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Hypospadias: The Principle of the Third Degree
THE JocR:::-.:rAL OF UROLOGY
·vol. 78, No. 6, December J9.5-7 Printed -1:n U.S.A.. 0
HYPOSPADIAS: THE PRINCIPLE OF THE THIRD DEGREE HOWARD T. THOlVIPSON AKD WARREN GEORGE From the Surgical Services r~f the Genesee Hospital and the Rochester General Hospital, Rochester, N. Y.
The literature on hypospadias describes many methods of repair and the good results are emphasized. ~ o one seems willing to give an analysis of his difficulties and his complications. The multiplicity of operations which have been recommended for the repair of hypospadias reflects the difficulties of surgical correction and the complications ensuing from various procedures. The actual technique of the repair of hypospadias deformities has become largely a matter of individual preference of the operating surgeon. Procedures successful or satisfactory in the hands of one surgeon may be less successful or less satisfactory for another. Reviews of the literature and discussions of the embryology have been adequately covered in other papers. No attempt -will be made to duplicate these efforts. Irrespective of the individual techniques which have been devised, the three basic principles of urethral reconstruction are 1) the use of a local skin flap, 2) the use of a pedicle flap formed into a tube, and 3) the use of a free graft. Let us first evaluate the various steps necessary for adequate repair of hypospadias. All operative procedures will fail unless adequate correction of the chordee is obtained. This has been stressed by all the authors in the field and means the meticulous excision of all restraining tissue, fascia and skin from the glans to behind and proximal to the urethral meatus (fig. l). Since thiB is such a necessary component of successful repair, it is to be accepted that adequate resection of the chordee is a fairly 1n,ll established surgical procedure and usually does not pre,;ent a problem to those operating for this condition. The second stage of hypospadias repair is the formation of a urethra. Davi,; has reported good results ,.-ith his tube or pedicle flap. Byars successfully treated GO cases by his use of a local skin flap. ;\folndoe, confining his surgery to older children and adults with the use of a free thin graft and indwelling dilators, reported good results. Young and Benjamin, modifying the operation of l\oye ,Josserand, reported 10 cases with primary anastomosis of a free graft with the urethra. Three ca::1cs were successful; seven acquired urinary fistulas which "-ere subsequently closed. Havens reported 29 cases operated upon by the method of :I\1dndoe with 27 good results, one fair and one a failure. 'We believe that complete correction should be performed in the preschool age if pm;sible. Almost all procedures designed, irrespective of the basic principle, create a distal urethra without anastornosis to the proximal portion. This is left for a third stage operation. It is not true in the technique advocated by Young and Benjamin who performed primary anastomosis of a free graft with the proximal Read ,it annual meeting of American Urological Association, Pittsburgh, Pa., May 6-9, 1957. 767
768
HOWARD T. THOMPSON AND WARREJ'\f GEORGE
FrG. 1. A, incisions for correction of chordee. Note incision into cleft of glans. B, note wide lateral exposure of skin flaps. Cleft in penis excised and reapproximated. All tissue removed down to corpora. Urethral meatus freed up to be moved proximally. C, closure of flap about corona. D, completion of correction of chordee with Z type closure. Foley catheter in place.
