- Email: [email protected]
Surgical correction of incomplete penoscrotal transposition associated with hypospadias
Surgical Correction of Incomplete Penoscrotal Transposition Associated With Hypospadias By Yoshinori Mori and Fumihiko Ikoma
Nishinomiya, Hyogo, Japan • A surgical technique for correction of incomplete penoscrotal transposition associated with hypospadias is presented. An inverted ~ skin incision is made around the scrotal skin, and the base of the penis and scrotal flaps are brought beneath the penis. The operation is performed after the completion of hypospadiac repair. This technique was applied to 20 cases and cosmetic results were satisfactory. © 1 9 8 6 by Grune & Stratton. Inc. INDEX WORDS: Hypospadias; penoscrotal transposition.
TRANSPOSITION is a rare p ~ENOSCROTAL anomaly of external genitalia. This anomaly may be partial or complete. Embryologically, the labioscrotal swellings are still anterior to the genital tubercle at 9 to 10 weeks of gestation when a formulation of the tubular urethra from the urethral folds occurs. Normally, therefore, the labioscrotal swellings migrate caudally and fusion at midline with formation of the scrotum takes place. When this caudal migration of the labioscrotal swellings is disturbed, the event leads to the development of a penoscrotal transposition. Penoscrotal transposition of incomplete form is sometimes associated with hypospadias, especially with hypospadias of proximal types. Surgical correction of the anomaly is necessary except for mild cases. At the Department of Urology, Hyogo College of Medicine, Japan, scrotoplasties for repair of penoscrotal transposition associated with hypospadias were performed in 20 pediatric cases with satisfactory results during nine years from 1974 to 1982. Herein, we would like to describe our technique of scrotoplasty for penoscrotal transposition of incomplete type.
hypospadia perinealis are common. Incidence of penoscrotal transposition in hypospadias in our department in 20 in 391 hypospadiac cases (5.1%). M A T E R I A L S A N D M E TH OD S
Our method of scrotoplasty for repair of incomplete penoscrotal transposition is shown schematically in Figs 1-3. An inverted fl skin incision was made around the scrotal skin and base of the penis (Fig 1). Scrotal flaps were prepared with abundant subcutaneous tissue and these were brought together beneath the penis (Fig 2). These scrotal flaps were sutured in a straight line or in Z form (Fig 3). These sutures were made in two layers: subcutaneous tissue with 3-0 or 4-0 chromic catgut and skin with 4-0 nylon. We performed this scrotoplasty six months after the completion of hypospadiac repair (chordeectomy and urethroplasty). Cosmetic results of this operation were excellent. Compared with a preoperative condition (Fig 4), a satisfactory male type external genitalia with correction of penoserotal transposition was formed postoperatively (Fig 5). Complication of the operation was seen in only one case. In this case, a ventral curvature of the penis was noted due to scar formation. This was corrected by penile skin plasty.
DISCUSSION
Several methods of operation for correction of the penoscrotal transposition have been reported. Campbell ~ bisected the scrotum and sutured the two halves beneath the penis. McIlvoy and Harris 2 placed the penis anterior to the scrotum through a subcutaneous tunnel. Glenn and Anderson 3 completely mobilized the two halves of the scrotum as rotational advancement flaps with relocation of the scrotal compartment in a normal dependent position. Ehrlich and Scardino 4 reported an operation similar to that by Glenn and Anderson with some modifications. We think the principle of the operation for correction of penoscrotal transposition should be moving the scrotum posteriorTable 1. Age at Operation
CASE REPORTS
Age at operation of 20 cases of penoscrotal transposition is shown in Table 1. Two-thirds of the patients were children of less than ten years old. Degree of hypospadias in those cases is shown in Table 2. Hypospadias of proximal type, namely hypospadia scrotalis and
From the Department of Urology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan. Address reprint requests to Yoshinori Mori, MD, Department of Urology, Hyogo College of Medicine, Mukogawa-cho 1-1, Nishinomiya, Hyogo, 663, Japan. © 1986 by Grune & Stratton, Inc. 0022-3468/86/2101~9016503.00/0
46
Age (yr)
No. of Patients
4
2
5 6 7
2 2 2
8
4
9 10 11 12 13 14 15
3 0 1 2 0
0 2
Journalof PediatricSurgery,Vol 21, No 1 (January), 1986: pp 46-48
47
REPAIR OF PENOSCROTAL TRANSPOSITION
Table 2, Degree of Hypospadias in 20 Cases of Penoscrotal Transposition Associated With Hypospadias Degree of Hypospadias Hypospadia Hypospadia Hypospadia Hypospadia Hypospadia
glans penis penoscrotalis scrotalis perinealis
A
No, of Patients 1 3 4 10 2
-
_
I
Fig 3. Suture of scrotal flaps beneath the penis in a straight line or in Z form, as in this fig.
