Penile Epispadias Reconstruction Treatment & Management
- Author: Fabio Santanelli di Pompeo, MD, PhD; Chief Editor: Jorge I de la Torre, MD, FACS more...
No medical treatment corrects epispadias.
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]
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.
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.
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.
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).
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).
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).
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.
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.
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.
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. Successful reconstruction of epispadias improves the body image and enables the patient to perform sexually.
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.
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.
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. 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.
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