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The Denis Browne Repair for Hypospadias: A Review of 14 Years of Consecutive Experience
0022-5347 /81/1255-0706$02.00/0 Vol.125,May
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1981 by The Williams & Wilkins Co.
THE DENIS BROWNE REPAIR FOR HYPOSPADIAS: A REVIEW OF 14 YEARS OF CONSECUTIVE EXPERIENCE BRYAN J. DONNELLY
AND J.
B. PRENDERVILLE
From the Department of Urology, Meath Hospital, Dublin, Ireland
ABSTRACT
We review 72 cases of hypospadias treated by the Denis Browne method. A low incidence of complications was recorded. We believe that the good results justify the continued use of this method of repair. Persistent chordee. Of those patients who have now reached puberty none has complained of persistent chordee.
Hypospadias is the most common congenital malformation of the urethra, with an incidence ranging from 1 in 620 to 1 in 250 births. Hypospadias may or may not be accompanied by a variable degree of chordee. Numerous operations have been devised to repair this defect, including the Denis Browne repair. This repair was first described in 19491 and has been performed at this hospital for the last 20 years. Many centers have stopped using this technique owing to the reported high incidence of fistula formation and because of poor cosmetic result. A recent report by Bailen and Howerton,2 presenting their low rate of fistula formation, prompted us to review our own experience with this technique.
DISCUSSION
The incidence of complication in this series is low. Our fistula rate compares to that of Bailen and Howerton,2 and we did not need to use their modification of the classical repair. These figures compare favorably with the range of 22 to 25 per cent incidence of fistula formation with the Denis Browne technique from other centers. 3 • 4 Bead fistulas were caused by technical errors of tightness or postoperative delay in removal of the beads for >5 days. It has been found that fistula closure is not as satisfactory as taking down and repeating the entire construe tion de novo. We had a stricture rate of only 4 per cent, which is in marked contrast to the report by Hinderer. 5 He noted a 55 per cent incidence of urethral stricture following the Denis Browne repair, 10 per cent after the Ombredanne repair and 5 per cent following the Mclndoe procedure. Valid criticisms of the repair are the slight cosmetic distortion and the fact that sometimes the meatus is not quite at the tip of the glans. This latter deficiency is probably owing to failure to perform a dorsal slit of the prepuce and fixation of the distal end of the reconstruction to the glans. The problem of redundant skin at the prepuce may be treated at a later stage when trimming of the prepuce can be done easily. Fortified by these good results, we believe the continued use of this method of repair of hypospadias is justified.
MATERIALS AND METHODS
We reviewed 72 consecutive cases of hypospadias that were treated by the Denis Browne method during a 14-year period at this hospital. All patients were followed at regular intervals for 3 to 5 years postoperatively. Those who had moved away were sent questionnaires. The response rate to the questionnaire was 67 per cent and 53 per cent were seen at a prearranged outpatient clinic to assess their results. Since the majority of the patients are prepubertal the straightness of the erect penis was not assessed and it was not possible to obtain information on the questions of potency and fertility in these patients. Preoperatively, the presence of chordee was sought by using a simple technique. Initially, only light anesthesia was given and the genitalia were massaged gently, thus, inducing erection that clearly demonstrated even slight degrees of chordee if present.
REFERENCES
1. Browne, D.: An operation for hypospadias. Proc. Roy. Soc. Med., 42: 466, 1949. 2. Bailen, J. and Howerton, L. W.: Decreased fistula formation with modified Denis Browne hypospadias repair. J. Urol., 123: 754, 1980. 3. Kelalis, P. P., Benson, R. C., Jr. and Culp, 0. S.: Complications of single and multistage operations for hypospadias: a comparative review. J. Urol., 118: 657, 1977. 4. Sowden, R. G., Duckett, J. W., Jr. and Filmer, R. B.: Hypospadias repair: a comparison of the Horton-Devine free skin graft and Hodgson type III techniques. Proceedings of the James Kimbrough Urological Seminar, vol. 10, p. 175, 1976. 5. Hinderer, J. T.: Secondary repair of hypospadias failures: another use of the penis tunnelization technique. Plast. Reconstr. Surg., 50: 13, 1972.
RESULTS
Chordee was present in 37 cases (50 per cent), which was repaired initially before proceeding to urethroplasty. A classical Denis Browne 1 method of repair was done, using beads and lead shot to maintain closure of the skin layer. The patients were between 3½ and 24 years old at the time of definitive repair, with the majority being <5 years old. The external meatus was subglandular in 22 cases (30 per cent), penile in 38 (53.5 per cent), penoscrotal in 9 (12.5 per cent) and perineal in 3 (3.2 per cent). One patient had primary hypogonadism, 1 had bilateral undescended testes and 1 had a micropenis that required a separate penile lengthening procedure. Complications. Following the Denis Browne repair 2 patients required a meatoplasty for a tight meatus. Fistulas. There were no cases of a permanent fistula. In 4 patients (5.5 per cent) a primary fistula occurred after breakdown of the wound owing to bead pressure. All had a repeat Denis Browne repair that was successful, although 1 patient required 3 repeat operations before a final success was achieved. Stricture. Strictures occurred in 3 patients and were treated by intermittent dilation, being not of severe degree. Accepted for publication January 23, 1981.
EDITORIAL COMMENT The Denis Browne urethroplasty continues to be a useful procedure and should not be discarded. Technically, it is applicable to all types of hypospadias, hence its versatility. However, I prefer to use it in the most severe degrees (scrotal and penoscrotal), choosing some form of 1-stage reconstruction for the majority of cases that involve minimal degrees of hypospadias. Unfortunately, we continue to lump our results together and I am afraid that they are meaningless. The same technique applied to a
706
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1981 by The Williams & Wilkins Co.
