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Three Stage Repair for Penoscrotal Hypospadias: Report of a Case1
THREE STAGE REPAIR FOR PENOSCROTAL HYPOSPADIAS: REPORT OF A CASE 1 JOHN R. HAND
The relatively common glandular hypospadias without deformity, it is generally agreed, requires no treatment. The rare vulvar variety, which has given rise to a good deal of confusion chiefly because the child so affi.icted is reared as a girl, requires both correction of the defect and changing of the sex. For the varieties of hypospadias between these two extremes-the penile, the penoscrotal, and the perineal-numerous operations are in vogue today. These are modifications, in varying degrees, of techniques evolved by such early workers as Thiersch, Duplay, Bucknall, Ombredanne, Beck. The aim of all these operations is twofold: 1) correction of the deformity as well as establishment of a normal-appearing phallus; and 2) construction of a well-calibrated urethra. The 3-stage operation I perform for the correction of hypospadias is a combination, with additional slight modifications, of suggestions from the procedures of several men, notably Duplay, Cecil, Nesbit, Charnock and Kiskadden, and Mclndoo. OPERATIVE TECHNIQUE
First stage, to straighten penis. The operative field is injected subcutaneously with a solution of 1 per cent procaine to which is added 10 to 20 drops of epinephrin to the ounce, as suggested by Charnock and Kiskadden. This measure assists in procuring a dry operative field, which is necessary to promote healing of the preputial flap used to cover the denuded penile area. An incision is made just below and along the ventral base of the glans (fig. 1). All constricting fibrous tissue, which includes remnants of the corpus spongiosum, is carefully dissected away. Often it is necessary to incise Buck's fascia before the corpora cavernosa are completely freed. As the dissection progresses, the urethra recedes proximally. When the ventral curvature has been relieved satisfactorily, the foreskin is incised around the glans and its two layers are separated. A transverse buttonhole is then made in the foreskin, as suggested by Nesbit (fig. 1). Care should be taken not to make this buttonhole too low on the foreskin. Two low a buttonhole will shorten the dorsum of the penis. The foreskin flap is pulled over the glall)3 and allowed to drop down like an apron over the denuded area on the ventral aspect of the penis. It is fixed first to the ventral surface of the glans, then to the dorsal glans surface, and finally to the edge of the penile wound with interrupted sutures of plain triple O catgut (fig. 1). This foreskin apron provides adequate covering for the denuded surface and an abundance of tissue for the subsequent urethroplasty. None of the tissue from the foreskin should be trimmed off at this stage of the operation. The tissue contracts. If trimming is necessary, it can be done at a later date. 1 Read at annual meeting, Western Section, American Urological Association, Yosemite Valley, Calif., May 21-23, 1947. 414
THREE STAGE REPAIR FOR PENOSCROTAL HYPOSPADIAS
415
Second stage, to construct urethra. The second stage of the operation is postponed until there is complete softening of the tissues about the operative site and, if necessary, until there is further penile growth. An interval of 15 months elapsed between these two stages in the case herein reported.
Fm. 1. Steps in first stage of operation. Constricting tissue has been freed. A, Foreskin dissected from around glans, its two layers separated and elongated. B, Buttonhole incision. C, Glans pulled through buttonhole. D, Flap fixed with interrupted sutures.
The operative field is injected with the procaine and epinephrin solution already referred to. Following this, a 12 F. catheter is placed in the proximal meatus and held against the midline of the ventral penile surface. A longitudinal incision is then made on either side of the catheter, according to the technique of Duplay (fig. 2). The incisions are placed far enough apart to insure a flap of sufficient width for construction of a well-calibrated urethra. Each lateral incision extends from the corona to about ½inch above the proximal meatus.
