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Surgical Treatment of Hypospadias, Especially Scrotal and Perineal
THE JOURNAL OF UROLOGY
Vol. 65, No. 4, April 1951 Printed in U.S.A.
SURGICAL TREATMENT OF HYPOSPADIAS, ESPECIALLY SCROTAL AND PERINEAL DAVID M. DA VIS From the Department of Urology, Jefferson Medical College, Philadelphia, Pa.
The combination of qualities necessary for the surgical treatment of hypospadias is found in comparatively few individuals. One can only say that hurried and ill-considered operations are sure to fail, and that no one should undertake to operate for hypospadias unless he is willing to devote the time and energy necessary for a thorough study of the methods ·which have proved satisfactory, and to a meticulous performance of the operative procedures. After that he may proceed to invent new and improved methods for himself. The method to be used in constructing the new urethra should be determined before the first operation, that for straightening the penis, is carried out. The straightening of the corpora and glans is comparatively easy, but since the ventrum of the penis is greatly lengthened thereby, skin must be found to cover the denuded area. If the prepuce is not to be used for the urethral tube, it is very satisfactory for covering the ventrum of the penis, but if it is to be used, other methods are necessary. By extending the ventral incision along the coronary sulcus on both sides of the frenum in the form of a Y and undermining the skin, it has been found possible to pull the lateral parts of the prepuce around to lengthen the covering of the ventrum without shortening the prepuce (fig. 1). This is important if the prepuce is to be used for a tube-flap. We may then consider the current methods of constructing the urethral tube. I think it is fair to say that the old standard Thiersch-Duplay procedure is definitely outmoded for the penile portion of the repair and should be abandoned. The reason for this is that it superimposes one line of suture on another, so that complete healing almost never occurs, and the usual result is a series of fistulas, large or small, and very difficult to close. In order to avoid the possibility of multiple fistulas, surgeons for a long time have attempted to create a tunnel within the penis, and line it in some manner with epithelium. For this purpose split thickness skin grafts, full thickness skin grafts, pedicle flaps, free grafts of bladder wall, and even pieces of large veins have been used. Many good results have been obtained, but failure has usually been due to necrosis of the graft. In my own experience, the Thiersch-Duplay operation was very satisfactory in the scrotal and perinea! regions, but the frequent occurrence of fistulas in the penile portion caused me to cast about for a better method for the construction of the penile urethra. Young had formed a tube from preputial skin, leaving the pedicle attached in the region of the coronary sulcus and passing the tube through a tunnel in the glans. These tubes usually underwent necrosis, and the obvious reason was that the blood supply was inadequate. Consideration of the vascular Read at annual meeting, Mid-Atlantic Section, American Urological Association, Hot Springs, Va., March 23, 1950. 595
596
DAVID M. DA VIS
system of the penis made it apparent that the arteries supplying blood to the prepuce were on the dorsal surface, near the midline and just beneath the skin, and they coursed from the base of the penis toward its tip. It therefore seemed possible to cut the flap in such a manner that its attachment or pedicle would be at its proximal end instead of at its distal end, and so preserve its blood supply. The attachment was of course at some distance from the tip of the glans, but it was found that the glans could easily be bent or folded back so that its tip reached the area of the attachment, and the whole length of the tube flap could be drawn into the tunnel in the glans (fig. 2). A few trials showed that the blood supply
~
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)!1;'5
~ ~
.PC
Fm. 1. 1, Anterior view of typical penoscrotal hypospadias; 2, L.I. is line of incision for straightening operation. Small quadrilateral piece of skin is excised with underlying fibrous band. Horns of incision extend around into loose preputial skin; 3, edges of incision are undermined; 4, all fibrous bands and adhesions are removed. Corpora must be completely freed. Urethra is separated from the corpora at A for some distance, and all fibrous tissue removed; 5, preputial skin pulled around penis in direction of arrow, giving plenty of skin for linear ventral closure. Penis held up to abdominal wall by rubber band.
