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Crawford Modification of Denis Browne Hypospadias Procedure
Vol. 117, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
Pediatric Article CRAWFORD MODIFICATION OF DENIS BROWNE HYPOSPADIAS PROCEDURE WILLIAM J. YARBROUGH*
AND
J. H. JOHNSTON
From the Department of Urology, Alder Hey Children's Hospital, Liverpool, England, and the Department of Urology, George Washington University Medical Center, Washington, D. C.
ABSTRACT
At Alder Hey Children's Hospital 96 hypospadias repairs were performed from 1969 to 1975, using the Crawford modification of the Denis Browne procedure. The technique is described in detail. A 7 .29 per cent fistula rate occurred in 69 distal penile, 18 penile, 8 penoscrotal and 1 perineal repairs. The advantageous difference between the Crawford modification and the original description of Denis Browne is that the meatus is placed well onto the glans penis. Hypospadias occurs in approximately 1 of 300 male births. Hypospadias is classified as glandular, distal penile, proximal penile, penoscrotal and perineal. There have been many types of single and multiple stage repairs described previously. Urologists performing infrequent hypospadias surgery may have fewer complications using a multistaged procedure. A multistaged procedure adaptable to all types ofhypospadias is the Crawford modification of the Denis Browne repair. 1 • 2 The technique and results of 96 hypospadias repairs, using the Crawford modification of the Denis Browne procedure at Alder Hey Children's Hospital, are described herein.
over the skin strip with a continuous 5-zero prolene suture. The skin is approximated with interrupted 5-zero prolene sutures (fig. 3, C). An adequate dorsal relaxing incision is made to relieve the tension from the suture line (fig. 3, D). A dressing soaked in friars' balsam is then applied. The sutures
TECHNIQUE
When the child is about 1½ to 2 years old he is hospitalized for the operation. A transverse incision is made just proximal to the glans on the ventral aspect of the penis (fig. 1, A). The chordee is excised completely and the incision is closed longitudinally with 5-zero dexon (fig. 1, B and C). A generous dorsal slit of the prepuce is performed (fig. 2, A). The dorsal slit is closed transversely with 5-zero dexon (fig. 2, B). The 2 wings of prepuce, thus, are formed and brought around their perspective sides of the glans penis to the ventral surface. A triangular-shaped wedge is removed from the glans on either side of where the new urethra will be formed. The incision is carried from the glans onto the adjacent preputial wings, removing a triangle of prepuce to form a diamond with the contiguous triangular area of the glans (fig. 2, C). The apex of the wing is sutured to the apex of the respective glandular segment (fig. 2, D). Several 5-zero dexon sutures are used to approximate the preputial wings to the glans penis. The second stage is performed in 6 to 12 months. First a perineal urethrostomy is performed. A long U-shaped incision is made around a 1 cm. median skin strip on the ventral surface of the penis, extending from the tip of the preputial wing that was sutured to the glans during the first stage. This is continued to and around the present meatus and to the top of the preputial wing on the opposite side (fig. 3, A). The lateral penile skin is undermined widely (fig. 3, B). The median skin strip is not undermined. The subcutaneous tissue is closed Accepted for publication July 9, 1976. Read at annual meeting of American Urological Association, Las Vegas, Nevada, May 16-20, 1976. *Requests for reprints: Department of Urology, Straub Clinic and Hospital, Inc., 888 South King St., Honolulu, Hawaii 96813. 782
Fm. 1. Stage I-release of chordee
D Fm. 2. Stage 1- Crawford modification
783
FIG. 3. Stage 2. A to C, formation of skin strip. D, dorsal relaxing incision
and dressings are removed 7 days later with the patient under anesthesia and the urethrostomy is removed on the tenth day. Occasionally, the patient may require a preputial trimming under a separate anesthetic for cosmetic reasons.
A fistula rate of 4.3 per cent in distal hypospadias and an over-all rate of 7 .29 per cent are lower than most series of single stage repairs. Strict attention to tissue handling and a generous dorsal relaxing incision are of paramount importance in reduction of fistula formation.
