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Repair of Hypospadias Complications Using the Meatal Based Flap Urethroplasty
0022-5347 /94/1512-0470$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 151, 470-472, February 1994 Printed in U.S.A.
REPAIR OF HYPOSPADIAS COMPLICATIONS USING THE MEATAL BASED FLAP URETHROPLASTY J. L. TEAGUE,* D. R. ROTH
AND
E. T. GONZALES
From the Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
ABSTRACT
While long used for primary hypospadias repair, meatal based flap urethroplasty has not been widely considered a viable alternative for a secondary procedure. We reviewed 200 patients who underwent meatal based flap urethroplasty and identified 9 (4.5%) who underwent the procedure for correction of complications of previous hypospadias repair, including urethrocutaneous fistula, severe meatal retraction, persistent chordee and hair in the urethra. The complication was corrected with a single operation in 8 of the 9 patients (89%). A single small fistula developed in 3 patients, which closed spontaneously in 2 and required another procedure in 1. Meatal based flap urethroplasty should be considered for correction of distal complications of hypospadias repair. KEY
W OROS: hypospadias, penis, urethra
Repair of hypospadias is a common operation for pediatric urologists. With refinement of the surgical techniques during the last decade, most pediatric hypospadias repairs can be performed on an outpatient basis with minimal morbidity. Although the incidence of complications has decreased substantially during the last 2 decades, secondary procedures to correct complications remain challenging. Two of the most common complications of hypospadias repair are urethrocutaneous fistulas and retraction of the neomeatus. Urethrocutaneous fistulas have been reported to occur with an incidence as high as 34 % depending on the severity of the defect and the type of repair performed. 1 • 2 This complication may be corrected easily if the fistula is small and well away from the glans penis. Unfortunately, many of these fistulas occur at the level of the corona, which can make adequate mobilization and primary closure of the fistula tract difficult. Meatal retraction may be the most common complication following hypospadias. 3 Fortunately, this retraction is usually not functionally significant. However, it may warrant intervention when associated with loss of the distal neourethra to a subcoronal position. The meatal based flap urethroplasty is widely used for primary correction of distal hypospadias. 4 •5 Due to possible disruption of the vascular supply of the flap, conventional surgical wisdom would advise against the meatal based flap for the child with a complication after hypospadias repair. We report on the successful use of the meatal based flap urethroplasty as a secondary procedure to correct urethrocutaneous fistulas, meatal retraction and other distal complications of hypospadias repair. MATERIALS AND METHODS
We reviewed 200 patients in whom a meatal based flap urethroplasty was performed by 1 of us between 1986 and 1991. These records were then reviewed to determine the indications for the procedure and whether a prior operation had been performed. All operative reports were reviewed for evidence of intraoperative complications and to ensure that a meatal based flap urethroplasty had been performed. Notes from office visits were examined to determine the incidence of postoperative complications and final cosmetic result. All procedures were performed by 1 of us. In all cases a Accepted for publication July 23, 1993. The opinions contained herein are those of the authors and do not necessarily reflect those of the Departments of the Air Force, Army or Defense. * Current address: Brooke Army Medical Center, Fort Sam Houston, Texas 78234-6200.
standard Mathieu type meatal based flap urethroplasty was done with optical magnification. Urine was drained per urethram by an 8F silicone catheter or urethral stent secured at the glans penis with 1 or 2 sutures. A compressive penile dressing was used for 2 to 4 days and catheters were left in place for 4 to 7 days. In younger children the catheters drained directly into the diaper while older children were managed with a closed drainage system or were allowed to void through a stent. RESULTS
Meatal based flap urethroplasty was performed for correction of complications related to previous penile surgery in 9 children (4.5% of the total). Prior surgical procedures included meatal advancement and glanuloplasty (MAGPI procedure) in 1 case, meatal based flap urethroplasty in 4, transverse island urethroplasty in 1, 2-stage urethroplasty in 1, release of chordee in 1 and an unspecified procedure in 1. Average patient age at the secondary procedure was 5.7 years (range 1 to 15). The interval from initial surgery to secondary meatal based flap urethroplasty was greater than 6 months in all patients. Complications that necessitated reoperation included urethrocutaneous fistulas (4 patients), retraction of the neomeatus (4), residual chordee (2) and hair in the distal neourethra (1, see table). Three patients had multiple complications. CASE HISTORY
A 3-year-old boy underwent meatal based flap urethroplasty for distal hypospadias. A urethral catheter was left in place for 5 days. Following removal of the catheter, the neourethra retracted to the level of the corona. At age 10 years he presented for repair of the meatal retraction. Examination at that time revealed a straight phallus with the meatus at the level of the corona (fig. 1). The surrounding tissue was supple without Study population Pt.-Age JC -11 yrs. DL-2 yrs. DT-lyr, MR-6 mos. JC -10 yrs. MV-7 yrs. JM-10 yrs. GE-3 yrs. CC -2 yrs.
