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Hypospadias: One-stage repair
HYPOSPADIAS
:
ONE-STAGE
REPAIR
By T. RAY BROADBENT,M.D., and ROBERTM. WOOLF,M.D.
From the Department of Plastic Surgery, Latter-Day Saints Hospital, Salt Lake City, Utah OUR first report of a one-stage repair of hypospadias was made in 1961. In this article we will re-appraise our experience with this procedure since that date. We shall also more clearly illustrate the urethral reconstruction as accomplished with a vascularised skin strip. Indeed, we emphasise that the strip of skin destined to become the new urethra hangs on a "mesentery " through which vessels run to nourish it. This was not well illustrated in our original article. The goals in hypospadias repair are well agreed upon. The patient should be operated upon a minimal number of times and incur, therefore, the least amount of scarring as well as expense. The end result should be a penis free of chordee during erection, with a pliable urethra capable of distention and possessed with capabilities of growth. The urethra should be free of hair, obstructing bands and stricture and the meatal orifice should begat or near the tip of the glans. In summary, our aim is for a penis that functions normally and has a normal appearance. In addition, these goals are preferably realised before a psychological problem develops. This implies satisfactory settlement, early in fife, of the major initial factor in the study of any hypospadiac, sex determination. We prefer to complete urethral reconstruction in the hypospadiac patient before his entrance into grade school. We wait, however, until age 5 to 5½ years before doing any surgery. The size of the penis is small in many individuals with hypospadias and waiting until age 5 adds growth and a more suitably sized penis. We advise the parents, when these patients are first seen, to avoid circumcision of the child for the prepuce is valuable, if not essential, in the one-stage repair as here presented. TECHNIQUE Diversion of the urinary stream for ten to fourteen days is accomplished with a perineal urethrostomy (Fig. 2). A strip of skin as wide as one-third the circumference of the penile shaft, or adequate to close quite loosely around a No. 12 French catheter, is outlined on the ventral aspect of the penis (Fig. I). The strip encompasses the hypospadiac opening near its proximal end and then extends distally, deviates to the right or left of the midline and gradually curves around and over the dorsum of the penis on the preputial skin to or beyond the dorsal midline (Fig. I). This strip is not undermined. Hmmostasis is with electrocoagulation and with i or 2 c.c. of I per cent. Xylocaine and adrenaline mixture injected along the planned incision lines a few minutes before the incisions are made. Through the incision nearest the midline, on the ventral surface of the penis, the chordee is corrected by complete resection of the characteristic restraining fibrous tissue. The glans on occasions is tunnelled and cored to receive the new urethra, but most commonly is split and its central bulk, though small, resected more adequately to receive and accommodate the new u~ethra (Fig. 2, B). The skin strip is not 4o6
HYPOSPADIAS"
ONE-STAGE REPAIR
407
undermined proximally to the coronal sulcus level and very minimally distal to this level. As the strip is tubed and positioned, therefore, the new urethra will angulate mildly from the lateral position of the strip back to the midline as it is threaded through or laid into the glans (Fig. 3). The very loose and mobile nature of the subcutaneous tissue allows easy mov,ement of the tubed skin strip without kinking. Of major importance is the fact that this mobility also allows sliding of the strip without interruption of its blood supply. As the tubed strip is picked up
FIG. I
FIG. ~
FIG. 3
Fig. I.--Artist's illustration of surgical planning, incisions~ for one-stage repair of hypospadias. See text. Fig. 2.--Skin strip has been outlined and tubed, preserving the vessels in the loose areolar tissue. The tube hands on its " mesentery " containing an adequate blood supply to insure viability. The tube is not a free graft. Be Note incised and cored out glans ready to receive the urethra and the mobilised dorsal prepuce being shifted around to the ventral side for covering of the new urethra. Fig. 3.--Completed one-stage repair of hypospadias. Note shaded-in urethra and perineal urethrostomy.
