. 673738). At the junctional area four fistulas occurred but three of these healed spontaneously within two weeks and the patients have had no further complications over the ensuing nine or more months (R. Z. No. 576878; M. G. No. 574605; and D. M. No. 644153). In the other case of fistula (D. V. No. 320001), the opening was successfully closed at the first attempt and the patient has a satisfactory result one year later. Four months after operation a small sterile abscess appeared in the perineum of one
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V. F. MARSHALL AND R. M. SPELLMAN
patient (J. H. No. 523811) which was incised and the patient has had no further complications over the succeeding year. The two poorest results were obtained on J.P. (No. 70035), whose case was just described, and in the case of a 7-yearold boy with a perineal hypospadias (F. W. No. 410788). This patient had a marked tendency to keloid formation and considerable peri-urethral thickening developed in the immediate postoperative period. The graft was instrumented during this time and there is now a 2 mm. area in the midshaft which is devoid of urethra, voiding being accomplished through a perineal urethrostomy. Surgical correction is anticipated. Four patients had no complications of any kind at any time during the immediate postoperative course and 6 patients have required no procedures of any type after the grafting operation. The patients in this series have been followed from four months to one year. We consider the results to be satisfactory at this time in 11 cases (the poor results being those in the cases of F. W. No. 410788, and J.P. No. 70035). By satisfactory is meant that the penis is straight, that there are no fistulas or strictures, the meatus is in the glans (not just short of it), the urethra is hairless, the stream is good, and the urine is clear. This latest technique appears as a definite improvement over the earlier one, most particularly at the anastomotic area. Several children in both series have passed through puberty following the procedure and, as might be expected from observing skin grafts, the new urethra has increased in size along with the rest of the organ. Particularly impressive has been the elasticity and distensibility of the new, hairless urethra. The absence of marked scarring and/or redundant longitudinal skin masses on the ventrum have been other attractive features. This technique requires time and attention to detail. It has been a distinct improvement over our previous experience with several other techniques. However, this past experience does not include the simpler appearing and currently popular procedure of Denis Browne. 1° Further improvements are, of course, desirable. SUMMARY
Free grafts of bladder mucosa have been used with reasonable success for the construction of a new urethra in cases of hypospadias. The program is planned as a two-stage procedure: correction of chordee, and construction of urethra. ,Vith one exception in 27 operations on humans the grafts survived. Nearly all complications have occurred at either end of the graft. The procedure is not surgically difficult and may be applied prior to school age. Although not ideal, the technique has represented an improvement in our experience. 10
Browne, D.: An operation for hypospadias. Proc. Roy. Soc. Med., 42: 466-468, 1949.
Vol. 73, No. 2, February 1955 Printed in U.S.A.
CONSTRCCTION OF URETHRA IN HYPOSPADIAS USING VESICAL lVfCCOSAL GRAFTS VICTOR F. MARSHALL
AND
ROBERT lVI. SPELLMAN
Front the Departrnent of Siagery (Urnlogy) of the Cornell University Medical College and the Department of Surgery (Urology), James Buchanan Brady Foundation, of the New York Hospita?, New York, N. Y.