urethra at the time of implantation. McCormick, who has also modified this operation, states that, "This procedure has worked very satisfactorily for the construction of a urethra to the point of the anastomosis but has given a considerable percentage of complications at the anastomotic site. These complications have been two: first, the development of a postoperative single fistula at the site of the anastomosis; and secondly, the development of a temporary contracture at the anastomotic site which required careful observation and periodic dilatation." Experience with our early cases resulted in just these complications and forced us to seek an answer to our problem. Of 21 cases treated by free skin grafts, six had immediate anastomosis and in all, fistulas developed. All required periodic dilatation. Three are successfully closed and voiding well but three still have fistulas. Mcindoe in dealing with thin skin grafts first recommended and used an indwelling dilator. This had to be changed frequently and cleansed. In 17 cases we have not performed primary anastomosis. In these we have used a permanent dilator of polyethylene tubing from a transfusion apparatus formed as a continuous loop in the graft. This has been left in for periods of six months to a year without changing and without any reaction or discharge about the grafted urethra. The new urethra has shown no tendency to contract after this period of time. Children ranged in ages from two years to eleven years and no problem has yet presented itself from the presence of the tube in the new urethra. Without this inlying dilator some degree of contracture will occur even though the rate may be only 10 to 25 per cent as predicted by McCormick. The third phase of the reconstruction, namely, the anastomosing of the new urethra with the proximal urethra has presented us our biggest problem. In six cases fistulas developed; three were closed in one attempt and three still have small fistulous openings. It was felt that these results were less than optimal and
IIYl'OSPADL\S: PRINCIPL~] OF TI-HRD DEGREE
7(\9
a search Yrns made to deYelop a technique to overcome this difficulty. Thi,.; problem ha:- uot only been our problem but is mentioned throughout the entire literature. Byars in reportiug on his technique for surgical repair of hypospadias states, "The o,·er-all problem of hypospadias repair is such that no scheme regardless of the skill of exeeution v,·ill not be complicated by the oecasional dc\·elopment of one or more fistulas m·en though in most instances proper planning, gentleness of execution, utilization of proper suture material and closure in depth 1,;ill avoid this complication." DaYid :'vi. Davis, in discussing his tube flap operation for repair of hypospadias, states with regard to his method of closiug such a fistula: "This method is successful iu at least two-thirds of the cases on the fast attempt and al,Yays on the second or third." It is obvious frmn this that more difficulty 1vith fistulas was encountered than was statistically stated. Douglas in recounting his experiences in the operative and postoperative management of hypospadias states, ''Small fistulas are to be expected in any work involving so much suturing of thin and some\\·bat scarred tissue and in a field which usually is not dry. 1n our series of cases, fistulas have been comparatiyely few, averaging slightly over one per case." To our ,1-ay of thinking, this is not fe,y and more than should occur. By means of the free graft using a tunne[ization method, only one postoperative fistula can occur and that at the proximal end of the tunneL vVe were not and are not sati"fied with such an incidence of fistula formation. This was one of the complications y,·hich impelled McCormick to modify the technique of Benjamin and Young. Tl-HJ PH!NCIPLE OF THE THIRD DFJGRI
It is conceded that the nearer to the perineum the anaiitomosifi cau be accomplished, the easier it is to perform. ·with this principle in mind, it was decided to convert a peuile or second degree hypospadias to third degree or s<:rotal hypospaclias (table I). The first t,rn cases were corrected by moving the urethral meatus back to the scrotum at the time of the chordee repair. These openings 1\·ere near the scrotum and easily transposed. For the lesser degrefls of hypospadias, a different technique has been devised. At the time of the formation of the urethra by a free skin graft, the graft is cut longer than is usually necessary, With a sound in the urethra a double barrel urethrostomy is performed in the midscrotal region. A free graft about a catheter is then passed through the ucw meatus at the tip of the glans, ::iubcutaneousl_y in the ne\\'[y formed tmmel, through the urethra and out the distal opening of the double barreled urethrostomy in the midscrotnm. The graft extends from beyond the tip of the penis through into the normal urethra. ~ o attempt is made to suture the graft to the proximal urethra. It is allowed to heal and anastomose itself over the polyethylene tube. The tissues over the penile portion of the urethra are then closed. in depth with interrupted 0000 chromic catgut (figs. 2 and ~;). After one week the rubber catheter is remowd, leaving the graft in place and a polyethylene tube is
770
HOWARD T. THOMPSON AND WARREN GEORGE TABLE
1. Plan of operation
I Correction of chordee (age-after 2 years) A) Sutures: 0000 chromic; No. 35 stainless steel wire B) Dressing: Elastoplast; penis free, not sewn to abdomen II Formation of urethra A) Time interval: 6 months or more B) Free graft 1) Site: inner side of arm 2) Thickness: 15-22 thousandths of inch (depends on age of patient) 3) Secured about 14F rubber catheter, fixed with plastic cement (dermatome) 4) Graft passed through tunnel from tip of glans to urethra, through urethra to double barreled scrotal urethrostomy 5) Urine diverted through proximal opening of urethrostomy 6) Sutures: 0000 chromic catgut 7) No dressing C) Polyethylene tubing Rubber catheter, removed on 7th or 8th day, replaced by polyethylene tube III Closure of double barreled scrotal urethrostomy A) Time interval: 6 months or more B) Urine diverted by perinea! urethrostomy or Foley catheter C) Closure 1) Interrupted inverting sutures 2) Fascia: 0000 chromic catgut 3) Skin: silk or chromic catgut 4) No dressing
FIG. 2. A, tunnelling with dissecting scissors to tip of glans. B, composite drawing shows free graft passing from tip of glans into normal urethra. Polyethylene tube in place through double barrel scrotal urethrostomy. Closure of opening on penis begun. Urine diverted by Foley catheter.