was entirely adequate and that sloughing never occurred. The idea at first was to use the preputial tube-flap only for the glandular part of the urethra, but it soon appeared, not only that the prepuce often furnished quite a long tube, but that, owing to the flexibility of the penis, the flap could be cut along the entire length of the dorsum of the penis, right up to the point at its base where hair follicles began to be present in the skin. It is now customary to make the tube flap as long as possible, measure its length, and then make the penile tunnel the same length as the tube flap. In a surprisingly large number of cases of penoscrotal hypospadias, the tube-flap is easily long enough to reach all the way to the meatus, so that no flap-cutting whatever is necessary on the ventral surface,
SURGICAL TREATMENT OF HYPOSPADIAS
597
and the new urethra can immediately be anastomosed with the pre-existing urethra (fig. 3). While it is true that good results can be obtained with free grafts placed in a tunnel, the advantage of the pedicle is that it assures complete viability of the flap in 100 per cent of the cases. The pedicle is cut in about three weeks (fig. 4). The tube flap method places the new urethral meatus at the tip of the glans, where it belongs. I believe that this point is important, particularly from the psychic and emotional point of view. With such a meatus in a well-straightened penis, both the patient and his parents can feel that the condition is indistinguishable from normal and that not even a remnant of malformation remains. This enables them to forget the whole distressing affair, with its implication of hidden weakness.
a
C
\;
FIG. 2. a, Operation for construction of tube-flap. The flap is outlined on the dorsum of the penis; b, flap raised from dorsal surface of corpora; c, flap sutured into a tube; d, tube completed; e, tunnel made from tip of glans, the same length as the tube-flap; f and g, tube drawn into tunnel, penis bent ventrally to bring tip of glans to base of pedicle of tube-flap.
In any tunnelization method, there can be at the maximum, only one postoperative fistula, namely, at the proximal end of the tunnel. The best method for closing such a fistula is the inversion method, described some years ago. 1 The tract is dissected free, with a little rim of external skin, and pulled inside out, so that it projects into the urethral lumen. This method is successful in at least two thirds of cases on the first attempt, and always on the second or third. The pedicle tube-flap method has been so uniformly successful that I have not felt impelled to turn to other methods, in spite of the good results reported. There are other considerations which I believe should carry a good deal of weight. With the pedicle tube-flap method, it is often possible to complete the construction of the entire urethra in one operation. It is never necessary for the patient to wear an apparatus of foreign material in the penis for a long time. 1
Surg., Gynec. & Obst., 71: 790-796, 1940.
598
DAYID M. DA VIS
1
:z.
ti!
3
',-
4
4
5
FIG. 3. FIG. 4. FIG. 3. 1, Manner of making tunnel when tube is long enough to reach meatus. Arrow shows direction in which end of tube is pulled through tunnel. 2, Curved hemostat passed through tunnel to make sure it is large enough; 3, Penis bent backward to receive tube flap. Tube sutured to freshened end of urethra. 4, Manner of anastomosing tube to urethra, end-to-end and mucosa-to-mucosa. Subcutaneous tissues are brought together over this anastomosis, and scrotum drawn up to bury it as deeply as possible. Frn. 4. 1, Manner of dividing pedicle of tube-flap. Grooved director is passed beneath pedicle. 2, After division of pedicle, arteries are ligated. 3, Cut edges of tube fastened to skin of glans with a few sutures; 4, Divided pedicle on dorsum of penis. 5, Skin edges loosely approximated with a few sutures.
Frn. 5. Operation for midscrotal hypospadias. I, Outline (L.I.) of incision. lI, Skin edges undermined, deep tissues of scrotum, including testes, exposed.
SURGICAL TREATMENT OF HYPOSPADIAS
599
It has been conclusively shmvn in a number of my patients that a urethra constructed from a full thickness pedicle tube-flap of preputial skin will grow as the penis grows, and the operation can be done at an early age, usually 4 to 6 years. It is my experience that this is extremely important, not only for the
Fm. 6. III, Strip of skin being sutured into a tube. l\Icanwhile a typical tube-flap has been raised from dorsum of penis and drawn into tunnel (T.F.). End-to-end anastomosis between it and the perineal portion of tube. Stab wound made in perineum well posterior to scrotum, tunnel made to a point near urethra. Urethrotomy made just proximal to meatus; IV, Perinea] part of tube completed and closed over meatus, catheter passed through tunnel and urethrotomy into bladder to divert urine. Closure of scrotal and penile tissues over tube begun.
