PENOSCROTAL HYPOSPADIAS
SAMI ARAP, ANUAR IBRAHIM MITRE
Division of Urology, School of Medicine, State University of São Paulo, SP, Brazil
ABSTRACT
Proximal
hypospadias include proximal penile, penoscrotal, scrotal and perineal
types in which the site of the urethral meatus is respectively the proximal
third of the penis, root of penis, scrotum or between the genital swellings
and below the genital swellings. Proximal hypospadias cause micturition
problems besides limiting sexual intercourse and fertility, and require
correction.
Newborn children with proximal hypospadias
bearing ambiguous genitalia characteristics or associated with cryptorchidism
must be better studied from the standpoint of sexual development prior
to gender assignment and before the birth certificate is obtained. This
evaluation should be multidisciplinary, consisting of tests such as sexual
chromatin investigation, karyotype, stimulation test using chorionic gonadotrophin,
pelvic sonographic screening and retrograde and urinary urethrocystography,
and eventually biopsy of the gonad. In the remaining cases, parents should
be assured of the neonate’s gender, and the only medical concern while
awaiting surgical repair is to make sure that no stricture of the urethral
meatus exists that may cause micturition difficulties.
Optimal age for hypospadias repair is between
eight and 12 months of age. At that stage, the size of the penis is almost
equivalent to that of a three year old child, and the trophic conditions
of the skin allow a high degree of safety during operation.
Multiple principles rule the techniques
used in hypospadias correction. This article will describe these principles
and the authors’ experience with some techniques for penoscrotal hypospadias
repair.
Key words:
hypospadia, penoscrotal hypospadias, indications, surgical techniques
Braz J Urol, 26 (3): 304-314, 2000
INTRODUCTION
Male
hypospadias is a congenital anomaly, which affect different structures
of the penis and eventually the scrotum and perineum. A wide range of
types of hypospadias can be observed according to the original site of
the opening of the urethral meatus and to other associated deformities.
They are found in varying configurations that range from an aspect of
ambiguous genitalia to a well-formed penis with a superficial defect.
Hypospadias is a common congenital anomaly
and its incidence in Brazil has been calculated as 1:565 live male birth
(1).
Some penile anomalies, often associated
with hypospadias, are related to cosmetic and functional aspects of the
penis (2). When in erection it is considered a significant ventral curvature
of the penis (chordee) a deflection angle of the shaft of the penis greater
than 20 degrees (3). In proximal hypospadias, the ventral curvature is
often caused by fibrous chordee. Chordee is formed by residual fibrous
tissue of the corpus spongiosum and is located on the ventral urethra,
distal to the urethral meatus, in close contact with the tunica albuginea.
Other significant causes of the ventral curvature began to be better defined
with the introduction of the artificial erection technique (3). The cutaneous
chordee arising out of the asymmetric distribution of the skin around
the penis can originate some degree of curvature both in distal and in
proximal hypospadias. Also, there can be an asymmetry of the tunica albuginea,
which accounts for the permanence of the curvature despite the excision
of the entire fibrous chordee (4). Other uncommon cause of penile curvature
is the growth differential between the corpora cavernosa and the corpus
spongiosum.
In proximal hypospadias, the prepuce is
asymmetric, accumulating on the dorsum of the penis and being deficient
on the ventral segment. The prepuce may be normal in distal hypospadias
in up to 7% of cases. Urethral meatus stenosis is less frequent in proximal
hypospadias, where it is observed in about 15% of cases. Axial kicking
of the shaft of the penis occurs in 14% of patients, and is not dependent
on the degree of hypospadias.
Proximal hypospadias are a less common occurrence
and correspond to 20% of total hypospadias. Proximal hypospadias are usually
associated with scrotal malformations, such as penoscrotal synaechia,
hypoplasia, bifid scrotum and high scrotum implantation.
The most commonly used classification of
hypospadias is Barcat’s, and it is based on the location of the urethral
meatus after correction of the associated curvature of the penis. Proximal
hypospadias include proximal penile, penoscrotal, scrotal and perineal
types in which the site of the urethral meatus is respectively the proximal
third of the penis, root of penis, scrotum or between the genital swellings
and below the genital swellings.