inserted. The ends of the tubing are sewed together to form an external loop. In the immediate postoperative period diversion of the urinary stream is accomplished through the proximal portion of the double barreled urethrostomy. Six months later the third stage is completed utilizing a perineal urethrostomy or
HYPOSPADIAS: PRINCIPLE OF THIRD DEGREE
771
Fm. 3. Closure of scrotal urethrostomy over Foley catheter. Note depth of tissue. Insert (a) shows final closure. TABLE
2
Total number of cases-29 Type of operation: 1) Free graft-21 2) Other methods-8 Modifications of free graft: 1) Primary anastomosis-6 a) Fistula-6 b) Healed and complete-3 c) To be completed-3 2) Delayed anastomosis-15 a) Fistula-6 I) Closed first attempt-3 2) With fistula-3 c) Unfinished-4 d) Converted to third degree or scrotal hypospadias 1) By moving back meatus a) Two closed; no fistula 2) By long graft to scrotum a) Three closed 2-no fistula at scrotum 2-no fistula on penis I-tiny fistula on penis I-tiny fistula at scrotum
Foley catheter per urethram for urinary diversion. The double barreled scrotal urethrostomy is closed in layers using an inverting interrupted suture on the urethra and closing the tissue in depth with interrupted 0000 chromic catgut. Three cases have now been completed successfully by this method. Our results are cited in table 2. Figures 4, 5 and 6 are illustrative cases.
772
HOWARD T. THOMPSON AND WARREN GEORGE
FIG. 4. P. D., No. 112951. Patient voiding; final result. Free graft with primary anastomosis required dilatation of the urethra.
FIG. 5. D. M., No. 164143. Polyethylene tube in place in penile hypospadias treated by principle of third degree. Tube is shown coming out of tip of penis and scrotal urethrostomy. Original opening on shaft of penis closed. It can be detected by scarring present in skin.
FIG. 6. C. C., No. 187187. Final result after closure in scrotum (principle of third degree). Patient was referred after two attempts at correction of chordee by general surgeon. Extensive scarring would preclude use of local skin flap.
HYPOSPADIAS: PRINCIPLE OF THIRD DEGREE
773
DISCUSSION
We believe that the repair of hypospadias should be performed in three stages. Correction of the chordee should be accomplished at an early age preferably between one and three years. This allows adequate growth of the penis. The free skin graft appears to grow clinically as the patients grow, and therefore offers no contraindication to its use in the young. Many authors advocate delay until the early teens before operative repair because the patients have not had psychological difficulties and have made good adjustments to their problem. These surely must be superficial clinical observations as no one has reported psychological or psychiatric evaluation of a group of unrepaired hypospadias. To us it is significant that invariably the parents will voluntarily report marked improvement in the child's social adjustment, decrease in difficulties of management of the child, and a noticeable increase in aggressiveness. While the repair of the chordee is a time-consuming, meticulous procedure, the second and third stages are usually easily and rapidly performed, rarely taking more than one half to three quarters of an hour. The plastic polyethylene tube in place has not presented a problem. In one instance the tube accidently came out and was replaced the next day without difficulty. No discharge or irritation has occurred around the tube. The mother is instructed to move the tube forward and backward occasionally and to use a lubricant locally if it fails to move with ease. The caliber of this polyethylene tube is approximately that of a 14F sound and provides a urethra with a very adequate caliber. McCormick reported an operation for simultaneous repair of the chordee and implantation of the graft in one stage. He reported three cases successfully treated by this method. He, too, no longer performs a primary anastomosis of the graft and the urethra but he does this at a later date preferrably at least six months after the first stage. The principle of third degree is based on sound surgical principles. It allows the closure of the fistula to be performed in an area of essentially normal tissues; permits the closure of several layers in depth over the opening in the urethra; and it contributes to an accurate and non-strictured anastomosis in a dry field over a period of six months. This plan of hypospadias repair creates a penis which 1) is normal in appearance, 2) has a nearly normal redundant foreskin, 3) has the urethral meatus at the tip of the glans where it belongs; and 4) does not have scar tissue in the urethra. SUMMARY
We believe that to our satisfaction the first two problems in the repair of hypospadias have been solved: 1) the adequate correction of the chordee and 2) the formation of an adequate urethra without scarring or contracture. The third and final problem of fistula formation seems to respond well to the principle of the third degree. One may be assured that irrespective of any type of repair some percentage of fistula will occur.
