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Penile Epispadias Reconstruction Treatment & Management

  • Author: Fabio Santanelli di Pompeo, MD, PhD; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Nov 04, 2015
 

Medical Therapy

No medical treatment corrects epispadias.

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Surgical Therapy

Most of the repair techniques are based on multistaged reconstruction procedures used in hypospadias correction.

The first stage addresses correction of the eventually stenotic meatus, the second stage addresses elimination of the dorsal chordee and penile straightening, and the third stage addresses the urethroplasty.

Together with the progress in surgical treatment of hypospadias, one-stage procedures have also been used to correct epispadias.

The goals of surgical procedures are (1) correction of the curvature, (2) reconstruction of the missing portion of urethra, (3) restoration of the normal aspect of the external genitalia, and (4) reconstruction of the anterior wall of the bladder when necessary. Surgery differs according to the complexity of the malformation.

Epispadias is treated with the same technique as hypospadias located in the same anatomic position, with the exception that the repair is reversed and the epispadias reconstruction is on the dorsal surface.

Continence is a difficult goal in exstrophy-epispadias complex repair. Presumably, all anatomic components involved in the exstrophy-epispadias abnormality are present but are displaced laterally and anteriorly. A staged approach has often been used for the management of the exstrophy-epispadias complex. The Cantwell-Ransley repair and the Young procedure have also been used.[2, 3, 4] Partial penile disassembly of the corporal bodies, leaving the urethral plate attached to preserve the blood supply, with their attachments extended down to the horizontal branches of the pubic bones, has been successfully used for primary or secondary repairs.[5, 6, 7]

Single-stage procedure

In glandular epispadias with a straight penis, local flaps based from the glans are often used to reconstruct the missing distal urethra (see following image). In penile malformation, accomplish a suprapubic urinary diversion before degloving the penile skin at the level of the Buck fascia.

Reconstruction of distal penile urethra using loca Reconstruction of distal penile urethra using local flaps (arrows).

Isolate the external urethral meatus, and resect it together with the most distal hypoplastic portion of the urethra. Induce an artificial erection with an intracavernous injection of saline solution to assess for the presence and the degree of curvature. Perform an extensive dorsal chordectomy and straightening of the penile shaft when needed.

According to the urethral defect and age-related urethral size, tailor a penile-preputial flap that was harvested longitudinally from the ventral penile and preputial skin (see following image). Stent the neourethra with a 12- or 14-Ch (Charrière) silicone catheter for 48 hours.

Vertical island flap drawn on the ventral aspect o Vertical island flap drawn on the ventral aspect of the penis.

Apply a mild compressive bandage. When possible, the glandular urethra can be reconstructed using local flaps from the glans. At the end of the procedure, the penis has a circumcised appearance.

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Intraoperative Details

After penile degloving, induce an artificial erection with an intracavernous injection of saline solution to assess for the presence and the degree of curvature. Perform cordectomy and straightening of the penile shaft if required. At this stage, the actual urethral defect shows, and the urethral reconstruction is planned.

Harvest a penile-preputial flap with the preferred technique, taking into consideration the age-related urethral size. Inset the flap to the proximal urethral stump, and tube it around a silicone catheter (see following images).

Island flap transferred dorsally and anastomosed t Island flap transferred dorsally and anastomosed to the urethra.
Island flap sutured into a tube to reconstruct the Island flap sutured into a tube to reconstruct the missing portion of the urethra.

Split the glans and elevate local flaps to cover the distal part of the neourethra that reaches the tip of the glans (see following image).

Urethral reconstruction is completed. Urethral reconstruction is completed.

Remove the redundant foreskin. Pull up the penile skin and suture it to the corona to achieve a final appearance similar to that of a circumcised penis (see following images).

Drawing of the final appearance at the end of the Drawing of the final appearance at the end of the operation.
Photograph of the final appearance at the end of t Photograph of the final appearance at the end of the operation.
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Postoperative Details

Arm and leg restraints may be necessary. 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 difficulty.