Proximal hypospadias cause micturition problems
besides limiting sexual intercourse and fertility, and require correction.
Moreover, nontreated hypospadias put the patients at risk emotionally,
regarding acceptance of their own body image, through the transference
of parents’ anxiety or the acknowledgement of the condition by friends
or a sexual partner, which leads to embarrassing situations (5).
PATIENT PREPARATION
Newborn
children with proximal hypospadias bearing ambiguous genitalia characteristics
or associated with cryptorchidism must be better studied from the standpoint
of sexual development prior to gender assignment and before the birth
certificate is obtained. This evaluation should be multidisciplinary,
consisting of tests such as sexual chromatin investigation, karyotype,
stimulation test using chorionic gonadotrophin, pelvic sonographic screening
and retrograde and urinary urethrocystography, and eventually biopsy of
the gonad.
In the remaining cases, parents should be
assured of the neonate’s gender, and the only medical concern while
awaiting surgical repair is to make sure that no stricture of the urethral
meatus exists that may cause micturition difficulties. Exceptionally,
a meatotomy may be necessary.
Optimal age for hypospadias repair is between
8 and 12 months of age. At that stage, the size of the penis is almost
equivalent to that of a 3 year old child, and the trophic conditions of
the skin allow a high degree of safety during operation. Children at that
age suffer much less emotionally during the postoperative period than
do older children and, as a consequence, parents’ anxiety is also
alleviated (2). During that period children are still in diapers and have
not been exposed to other people’s observation. Still more important,
in case of complications that require reintervention further correction
can be carried out sometime before the second year. At about this time
the genital awareness begins and the child becomes more prone to psychological
problems.
POSTINFORMED CONSENT
Parents must be informed with regard to prospects of success, care and inconvenient that involve the postoperative period, occurrence of complications associated with the repair of hypospadias and its treatment. In countries where this is customary the information should be provided to parents in written and contain the respective signatures of consent.
PREOPERATIVE PREPARATION
Preoperative
laboratory tests are the basic required for this type of surgery. An ultrasonographic
screening of the urinary tract is essential to rule out associated anomalies.
Preparation of the skin is obtained by washing
it extensively with an iodized germicide solution (1% active iodine) and
saline, from some centimeters above de umbilical scar to the knees, including
the entire perineum. The germicide solution is removed with pads and the
desinfection is concluded with the topical use of the same solution.
INSTRUMENTATION
The suture material employed should be atraumatic; monofilament sutures are preferable (PDS or Vycril 6-0). The surgical material consists of the delicate instruments used in plastic surgery. Often a loupe is utilized with magnification at 2.5 power and a large focal length, which offers a detailed field of vision during surgery. The glans is fixed with nylon 5-0 suture to facilitate presentation of the penis throughout surgery.
DESCRIPTION OF SURGICAL PROCEDURES
Multiple
principles rule the techniques used in hypospadias correction. We will
indicate some examples, since it is impossible to mention here all the
techniques described. The first reports of hypospadias surgery date back
to the second century. Techniques proposing neourethroplasty via a dermal
graft, extending from the urethral meatus to the glans, date from 1836,
when Dieffenbach, and, later, Duplay, with 2 lateral incisions brought
together the edges of the urethral floor to form a new urethra. In spite
of initial failures, for the first time valid principles of the hypospadias
surgery were employed (6).
At that period the correction of the ventral
curvature by excision of the fibrous chordee began to be recognized. The
concept of treating the ventral curvature at an initial and isolated stage
(orthophaloplasty) became a dogma for all degrees of hypospadias (7).
Smith (8), in 1973, modified Duplay’s
technique proposing the coverage of the neourethra with a de-epithelialized
skin flap, thus considerably reducing the incidence of urethrocutaneous
fistula (9).
