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Modern Treatment of Hypospadias
THE JOURNAL OF UROLOGY
Vol. 67, No. 6, .June 1952 Printed in U.S.A.
MODERN TREATMENT OF HYPOSPADIAS ARTHUR B. CECIL
The modern treatment of hypospadias has been evolved over many years. There are no operations today that have not had their roots in the past. I do not intend to discuss this subject before this association in any didactic manner, but I hope that you will permit me to discuss some phases of the treatment of this deformity. I should first like to say something in regard to the treatment of certain cases of perineal hypospadias, as these present problems not only of today but of tomorrow. When a baby is born, who from external examination it is impossible to say whether it is a case of perineal hypospadias or female pseudohermaphroditism, we as urologists have no more ability to determine its gonadal sex than has a midwife. At no age will any cystoscopic, endoscopic or x-ray examination be of any value whatsoever, nor are there at present any chemical or biological tests for the determination of sex; but this determination must be made and made at once, unless the parents are to take home a child that will wreak as much havoc as if they had taken home a mongolian idiot. From the very moment of birth there is no place in the world for an intersex individual. The first question is, "Is it a boy, or is it a girl?" Within a few hours the State must have a report, later the Church, and make no mistake about the determination of prying neighbors to wreak vengeance on the parents of such a baby. Hmv is this determination to be made, and v,rhen is it to be made? It must be made on the day the baby is born or within the succeeding few days according to the baby's condition by exploratory operation. Coffey, in cases of exstrophy of the bladder, successfully performed uretero-intestinal implants before the mother ever saw the child. Babies stand anesthesia well. They are accustomed to anoxia. Howard has pointed out that the greater the degree of hypospadias the greater the degree of feminism, and that in practically all cases of perineal hypospadias there will be present a vagina, uterus and tubes, so that sex is not to he determined by the finding of these organs but hy gonads alone. Among the problems of today and of tomorrow are to determine whether the chromosomal content of intersex individuals is normal and as to whether it corresponds with the gonadal sex. Since I have started on the discussion of perineal hypospadias, I shall continue with this discussion to the cure of this condition. ,Ve will assume that the penis has been straightened. It has been determined by a vaginogram that the child has a vagina, and the question comes up as to what to do with this vagina. From Howard's observation that a vagina was constantly present in perinea! hypospadias, it occurred to me that since I had cured many cases of perineal hypospadias without removal of the vagina, that simply because I now knew of its presence was no reason for its excision as had been previously advocated. I, therefore, constructed the urethra from the opening of the urogenital sinus Read at annual meeting, American Association of Genito-Urinary Surgeons, Skytop, Pa., May 18, 1951. 1005
'.VIODERN 'rRJDATMEN'l' OF HYPOSPADIAS
1007
to the end of the thus throwing the vagina to empty into the urethra instead of excising it. I am sure that this i:o the best method for dealing with the vagina in cases of perineal hypospadias. I will briefly discuss the treatment of chordee in hypospadias. This operation should be done ,Yhen the child is 2½ years old. A ventral incision is made and the fibrous corpus spongiosum is dissected out. With the penis bent hack over the hand, lateral hindering bands are also dissected out. Scissors are used to free the skin laterally and up under the foreskin ,Yhere right angle cuts are made to lengthen the skin. It is usually necessary to make other lateral cuts near the scrotum or any other region in which lengthening is required, hut at the finish the ventral surface must be smooth without any redundancy or lumpiness of the skin. The incision is carried entirely around a Ko. 14 Foley catheter which has been put into the urethra. As the fibrous tissue is dissected out, the urethra moves backward, but do not cut off the cuff of the urethra as it ,vill not leave enough urethral mucosa to easily reach the surface when healing has taken and stricture will occur. Only spurting vessels are ligated. The urethra is sutured about with interrupted 0-0-0 plain catgut. The subcutaneous tissue and skin are closed with 0-0-0 plain catgut. If tension is present, a dorsal incision may be made ,Yithout suturing. One is usually necessary at the ju11ction of the penis with the abdomen. I have not found it necessary to suture the penis up over the abdomen. The penis is dusted with sulfanilamide powder. A pad is put over and adhesive tape is fastened to the thighs and brought diagonally across and another piece directly up the midline, so that the penis is in this manner up over the abdomen, but the strapping must not be tight. The child \\-ill require some sedation. A 2½ year old child can be kept reasonably comfortable with 1\ gr. of morphine every 4~6 hours and one, 1 gr. nembutal