Bhat's modifications of Glassberg–Duckett repair to reduce complications in management severe hypospadias with curvature

ObjectiveDisadvantages of two-stage hypospadias repair are the necessity of 2 or 3 surgeries, loss of time/money, complications like splaying of the stream, dribbling of urine or ejaculate and milking of the ejaculate due to a poor-quality urethra. The current article details our modifications of flap repair allowing to manage such patients in one stage and reducing the complications.Subjects and methodsTwenty one patients (aged 2–23 years, between January 2006 and June 2012 mean 11.5 years) of severe hypospadias were managed with flap tube urethroplasty combined with TIP since June 2006 and June 2012. Curvature was corrected by penile de-gloving, mobilization of urethral plate/urethra with corpus spongiosum and transecting urethral plate at corona. Buck's fascia was dissected between the corporeal bodies and superficial corporotomies were done as required. Mobilized urethral plate was tubularized to reconstruct proximal urethra up to peno-scrotal junction and distal tube was reconstructed with raised inner preputial flap after measuring adequacy of skin width. Both neo-urethrae were anastomosed in elliptical shape and covered with spongiosum. Distal anastomosis was done 5–8 mm proximal to tip of glans preventing protrusion of skin on glans. Tubularized urethral plate was covered by spongioplasty. Skin tube was covered by dartos pedicle and fixed to corpora. Scrotoplasty was done in layers, covering the anastomosis.ResultsType of hypospadias was scrotal 10, perineo-scrotal 5, penoscrotal 4 and proximal penile in 2 cases. Chordee (severe 15 and moderate 6) correction was possible penile de-gloving with mobilization of urethral plate with spongiosum after dividing urethral plate at corona 8, next 5 cases required dissection of corporal bodies, superficial corporotomy 5 and 3 cases lateral dissection of Buck's fascia. Length of tubularized urethral plate varied from 3 to 5 cm and flap tube varied from 5.5 to 13 cm (average 7.5 cm). Complications were fistula 2, meatal stenosis 1, and dilated distal urethra1 with overall success rate of 81%. None of them had residual curvature, torsion, splaying or dribbling urine in follow up of 10–36 (average 18) months.ConclusionsTIPU with spongioplasty of proximal urethra and dartos cover on skin tube reconstructs functional urethra. Distal end skin sutured to glans mucosa 5–8 mm proximal to the tip of glans reconstructs a cosmetically normal looking meatus. An exact measurement of the width and length of the stretched dartos, fixation of the skin tube to the corpora and covering the skin tube with dartos helps in prevention of diverticula. Elliptical anastomosis covered with spongiosum prevents fistula and stricture at anastomotic site.     

Use of distal Thiersch-Duplay urethroplasty for proximal hypospadias repairs in conjunction with short island pedicle flap

Experience with 8 boys having proximal hypospadias with severe chordee and a foreshortened dorsal hooded foreskin is presented. Use of a distal Thiersch-Duplay tube was incorporated in addition to an island pedicle flap to achieve the correct meatal location on the glans. One boy with perineal hypospadias required both proximal and distal Thiersch tube with an island flap interposition. Follow-up of nine months to 3.5 years demonstrated excellent cosmetic and functional results with no recurrent chordee or urethral stenosis. The only fistula noted developed at the proximal Thiersch tube-island flap anastomosis in the boy with perineal hypospadias. Advantages of the aforementioned procedure include decreasing the risk of chordee on the basis of a foreshortened island pedicle flap, use of vascularized flaps, and completing the procedure in one stage with a satisfactory result.     

A method of hypospadias repair

Summary The treatment of hypospadias requires the release of chordee and the reconstruction of a new urethra to provide for a satisfactory sexual function and normal micturition. A technique is described in two stages. In the first stage a large dorsal apron flap of prepuce skin is developed by a pericoronal incision. The chordee is released well beyond the urethral opening. A button-hole incision allows the prepuce flap to be reflected to the ventral surface. The distal part of this flap is formed into a skinlined tube with raw surface outward and pulled through a transglandular tunnel incision to the tip of the glans while rotating it 180 degrees. The ventral surface is closed. After three to six months, the penis presenting with a subglandular opening of the tube and the proximal hypospadiac urethra, the final reconstruction is undertaken. The excess ventrally shifted skin from the first stage between both orifices is incised by means of two parallel incisions and tubed to form one continuous urethral skin tube. A multi-layer closure burying the tube completes the procedure. The technique has given very encouraging results.     