or slid into place, the loose areolar tissue and contained blood supply can be seen streaming from the penis to the skin strip much as the vessels run through a mesentery to any organ (Fig. 2). The strip is viable, pink, and its cut edges bleed freely. It is not a free graft. We would emphasise making the skin strip generously wide. This is especially important at the level of the hypospadiac opening and at the corona, the point of most angulation as the strip curves around and on to the dorsum of the prepuce. These two areas are the tightest when the strip is tubed and a generous and relaxed closure is essential to good healing and the avoidance of fistula formation. It is recognised clearly that with correction of the chordee the penile shaft uncoils, and the hypospadiac opening retires toward the scrotum. The skin strip should therefore be long and, for safety, extend to at least the dorsal midline or one-fourth inch beyond this point (Fig. I, c). The skin strip is tubed with a
408
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. 4 Perineal type of hypospadias with blind vaginal pouch and cleft scrotum. Outline of incisions, skin strip, the tubed skin strip as a constructed urethra with its " mesentery " and blood supply noted in the top three photographs. The urethra laid into the glans and the new urethra covered with the foreskin that has been shifted ventrally and the end result noted in the lower three photographs. See text.
HYPOSPADIAS :
ONE-STAGE
REPAIR
409
continuous 6/0 chromic catgut suture placed to invert the skin edge but not leave suture material within the urethra. One, and if possible, two additional layers of interrupted 6/0 or 7/o non-absorbable or 6/o chromic catgut sutures are used to reinforce the closure much as one would an intestinal anastomosis (Fig. 2, A). As the urethra is slid or rolled into the midline,.the suture line rolls and, for the most part, faces laterally or into the penile shaft. The skin closure is not, therefore,
FI~. 5 Penile-scrotal h y p o s p a d i a s d e m o n s t r a t i n g same surgical aspects as described u n d e r Fig. 4.
for the most part, superimposed on the urethral closure. The incision on the distal prepuce is continued around the penis to the ventral surface and the prepuce remaining, after the new urethra is formed, is mobilised and shifted ventrally (Fig. 2, B). This incision is so placed as to accomplish the desired circumcision. The dorsal preputial skin is freed for ventral rotation and repositioning by a short dorsal slit at the end of the skin strip, essentially as described by Byars (1951). This portion of the preputial skin is used to cover the new urethra and is approximated with two subcutaneous and one subcuticular or a skin layer of 6/o sutures (Fig. 3)- It has not been necessary to incise and relax the skin over the
410
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. 6 Mid-shaft hypospadias with pronounced chordee. Note lower left photograph with forceps pushing under the constructed urethra demonstrating the " mesentery " carrying the blood supply to the urethra.including its tip. See text.
HYPOSPADIAS :
ONE-STAGE
REPAIR
411
dorsum of the penis. Grafts in this area, as originally described, are rarely required. The necessity of a graft is usually found in children who have been circumcised before repair of their hypospadias. An impregnated fine-mesh gauze dressing is held on the penis with tensoplast, applied for modest restraint without pressure. Ten to fourteen days post-operatively, the perineal catheter is removed.
