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The Surgical Correction of Incomplete Scrotal Transposition Associated with Hypospadias
\/ cl.. l2'f\ The \Villiari1S & Vli)kins Co.
Printed in U.S.A.
JOHN F. REDMAN From the Department of Urology, University of Arkansas College of Jl;fedicine and Arkansas Children's Hospital, Little Rock, Arkansas
ABSTRACT
A simple technique for the surgical correction of incomplete scrotal transposition with the :results in 6 patients is presented. Some degree of scrotal transposition is not an uncommon occurrence with hypospadias, particularly when the urethral meatus is located proximal to the penile corona. 1 Attention to surgical correction of the anomaly generally has been directed only to the more pronounced transpositions. 2- 4 The necessity for surgical correction has been stated to depend on the degree
Pt. Age-Race
Position of Meatus
Side of Transposition
3-Black 5-White 6-White 8-White 11-White 11-White 15-White
Penile Mid penile Coronal Coronal Penoscrotal Coronal Perinea!
Bilat. Lt. Lt. Bilat. Lt. Lt. Bilat.
FIG. 2. Outline of initial incision for incomplete transposition on right side.
FIG. 1. Incomplete scrotal transposition in 25-year-old man
B
FIG. 3. A, preoperative appearance. B, appearance following closure of incision
Accepted for publication July 23, 1982. 565
566
REDMAN
FIG. 4. Surgical technique for correction of partial penoscrotal transposition. A, line of initial incision. B, appearance following elevation of cutaneous flap. C, limbs of incision held together with forceps producing "dog ear". Dotted lines indicate proposed incision.
FIG. 5. A, preoperative appearance of 8-year-old boy with bilateral incomplete scrotal transposition. B, postoperative appearance
of displacement and the presence or absence of associated anomalies. 4 It has become increasingly apparent to me that the presence of rugal skin cranial to the base of the penis gives a labia-like and unmasculine appearance to the external genitalia. I have further noted in adults with this anomaly that the appearance persists and is not masked by the pubic hair (fig. 1). Herein an operative procedure is described to correct this anomaly. MATERIAL
Six boys, between 3 and 15 years old, were operated on for the correction of hypospadias and incomplete scrotal transpo-
sition. Their age, race, position of urethral meatus and side of incomplete penoscrotal transposition are listed in the table. OPERATIVE TECHNIQUE
A V-shaped incision was outlined to encompass the rugal skin cranial to the penile base and carried through the dartos tunic (fig. 2). The limbs of the V were held together with forceps and the remaining "dog ear" of tissue was excised caudally to effect a smooth appearance of the scrotum. Closure of the skin only with chromic catgut suture material was needed for approximation of the scrotum (figs. 3 and 4).
INCO]/f~?LETE SCROI\?"L TRitNSPOSITJ:.DN. ASSOCIATED ';MITH IIYP()SPADlA.S
stances of uc,u"v-oac.c, infection or herflatoma. '1.,he cosmetic appearances were uniformly good. DISCUSSION
The technique described is simple in concept and execution, providing an embellishment to hypospadias sii.rgery relatively free of risk. The optical illusion is that the penis has assumed a more cranial and, thus, a more non.aal appearance. This technique requires less dissection than any method previously described. The incisions in no way encroach on the hypospadias repair and, therefore, may be applied to any degree of hypospadias or type of repair. Although some degree of the anomaly was present bilaterally in all cases the transposition was much more pronounced on only l side in the 4 patients who underwent unilateral operations. It should be noted that Marshall and associates used a similar incision but, instead of excising the flap, applied the skin to the ventrum of the penis as an adjunct to a Cecil urethroplasty. 5 REFERENCES
Y., Nagata, H., Shimada, K. and Nagano, S.: Developmental anomalies associated with hypospadias. J. UroL, 122: 619, 1979. Glenn, J. F. and Anderson,E. E.: Surgical correction of incomplete penoscrotal trnnsposition. J. Urol., 110: 603, 1973. Woodard, J. R. and Green, B. G.: A technique for the correction of bifid scrotum in patients with hypospadias. J. Urol., 117: 516, 1977. Ehrlich, R. M. and Scardino, P. T.: Simultaneous surgical correction of scrotal transposition and perineal hypospadias. Urol. Clin. N. Amer., 8: 531, 1981. Marshall, M., Jr., Johnson, S. H., III, Price, S. E., Jr. and Barnhouse, D. H.: Cecil urethroplasty with concurrent scrotoplasty for repair of hypospadias. J. Urol., 121: 335, 1979.
