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The Bladder Mucosal Graft Technique for Hypospadias Repair
0022-5347 /81/1255-0708$02.00/0 Vol.125, May
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1981 by The Williams & Wilkins Co.
THE BLADDER MUCOSAL GRAFT TECHNIQUE FOR HYPOSPADIAS REPAIR JOHN W. COLEMAN From the James Buchanan Brady Foundation, Cornell University Medical College and The New York Hospital,.New York, New York
ABSTRACT
A technique for the repair of severe hypospadias is described. The essential features include a chordee release and cosmetic repair of the previously tethered penis, the construction of a new urethra using bladder mucosa in a subcutaneous tunnel and an oblique anastomosis of the graft and true urethra as deep within the shaft of the penis as possible. One stricture has developed with this technique and meatal stenosis requiring dilation remains a minor problem. However, the over-all results of this technique appear to be good. The use of bladder mucosal grafts in cases in which previous repairs have failed or in which adequate foreskin for urethral reconstruction is lacking is feasible and has been performed successfully in adults. The combination of a chordee release and bladder mucosa! inlay graft as a single stage procedure in a small child has not yet been attempted. The idea of constructing a urethra with a free graft was originally described in 1914 by Nove Josserand. 1 He used a split thickness skin graft rolled into a tube with the raw side out. Unfortunately, there was marked contracture of the graft and the technique was discarded after a brief time. Other materials used in this manner included the saphenous vein transplant reported in 1910 by Tuffier, 2 the ureter in 1909 by Schmieden,3 the appendix in 1911 by Lexer4 and bladder mucosa in 1947 by Memmalaar. 5 In 1948 Mcindoe modified Nove Josserand's technique by using a split thickness graft in which the patient wore a dilator for 6 months before attempting an anastomosis. 6 Young and Benjamin modified this technique, performing an immediate anastomosis of the skin graft and the hypospadiac meatus. 7 The splint through a perinea! urethrostomy was removed after 7 days. Unfortunately, 7 fistulas developed in their 10 children. McCormack advocated the use of a full thickness free skin graft because it was more pliable and tended to contract less. 8 He advised delay in anastomosing the graft for 3 to 6 months to allow all graft contracture to cease. In 1941 Humby described a 1-stage graft technique using the full thickness offoreskin. 9 In 1961 Devine and Horton finally popularized this method. 10 Of their initial 20 cases only 6 had fistulas and there were no strictures at the site of the anastomosis. In 1977 their figures were updated and only 20 fistulas were found in 75 successive tube grafts. 11 In 194 7 Memmalaar described a 1-stage repair of penoscrotal hypospadias using bladder mucosa as the graft material. 5 Three patients derived a good result but 1 died postoperatively of sepsis. In 1955 Marshall and Spellman reported a 2-stage technique in 39 patients. 12 Bladder mucosa was used to reconstruct the urethra. Different anastomotic techniques were used because of the recurring problem of strictures and fistulas at the anastomotic site. In their last group of 13 patients strictures developed in 2 and fistulas occurred in 3 at the anastomosis. Because of the mediocre results the technique gradually fell into disuse and only anecdotal cases were performed after 1957. I assisted Dr. John H. McGovern when he operated on an adult with penoscrotal hypospadias who had undergone multiple unsuccessful fistula and stricture repairs. The penile urethra was badly deformed and a new urethra was constructed out of bladder mucosa. The technique worked quite satisfactorily and the patient has required no surgery since that time. Stimulated by this operation 7 children with penoscrotal or Accepted for publication November 26, 1980.