470
Previous Operation 2-stage urethroplasty
Complication
Residual chordee, meatal retraction Transverse island flap Fistula Meatal based flap, Fistula fistulectomy Meatal based flap Fistula Meatal based flap Meatal retraction Meatal based flap Meatal retraction Hair in urethra, fistula Unknown Chordee release Meatal retraction, residual chordee MAGPI Meatal retraction
REPAIR OF HYPOSPADJ:AS COMPUCAT!ONS USJ:NG MEATAL BASED FLAP DRETHROPLASTY
FIG. 1. Meatal retraction due to loss of neourethra following Mathieu hypospadias repair.
471
evidence of fibrosis. At operation a repeat meatal based flap was outlined (fig. 2) and elevated from the underlying urethra without difficulty (fig. 3, A). The flap was rotated distally to advance the meatus to the tip of the glans (fig. 3, B). All incisions were closed primarily with subcuticular absorbable suture~ (fig. 4). Postoperatively, the patient did well with an excellent cosmetic result. As illustrated by this case, the meatal based flap urethroplasty is effective in advancing the meatus on the glans. Use of this technique to close urethrocutaneous fistulas has achieved similar success. No intraoperative complications related to the secondary meatal based flap urethroplasty were identified. Specifically, there was no increased difficulty in dissection of the meatal based flap within the previously operated field. Mobility of the flap did not present a problem even if the meatal based flap crossed a suture line from the prior operation. Postoperative complications occurred in 3 of the 9 patients (33%), consisting of a single, small urethrocutaneous fistula in the area of the repair. Two of these fistulas closed spontaneously. One patient suffered a postoperative hematoma that resolved with conservative therapy. Only 1 patient required another procedure following the secondary meatal based flap urethroplasty, for a reoperation rate of 11 %. DISCUSSION
Fm. 2. Meatal based flap outlined on ventral surface of penis in preparation for secondary urethroplasty.
Distal complications following hypospadias repair, including urethrocutaneous fistulas and meatal retraction, occur regardless of the type of repair performed. In our patients who presented for correction of surgical complications the severity of the original defects varied widely and they had previously undergone several different types of repairs. The type of previous repair did not hinder the effectiveness of the secondary meatal based flap urethroplasty. Complications are an unfortunate consequence of hypospadias repair, 1• 4 • 5 ranging from a small fistula that requires only simple closure to complete loss of the neourethra requiring total reconstruction. The incidence of fistulas after primary urethroplasty has been reported to range from less than 1 % following the MAGPI procedure 6 to as high as 34% following transverse island preputial flap repair or free grafts. 1 • 2 With the use of optical magnification and fine suture material, this incidence can be significantly decreased but rarely does it reach zero. 7 Late meatal retraction has been reported in as many as 95% of the patients following a MAGPI procedure, although this retraction is rarely functionally significant. 3 The incidence of retraction can be significantly decreased by proper patient selection and surgical experience. 6 Surgical therapy of these complications can be challenging. The most abundant source of tissue for the creation of a neourethra, the prepuce, has generally been used or removed in the initial repair. Therefore, another source of tissue suitable for urethroplasty must be found if a second neourethra or closure of a large fistula is required. Urologists have used scrotal flaps, free grafts of extragenital skin, bladder mucosa, ureter, tunica vaginalis and buccal mucosa8 in an attempt to identify the perfect urethral substitute. An alternative that is often overlooked in secondary urethroplasty is the use of meatal based skin flaps. Many techniques using a meatal based flap have been described for the unoperated penis and, with creative dissection, a defect of several centimeters can be bridged. While the use of local skin flaps has long been considered an excellent choice in the patient undergoing primary repair, it has generally been considered unwise to use such a flap in a patient who has already undergone penile surgery. In these patients the meatal flap is based within a previously operated field. This surgery may have caused disruption of the native vasculature and lymphatic outflow thereby interfering with survival of the flap. In addition, the flap would probably have to cross 1 or more suture lines from
472
REPAIR OF HYPOSPADIAS COMPLICATIONS USING MEATAL BASED FLAP URETHROPLASTY
FIG. 3. A, meatal based flap elevated and glans wings developed. Note use of Scott retractor to secure phallus. B, meatal based flap rotated distally to create neourethra.