1. Shima, H., Ikoma, F., Terakawa, T., Satoh,
2. 3.
4. 5.
EDITORIAL COMMENT Anterior displacement of the scrotum is not unusual in patients with hypospadias and in some in whom the urethra has been formed all the way to the tip of the penis. The author describes a procedure which he excises this scrotal tissue lying lateral to the penis. his illustrations it is apparent that this can help to make the penis look more normal. In our own experience it would be better to continue the incision beneath the shaft of the penis and incorporate these flaps in the scrotum. This better defines the penoscrotal angle and adds tissue to the scrotum where it is often needed. Sometimes this can be avcv,n1"'"""''u simultaneously with a uypv'opau,ao repai!' but at other would be dangerous to do so of the fact that it may blood supply to the penile shaft skin and put the urethrop!asty
C.J.D.
REPLY BY AUTHOR FIG. 6. A, preoperative appearance of 3-year-old boy with bilateral incomplete scrotal transposition. B, postoperative appearance. RESULTS
Unilateral operation was done in 4 patients, while 2 underwent bilateral procedures (figs. 5 and 6). There were no in-
Initially, I was reluctant to discard the rugal skin that I had reflected in my ~t,>,,,inr.ro to correct partial penoscrotal ansp<)s1t10,n and did incorporate tissue into the scrotum. My now is that the appearance is much improved by simply excising the reflected skin. A further advantage of this technique is that it may be used even in instances of proximal hypospadias without compromising penile skin, since longitudinal bridges between the penile and scrotal skin are left intact even when accomplished bilaterally.
Printed in U.S.A.
JOHN F. REDMAN From the Department of Urology, University of Arkansas College of Jl;fedicine and Arkansas Children's Hospital, Little Rock, Arkansas
ABSTRACT
A simple technique for the surgical correction of incomplete scrotal transposition with the :results in 6 patients is presented. Some degree of scrotal transposition is not an uncommon occurrence with hypospadias, particularly when the urethral meatus is located proximal to the penile corona. 1 Attention to surgical correction of the anomaly generally has been directed only to the more pronounced transpositions. 2- 4 The necessity for surgical correction has been stated to depend on the degree
Pt. Age-Race
Position of Meatus
Side of Transposition
3-Black 5-White 6-White 8-White 11-White 11-White 15-White
Penile Mid penile Coronal Coronal Penoscrotal Coronal Perinea!
Bilat. Lt. Lt. Bilat. Lt. Lt. Bilat.
FIG. 2. Outline of initial incision for incomplete transposition on right side.
FIG. 1. Incomplete scrotal transposition in 25-year-old man
B
FIG. 3. A, preoperative appearance. B, appearance following closure of incision
Accepted for publication July 23, 1982. 565
566
REDMAN
FIG. 4. Surgical technique for correction of partial penoscrotal transposition. A, line of initial incision. B, appearance following elevation of cutaneous flap. C, limbs of incision held together with forceps producing "dog ear". Dotted lines indicate proposed incision.