perineal hypospadias and chordee have now had a chordee correction and, subsequently, a bladder mucosal graft repair. A stricture has developed at the anastomotic site in 1 case. The remainder are voiding well with followup ranging from 1 to 3 years. TECHNIQUE
The technique presently used differs from that of Marshall and Spellman. At the first stage a chordee release is performed according to the method of Byars. 13 A circumferential incision is made proximal to the glans penis. The foreskin, if present, and the skin of the shaft of the penis are retracted back with careful attention to preserve as much subcutaneous tissue as possible. The chordee tissue is removed and the foreskin is incised in the midline, allowing it to be drawn around to the ventral surface of the penis. As symmetrical a closure as possible is obtained, the location of the suture lines being determined by aesthetics only (fig. 1). The main objective is to create a penis that looks presentable. Great emphasis is placed on leaving the hypospadiac meatus undisturbed so that there is a minimal amount of scar tissue present 6 months to a year later when the mucosal graft is attempted. A sterile, non-adhering compressive dressing is applied to the penis and a Foley catheter is left in the hypospadiac meatus until the dressings are removed. At the second stage a small Pfannenstiel incision is made and the bladder is distended so that its anterior surface is identified easily. The peritoneum is reflected cephalad. An incision in the detrusor muscle is carried deeply until the "blue dome cyst" of the mucosa is exposed. The graft is then obtained, either by dissecting out the mucosa without entering the bladder or by immediate entry into the bladder, which is followed by dissection of a 2 X 6 cm. graft from 1 side of the incision. The muscle of the bladder wall may be grasped with Allis clamps to facilitate better exposure and a plane is developed easily between the mucosa and the muscles of the bladder wall. The free graft is removed and the bladder is closed over a Malecot catheter (fig. 2). While the bladder and suprapubic incisions are being closed, the free graft of mucosa is fashioned around a 16 or 18F coude catheter with the mucosal surface directed inward. Six-zero non-absorbable suture material is used for this closure. Occasional interrupted sutures along the closure line are used. About 0.5 cm. of graft is left unopposed at either end for later trimming and for creation of the urethral meatus. The graft is kept continuously wet with saline until ready for reimplantation.
708
BLADDER JVPJCOS_t\:S GRA~FT TECHNIQlJE FOR HYF·OSPADIAS REPAIR
Fm. 1. First stage, correction of chordee
709
FIG. 3. Creation of penile tunnel, incision of glans penis and beginning of oblique end-to-end anastomosis proximally.
Fm. 2. Retrieval of bladder mucosa! graft and tubularization over coude catheter.
The hypospadiac meatus, usually at the penoscrotal junction, is now freed up with a circumferential incision that is carried deeply for at least 1 cm. The object is to free up enough urethra and to freshen its edges so that an oblique anastomosis is performed as deep within the substance of the penis as possible. A Horton-Devine V flip-flap incision then is made in the glans which has been injected with diluted epinephrine soluTunneling is begun at the glandular meatus and carried deep within the subcutaneous tissue of the ventral surface of the to the incision where the true urethra has been dissected (fig. 3). The tunnel exits at a level well below the skin surface. The depth of the tunnel. and the to perform an end-to-end anastomosis at this are vital to prevent the formation of a fistula. The mucosal graft is then drawn into the tunnel on the coude catheter with the suture line facing the dorsal aspect of the penis. The end of the graft and true urethra are freshened and an oblique anastomosis is performed. The coude catheter is passed into the true urethra after several anastomotic sutures have been tied and the remainder of the anastomosis is performed over this catheter. Closure of the subcutaneous tissues in 2 layers is performed to eliminate dead space. The scrotal skin is closed with 4-zero chromic catgut. At the distal meatus the broad-based V flap of glans is sewn into the splayed end of the bladder mucosa. The side flaps and mucosa are anastomosed and drawn together toward the midline (fig. 4). A non-adherent compressive dressing is applied for 3 to 4 days. The coude catheter is left indwelling until the dressings are removed. Suture removal under general anesthesia and irrigation of the urethra via the cystotomy tube are
FIG. 4. Completion of proximal oblique end-to-end anastomosis and creation of distal urethral meatus.
performed before the catheter is removed several weeks later. RESULTS
In 7 children there has been l stricture at the anastomotic site and 6 have required urethral meatal dilation or Gentle dilation at home has seemed to reduce the need for in the last several ,-,-v·-""'"· Because the procedure is new pediatric cy,~um~,u~1_1 has been done whenever possible. The mucosal graft shown no areas of slough and the bladder donor site is completely re-epithelialized within 8 weeks. The donor site cannot be identified after this time. DISCUSSION
The bladder mucosa! graft offers several theoretical advantages. It is of the same histologic character as the normal urethra, is not hair-bearing, tends to re-epithelialize exposed surfaces and has great distensibility. Its use for correction of penoscrotal or perinea! hypospadias has proved quite satisfactory thus far. There have been no fistulas and 1 stricture at the site of anastomosis of the graft and true urethra. Despite adaptation of the Horton-Devine type V-flap and flip-flap construction of the urethral meatus, stenosis continues to be a problem, albeit a minor one. The cosmetic result has been quite satisfactory.