分期包皮岛状皮瓣尿道板重建术式治疗重度尿道下裂的疗效评价

目的:评价分期包皮岛状皮瓣尿道板重建术式治疗重度尿道下裂的疗效.方法:回顾性分析南京医科大学附属儿童医院泌尿外科2014年5月至2019年2月收治的重度尿道下裂患者91例的临床资料.按手术方法不同分为一期手术组和分期手术组.分析比较两组患者手术年龄、阴茎头直径、矫直后尿道缺损长度及术后尿道瘘、阴茎头裂开、尿道憩室、尿道...     

A combined tubularized/onlay graft technique for total correction of severe hypospadias.

BACKGROUND/PURPOSE: A combined tubularized/onlay graft technique is described for the complete correction of chordee with urethroplasty in a single stage in cases of severe hypospadias. METHODS: Twenty-two patients with severe hypospadias ranging in age from 9 months to 11 years underwent single-stage correction using a technique developed by the author. In this method, chordee is first completely excised by removing all fibrotic tissue both proximal and distal to the urethral orifice, preserving the meatal groove. A dorsolateral preputial flap is then raised and tubularized to form the neourethra. The proximal end of this tube is anastomosed to the urethral opening using a continuous absorbable suture. Two parallel incisions are made in the glans on either side of the meatal groove. The distal part of the neourethral flap is laid over the groove and sutured on either side to create the glanular part of the urethra, after which the glans is reconstructed with the new meatal opening at the tip. The neourethral suture line is covered with a layer of vascularized subcutaneous tissue to protect against fistula formation, and the rest of the preputial skin is transferred ventrally to provide cover for the penile shaft. RESULTS: There were no major complications with minimum follow-up of 20 months. Meatal stenosis developed in two patients, and one had stricture at the proximal anastomosis. These were treated successfully with minor corrective procedures. All other patients had good results, and there were no cases of fistula. CONCLUSIONS: The method described has proved successful in the surgical correction of severe hypospadias in a single stage. It is easily adapted to permit urethral reconstruction after varying degrees of tissue excision required to obtain satisfactory correction of chordee. Patients do not need to undergo multiple procedures, and no major complications were encountered in this series.     

Two-stitch technique for distal shaft hypospadias repair

The authors present a new technique for distal shaft hypospadias repair using a flip flap fashioned with only two stitches. In raising the flap, the tissues lateral and proximal to the flap are undermined but there is no undermining beneath the flap. The flap is sutured up to the glans with two 4-0 Vicryl sutures. No sutures are placed at the lateral edges of the flap to create the "tube" of the neo-urethra, and no postoperative urinary drainage is used. Thirty-three children with distal shaft hypospadias underwent the "two-stitch" flip flap operation. The complications were one fistula and one case of urinary retention. The technique is an easy method for reconstructing distal penile hypospadias with a very low rate of complications and is suitable for an outpatient surgical setting.     

尿道口蒂皮瓣与口腔黏膜联合一期修复尿道下裂

目的探讨尿道口蒂皮瓣与口腔黏膜对合重建尿道的方法.方法 2002年3月～2004年5月,采用尿道口蒂皮瓣与口腔黏膜联合重建尿道21例,年龄14个月～8岁.切断挛缩尿道板,彻底矫直阴茎后,将口腔黏膜移植于阴茎腹侧白膜,尿道口蒂皮瓣翻转后与口腔黏膜对合,形成管状尿道.结果术后所有患儿均获3～18个月随访,平均7个月.阴茎弯曲完全矫正,尿道外口位于阴茎头前端,阴茎外形良好,排尿通畅.2例发生尿瘘,其中1例自愈,1例术后6个月再修补成功.结论尿道口蒂皮瓣与口腔黏膜联合重建尿道能彻底矫正阴茎弯曲,提高手术成功率和改善术后阴茎外形.     