FIG. 5. A, preoperative appearance of 8-year-old boy with bilateral incomplete scrotal transposition. B, postoperative appearance
of displacement and the presence or absence of associated anomalies. 4 It has become increasingly apparent to me that the presence of rugal skin cranial to the base of the penis gives a labia-like and unmasculine appearance to the external genitalia. I have further noted in adults with this anomaly that the appearance persists and is not masked by the pubic hair (fig. 1). Herein an operative procedure is described to correct this anomaly. MATERIAL
Six boys, between 3 and 15 years old, were operated on for the correction of hypospadias and incomplete scrotal transpo-
sition. Their age, race, position of urethral meatus and side of incomplete penoscrotal transposition are listed in the table. OPERATIVE TECHNIQUE
A V-shaped incision was outlined to encompass the rugal skin cranial to the penile base and carried through the dartos tunic (fig. 2). The limbs of the V were held together with forceps and the remaining "dog ear" of tissue was excised caudally to effect a smooth appearance of the scrotum. Closure of the skin only with chromic catgut suture material was needed for approximation of the scrotum (figs. 3 and 4).
INCO]/f~?LETE SCROI\?"L TRitNSPOSITJ:.DN. ASSOCIATED ';MITH IIYP()SPADlA.S
stances of uc,u"v-oac.c, infection or herflatoma. '1.,he cosmetic appearances were uniformly good. DISCUSSION
The technique described is simple in concept and execution, providing an embellishment to hypospadias sii.rgery relatively free of risk. The optical illusion is that the penis has assumed a more cranial and, thus, a more non.aal appearance. This technique requires less dissection than any method previously described. The incisions in no way encroach on the hypospadias repair and, therefore, may be applied to any degree of hypospadias or type of repair. Although some degree of the anomaly was present bilaterally in all cases the transposition was much more pronounced on only l side in the 4 patients who underwent unilateral operations. It should be noted that Marshall and associates used a similar incision but, instead of excising the flap, applied the skin to the ventrum of the penis as an adjunct to a Cecil urethroplasty. 5 REFERENCES
Y., Nagata, H., Shimada, K. and Nagano, S.: Developmental anomalies associated with hypospadias. J. UroL, 122: 619, 1979. Glenn, J. F. and Anderson,E. E.: Surgical correction of incomplete penoscrotal trnnsposition. J. Urol., 110: 603, 1973. Woodard, J. R. and Green, B. G.: A technique for the correction of bifid scrotum in patients with hypospadias. J. Urol., 117: 516, 1977. Ehrlich, R. M. and Scardino, P. T.: Simultaneous surgical correction of scrotal transposition and perineal hypospadias. Urol. Clin. N. Amer., 8: 531, 1981. Marshall, M., Jr., Johnson, S. H., III, Price, S. E., Jr. and Barnhouse, D. H.: Cecil urethroplasty with concurrent scrotoplasty for repair of hypospadias. J. Urol., 121: 335, 1979.
1. Shima, H., Ikoma, F., Terakawa, T., Satoh,
2. 3.
4. 5.
EDITORIAL COMMENT Anterior displacement of the scrotum is not unusual in patients with hypospadias and in some in whom the urethra has been formed all the way to the tip of the penis. The author describes a procedure which he excises this scrotal tissue lying lateral to the penis. his illustrations it is apparent that this can help to make the penis look more normal. In our own experience it would be better to continue the incision beneath the shaft of the penis and incorporate these flaps in the scrotum. This better defines the penoscrotal angle and adds tissue to the scrotum where it is often needed. Sometimes this can be avcv,n1"'"""''u simultaneously with a uypv'opau,ao repai!' but at other would be dangerous to do so of the fact that it may blood supply to the penile shaft skin and put the urethrop!asty
C.J.D.
REPLY BY AUTHOR FIG. 6. A, preoperative appearance of 3-year-old boy with bilateral incomplete scrotal transposition. B, postoperative appearance. RESULTS
Unilateral operation was done in 4 patients, while 2 underwent bilateral procedures (figs. 5 and 6). There were no in-
Initially, I was reluctant to discard the rugal skin that I had reflected in my ~t,>,,,inr.ro to correct partial penoscrotal ansp<)s1t10,n and did incorporate tissue into the scrotum. My now is that the appearance is much improved by simply excising the reflected skin. A further advantage of this technique is that it may be used even in instances of proximal hypospadias without compromising penile skin, since longitudinal bridges between the penile and scrotal skin are left intact even when accomplished bilaterally.