710
COLEMAN
and a dermoepidermal graft in severe forms of hypospadias and Emphasis on certain portions of the technique seems warepispadias. J. d'Urol., 5: 393, 1914. ranted. The preservation during the correction of the chordee of the foreskin and penile skin with as much subcutaneous 2. Tuffier, T.: Apropos des greffes veineuses uretroplastiques. Bull. et Mem. Soc. de Chir. de Paris, 36: 589, 1910. tissue as possible is important. This provides a good cosmetic 3. Schmieden, V.: New method for operation for male hypospadias: result and allows space for the subsequent mucosal graft tunnel. free transplant of ureter to form urethra. Arch. f. Klin. Chir., 90: The suture line may be placed wherever it provides the best 748, 1909. aesthetic result. There is no need to create large flaps crossing 4. Lexer, E.: On free transplantations. Verhandl. d. Deutsch. Gesthe midline, which distort the over-all appearance of the penis. sellsch. f. Chir., 40: 386, 1911. When a suprapubic cystostomy is used, as has been done 5. Memmalaar, J.: Use of bladder mucosa in a one-stage repair of hypospadias. J. Urol., 58: 68, 1947. routinely at this hospital, retrieval of the mucosal graft requires little extra time to effect and the donor site is completely healed 6. Mclndoe, A. H.: Deformities of the male urethra. Brit. J. Plast. Surg., 1: 29, 1948. within 8 weeks. Meticulous attention to detail is required in 7. Young, F. and Benjamin, J. A.: Repair of hypospadias with free fashioning the graft and performing the meatal and proximal inlay skin graft. Surg., Gynec. & Obst., 86: 439, 1948. anastomosis. Emphasis is placed on performing the anastomosis 8. McCormack, R. M.: Simultaneous chordee repair and urethral as deep within the proximal incision as possible. reconstruction for hypospadias. Plast. Reconstr. Surg., 13: 257, The urge to attempt a 1-stage correction of the chordee and 1954. simultaneously construct a bladder mucosal graft has been 9. Humby, G.: One-stage operation for hypospadias. Brit. J. Surg., 29: resisted thus far. The first objective of the technique is to 84, 1941. produce as good a cosmetic result as possible. The second 10. Devine, C. J ., Jr. and Horton, C. E.: A one stage hypospadias repair. J. Urol., 85: 166, 1961. objective is to minimize the risk of a fistula or stenosis at the anastomotic site. By staging the procedure the suture lines from 11. Devine, C. J., Jr. and Horton, C. E.: Hypospadias repair. J. Urol., 118: 188, 1977. the chordee correction can be placed anywhere. Because of the 12. Marshall, V. F. and Spellman, R. M.: Construction of urethra in later tunneling and inlay of a mucosal graft the risk of a fistula hypospadias using vesical mucosal grafts. J. Urol., 73: 335, 1955. is only possible at 1 point, since the full thickness of skin from 13. Byars, L. T.: A technique for consistently satisfactory repair of the meatus to the site of the hypospadiac urethra is already hypospadias. Surg., Gynec. & Obst., 100: 184, 1955. healed. While the mucosal graft technique described herein has been EDITORIAL COMMENT successful in 7 children with penoscrotal or perineal hypospadias, the risk of a slough of the graft still exists. The length This is another way of doing hypospadias repair and it seems in this and complexity of the technique make its use in lesser degrees of hypospadias unwarranted. The technique does have appli- small series that the author has managed to avoid some of the problems cation in children and adults in whom foreskin is not available that others have had with the use of bladder mucosa. Transitional for grafting or in whom multiple repairs have been unsuccessful bladder mucosa is not as close to the normal epithelium of the urethra as is skin and this thin tissue is more likely to have problems, for and a total reconstruction of the urethra seems necessary. example the meatal stenosis seen in most of his patients. There is no
REFERENCES 1. Nove Josserand, G.: Late results of urethroplasty by tunnelization
one way to repair hypospadias and the surgeon must consider every technique in the armamentarium. The fact that bladder mucosa can be used should be remembered in difficult situations. C.J.D.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1981 by The Williams & Wilkins Co.