difficult cases. Of 9 patients so treated 8 did well with complete correction of the previous surgical complication during 1 procedure. This result compares favorably with other forms of therapy. 2• 5• 8• 9 Although 3 patients did have a small fistula postoperatively, 2 of them closed spontaneously. We believe that concerns regarding the vascularity of a secondary meatal based flap urethroplasty are overstated. The reason for this finding may be related to the method of skin coverage used during primary urethroplasty. In most primary hypospadias repairs the well vascularized dorsal preputial skin is rotated ventrally to cover any skin defect. Indeed, the blood supply of this dorsal skin may be better than that of the dysplastic ventral skin that usually surrounds a hypospadiac meatus, which may explain why this ventral skin can be safely mobilized during a secondary meatal based flap urethroplasty. The mobility of a secondary meatal based flap did not present a problem even if the flap crossed a suture line. Because we waited at least 6 months from the initial operation, the suture lines were soft and pliable. If this were not the case, the flap could be directed circumferentially around the shaft of the penis to obtain adequate length and avoid fibrotic regions. In light of our experience, we suggest consideration of a meatal based flap urethroplasty for boys with distal urethral complications following hypospadias repair. Unless the skin surrounding the meatus is unusually fibrotic, a viable meatal based flap can be readily created. With proper surgical technique and experience, the procedure can be performed with a complication rate not much greater than that of primary procedures.
FIG. 4. Completed repair with urethral stent in place
the previous urethroplasty, which could make the dissection difficult and possibly endanger the underlying urethra. For these reasons, the meatal based flap has not been widely used as a secondary technique. Our data demonstrate, however, that the procedure can be used safely and effectively in these
REFERENCES 1. Dewan, P. A., Dinneen, M. D., Winkle, D., Duffy, P. G. and Ransley, P. G.: Hypospadias: Duckett pedicle tube urethroplasty. Eur. Urol., 20: 39, 1991. 2. Rober, P. E., Perlmutter, A. D. and Reitelman, C.: Experience with 81, 1-stage hypospadias/chordee repairs with free graft urethroplasties. J. Urol., part 2, 144: 526, 1990. 3. Hastie, K. J., Deshpande, S. S. and Moisey, C. U.: Long-term follow-up of the MAGPI operation for distal hypospadias. Brit. J. Urol., 63: 320, 1989. 4. Rickwood,. A. M. and Anderson, P. A.: One-stage hypospadias repair: experience of 367 cases. Brit. J. Urol., 67: 424, 1991. 5. de Badiola, F., Anderson, K. and Gonzalez, R.: Hypospadias repair in an outpatient setting without proximal urinary diversion: experience with 113 urethroplasties. J. Ped. Surg., 26: 461, 1991. 6. Duckett, J. W. and Snyder, H. M., III: Meatal advancement and glanuloplasty hypospadias repair after 1,000 cases: avoidance of meatal stenosis and regression. J. Urol., 147: 665, 1992. 7. Kass, E. J. and Bolong, D.: Single stage hypospadias reconstruction without fistula. J. Urol., part 2, 144: 520, 1990. 8. Burger, R. A., Muller, S. C., El-Damanhoury, H., Tschakaloff, A., Riedmiller, H. and Hohenfellner, R.: The buccal mucosal graft for urethral reconstruction: a preliminary report. J. Urol., 147: 662, 1992. 9. Spencer, J. R. and Perlmutter, A. D.: Sleeve advancement distal hypospadias repair. J. Urol., part 2, 144: 523, 1990.