Fig 1. penis.
Skin incision around the scrotal skin and base of the
Fig 2. tissue.
Preparation of the scrotal flaps w i t h subcutaneous Fig 4.
Preoperative condition in a nine-year-old boy.
48
MORI AND IKOMA
Fig 5. Postoperative condition in an eightyear-old boy.
ly, not moving the penis anteriorly because the crus of the penis is fixed to the pubic bone. W h e n scrotoplasty is performed simultaneously with chordeectomy as in the Glenn-Anderson technique, a part of scrotal skin is integrated to future urethra and hair-bearing problems can occur. We performed scrotoplasy as a separate operation following chordeectomy and urethroplasty. W e think that the final results are better when this operative procedure is performed after hypospadiac repair.
REFERENCES
1. Campbell MF: Anomalies of the genital tract, in Campbell MF, Harrison JH (eds): Urology (ed 3). Philadelphia, Saunders, 1970, p 1576-1577 2. McIlvoy DB, Harris HS: Transposition of the penis and scrotum; case report. J Urol 73:540 543, 1955 3. Glenn JF, Anderson EE: Surgical correction of incomplete penoscrotal transposition. J Urol 110:603-605, 1973 4. Ehrlich RM, Scardino PT: Surgical correction of scrotal transposition and perineal hypospadias. J Pediatr Surg 17:175-177, 1982
Nishinomiya, Hyogo, Japan • A surgical technique for correction of incomplete penoscrotal transposition associated with hypospadias is presented. An inverted ~ skin incision is made around the scrotal skin, and the base of the penis and scrotal flaps are brought beneath the penis. The operation is performed after the completion of hypospadiac repair. This technique was applied to 20 cases and cosmetic results were satisfactory. © 1 9 8 6 by Grune & Stratton. Inc. INDEX WORDS: Hypospadias; penoscrotal transposition.
TRANSPOSITION is a rare p ~ENOSCROTAL anomaly of external genitalia. This anomaly may be partial or complete. Embryologically, the labioscrotal swellings are still anterior to the genital tubercle at 9 to 10 weeks of gestation when a formulation of the tubular urethra from the urethral folds occurs. Normally, therefore, the labioscrotal swellings migrate caudally and fusion at midline with formation of the scrotum takes place. When this caudal migration of the labioscrotal swellings is disturbed, the event leads to the development of a penoscrotal transposition. Penoscrotal transposition of incomplete form is sometimes associated with hypospadias, especially with hypospadias of proximal types. Surgical correction of the anomaly is necessary except for mild cases. At the Department of Urology, Hyogo College of Medicine, Japan, scrotoplasties for repair of penoscrotal transposition associated with hypospadias were performed in 20 pediatric cases with satisfactory results during nine years from 1974 to 1982. Herein, we would like to describe our technique of scrotoplasty for penoscrotal transposition of incomplete type.