Devine
& Horton (6) used a preputial skin graft after release of the fibrous
chordee in a single procedure and reported good results with one-stage
repairs. Hodgson (3) and, later, Asopa & Asopa (11) utilized the prepuce
in the construction of the neourethra and to bridge the cutaneous defect
of the urethral ventrum. Although the graft of the mucosal surface had
the shape of an island its pedicle was not dissected but was brought along
with the cutaneous surface of the prepuce onto the urethral ventrum. The
advantage of this technique over the technique previously described lies
in that the blood supply to the same tissues does not suffer interruption.
Duckett (12) suggested the use of a preputial
island flap, where the preputial mucosa used to form the new urethra has
a well-individualized pedicle containing superficial dorsal penile vessels
and, when dissected to a certain extent, allows the neourethra to be advanced
to the urethral plate without traction of the pedicle (Figure-1). With
this technique the cutaneous surface of the prepuce becomes less vascularized
and the tailoring of the skin around the penis using the Blair-Byars technique
is more difficult.
Asopa & Asopa (11) devised the double-faced
preputial island flap which consists of an adjacent skin flap covering
the mucosal flap which serves as the new urethra, both being maintained
by the same pedicle. The cutaneous surface graft is thus very well vascularized
and when advanced along with the neourethra to the urethral ventrum permits
a uniform distribution of the skin around the penis.
Considering hypospadias globally, to the
present more than 300 original techniques and their variations have been
described for its correction. The ultimate goal of hypospadiology is to
achieve a normal penis regarding both function and morphology.
In the 1980s distal hypospadias began to
be repaired in one procedure. At a later period, one-stage techniques
were adopted for the correction of more complex hypospadias (13). In 1984
we began to use the Double Preputial Island Flap procedure (DIF) in substitution
to the Preputial Island Flap as this technique ensures a better vascularization
of the skin flap employed in the coverage of the ventral raw surface and
allows a more homogeneous skin distribution around the penis.
The utilization of one-stage techniques
became more popular as surgeons gained experience with
these procedures, and the results obtained proved to be satisfactory.
Familiarity with these methods represented an additional resource for
electing the procedure that best applies in each individual case.
In March 1985 we began to perform on the
cutaneous aspect of the preputial island double-flap (14,15), similar
to the technique used by Smith (8), the de-epithelization of two rectangular
strips close to the proximal and contralateral edges of the pedicle. Another
tissue plane was created to offer a better protection against the formation
of urethrocutaneous fistulas (Figure-2). With this method we were also
able to avoid the depression that may occur between the neourethra and
the corpus cavernous on the opposite side of the pedicle. Besides, it
was possible to use the redundant skin from the cutaneous portion of the
double island flap. After the modification introduced by us, this procedure
is now called the Modified Preputial Island Double-Flap operation (MDIF).
Later on, the application of the MDIF surgery was extended to include
scrotal and perineal hypospadias, and the technique was further developed
by adding to it the tubularization of the urethral plate up to the base
of the penis, according to Duplay’s technique (Figure-3).
More recently, due to the incidence of stenosis
at the level of the anastomoses, and to the occurrence of urethrocutaneous
fistulas, we have focused our attention on the preservation of the urethral
plate. Despite the presence of 2 suture lines, the flaps are fixed to
the spongiosum, which is a very well vascularized tissue and ensures a
much lower incidence of fistulas. At the same time, circular sutures no
longer exist at the level of the anastomoses, minimizing the risks of
scar retraction and of meatal stenosis or proximal anastomotic strictures.
Moreover, the neourethra stands well rectified which makes easier an eventual
catheterization.
The preservation of the urethral plate applies
to hypospadias: 1)- without penile bend; 2)- with penile curvatures caused
by cutaneous chordee; 3)- with mild penile curvatures by fibrous chordee
which can be excised below the urethral plate; 4)- with moderate curvatures
or residual bends caused by fibrous chordee or by asymmetry of the tunica
albuginea where the contralateral plication does not significantly reduce
the size of the penis. If necessary, the surgeon should not hesitate to
discard the urethral plate in order not to shorten excessively the penis.