Vol. 151, 470-472, February 1994 Printed in U.S.A.
REPAIR OF HYPOSPADIAS COMPLICATIONS USING THE MEATAL BASED FLAP URETHROPLASTY J. L. TEAGUE,* D. R. ROTH
AND
E. T. GONZALES
From the Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
ABSTRACT
While long used for primary hypospadias repair, meatal based flap urethroplasty has not been widely considered a viable alternative for a secondary procedure. We reviewed 200 patients who underwent meatal based flap urethroplasty and identified 9 (4.5%) who underwent the procedure for correction of complications of previous hypospadias repair, including urethrocutaneous fistula, severe meatal retraction, persistent chordee and hair in the urethra. The complication was corrected with a single operation in 8 of the 9 patients (89%). A single small fistula developed in 3 patients, which closed spontaneously in 2 and required another procedure in 1. Meatal based flap urethroplasty should be considered for correction of distal complications of hypospadias repair. KEY
W OROS: hypospadias, penis, urethra
Repair of hypospadias is a common operation for pediatric urologists. With refinement of the surgical techniques during the last decade, most pediatric hypospadias repairs can be performed on an outpatient basis with minimal morbidity. Although the incidence of complications has decreased substantially during the last 2 decades, secondary procedures to correct complications remain challenging. Two of the most common complications of hypospadias repair are urethrocutaneous fistulas and retraction of the neomeatus. Urethrocutaneous fistulas have been reported to occur with an incidence as high as 34 % depending on the severity of the defect and the type of repair performed. 1 • 2 This complication may be corrected easily if the fistula is small and well away from the glans penis. Unfortunately, many of these fistulas occur at the level of the corona, which can make adequate mobilization and primary closure of the fistula tract difficult. Meatal retraction may be the most common complication following hypospadias. 3 Fortunately, this retraction is usually not functionally significant. However, it may warrant intervention when associated with loss of the distal neourethra to a subcoronal position. The meatal based flap urethroplasty is widely used for primary correction of distal hypospadias. 4 •5 Due to possible disruption of the vascular supply of the flap, conventional surgical wisdom would advise against the meatal based flap for the child with a complication after hypospadias repair. We report on the successful use of the meatal based flap urethroplasty as a secondary procedure to correct urethrocutaneous fistulas, meatal retraction and other distal complications of hypospadias repair. MATERIALS AND METHODS
We reviewed 200 patients in whom a meatal based flap urethroplasty was performed by 1 of us between 1986 and 1991. These records were then reviewed to determine the indications for the procedure and whether a prior operation had been performed. All operative reports were reviewed for evidence of intraoperative complications and to ensure that a meatal based flap urethroplasty had been performed. Notes from office visits were examined to determine the incidence of postoperative complications and final cosmetic result. All procedures were performed by 1 of us. In all cases a Accepted for publication July 23, 1993. The opinions contained herein are those of the authors and do not necessarily reflect those of the Departments of the Air Force, Army or Defense. * Current address: Brooke Army Medical Center, Fort Sam Houston, Texas 78234-6200.
standard Mathieu type meatal based flap urethroplasty was done with optical magnification. Urine was drained per urethram by an 8F silicone catheter or urethral stent secured at the glans penis with 1 or 2 sutures. A compressive penile dressing was used for 2 to 4 days and catheters were left in place for 4 to 7 days. In younger children the catheters drained directly into the diaper while older children were managed with a closed drainage system or were allowed to void through a stent. RESULTS
Meatal based flap urethroplasty was performed for correction of complications related to previous penile surgery in 9 children (4.5% of the total). Prior surgical procedures included meatal advancement and glanuloplasty (MAGPI procedure) in 1 case, meatal based flap urethroplasty in 4, transverse island urethroplasty in 1, 2-stage urethroplasty in 1, release of chordee in 1 and an unspecified procedure in 1. Average patient age at the secondary procedure was 5.7 years (range 1 to 15). The interval from initial surgery to secondary meatal based flap urethroplasty was greater than 6 months in all patients. Complications that necessitated reoperation included urethrocutaneous fistulas (4 patients), retraction of the neomeatus (4), residual chordee (2) and hair in the distal neourethra (1, see table). Three patients had multiple complications. CASE HISTORY
A 3-year-old boy underwent meatal based flap urethroplasty for distal hypospadias. A urethral catheter was left in place for 5 days. Following removal of the catheter, the neourethra retracted to the level of the corona. At age 10 years he presented for repair of the meatal retraction. Examination at that time revealed a straight phallus with the meatus at the level of the corona (fig. 1). The surrounding tissue was supple without Study population Pt.-Age JC -11 yrs. DL-2 yrs. DT-lyr, MR-6 mos. JC -10 yrs. MV-7 yrs. JM-10 yrs. GE-3 yrs. CC -2 yrs.