THE BLADDER MUCOSAL GRAFT TECHNIQUE FOR HYPOSPADIAS REPAIR JOHN W. COLEMAN From the James Buchanan Brady Foundation, Cornell University Medical College and The New York Hospital,.New York, New York
ABSTRACT
A technique for the repair of severe hypospadias is described. The essential features include a chordee release and cosmetic repair of the previously tethered penis, the construction of a new urethra using bladder mucosa in a subcutaneous tunnel and an oblique anastomosis of the graft and true urethra as deep within the shaft of the penis as possible. One stricture has developed with this technique and meatal stenosis requiring dilation remains a minor problem. However, the over-all results of this technique appear to be good. The use of bladder mucosal grafts in cases in which previous repairs have failed or in which adequate foreskin for urethral reconstruction is lacking is feasible and has been performed successfully in adults. The combination of a chordee release and bladder mucosa! inlay graft as a single stage procedure in a small child has not yet been attempted. The idea of constructing a urethra with a free graft was originally described in 1914 by Nove Josserand. 1 He used a split thickness skin graft rolled into a tube with the raw side out. Unfortunately, there was marked contracture of the graft and the technique was discarded after a brief time. Other materials used in this manner included the saphenous vein transplant reported in 1910 by Tuffier, 2 the ureter in 1909 by Schmieden,3 the appendix in 1911 by Lexer4 and bladder mucosa in 1947 by Memmalaar. 5 In 1948 Mcindoe modified Nove Josserand's technique by using a split thickness graft in which the patient wore a dilator for 6 months before attempting an anastomosis. 6 Young and Benjamin modified this technique, performing an immediate anastomosis of the skin graft and the hypospadiac meatus. 7 The splint through a perinea! urethrostomy was removed after 7 days. Unfortunately, 7 fistulas developed in their 10 children. McCormack advocated the use of a full thickness free skin graft because it was more pliable and tended to contract less. 8 He advised delay in anastomosing the graft for 3 to 6 months to allow all graft contracture to cease. In 1941 Humby described a 1-stage graft technique using the full thickness offoreskin. 9 In 1961 Devine and Horton finally popularized this method. 10 Of their initial 20 cases only 6 had fistulas and there were no strictures at the site of the anastomosis. In 1977 their figures were updated and only 20 fistulas were found in 75 successive tube grafts. 11 In 194 7 Memmalaar described a 1-stage repair of penoscrotal hypospadias using bladder mucosa as the graft material. 5 Three patients derived a good result but 1 died postoperatively of sepsis. In 1955 Marshall and Spellman reported a 2-stage technique in 39 patients. 12 Bladder mucosa was used to reconstruct the urethra. Different anastomotic techniques were used because of the recurring problem of strictures and fistulas at the anastomotic site. In their last group of 13 patients strictures developed in 2 and fistulas occurred in 3 at the anastomosis. Because of the mediocre results the technique gradually fell into disuse and only anecdotal cases were performed after 1957. I assisted Dr. John H. McGovern when he operated on an adult with penoscrotal hypospadias who had undergone multiple unsuccessful fistula and stricture repairs. The penile urethra was badly deformed and a new urethra was constructed out of bladder mucosa. The technique worked quite satisfactorily and the patient has required no surgery since that time. Stimulated by this operation 7 children with penoscrotal or Accepted for publication November 26, 1980.