416
JOHN R. HAND
The edges of the internal flap are now dissected free. But the dissection is continued only far enough to bring the skin edges over the catheter and to invert them accurately without tension, using interrupted mattress sutures of Deknatel C for the inversion. Thus, the newly formed tube has a relatively wide base and, consequently, an adequate blood supply. In the original Duplay operation the edges of the newly formed urethra are not approximated, the missing portion of the wall being supplied by the overlapping superficial skin. Charnock
Fm. 2. Second stage of operation. A, Catheter in proximal urethra. Broken lines show site of lateral incisions. B, Incision being made on one side of catheter. C, Interrupted suture line inverting edges of newly formed tube. D, Skin closure. Note suture line of urethral channel pulled to side so that it will not lie directly under suture line of superficial skin.
and Kiskadden used the Duplay incision, but inverted the inner layer with interrupted mattress sutures. As soon as the urethral channel has been completed, it is rotated gently to one side and anchored with interrupted silk sutures under the lateral. skin edge, which has been freed just enough to permit this maneuver (fig. 2). Both lateral skin edges are united in the midline over the newly formed tube. By rotating the new channel, the two suture lines do not overlap, a danger against which Cecil warned. The preliminary preputial graft provides sufficient tissue for execution of these measures without tension.
THREE STAGE REAPIR FOR PENOSCROTAL HYPOSPADIAS
417
The catheter is removed immediately after completion of the second stage. This is done to relieve tension on the suture lines. No dressing is applied. A cradle is placed over the patient to keep the covers off the operative site. Sulfathiazole powder (not crystals) is dusted lightly on the wound 4 times a day. This keeps the wound dry and at the same time prevents crusting. Erections are discouraged by an ice bag on the lower abdomen and by administration of triple bromides 4 times a day. The urine is not diverted during the operation. It is unnecessary to divert the urine because the proximal end of the newly formed urethra terminates just
Fm. 3. Third operative stage. A, Catheter in urethra. B, Inner layer, inverted with interrupted mattress sutures. C, Subcuticular suture line,interrupted silk sutures. D, Skin closure over short pieces of rubber catheter which compress skin edges without tension, as suggested by Mclndoo.
above the scrotal meatus. Hence, the old meatus continues to serve for voiding purposes until the third stage of the operation is completed. No attempt is made to bring the urethra through the tip of the glans. This procedure predisposes to stricture formation. Approximately 6 weeks postoperatively a catheter is inserted into the new urethra for the purpose of testing its patency. The procedure should be repeated, if necessary, to make sure there is no obstruction in the new channel. Obstruction in this channel would create pressure on the third stage anastomosis. All hair follicles observed near the proximal urethra are destroyed with an electric needle prior to the third stage repair. Third stage, to close scrotal meatus. The third stage, like the second, should not be undertaken until there is complete healing and softening of the operative
418
JOHN R. HAND
area. In the case herein reported, there was an interval of 9 months between the second and the third stages. The repair is carried out over a 14 F. catheter. An incision is made around the circumference of the scrotal meatus, leaving a sufficient margin of tissue to permit inversion of the skin edges without tension (fig. 3). A subcuticular
Frn. 4. A, Characteristic hypospadiac deformity. Note hooded prepuce. B, Just before undergoing second stage of operation, 15 months after first stage. Probe in proximal meatus. C, Nine months after second operation. Catheter in urethral channel prior to closure of penoscrotal meatus at third stage of operation. D, Urinary stream after completion of third stage repair.
layer of interrupted silk sutures is then placed. The skin wound is closed in the manner suggested by Mclndoo. That is, sutures are placed over 2 small pieces of rubber catheter, one along either edge of the incision (fig. 3). When the sutures are tied, the skin edges are compressed snugly without tension. McIndoo tied the knot of the inverting suture inside the urethra. ::VIy inverting suture is a mattress that goes into but not through the epithelium. Thus there is no suture material inside the new urethral channel.