Fm. 7. V, Closure of scrotum continued, burying new urethra as deeply as possible. Anterior part of incision closed transversely, to bury anastomosis between perinea! part of urethral tube and penile tube-flap as deeply as possible. This pulls penis and scrotum together. Any web formed can be easily divided later. VI, Diagrammatic cross section shmving situation after operation when pedicle of the tube-flap is divided. 1Inlined scrotal tunnel heals quickly after the catheter is withdrawn.
sake of the patient, but especially for the sake of the parents, who usually suffer emotionally from the congenital defects of their offspring more than the patients themselves do. The more severe degrees of hypospadias, that the scrotal and perinea], appear at first to offer much greater surgical problems. This I believe not to
600
DAYID M. DAVIS
be the case. The reason for this is that the new urethra can be buried deep within the tissues of the perineum and scrotum, which makes fistula formation unlikely, regardless of the method of plastic reconstruction used. The tendency toward healing is in fact so great that we now do not hesitate to leave a fistulous tract in this region, for the diversion of urine, and find that it heals spontaneously after the withdrawal of the drainage catheter. Some years ago a method was devised to obviate the necessity for suprapubic diversion of urine in scrotal hypospadias. The scrotal part of the urethra
FIG. 8. Final results in 2 cases of perineal hypospadias. Upper row, left panel, case 1,
J. S. Scar just below posterior edge of the scrotum marks site of original meatus. Patient now 24 years old, and is married. Urethra admits a 24F instrument easily. Lower photograph, case 2, R. L. Case was unusual in that penis was large, and was buried beneath perineal skin, except a bifid glans which overhung meatus just in front of anus. Result is satisfactory in every respect. Patient now 19 years old.
was made by the Thiersch-Duplay method, using the strip of hairless skin in the midline. The Thiersch-Duplay reconstruction was continued posteriorly, past the urethral orifice and well into the perineal region. This produced a T shaped urethra, and through its posterior limb a catheter was brought from the bladder to divert the urine. All of the scrotal and perineal portions of the urethra were then buried very deeply by suturing the scrotal halves together over them with many layers of fine catgut sutures. The results were excellent.2 The posterior limb of the new urethra of course remained patent, being lined with skin. At a later date this skin lining was excised, and the resulting fistula closed quickly. 2
J. Urol., 62: 340, 1944.
SURGICAL TREATl11El\"T OF IIYPOSPADIAS
601
how quickly and easily these fistulas healed, it occurred to me to omit the lining of the posterior limb with skin, and to bring the drainage catheter out through the scrotal and perineal tissues, but buried as deeply as before. This proved to be even more satisfactory, as the perinea! fistulas closed spontaneously after the removal of the catheter (figs. 5, 6, 7). This method has been used in a number of cases of scrntal hypospadias, ·with uniformly good results. It has not as yet been used in true perinea! ""n .. ,onn but I should not hesitate to attempt it. T"·o cases of perineal hypospadias are
l<'rn. 9. :Final results in 8 typical cases of penoscrotal hypospadia.s. Note straight penis, norm,iJ-appea.ring glans, and straight, strong urinary stream.
illustrated in this paper (fig. 8). In both of these the usual procedure of suprapubic cystostomy was used for diversion of the urine. The results were satisfactory in both, but there is no doubt that suprapubic drainage adds to the discomforts of the patient. If more than one operation is necessary for the urethral construction, one must either maintain the suprapubic drain for a long time, or reinsert it at each operation, a procedure which grows more dif-ficult ·with each repetition. Urinary drainage tubes or catheters, of whatever sort, must be watched carefully for sanding, and if it occurs, irrigated frequently, with acid
602
DAVID M. DAVIS
such as Suby's solution, or solution G. Antibiotics undoubtedly increase the incidence of primary healing. Of late months, I have been irrigating the wounds, just before closure, with bacitracin solution, with apparently good results (fig. 9). In conclusion, I would like to say that I believe the time has arrived to state that the surgical repair of hypospadias is no longer dubious, unreliable, or even extremely difficult. If tried and proven methods are scrupulously followed, a good result should be obtained in every case. Anything less than this suggests that the surgeon is not temperamentally fitted for this kind of surgery.