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Follow-up

Monitor patients with a flow rate study at 3 weeks and at 3 and 12 months postoperatively. If a mild urethral stenosis is noticed, dilate the urethra with probes of increasing sizes and repeat the flow rate study after 3 weeks. Question patients about persistence of the curvature 3 weeks postoperatively.

Long-term follow-up care is necessary at least through puberty to exclude late failure due to hypertrophic urethral scarring or undetected chronic inflammation.

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Complications

Early complications include bleeding, infection, wound separation, flap necrosis, and edema. Urethrocutaneous fistula with urinary leakage from the new urethra and urethral stricture occur in approximately 10-19% of all epispadias repairs.[8]

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Outcome and Prognosis

In terms of overall success rates, the incidence of fistulas or stenosis, and the mean hospitalization time, functional results obtained with one-stage epispadias correction have proved to be superior to those obtained with multistage procedures; the prognosis is good.

For one-stage reconstruction, the use of a well-nourished and innervated flap with a long and pliable pedicle is necessary to achieve the high success rate reported in the literature.

Surgical repair generally results in both continence (ability to control the flow of urine) and a good cosmetic outcome.[2] Successful reconstruction of epispadias improves the body image and enables the patient to perform sexually.[9]

A study by Kertai et al indicated that in patients with bony pelvic abnormalities associated with exstrophy-epispadias complex, those who as newborns undergo symphyseal approximation without osteotomy do not suffer impairment of long-term hip function. The study included 17 postpubescent patients (14 male; 3 female) who had undergone the procedure in early childhood. The great majority of patients demonstrated no dysplastic or degenerative hip disease on follow-up.[10]

In a study of male patients who underwent reconstruction for epispadias, Reddy et al reported that these individuals were able to engage in postoperative intercourse and impregnate a sexual partner. Twelve of the study’s 15 patients stated that the quality of sexual intercourse was satisfactory overall, although 11 patients experienced at least one problem with sexual function, such as abnormal ejaculation, reduced sensation, or difficulty maintaining an erection. Five patients reported that they had impregnated a partner.[11]

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Future and Controversies

Recent great interest is in developing engineered tissues from autologous materials, such as mature bladder cells, bone marrow, or adipocytes derived stem cells.[12] Ideally, regenerative medicine has the potential to preserve the normal function of the organ it is replacing or augmenting. These studies are still in the early stages with regard to urologic tract malformations.[13]

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Contributor Information and Disclosures
Author

Fabio Santanelli di Pompeo, MD, PhD Associate Professor of Plastic Surgery, Sapienza University of Rome School of Medicine and Psychology; Chief of Plastic Surgery Unit, Sant'Andrea Hospital, Rome

Fabio Santanelli di Pompeo, MD, PhD is a member of the following medical societies: American Society of Plastic Surgeons, International Confederation for Plastic and Reconstructive and Aesthetic Surgery, European Association of Plastic Surgeons, Societa Italiana di Microchirurgia, Swedish Associations of Plastic Surgeons, Osservatorio Nazionale Identit? di Genere

Disclosure: Nothing to disclose.

Coauthor(s)

Francesca Romana Grippaudo, MD, PhD Assistant Professor, Department of Plastic Surgery, S Andrea Hospital, Faculty of Medicine and Psycology, Sapienza University of Rome, Italy

Francesca Romana Grippaudo, MD, PhD is a member of the following medical societies: International Confederation for Plastic and Reconstructive and Aesthetic Surgery, Italian Society of Plastic Reconstructive Surgery and Aesthetics

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

Dennis P Orgill, MD, PhD Professor of Surgery, Harvard Medical School; Associate Chief of Plastic Surgery, Brigham and Women's Hospital

Dennis P Orgill, MD, PhD is a member of the following medical societies: American Society for Reconstructive Microsurgery, Plastic Surgery Research Council, American Medical Association, Massachusetts Medical Society

Disclosure: Received consulting fee from Integra LifeSciences, Inc for consulting; Received consulting fee from Integra LifeSciences, Inc. for program and training services agreement; Received grant/research funds from Integra LifeSciences, Inc. for clinical research; Received grant/research funds from KCI for basic science research; Received grant/research funds from KCI for clinical research; Received consulting fee from DSM for consulting; Received consulting fee from Musculoskeletal Transplant Foundatio.

