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PEDIATRIC
UROLOGY
Outcome
analysis of severe chordee correction using tunica vaginalis as a flap
in boys with proximal hypospadias
Braga LH, Pippi Salle JL, Dave S, Bagli DJ, Lorenzo AJ, Khoury AE
Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
J Urol. 2007; 178: 1693-7; discussion 1697
- Purpose:
There is ongoing controversy regarding optimal treatment for severe
ventral curvature. It has been suggested that ventral corporeal lengthening
may be associated with recurrent curvature and erectile dysfunction.
To further assess these issues we reviewed our experience with ventral
penile lengthening for correcting the severe ventral curvature associated
with proximal hypospadias.
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Materials and Methods:
We reviewed the records of 38 boys with severe hypospadias and congenital
ventral curvature greater than 45 degrees who were treated at our institution
from 1995 to 2004 with placement of a flap or graft in the corporeal
bodies to straighten the phallus. Of the patients 21 had perineal and
17 had penoscrotal hypospadias, including 22 with associated penoscrotal
transposition and/or bifid scrotum and 6 with ambiguous genitalia. Testosterone
stimulation before surgery was given in 11 children at surgeon discretion.
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Results:
Median age at surgery was 15 months. The urethral plate was divided
in 94.7% of patients. A tunica vaginalis flap was used alone in 23 cases
and associated with dura, pericardium or small intestinal submucosa
in 8, 2 and 1, respectively. The remaining 4 patients underwent ventral
grafting alone, including lyophilized dura in 1, pericardium in 1 and
dermis in 1. Urethral reconstruction was achieved by the transverse
island flap technique or 1 of its modifications in 34 children. Four
boys underwent a 2-stage procedure. Followup available on 35 of 38 patients
was 1 to 11 years (median 5.3). Recurrent ventral curvature in 5 of
35 patients was mild in 1 and clinically significant, requiring re-intervention,
in 4. Four of 9 patients (44.4%) who underwent corporeal grafting with
lyophilized dura had recurrent ventral curvature vs. 1 of 23 (4.3%)
who had a tunica vaginalis flap (chi-square 5.14, p = 0.02). At last
followup straight erections were documented by patients and/or parents
in 30 of 35 children (85.7%).
- Conclusions:
The short-term outcome of ventral penile lengthening using tunica vaginalis
flap alone for correcting severe chordee is favorable with a 95% success
rate. Dural grafts were associated with a higher risk of recurrent ventral
curvature compared to tunica vaginalis flaps. Although most of our patients
were not yet adults, when chordee and erectile dysfunction may become
apparent, we believe that tunica vaginalis flap repair is a good option
for correcting severe ventral curvature.
- Editorial
Comment
Important points made in the manuscript include that if grafting is
the surgeon’s choice, that the grafts should be 20-30% larger
than the defect. The tunica vaginalis flap was easy to harvest and these
authors had excellent success. Being a flap rather than a graft, it
can be cut to the appropriate size. The blood supply has been shown
to be reliable and the complications noted doing a one-stage repair
are in line with what one would expect from one-stage repairs without
the severe curvature correction. I find most mild chordee can be corrected
dorsally but I agree with these authors that the tunica vaginalis flap
is their procedure of choice to correct severe chordee on the ventral
aspect of the penis.
Dr.
Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu |