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Results of Early Hypospadias Surgery Using Optical Magnification
0022-534 7/84/1313-0516$02.00/0 Vol. 131, March Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1984 by The Williams & Wilkins Co.
RESULTS OF EARLY HYPOSPADIAS SURGERY USING OPTICAL MAGNIFICATION JEFFERY W ACKSMAN From the Division of Urology, Department of Surgery, Children's Hospital Medical Center, Cincinnati, Ohio
ABSTRACT
Between 1977 and 1981, 106 children were operated on for hypospadias anomalies. Of these patients 51 have undergone the modified flip-flap urethroplasty or meatal advancement and glanuloplasty, 30 were repaired using a 1-stage Hodgson or Duckett tube urethroplasty, 10 have completed a 2-stage Belt-Fuqua procedure and 15 were treated for multiple complications. A urethrocutaneous fistula developed in 4 patients (4 per cent), meatal stenosis in 3 (3 per cent) and a transient urethral stricture in 1 (1 per cent). All procedures were performed using optical magnification, 2.5 times during the first 1½ years followed by 4.5 times during the subsequent years. In addition, 58 children completed repair before age 2 years, with a mean age of 16 months, with no difference in complication rate. These resuits indicate that through the use of optical magnification hypospadias surgery can be accomplished safely using a 1-stage reconstruction repair before the child is 2 years old. Hypospadias is a disease affecting 1 in 300 live births. During the last 100 years numerous operative procedures have been advocated for children with different degrees of hypospadias. In this series hypospadias was divided into distal penile without significant chordee, penile with deep chordee and penoscrotal. With the more severe forms of hypospadias there exists a greater degree of penile chordee and/or associated penile torsion. Because of these findings (chordee and/or torsion) many surgeons have advocated a 2 or even 3-stage operative procedure. Within the last 15 years Devine and Horton,1 Hodgson 2 and Duckett3 have advocated a 1-stage repair. These procedures are designed to release chordee and to construct a neourethra using the penile preputial foreskin. To treat the more distal hypospadias urologists have advocated a 1-stage procedure. Recently, the advent of optical magnification has allowed the surgeon to accomplish a higher number of 1-stage repairs in children at a younger over-all age. METHODS
Between 1977 and 1981, 106 children were operated on using optical magnification (2.5 times in the early years and 4.5 times in the last 2 years). Surgical technique involved the use of fine (5 or 6-zero chromic) suture and a watertight anastomosis. Suture lines were secured with interrupted full thickness sutures and no attempt was made to create an inverting subcuticular closure. Urinary diversion was established with an indwelling 8F silicone catheter. In addition, a 12F suprapubic cystocatheter was used in tube graft urethroplasties or hypospadias cripples. Urethral catheters were left in place for 5 to 7 days and all patients had a compression dressing as well as systemic antimicrobial therapy. Children included in the series were followed for at least 6 months. Distal penile hypospadias. Of 51 children who presented with distal penile hypospadias 46 underwent a modification of the flip-flap urethroplasty (fig. 1),4 while 5 underwent meatal advancement and glanuloplasty. 5 There was 1 urethral fistula that closed spontaneously and 1 meatal stenosis requiring a dorsal meatotomy. No strictures or occult fistulas were seen in 35 patients who had undergone the flip-flap procedures and were examined under anesthesia. All urethras calibrated to lOF. In addition, 30 children were <2 years old at the time of repair, with a mean age at surgery of 15 months. There was no Accepted for publication September 2, 1983. Read at annual meeting of North Central Section, American Urological Association, Marco Island, Florida, October 17-23, 1982. 516
difference in the complication rates when compared to those in children who underwent repair after they were 2 years old. Penile hypospadias with deep chordee. There were 30 children who underwent a modified Hodgson II2 or a Duckett transverse preputial pedicle flap urethroplasty (fig. 2) 3 for penile hypospadias and associated chordee. A urethral fistula developed in 1 child and required a separate procedure, while a urethral stricture occurred in 1 and responded to cold knife incision. Of the 30 children 20 underwent complete repair before they were 2 years old, with a mean age of 17 months. No additional findings were noted in 29 children who were assessed under light anesthesia 6 months postoperatively. Proximal penile hypospadias. There were 10 children who underwent the 2-stage Belt-Fuqua modified urethroplasty. 6 Meatal stenosis developed in 1 patient and a urethral fistula occurred in 1, which required subsequent closure. Patient age at the time of the 2-stage procedures was ~2 years in 8 and >2 years in 2. Hypospadias cripples. There were 15 children operated on who were classified as hypospadias cripples. Urethral strictures in 8 patients required a patch graft urethroplasty, while persistent fistulas were repaired in 3. One child had had 13 previous operations. To date, all but 1 patient have subsequently responded to a single surgical procedure.
FIG. 1. A, preoperative appearance of distal penile hypospadias. B, at followup 6 months after modified flip-flap procedure.
517
RES1JLTS 01? E.ARLY HYf'OSPADIAS SUR.GERY {JS[NG· OPTICAL l\1AGi~IFICATI0l'1'
Ouer--all results of 106 patients Fistula Flip-flap urethroplasty (25 of 46 pts. <2 yrs. old) Modified Hodgson II or Duckett transverse preputial pedicle flap urethroplasty (20 of 30 pts. <2 yrs. old) 2-Stage Belt-Fuqua (8 of 10 pts. <2 yrs. old) Hypospadias cripples (15 pts.)
Stricture
Meatal Stenosis
0
l''
1
0
1*
0
l
0
0
All 5 patients who underwent meatal advancement and glanuloplasty were <2
years old. * Patient was <2 years old.
before they were 2 years old, with a mean age of 16 months and with no difference in the complication rate. These results indicate that hypospadias surgery can be performed safely using a 1-stage reconstruction in children <2 years old. Because of the psychological concerns, it is currently our practice to operate on patients between 8 and 14 months old, using a planned 1-stage approach. 9 However, as emphasized by Belman and Kass, 8 this approach must be modified to suit the surgeon's own setting, that is technical expertise and hospital setting. REFERENCES 1. Devine, C.
FIG. 2. A, preoperative appearance of penile hypospadias and chordee. B, at followup 6 months after Duckett transverse preputial island flap urethroplasty. DISCUSSION
Our results show that 81 children have undergone a 1-stage repair, while 10 have completed a 2-stage Belt-Fuqua procedure (see table). Of the 1-stage repairs 50 were completed successfully before age 2 years. Of the 2-stage procedures 8 were completed at age 2½ yearn. Of the 81 children who underwent a 1-stage repair only 4 (5 per cent) «sc1u1Jl"'-' subsequent surgery, while 2 of 25 children (10 per had a 2-stage repair or repair of multiple hypospadias co1mi:m,:at1m1s required a second Recently, Shultz and associates indicated the psy~"V"~'"""~-· advantages of ypos1paii12:s surgery. 7 Their retrospective review of this suggests that an optimal window· may be in children between 8 and 14 months old. Our results in 50 children <2 yearn old illustrate the technical u,c,m,vu,sy of accomplishing early surgery. In uu,rn,wu Bel.man and Kass also have performed successful ypos1Jai:na1s surger<; in children at an early age. 8 From this analysis of 106 children who have undergone hypospadias surgery it appears that the use of optical magnification with fine suture material leads to a fairly low over-all complication rate. In addition, 58 children completed repair
J., Jr. and Horton, C. E.: A one stage hypospadias repair.
J. Urol., 85: 166, 1961. 2. Hodgson, N. B.: Use of vascularized flaps in hypospadias repair. Urol. Clin. N. Amer., 8: 471, 1981. 3. Duckett, J. W.: The island flap technique for hypospadias repair. Urol. Clin. K Amer., 8: 503, 198i. 4. Wacksman, J.: Modification of the one-stage flip-flap procedure to repair distal penile hypospadias. Urol. Clin. N. Amer., 8: 527, 1981. 5. Duckett, J. W.: MAG PI (meatoplasty and glanuloplasty): a procedure for subcoronal hypospadias. UroL Clin. N. Amer., 8: 513, 1981. 6. Hendren, W. H.: The Belt-Fuqua technique for repair of hypospadias. Urol. Clin. N. Amer., 8: 431, 1981. 7. Schultz, J. R., Klykylo, W. M. and Wacksman, J.: Timing of elective hypospadias repair in children. Pediatrics, 71: 342, 1983. 8. Belman, A. B. and Kass, E. J.: Hypospadias repair in children less than 1 year old. J. Urol., 128: 1273, 1982. 9. Wacksman, Jo: Genital surgery timing: psychological and surgical aspects. Dialogo Ped. Urol., 6: 5, May 1983. EDITORIAL COMM:ENT This author has emphasized the value of magnification in undertaking hypospadias repair in children during the first 2 years of life. This concept is important since magnification does more than just make the tissues larger. It develops a conscious awareness of the fine vessels and their handling in assuring the ultimate best result. With the delicate instrumentation and technology now available one can assure the successful result in the vast majority of patients in this early age gi:oup. These successes have the benefit of minimizing the implications of ps'vcttol(Jg1,cal trauma. Series are now beginning to appear with complirates collectively less than 10 per cent and hopefully time, technique and experience will allow us to reduce these even further. Norman B. Hodgson Department of Urology Medical College of Wisconsin Milwaukee, Wisconsin
THE JOURNAL OF UROLOGY
Copyright© 1984 by The Williams & Wilkins Co.