Concerning this decision it is important to emphasize that performing
the artificial erection is essential not only at the beginning of the
procedure but especially during surgery.
Often, the tip of the hypospadic urethra
is hypoplastic, which only conceals a more severe degree of hypospadia.
Since this is a poorly vascularized tissue, not fitted for the anastomosis,
it should be discarded and the urethra cut back to good spongiosum.
For more than one decade and a half we have
being repairing all types of hypospadias, regardless of their degree in
one operation. Techniques in 2 or 3 stages are reserved to patients previously
submitted to surgery in whom the preputial hood is not available and that
require us to adapt to existing conditions.
Operative
Act for Correction of Proximal Hypospadias without Preservation of the
Urethral Plate (Figures-2 and 3)
A
circular incision is made distally to the urethral meatus, approximately
3-mm from the glans neck, and the fibrous chordee is excised on the urethral
plate obtaining a progressive straightening of the penis. If a significant
curvature still persists, by asymmetry of the tunica albuginea we proceed
to plicate it on the dorsum of the penis, thus achieving the straightening
of the organ. With the assistance of stitches, we present and outline
with stain a horizontal rectangle on the mucosal surface of the prepuce
which will constitute the neourethra with a length that will extend from
the new position of the urethral meatus to the apex of the glans and whose
caliber will equal that of the normal urethra. Superficial incisions are
made following the previously drawn lines, deep enough to allow tubularization
of the new urethra. The neourethra is created over a 6F plastic catheter.
Several interrupted sutures are used on the edges of the neourethra; care
must be taken to leave them spatulated. The neourethra is completed using
a continuous suture. Afterwards, a rectangle is outlined on the cutaneous
portion of the prepuce keeping the same direction as the coverage of the
neourethra and raw surface of the urethral plate. As a reference we use
the glans neck which represents the inferior side of the rectangular flap.
After incising the skin, we proceed to dissect the pedicle responsible
for the vascularization of the preputial island double-flap immediately
below the superficial fascia, towards the base of the penis. The other
dissection plane of the pedicle is right above de deep fascia of the penis,
close to the tunica albuginea of the corpora cavernosa. The pedicle thus
defined and which contains the penile superficial dorsal vessels is dissected
to a sufficient extent permitting the preputial island double-flap to
pass without any tension to the urethral plate, parallel to the shaft
of the penis. Then the proximal anastomosis is made between the neourethra
and the urethra, both espatulated, using interrupted sutures over a urethral
catheter. Next, the distal anastomosis is made between the neourethra
and the glans. The technique proposed by Devine & Horton is preferred;
according to this method, 3 flaps are created originating from the V or
Y-incision of the glans; the distal flap is incorporated to the distal
end of the neourethra and the other 2, lateral, cover it. In the MDIF
technique 2 strips of approximately 4 mm are outlined with stain on the
inferior portion of the preputial island double-flap and on the margin
contralateral to the passage of the pedicle relatively to the shaft of
the penis. Both segments are de-epithelialized with a scalpel and/or iris
scissors and then sutured laterally to the deeper fascia of the penis
and proximally to the subcutaneous cellular tissue covering the anastomosis.
Then the skin is closed and sutured to the mucosa of the glans neck at
the correspondent points.
In patients with scrotal and perineal hypospadias,
a Duplay-type neourethroplasty is performed, beginning at the urethral
meatus and extending up to the base of the penis, thus allowing the neourethra
made using the preputial mucosa graft to be sufficiently long to reach
the tip of the glans. In these cases, the proximal anastomosis is made
between two neourethras.
Operative
Act with Preservation of the Urethral Plate (Figure-4)
We
will point out only the aspects that distinguish this procedure from the
method previously described.
