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Hypospadias Repair Using Free Graft from Prepuce
Penis 977
978
A TWO-STAGE HYPOSPADIAS REPAIR APPLICABLE TO ALL DEGREES OF THE ANOMALY. *Hyman H. Rabinovitch, MD, Philadelphia, PA (Presentation to be made by Dr. Rabinovitch) A technique of hypospadias repair is described which is applicable to all degrees of the anomaly, including chordee without hypospadias. When complication free, the final result is a normal appearing penis, urethral meatus, and urinary stream. The first stage is done at age one year. A circumcision is performed and the prepuce prepared as a full thickness skin graft. With hemostasis provided by a tourniquet applied to the base of the penis, the chordee is excised and the glans incised deeply (longitudinally) on its ventral aspect. The previously prepared skin is grafted on the ventral aspect of the penile shaft and glans distal to the meatus. Diversion (for six days) is by a #SF Foley catheter per urethra. The second stage is performed six months later. It consists of tubularization of a urethral strip from the meatus to the glans. A flap of subcutaneous tissue covers the suture line and the skin is closed with a 5-0 nylon subcuticular pull-out stitch. The cleft glans is tubularized. Diversion is by suprapubic tube with periodic allowance of voiding to wash out urethral secretions which are felt to be a cause of urethral fistulae. The diverting tube is removed on the 6th post-op day. Each hospitalization may be shortened to overnight stays. Twenty-nine patients have been treated in this manner with five post-op fistulae, a complication rate of 17%.
HYPOSPADIAS REPAIR USING FREE GRAFT FR()I,! PREPUCE w. Hardy Hendren, and *Charles E. Horton, Jr., Boston, Mass. (Presentation to be made by Dr. Horton) From 1978 to 1986 the Horton-Devine one stage operation was used in 88 patients with hypospadias and chordee. Chordee was resected and a free prepucial graft was used to lengthen the urethra to the tip of the glans. Perineal urethrostomy diversion was used in all cases. The degree of hypospadias varied: 28% subcoronal, 19% distal shaft, 38% midshaft, 6% proximal shaft, 7% penoscrotal. The dE,;:Jree of chordee included 10% minimal, 67% !1Klderate, and 23% severe. Complications included: 10 fistulas (4 closed spontaneously; 6 required surgical closure, i.e. 6.8% of all cases); 1 mild stenosis (cured by one dilatation); 4 meatal stenoses (2 corrected surgically and 2 treated by dilatation). A year or more postoperatively a minor outpatient trimming procedure was done in 50% of patients to remove any redundant skin which was present at the meatus or on the penile shaft. Comparing this experience to a prior one with the two stage Belt-Fugua operation we conclude that: lj a free graft covered by two layers of well vascularized subcutaneous tissue and skin fares as well as a pedicle flap technique; 2) most cases can be managed by single stage procedure; however, we do not use this method for extremely severe cases where there is a paucity of skin; 3) the complication rate is low (6.8% needed fistula closure); 4) the end result is a normal phallus with a straight shaft, meatus at the tip, a normally shaped glans, and no unsightly scars.
979
980
A COMPARATIVE TRIAL OF HYPOSPADIAS DRESSINGS. Gerald H. Jordan*, Boyd H. Winslow, David A. Gilbert*, Patrick C. Devine, Charles E. Horton*, and Charles J. Devine, Jr. Norfolk, VA (Presentation to be made by Dr. Jordan)
A TRIAL TO INVESTIGATE THE EFFICACY OF INTRAVENOUS DURING SURGERY REDUCE HYPOSPADIAS TO STEROIDS POSTOPERATIVE EDEMA. Charles N. Burns, Jr. Gerald H. Jordan*, Charles E. Horton, and Charles J. Devine, Jr. Norfolk, VA (Presentation to be made by Dr. Burns) It has been suggested that edema retards healing. Edema of the ptnis following hypospadias repair can often times be profound. In an attempt to find a means of suppressing the edematous response, a randomized trial of patients ( one group given steroids at the time of induction the other group not given steroids) was undertaken. The dressings used postoperatively were uniform for both groups as was postoperative care (i.e., position, bedrest, antibiotics, etc.) 69 patients were entered into the study, roughly half in each group. The group given steroids were given approximately 10 mg/kg of Solu-Medrol IV (maximum 250 mg) at the time of induction. The patients were evaluated pos toper a ti ve ly by a single investigator (CNB) and evaluated on a 1-5+ edema scale. While steroids have clearly been shown to reduce swelling in the GI tract, upper airway, and in certain inflammatory conditions of the skin, we found no differences when applied to these groups of patients undergoing hypospadias surgery. Incidentally noted were slightly more postoperative complications in the group receiving steroids; but due to the limited number of patients having complications, the observation is not statistically significant.