FIG. 7 Balanitic or c o r o n a l hypospadias. N o t e t y p e of dressing a n d e n d result. T h e p e n i s is a f u n c t i o n a l o r g a n t h a t also appears as a n o r m a l male organ as n o t e d here a n d in Figs. 4, 5, a n d 6. DISCUSSION AND C O N C L U S I O N S
Eighteen cases of hypospadias, corrected in one stage, are reviewed in this report. This represents eighteen of the last twenty-six consecutive cases operated. The other eight had either had previous surgery, had been circumcised, or had other extenuating circumstances precluding a one-stage repair. Seven of the eighteen were of a penile-scrotal junction variety (Fig. 5), six had the hypospadiac opening about in the central one-third of the penile shaft (Fig. 6), four were
412
BRITISH JOURNAL OF PLASTIC SURGERY
balanitic or coronal in type (Fig. 7), and one was perineal (Fig. 4). The newly constructed urethra has been viable as vascularised tissue in all cases. It is not a free skin graft, and indeed, it hangs on loose areolar tissue traversed by blood vessels similar to a "mesentery." No strictures have developed, and no postoperative dilatations have been required. In all cases the chordee has been corrected, and in all cases erection is possible. All perineal urethrostomy wounds have healed spontaneously within five days. Four cases developed a fistula post-operatively. All of these were successfully dosed by the David Davis technique (I949). Admittedly, these four had, in final form~ a two-stage procedure. The second stage was minimal, however, and it is anticipated that the incidence of fistula complication will decrease with increasing experience. Three of the fistula~ were at the corona and one at the penilescrotal junction. It can be concluded that hypospadias of the balanitic, penile, peno-scrotal, or perineal type can be corrected in many, if not in most, instances in one stage. In one of our cases, a cleft scrotum was repaired, a blind vaginal tract resected, and a complete urethral reconstruction carried out in one stage. No fistuke developed in this case. The success in this instance is not surprising, for the more proximal the hypospadiac opening, the easier the repair. In the balanitic type, the skin strip angulates sharply around the dorsum of the penis (Fig. 7), whereas the variety with the hypospadiac opening more proximally located allows a gentle deviation of the strip to right (Figs. 4 and 5) or left (Fig. 6). This results in less angulation of the urethra as the strip is tubed and positioned. Urethral reconstruction is accomplished with tissue that is well vascularised, heals well, grows well, is free of hair and stricture, distends and functions well, and the penis looks like a reasonably normal male organ (Fig. 4 through 7). A one-stage approach to the problem of hypospadias is again encouraged in this follow-up report. REFERENCES BROADBENT, T. R., WOOLF, R. M., and TOKSU, E. (I96r). Plast. reconstr. Surg., 27, I54. BYARS, L. T. (r95I). Surg. Gynec. Obstet., 92, I49. DAVIS, D. M. (I949). In " Reconstructive and Reparative Surgery/' p. 440. Ed. by Hans May. Philadelphia : F . A . Davis Co.
Submitted for publication, June I964.
:
ONE-STAGE
REPAIR
By T. RAY BROADBENT,M.D., and ROBERTM. WOOLF,M.D.
From the Department of Plastic Surgery, Latter-Day Saints Hospital, Salt Lake City, Utah OUR first report of a one-stage repair of hypospadias was made in 1961. In this article we will re-appraise our experience with this procedure since that date. We shall also more clearly illustrate the urethral reconstruction as accomplished with a vascularised skin strip. Indeed, we emphasise that the strip of skin destined to become the new urethra hangs on a "mesentery " through which vessels run to nourish it. This was not well illustrated in our original article. The goals in hypospadias repair are well agreed upon. The patient should be operated upon a minimal number of times and incur, therefore, the least amount of scarring as well as expense. The end result should be a penis free of chordee during erection, with a pliable urethra capable of distention and possessed with capabilities of growth. The urethra should be free of hair, obstructing bands and stricture and the meatal orifice should begat or near the tip of the glans. In summary, our aim is for a penis that functions normally and has a normal appearance. In addition, these goals are preferably realised before a psychological problem develops. This implies satisfactory settlement, early in fife, of the major initial factor in the study of any hypospadiac, sex determination. We prefer to complete urethral reconstruction in the hypospadiac patient before his entrance into grade school. We wait, however, until age 5 to 5½ years before doing any surgery. The size of the penis is small in many individuals with hypospadias and waiting until age 5 adds growth and a more suitably sized penis. We advise the parents, when these patients are first seen, to avoid circumcision of the child for the prepuce is valuable, if not essential, in the one-stage repair as here presented. TECHNIQUE Diversion of the urinary stream for ten to fourteen days is accomplished with a perineal urethrostomy (Fig. 2). A strip of skin as wide as one-third the circumference of the penile shaft, or adequate to close quite loosely around a No. 12 French