The incision of the skin is circular and
made on its dorsal and lateral aspects 3 mm from the glans neck. It is
U-shaped on the urethral plate and surrounds the urethral floor. In order
to avoid any accidental lesion to the urethra, next to the meatus, we
recommend injection of normal saline using a fine needle (insulin needle)
to achieve separation of adherent skin from the urethra. If exists a curvature
caused by cutaneous chordee this is corrected after the incision of the
skin. When the bend is moderate, regardless of the cause, it can be eliminated
by plicating the dorsal tunica albuginea on each side relatively to the
neurovascular bundle. When fibrous chordee is responsible for the curvature
it can be excised laterally and inferiorly to the urethral plate. If a
slight bend caused by fibrous chordee or asymmetry of the corpora cavernosa
still persists the dorsal plication may be associated. However, when the
remaining curvature is significant and due to the urethral plate, the
latter should not be preserved and the technique previously described
above is utilized.
Next,
the preputial mucosal island flap is delimited and once it has been sutured
to the mucosal plate it will form the neourethra. For this reason, it
has the same length as the urethral plate but is narrower. The width of
the flap associated with the width of the urethral plate should offer
a neourethra whose diameter is the same as that of the normal urethra.
The preputial skin island flap is delimited and the dissection of the
pedicle is carried out as previously described.
After bringing the preputial island flaps
to the urethral plate and placing the pedicle alongside the shaft of the
penis, the mucosal flap is incorporated to the urethral plate with continuous
sutures beginning at the urethral meatus and initially lying on the same
side of the pedicle. The next steps are identical to what has been already
described.
POSTOPERATIVE CARE
Postoperative
care is mainly related to drainage of urine and to dressing.
In
proximal hypospadias urinary drainage is necessary. The most commonly
employed methods of urinary drainage are the urethral catheter, either
continent or incontinent, and the suprapubic catheter (Figure-5).
In children still in diapers we prefer to
leave the internal end of the urethral catheter in the bladder and to
section the external end, fixing it to the glans. The urine drips continuously
into the diaper. Another common alternative used by other surgeons is
to leave the external end longer and allow it to drain between 2 diapers.
In older children, that no longer use diapers,
the internal end can be left in the bulbous urethra in order to maintain
the child continent, and the urine is eliminated through the catheter
only during micturition. The urethral stenting avoids excess pressure
inside the neourethra and ensures the drainage of eventual secretions.
The suprapubic catheter method is also often
used and permits the introduction of larger caliber stents than it is
possible via the urethra. However, with relative frequency it can cause
spasms and undesirable urethral micturitions. In fact, the choice depends
on the surgeon’s preference.
Dressings should provide more immobilization
than compression. If an incontinent urethral catheter is used, the best
option is a bio-occlusive dressing that provides a good aeration but protects
the surgical wound from permeation of bacteria or urine. This dressing
is transparent and the surgical wound remains visible. With the suprapubic
catheter a dressing with a layer of rayon or vaselinated gauze may be
used with Coban (autostatic elastic dressing) to maintain it in position.
The surgical wound must be kept clean to
prevent infections and gauze dressings should be changed every 2 to 4
days or simply be removed after a week in the case of a plastic dressing.
RESULTS
Cosmetic and functional results of one-stage repairs of proximal hypospadias are better than the results obtained with multistage corrections. Moreover, single-stage operations represent less physical and psychological discomfort for the patients who can have their problem solved with only one surgery. To parents it means fewer days of leave from work to accompany their child during the treatment. Consequently, costs of treatment are likely to be lower. Secondary procedures considered, we obtained good final plastic and functional results, in respectively 89.5 and 94.7% of patients with a surgery ratio of 1.7 per patient, using the DIF and MDIF techniques, either associated or not with a Duplay-type urethroplasty for the scrotal or perineal segments. The preservation of the urethral plate added to a significant improvement of results.
COMPLICATIONS
The
incidence of complications of proximal hypospadias repair is far larger
than with distal hypospadias. Perhaps for this reason proximal hypospadias
should be corrected only by experienced surgeons in the treatment of hypospadias.
Generally, complication rates of penile,
scrotal and perineal hypospadias correction have been similar. Therefore,
the addition of the DIF or MDIF techniques for the penile segment to the
Duplay-type urethroplasty for the scrotal and perineal segments did not
contribute to an increase of complication rates. The incidence of urethrocutaneous
fistulas and of stenosis of the anastomoses observed with the preservation
of the urethral plate was considerably lower than with tubular neourethras.