THREEf STAGE REPAIR FOR PENOSCROTAL HYPOSPADIAS
419
The catheter inserted in the urethral channel at the beginning of the repair, may be removed as soon as the operation is completed, or it may be left in situ for 24 hours. It must not, however, be left in the urethra for more than 48 hours. CASE REPORT
A Negro boy was first seen on February 12, 1945, when he was 13 years old. He had a penoscrotal hypospadias of extreme degree (fig. 4, A). The first stage of the operation was carried out on February 28, 1945; the second stage on June 16, 1946 (fig. 4, .B); and the third stage on April 30, 1947 (fig. 4, C). In this case two things occurred ·which were instrumental in changing my technique: 1) The sutures placed during the third stage of the repair did not hold. The new urethra had been carried down too close to the proximal (scrotal) meatus. For this reason a ,vide enough margin of tissue had not been utilized about the overhanging urethral orifice to allow for proper inversion of the skin edges. Therefore, when I repeated this part of the repair, I allowed for a wider margin of tissue and followed Mcindoo's suggestion of using pieces of rubber catheter for compression of the suture line (fig. 3). This change in the technique of closing the skin has been satisfactorily carried out. 2) Following completion of the third stage, dampness was noted during urination at one point along the newly constructed anterior urethra. A sinus not large enough to be seen grossly allowed urine to come through at this point. This experience led to my present practice of rotating the urethral channel I construct so that its suture line ,Yill not lie directly underneath the suture line in the superficial skin. I report this case because it illustrates some of the difficulties encountered in the management of hypospadias. COMMEN"l'
There is a difference of opm10n concernmg the age at which operation for hypospadias can be carried out successfully. Many authors have suggested that the deformity should be corrected when the child is 2 or 3 years old. The reason for this veiw, as Cecil explained, is to allow the corpora cavernosa to grow normally. Cabot, Walters, and Counsellor, who are among the advocates of early straightening of the deformed penis, recommended completion of the plastic repair by the time the child is 9 years old. Although I have also performed the straightening operation on young children, my final results in the case reported lead me to believe that it may be better to defer the operation as long as possible prior to puberty. In spite of the fact that my patient had an extreme degree of penile deformity when I first saw him at the age of 13, he showed no impairment in the development of the corpora cavernosa. In evaluating the whole problem of hypospadias, the age of the child is in itself not the determining factor for undertaking operation. }\fore important than age is the type of urethroplasty which is to be done after the penis has been straightened. If the deformity is of minor degree and it is possible to approximate the skin edges accurately without tension after the constricting tissue is
420
JOHN R. HAND
disr3ected, then the straightening operation can be done at any age, even when the child is 2 or 3 years old. If, however, the contemplated urethroplasty requires utilization of the foreskin, then the size of the penis becomes the more important consideration. A foreskin flap must be kept on slight tension with even pressure until its "take" is assured. This is easier to accomplish ,vhen the child is at least 7 years old. One cannot minimize the psychologic trauma of hypospadias. On the other hand, numerous operative failures have a far more detrimental psychologic effect on the young child than his awareness of a deformed penis. Another controversial point is the diversion of the urinary stream at the time of the urethroplasty. As I have already stated, I do not divert the urine. This procedure is unnecessary if the plastic repair is done in two stages-one stage for the construction of the urethral channel, the other for uniting the new channel with the old meatus. During the interval between the two plastic operations the original meatus continues to serve for voiding purposes. The new channel thus has an opportunity to heal thoroughly before it is put to its intended use as a urinary outlet. In conclusion, I wish to emphasize that there is as yet no royal road to success in the treatment of hypospadias. However, reports of our failures and successes will indicate to others not only the pitfalls to avoid but the suggestions that can be further improved. SUMMARY
A modified 3-stage operation, using a foreskin graft, has been suggested for the repair of hypospadias. This operation makes available adequate tissue for covering denuded surfaces and for urethroplasty, it permits inversion of the suture lines without tension, and it minimizes the formation of postoperative fistulas. Emphasis was placed on the following points: 1) A dry operative field; 2) spacing of lateral incisions to allow a flap wide enough for construction of a wellcalibrated urethra; 3) allowance for a wide urethral base to insure an adequate blood supply; 4) meticulous approximation of inverted skin edges without tension, using interrupted mattress sutures; 5) staggering of the suture lines by rotating the inner tube to one side and anchoring it under the lateral skin edge; 6) calibration of the healed urethral channel before the third stage repair; 7) destruction of all hair follicles near the proximal urethra prior to the third stage repair; 8) support of the third stage suture line by means of a piece of rubber catheter on either side of the incision. A case of penoscrotal hypospadias is reported. The patient was 13 years old when the first stage of the operation was carried out. The opinion is presented that the type of urethroplasty contemplated is more important than the age of the child in determining when to undertake the operation for straightening the penis. Diversion of the urinary stream is not deemed necessary when a 3-stage repair is done. 1216 S. W. Yamhill St., Portland 5, Ore.
THREE STAGE REPAIR FOR PENOSCROTAL HYPOSPADIAS
421
REFERENCES BECK, CARL: Hypospadias and its treatment. Surg., Gynec. & Obst., 24: 511, 1917. BucKNALL, R. T. H.: A new operation for penile hypospadias. Lancet, 2: 887, 1907. CABOT, H., WALTERS, W. AND CouNSELLER, V. S.: Principles of treatment of hypospadias, J. Urol., 33: 400, 1935. CECIL, A. B.: Surgery of hypospadias and epispadias in the male. J. Urol., 27: 507, 1932. CECIL, A. B.: A further report on the cum of hypospadias ... J. Urol., 34: 278, 1935. CHARNOCK,D. A. ANDKISKADDEN, W. S'.: Hypospadias. J. Urol.,49:444, 1943. DuPLAY, SIMON: Injuries and diseases of the urethra. Internat. Encycl. Surg., 6: 487, 1886. McINDoo, A.H.: The treatment of hypospadias. Am. J. Surg., 38: 176, 1937. NESBIT, R. M.: Plastic procedure for correction of hypospadias. J. Urol., 45: 699, 1941. 0MBREDANNE, L.: cited by Cecil. THIERSCH, in GUITERAS, RAMON: Urology, The Diseases of the Urinary Tract in Men and Women. New York: D. Appleton and Co., 1912, vol. 2, chap. 54, p. 322.
The relatively common glandular hypospadias without deformity, it is generally agreed, requires no treatment. The rare vulvar variety, which has given rise to a good deal of confusion chiefly because the child so affi.icted is reared as a girl, requires both correction of the defect and changing of the sex. For the varieties of hypospadias between these two extremes-the penile, the penoscrotal, and the perineal-numerous operations are in vogue today. These are modifications, in varying degrees, of techniques evolved by such early workers as Thiersch, Duplay, Bucknall, Ombredanne, Beck. The aim of all these operations is twofold: 1) correction of the deformity as well as establishment of a normal-appearing phallus; and 2) construction of a well-calibrated urethra. The 3-stage operation I perform for the correction of hypospadias is a combination, with additional slight modifications, of suggestions from the procedures of several men, notably Duplay, Cecil, Nesbit, Charnock and Kiskadden, and Mclndoo. OPERATIVE TECHNIQUE
First stage, to straighten penis. The operative field is injected subcutaneously with a solution of 1 per cent procaine to which is added 10 to 20 drops of epinephrin to the ounce, as suggested by Charnock and Kiskadden. This measure assists in procuring a dry operative field, which is necessary to promote healing of the preputial flap used to cover the denuded penile area. An incision is made just below and along the ventral base of the glans (fig. 1). All constricting fibrous tissue, which includes remnants of the corpus spongiosum, is carefully dissected away. Often it is necessary to incise Buck's fascia before the corpora cavernosa are completely freed. As the dissection progresses, the urethra recedes proximally. When the ventral curvature has been relieved satisfactorily, the foreskin is incised around the glans and its two layers are separated. A transverse buttonhole is then made in the foreskin, as suggested by Nesbit (fig. 1). Care should be taken not to make this buttonhole too low on the foreskin. Two low a buttonhole will shorten the dorsum of the penis. The foreskin flap is pulled over the glall)3 and allowed to drop down like an apron over the denuded area on the ventral aspect of the penis. It is fixed first to the ventral surface of the glans, then to the dorsal glans surface, and finally to the edge of the penile wound with interrupted sutures of plain triple O catgut (fig. 1). This foreskin apron provides adequate covering for the denuded surface and an abundance of tissue for the subsequent urethroplasty. None of the tissue from the foreskin should be trimmed off at this stage of the operation. The tissue contracts. If trimming is necessary, it can be done at a later date. 1 Read at annual meeting, Western Section, American Urological Association, Yosemite Valley, Calif., May 21-23, 1947. 414
THREE STAGE REPAIR FOR PENOSCROTAL HYPOSPADIAS
415
Second stage, to construct urethra. The second stage of the operation is postponed until there is complete softening of the tissues about the operative site and, if necessary, until there is further penile growth. An interval of 15 months elapsed between these two stages in the case herein reported.