“Limited” double dorsal dartos flap coverage. An effective alternative to conventional flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias

OBJECTIVES: Double dorsal dartos flap coverage of the neourethra has been reported to be superior to single flap coverage for the prevention of urethrocutaneous fistula following hypospadias surgery. Conventional flap coverage involves covering the entire neourethra with vascularised flap. We describe a "limited" double dorsal dartos flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias. MATERIALS AND METHODS: In a prospective study conducted between Feb 2003 and Feb 2007, 31 patients with primary subcoronal hypospadias who had a flat and narrow urethral plate with a healthy urethral meatus and minimal or no chordee underwent Mathieu hypospadias repair. A "limited" double dorsal dartos flap coverage of the neourethra was done in all patients. This involved covering only that portion of the neourethra which remained exposed after glans closure, i.e. the proximal neourethra. Primary surgical outcome assessed was the development of urethrocutaneous fistula following surgery. RESULTS: The mean age at the time of repair was seven years and mean follow up was eight months. There was no flap loss, urethrocutaneous fistula formation, or glanular dehiscence in any of the 31 patients. One patient developed meatal stenosis which was managed by dilatation. One patient developed superficial sloughing of the penile skin. Overall complication rate was 6.45%. CONCLUSION: "Limited" double dorsal dartos flap coverage of the neourethra seems to be an effective method to reduce the fistulous complication rate following Mathieu repair for subcoronal hypospadias. A larger comparative study needs to be done to evaluate conventional neourethral coverage with "limited" neourethral coverage.     

Fistula advancement operation in the treatment of selected cases of persistently recurrent urethrocutaneous fistula following distal penile hypospadias repair

BACKGROUND: Hypospadias fistula may be a persistently recurrent problem in some cases. The present paper describes a urethral mobilization procedure as a new way to solve this problem. METHODS: The procedure was performed on seven children suffering from recurrent hypospadias fistula that had failed more than once to be repaired by the classic ways of closure. Selection of suitable cases should be done intra-operatively, when urethral mobilization has successfully allowed the fistula opening to easily reach the glans top. The described procedure is an extensive urethral mobilization that advances the fistula opening to the neomeatus at the glans top through a glanular tunnel. RESULTS: The operation resulted in a straight penis with the neomeatus at the glans top in all seven children, without complications, over a period of 6-18 months follow up. CONCLUSIONS: The fistula advancement operation, as it is called by the author, can, in selected cases, solve the problem of persistently recurrent hypospadias fistula with a high success rate. Thus, the author recommends that this technique is added to urologists' armamentarium.     

Tubularization of the incised urethral plate (Snodgrass procedure) for primary hypospadias surgery

OBJECTIVE: To evaluate the Snodgrass procedure for patients with hypospadias who have not undergone previous surgery and whose urethral plate is too narrow for tubularization alone. PATIENTS AND METHODS: Thirty-two boys (mean age 18 months) underwent primary hypospadiac surgery performed by one surgeon (P.S.M.). Twenty-five boys had a distal hypospadias (coronal, subcoronal) and seven had a more proximal defect (penile shaft, penoscrotal). The operation involved incision of the urethral plate, which was then tubularized (Snodgrass procedure). The neourethra was then covered with a de-epithelialized pedicled dartos flap from the inner prepuce before glans and skin closure. RESULTS: With a mean follow-up of 10 months (range 2-14) there were two complications; one child with a coronal hypospadias developed a fistula whist one with a penile shaft defect had complete breakdown of the neourethra. The cosmetic appearance in the other 30 patients is that of a normal slit-like terminal meatus. CONCLUSION: Tubularization of the incised urethral plate is a safe advance in the surgery of hypospadias. We recommend it for both distal and proximal defects, in patients where the urethral plate is insufficient for tubularization alone.     