In spite of the existence of two suture lines these are between well-vascularized
tissues and a circular suture of the anastomoses is absent; the anastomoses,
although left espatulated, tend to suffer scar retraction and stenosis.
Vascularization of the island flap was considered
adequate in 92% of cases, and when considered inadequate in none of the
cases the outcome was total necrosis of the island flap. However, it may
occur and it is a most feared possibility as it eliminates the best source
of tissue there is for the correction of hypospadias.
Necrosis of the dorsal and lateral skin
occurred in 4% of cases and was probably due to the dissection of the
superficial plane of the pedicle too close to the skin, compromising the
intradermic vascularization and resulting in suffering of the blood supply.
Difference in results between the DIF and
the MDIF methods was mainly the decrease in the incidence of urethrocutaneous
fistulas by 50% (from 58 to 29%). Almost all urethrocutaneous fistulas
could be repaired through fistulorrhaphy using the Smith-Belman technique,
with insertion of a de-epithelialized cutaneous flap and creation of an
intermediate plane, which minimizes the risk of fistula recurrence. The
fistulorrhaphies were performed on an outpatient basis without necessity
for postoperative bladder drainage.
Stenoses are a more serious complication
than fistulas for depending on their degree they may affect the bladder
and the upper urinary tract if their treatment is delayed. The incidence
rate of stenosis of the anastomosis found with both the DIF and the MDIF
methods was 9%. When possible, the stenosis may be treated by internal
ureterotomy or using the Mickulicz technique (longitudinal incision and
transversal suture). However, without a logical explanation, there was
a 30% incidence of neomeatus stenosis with the MDIF technique against
9% for the DIF technique. Dilation of the urethral neomeatus can be initially
tried but recurrence rates are high. The treatment we favor as a routine
procedure is the meatoplasty, which can be distal and/or proximal. One
should not hesitate when it comes to treatment of neomeatus stenosis because
besides a larger incidence of urethrocutaneous fistulas it can cause dilation
of the neourethra and allow its ballooning.
REFERENCES
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- Nesbit RM: Operation for correction of distal penile ventral curvature with or without hypospadias. J Urol, 97: 720, 1967.
- Smith D: A de-epithelialized overlap flap technique in the repair of hypospadias. Brit J Plast Surg, 26: 106, 1973.
- Belman AB: De-epithelialized skin flap coverage in hypospadias repair. J Urol, 140: 1273, 1988.
- Hodgson NB: Use of vascularized flaps in hypospadias repair. Urol Clin North Am, 8: 471, 1981.
- Asopa R, Asopa HS: One stage repair of hypospadias using double island flap preputial skin tube. Indian J Urol, 1: 41, 1984.
- Duckett JW: The island flap technique for hypospadias repair. Urol Clin North Am, 8: 503, 1981.
- De Sy WA, Oosterlinck W: One-stage hypospadias repair by. Urol Clin North Am, 8: 491, 1981.
- Arap S, Mitre AI, Giron AM, Nahas WC: Correção cirurgica de hipospadia medio-peniana, peniana proximal e peno-escrotal utilizando duplo retalho em ilha de prepucio (Double Island Flap). Rev Hosp Clin Fac Med S Paulo, 40: 223, 1985.
- Mitre AI: Duplo Retalho em Ilha de Prepúcio na Correção de Hipospadias e de outros Defeitos Uretrais Congenitos. Tese de Livre-Docência, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, 1990.
______________________
Received: March 22, 2000
Accepted: April 22, 2000
_______________________
Correspondence
address:
Anuar I. Mitre
Av. Dr. Enéas de Carvalho Aguiar,
No. 255, 7o. andar, sala 710-F
São Paulo, SP, 05403-000, Brazil
Fax: + + (55) (11) 3064-7013
E-mail: divisao@urologia.hcnet.usp.br