RESULTS
Of the 96 hypospadias repairs 69 were distal penile, 18 were proximal penile and 9 were penoscrotal or perineal. Of the 7 fistulas that occurred 3 were distal penile, 2 were proximal penile and 2 were penoscrotal. Two strictures occurred in patients with penoscrotal repairs and both responded to urethral dilatation. One meatal stenosis occurred in a distal hypospadias repair. The over-all fistula rate was 7.29 per cent and only 4.34 per cent for the distal penile repairs. No other complications occurred. A few patients required 2 first stage procedures to release the chordee completely. DISCUSSION
The most appealing type of hypospadias repair is the single stage procedure. Excellent results have been reported using various I-stage procedures.3--6 However, the urologist performing only 1 or 2 hypospadias repairs each year may have fewer complications with a multistaged procedure. The Crawford modification of the Denis Browne procedure is an excellent multistage repair with a low complication rate. With the addition of the modification the urethral meatus opens well onto the glans penis, producing a better cosmetic result. The procedure is easier technically than the single stage repairs. After aggressive release of chordee an occasional second straightening procedure is necessary. With the Denis Browne technique the first stage is simply repeated omitting the Crawford modification. Excision of chordee after a single stage procedure may become a major undertaking. Less skin is required with the Denis Browne technique than in single stage procedures, making it ideal for hypospadias, perineal hypospadias and h.rnm_,_,.,~_.,,, __;_,___ _
REFERENCES
1. Crawford, B. S.: The management ofhypospadias. Brit. J. Clin.
Pract., 17: 273, 1963. 2. Crawford, B. S.: The reconstructive surgery of the urethra with special reference to hypospadias. Ann. Roy. Coll. Surg., 41: 321, 1967. 3. Hodgson, N. B.: A one-stage hypospadias repair. J. Urol., 104: 281, 1970. 4. Engel, R. M. E. and Scott, W.W.: Hypospadias: results with the Hodgson urethropiasty. J. Urol., 109: 115, 1973. 5. Horton, C. E. and Devine, C. J., Jr.: Hypospadias and epispadias. Clin. Symp., vol. 24, No. 3, 1972. 6. Horton, C. E. and Devine, C. J., Jr.: Plastic and Reconstructive Surgery of the Genital Area. Boston: Little, Brown and Co., p. 273, 1973. COMMENT These authors have re-emphasized the virtues of the Denis Browne (Marion, Duplay) procedure. The Crawford technique for adding skin to the navicular fossa is only slightly different from a Cronin-Guthrie repair. Both techniques are a complement to the classic work of Byars, who worked with Blair in the 1930s. As one can see the names get confusing but the concepts remain much the same. It would be uncommon in the United States to use a HeinekeMikulicz approach to fibrous chordee and then use a Crawford supplement to the fossa navicularis. It would seem simpler to go with Byars flaps initially. · I personally could not get along without the Denis Browne urethroplasty but I would not use it as commonly as the authors have. The technique described emphasizes the virtue of the subcutaneous continuous stitch. Frequently, an intracuticular continuous stitch has additional merit. N.B .H.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
Pediatric Article CRAWFORD MODIFICATION OF DENIS BROWNE HYPOSPADIAS PROCEDURE WILLIAM J. YARBROUGH*
AND
J. H. JOHNSTON
From the Department of Urology, Alder Hey Children's Hospital, Liverpool, England, and the Department of Urology, George Washington University Medical Center, Washington, D. C.
ABSTRACT
At Alder Hey Children's Hospital 96 hypospadias repairs were performed from 1969 to 1975, using the Crawford modification of the Denis Browne procedure. The technique is described in detail. A 7 .29 per cent fistula rate occurred in 69 distal penile, 18 penile, 8 penoscrotal and 1 perineal repairs. The advantageous difference between the Crawford modification and the original description of Denis Browne is that the meatus is placed well onto the glans penis. Hypospadias occurs in approximately 1 of 300 male births. Hypospadias is classified as glandular, distal penile, proximal penile, penoscrotal and perineal. There have been many types of single and multiple stage repairs described previously. Urologists performing infrequent hypospadias surgery may have fewer complications using a multistaged procedure. A multistaged procedure adaptable to all types ofhypospadias is the Crawford modification of the Denis Browne repair. 1 • 2 The technique and results of 96 hypospadias repairs, using the Crawford modification of the Denis Browne procedure at Alder Hey Children's Hospital, are described herein.