Fm. 1. Steps in first stage of operation. Constricting tissue has been freed. A, Foreskin dissected from around glans, its two layers separated and elongated. B, Buttonhole incision. C, Glans pulled through buttonhole. D, Flap fixed with interrupted sutures.
The operative field is injected with the procaine and epinephrin solution already referred to. Following this, a 12 F. catheter is placed in the proximal meatus and held against the midline of the ventral penile surface. A longitudinal incision is then made on either side of the catheter, according to the technique of Duplay (fig. 2). The incisions are placed far enough apart to insure a flap of sufficient width for construction of a well-calibrated urethra. Each lateral incision extends from the corona to about ½inch above the proximal meatus.
416
JOHN R. HAND
The edges of the internal flap are now dissected free. But the dissection is continued only far enough to bring the skin edges over the catheter and to invert them accurately without tension, using interrupted mattress sutures of Deknatel C for the inversion. Thus, the newly formed tube has a relatively wide base and, consequently, an adequate blood supply. In the original Duplay operation the edges of the newly formed urethra are not approximated, the missing portion of the wall being supplied by the overlapping superficial skin. Charnock
Fm. 2. Second stage of operation. A, Catheter in proximal urethra. Broken lines show site of lateral incisions. B, Incision being made on one side of catheter. C, Interrupted suture line inverting edges of newly formed tube. D, Skin closure. Note suture line of urethral channel pulled to side so that it will not lie directly under suture line of superficial skin.
and Kiskadden used the Duplay incision, but inverted the inner layer with interrupted mattress sutures. As soon as the urethral channel has been completed, it is rotated gently to one side and anchored with interrupted silk sutures under the lateral. skin edge, which has been freed just enough to permit this maneuver (fig. 2). Both lateral skin edges are united in the midline over the newly formed tube. By rotating the new channel, the two suture lines do not overlap, a danger against which Cecil warned. The preliminary preputial graft provides sufficient tissue for execution of these measures without tension.
THREE STAGE REAPIR FOR PENOSCROTAL HYPOSPADIAS
417
The catheter is removed immediately after completion of the second stage. This is done to relieve tension on the suture lines. No dressing is applied. A cradle is placed over the patient to keep the covers off the operative site. Sulfathiazole powder (not crystals) is dusted lightly on the wound 4 times a day. This keeps the wound dry and at the same time prevents crusting. Erections are discouraged by an ice bag on the lower abdomen and by administration of triple bromides 4 times a day. The urine is not diverted during the operation. It is unnecessary to divert the urine because the proximal end of the newly formed urethra terminates just
Fm. 3. Third operative stage. A, Catheter in urethra. B, Inner layer, inverted with interrupted mattress sutures. C, Subcuticular suture line,interrupted silk sutures. D, Skin closure over short pieces of rubber catheter which compress skin edges without tension, as suggested by Mclndoo.