suppository at night which may be repeated. The catheter is connected -with a bottle by a plastic tube. On the fourth day, the dressings are removed and the catheter is removed. There will then develop considerable edema of the penis which will subside within about three days and is of no consequence. There are cases in ,vhich the penis is in marked ventral curvature, and in ,vhich from the region of the frenum to the urethra there is very little of the corpus spongiosum, but proximal to this, one will feel a dense fibrous corpus spongiosum running down to the region of the bulb. Just as the urethra lies belmY the corpus spongiosum in the ordinary case of hypospadias, so, too, in these cases, it lies below the fibrous bulb. This fibrous band must be dissected out just as if it ,vere anterior to the urethra. I do not believe that operations for transplanting the foreskin to the ventral surface of the penis are of value. In fact, I think they are a distinct drawback ·when it comes to building the urethra, nor do I believe that operations that have been devised for transplanting the foreskin to the dorsal surface of the penis are of value. Diversion of the urinary stream is necessary for a successful urethroplasty. Culp has very successfully used a retention catheter, thus avoiding an external urethrotomy. I have previously described a method for doing external urethrotomy in hypospadias. This consists of passing a Ko. 16 Foley catheter through
1008
ARTHUR B. CECIL
the urethra into the bladder, and passing it in for a considerable distance so that the catheter is curled up in the bladder. Now, a straight stylet about 8 inches in length (I use a bone pin), is passed down through the catheter so that its tip within the catheter can be used to make the catheter prominent in the perineum. Having cut down upon the catheter, the stylet is used to lift the catheter into the wound, which is then grasped with a pair of forceps to keep the proximal end of the catheter from being pulled out of the bladder. The distal end is caught by a pair of forceps and pulled out through the perineal incision. To do this, it is advisable to cut off part of the funnel tip of the catheter. The object in using a straight stylet is that it is easily introduced and, what is more important, is easily removed (fig. 1). 2
Fm. 1. Cecil operation for external urethrotomy drainage
The urethroplasty is best done between 4 and 5 years of age. Like tonsillectomy, children stand this operation better than older individuals. Erections do no damage to these children, but if one has to operate upon an individual beyond the age of puberty, erections are best combated by leaving nothing to chance, and every night for at least 5 or 6 nights, give HMO No. 2 or less quantity according to the age of the patient. I believe this is far more satisfactory and direct than depending upon estrogens or bromides. There are four technical essentials for the construction of a urethra in hypospadias: 1) lack of tension; 2) a strip of undetached skin running from thehypospadias opening to the tip of the penis; 3) broad-bearing surfaces; 4) diversion of the urinary stream either by external urethrotomy or by retention catheter as advocated by Culp. An operation which I have previously described and which has been used with uniformly good results by Cabot, Culp, Kimbrough and others, I believe most perfectly fulfills these requirements.
MODERN TREATMENT OF HYPOSPADIAS
1000
The operation which I devised is a modification of Bucknall's operation. The Bucknall operation had much in its favor, but there -was one fault, namely, that in using the skin of the scrotum to form a part of the urethra, hair grew into the urethra and calculi formed on these hairs. It, therefore, occurred to me that it was not necessary to use any skin from the scrotum whatsoever, and so I devised an operah011 in which the urethra vrns formed from the skin of the penis and this -was then buried in a midline incision in the scrotum. In cases of bifid scrotum or perineal hypospadias, a layer of deep scrotal tissue is inter-
3
4
6
Fm. 2. Cecil operation for hypospadias
posed to cover the scrotal segment of the new channel. (Culp.) The steps of this operation are illustrated in figures 2, 3 and 4. The sutures used for constructing the tube are 4-0 plain catgut, and this same material is used for fastening the penis to the subcutaneous scrotal tissues. The skin layer is closed with interrupted silk. At the conclusion of the operation sulfa powder is dusted on the wound and no dressing is applied. Culp's report last year before the American Urological Association on the use of this operation is one of the most comprehensive reports that has ever been published on the cure of hypospadias. Among the cured cases reported were 5 patients ,-rho had had t,Yo or more failures in the construction of the
1010
AR'l'HUR B. CECIL
r
FIG. 3. Cecil operation to be used in cases of bifid scrotum or perinea! hypospadias
FIG. 4. Cecil operation for urethral fistulas
urethra, and 1 patient who was cured after 9 previous operations. The operation is not only one of the most satisfactory for the cure of hypospadias but, as I have previously pointed out, for cure of urethral fistulas. It will undoubtedly play a large part in the treatment of war injuries of the urethra.