The presentation of another technique for the construction of a new urethra in cases of hypospadias seems justified by the reasonably satisfactory results that have been obtained in twenty-six cases. The mucosa of the urinary bladder appeared to be particularly suitable material. Certainly this mucosa is plentiful, easy to obtain and, in most cases, sterile. Surely it would not produce hair, and excoriation and desquamation from exposure to the urine would not be expected. Furthermore, bladder mucosa, being soft, pliable and elastic, might remain so after transplantation. In recent times we have favored the correction of the chordee after the method described by Nesbit 1 (fig. 1). This method limits the cutaneous scar tissue on the ventral surface to a small transverse area and provides excellent correction of the curvature. In December 1947 a segment of vesical mucosa was transplanted as a free tube graft about a splinting catheter through a subciltaneous tunnel in the ventral surface of the penis (J. S. NYH No. 482181). The proximal end of the graft was anastomosed to the partially amputated hypospadiac urethra in an end-to-end manner. Urinary diversion was supplied by cystostomy. The splinting catheter was removed on the seventeenth postoperative day and the supra.pubic tube the following day. The cystostomy opening closed at once and the patient voided without difficulty from the glandular meatus, without the presence of fistula or stricture. Memmelaar 2 also found that the bladder mucosa transplanted readily as a tube into a longitudinal incision on the ventral surface of the penis. The possibility of fistulas along the body of the graft would seem to be lessened by leaving the skin and subcutaneous tissues intact over this distance rather than performing the long, trough-like incision of l\;Iemmelaar. In fact, in our twenty-six consecutive cases in which the graft has been placed through a subcutaneous tunnel, not one fistula has developed along the body of the graft (exclusive of the ends of the graft). The possibility of bone formation was brought to our attention by the work of HuggiDs 3 • 4 and Copher. 5 • 6 • 7 These workers demonstrated that a flat piece of Read at annual meeting, American Urological Association, New York, N. Y. June 3, 1954. 1 Nesbit, R. M.: Plastic procedure for correction of hypospadias. J. Urol., 45: 699-702, 1941. 2 ]VIemmelaar, J.: Use of bladder mucosa in a one-stage repair of hypospadias. J. Urol., 58: 68-73, 1947. 3 Hug;gins, C. B.: The formation of bone under the influence of epithelium of the urinary tract. Arch. Surg., 22: 377-408, 1931. 4 Huggins, C. B.: Bone and calculi in the collecting tubules of the kidney. Arch. Surg., 27: 203-215, 1933. 335
336
V. F. MARSHALL AND R. M. SPELLMAN
Fm. 1. Correction of chordee. A, B, C, method of developing and perforating dorsal skin flap following excision of ventral fibrous tissue. D, approximating skin edges. Note that linear ventral scar in skin is avoided. After Nesbit.
vesical mucosa of a dog buried in connective tissue of certain locations routinely resulted in the transition of such connective tissue into actual bone. Forty-seven transplantations of free bladder mucosa were carried out by us in dogs. Fortythree of the grafts were transplanted successfully, i.e., they were "takes." Bone formation was induced only when the connective tissue was directly exposed to the mucosal surface. Actually the grafts, both here and in the human cases, consist not only of the transitional epithelium but also of some submucosa. If a tubular graft was transplanted with the transitional celled surface facing the lumen, and opening to the exterior, no bone formed in any case. Also, if a continuous cyst with the transitional celled surface inside was transplanted into a usual site for bone formation (just over the rectus sheath) no bone was found in any case. Contrariwise, if the transitional celled surface was placed on the out6 Copher, G. H. and Key, J. A.: Influence of bladder transplants on the healing of defects of bone. Arch. Surg., 29: 64--76, 1934. 6 Copher, G. H.: The influence of urinary bladder transplants on hyaline cartilage. Ann. Surg., 102: 927-939, 1935. 7 Copher, G. H.: The effect of urinary bladder transplants and extracts on the formation of bone (an experimental study). Ann. Surg. 108: 934--940, 1938.
HYPOSPADIAS
337
side of either the tube or cyst, i.e., in direct contact with the adjacent connective tissue, bone formation resulted routinely. Thus it seemed impossible that bone would form in the human so long as the mucosal surface faced the lumen and no bits of epithelium became buried against connective tissue ,vithout drainage to the exterior. 