THE DENIS BROWNE REPAIR FOR HYPOSPADIAS: A REVIEW OF 14 YEARS OF CONSECUTIVE EXPERIENCE BRYAN J. DONNELLY
AND J.
B. PRENDERVILLE
From the Department of Urology, Meath Hospital, Dublin, Ireland
ABSTRACT
We review 72 cases of hypospadias treated by the Denis Browne method. A low incidence of complications was recorded. We believe that the good results justify the continued use of this method of repair. Persistent chordee. Of those patients who have now reached puberty none has complained of persistent chordee.
Hypospadias is the most common congenital malformation of the urethra, with an incidence ranging from 1 in 620 to 1 in 250 births. Hypospadias may or may not be accompanied by a variable degree of chordee. Numerous operations have been devised to repair this defect, including the Denis Browne repair. This repair was first described in 19491 and has been performed at this hospital for the last 20 years. Many centers have stopped using this technique owing to the reported high incidence of fistula formation and because of poor cosmetic result. A recent report by Bailen and Howerton,2 presenting their low rate of fistula formation, prompted us to review our own experience with this technique.
DISCUSSION
The incidence of complication in this series is low. Our fistula rate compares to that of Bailen and Howerton,2 and we did not need to use their modification of the classical repair. These figures compare favorably with the range of 22 to 25 per cent incidence of fistula formation with the Denis Browne technique from other centers. 3 • 4 Bead fistulas were caused by technical errors of tightness or postoperative delay in removal of the beads for >5 days. It has been found that fistula closure is not as satisfactory as taking down and repeating the entire construe tion de novo. We had a stricture rate of only 4 per cent, which is in marked contrast to the report by Hinderer. 5 He noted a 55 per cent incidence of urethral stricture following the Denis Browne repair, 10 per cent after the Ombredanne repair and 5 per cent following the Mclndoe procedure. Valid criticisms of the repair are the slight cosmetic distortion and the fact that sometimes the meatus is not quite at the tip of the glans. This latter deficiency is probably owing to failure to perform a dorsal slit of the prepuce and fixation of the distal end of the reconstruction to the glans. The problem of redundant skin at the prepuce may be treated at a later stage when trimming of the prepuce can be done easily. Fortified by these good results, we believe the continued use of this method of repair of hypospadias is justified.
MATERIALS AND METHODS
We reviewed 72 consecutive cases of hypospadias that were treated by the Denis Browne method during a 14-year period at this hospital. All patients were followed at regular intervals for 3 to 5 years postoperatively. Those who had moved away were sent questionnaires. The response rate to the questionnaire was 67 per cent and 53 per cent were seen at a prearranged outpatient clinic to assess their results. Since the majority of the patients are prepubertal the straightness of the erect penis was not assessed and it was not possible to obtain information on the questions of potency and fertility in these patients. Preoperatively, the presence of chordee was sought by using a simple technique. Initially, only light anesthesia was given and the genitalia were massaged gently, thus, inducing erection that clearly demonstrated even slight degrees of chordee if present.
REFERENCES
1. Browne, D.: An operation for hypospadias. Proc. Roy. Soc. Med., 42: 466, 1949. 2. Bailen, J. and Howerton, L. W.: Decreased fistula formation with modified Denis Browne hypospadias repair. J. Urol., 123: 754, 1980. 3. Kelalis, P. P., Benson, R. C., Jr. and Culp, 0. S.: Complications of single and multistage operations for hypospadias: a comparative review. J. Urol., 118: 657, 1977. 4. Sowden, R. G., Duckett, J. W., Jr. and Filmer, R. B.: Hypospadias repair: a comparison of the Horton-Devine free skin graft and Hodgson type III techniques. Proceedings of the James Kimbrough Urological Seminar, vol. 10, p. 175, 1976. 5. Hinderer, J. T.: Secondary repair of hypospadias failures: another use of the penis tunnelization technique. Plast. Reconstr. Surg., 50: 13, 1972.
RESULTS
Chordee was present in 37 cases (50 per cent), which was repaired initially before proceeding to urethroplasty. A classical Denis Browne 1 method of repair was done, using beads and lead shot to maintain closure of the skin layer. The patients were between 3½ and 24 years old at the time of definitive repair, with the majority being <5 years old. The external meatus was subglandular in 22 cases (30 per cent), penile in 38 (53.5 per cent), penoscrotal in 9 (12.5 per cent) and perineal in 3 (3.2 per cent). One patient had primary hypogonadism, 1 had bilateral undescended testes and 1 had a micropenis that required a separate penile lengthening procedure. Complications. Following the Denis Browne repair 2 patients required a meatoplasty for a tight meatus. Fistulas. There were no cases of a permanent fistula. In 4 patients (5.5 per cent) a primary fistula occurred after breakdown of the wound owing to bead pressure. All had a repeat Denis Browne repair that was successful, although 1 patient required 3 repeat operations before a final success was achieved. Stricture. Strictures occurred in 3 patients and were treated by intermittent dilation, being not of severe degree. Accepted for publication January 23, 1981.
EDITORIAL COMMENT The Denis Browne urethroplasty continues to be a useful procedure and should not be discarded. Technically, it is applicable to all types of hypospadias, hence its versatility. However, I prefer to use it in the most severe degrees (scrotal and penoscrotal), choosing some form of 1-stage reconstruction for the majority of cases that involve minimal degrees of hypospadias. Unfortunately, we continue to lump our results together and I am afraid that they are meaningless. The same technique applied to a
706