MODERN TREATMENT OF HYPOSPADIAS
1011
Denis Browne has recently revived an operation that was first described and illustrated by Duplay in 1880 and again in 1886, and was reviewed by me in 1936 in Modern Urology edited by Cabot. Duplay first originated the idea that a strip of skin left on the ventral surface of the penis, not made into a tube, would when enveloped by broad-bearing lateral flaps develop a urethral tube. He pointed out the value of broad-bearing surfaces in wide dissection of the lateral flaps. He used single sutures which were doubly locked, the single sutures not cutting holes as would loops, and sutured the skin edges with fine catgut. He described the dorsal relaxing incision. Duplay reported 5 cases that he had cured by this method. Burns has recently reported a series of cures in which he used the Denis Browne operation. Any operation founded upon the four principles which I have stated will bring about the cure of hypospadias. It is my opinion that no operation will be so uniformly successful at all ages and in all cases, both in hypospadias and in the cure of urethral fistulas, as the technique which I have described. Any operation that requires a child to be in the hospital more than 9 days, or that requires postoperative dilatation, or that results in fistulas, is not a modern operation for hypospadias. 1136 W. Sixth St., Los Angeles 17, Calif. REFERENCES BROWNE, DENIS: Postgrad. Med. J., 25: 367-372, 1949. BROWNE, DENIS: Overseas Postgrad. Med. J., 4: 103-108, 1949. BROWNE, DENIS: Proc. Royal Soc. Med., 42: 466-468, 1949. BURNS, E.: J. Urol., 64: 382-386, 1950. CABOT, H.: Proc. Staff Meet. Mayo Clinic, 10: 796, 1935. CECIL, A. B.: Modern Urology, edited by Cabot. Philadelphia: Lea & Febiger, vol. 1, pp. 115---168, 1936. CECIL, A. B.: J. Urol., 56: 237-242, 1946. CECIL, A. B.: J. Urol., 62: 709-712, 1949. CuLP, 0. S.: J. Urol., 65: 264-274, 1951. DuPLAY, S.: Arch. Gen. d'med., pp. 257-274, 1880. DuPLAY, S.: Internat. Encycl. Surg., 6: 487, 1886. HowARD, F. S.: Surg., Gynec. & Obst., 86: 307-316, 1948.
Vol. 67, No. 6, .June 1952 Printed in U.S.A.
MODERN TREATMENT OF HYPOSPADIAS ARTHUR B. CECIL
The modern treatment of hypospadias has been evolved over many years. There are no operations today that have not had their roots in the past. I do not intend to discuss this subject before this association in any didactic manner, but I hope that you will permit me to discuss some phases of the treatment of this deformity. I should first like to say something in regard to the treatment of certain cases of perineal hypospadias, as these present problems not only of today but of tomorrow. When a baby is born, who from external examination it is impossible to say whether it is a case of perineal hypospadias or female pseudohermaphroditism, we as urologists have no more ability to determine its gonadal sex than has a midwife. At no age will any cystoscopic, endoscopic or x-ray examination be of any value whatsoever, nor are there at present any chemical or biological tests for the determination of sex; but this determination must be made and made at once, unless the parents are to take home a child that will wreak as much havoc as if they had taken home a mongolian idiot. From the very moment of birth there is no place in the world for an intersex individual. The first question is, "Is it a boy, or is it a girl?" Within a few hours the State must have a report, later the Church, and make no mistake about the determination of prying neighbors to wreak vengeance on the parents of such a baby. Hmv is this determination to be made, and v,rhen is it to be made? It must be made on the day the baby is born or within the succeeding few days according to the baby's condition by exploratory operation. Coffey, in cases of exstrophy of the bladder, successfully performed uretero-intestinal implants before the mother ever saw the child. Babies stand anesthesia well. They are accustomed to anoxia. Howard has pointed out that the greater the degree of hypospadias the greater the degree of feminism, and that in practically all cases of perineal hypospadias there will be present a vagina, uterus and tubes, so that sex is not to he determined by the finding of these organs but hy gonads alone. Among the problems of today and of tomorrow are to determine whether the chromosomal content of intersex individuals is normal and as to whether it corresponds with the gonadal sex. Since I have started on the discussion of perineal hypospadias, I shall continue with this discussion to the cure of this condition. ,Ve will assume that the penis has been straightened. It has been determined by a vaginogram that the child has a vagina, and the question comes up as to what to do with this vagina. From Howard's observation that a vagina was constantly present in perinea! hypospadias, it occurred to me that since I had cured many cases of perineal hypospadias without removal of the vagina, that simply because I now knew of its presence was no reason for its excision as had been previously advocated. I, therefore, constructed the urethra from the opening of the urogenital sinus Read at annual meeting, American Association of Genito-Urinary Surgeons, Skytop, Pa., May 18, 1951. 1005
'.VIODERN 'rRJDATMEN'l' OF HYPOSPADIAS
1007