The optimal dressing for the hypospadias patient would allow for inspection of all aspects of the penis during the early postoperative course, serve as a barrier to contamination, and limit postoperative edema during the initial phases of healing. In an attempt to develop such a dressing, patients were randomized into 3 groups: (1) The first group received iced saline dressings only (a dressing we have used for several years). (2) The second group was placed in a clear plastic surgical dressing (we chose the Bioclusive dressing because of its ease of application and the characteristics of its membrane and adhesive. (3) The third group was placed in Bioclusive and received cold soakso The patients were then evaluated on a 1+ to 3+ edema sea le during the postoperative course. The Bioclusive group and Bioclusive and soaks group clearly had less edema than the soaks only group; after 30 patients (roughly 10 in each group) that dressing was dropped. Our results showed no difference in edema or wound appearance between the Bioclusive group and the Bioclusive soaks group during the initial postoperative period. At about 7 days the Bioclusive dressing was routinely removed. It was found that most patients in the Bioclusive only group developed rather significant edema during the ensuing 24 hours, and we termed this rebound edema, while the Bioclusive and soaks patients did not develop rebound edema to the same extent. When the results were analyzed, the groups contained roughly equal numbers of cases of equal complexity. 88 patients were studied with 10 patients in Group I, 40 in Group 2 and 38 in Group 3.
348A
978
A TWO-STAGE HYPOSPADIAS REPAIR APPLICABLE TO ALL DEGREES OF THE ANOMALY. *Hyman H. Rabinovitch, MD, Philadelphia, PA (Presentation to be made by Dr. Rabinovitch) A technique of hypospadias repair is described which is applicable to all degrees of the anomaly, including chordee without hypospadias. When complication free, the final result is a normal appearing penis, urethral meatus, and urinary stream. The first stage is done at age one year. A circumcision is performed and the prepuce prepared as a full thickness skin graft. With hemostasis provided by a tourniquet applied to the base of the penis, the chordee is excised and the glans incised deeply (longitudinally) on its ventral aspect. The previously prepared skin is grafted on the ventral aspect of the penile shaft and glans distal to the meatus. Diversion (for six days) is by a #SF Foley catheter per urethra. The second stage is performed six months later. It consists of tubularization of a urethral strip from the meatus to the glans. A flap of subcutaneous tissue covers the suture line and the skin is closed with a 5-0 nylon subcuticular pull-out stitch. The cleft glans is tubularized. Diversion is by suprapubic tube with periodic allowance of voiding to wash out urethral secretions which are felt to be a cause of urethral fistulae. The diverting tube is removed on the 6th post-op day. Each hospitalization may be shortened to overnight stays. Twenty-nine patients have been treated in this manner with five post-op fistulae, a complication rate of 17%.
