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PEDIATRIC
UROLOGY
Corporeal
grafting for severe hypospadias: a single institution experience with
3 techniques
Leslie JA, Cain MP, Kaefer M, Meldrum KK, Misseri R, Rink RC
Department of Urology, Indiana University, Indianapolis, Indiana 46202,
USA
J Urol. 2008; 180 (4 Suppl): 1749-52; discussion 1752
- Purpose:
Correction
of severe chordee by corporeal body grafting has been successfully performed
using various grafts and biomaterials. We report a single institution
comparison of our experience using small intestinal submucosa, tunica
vaginalis and dermal grafts at stage 1 hypospadias repair.
- Materials
and Methods: A retrospective chart review was performed of
the records of all patients who underwent staged hypospadias repair
from 1985 to 2006 with corporeal body grafting at stage 1 with small
intestinal submucosa, tunica vaginalis or dermal grafts. Age at grafting,
time between stages, residual chordee at stage 2 repair and the need
for additional plication or chordee correction at stage 2 were recorded.
-
Results:
A total of 71 patients were identified with a median age of 10 months
at stage 1 repair and a median of 7.6 months between stages 1 and 2
repair. Dermal grafts, tunica vaginalis and small intestinal submucosa
grafts were used in 29, 21 and 20 patients, respectively. One patient
received a combination of small intestinal submucosa and tunica vaginalis.
None of the patients receiving tunica vaginalis graft required any further
correction of chordee. One patient with a dermal graft and 1 receiving
small intestinal submucosa required Nesbit plication at stage 2 repair
for minor ventral chordee. One patients receiving small intestinal submucosa
showed severe fibrosis at the graft site, requiring excision and repeat
grafting with tunica vaginalis. This patient has been previously described.
The 2 patients with small intestinal submucosa related complications
had 4-ply grafts. We have seen no complications associated with 1-ply
small intestinal submucosa. At limited followup we have not seen residual
chordee after stage 2 repair.
- Conclusions:
In a large group of children requiring corporeal grafting for severe
chordee we observed successful chordee correction with 1-ply small intestinal
submucosa, tunica vaginalis or dermal grafts.
- Editorial
Comment
A 20-year experience of corporeal grafting in a staged hypospadias procedure
is reported. Grafts were either small intestine submucosa, tunica vaginalis
or dermal grafts. All of the patients have completed a second stage
hypospadias repair. The urethral plate was divided when routine maneuvers
to correct chordee still left 45° of ventral curvature. Tunica vaginalis
was used as a graft in all the cases rather than a flap and each of
the grafts were approximately 25% larger than the corporeal defect that
was created to correct the chordee. Graft placement and success were
verified after suturing the graft in place by an artificial erection.
Initially for the SIS graft, 4-ply SIS was used in 12 patients and subsequently
1-ply has been used. Of the 71 patients in this study, the median age
was 10 months. 29 dermal grafts, 21 tunica vaginalis grafts and 20 SIS
grafts were used. One of the dermal graft patients and one of the 4-ply
SIS patients required a subsequent repair. The authors concluded that
each of the grafting materials were successful. They note that they
have not used 4-ply SIS for several years and that long-term and post-pubertal
outcome is not available.
This manuscript shows that over two decades, several types of grafting
materials have been used and each showing good success. In skilled hands,
there is not a reason to choose one graft material over another. The
second stage of the repair was not made more difficult by any of the
graft procedures and it is heartening to know that the surgeon can make
a personal and patient-appropriate choice and expect good outcomes.
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 |