Eye socket and eyelid reconstruction using the combined island frontal flap and retroauricular island flap: a preliminary report

One-stage eye socket and eyelid reconstruction was performed, with relatively satisfactory results, on a patient with a broad forehead. This was done after the complete exenteration of the orbit, using an island frontal flap and a retroauricular island flap with the common superficial temporal vessels. A Foley urethral catheter and a continuous suction drainage tube were effective for good wound healing between the bony orbit and a skin bag, made with a frontal flap, which was hidden in the orbital cavity. On the eighth postoperative day, the skin incision producing the false palpebral fissure was made, and it was enlarged slightly thereafter. A nylon implant was inserted into the orbital apex and cartilage grafts from the auricle to the false upper and lower eyelids were performed secondarily. The fundamental consideration of the eye socket and facial coverage corresponding to the eyelids and the possibility of modification of the author's method are briefly discussed.     

Multiple failed urethroplasties: definitive repair with the Duckett island-flap technique

Background/Purpose:

The correction of postoperative complications after hypospadias repair presents frequently serious problems, and the results are not always satisfactory. The aim of this study is to present our experience with the tubularized island flap technique (Duckett procedure) in patients who had been submitted to repeated unsuccessful attempts for the repair of hypospadias and its complications.

Methods:

During an 8-year period (1994 through 2001), 21 patients, aged 4 to 18 years, presented with severe recurrent hypospadias (3 to 13 times). In all patients, the urethral orifice was quite proximal because of disruption of the neourethra and was associated with severe penile ventriflexion. In addition, there were diverticula with hair ingrowth in 5 boys and lack of the prepuce in 4. All patients underwent the Duckett island-flap technique. The inner layer of the prepuce was used in 17. The dorsal penile skin was used for the island flap formation in the remaining 4 patients in whom the prepuce had been resected during the previous operations.

Results:

After repair, the meatus was located at the top of the glans in all patients. There were 5 complications (24%): distal fistula near the glans (n = 1), meatal stenosis (n = 1), diverticula at the proximal anastomosis (n = 2), and anastomotic stenosis (n = 1). All of them were treated successfully by meatotomy, fistula closure, diverticula tapering, and dilatations, respectively.

Conclusions:

The island-flap technique gives satisfactory results in patients with multiple failed urethroplasties; it is applicable even in boys with resected prepuce and has an acceptable complication rate.     

Urethroplasty in severe hypospadias. Description and evaluation of a one-stage technic used in 54 cases

From July 1980 to November 1982, 54 cases with severe hypospadias underwent one-stage urethroplasty at the urology departments of the Ain Shams University Hospital and Dar El-Shefa Hospital. Their age ranged between 9 months and 19 years. The original urethral meatus was located at mid penile in 40 occasions, peno-scrotal in 12 and perineal in only two cases. The technique used for urethroplasty was a combination of that of Duckett (transverse preputial island flap) for the creation of the urethral tube, and Devine's glandular flaps to bring the urethral meatus to the tip of the glans. The rate of complications was very low, only two cases developed fistula (3.7%). None of the cases developed kinks or strictures of the neo-urethral tube.     

长隧道带蒂包皮内板尿道成形术治疗阴茎体型尿道下裂的疗效分析

目的 探讨长隧道带蒂包皮内板尿道成形术治疗阴茎体型尿道下裂的疗效. 方法 2007年9月至2010年4月收治阴茎体型尿道下裂患儿28例,年龄1.5 ～6.0岁,平均2.0岁.均行长隧道带蒂包皮内板尿道成形术.尿道开口均位于阴茎体部,距离阴茎头顶端16 ～ 37 mm,平均25immn;分离尿道及纠正阴茎下曲后尿道缺损30 ～ 42 mm,平均38 mm.手术要点:沿尿道开口环形切开阴茎皮肤,分离至尿道板,横断尿道板,沿尿道板与海绵体之间分离隧道至阴茎头正中,隧道长度26～38 mm,平均33 mm.尿道开口至阴茎头之间全程由隧道贯通,尽量保持阴茎腹侧皮肤与组织完整,取带蒂包皮内板制作新尿道,将新尿道通过阴茎侧方深筋膜下通道转移至腹侧隧道进行吻合.术中人工勃起试验证实合并轻度阴茎下曲13例,无明显阴茎下曲15例. 结果 28例均一期修复成功,手术时间50～70 min,平均55min.随访时间6～31个月,平均20个月.28例患儿均排尿通畅,尿线粗直.尿道呈矢状开口于阴茎头正中,阴茎下曲纠正满意,外观好,未发生尿瘘或狭窄. 结论 长隧道带蒂包皮内板尿道成形术适用于无或合并轻度阴茎下曲的阴茎体型尿道下裂,尤其适合年龄小或阴茎体细小患儿,手术简单,效果好,外观满意.     