8 In twenty-six consecutive human cases in ,Yhich we have used vesical mucosal grafts for the construction of a new urethra, there has been no clinical evidence of bone formation. Encouraged by the results in the first case and supported by the findings in the animal experiments, twelve additional patients were operated on using this early technique. The patients ranged from six to thirty-seven years of age. The meatus was midshaft in two, penoscrotal in seven, and perineal in four. Three patients had had previous attempts to construct a urethra from skin. Although all grafts in this original series survived in their entirety and although no fistulas or strictures occurred along the body of the graft, the occurrence of complications at each end of the graft was not unusual. At the distal meatus four strictures occurred, but all were readily corrected by meatotomy. At the proximal end of the graft, i.e., at the juncture of the graft and the urethra, six fistulas occurred. One of these fistulas healed spontaneously within two weeks and the patient has had no other complications over the next three years (P. S. ::\:YH No. 323810). An almost microscopic fistula at the junctional area has remained unchanged over a 7-year period because the patient (C. S. NYH No. 428078) refused further treatment, having married and become a father during that time. On three patients, six surgical procedures successfully closed the fistula and these patients have now been followed for 3 years (H. W. No. 606254; R. W. No. 441552; R. W. No. 415856). The remaining patient with a fistula (R. 0. No. 430380) had the only large one at the junctional area and this resisted two premature attempts at surgical closure. Subsequently closure was accomplished by Mr. Denis Bmwne 9 using his technique. Four strictures occurred at the junctional area. One of these (M. M No. 597670) has been relieved for 3 years by one dilation under anesthesia. Another CW. M. No. 547377) has been relieved for 4 years following three dilations. A third patient with junctional stricture (W. B. Ko. 462847) has required no further therapy after two internal urethrotomies, the follow-up period now being 3 years since the last procedure. The fourth stricture occurred in a complicated case (R.H. No. 371016) in which six previous attempts to construct a urethra from the perineal meatus, using skin, had failed. Several remnants of skin tubes ·were excised at the mucosal grafting operation, but a stricture and the only diverticulum in this series developed at the junctional area. These were surgically corrected but urethral dilations have been required approximately every SL'{ to eight weeks over the succeeding four years, this being the only patient now receiving dilations. Another patient (C. K. No. 498513) had a peculiar, but fortunately transient, valve-like obstruction at the junctional area which was relieved following two apparently unrevealing endoscopic exami8 Marshall, V. F. and Spellman, R. M.: The use of bladder mucosa for the construction of a urethra in hypospadias. Scientific exhibit, Am. Ural. Ass'n., Atlantic City, 1952. 9 Browne, D.: Personal communication, 1954.
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V. F. MARSHALL AND R. M. SPELLMAN
nations. Four years later the patient has an occasional dribble but has a good stream, clear urine, and no evidence of stricture or fistula. Severe bladder spasms occurred in one patient (A. K. No. 389920) with an hysterical type of personality, so that it was necessary to make a perineal urethrostomy which is his present functioning meatus, although a mucosal-lined urethra is present from the urethrostomy to the glans. Thus, nine of the original thirteen patients now have achieved a satisfactory result. By satisfactory result is meant that the penis is straight, there are no fistulas or strictures, the meatus is at or on the glans, the urethra is without hair, the stream is good, and the urine is clear. To this group may be added the case of R. 0. whose fistula was subsequently closed by the Denis Browne procedure. Three unsatisfactory results are in the patient who will not permit closure of his minute fistula, the patient requiring dilations, and the patient currently with the urethrostomy. The follow-up period varies from three years to over seven years in these cases. Although most of the complications were fairly readily and apparently permanently overcome, it became apparent that an improved method for managing the ends of the grafts was highly desirable, since all of the difficulties had occurred either at the junctional area or at the new meatus. In the early technique the original urethra and the graft were anastomosed end-to-end and this anastomosis was situated in a potentially large dead space. Perhaps also, the graft at the anastomotic site was not sufficiently supported by immediately adjacent tissues. Furthermore, the suture line of the skin was immediately over the anastomosis, thus encouraging fistula formation. At the distal or glandular end of the graft even a slight slough at the skin edge would leave a contracting ring of fibrous tissue which might result in stricture. Bearing these considerations in mind, the following technique was devised and has now been applied in another thirteen consecutive cases. After the elapse of approximately six months from the time of chordee correction the second stage of the program is undertaken (figs. 2 and 3). The anesthetized patient is placed in a semi-lithotomy position with the buttocks elevated and slightly protruding over the end of the table. The field is prepared from
A
·... _,.. __
~--____ r_ !__ ~---~-
Fw. 2. Improved technique. A, suprapubic dissection of vesical mucosa from distended bladder wall. B, excision of mucosal and submucosal segment.