255 S. 17th St., Philadelphia 3, Pa.
Vol. 65, No. 4, April 1951 Printed in U.S.A.
SURGICAL TREATMENT OF HYPOSPADIAS, ESPECIALLY SCROTAL AND PERINEAL DAVID M. DA VIS From the Department of Urology, Jefferson Medical College, Philadelphia, Pa.
The combination of qualities necessary for the surgical treatment of hypospadias is found in comparatively few individuals. One can only say that hurried and ill-considered operations are sure to fail, and that no one should undertake to operate for hypospadias unless he is willing to devote the time and energy necessary for a thorough study of the methods ·which have proved satisfactory, and to a meticulous performance of the operative procedures. After that he may proceed to invent new and improved methods for himself. The method to be used in constructing the new urethra should be determined before the first operation, that for straightening the penis, is carried out. The straightening of the corpora and glans is comparatively easy, but since the ventrum of the penis is greatly lengthened thereby, skin must be found to cover the denuded area. If the prepuce is not to be used for the urethral tube, it is very satisfactory for covering the ventrum of the penis, but if it is to be used, other methods are necessary. By extending the ventral incision along the coronary sulcus on both sides of the frenum in the form of a Y and undermining the skin, it has been found possible to pull the lateral parts of the prepuce around to lengthen the covering of the ventrum without shortening the prepuce (fig. 1). This is important if the prepuce is to be used for a tube-flap. We may then consider the current methods of constructing the urethral tube. I think it is fair to say that the old standard Thiersch-Duplay procedure is definitely outmoded for the penile portion of the repair and should be abandoned. The reason for this is that it superimposes one line of suture on another, so that complete healing almost never occurs, and the usual result is a series of fistulas, large or small, and very difficult to close. In order to avoid the possibility of multiple fistulas, surgeons for a long time have attempted to create a tunnel within the penis, and line it in some manner with epithelium. For this purpose split thickness skin grafts, full thickness skin grafts, pedicle flaps, free grafts of bladder wall, and even pieces of large veins have been used. Many good results have been obtained, but failure has usually been due to necrosis of the graft. In my own experience, the Thiersch-Duplay operation was very satisfactory in the scrotal and perinea! regions, but the frequent occurrence of fistulas in the penile portion caused me to cast about for a better method for the construction of the penile urethra. Young had formed a tube from preputial skin, leaving the pedicle attached in the region of the coronary sulcus and passing the tube through a tunnel in the glans. These tubes usually underwent necrosis, and the obvious reason was that the blood supply was inadequate. Consideration of the vascular Read at annual meeting, Mid-Atlantic Section, American Urological Association, Hot Springs, Va., March 23, 1950. 595
596
DAVID M. DA VIS
system of the penis made it apparent that the arteries supplying blood to the prepuce were on the dorsal surface, near the midline and just beneath the skin, and they coursed from the base of the penis toward its tip. It therefore seemed possible to cut the flap in such a manner that its attachment or pedicle would be at its proximal end instead of at its distal end, and so preserve its blood supply. The attachment was of course at some distance from the tip of the glans, but it was found that the glans could easily be bent or folded back so that its tip reached the area of the attachment, and the whole length of the tube flap could be drawn into the tunnel in the glans (fig. 2). A few trials showed that the blood supply
~
'
J
)!1;'5
~ ~
.PC
Fm. 1. 1, Anterior view of typical penoscrotal hypospadias; 2, L.I. is line of incision for straightening operation. Small quadrilateral piece of skin is excised with underlying fibrous band. Horns of incision extend around into loose preputial skin; 3, edges of incision are undermined; 4, all fibrous bands and adhesions are removed. Corpora must be completely freed. Urethra is separated from the corpora at A for some distance, and all fibrous tissue removed; 5, preputial skin pulled around penis in direction of arrow, giving plenty of skin for linear ventral closure. Penis held up to abdominal wall by rubber band.
