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PENILE DISASSEMBLY TECHNIQUE FOR EPISPADIAS REPAIR: VARIANTS OF TECHNIQUE
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PENILE DISASSEMBLY TECHNIQUE FOR EPISPADIAS REPAIR
FIG. 5. A, marked dorsal curvature with corpora cavernosa free and erect, lying on anterior abdominal wall. B , curvature is repaired by incisional grafting technique. Erection shows completely straightened corpora cavernosa.
CONCLUSIONS
dinal prominence of the thickened duplicated tunica albuginea. Corporotomies with grafting were necessary to repair these cases without penile shortening. This correction may only be performed in completely free cavernous bodies. There is a risk of damage to the neurovascular bundles during lifting. However, the Cantwell-Ransley technique, which includes dissection of the neurovascular bundles, has proved successful with time. This risk inspired us to introduce 2 variants of the Mitchell technique. In variant 1 the hemiglans and urethral plate are connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. This maneuver does not affect mobility of the tips of the corporeal bodies or their complete dorsal placement. In variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. Our penile disassembly technique enables preservation of the blood supply to the most distal portion of the urethral plate as well as great mobility and an excellent approach to repairing the completely free corpora cavernosa. Our variants of the Mitchell technique have some disadvantages. They cannot be used in newborns, especially for simultaneous exstrophy closure and epispadias repair. These variants are also not recommended for inexperienced surgeons who are unfamiliar with dissecting the penis. Overall this is not a routine procedure.
The Mitchell technique is a great advance in the evolution of epispadias repair. Our variants of this procedure may be good alternatives only in select cases and in the hands of experienced surgeons who are highly familiar with dissecting the penis. More patients and long-term followup are needed t o confirm how our variants of the Mitchell technique fit in the surgical armamentarium of epispadias repair. REFERENCES
1. Ransley, P. G., Duffy, P. G. and Wollin, M.: Bladder exstrophy closure and epispadias repair. In: Rob and Smith's Operative Surgery. Paediatric Surgery, 4th ed. Edited by L. Spitz and H. H. Nixon. Boston: Buttenvorths, pp. 620-622, 1988. 2. Mitchell, M. E. and Bagli, D. J.: Complete penile disassembly for epispadias repair: Mitchell technique. J. Urol., 155 300, 1996. 3. Perovic, S., Djordjevic, M. and Djakovic, N.: Natural erection induced by prostaglandin-El in the diagnosis and treatment of congenital penile anomalies. Brit. J. Urol., 7 9 43, 1997. 4. Cantwell, F. V.: Operative treatment of epispadias by transplantation of the urethra. Ann. Surg., 2 2 689, 1895. 5. Gearhart, J. P.: Editorial: evolution of epispadias repairtiming, techniques and results. J. Urol., 160 177, 1998. 6. Mollard, P., Basset, T. and Mure, P. Y.: Male epispadias: experience with 45 cases. J. Urol., 160 55, 1998. 7. Zaontz, M. R., Steckler, R. E., Dairiki Shortliffe, L. M., Kogan, B. A. and Tekgul, S.: Multicenter experience with the Mitchell technique for epispadias repair. J. Urol., 160 172, 1998. 8. Grady, R. W. and Mitchell, M. E.: Newborn exstrophy and epispadias repair. World J. Urol., 1 6 200, 1998.
DISCUSSION
Dr. Howard M. Snyder. I am impressed with the experience with the Mitchell dissection. If you start dissection in the mid shaft, the dissection plane is established. By doing that you may preseme the full length of the urethral plate. That combined with increased exposure proximally by taking the corporeal bodies completely apart gives much better exposure. Dr. Sava V.Perovic. My preference in this type of surgery is to find the correct plane, which you may fmd if you approach the mid part of the corpora cavernosa first ventrally and then dorsally, and then go farther proximal and strictly distal to the glans to avoid injury.In this disassembly technique you must be familiar with dissection. I think that there are good conditions of epispadias anatomically for dissecting the penis without a problem. Dr. Michael E. Mitchell. I agree that the initial approach is on the underside of the penis in the mid urethra, where the corpora start to separate. Remember that this is a triangle of tissue. Just follow the corpora around and then go dorsal. Start in the mid portion of the plate on the lateral aspects and follow the tunica albuginea around. Sooner or later you come together.