hypospadia perinealis are common. Incidence of penoscrotal transposition in hypospadias in our department in 20 in 391 hypospadiac cases (5.1%). M A T E R I A L S A N D M E TH OD S
Our method of scrotoplasty for repair of incomplete penoscrotal transposition is shown schematically in Figs 1-3. An inverted fl skin incision was made around the scrotal skin and base of the penis (Fig 1). Scrotal flaps were prepared with abundant subcutaneous tissue and these were brought together beneath the penis (Fig 2). These scrotal flaps were sutured in a straight line or in Z form (Fig 3). These sutures were made in two layers: subcutaneous tissue with 3-0 or 4-0 chromic catgut and skin with 4-0 nylon. We performed this scrotoplasty six months after the completion of hypospadiac repair (chordeectomy and urethroplasty). Cosmetic results of this operation were excellent. Compared with a preoperative condition (Fig 4), a satisfactory male type external genitalia with correction of penoserotal transposition was formed postoperatively (Fig 5). Complication of the operation was seen in only one case. In this case, a ventral curvature of the penis was noted due to scar formation. This was corrected by penile skin plasty.
DISCUSSION
Several methods of operation for correction of the penoscrotal transposition have been reported. Campbell ~ bisected the scrotum and sutured the two halves beneath the penis. McIlvoy and Harris 2 placed the penis anterior to the scrotum through a subcutaneous tunnel. Glenn and Anderson 3 completely mobilized the two halves of the scrotum as rotational advancement flaps with relocation of the scrotal compartment in a normal dependent position. Ehrlich and Scardino 4 reported an operation similar to that by Glenn and Anderson with some modifications. We think the principle of the operation for correction of penoscrotal transposition should be moving the scrotum posteriorTable 1. Age at Operation
CASE REPORTS
Age at operation of 20 cases of penoscrotal transposition is shown in Table 1. Two-thirds of the patients were children of less than ten years old. Degree of hypospadias in those cases is shown in Table 2. Hypospadias of proximal type, namely hypospadia scrotalis and
From the Department of Urology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan. Address reprint requests to Yoshinori Mori, MD, Department of Urology, Hyogo College of Medicine, Mukogawa-cho 1-1, Nishinomiya, Hyogo, 663, Japan. © 1986 by Grune & Stratton, Inc. 0022-3468/86/2101~9016503.00/0
46
Age (yr)
No. of Patients
4
2
5 6 7
2 2 2
8
4
9 10 11 12 13 14 15
3 0 1 2 0
0 2
Journalof PediatricSurgery,Vol 21, No 1 (January), 1986: pp 46-48
47
REPAIR OF PENOSCROTAL TRANSPOSITION
Table 2, Degree of Hypospadias in 20 Cases of Penoscrotal Transposition Associated With Hypospadias Degree of Hypospadias Hypospadia Hypospadia Hypospadia Hypospadia Hypospadia
glans penis penoscrotalis scrotalis perinealis
A
No, of Patients 1 3 4 10 2
-
_
I
Fig 3. Suture of scrotal flaps beneath the penis in a straight line or in Z form, as in this fig.
Fig 1. penis.
Skin incision around the scrotal skin and base of the
Fig 2. tissue.
Preparation of the scrotal flaps w i t h subcutaneous Fig 4.
Preoperative condition in a nine-year-old boy.
48
MORI AND IKOMA
Fig 5. Postoperative condition in an eightyear-old boy.
ly, not moving the penis anteriorly because the crus of the penis is fixed to the pubic bone. W h e n scrotoplasty is performed simultaneously with chordeectomy as in the Glenn-Anderson technique, a part of scrotal skin is integrated to future urethra and hair-bearing problems can occur. We performed scrotoplasy as a separate operation following chordeectomy and urethroplasty. W e think that the final results are better when this operative procedure is performed after hypospadiac repair.
REFERENCES
1. Campbell MF: Anomalies of the genital tract, in Campbell MF, Harrison JH (eds): Urology (ed 3). Philadelphia, Saunders, 1970, p 1576-1577 2. McIlvoy DB, Harris HS: Transposition of the penis and scrotum; case report. J Urol 73:540 543, 1955 3. Glenn JF, Anderson EE: Surgical correction of incomplete penoscrotal transposition. J Urol 110:603-605, 1973 4. Ehrlich RM, Scardino PT: Surgical correction of scrotal transposition and perineal hypospadias. J Pediatr Surg 17:175-177, 1982