261 Alexander St., Rochester 7, N. Y.
774
HOWARD T. THOMPSON AND WARREN GEORGE
REFERENCES BYARS, L. L.: Surg., Gynec. & Obst., 75: 8, 1942. BYARS, L. L.: Surg., Gynec. & Obst., 92: 149, 1957. BYARS, L. L.: Surg. Clin. N. Amer., 30: 1371, 1950. DAVIS, D. M.: Plastic and Reconstr. Surg., 5: 373, 1950. DouGLAS, BEVERLY: Plastic and Reconstr. Surg., 2: 107, 1953. HAVENS, F. Z. AND BLOCK, A. S.: J. Urol., 61: 1053, 1949. HAVENS, F. Z.: Surg., Gynec. & Obst., 87: 239, 1948. MAcCoLLOM, D. W., LowGINO, L.A. AND MEEKER, I. A.: Surg. Clinics of N. Amer., 36: 1, 1956. McCORMICK, R. M.: Plastic and Reconstr. Surg., 13: 257, 1954. MclNDOE, A.H.: Brit. Med. J., 1: 385, 1937. MclNDOE, A. H.: Brit. J. Plastic Surg., 1: 29, 1948. MclNDOE, A.H.: Am. J. Surg., 38: 176, 1937. YOUNG, F. AND BENJAMIN, J. A.: Surg., Gynec. & Obst., 86: 439, 1948.
·vol. 78, No. 6, December J9.5-7 Printed -1:n U.S.A.. 0
HYPOSPADIAS: THE PRINCIPLE OF THE THIRD DEGREE HOWARD T. THOlVIPSON AKD WARREN GEORGE From the Surgical Services r~f the Genesee Hospital and the Rochester General Hospital, Rochester, N. Y.
The literature on hypospadias describes many methods of repair and the good results are emphasized. ~ o one seems willing to give an analysis of his difficulties and his complications. The multiplicity of operations which have been recommended for the repair of hypospadias reflects the difficulties of surgical correction and the complications ensuing from various procedures. The actual technique of the repair of hypospadias deformities has become largely a matter of individual preference of the operating surgeon. Procedures successful or satisfactory in the hands of one surgeon may be less successful or less satisfactory for another. Reviews of the literature and discussions of the embryology have been adequately covered in other papers. No attempt -will be made to duplicate these efforts. Irrespective of the individual techniques which have been devised, the three basic principles of urethral reconstruction are 1) the use of a local skin flap, 2) the use of a pedicle flap formed into a tube, and 3) the use of a free graft. Let us first evaluate the various steps necessary for adequate repair of hypospadias. All operative procedures will fail unless adequate correction of the chordee is obtained. This has been stressed by all the authors in the field and means the meticulous excision of all restraining tissue, fascia and skin from the glans to behind and proximal to the urethral meatus (fig. l). Since thiB is such a necessary component of successful repair, it is to be accepted that adequate resection of the chordee is a fairly 1n,ll established surgical procedure and usually does not pre,;ent a problem to those operating for this condition. The second stage of hypospadias repair is the formation of a urethra. Davi,; has reported good results ,.-ith his tube or pedicle flap. Byars successfully treated GO cases by his use of a local skin flap. ;\folndoe, confining his surgery to older children and adults with the use of a free thin graft and indwelling dilators, reported good results. Young and Benjamin, modifying the operation of l\oye ,Josserand, reported 10 cases with primary anastomosis of a free graft with the urethra. Three ca::1cs were successful; seven acquired urinary fistulas which "-ere subsequently closed. Havens reported 29 cases operated upon by the method of :I\1dndoe with 27 good results, one fair and one a failure. 'We believe that complete correction should be performed in the preschool age if pm;sible. Almost all procedures designed, irrespective of the basic principle, create a distal urethra without anastornosis to the proximal portion. This is left for a third stage operation. It is not true in the technique advocated by Young and Benjamin who performed primary anastomosis of a free graft with the proximal Read ,it annual meeting of American Urological Association, Pittsburgh, Pa., May 6-9, 1957. 767
768
HOWARD T. THOMPSON AND WARREJ'\f GEORGE
FrG. 1. A, incisions for correction of chordee. Note incision into cleft of glans. B, note wide lateral exposure of skin flaps. Cleft in penis excised and reapproximated. All tissue removed down to corpora. Urethral meatus freed up to be moved proximally. C, closure of flap about corona. D, completion of correction of chordee with Z type closure. Foley catheter in place.