PENILE DISASSEMBLY TECHNIQUE FOR EPISPADIAS REPAIR
FIG. 5. A, marked dorsal curvature with corpora cavernosa free and erect, lying on anterior abdominal wall. B , curvature is repaired by incisional grafting technique. Erection shows completely straightened corpora cavernosa.
CONCLUSIONS
dinal prominence of the thickened duplicated tunica albuginea. Corporotomies with grafting were necessary to repair these cases without penile shortening. This correction may only be performed in completely free cavernous bodies. There is a risk of damage to the neurovascular bundles during lifting. However, the Cantwell-Ransley technique, which includes dissection of the neurovascular bundles, has proved successful with time. This risk inspired us to introduce 2 variants of the Mitchell technique. In variant 1 the hemiglans and urethral plate are connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. This maneuver does not affect mobility of the tips of the corporeal bodies or their complete dorsal placement. In variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. Our penile disassembly technique enables preservation of the blood supply to the most distal portion of the urethral plate as well as great mobility and an excellent approach to repairing the completely free corpora cavernosa. Our variants of the Mitchell technique have some disadvantages. They cannot be used in newborns, especially for simultaneous exstrophy closure and epispadias repair. These variants are also not recommended for inexperienced surgeons who are unfamiliar with dissecting the penis. Overall this is not a routine procedure.
The Mitchell technique is a great advance in the evolution of epispadias repair. Our variants of this procedure may be good alternatives only in select cases and in the hands of experienced surgeons who are highly familiar with dissecting the penis. More patients and long-term followup are needed t o confirm how our variants of the Mitchell technique fit in the surgical armamentarium of epispadias repair. REFERENCES
1. Ransley, P. G., Duffy, P. G. and Wollin, M.: Bladder exstrophy closure and epispadias repair. In: Rob and Smith's Operative Surgery. Paediatric Surgery, 4th ed. Edited by L. Spitz and H. H. Nixon. Boston: Buttenvorths, pp. 620-622, 1988. 2. Mitchell, M. E. and Bagli, D. J.: Complete penile disassembly for epispadias repair: Mitchell technique. J. Urol., 155 300, 1996. 3. Perovic, S., Djordjevic, M. and Djakovic, N.: Natural erection induced by prostaglandin-El in the diagnosis and treatment of congenital penile anomalies. Brit. J. Urol., 7 9 43, 1997. 4. Cantwell, F. V.: Operative treatment of epispadias by transplantation of the urethra. Ann. Surg., 2 2 689, 1895. 5. Gearhart, J. P.: Editorial: evolution of epispadias repairtiming, techniques and results. J. Urol., 160 177, 1998. 6. Mollard, P., Basset, T. and Mure, P. Y.: Male epispadias: experience with 45 cases. J. Urol., 160 55, 1998. 7. Zaontz, M. R., Steckler, R. E., Dairiki Shortliffe, L. M., Kogan, B. A. and Tekgul, S.: Multicenter experience with the Mitchell technique for epispadias repair. J. Urol., 160 172, 1998. 8. Grady, R. W. and Mitchell, M. E.: Newborn exstrophy and epispadias repair. World J. Urol., 1 6 200, 1998.
DISCUSSION
Dr. Howard M. Snyder. I am impressed with the experience with the Mitchell dissection. If you start dissection in the mid shaft, the dissection plane is established. By doing that you may preseme the full length of the urethral plate. That combined with increased exposure proximally by taking the corporeal bodies completely apart gives much better exposure. Dr. Sava V.Perovic. My preference in this type of surgery is to find the correct plane, which you may fmd if you approach the mid part of the corpora cavernosa first ventrally and then dorsally, and then go farther proximal and strictly distal to the glans to avoid injury.In this disassembly technique you must be familiar with dissection. I think that there are good conditions of epispadias anatomically for dissecting the penis without a problem. Dr. Michael E. Mitchell. I agree that the initial approach is on the underside of the penis in the mid urethra, where the corpora start to separate. Remember that this is a triangle of tissue. Just follow the corpora around and then go dorsal. Start in the mid portion of the plate on the lateral aspects and follow the tunica albuginea around. Sooner or later you come together.