perineal hypospadias and chordee have now had a chordee correction and, subsequently, a bladder mucosal graft repair. A stricture has developed at the anastomotic site in 1 case. The remainder are voiding well with followup ranging from 1 to 3 years. TECHNIQUE
The technique presently used differs from that of Marshall and Spellman. At the first stage a chordee release is performed according to the method of Byars. 13 A circumferential incision is made proximal to the glans penis. The foreskin, if present, and the skin of the shaft of the penis are retracted back with careful attention to preserve as much subcutaneous tissue as possible. The chordee tissue is removed and the foreskin is incised in the midline, allowing it to be drawn around to the ventral surface of the penis. As symmetrical a closure as possible is obtained, the location of the suture lines being determined by aesthetics only (fig. 1). The main objective is to create a penis that looks presentable. Great emphasis is placed on leaving the hypospadiac meatus undisturbed so that there is a minimal amount of scar tissue present 6 months to a year later when the mucosal graft is attempted. A sterile, non-adhering compressive dressing is applied to the penis and a Foley catheter is left in the hypospadiac meatus until the dressings are removed. At the second stage a small Pfannenstiel incision is made and the bladder is distended so that its anterior surface is identified easily. The peritoneum is reflected cephalad. An incision in the detrusor muscle is carried deeply until the "blue dome cyst" of the mucosa is exposed. The graft is then obtained, either by dissecting out the mucosa without entering the bladder or by immediate entry into the bladder, which is followed by dissection of a 2 X 6 cm. graft from 1 side of the incision. The muscle of the bladder wall may be grasped with Allis clamps to facilitate better exposure and a plane is developed easily between the mucosa and the muscles of the bladder wall. The free graft is removed and the bladder is closed over a Malecot catheter (fig. 2). While the bladder and suprapubic incisions are being closed, the free graft of mucosa is fashioned around a 16 or 18F coude catheter with the mucosal surface directed inward. Six-zero non-absorbable suture material is used for this closure. Occasional interrupted sutures along the closure line are used. About 0.5 cm. of graft is left unopposed at either end for later trimming and for creation of the urethral meatus. The graft is kept continuously wet with saline until ready for reimplantation.
708
BLADDER JVPJCOS_t\:S GRA~FT TECHNIQlJE FOR HYF·OSPADIAS REPAIR
Fm. 1. First stage, correction of chordee
709
FIG. 3. Creation of penile tunnel, incision of glans penis and beginning of oblique end-to-end anastomosis proximally.
Fm. 2. Retrieval of bladder mucosa! graft and tubularization over coude catheter.
The hypospadiac meatus, usually at the penoscrotal junction, is now freed up with a circumferential incision that is carried deeply for at least 1 cm. The object is to free up enough urethra and to freshen its edges so that an oblique anastomosis is performed as deep within the substance of the penis as possible. A Horton-Devine V flip-flap incision then is made in the glans which has been injected with diluted epinephrine soluTunneling is begun at the glandular meatus and carried deep within the subcutaneous tissue of the ventral surface of the to the incision where the true urethra has been dissected (fig. 3). The tunnel exits at a level well below the skin surface. The depth of the tunnel. and the to perform an end-to-end anastomosis at this are vital to prevent the formation of a fistula. The mucosal graft is then drawn into the tunnel on the coude catheter with the suture line facing the dorsal aspect of the penis. The end of the graft and true urethra are freshened and an oblique anastomosis is performed. The coude catheter is passed into the true urethra after several anastomotic sutures have been tied and the remainder of the anastomosis is performed over this catheter. Closure of the subcutaneous tissues in 2 layers is performed to eliminate dead space. The scrotal skin is closed with 4-zero chromic catgut. At the distal meatus the broad-based V flap of glans is sewn into the splayed end of the bladder mucosa. The side flaps and mucosa are anastomosed and drawn together toward the midline (fig. 4). A non-adherent compressive dressing is applied for 3 to 4 days. The coude catheter is left indwelling until the dressings are removed. Suture removal under general anesthesia and irrigation of the urethra via the cystotomy tube are
FIG. 4. Completion of proximal oblique end-to-end anastomosis and creation of distal urethral meatus.
performed before the catheter is removed several weeks later. RESULTS
In 7 children there has been l stricture at the anastomotic site and 6 have required urethral meatal dilation or Gentle dilation at home has seemed to reduce the need for in the last several ,-,-v·-""'"· Because the procedure is new pediatric cy,~um~,u~1_1 has been done whenever possible. The mucosal graft shown no areas of slough and the bladder donor site is completely re-epithelialized within 8 weeks. The donor site cannot be identified after this time. DISCUSSION
The bladder mucosa! graft offers several theoretical advantages. It is of the same histologic character as the normal urethra, is not hair-bearing, tends to re-epithelialize exposed surfaces and has great distensibility. Its use for correction of penoscrotal or perinea! hypospadias has proved quite satisfactory thus far. There have been no fistulas and 1 stricture at the site of anastomosis of the graft and true urethra. Despite adaptation of the Horton-Devine type V-flap and flip-flap construction of the urethral meatus, stenosis continues to be a problem, albeit a minor one. The cosmetic result has been quite satisfactory.
