Urethroplasty using a pedicled skin graft in one-stage treatment of urethral stenosis. Review of 87 cases

118 cases of urethral stenosis treated by the same surgeon from September, 1984, to December, 1989, have led the author to describing a one-stage technique for the surgical treatment of urethral stenosis using a widening implant or a pedicled penoscrotal tube. This technique is patterned on ORANDI's and BLANDY's procedures and utilizes a pedicled skin graft taken from a remote, therefore unaffected, site. 87 patients were treated with this procedure for urethral stenosis, often complicated by infection and fistulae, 34 after the failure of previous treatment. With a distance in time exceeding 2 years for most operated cases, the percentage of satisfied patients is of about 95%. The results were estimated according to the quality of urination, to the strength of the urine flow, to micturating and retrograde pyelography and to a fiberendoscopic checkup. In 71 cases (81.6%), the result was rated as good, immediately in 66 cases, after a second operation in 4 and after 3 operations in 1 case. The results were regarded as average in 12 cases (13.5%) and poor in 4 cases (4.6%). Cutaneous urethroplasty using a pedicled skin flap is relatively easy and represents an excellent procedure for the treatment of urethral stenosis owing to the low rate of failure and to the quality of the results obtained. The author stresses the advantages of grafting a well-vascularized skin flap, which is particularly indicated, whatever the site and extent, in cases of urethral stenosis with infection, fistulae or following several operations, the pedicled skin graft being a procedure of choice for all these aggravating factors.     

联合应用包皮与阴囊独立皮瓣一期修复尿道下裂的探讨

目的：探讨阴囊及会阴型尿道下裂患者一期修复重建尿道的新术式。方法：联合应用包 阴囊两独立带蒂皮瓣施行尿道重建术一期修复阴囊及会阴型尿道下裂患者１３例。结果：１１例获得成功。２例术后出现尿瘘,其中１例经尿道扩张治疗。３周后尿瘘愈合,另１例行二期尿道成形术后尿瘘痊愈。结论：联合应用包皮与阴囊两独立皮瓣重建尿道的优势明显,更我的集中了目前治疗阴囊及会阴型尿道下裂众多术式的优点。获得满意疗效。     

The use of the pedicled transverse island flap of the inner prepuce in hypospadias,epispadias and urethral stricture repair

Summary The use of the pedicled transverse island flap in reconstructive repairs is described. Experience with 35 hypospadias repairs shows that excellent cosmetic and functional results may be obtained, and 5 epispadias cases were corrected in this way with good results. The use of this technique is advocated in cases of severe urethral stricture and is demonstrated on 3 patients. The different techniques are described with emphasis on the critical surgical points and on the importance of the wound dressing.     

Transplantation of the prepuce to facilitate hypospadias repair in monozygotic twins

We report a case of free transplantation of the prepuce derived from a monozygotic twin to aid in the reconstruction of penoscrotal hypospadias in his brother. Although monozygotic twins discordant for hypospadias are seen rarely the possibility of preserving and transplanting the prepuce of the unaffected sibling should be considered to facilitate reconstruction of the phallus with hypospadias.     

Vascularization of the hypospadiac prepuce and its impact on hypospadias repair

PURPOSE: Only sparse data are available on the blood supply of the hypospadiac prepuce. We investigated the development and course of the preputial blood vessels, and applied the results of this study to surgery for hypospadias. MATERIALS AND METHODS: In 157 patients who underwent hypospadias surgery from October 1996 to December 2000 the prepuce was illuminated by a front and back lighting technique using endoscopic cold light and then photographed. Its blood vessel course and development were schematically presented. In 65 patients in whom the prepuce was not used for urethroplasty or penile body skin reconstruction the specimen was removed and its blood vessels were identified after injection with gelatin and Indian ink. The results of the 2 methods were compared. RESULTS: Based on the predominant blood vessels we classified preputial vascularization in hypospadias cases into groups, including 1-1 blood vessel predominant in 43%, 2-2 blood vessels predominant in 12%, 3-an H-like form with communication between 2 well developed blood vessels in 14% and 4-a net-like form with no predominant blood vessels in 29%. After comparing the results of the illumination technique versus specimen study in the same preputial tissue the illumination method was confirmed to be precise and easy to perform. CONCLUSIONS: Vascularization of the prepuce is crucial for hypospadias repair. Identification with high precision is achieved by the illumination technique. This method helps create the best vascularized flaps, whether longitudinal, oblique or spiral.     

Classification of prepuce in hypospadias according to morphological abnormalities and their impact on hypospadias repair

PURPOSE: We investigated the morphology of the hypospadiac prepuce to develop a classification of different prepuce types in hypospadias. We also assessed the correlation between morphology and vascularization of the prepuce and their impact on results of hypospadias repair. MATERIALS AND METHODS: From September 1997 to December 2001, 174 patients 18 months to 24 years old (mean age 49 months) underwent hypospadias surgery. The prepuce morphology was analyzed by evaluation of the prepuce skin distribution, development and deformities. The development and course of blood vessels were analyzed using preputial illumination. According to morphology and blood supply, different types were compared. Of 174 analyzed cases 163 prepuces were used for urethroplasty. RESULTS: Based on the predominant morphology characteristics and abnormalities, we classified the analyzed prepuces into 6 groups of A-"monk's hood" or "1 humped" (43 cases, 24.7%), B-"cobra eyes" (80, 45.9%), C-"normal" (intact) (4, 2.3%), D-"flat" (24, 13.8%), E-"v"-shaped (16, 9.2%), and F-"collar-scarf" (7, 4.0%). Cobra eyes and monk's hood prepuces had the most favorable vascular pattern for the creation of flaps, the prepuces while the "flat" and "v"-shaped prepuces had the most unfavorable vascular pattern. Mean followup after hypospadias repair was 34 months (range 24 to 48). Complications (stenosis, fistula diverticulum) developed in 8.9% of the patients after "cobra eyes" and "monk's hood" prepuces were used for urethroplasty and in 25% when "v"-shaped and "flat" prepuces were used. CONCLUSIONS: Morphological characteristics correlated with vascularization of the hypospadiac prepuce. Underdeveloped prepuces and those with unfavorable vascular pattern used for urethroplasty had a higher percentage of complications. In severe hypospadias the anatomical features of the prepuce have greater influence on the proper choice of 1 or 2-stage repair.     