to the end of the thus throwing the vagina to empty into the urethra instead of excising it. I am sure that this i:o the best method for dealing with the vagina in cases of perineal hypospadias. I will briefly discuss the treatment of chordee in hypospadias. This operation should be done ,Yhen the child is 2½ years old. A ventral incision is made and the fibrous corpus spongiosum is dissected out. With the penis bent hack over the hand, lateral hindering bands are also dissected out. Scissors are used to free the skin laterally and up under the foreskin ,Yhere right angle cuts are made to lengthen the skin. It is usually necessary to make other lateral cuts near the scrotum or any other region in which lengthening is required, hut at the finish the ventral surface must be smooth without any redundancy or lumpiness of the skin. The incision is carried entirely around a Ko. 14 Foley catheter which has been put into the urethra. As the fibrous tissue is dissected out, the urethra moves backward, but do not cut off the cuff of the urethra as it ,vill not leave enough urethral mucosa to easily reach the surface when healing has taken and stricture will occur. Only spurting vessels are ligated. The urethra is sutured about with interrupted 0-0-0 plain catgut. The subcutaneous tissue and skin are closed with 0-0-0 plain catgut. If tension is present, a dorsal incision may be made ,Yithout suturing. One is usually necessary at the ju11ction of the penis with the abdomen. I have not found it necessary to suture the penis up over the abdomen. The penis is dusted with sulfanilamide powder. A pad is put over and adhesive tape is fastened to the thighs and brought diagonally across and another piece directly up the midline, so that the penis is in this manner up over the abdomen, but the strapping must not be tight. The child \\-ill require some sedation. A 2½ year old child can be kept reasonably comfortable with 1\ gr. of morphine every 4~6 hours and one, 1 gr. nembutal suppository at night which may be repeated. The catheter is connected -with a bottle by a plastic tube. On the fourth day, the dressings are removed and the catheter is removed. There will then develop considerable edema of the penis which will subside within about three days and is of no consequence. There are cases in ,vhich the penis is in marked ventral curvature, and in ,vhich from the region of the frenum to the urethra there is very little of the corpus spongiosum, but proximal to this, one will feel a dense fibrous corpus spongiosum running down to the region of the bulb. Just as the urethra lies belmY the corpus spongiosum in the ordinary case of hypospadias, so, too, in these cases, it lies below the fibrous bulb. This fibrous band must be dissected out just as if it ,vere anterior to the urethra. I do not believe that operations for transplanting the foreskin to the ventral surface of the penis are of value. In fact, I think they are a distinct drawback ·when it comes to building the urethra, nor do I believe that operations that have been devised for transplanting the foreskin to the dorsal surface of the penis are of value. Diversion of the urinary stream is necessary for a successful urethroplasty. Culp has very successfully used a retention catheter, thus avoiding an external urethrotomy. I have previously described a method for doing external urethrotomy in hypospadias. This consists of passing a Ko. 16 Foley catheter through
1008
ARTHUR B. CECIL
the urethra into the bladder, and passing it in for a considerable distance so that the catheter is curled up in the bladder. Now, a straight stylet about 8 inches in length (I use a bone pin), is passed down through the catheter so that its tip within the catheter can be used to make the catheter prominent in the perineum. Having cut down upon the catheter, the stylet is used to lift the catheter into the wound, which is then grasped with a pair of forceps to keep the proximal end of the catheter from being pulled out of the bladder. The distal end is caught by a pair of forceps and pulled out through the perineal incision. To do this, it is advisable to cut off part of the funnel tip of the catheter. The object in using a straight stylet is that it is easily introduced and, what is more important, is easily removed (fig. 1). 2
Fm. 1. Cecil operation for external urethrotomy drainage
The urethroplasty is best done between 4 and 5 years of age. Like tonsillectomy, children stand this operation better than older individuals. Erections do no damage to these children, but if one has to operate upon an individual beyond the age of puberty, erections are best combated by leaving nothing to chance, and every night for at least 5 or 6 nights, give HMO No. 2 or less quantity according to the age of the patient. I believe this is far more satisfactory and direct than depending upon estrogens or bromides. There are four technical essentials for the construction of a urethra in hypospadias: 1) lack of tension; 2) a strip of undetached skin running from thehypospadias opening to the tip of the penis; 3) broad-bearing surfaces; 4) diversion of the urinary stream either by external urethrotomy or by retention catheter as advocated by Culp. An operation which I have previously described and which has been used with uniformly good results by Cabot, Culp, Kimbrough and others, I believe most perfectly fulfills these requirements.