above the scrotal meatus. Hence, the old meatus continues to serve for voiding purposes until the third stage of the operation is completed. No attempt is made to bring the urethra through the tip of the glans. This procedure predisposes to stricture formation. Approximately 6 weeks postoperatively a catheter is inserted into the new urethra for the purpose of testing its patency. The procedure should be repeated, if necessary, to make sure there is no obstruction in the new channel. Obstruction in this channel would create pressure on the third stage anastomosis. All hair follicles observed near the proximal urethra are destroyed with an electric needle prior to the third stage repair. Third stage, to close scrotal meatus. The third stage, like the second, should not be undertaken until there is complete healing and softening of the operative
418
JOHN R. HAND
area. In the case herein reported, there was an interval of 9 months between the second and the third stages. The repair is carried out over a 14 F. catheter. An incision is made around the circumference of the scrotal meatus, leaving a sufficient margin of tissue to permit inversion of the skin edges without tension (fig. 3). A subcuticular
Frn. 4. A, Characteristic hypospadiac deformity. Note hooded prepuce. B, Just before undergoing second stage of operation, 15 months after first stage. Probe in proximal meatus. C, Nine months after second operation. Catheter in urethral channel prior to closure of penoscrotal meatus at third stage of operation. D, Urinary stream after completion of third stage repair.
layer of interrupted silk sutures is then placed. The skin wound is closed in the manner suggested by Mclndoo. That is, sutures are placed over 2 small pieces of rubber catheter, one along either edge of the incision (fig. 3). When the sutures are tied, the skin edges are compressed snugly without tension. McIndoo tied the knot of the inverting suture inside the urethra. ::VIy inverting suture is a mattress that goes into but not through the epithelium. Thus there is no suture material inside the new urethral channel.
THREEf STAGE REPAIR FOR PENOSCROTAL HYPOSPADIAS
419
The catheter inserted in the urethral channel at the beginning of the repair, may be removed as soon as the operation is completed, or it may be left in situ for 24 hours. It must not, however, be left in the urethra for more than 48 hours. CASE REPORT
A Negro boy was first seen on February 12, 1945, when he was 13 years old. He had a penoscrotal hypospadias of extreme degree (fig. 4, A). The first stage of the operation was carried out on February 28, 1945; the second stage on June 16, 1946 (fig. 4, .B); and the third stage on April 30, 1947 (fig. 4, C). In this case two things occurred ·which were instrumental in changing my technique: 1) The sutures placed during the third stage of the repair did not hold. The new urethra had been carried down too close to the proximal (scrotal) meatus. For this reason a ,vide enough margin of tissue had not been utilized about the overhanging urethral orifice to allow for proper inversion of the skin edges. Therefore, when I repeated this part of the repair, I allowed for a wider margin of tissue and followed Mcindoo's suggestion of using pieces of rubber catheter for compression of the suture line (fig. 3). This change in the technique of closing the skin has been satisfactorily carried out. 2) Following completion of the third stage, dampness was noted during urination at one point along the newly constructed anterior urethra. A sinus not large enough to be seen grossly allowed urine to come through at this point. This experience led to my present practice of rotating the urethral channel I construct so that its suture line ,Yill not lie directly underneath the suture line in the superficial skin. I report this case because it illustrates some of the difficulties encountered in the management of hypospadias. COMMEN"l'
There is a difference of opm10n concernmg the age at which operation for hypospadias can be carried out successfully. Many authors have suggested that the deformity should be corrected when the child is 2 or 3 years old. The reason for this veiw, as Cecil explained, is to allow the corpora cavernosa to grow normally. Cabot, Walters, and Counsellor, who are among the advocates of early straightening of the deformed penis, recommended completion of the plastic repair by the time the child is 9 years old. Although I have also performed the straightening operation on young children, my final results in the case reported lead me to believe that it may be better to defer the operation as long as possible prior to puberty. In spite of the fact that my patient had an extreme degree of penile deformity when I first saw him at the age of 13, he showed no impairment in the development of the corpora cavernosa. In evaluating the whole problem of hypospadias, the age of the child is in itself not the determining factor for undertaking operation. }\fore important than age is the type of urethroplasty which is to be done after the penis has been straightened. If the deformity is of minor degree and it is possible to approximate the skin edges accurately without tension after the constricting tissue is