710
COLEMAN
and a dermoepidermal graft in severe forms of hypospadias and Emphasis on certain portions of the technique seems warepispadias. J. d'Urol., 5: 393, 1914. ranted. The preservation during the correction of the chordee of the foreskin and penile skin with as much subcutaneous 2. Tuffier, T.: Apropos des greffes veineuses uretroplastiques. Bull. et Mem. Soc. de Chir. de Paris, 36: 589, 1910. tissue as possible is important. This provides a good cosmetic 3. Schmieden, V.: New method for operation for male hypospadias: result and allows space for the subsequent mucosal graft tunnel. free transplant of ureter to form urethra. Arch. f. Klin. Chir., 90: The suture line may be placed wherever it provides the best 748, 1909. aesthetic result. There is no need to create large flaps crossing 4. Lexer, E.: On free transplantations. Verhandl. d. Deutsch. Gesthe midline, which distort the over-all appearance of the penis. sellsch. f. Chir., 40: 386, 1911. When a suprapubic cystostomy is used, as has been done 5. Memmalaar, J.: Use of bladder mucosa in a one-stage repair of hypospadias. J. Urol., 58: 68, 1947. routinely at this hospital, retrieval of the mucosal graft requires little extra time to effect and the donor site is completely healed 6. Mclndoe, A. H.: Deformities of the male urethra. Brit. J. Plast. Surg., 1: 29, 1948. within 8 weeks. Meticulous attention to detail is required in 7. Young, F. and Benjamin, J. A.: Repair of hypospadias with free fashioning the graft and performing the meatal and proximal inlay skin graft. Surg., Gynec. & Obst., 86: 439, 1948. anastomosis. Emphasis is placed on performing the anastomosis 8. McCormack, R. M.: Simultaneous chordee repair and urethral as deep within the proximal incision as possible. reconstruction for hypospadias. Plast. Reconstr. Surg., 13: 257, The urge to attempt a 1-stage correction of the chordee and 1954. simultaneously construct a bladder mucosal graft has been 9. Humby, G.: One-stage operation for hypospadias. Brit. J. Surg., 29: resisted thus far. The first objective of the technique is to 84, 1941. produce as good a cosmetic result as possible. The second 10. Devine, C. J ., Jr. and Horton, C. E.: A one stage hypospadias repair. J. Urol., 85: 166, 1961. objective is to minimize the risk of a fistula or stenosis at the anastomotic site. By staging the procedure the suture lines from 11. Devine, C. J., Jr. and Horton, C. E.: Hypospadias repair. J. Urol., 118: 188, 1977. the chordee correction can be placed anywhere. Because of the 12. Marshall, V. F. and Spellman, R. M.: Construction of urethra in later tunneling and inlay of a mucosal graft the risk of a fistula hypospadias using vesical mucosal grafts. J. Urol., 73: 335, 1955. is only possible at 1 point, since the full thickness of skin from 13. Byars, L. T.: A technique for consistently satisfactory repair of the meatus to the site of the hypospadiac urethra is already hypospadias. Surg., Gynec. & Obst., 100: 184, 1955. healed. While the mucosal graft technique described herein has been EDITORIAL COMMENT successful in 7 children with penoscrotal or perineal hypospadias, the risk of a slough of the graft still exists. The length This is another way of doing hypospadias repair and it seems in this and complexity of the technique make its use in lesser degrees of hypospadias unwarranted. The technique does have appli- small series that the author has managed to avoid some of the problems cation in children and adults in whom foreskin is not available that others have had with the use of bladder mucosa. Transitional for grafting or in whom multiple repairs have been unsuccessful bladder mucosa is not as close to the normal epithelium of the urethra as is skin and this thin tissue is more likely to have problems, for and a total reconstruction of the urethra seems necessary. example the meatal stenosis seen in most of his patients. There is no
REFERENCES 1. Nove Josserand, G.: Late results of urethroplasty by tunnelization
one way to repair hypospadias and the surgeon must consider every technique in the armamentarium. The fact that bladder mucosa can be used should be remembered in difficult situations. C.J.D.