over the skin strip with a continuous 5-zero prolene suture. The skin is approximated with interrupted 5-zero prolene sutures (fig. 3, C). An adequate dorsal relaxing incision is made to relieve the tension from the suture line (fig. 3, D). A dressing soaked in friars' balsam is then applied. The sutures
TECHNIQUE
When the child is about 1½ to 2 years old he is hospitalized for the operation. A transverse incision is made just proximal to the glans on the ventral aspect of the penis (fig. 1, A). The chordee is excised completely and the incision is closed longitudinally with 5-zero dexon (fig. 1, B and C). A generous dorsal slit of the prepuce is performed (fig. 2, A). The dorsal slit is closed transversely with 5-zero dexon (fig. 2, B). The 2 wings of prepuce, thus, are formed and brought around their perspective sides of the glans penis to the ventral surface. A triangular-shaped wedge is removed from the glans on either side of where the new urethra will be formed. The incision is carried from the glans onto the adjacent preputial wings, removing a triangle of prepuce to form a diamond with the contiguous triangular area of the glans (fig. 2, C). The apex of the wing is sutured to the apex of the respective glandular segment (fig. 2, D). Several 5-zero dexon sutures are used to approximate the preputial wings to the glans penis. The second stage is performed in 6 to 12 months. First a perineal urethrostomy is performed. A long U-shaped incision is made around a 1 cm. median skin strip on the ventral surface of the penis, extending from the tip of the preputial wing that was sutured to the glans during the first stage. This is continued to and around the present meatus and to the top of the preputial wing on the opposite side (fig. 3, A). The lateral penile skin is undermined widely (fig. 3, B). The median skin strip is not undermined. The subcutaneous tissue is closed Accepted for publication July 9, 1976. Read at annual meeting of American Urological Association, Las Vegas, Nevada, May 16-20, 1976. *Requests for reprints: Department of Urology, Straub Clinic and Hospital, Inc., 888 South King St., Honolulu, Hawaii 96813. 782
Fm. 1. Stage I-release of chordee
D Fm. 2. Stage 1- Crawford modification
783
FIG. 3. Stage 2. A to C, formation of skin strip. D, dorsal relaxing incision
and dressings are removed 7 days later with the patient under anesthesia and the urethrostomy is removed on the tenth day. Occasionally, the patient may require a preputial trimming under a separate anesthetic for cosmetic reasons.
A fistula rate of 4.3 per cent in distal hypospadias and an over-all rate of 7 .29 per cent are lower than most series of single stage repairs. Strict attention to tissue handling and a generous dorsal relaxing incision are of paramount importance in reduction of fistula formation.
RESULTS
Of the 96 hypospadias repairs 69 were distal penile, 18 were proximal penile and 9 were penoscrotal or perineal. Of the 7 fistulas that occurred 3 were distal penile, 2 were proximal penile and 2 were penoscrotal. Two strictures occurred in patients with penoscrotal repairs and both responded to urethral dilatation. One meatal stenosis occurred in a distal hypospadias repair. The over-all fistula rate was 7.29 per cent and only 4.34 per cent for the distal penile repairs. No other complications occurred. A few patients required 2 first stage procedures to release the chordee completely. DISCUSSION
The most appealing type of hypospadias repair is the single stage procedure. Excellent results have been reported using various I-stage procedures.3--6 However, the urologist performing only 1 or 2 hypospadias repairs each year may have fewer complications with a multistaged procedure. The Crawford modification of the Denis Browne procedure is an excellent multistage repair with a low complication rate. With the addition of the modification the urethral meatus opens well onto the glans penis, producing a better cosmetic result. The procedure is easier technically than the single stage repairs. After aggressive release of chordee an occasional second straightening procedure is necessary. With the Denis Browne technique the first stage is simply repeated omitting the Crawford modification. Excision of chordee after a single stage procedure may become a major undertaking. Less skin is required with the Denis Browne technique than in single stage procedures, making it ideal for hypospadias, perineal hypospadias and h.rnm_,_,.,~_.,,, __;_,___ _
REFERENCES
1. Crawford, B. S.: The management ofhypospadias. Brit. J. Clin.
Pract., 17: 273, 1963. 2. Crawford, B. S.: The reconstructive surgery of the urethra with special reference to hypospadias. Ann. Roy. Coll. Surg., 41: 321, 1967. 3. Hodgson, N. B.: A one-stage hypospadias repair. J. Urol., 104: 281, 1970. 4. Engel, R. M. E. and Scott, W.W.: Hypospadias: results with the Hodgson urethropiasty. J. Urol., 109: 115, 1973. 5. Horton, C. E. and Devine, C. J., Jr.: Hypospadias and epispadias. Clin. Symp., vol. 24, No. 3, 1972. 6. Horton, C. E. and Devine, C. J., Jr.: Plastic and Reconstructive Surgery of the Genital Area. Boston: Little, Brown and Co., p. 273, 1973. COMMENT These authors have re-emphasized the virtues of the Denis Browne (Marion, Duplay) procedure. The Crawford technique for adding skin to the navicular fossa is only slightly different from a Cronin-Guthrie repair. Both techniques are a complement to the classic work of Byars, who worked with Blair in the 1930s. As one can see the names get confusing but the concepts remain much the same. It would be uncommon in the United States to use a HeinekeMikulicz approach to fibrous chordee and then use a Crawford supplement to the fossa navicularis. It would seem simpler to go with Byars flaps initially. · I personally could not get along without the Denis Browne urethroplasty but I would not use it as commonly as the authors have. The technique described emphasizes the virtue of the subcutaneous continuous stitch. Frequently, an intracuticular continuous stitch has additional merit. N.B .H.