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Urogenital Reconstruction, Penile Hypospadias: Treatment
Updated: Jun 30, 2008
Treatment
Medical Therapy
No medical treatment exists to correct hypospadias.
Surgical Therapy
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 6-11).
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 Image 2, Image 3).
- 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 Image 12, Image 13). Perform chordectomy and straightening of the penile shaft when needed.
- 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 Image 14, Image 15). 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 Mobilize the flap with a large subcutaneous pedicle from the dartos fascia to ensure an appropriate vascularization (see Image 16, Image 17).
- In the Scuderi procedure, a buttonhole incision is performed bluntly into the pedicle (see Image 18, Image 19), and the flap is transposed ventrally by passing the penile body through the pedicle (see Image 20, Image 21).
- 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 Image 22, Image 23) and extend it by rolling the flap into a tube around a 12F or 14F silicone catheter (see Image 24).
- Remove a vertical strip of tissue from the ventral surface of the glans (see Image 25, Image 26) and raise two triangular flaps to cover the terminal part of the neo-urethra (see Image 27).
- Carry out the distal anastomosis. At the end of the procedure, discharge redundant poorly vascularized foreskin (see Image 28, Image 29) and pull up the penile skin and suture it to the corona, creating an appearance similar to a circumcised penis (see Image 30, Image 31).
- Stent the urethra and apply a mild compressive dressing.
Preoperative Details
- 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.
Intraoperative Details
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.
Postoperative Details
- 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.
Follow-up
- 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 32) 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.
- Perform a flow rate study at 3 weeks postoperatively (see Image 33). 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.
- 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.
Complications
- 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.
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References
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Further Reading
Keywords
hypospadias repair, urogenital reconstruction, penile hypospadias, penile reconstruction, urethroplasty, hypospadias, epispadias, bifid clitoris, bladder exstrophy, hidden penis, penile curvature, urethral hypoplasia, urethra reconstruction, urethra repair, urethral repair, urethra surgery, hypospadias malformation
