Urogenital Reconstruction, Penile Hypospadias Treatment & Management

No medical treatment exists to correct hypospadias.

The aims of the surgical procedures are as follow:

• Widening of the meatus
• Correction of the curvature
• Reconstruction of the missing portion of the urethra
• Restoration of the normal aspect of the external genitalia

Surgery differs according to the severity of the malformation.

A meatotomy is required if the size of the external urethral meatus is inferior to that considered normal according to the age of the patient.

The distal urethra missing in glanular hypospadias, usually without recurvatum, is well reconstructed with local flaps based on the meatus (eg, Santanelli procedure, Flip Flap, MAGPI [meatal advancement and glanuloplasty]), including preputium plasty at the same sitting (see images below).

In penile and penoscrotal types of malformation, resection of the chordee and reconstruction of the missing part of the urethra are performed with a single-stage procedure (eg, Duckett, Standoli, Scuderi, modified Koyanagi).

In some clinical situations (eg, perineal hypospadias, genital ambiguity, significant hypospadias with previous circumcision), more extensive operations are necessary, and the former multistage operations may be of occasional use.

Single-stage procedure

• Place a traction suture through the glans and extend a coronal incision around the meatus (see images below).Distal hypospadias: spatulated glans, ventrally cleft preputium. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.) Distal hypospadias. A traction suture is placed through the glans. Incision lines according to Scuderi repair: a coronal incision extended up to and around the meatus. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• Lift the penile skin, including the prepuce, and raise it in the plane between the Buck and dartos fascia.
• Deglove the meatus and penile urethra and separate them from the corpora cavernosa to the point that normal spongy tissue is detected. Excise the hypoplastic stenotic portion of the urethra.
• Perform an artificial erection with intracavernous injection of saline solution to assess the presence and degree of curvature (see images below). Perform chordectomy and straightening of the penile shaft when needed. Artificial erection. An intracavernous injection of saline is performed while controlling the back flow at the basis of the penis with an elastic band. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.) Artificial erection achieved with normal saline injected in the corpora cavernosa while controlling the backward flow. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• At this point, evaluate the actual urethral defect and begin the reconstruction. Harvest a peno-preputial skin flap, which may include both sides of the apron to increase its length, longitudinally along the penile vascular axis according to Scuderi and Koyanagi (Scuderi technique, see images below). The preputial flap can also be raised transversally from the ventral surface (according to Duckett)^[5] or from the dorsal aspect of the apron (according to Standoli).^[7] Two 5/0 traction sutures are placed on either side of the preputial apron. Outlining of the vertical preputial flap after resection of the chordee and evaluation of the urethral defect. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.) Vertical preputium flap after Scuderi repair. Note the "V" shape pattern on the inferior part of the cutaneous flap. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• Mobilize the flap with a large subcutaneous pedicle from the dartos fascia to ensure an appropriate vascularization (see images below). The vertical preputial flap is elevated on the dorsal cutaneous side of the penis, vertically disposed along the vascular axis (Scuderi technique), to comply with the defect to be reconstructed. The flap is mobilized with a large subcutaneous pedicle. Elevation of the vertical preputial flap with its subcutaneous pedicle.
• In the Scuderi procedure, a buttonhole incision is performed bluntly into the pedicle (see first 2 images below), and the flap is transposed ventrally by passing the penile body through the pedicle (see second 2 images below). Buttonhole incision along the midline of the subcutaneous pedicle of the vertical preputial flap, along the axis of the blood vessel, taking care not to jeopardize the vascularization. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.) Buttonhole incision along the median line of the pedicle. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.) The flap is transposed ventrally through the buttonhole incision without tractioning or twisting the pedicle, which may impair the blood supply. Key suture between the flap and the urethra. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.) Key suture between the flap and the urethra. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• If raised according to Koyanagi, the skin flap is divided into two portions at the 12 o'clock position to form a Y-shape, whereas in the modified Koyanagi repair, a button-hole is made trough the pedicle.^[6]
• If raised according to Duckett or Standoli, ventrally transpose the flap by its rotation around the corpora cavernosa.^{[5, 7]} To reduce the incidence of stenosis of the proximal urethral anastomosis, the preputial flap must be V-shaped proximally and joined to a distal incision of 5 mm performed on the ventral wall of the urethra along its medial line.
• Continue suturing between the proximal side of the flap and the urethra (see first 2 images below) and extend it by rolling the flap into a tube around a 12F or 14F silicone catheter (see third image below). The lower edge of the flap is sewn all around the urethral orifice. The flap is transferred ventrally, and the lower edge of the flap is sewn all around the urethral orifice. The flap is tubed around a urinary catheter. In this manner, the anastomosis is covered by the pedicle and the longitudinal suture lies deep between the corporeal bodies, reducing the possibility of fistula occurrence. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• Remove a vertical strip of tissue from the ventral surface of the glans (see first 2 images below) and raise two triangular flaps to cover the terminal part of the neo-urethra (see third image below). The flap is rolled into a tube. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.) The glans is split to permit the placement of the exit of the neo-meatus at the tip of the glans. A vertical strip of tissue from the ventral surface of glans is removed, and two thick triangular flaps are raised to cover the distal part of the neo-urethra. A well-closed urethra during intercourse is achieved. Splitting of the glans. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• Carry out the distal anastomosis. At the end of the procedure, discharge redundant poorly vascularized foreskin (see first 2 images below) and pull up the penile skin and suture it to the corona, creating an appearance similar to a circumcised penis (see second 2 images below). Trimming of the preputium in excess. The excess preputium is removed to provide the penis a circumcised appearance. Final appearance at the end of the operation. Final appearance. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• Stent the urethra and apply a mild compressive dressing.