References
  1. Kureel SN, Gupta A, Singh CS, Kumar M. Surgical anatomy of penis in exstrophy-epispadias: a study of arrangement of fascial planes and superficial vessels of surgical significance. Urology. 2013 Oct. 82(4):910-6. [Medline].

  2. Ben-Chaim J, Peppas DS, Jeffs RD, Gearhart JP. Complete male epispadias: genital reconstruction and achieving continence. J Urol. 1995 May. 153(5):1665-7. [Medline].

  3. Mollard P, Basset T, Mure PY. Male epispadias: experience with 45 cases. J Urol. 1998 Jul. 160(1):55-9. [Medline].

  4. Surer I, Baker LA, Jeffs RD, Gearhart JP. The modified Cantwell-Ransley repair for exstrophy and epispadias: 10- year experience. J Urol. 2000 Sep. 164(3 Pt 2):1040-2; discussion 1042-3. [Medline].

  5. Mokhless I, Youssif M, Ismail HR, Higazy H. Partial penile disassembly for isolated epispadias repair. Urology. 2008 Feb. 71(2):235-8. [Medline].

  6. Kibar I, Roth C, Frimberger D, Kropp BP. Long-term results of penile disassembly technique for correction of epispadias. Urology. 2009/03. 73:510-4.

  7. Hafez AT, Helmy T. Complete penile disassembly for epispadias repair in postpuberal patients. Urology. 2011/12. 78:1407-10. [Full Text].

  8. Stewart D, Inouye BM, Goldstein SD, et al. Pediatric surgical complications of major genitourinary reconstruction in the exstrophy-epispadias complex. J Pediatr Surg. 2015 Jan. 50 (1):167-70. [Medline].

  9. Kramer SA, Mesrobian HG, Kelalis PP. Long-term followup of cosmetic appearance and genital function in male epispadias: review of 70 patients. J Urol. 1986 Mar. 135(3):543-7. [Medline].

  10. Kertai MA, Rosch WH, Brandl R, Hirschfelder H, Zwink N, Ebert AK. Morphological and Functional Hip Long-Term Results after Exstrophy Repair. Eur J Pediatr Surg. 2015 Oct 7. [Medline].

  11. Reddy SS, Inouye BM, Anele UA, et al. Sexual Health Outcomes in Adults with Complete Male Epispadias. J Urol. 2015 Oct. 194 (4):1091-5. [Medline].

  12. Kollhoff DM, Cheng EY, Sharma AK. Urologic applications of engineered tissue. Regen Med. 2011 Nov. 6(6):757-65. [Medline].

  13. Caione P, Boldrini R, Salerno A, Nappo SG. Bladder augmentation using acellular collagen biomatrix: a pilot experience in exstrophic patients. Pediatr Surg Int. 2012 Apr. 28(4):421-8. [Medline].

  14. Gearhart JP. Re: results of complete penile disassembly for epispadias repair in 42 patients. J Urol. 2004 Jun. 171(6 Pt 1):2386; author reply 2386. [Medline].

 
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Distal penile epispadias.
Wide diastasis of the pubic bone and external displacement of the hips in epispadias.
Distal epispadias. Outlining of local flaps from the glans to reconstruct the distal urethra.
Reconstruction of distal penile urethra using local flaps (arrows).
Vertical island flap drawn on the ventral aspect of the penis.
Island flap transferred dorsally and anastomosed to the urethra.
Island flap sutured into a tube to reconstruct the missing portion of the urethra.
Urethral reconstruction is completed.
Drawing of the final appearance at the end of the operation.
Photograph of the final appearance at the end of the operation.
 
 
 
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