was entirely adequate and that sloughing never occurred. The idea at first was to use the preputial tube-flap only for the glandular part of the urethra, but it soon appeared, not only that the prepuce often furnished quite a long tube, but that, owing to the flexibility of the penis, the flap could be cut along the entire length of the dorsum of the penis, right up to the point at its base where hair follicles began to be present in the skin. It is now customary to make the tube flap as long as possible, measure its length, and then make the penile tunnel the same length as the tube flap. In a surprisingly large number of cases of penoscrotal hypospadias, the tube-flap is easily long enough to reach all the way to the meatus, so that no flap-cutting whatever is necessary on the ventral surface,
SURGICAL TREATMENT OF HYPOSPADIAS
597
and the new urethra can immediately be anastomosed with the pre-existing urethra (fig. 3). While it is true that good results can be obtained with free grafts placed in a tunnel, the advantage of the pedicle is that it assures complete viability of the flap in 100 per cent of the cases. The pedicle is cut in about three weeks (fig. 4). The tube flap method places the new urethral meatus at the tip of the glans, where it belongs. I believe that this point is important, particularly from the psychic and emotional point of view. With such a meatus in a well-straightened penis, both the patient and his parents can feel that the condition is indistinguishable from normal and that not even a remnant of malformation remains. This enables them to forget the whole distressing affair, with its implication of hidden weakness.
a
C
\;
FIG. 2. a, Operation for construction of tube-flap. The flap is outlined on the dorsum of the penis; b, flap raised from dorsal surface of corpora; c, flap sutured into a tube; d, tube completed; e, tunnel made from tip of glans, the same length as the tube-flap; f and g, tube drawn into tunnel, penis bent ventrally to bring tip of glans to base of pedicle of tube-flap.
In any tunnelization method, there can be at the maximum, only one postoperative fistula, namely, at the proximal end of the tunnel. The best method for closing such a fistula is the inversion method, described some years ago. 1 The tract is dissected free, with a little rim of external skin, and pulled inside out, so that it projects into the urethral lumen. This method is successful in at least two thirds of cases on the first attempt, and always on the second or third. The pedicle tube-flap method has been so uniformly successful that I have not felt impelled to turn to other methods, in spite of the good results reported. There are other considerations which I believe should carry a good deal of weight. With the pedicle tube-flap method, it is often possible to complete the construction of the entire urethra in one operation. It is never necessary for the patient to wear an apparatus of foreign material in the penis for a long time. 1
Surg., Gynec. & Obst., 71: 790-796, 1940.
598
DAYID M. DA VIS
1
:z.
ti!
3
',-
4
4
5
FIG. 3. FIG. 4. FIG. 3. 1, Manner of making tunnel when tube is long enough to reach meatus. Arrow shows direction in which end of tube is pulled through tunnel. 2, Curved hemostat passed through tunnel to make sure it is large enough; 3, Penis bent backward to receive tube flap. Tube sutured to freshened end of urethra. 4, Manner of anastomosing tube to urethra, end-to-end and mucosa-to-mucosa. Subcutaneous tissues are brought together over this anastomosis, and scrotum drawn up to bury it as deeply as possible. Frn. 4. 1, Manner of dividing pedicle of tube-flap. Grooved director is passed beneath pedicle. 2, After division of pedicle, arteries are ligated. 3, Cut edges of tube fastened to skin of glans with a few sutures; 4, Divided pedicle on dorsum of penis. 5, Skin edges loosely approximated with a few sutures.
Frn. 5. Operation for midscrotal hypospadias. I, Outline (L.I.) of incision. lI, Skin edges undermined, deep tissues of scrotum, including testes, exposed.
SURGICAL TREATMENT OF HYPOSPADIAS
599
It has been conclusively shmvn in a number of my patients that a urethra constructed from a full thickness pedicle tube-flap of preputial skin will grow as the penis grows, and the operation can be done at an early age, usually 4 to 6 years. It is my experience that this is extremely important, not only for the
Fm. 6. III, Strip of skin being sutured into a tube. l\Icanwhile a typical tube-flap has been raised from dorsum of penis and drawn into tunnel (T.F.). End-to-end anastomosis between it and the perineal portion of tube. Stab wound made in perineum well posterior to scrotum, tunnel made to a point near urethra. Urethrotomy made just proximal to meatus; IV, Perinea] part of tube completed and closed over meatus, catheter passed through tunnel and urethrotomy into bladder to divert urine. Closure of scrotal and penile tissues over tube begun.