catheter, is outlined on the ventral aspect of the penis (Fig. I). The strip encompasses the hypospadiac opening near its proximal end and then extends distally, deviates to the right or left of the midline and gradually curves around and over the dorsum of the penis on the preputial skin to or beyond the dorsal midline (Fig. I). This strip is not undermined. Hmmostasis is with electrocoagulation and with i or 2 c.c. of I per cent. Xylocaine and adrenaline mixture injected along the planned incision lines a few minutes before the incisions are made. Through the incision nearest the midline, on the ventral surface of the penis, the chordee is corrected by complete resection of the characteristic restraining fibrous tissue. The glans on occasions is tunnelled and cored to receive the new urethra, but most commonly is split and its central bulk, though small, resected more adequately to receive and accommodate the new u~ethra (Fig. 2, B). The skin strip is not 4o6
HYPOSPADIAS"
ONE-STAGE REPAIR
407
undermined proximally to the coronal sulcus level and very minimally distal to this level. As the strip is tubed and positioned, therefore, the new urethra will angulate mildly from the lateral position of the strip back to the midline as it is threaded through or laid into the glans (Fig. 3). The very loose and mobile nature of the subcutaneous tissue allows easy mov,ement of the tubed skin strip without kinking. Of major importance is the fact that this mobility also allows sliding of the strip without interruption of its blood supply. As the tubed strip is picked up
FIG. I
FIG. ~
FIG. 3
Fig. I.--Artist's illustration of surgical planning, incisions~ for one-stage repair of hypospadias. See text. Fig. 2.--Skin strip has been outlined and tubed, preserving the vessels in the loose areolar tissue. The tube hands on its " mesentery " containing an adequate blood supply to insure viability. The tube is not a free graft. Be Note incised and cored out glans ready to receive the urethra and the mobilised dorsal prepuce being shifted around to the ventral side for covering of the new urethra. Fig. 3.--Completed one-stage repair of hypospadias. Note shaded-in urethra and perineal urethrostomy.
or slid into place, the loose areolar tissue and contained blood supply can be seen streaming from the penis to the skin strip much as the vessels run through a mesentery to any organ (Fig. 2). The strip is viable, pink, and its cut edges bleed freely. It is not a free graft. We would emphasise making the skin strip generously wide. This is especially important at the level of the hypospadiac opening and at the corona, the point of most angulation as the strip curves around and on to the dorsum of the prepuce. These two areas are the tightest when the strip is tubed and a generous and relaxed closure is essential to good healing and the avoidance of fistula formation. It is recognised clearly that with correction of the chordee the penile shaft uncoils, and the hypospadiac opening retires toward the scrotum. The skin strip should therefore be long and, for safety, extend to at least the dorsal midline or one-fourth inch beyond this point (Fig. I, c). The skin strip is tubed with a
408
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. 4 Perineal type of hypospadias with blind vaginal pouch and cleft scrotum. Outline of incisions, skin strip, the tubed skin strip as a constructed urethra with its " mesentery " and blood supply noted in the top three photographs. The urethra laid into the glans and the new urethra covered with the foreskin that has been shifted ventrally and the end result noted in the lower three photographs. See text.
HYPOSPADIAS :
ONE-STAGE
REPAIR
409
continuous 6/0 chromic catgut suture placed to invert the skin edge but not leave suture material within the urethra. One, and if possible, two additional layers of interrupted 6/0 or 7/o non-absorbable or 6/o chromic catgut sutures are used to reinforce the closure much as one would an intestinal anastomosis (Fig. 2, A). As the urethra is slid or rolled into the midline,.the suture line rolls and, for the most part, faces laterally or into the penile shaft. The skin closure is not, therefore,
FI~. 5 Penile-scrotal h y p o s p a d i a s d e m o n s t r a t i n g same surgical aspects as described u n d e r Fig. 4.
for the most part, superimposed on the urethral closure. The incision on the distal prepuce is continued around the penis to the ventral surface and the prepuce remaining, after the new urethra is formed, is mobilised and shifted ventrally (Fig. 2, B). This incision is so placed as to accomplish the desired circumcision. The dorsal preputial skin is freed for ventral rotation and repositioning by a short dorsal slit at the end of the skin strip, essentially as described by Byars (1951). This portion of the preputial skin is used to cover the new urethra and is approximated with two subcutaneous and one subcuticular or a skin layer of 6/o sutures (Fig. 3)- It has not been necessary to incise and relax the skin over the
410
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. 6 Mid-shaft hypospadias with pronounced chordee. Note lower left photograph with forceps pushing under the constructed urethra demonstrating the " mesentery " carrying the blood supply to the urethra.including its tip. See text.