SURGICAL REPAIR OF URETHRAL CIRCUMCISION INJURIES

Purpose

The 2 types of urethral injury that can occur during circumcision are urethrocutaneous fistula and urethral distortion secondary to partial glans amputation. We report the surgical repair of these rare injuries.

Materials and Methods

In 8 patients urethrocutaneous fistulas located on the distal penile shaft or at the coronal margin were managed by splitting the glans and using a Mathieu style skin flap in 4 or vascularized penile skin flap in 4 to bridge the urethral defect. Three patients underwent repair of a hypospadiac deviated urethra secondary to partial glans amputation by 1 cm. of urethral mobilization and repositioning the meatus into a terminal position within the remaining glans tissue.

Results

The 8 patients with urethrocutaneous fistulas voided via a terminal meatus without fistula recurrence at a mean followup of 3.2 years (range 1 to 6). The 3 patients with partial glans amputation and urethral deviation repaired by short urethral advancement had functionally acceptable results, defined as a normal urinary stream, although 1 required meatal dilation postoperatively.

Conclusions

The 2 types of urethral injuries that can occur during circumcision are a subcoronal urethrocutaneous fistula and scarred abnormal urethra from partial glans amputation. The urethrocutaneous fistula can be successfully repaired by splitting the glans and forming a neourethra from a vascularized pedicle flap of penile skin. The abnormal urethra after partial glans amputation is more difficult to repair but repositioning the urethra in a more cosmetic location has restored function.     

Urethral advancement and glanuloplasty with V flap of the glans in the repair of anterior hypospadias

BACKGROUND: Hypospadias is a common urethral anomaly in boys. More than 65% of hypospadias cases are anterior (glanular, coronal and distal penile shaft). More than 200 original techniques have been applied to correct hypospadias. Each of these techniques has some complications, the most common of which are fistula and meatal stenosis. METHODS: A total of 74 boys with anterior hypospadias underwent the procedure of urethral advancement and glanuloplasty (UAGP) with V flap of the glans in our medical centres between March 1994 and March 2000. The procedure included degloving, correction of chordee, urethral mobilization and glans plasty. RESULTS: Cosmetic results were excellent in most patients. There was no fistula, and meatal stenosis was also not observed after applying V flap of the glans. In a 1-6-year follow-up (mean +/- SD, 3.15 +/- 1.79 years), the results, functionally and cosmetically, were satisfactory in all cases, with no long-term complication or chordee. CONCLUSION: Our findings suggest that UAGP is an excellent technique for repairing anterior hypospadias with satisfactory results and low complication rate.     

Tubularized incised plate urethroplasty for proximal hypospadias

OBJECTIVES: Numerous surgical procedures have been used to correct distal hypospadias. Among them, the tubularized incised plate urethroplasty (Snodgrass procedure) has become a mainstay for the repair of distal hypospadias. We applied the procedure to proximal hypospadias. METHODS: Three patients with proximal hypospadias underwent a tubularized incised urethral plate urethroplasty. The location of the meatus was proximal penis in one, penoscrotal margin in one and scrotum in one. A perimeatal incision was made and the two paramedian incisions were extended to the tip of the glans. The skin of the penile shaft was dissected free to the penoscrotal junction and bands of fibrous tissue were excised until the corpus spongiosum proximal to the meatus was completely exposed inside the scrotum. The urethral plate was then incised in its midline from the tip of the glans to the hypospadiac meatus and was tubularized without tension. The neourethra was covered with a pedicle of subcutaneous tissue dissected from the dorsal skin or the scrotal skin to avoid fistula formation. RESULTS: The tubularized incised urethral plate urethroplasty was carried out successfully in one stage on three patients with proximal hypospadias. CONCLUSIONS: The Snodgrass procedure is suitable for correcting hypospadias in patients with a healthy urethral plate. It is also suitable in patients with proximal hypospadias.     