Urethroplasty using transverse penile island flap for hypospadias

We describe a new procedure in which dorsal penile skin is used to correct hypospadias in circumcised patients and those in whom surgical correction usually is difficult. Of 48 hypospadiac patients treated by this technique 26 (54 per cent) had been circumcised previously, while 22 (46 per cent) had undergone a prior hypospadias repair that resulted in marked tissue scarring and fistulas. The procedure is accomplished in 2 stages. In stage 1 the urethra is reconstructed and the penis is buried in the scrotum. Separation is done after an average of 6 weeks (stage 2). The results were satisfactory in 45 patients and in all cases a viable new urethra of adequate caliber and length was created with the end at the tip of the glans. The procedure is simple and safe, and complications were minimal.     

Urethroplasty using a free full thickness skin graft for stenosis of the bulbar or bulbo-membranous urethra

Nineteen patients with urethral stricture involving the bulbar urethra were treated by a one-stage free full-thickness skin graft urethroplasty. Results with one year follow-up: excellent: 16--fair: 1--poor: 2. These results are slightly altered with 5 years follow-up: excellent: 12--fair: 3--poor: 3. An urethrotomy was necessary for three patients.     

Urethroplasty using the pedicled island flap technique in complicated urethral strictures

Many techniques have been described for the repair of recurrent urethral strictures. Experience with 1-stage correction of hypospadias and epispadias, using a vascularized island flap technique, has led to its increased application for complicated adult urethral strictures. The advantage of the vascularized island flap technique is that reconstruction can be completed with only 1 operation, and it provides good subjective and objective results. Analysis of 50 consecutive cases treated by this approach has proved its validity. Of the 50 cases fistulas occurred in 20%, of which 12% required surgical correction, and stricture recurred in 32%. The largest proportion of recurrence was noted in patients who were primarily treated with 3 or more urethrotomies within a short time. Therefore, we recommend open surgical repair when 1 or 2 internal urethrotomies fail to produce a good result.     

Correction of penile curvatures caused by unsuccessful hypospadias repair using the scrotal septum pedicled skin tube principle combined with corporoplasty and a modified meatoglanuloplasty

Scrotal septum pedicled skin tube urethroplasty combined with a modified meatoglanuloplasty and corporoplsty were used in 2 adults. They had three previous hypospadias repair attempts in their childhood, leaving them with a meatus near the glans but with severe ventral penile curvature. Scrotal septum pedicled skin flaps used for the repair, by providing natural vascularization and offering more flexibility, allow the surgeon to reconstruct long urethral defects. The cosmetic and functional results of this combined technique are satisfactory. This principle can also be applied in adult hypospadias cases with deficient preputium in which the midanterior scrotum contains a shiny non-hair-bearing skin.     

改良脱套式修补法治疗尿道下裂术后尿瘘的疗效观察

目的:探讨改良包皮脱套式修补法在治疗尿道下裂术后并发尿瘘的疗效和应用价值。方法:回顾性总结2001年5月至2011年12月因尿道下裂修复术后并发尿道瘘而接受治疗的87例患者临床资料。其中61例患者采用简单缝合或者Y-V成形术(A组),而另外26例患者采用改良的包皮脱套式修补法(B组)。比较两组患者的手术成功率及远期复发情况。结果:A组有13例术后仍存在尿瘘,而B组仅有1例术后尿瘘复发,两组总体修复成功率分别为78.7%和96.2%。A组第二次手术后仍有6例失败,随后对6例患者运用包皮脱套式修补法修复成功;B组第二次手术修复成功。经过4.5年的随访两组患者中没有发现复发病例。结论:包皮脱套式修补法可以显著提高尿瘘修复的成功率,有临床推广价值。     

带蒂阴囊正中皮瓣一期尿道下裂成形术的疗效分析

目的:总结带蒂阴囊正中皮瓣一期治疗各型尿道下裂的经验,提高一期治疗尿道下裂疗效。方法:回顾分析本科室1993年5月至2010年12月收治310例各型(除冠状沟型)采用该术式治疗尿道下裂患者的临床资料,所有病例均随访6个月至2年。结果:310例尿道下裂患者,手术治愈271例,治愈率为87.4%(271/310),术后尿道发生尿屡39例,尿瘘发生率为12.6%,无其他并发症发生。术后尿瘘形成与尿道下裂分型、术后综合用药与否及成形皮管长度等因素有关,而与支架管留置时间无关。尿瘘患者瘘口多位于阴茎根部。结论:对于除冠状沟型外的各型尿道下裂,该术式均是一种疗效可靠且简单易行的治疗方案,同时其术后处理也非常重要。