urethra at the time of implantation. McCormick, who has also modified this operation, states that, "This procedure has worked very satisfactorily for the construction of a urethra to the point of the anastomosis but has given a considerable percentage of complications at the anastomotic site. These complications have been two: first, the development of a postoperative single fistula at the site of the anastomosis; and secondly, the development of a temporary contracture at the anastomotic site which required careful observation and periodic dilatation." Experience with our early cases resulted in just these complications and forced us to seek an answer to our problem. Of 21 cases treated by free skin grafts, six had immediate anastomosis and in all, fistulas developed. All required periodic dilatation. Three are successfully closed and voiding well but three still have fistulas. Mcindoe in dealing with thin skin grafts first recommended and used an indwelling dilator. This had to be changed frequently and cleansed. In 17 cases we have not performed primary anastomosis. In these we have used a permanent dilator of polyethylene tubing from a transfusion apparatus formed as a continuous loop in the graft. This has been left in for periods of six months to a year without changing and without any reaction or discharge about the grafted urethra. The new urethra has shown no tendency to contract after this period of time. Children ranged in ages from two years to eleven years and no problem has yet presented itself from the presence of the tube in the new urethra. Without this inlying dilator some degree of contracture will occur even though the rate may be only 10 to 25 per cent as predicted by McCormick. The third phase of the reconstruction, namely, the anastomosing of the new urethra with the proximal urethra has presented us our biggest problem. In six cases fistulas developed; three were closed in one attempt and three still have small fistulous openings. It was felt that these results were less than optimal and
IIYl'OSPADL\S: PRINCIPL~] OF TI-HRD DEGREE
7(\9
a search Yrns made to deYelop a technique to overcome this difficulty. Thi,.; problem ha:- uot only been our problem but is mentioned throughout the entire literature. Byars in reportiug on his technique for surgical repair of hypospadias states, "The o,·er-all problem of hypospadias repair is such that no scheme regardless of the skill of exeeution v,·ill not be complicated by the oecasional dc\·elopment of one or more fistulas m·en though in most instances proper planning, gentleness of execution, utilization of proper suture material and closure in depth 1,;ill avoid this complication." DaYid :'vi. Davis, in discussing his tube flap operation for repair of hypospadias, states with regard to his method of closiug such a fistula: "This method is successful iu at least two-thirds of the cases on the fast attempt and al,Yays on the second or third." It is obvious frmn this that more difficulty 1vith fistulas was encountered than was statistically stated. Douglas in recounting his experiences in the operative and postoperative management of hypospadias states, ''Small fistulas are to be expected in any work involving so much suturing of thin and some\\·bat scarred tissue and in a field which usually is not dry. 1n our series of cases, fistulas have been comparatiyely few, averaging slightly over one per case." To our ,1-ay of thinking, this is not fe,y and more than should occur. By means of the free graft using a tunne[ization method, only one postoperative fistula can occur and that at the proximal end of the tunneL vVe were not and are not sati"fied with such an incidence of fistula formation. This was one of the complications y,·hich impelled McCormick to modify the technique of Benjamin and Young. Tl-HJ PH!NCIPLE OF THE THIRD DFJGRI