Fm. 7. V, Closure of scrotum continued, burying new urethra as deeply as possible. Anterior part of incision closed transversely, to bury anastomosis between perinea! part of urethral tube and penile tube-flap as deeply as possible. This pulls penis and scrotum together. Any web formed can be easily divided later. VI, Diagrammatic cross section shmving situation after operation when pedicle of the tube-flap is divided. 1Inlined scrotal tunnel heals quickly after the catheter is withdrawn.
sake of the patient, but especially for the sake of the parents, who usually suffer emotionally from the congenital defects of their offspring more than the patients themselves do. The more severe degrees of hypospadias, that the scrotal and perinea], appear at first to offer much greater surgical problems. This I believe not to
600
DAYID M. DAVIS
be the case. The reason for this is that the new urethra can be buried deep within the tissues of the perineum and scrotum, which makes fistula formation unlikely, regardless of the method of plastic reconstruction used. The tendency toward healing is in fact so great that we now do not hesitate to leave a fistulous tract in this region, for the diversion of urine, and find that it heals spontaneously after the withdrawal of the drainage catheter. Some years ago a method was devised to obviate the necessity for suprapubic diversion of urine in scrotal hypospadias. The scrotal part of the urethra
FIG. 8. Final results in 2 cases of perineal hypospadias. Upper row, left panel, case 1,
J. S. Scar just below posterior edge of the scrotum marks site of original meatus. Patient now 24 years old, and is married. Urethra admits a 24F instrument easily. Lower photograph, case 2, R. L. Case was unusual in that penis was large, and was buried beneath perineal skin, except a bifid glans which overhung meatus just in front of anus. Result is satisfactory in every respect. Patient now 19 years old.
was made by the Thiersch-Duplay method, using the strip of hairless skin in the midline. The Thiersch-Duplay reconstruction was continued posteriorly, past the urethral orifice and well into the perineal region. This produced a T shaped urethra, and through its posterior limb a catheter was brought from the bladder to divert the urine. All of the scrotal and perineal portions of the urethra were then buried very deeply by suturing the scrotal halves together over them with many layers of fine catgut sutures. The results were excellent.2 The posterior limb of the new urethra of course remained patent, being lined with skin. At a later date this skin lining was excised, and the resulting fistula closed quickly. 2
J. Urol., 62: 340, 1944.
SURGICAL TREATl11El\"T OF IIYPOSPADIAS
601
how quickly and easily these fistulas healed, it occurred to me to omit the lining of the posterior limb with skin, and to bring the drainage catheter out through the scrotal and perineal tissues, but buried as deeply as before. This proved to be even more satisfactory, as the perinea! fistulas closed spontaneously after the removal of the catheter (figs. 5, 6, 7). This method has been used in a number of cases of scrntal hypospadias, ·with uniformly good results. It has not as yet been used in true perinea! ""n .. ,onn but I should not hesitate to attempt it. T"·o cases of perineal hypospadias are
l<'rn. 9. :Final results in 8 typical cases of penoscrotal hypospadia.s. Note straight penis, norm,iJ-appea.ring glans, and straight, strong urinary stream.
illustrated in this paper (fig. 8). In both of these the usual procedure of suprapubic cystostomy was used for diversion of the urine. The results were satisfactory in both, but there is no doubt that suprapubic drainage adds to the discomforts of the patient. If more than one operation is necessary for the urethral construction, one must either maintain the suprapubic drain for a long time, or reinsert it at each operation, a procedure which grows more dif-ficult ·with each repetition. Urinary drainage tubes or catheters, of whatever sort, must be watched carefully for sanding, and if it occurs, irrigated frequently, with acid
602
DAVID M. DAVIS
such as Suby's solution, or solution G. Antibiotics undoubtedly increase the incidence of primary healing. Of late months, I have been irrigating the wounds, just before closure, with bacitracin solution, with apparently good results (fig. 9). In conclusion, I would like to say that I believe the time has arrived to state that the surgical repair of hypospadias is no longer dubious, unreliable, or even extremely difficult. If tried and proven methods are scrupulously followed, a good result should be obtained in every case. Anything less than this suggests that the surgeon is not temperamentally fitted for this kind of surgery.
255 S. 17th St., Philadelphia 3, Pa.