The dorsal inlay graft for hypospadias repair

PURPOSE: Hypospadias is a common genitourinary anomaly affecting every 1/300 male newborns. The goals of hypospadiac surgery include a straight penis with a urethral meatus at the tip of the glans, a well vascularized neourethra of adequate caliber with a solid, straight urinary stream and achievement of sexual function when mature. Current theory advocates preservation of the urethral plate with chordee correction. Hypospadias repair without an adequate urethral plate to roll into a tube requires longitudinal incision of the plate or a transverse preputial island flap. We describe a technique of 1-stage urethroplasty using an inner preputial based dorsal inlay graft. MATERIALS AND METHODS: After the penis is degloved and chordee corrected incisions are made bilaterally along the urethral plate from the native urethral meatus to the glans tip. The urethral plate is incised longitudinally. A graft harvested from the inner prepuce is defatted and sutured onto the incised urethral plate. The neourethra is rolled into a tube in Thiersch-Duplay fashion. RESULTS: This technique was used in 32 patients. The original urethral meatus was coronal to penoscrotal and chordee release was performed concomitantly. At 21 months of followup no patient had a stricture, fistula or diverticulum at the inlay graft site. CONCLUSIONS: This technique successfully fulfills all traditional hypospadias repair criteria. We believe that the dorsal inlay graft after incision of the urethral plate is a rapid, easy and successful addition to the armamentarium of the "hypospadiologist."     

An objective assessment of the results of hypospadias surgery

OBJECTIVE: To compare the cosmetic result of tubularized incised-plate urethroplasty (Snodgrass method) with that of two established techniques, the meatal-based flap and onlay island flap repair. SUBJECTS AND METHODS: Photographs of the penis after hypospadias repair in 32 boys were assessed by a panel of five independent health professionals, including four surgeons with variable paediatric urological experience and a urology nurse. Twenty patients had a distal and 12 a proximal meatus. The Snodgrass technique was applied by one paediatric urologist for either distal (10) or proximal (six) hypospadias. A Mathieu repair was used for distal hypospadias (10) and an onlay preputial island flap for proximal hypospadias (six) by a second paediatric urologist. The panel was asked to grade cosmesis as poor, unsatisfactory, satisfactory or very good (points 1-4) for each of the following aspects of penile appearance: meatus, glans, shaft and overall appearance. Photographs were taken in a standard way, with a standard distance, lighting and two views, one of the dorsal surface and one ventral, for each patient. Signed written consent for the study was obtained from each family. RESULTS: The mean assessment score for any aspect of cosmesis was significantly higher for the Snodgrass technique (P < 0.05). The mean score (95% confidence interval) for the meatus was 0.76 (0.4-1.1) points higher for the patients with a Snodgrass repair than those with a Mathieu or onlay island flap repair (P = 0.002). Correspondingly, the values for the glans were 0.67 (0.38-0.97) (P = 0.003), shaft 0.42 (0.16-0.69) (P = 0.01) and overall appearance 0.62 (0.24-1.0) (P = 0.01) points higher for the Snodgrass repair. The Snodgrass technique was more effective in producing a vertically orientated meatus (87.5%) than the Mathieu and Duckett onlay repairs (37.5%; P = 0.009). CONCLUSION: The Snodgrass technique, as assessed by this panel, had a better cosmetic outcome than the Mathieu and Duckett onlay island flap repairs. The assessment of cosmesis in hypospadias surgery is potentially more objective when several health professionals, not involved in the surgery, compared the various methods of repair.     

Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience

It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20−60 months) and 35 months (18−60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.