470
Previous Operation 2-stage urethroplasty
Complication
Residual chordee, meatal retraction Transverse island flap Fistula Meatal based flap, Fistula fistulectomy Meatal based flap Fistula Meatal based flap Meatal retraction Meatal based flap Meatal retraction Hair in urethra, fistula Unknown Chordee release Meatal retraction, residual chordee MAGPI Meatal retraction
REPAIR OF HYPOSPADJ:AS COMPUCAT!ONS USJ:NG MEATAL BASED FLAP DRETHROPLASTY
FIG. 1. Meatal retraction due to loss of neourethra following Mathieu hypospadias repair.
471
evidence of fibrosis. At operation a repeat meatal based flap was outlined (fig. 2) and elevated from the underlying urethra without difficulty (fig. 3, A). The flap was rotated distally to advance the meatus to the tip of the glans (fig. 3, B). All incisions were closed primarily with subcuticular absorbable suture~ (fig. 4). Postoperatively, the patient did well with an excellent cosmetic result. As illustrated by this case, the meatal based flap urethroplasty is effective in advancing the meatus on the glans. Use of this technique to close urethrocutaneous fistulas has achieved similar success. No intraoperative complications related to the secondary meatal based flap urethroplasty were identified. Specifically, there was no increased difficulty in dissection of the meatal based flap within the previously operated field. Mobility of the flap did not present a problem even if the meatal based flap crossed a suture line from the prior operation. Postoperative complications occurred in 3 of the 9 patients (33%), consisting of a single, small urethrocutaneous fistula in the area of the repair. Two of these fistulas closed spontaneously. One patient suffered a postoperative hematoma that resolved with conservative therapy. Only 1 patient required another procedure following the secondary meatal based flap urethroplasty, for a reoperation rate of 11 %. DISCUSSION
Fm. 2. Meatal based flap outlined on ventral surface of penis in preparation for secondary urethroplasty.
Distal complications following hypospadias repair, including urethrocutaneous fistulas and meatal retraction, occur regardless of the type of repair performed. In our patients who presented for correction of surgical complications the severity of the original defects varied widely and they had previously undergone several different types of repairs. The type of previous repair did not hinder the effectiveness of the secondary meatal based flap urethroplasty. Complications are an unfortunate consequence of hypospadias repair, 1• 4 • 5 ranging from a small fistula that requires only simple closure to complete loss of the neourethra requiring total reconstruction. The incidence of fistulas after primary urethroplasty has been reported to range from less than 1 % following the MAGPI procedure 6 to as high as 34% following transverse island preputial flap repair or free grafts. 1 • 2 With the use of optical magnification and fine suture material, this incidence can be significantly decreased but rarely does it reach zero. 7 Late meatal retraction has been reported in as many as 95% of the patients following a MAGPI procedure, although this retraction is rarely functionally significant. 3 The incidence of retraction can be significantly decreased by proper patient selection and surgical experience. 6 Surgical therapy of these complications can be challenging. The most abundant source of tissue for the creation of a neourethra, the prepuce, has generally been used or removed in the initial repair. Therefore, another source of tissue suitable for urethroplasty must be found if a second neourethra or closure of a large fistula is required. Urologists have used scrotal flaps, free grafts of extragenital skin, bladder mucosa, ureter, tunica vaginalis and buccal mucosa8 in an attempt to identify the perfect urethral substitute. An alternative that is often overlooked in secondary urethroplasty is the use of meatal based skin flaps. Many techniques using a meatal based flap have been described for the unoperated penis and, with creative dissection, a defect of several centimeters can be bridged. While the use of local skin flaps has long been considered an excellent choice in the patient undergoing primary repair, it has generally been considered unwise to use such a flap in a patient who has already undergone penile surgery. In these patients the meatal flap is based within a previously operated field. This surgery may have caused disruption of the native vasculature and lymphatic outflow thereby interfering with survival of the flap. In addition, the flap would probably have to cross 1 or more suture lines from
472
REPAIR OF HYPOSPADIAS COMPLICATIONS USING MEATAL BASED FLAP URETHROPLASTY
FIG. 3. A, meatal based flap elevated and glans wings developed. Note use of Scott retractor to secure phallus. B, meatal based flap rotated distally to create neourethra.