339
HYPOSP ADIAS
C
u H
Fw. 3. A and B, opening of perineum and urethral floor. C and D, excision of mucosal patch in urethral roof and removal of small patch of skin from glans. E and F, development of submucous tunnel (between corpora cavernosa and skin). G and H, graft in place with proximal edge sutured to mucosal opening previously made, D, as splinting catheter is passed into bladder. I, J, K, excising excess mucosa except that necessary for a side-toside closure. Eversion and suturing of graft on glans. L, cross section showing splint, graft, perineal closure and cystostomy tube.
above the umbilicus to well below the hypospadiac meatus. A catheter is inserted into the bladder which is distended with saline. The anterior bladder wall is exposed through the usual suprapubic incision. By sharp and blunt dissection a line of cleavage between the mucosa (with submucosa) and the muscularis is developed. This is usually easier than excising an oblong, full thickness segment
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of the bladder wall, pinning it to a board and dissecting the mucosa and submucosa off the muscle layer. This mucosal and submucosal graft tissue has surprising strength and is quite elastic. We have always obtained more than needed by excising the estimated length required and a width of about two centimeters from the distended bladder. A cystostomy catheter is placed, the inner end of the transurethral catheter (used to distend the bladder) brought out beside it, and the wound closed in routine fashion. The graft is stabilized by pinning it with fine needles to a moistened board. A latex catheter, usually 12F for children but larger for adults, is placed over the mucosal side of the rectangular strip of tissue to be grafted. The graft is made into a tube over the catheter by loose approximation with a continuous 6-0 atraumatic chromic catgut suture. Extraneous tissue adherent to the graft and irregularities are carefully trimmed away. At all times the graft is kept moist with warm saline. A ventral midline incision of three or more centimeters is then made from the hypospadiac meatus backward through the skin, connective tissue of the perineum, and urethral floor. The inlying catheter is retracted toward the rectum, thus providing exposure of the mucosal roof of the natural urethra in its distal three or more centimeters. A circular or diamond-shaped piece of mucosa in the roof of the urethra at least one centimeter proximal to the mucocutaneous junction is then excised. The diameter of this bit of mucosa removed is intended to be slightly larger than the diameter of the splinting catheter to be used. The skin is superficially removed for a radius of five or six millimeters about the urethral dimple on the glans. A sharp-pointed blade (No. 11, Bard-Parker) on a narrow handle is introduced at the most proximal edge of the prepared opening in the roof of the urethra. The knife is carefully passed subcutaneously along the ventral surface of the penis and out through the center of the prepared area in the glans, taking care not to buttonhole the skin or pass into the corpora cavernosa. The handle of the knife is grasped with a small clamp and the latter is guided through the tunnel. The tip of the splinting catheter and the graft are grasped with this clamp and drawn through the tunnel. Any damaged bits of the end of the graft are carefully excised. The graft is grasped on its most distal or glandular end with a small clamp and the well moistened splinting catheter is pulled through this mucosal sleeve toward the bladder for fifteen or twenty centimeters. The proximal end of the splinting catheter is now held upward for exposure, so one half of the circumference of the proximal end of the graft can be approximated to the mucosal edge of the proximal aspect of the diamondshaped defect with 6-0 catgut sutures. The tip of the splinting catheter is next attached to the perineal end of the transurethral catheter and is introduced into the bladder and out the cystostomy opening by simple traction. The remaining circumference of the juncture of the graft and the urethra is then approximated. The incision in the natural urethra now appears similar to the usual external urethrostomy. The excess mucosa of this area is excised and the ventral urethral mucosa is closed over the splinting catheter with a continuous 6-0 atraumatic chromic catgut suture. The remainder of the perineal defect is closed in layers with interrupted 4-0 atraumatic chromic sutures. Both ends of the splinting
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catheter are joined over the anterior abdominal wall and secured to the cystostomy tube. After excising excess graft at the distal glandular end, the tissue is fanned out over the prepared raw area and attached there with interrupted single sutures of 4-0 plain catgut. A saline soaked gauze is placed over the glans and kept moist for the next four to five days. No other dressings are applied except about the cystostomy wound. Penile edema which may be quite marked usually subsides by the fifth day. A mild degree of ecchymosis is common but actual hematoma formation has been rare, due no doubt to avoiding the corpora when making the subcutaneous tunnel. The cystostomy tube is kept open at all times and is only irrigated on indication. The patient is kept in bed for the first three or four days and then mobilized. Prophylactic