It is conceded that the nearer to the perineum the anaiitomosifi cau be accomplished, the easier it is to perform. ·with this principle in mind, it was decided to convert a peuile or second degree hypospadias to third degree or s<:rotal hypospaclias (table I). The first t,rn cases were corrected by moving the urethral meatus back to the scrotum at the time of the chordee repair. These openings 1\·ere near the scrotum and easily transposed. For the lesser degrefls of hypospadias, a different technique has been devised. At the time of the formation of the urethra by a free skin graft, the graft is cut longer than is usually necessary, With a sound in the urethra a double barrel urethrostomy is performed in the midscrotal region. A free graft about a catheter is then passed through the ucw meatus at the tip of the glans, ::iubcutaneousl_y in the ne\\'[y formed tmmel, through the urethra and out the distal opening of the double barreled urethrostomy in the midscrotnm. The graft extends from beyond the tip of the penis through into the normal urethra. ~ o attempt is made to suture the graft to the proximal urethra. It is allowed to heal and anastomose itself over the polyethylene tube. The tissues over the penile portion of the urethra are then closed. in depth with interrupted 0000 chromic catgut (figs. 2 and ~;). After one week the rubber catheter is remowd, leaving the graft in place and a polyethylene tube is
770
HOWARD T. THOMPSON AND WARREN GEORGE TABLE
1. Plan of operation
I Correction of chordee (age-after 2 years) A) Sutures: 0000 chromic; No. 35 stainless steel wire B) Dressing: Elastoplast; penis free, not sewn to abdomen II Formation of urethra A) Time interval: 6 months or more B) Free graft 1) Site: inner side of arm 2) Thickness: 15-22 thousandths of inch (depends on age of patient) 3) Secured about 14F rubber catheter, fixed with plastic cement (dermatome) 4) Graft passed through tunnel from tip of glans to urethra, through urethra to double barreled scrotal urethrostomy 5) Urine diverted through proximal opening of urethrostomy 6) Sutures: 0000 chromic catgut 7) No dressing C) Polyethylene tubing Rubber catheter, removed on 7th or 8th day, replaced by polyethylene tube III Closure of double barreled scrotal urethrostomy A) Time interval: 6 months or more B) Urine diverted by perinea! urethrostomy or Foley catheter C) Closure 1) Interrupted inverting sutures 2) Fascia: 0000 chromic catgut 3) Skin: silk or chromic catgut 4) No dressing
FIG. 2. A, tunnelling with dissecting scissors to tip of glans. B, composite drawing shows free graft passing from tip of glans into normal urethra. Polyethylene tube in place through double barrel scrotal urethrostomy. Closure of opening on penis begun. Urine diverted by Foley catheter.
inserted. The ends of the tubing are sewed together to form an external loop. In the immediate postoperative period diversion of the urinary stream is accomplished through the proximal portion of the double barreled urethrostomy. Six months later the third stage is completed utilizing a perineal urethrostomy or
HYPOSPADIAS: PRINCIPLE OF THIRD DEGREE
771
Fm. 3. Closure of scrotal urethrostomy over Foley catheter. Note depth of tissue. Insert (a) shows final closure. TABLE
2
Total number of cases-29 Type of operation: 1) Free graft-21 2) Other methods-8 Modifications of free graft: 1) Primary anastomosis-6 a) Fistula-6 b) Healed and complete-3 c) To be completed-3 2) Delayed anastomosis-15 a) Fistula-6 I) Closed first attempt-3 2) With fistula-3 c) Unfinished-4 d) Converted to third degree or scrotal hypospadias 1) By moving back meatus a) Two closed; no fistula 2) By long graft to scrotum a) Three closed 2-no fistula at scrotum 2-no fistula on penis I-tiny fistula on penis I-tiny fistula at scrotum
Foley catheter per urethram for urinary diversion. The double barreled scrotal urethrostomy is closed in layers using an inverting interrupted suture on the urethra and closing the tissue in depth with interrupted 0000 chromic catgut. Three cases have now been completed successfully by this method. Our results are cited in table 2. Figures 4, 5 and 6 are illustrative cases.
772
HOWARD T. THOMPSON AND WARREN GEORGE
FIG. 4. P. D., No. 112951. Patient voiding; final result. Free graft with primary anastomosis required dilatation of the urethra.