difficult cases. Of 9 patients so treated 8 did well with complete correction of the previous surgical complication during 1 procedure. This result compares favorably with other forms of therapy. 2• 5• 8• 9 Although 3 patients did have a small fistula postoperatively, 2 of them closed spontaneously. We believe that concerns regarding the vascularity of a secondary meatal based flap urethroplasty are overstated. The reason for this finding may be related to the method of skin coverage used during primary urethroplasty. In most primary hypospadias repairs the well vascularized dorsal preputial skin is rotated ventrally to cover any skin defect. Indeed, the blood supply of this dorsal skin may be better than that of the dysplastic ventral skin that usually surrounds a hypospadiac meatus, which may explain why this ventral skin can be safely mobilized during a secondary meatal based flap urethroplasty. The mobility of a secondary meatal based flap did not present a problem even if the flap crossed a suture line. Because we waited at least 6 months from the initial operation, the suture lines were soft and pliable. If this were not the case, the flap could be directed circumferentially around the shaft of the penis to obtain adequate length and avoid fibrotic regions. In light of our experience, we suggest consideration of a meatal based flap urethroplasty for boys with distal urethral complications following hypospadias repair. Unless the skin surrounding the meatus is unusually fibrotic, a viable meatal based flap can be readily created. With proper surgical technique and experience, the procedure can be performed with a complication rate not much greater than that of primary procedures.
FIG. 4. Completed repair with urethral stent in place
the previous urethroplasty, which could make the dissection difficult and possibly endanger the underlying urethra. For these reasons, the meatal based flap has not been widely used as a secondary technique. Our data demonstrate, however, that the procedure can be used safely and effectively in these
REFERENCES 1. Dewan, P. A., Dinneen, M. D., Winkle, D., Duffy, P. G. and Ransley, P. G.: Hypospadias: Duckett pedicle tube urethroplasty. Eur. Urol., 20: 39, 1991. 2. Rober, P. E., Perlmutter, A. D. and Reitelman, C.: Experience with 81, 1-stage hypospadias/chordee repairs with free graft urethroplasties. J. Urol., part 2, 144: 526, 1990. 3. Hastie, K. J., Deshpande, S. S. and Moisey, C. U.: Long-term follow-up of the MAGPI operation for distal hypospadias. Brit. J. Urol., 63: 320, 1989. 4. Rickwood,. A. M. and Anderson, P. A.: One-stage hypospadias repair: experience of 367 cases. Brit. J. Urol., 67: 424, 1991. 5. de Badiola, F., Anderson, K. and Gonzalez, R.: Hypospadias repair in an outpatient setting without proximal urinary diversion: experience with 113 urethroplasties. J. Ped. Surg., 26: 461, 1991. 6. Duckett, J. W. and Snyder, H. M., III: Meatal advancement and glanuloplasty hypospadias repair after 1,000 cases: avoidance of meatal stenosis and regression. J. Urol., 147: 665, 1992. 7. Kass, E. J. and Bolong, D.: Single stage hypospadias reconstruction without fistula. J. Urol., part 2, 144: 520, 1990. 8. Burger, R. A., Muller, S. C., El-Damanhoury, H., Tschakaloff, A., Riedmiller, H. and Hohenfellner, R.: The buccal mucosal graft for urethral reconstruction: a preliminary report. J. Urol., 147: 662, 1992. 9. Spencer, J. R. and Perlmutter, A. D.: Sleeve advancement distal hypospadias repair. J. Urol., part 2, 144: 523, 1990.