HYPOSPADIAS :
ONE-STAGE
REPAIR
411
dorsum of the penis. Grafts in this area, as originally described, are rarely required. The necessity of a graft is usually found in children who have been circumcised before repair of their hypospadias. An impregnated fine-mesh gauze dressing is held on the penis with tensoplast, applied for modest restraint without pressure. Ten to fourteen days post-operatively, the perineal catheter is removed.
FIG. 7 Balanitic or c o r o n a l hypospadias. N o t e t y p e of dressing a n d e n d result. T h e p e n i s is a f u n c t i o n a l o r g a n t h a t also appears as a n o r m a l male organ as n o t e d here a n d in Figs. 4, 5, a n d 6. DISCUSSION AND C O N C L U S I O N S
Eighteen cases of hypospadias, corrected in one stage, are reviewed in this report. This represents eighteen of the last twenty-six consecutive cases operated. The other eight had either had previous surgery, had been circumcised, or had other extenuating circumstances precluding a one-stage repair. Seven of the eighteen were of a penile-scrotal junction variety (Fig. 5), six had the hypospadiac opening about in the central one-third of the penile shaft (Fig. 6), four were
412
BRITISH JOURNAL OF PLASTIC SURGERY
balanitic or coronal in type (Fig. 7), and one was perineal (Fig. 4). The newly constructed urethra has been viable as vascularised tissue in all cases. It is not a free skin graft, and indeed, it hangs on loose areolar tissue traversed by blood vessels similar to a "mesentery." No strictures have developed, and no postoperative dilatations have been required. In all cases the chordee has been corrected, and in all cases erection is possible. All perineal urethrostomy wounds have healed spontaneously within five days. Four cases developed a fistula post-operatively. All of these were successfully dosed by the David Davis technique (I949). Admittedly, these four had, in final form~ a two-stage procedure. The second stage was minimal, however, and it is anticipated that the incidence of fistula complication will decrease with increasing experience. Three of the fistula~ were at the corona and one at the penilescrotal junction. It can be concluded that hypospadias of the balanitic, penile, peno-scrotal, or perineal type can be corrected in many, if not in most, instances in one stage. In one of our cases, a cleft scrotum was repaired, a blind vaginal tract resected, and a complete urethral reconstruction carried out in one stage. No fistuke developed in this case. The success in this instance is not surprising, for the more proximal the hypospadiac opening, the easier the repair. In the balanitic type, the skin strip angulates sharply around the dorsum of the penis (Fig. 7), whereas the variety with the hypospadiac opening more proximally located allows a gentle deviation of the strip to right (Figs. 4 and 5) or left (Fig. 6). This results in less angulation of the urethra as the strip is tubed and positioned. Urethral reconstruction is accomplished with tissue that is well vascularised, heals well, grows well, is free of hair and stricture, distends and functions well, and the penis looks like a reasonably normal male organ (Fig. 4 through 7). A one-stage approach to the problem of hypospadias is again encouraged in this follow-up report. REFERENCES BROADBENT, T. R., WOOLF, R. M., and TOKSU, E. (I96r). Plast. reconstr. Surg., 27, I54. BYARS, L. T. (r95I). Surg. Gynec. Obstet., 92, I49. DAVIS, D. M. (I949). In " Reconstructive and Reparative Surgery/' p. 440. Ed. by Hans May. Philadelphia : F . A . Davis Co.
Submitted for publication, June I964.