FIG. 5. D. M., No. 164143. Polyethylene tube in place in penile hypospadias treated by principle of third degree. Tube is shown coming out of tip of penis and scrotal urethrostomy. Original opening on shaft of penis closed. It can be detected by scarring present in skin.
FIG. 6. C. C., No. 187187. Final result after closure in scrotum (principle of third degree). Patient was referred after two attempts at correction of chordee by general surgeon. Extensive scarring would preclude use of local skin flap.
HYPOSPADIAS: PRINCIPLE OF THIRD DEGREE
773
DISCUSSION
We believe that the repair of hypospadias should be performed in three stages. Correction of the chordee should be accomplished at an early age preferably between one and three years. This allows adequate growth of the penis. The free skin graft appears to grow clinically as the patients grow, and therefore offers no contraindication to its use in the young. Many authors advocate delay until the early teens before operative repair because the patients have not had psychological difficulties and have made good adjustments to their problem. These surely must be superficial clinical observations as no one has reported psychological or psychiatric evaluation of a group of unrepaired hypospadias. To us it is significant that invariably the parents will voluntarily report marked improvement in the child's social adjustment, decrease in difficulties of management of the child, and a noticeable increase in aggressiveness. While the repair of the chordee is a time-consuming, meticulous procedure, the second and third stages are usually easily and rapidly performed, rarely taking more than one half to three quarters of an hour. The plastic polyethylene tube in place has not presented a problem. In one instance the tube accidently came out and was replaced the next day without difficulty. No discharge or irritation has occurred around the tube. The mother is instructed to move the tube forward and backward occasionally and to use a lubricant locally if it fails to move with ease. The caliber of this polyethylene tube is approximately that of a 14F sound and provides a urethra with a very adequate caliber. McCormick reported an operation for simultaneous repair of the chordee and implantation of the graft in one stage. He reported three cases successfully treated by this method. He, too, no longer performs a primary anastomosis of the graft and the urethra but he does this at a later date preferrably at least six months after the first stage. The principle of third degree is based on sound surgical principles. It allows the closure of the fistula to be performed in an area of essentially normal tissues; permits the closure of several layers in depth over the opening in the urethra; and it contributes to an accurate and non-strictured anastomosis in a dry field over a period of six months. This plan of hypospadias repair creates a penis which 1) is normal in appearance, 2) has a nearly normal redundant foreskin, 3) has the urethral meatus at the tip of the glans where it belongs; and 4) does not have scar tissue in the urethra. SUMMARY
We believe that to our satisfaction the first two problems in the repair of hypospadias have been solved: 1) the adequate correction of the chordee and 2) the formation of an adequate urethra without scarring or contracture. The third and final problem of fistula formation seems to respond well to the principle of the third degree. One may be assured that irrespective of any type of repair some percentage of fistula will occur.
261 Alexander St., Rochester 7, N. Y.
774
HOWARD T. THOMPSON AND WARREN GEORGE
REFERENCES BYARS, L. L.: Surg., Gynec. & Obst., 75: 8, 1942. BYARS, L. L.: Surg., Gynec. & Obst., 92: 149, 1957. BYARS, L. L.: Surg. Clin. N. Amer., 30: 1371, 1950. DAVIS, D. M.: Plastic and Reconstr. Surg., 5: 373, 1950. DouGLAS, BEVERLY: Plastic and Reconstr. Surg., 2: 107, 1953. HAVENS, F. Z. AND BLOCK, A. S.: J. Urol., 61: 1053, 1949. HAVENS, F. Z.: Surg., Gynec. & Obst., 87: 239, 1948. MAcCoLLOM, D. W., LowGINO, L.A. AND MEEKER, I. A.: Surg. Clinics of N. Amer., 36: 1, 1956. McCORMICK, R. M.: Plastic and Reconstr. Surg., 13: 257, 1954. MclNDOE, A.H.: Brit. Med. J., 1: 385, 1937. MclNDOE, A. H.: Brit. J. Plastic Surg., 1: 29, 1948. MclNDOE, A.H.: Am. J. Surg., 38: 176, 1937. YOUNG, F. AND BENJAMIN, J. A.: Surg., Gynec. & Obst., 86: 439, 1948.