antibiotics are administered. According to the appearance of the operative area, the splinting catheter is removed between the seventh and tenth days. After twenty-four to forty-eight hours the cystostomy tube is clamped and the patient is allowed to void. As a rule there is dysuria and often it is necessary to reopen the cystostomy tube for another 24 hours. If all is then satisfactory the cystostomy tube is removed. Many of the complications in this series, and in the earlier series, can be attributed directly to anxious early instrumentation. Occasionally the anterior meatus may require a very gentle dilation, but otherwise it is best to forego all instrumentation for at least two weeks, even to the extent of replacing the cystostomy tube if needed. After the patient is voiding well he is discharged to be followed. Excretory urograms have been routinely employed as a follmv-up procedure and often an atraumatic voiding urethrogram can be obtained after the pyelogram when concentrated intravenous media (70 per cent urokon) are used. This improved technique has now been applied to thirteen consecutive patients ranging in age from four to thirty-one years. The meatus was midshaft in one, penoscrotal in five, and perineal in seven. There was one complete failure which yielded to a repetition of the technique: J.P. (NYH No. 70035), a 31year-old white man ,vith a perineal hypospadias, had had at least twelve unsuccessful attempts to form a urethra from skin. On the third postoperative day the splinting catheter was inadvertently disturbed and presumably the graft was damaged. Eventually there was no demonstrable mucosa persisting. Two months later the procedure was repeated and the patient, for the first time, voids from a glandular meatus without a fistula. However, there is a stricture at the meatus and in spite of two meatotomies the patient dilates his urethra with a bougie as necessary to maintain a good stream. In addition to this meatal stricture there were three others, all yielding satisfactorily to one meatotomy each (A. K. No. 465673; A. C. No. 643942; and J.P. No. 673738). At the junctional area four fistulas occurred but three of these healed spontaneously within two weeks and the patients have had no further complications over the ensuing nine or more months (R. Z. No. 576878; M. G. No. 574605; and D. M. No. 644153). In the other case of fistula (D. V. No. 320001), the opening was successfully closed at the first attempt and the patient has a satisfactory result one year later. Four months after operation a small sterile abscess appeared in the perineum of one
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patient (J. H. No. 523811) which was incised and the patient has had no further complications over the succeeding year. The two poorest results were obtained on J.P. (No. 70035), whose case was just described, and in the case of a 7-yearold boy with a perineal hypospadias (F. W. No. 410788). This patient had a marked tendency to keloid formation and considerable peri-urethral thickening developed in the immediate postoperative period. The graft was instrumented during this time and there is now a 2 mm. area in the midshaft which is devoid of urethra, voiding being accomplished through a perineal urethrostomy. Surgical correction is anticipated. Four patients had no complications of any kind at any time during the immediate postoperative course and 6 patients have required no procedures of any type after the grafting operation. The patients in this series have been followed from four months to one year. We consider the results to be satisfactory at this time in 11 cases (the poor results being those in the cases of F. W. No. 410788, and J.P. No. 70035). By satisfactory is meant that the penis is straight, that there are no fistulas or strictures, the meatus is in the glans (not just short of it), the urethra is hairless, the stream is good, and the urine is clear. This latest technique appears as a definite improvement over the earlier one, most particularly at the anastomotic area. Several children in both series have passed through puberty following the procedure and, as might be expected from observing skin grafts, the new urethra has increased in size along with the rest of the organ. Particularly impressive has been the elasticity and distensibility of the new, hairless urethra. The absence of marked scarring and/or redundant longitudinal skin masses on the ventrum have been other attractive features. This technique requires time and attention to detail. It has been a distinct improvement over our previous experience with several other techniques. However, this past experience does not include the simpler appearing and currently popular procedure of Denis Browne. 1° Further improvements are, of course, desirable. SUMMARY
Free grafts of bladder mucosa have been used with reasonable success for the construction of a new urethra in cases of hypospadias. The program is planned as a two-stage procedure: correction of chordee, and construction of urethra. ,Vith one exception in 27 operations on humans the grafts survived. Nearly all complications have occurred at either end of the graft. The procedure is not surgically difficult and may be applied prior to school age. Although not ideal, the technique has represented an improvement in our experience. 10
Browne, D.: An operation for hypospadias. Proc. Roy. Soc. Med., 42: 466-468, 1949.