MODERN TREATMENT OF HYPOSPADIAS
1000
The operation which I devised is a modification of Bucknall's operation. The Bucknall operation had much in its favor, but there -was one fault, namely, that in using the skin of the scrotum to form a part of the urethra, hair grew into the urethra and calculi formed on these hairs. It, therefore, occurred to me that it was not necessary to use any skin from the scrotum whatsoever, and so I devised an operah011 in which the urethra vrns formed from the skin of the penis and this -was then buried in a midline incision in the scrotum. In cases of bifid scrotum or perineal hypospadias, a layer of deep scrotal tissue is inter-
3
4
6
Fm. 2. Cecil operation for hypospadias
posed to cover the scrotal segment of the new channel. (Culp.) The steps of this operation are illustrated in figures 2, 3 and 4. The sutures used for constructing the tube are 4-0 plain catgut, and this same material is used for fastening the penis to the subcutaneous scrotal tissues. The skin layer is closed with interrupted silk. At the conclusion of the operation sulfa powder is dusted on the wound and no dressing is applied. Culp's report last year before the American Urological Association on the use of this operation is one of the most comprehensive reports that has ever been published on the cure of hypospadias. Among the cured cases reported were 5 patients ,-rho had had t,Yo or more failures in the construction of the
1010
AR'l'HUR B. CECIL
r
FIG. 3. Cecil operation to be used in cases of bifid scrotum or perinea! hypospadias
FIG. 4. Cecil operation for urethral fistulas
urethra, and 1 patient who was cured after 9 previous operations. The operation is not only one of the most satisfactory for the cure of hypospadias but, as I have previously pointed out, for cure of urethral fistulas. It will undoubtedly play a large part in the treatment of war injuries of the urethra.
MODERN TREATMENT OF HYPOSPADIAS
1011
Denis Browne has recently revived an operation that was first described and illustrated by Duplay in 1880 and again in 1886, and was reviewed by me in 1936 in Modern Urology edited by Cabot. Duplay first originated the idea that a strip of skin left on the ventral surface of the penis, not made into a tube, would when enveloped by broad-bearing lateral flaps develop a urethral tube. He pointed out the value of broad-bearing surfaces in wide dissection of the lateral flaps. He used single sutures which were doubly locked, the single sutures not cutting holes as would loops, and sutured the skin edges with fine catgut. He described the dorsal relaxing incision. Duplay reported 5 cases that he had cured by this method. Burns has recently reported a series of cures in which he used the Denis Browne operation. Any operation founded upon the four principles which I have stated will bring about the cure of hypospadias. It is my opinion that no operation will be so uniformly successful at all ages and in all cases, both in hypospadias and in the cure of urethral fistulas, as the technique which I have described. Any operation that requires a child to be in the hospital more than 9 days, or that requires postoperative dilatation, or that results in fistulas, is not a modern operation for hypospadias. 1136 W. Sixth St., Los Angeles 17, Calif. REFERENCES BROWNE, DENIS: Postgrad. Med. J., 25: 367-372, 1949. BROWNE, DENIS: Overseas Postgrad. Med. J., 4: 103-108, 1949. BROWNE, DENIS: Proc. Royal Soc. Med., 42: 466-468, 1949. BURNS, E.: J. Urol., 64: 382-386, 1950. CABOT, H.: Proc. Staff Meet. Mayo Clinic, 10: 796, 1935. CECIL, A. B.: Modern Urology, edited by Cabot. Philadelphia: Lea & Febiger, vol. 1, pp. 115---168, 1936. CECIL, A. B.: J. Urol., 56: 237-242, 1946. CECIL, A. B.: J. Urol., 62: 709-712, 1949. CuLP, 0. S.: J. Urol., 65: 264-274, 1951. DuPLAY, S.: Arch. Gen. d'med., pp. 257-274, 1880. DuPLAY, S.: Internat. Encycl. Surg., 6: 487, 1886. HowARD, F. S.: Surg., Gynec. & Obst., 86: 307-316, 1948.