• An accurate physical examination of the external genitalia of the patient is required to assess the severity of the malformation. Check the position of the meatus, dimension of the penis, and presence of the testicles.
• If a hypospadias condition is associated with impalpable testes, obtain appropriate tests (eg, complete endocrine screen, chromosome analysis, ultrasonography) to exclude an intersex condition.

• After penile degloving, an artificial erection with intracavernous injection of saline solution is performed to assess the presence and degree of curvature.
• The external urethral meatus is then resected together with the most distal hypoplastic portion of the urethra.
• Cordectomy and straightening of the penile shaft is performed if required.
• At this stage, the actual urethral defect shows and the urethral reconstruction is planned.
• A penile-preputial flap is harvested according to the preferred technique, taking into consideration the age-related urethral size. The flap is inset to the proximal urethral stump and tubed around a silicone catheter.
• The glans is split and two flaps that reach the tip of the glans are elevated to cover the distal part of the neo-urethra.
• The redundant foreskin is discharged and the penile skin is pulled up and sutured to the corona to achieve a final aspect similar to a circumcised penis.

• Restraints for arm and legs may be necessary.
• Remove the urethral stent after 48 hours.
• The dressings remain in place for 4 days if no problems occur.
• Remove the diverting urinary catheter after 8-10 days.
• Discharge the patient after removal of the urinary diversion and when spontaneous voiding occurs without difficulties.

• Patients are observed with fluximetry tests including registration of the micturition volume, maximum flow, medium flow, and micturition time.
• A pressure-flow study with urethrogram and endoscopy (see image below) before removal of the urinary diversion may be indicated to evaluate the detrusorial pressure and the morphologic and urodynamic aspects of the newly reconstructed urethra. Poor flow rate in a junctional stenosis (above). Normal flow rate (down) 1 year after dilatation. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• Perform a flow rate study at 3 weeks postoperatively (see image below). Examine patients showing a normal flow rate again at 3 and 12 months postoperatively. In patients exhibiting mild stenosis, urethra dilatation is indicated; repeat the flow rate study after 3 weeks. Endoscopic view of the anastomosis. (Published in Scand J Plast Reconstr Surg Hand Surg 1990; 24 (1): 67-73. Reprinted with permission of the editor.)
• At the 3-month follow-up visit, question patients about the persistence of the curvature or other problems.
• Long-term follow-up care is necessary at least through puberty to exclude late failure caused by hypertrophic urethral scarring or undetected chronic inflammation.

• Early complications include bleeding, infection, wound separation, flap necrosis, and edema.
• Temporary stenosis from edema or hypertrophic scarring at the anastomotic site may occur in 7% of repairs. Normalization is achieved after dilatation with urethral probes of progressive caliber and stabilization of the healing process.
• Early urinary leakage from delayed healing of the urethral suture has been reported with an incidence of 3-9%. Spontaneous resolution occurs by keeping the suprapubic diversion for a longer time.
• Urethrocutaneous fistulas with urinary leakage from the new urethra range from 0.6-23% in the one-stage operation and from 2-37.3% in the two-stage operation.
• Urethral stricture complicates approximately 8.5% of hypospadias repairs.
• Persistent chordee caused by incomplete excision requires secondary surgical excision of all fibrous tissue.

Functional results obtained with one-stage correction of hypospadias in terms of overall success rate, incidence of fistulas or stenosis, and mean hospitalization time have proved to be superior than those obtained with multistage procedures, and the prognosis is good.

The use of a well-nourished and innervated flap with a long and pliable pedicle is the reason for the high success rate reported in the literature when using one-stage reconstruction.

Glanuloplasty and residual preputial trimming are always associated with urethral repair and allow the reconstruction of a cosmetically acceptable glans with a neomeatus at the tip, closed during intercourse, and with a final appearance close to a normal circumcised penis.

The different techniques of preputial flap (Duckett, Standoli, Scuderi, Koyanagi) allow good functional results in primary hypospadias or in physically disabled patients where prepuce is no longer available and the flap can be harvested from the dorsal preputial skin.^{[5, 7, 8, 6]}

Several problems are related to the older multistage techniques. Repeated surgery, high percentage of fistulas and strictures of the urethra, extensive scarring, and the presence of hairs in the neo-urethra were the most frequent complaints.

One-stage hypospadias repairs offer the advantages of a single procedure using unscarred tissue performed when the patient is younger than school age.