420
JOHN R. HAND
disr3ected, then the straightening operation can be done at any age, even when the child is 2 or 3 years old. If, however, the contemplated urethroplasty requires utilization of the foreskin, then the size of the penis becomes the more important consideration. A foreskin flap must be kept on slight tension with even pressure until its "take" is assured. This is easier to accomplish ,vhen the child is at least 7 years old. One cannot minimize the psychologic trauma of hypospadias. On the other hand, numerous operative failures have a far more detrimental psychologic effect on the young child than his awareness of a deformed penis. Another controversial point is the diversion of the urinary stream at the time of the urethroplasty. As I have already stated, I do not divert the urine. This procedure is unnecessary if the plastic repair is done in two stages-one stage for the construction of the urethral channel, the other for uniting the new channel with the old meatus. During the interval between the two plastic operations the original meatus continues to serve for voiding purposes. The new channel thus has an opportunity to heal thoroughly before it is put to its intended use as a urinary outlet. In conclusion, I wish to emphasize that there is as yet no royal road to success in the treatment of hypospadias. However, reports of our failures and successes will indicate to others not only the pitfalls to avoid but the suggestions that can be further improved. SUMMARY
A modified 3-stage operation, using a foreskin graft, has been suggested for the repair of hypospadias. This operation makes available adequate tissue for covering denuded surfaces and for urethroplasty, it permits inversion of the suture lines without tension, and it minimizes the formation of postoperative fistulas. Emphasis was placed on the following points: 1) A dry operative field; 2) spacing of lateral incisions to allow a flap wide enough for construction of a wellcalibrated urethra; 3) allowance for a wide urethral base to insure an adequate blood supply; 4) meticulous approximation of inverted skin edges without tension, using interrupted mattress sutures; 5) staggering of the suture lines by rotating the inner tube to one side and anchoring it under the lateral skin edge; 6) calibration of the healed urethral channel before the third stage repair; 7) destruction of all hair follicles near the proximal urethra prior to the third stage repair; 8) support of the third stage suture line by means of a piece of rubber catheter on either side of the incision. A case of penoscrotal hypospadias is reported. The patient was 13 years old when the first stage of the operation was carried out. The opinion is presented that the type of urethroplasty contemplated is more important than the age of the child in determining when to undertake the operation for straightening the penis. Diversion of the urinary stream is not deemed necessary when a 3-stage repair is done. 1216 S. W. Yamhill St., Portland 5, Ore.
THREE STAGE REPAIR FOR PENOSCROTAL HYPOSPADIAS
421
REFERENCES BECK, CARL: Hypospadias and its treatment. Surg., Gynec. & Obst., 24: 511, 1917. BucKNALL, R. T. H.: A new operation for penile hypospadias. Lancet, 2: 887, 1907. CABOT, H., WALTERS, W. AND CouNSELLER, V. S.: Principles of treatment of hypospadias, J. Urol., 33: 400, 1935. CECIL, A. B.: Surgery of hypospadias and epispadias in the male. J. Urol., 27: 507, 1932. CECIL, A. B.: A further report on the cum of hypospadias ... J. Urol., 34: 278, 1935. CHARNOCK,D. A. ANDKISKADDEN, W. S'.: Hypospadias. J. Urol.,49:444, 1943. DuPLAY, SIMON: Injuries and diseases of the urethra. Internat. Encycl. Surg., 6: 487, 1886. McINDoo, A.H.: The treatment of hypospadias. Am. J. Surg., 38: 176, 1937. NESBIT, R. M.: Plastic procedure for correction of hypospadias. J. Urol., 45: 699, 1941. 0MBREDANNE, L.: cited by Cecil. THIERSCH, in GUITERAS, RAMON: Urology, The Diseases of the Urinary Tract in Men and Women. New York: D. Appleton and Co., 1912, vol. 2, chap. 54, p. 322.