RESULTS OF EARLY HYPOSPADIAS SURGERY USING OPTICAL MAGNIFICATION JEFFERY W ACKSMAN From the Division of Urology, Department of Surgery, Children's Hospital Medical Center, Cincinnati, Ohio
ABSTRACT
Between 1977 and 1981, 106 children were operated on for hypospadias anomalies. Of these patients 51 have undergone the modified flip-flap urethroplasty or meatal advancement and glanuloplasty, 30 were repaired using a 1-stage Hodgson or Duckett tube urethroplasty, 10 have completed a 2-stage Belt-Fuqua procedure and 15 were treated for multiple complications. A urethrocutaneous fistula developed in 4 patients (4 per cent), meatal stenosis in 3 (3 per cent) and a transient urethral stricture in 1 (1 per cent). All procedures were performed using optical magnification, 2.5 times during the first 1½ years followed by 4.5 times during the subsequent years. In addition, 58 children completed repair before age 2 years, with a mean age of 16 months, with no difference in complication rate. These resuits indicate that through the use of optical magnification hypospadias surgery can be accomplished safely using a 1-stage reconstruction repair before the child is 2 years old. Hypospadias is a disease affecting 1 in 300 live births. During the last 100 years numerous operative procedures have been advocated for children with different degrees of hypospadias. In this series hypospadias was divided into distal penile without significant chordee, penile with deep chordee and penoscrotal. With the more severe forms of hypospadias there exists a greater degree of penile chordee and/or associated penile torsion. Because of these findings (chordee and/or torsion) many surgeons have advocated a 2 or even 3-stage operative procedure. Within the last 15 years Devine and Horton,1 Hodgson 2 and Duckett3 have advocated a 1-stage repair. These procedures are designed to release chordee and to construct a neourethra using the penile preputial foreskin. To treat the more distal hypospadias urologists have advocated a 1-stage procedure. Recently, the advent of optical magnification has allowed the surgeon to accomplish a higher number of 1-stage repairs in children at a younger over-all age. METHODS
Between 1977 and 1981, 106 children were operated on using optical magnification (2.5 times in the early years and 4.5 times in the last 2 years). Surgical technique involved the use of fine (5 or 6-zero chromic) suture and a watertight anastomosis. Suture lines were secured with interrupted full thickness sutures and no attempt was made to create an inverting subcuticular closure. Urinary diversion was established with an indwelling 8F silicone catheter. In addition, a 12F suprapubic cystocatheter was used in tube graft urethroplasties or hypospadias cripples. Urethral catheters were left in place for 5 to 7 days and all patients had a compression dressing as well as systemic antimicrobial therapy. Children included in the series were followed for at least 6 months. Distal penile hypospadias. Of 51 children who presented with distal penile hypospadias 46 underwent a modification of the flip-flap urethroplasty (fig. 1),4 while 5 underwent meatal advancement and glanuloplasty. 5 There was 1 urethral fistula that closed spontaneously and 1 meatal stenosis requiring a dorsal meatotomy. No strictures or occult fistulas were seen in 35 patients who had undergone the flip-flap procedures and were examined under anesthesia. All urethras calibrated to lOF. In addition, 30 children were <2 years old at the time of repair, with a mean age at surgery of 15 months. There was no Accepted for publication September 2, 1983. Read at annual meeting of North Central Section, American Urological Association, Marco Island, Florida, October 17-23, 1982. 516
difference in the complication rates when compared to those in children who underwent repair after they were 2 years old. Penile hypospadias with deep chordee. There were 30 children who underwent a modified Hodgson II2 or a Duckett transverse preputial pedicle flap urethroplasty (fig. 2) 3 for penile hypospadias and associated chordee. A urethral fistula developed in 1 child and required a separate procedure, while a urethral stricture occurred in 1 and responded to cold knife incision. Of the 30 children 20 underwent complete repair before they were 2 years old, with a mean age of 17 months. No additional findings were noted in 29 children who were assessed under light anesthesia 6 months postoperatively. Proximal penile hypospadias. There were 10 children who underwent the 2-stage Belt-Fuqua modified urethroplasty. 6 Meatal stenosis developed in 1 patient and a urethral fistula occurred in 1, which required subsequent closure. Patient age at the time of the 2-stage procedures was ~2 years in 8 and >2 years in 2. Hypospadias cripples. There were 15 children operated on who were classified as hypospadias cripples. Urethral strictures in 8 patients required a patch graft urethroplasty, while persistent fistulas were repaired in 3. One child had had 13 previous operations. To date, all but 1 patient have subsequently responded to a single surgical procedure.