HYPOSPADIAS REPAIR USING FREE GRAFT FR()I,! PREPUCE w. Hardy Hendren, and *Charles E. Horton, Jr., Boston, Mass. (Presentation to be made by Dr. Horton) From 1978 to 1986 the Horton-Devine one stage operation was used in 88 patients with hypospadias and chordee. Chordee was resected and a free prepucial graft was used to lengthen the urethra to the tip of the glans. Perineal urethrostomy diversion was used in all cases. The degree of hypospadias varied: 28% subcoronal, 19% distal shaft, 38% midshaft, 6% proximal shaft, 7% penoscrotal. The dE,;:Jree of chordee included 10% minimal, 67% !1Klderate, and 23% severe. Complications included: 10 fistulas (4 closed spontaneously; 6 required surgical closure, i.e. 6.8% of all cases); 1 mild stenosis (cured by one dilatation); 4 meatal stenoses (2 corrected surgically and 2 treated by dilatation). A year or more postoperatively a minor outpatient trimming procedure was done in 50% of patients to remove any redundant skin which was present at the meatus or on the penile shaft. Comparing this experience to a prior one with the two stage Belt-Fugua operation we conclude that: lj a free graft covered by two layers of well vascularized subcutaneous tissue and skin fares as well as a pedicle flap technique; 2) most cases can be managed by single stage procedure; however, we do not use this method for extremely severe cases where there is a paucity of skin; 3) the complication rate is low (6.8% needed fistula closure); 4) the end result is a normal phallus with a straight shaft, meatus at the tip, a normally shaped glans, and no unsightly scars.
979
980
A COMPARATIVE TRIAL OF HYPOSPADIAS DRESSINGS. Gerald H. Jordan*, Boyd H. Winslow, David A. Gilbert*, Patrick C. Devine, Charles E. Horton*, and Charles J. Devine, Jr. Norfolk, VA (Presentation to be made by Dr. Jordan)
A TRIAL TO INVESTIGATE THE EFFICACY OF INTRAVENOUS DURING SURGERY REDUCE HYPOSPADIAS TO STEROIDS POSTOPERATIVE EDEMA. Charles N. Burns, Jr. Gerald H. Jordan*, Charles E. Horton, and Charles J. Devine, Jr. Norfolk, VA (Presentation to be made by Dr. Burns) It has been suggested that edema retards healing. Edema of the ptnis following hypospadias repair can often times be profound. In an attempt to find a means of suppressing the edematous response, a randomized trial of patients ( one group given steroids at the time of induction the other group not given steroids) was undertaken. The dressings used postoperatively were uniform for both groups as was postoperative care (i.e., position, bedrest, antibiotics, etc.) 69 patients were entered into the study, roughly half in each group. The group given steroids were given approximately 10 mg/kg of Solu-Medrol IV (maximum 250 mg) at the time of induction. The patients were evaluated pos toper a ti ve ly by a single investigator (CNB) and evaluated on a 1-5+ edema scale. While steroids have clearly been shown to reduce swelling in the GI tract, upper airway, and in certain inflammatory conditions of the skin, we found no differences when applied to these groups of patients undergoing hypospadias surgery. Incidentally noted were slightly more postoperative complications in the group receiving steroids; but due to the limited number of patients having complications, the observation is not statistically significant.
The optimal dressing for the hypospadias patient would allow for inspection of all aspects of the penis during the early postoperative course, serve as a barrier to contamination, and limit postoperative edema during the initial phases of healing. In an attempt to develop such a dressing, patients were randomized into 3 groups: (1) The first group received iced saline dressings only (a dressing we have used for several years). (2) The second group was placed in a clear plastic surgical dressing (we chose the Bioclusive dressing because of its ease of application and the characteristics of its membrane and adhesive. (3) The third group was placed in Bioclusive and received cold soakso The patients were then evaluated on a 1+ to 3+ edema sea le during the postoperative course. The Bioclusive group and Bioclusive and soaks group clearly had less edema than the soaks only group; after 30 patients (roughly 10 in each group) that dressing was dropped. Our results showed no difference in edema or wound appearance between the Bioclusive group and the Bioclusive soaks group during the initial postoperative period. At about 7 days the Bioclusive dressing was routinely removed. It was found that most patients in the Bioclusive only group developed rather significant edema during the ensuing 24 hours, and we termed this rebound edema, while the Bioclusive and soaks patients did not develop rebound edema to the same extent. When the results were analyzed, the groups contained roughly equal numbers of cases of equal complexity. 88 patients were studied with 10 patients in Group I, 40 in Group 2 and 38 in Group 3.
348A