FIG. 1. A, preoperative appearance of distal penile hypospadias. B, at followup 6 months after modified flip-flap procedure.
517
RES1JLTS 01? E.ARLY HYf'OSPADIAS SUR.GERY {JS[NG· OPTICAL l\1AGi~IFICATI0l'1'
Ouer--all results of 106 patients Fistula Flip-flap urethroplasty (25 of 46 pts. <2 yrs. old) Modified Hodgson II or Duckett transverse preputial pedicle flap urethroplasty (20 of 30 pts. <2 yrs. old) 2-Stage Belt-Fuqua (8 of 10 pts. <2 yrs. old) Hypospadias cripples (15 pts.)
Stricture
Meatal Stenosis
0
l''
1
0
1*
0
l
0
0
All 5 patients who underwent meatal advancement and glanuloplasty were <2
years old. * Patient was <2 years old.
before they were 2 years old, with a mean age of 16 months and with no difference in the complication rate. These results indicate that hypospadias surgery can be performed safely using a 1-stage reconstruction in children <2 years old. Because of the psychological concerns, it is currently our practice to operate on patients between 8 and 14 months old, using a planned 1-stage approach. 9 However, as emphasized by Belman and Kass, 8 this approach must be modified to suit the surgeon's own setting, that is technical expertise and hospital setting. REFERENCES 1. Devine, C.
FIG. 2. A, preoperative appearance of penile hypospadias and chordee. B, at followup 6 months after Duckett transverse preputial island flap urethroplasty. DISCUSSION
Our results show that 81 children have undergone a 1-stage repair, while 10 have completed a 2-stage Belt-Fuqua procedure (see table). Of the 1-stage repairs 50 were completed successfully before age 2 years. Of the 2-stage procedures 8 were completed at age 2½ yearn. Of the 81 children who underwent a 1-stage repair only 4 (5 per cent) «sc1u1Jl"'-' subsequent surgery, while 2 of 25 children (10 per had a 2-stage repair or repair of multiple hypospadias co1mi:m,:at1m1s required a second Recently, Shultz and associates indicated the psy~"V"~'"""~-· advantages of ypos1paii12:s surgery. 7 Their retrospective review of this suggests that an optimal window· may be in children between 8 and 14 months old. Our results in 50 children <2 yearn old illustrate the technical u,c,m,vu,sy of accomplishing early surgery. In uu,rn,wu Bel.man and Kass also have performed successful ypos1Jai:na1s surger<; in children at an early age. 8 From this analysis of 106 children who have undergone hypospadias surgery it appears that the use of optical magnification with fine suture material leads to a fairly low over-all complication rate. In addition, 58 children completed repair
J., Jr. and Horton, C. E.: A one stage hypospadias repair.
J. Urol., 85: 166, 1961. 2. Hodgson, N. B.: Use of vascularized flaps in hypospadias repair. Urol. Clin. N. Amer., 8: 471, 1981. 3. Duckett, J. W.: The island flap technique for hypospadias repair. Urol. Clin. K Amer., 8: 503, 198i. 4. Wacksman, J.: Modification of the one-stage flip-flap procedure to repair distal penile hypospadias. Urol. Clin. N. Amer., 8: 527, 1981. 5. Duckett, J. W.: MAG PI (meatoplasty and glanuloplasty): a procedure for subcoronal hypospadias. UroL Clin. N. Amer., 8: 513, 1981. 6. Hendren, W. H.: The Belt-Fuqua technique for repair of hypospadias. Urol. Clin. N. Amer., 8: 431, 1981. 7. Schultz, J. R., Klykylo, W. M. and Wacksman, J.: Timing of elective hypospadias repair in children. Pediatrics, 71: 342, 1983. 8. Belman, A. B. and Kass, E. J.: Hypospadias repair in children less than 1 year old. J. Urol., 128: 1273, 1982. 9. Wacksman, Jo: Genital surgery timing: psychological and surgical aspects. Dialogo Ped. Urol., 6: 5, May 1983. EDITORIAL COMM:ENT This author has emphasized the value of magnification in undertaking hypospadias repair in children during the first 2 years of life. This concept is important since magnification does more than just make the tissues larger. It develops a conscious awareness of the fine vessels and their handling in assuring the ultimate best result. With the delicate instrumentation and technology now available one can assure the successful result in the vast majority of patients in this early age gi:oup. These successes have the benefit of minimizing the implications of ps'vcttol(Jg1,cal trauma. Series are now beginning to appear with complirates collectively less than 10 per cent and hopefully time, technique and experience will allow us to reduce these even further. Norman B. Hodgson Department of Urology Medical College of Wisconsin Milwaukee, Wisconsin