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.     

Successful hypospadias repair with ventral based vascular dartos pedicle for urethral coverage

PURPOSE: We describe an easy technique to reliably harvest a vascularized dartos pedicle for urethral coverage at the time of urethroplasty in hypospadias surgery. The complication of urethrocutaneous fistula in hypospadias surgery as a result of using this technique is also evaluated. MATERIALS AND METHODS: A retrospective review (July 1999 to September 2002) identified 180 pediatric patients who had undergone primary hypospadias surgery by a single surgeon. A modified technique of harvesting a vascularized dartos pedicle was incorporated in 111 hypospadias repairs. A ventral based vascularized dartos pedicle of tissue was used to cover a modified urethroplasty as described by Snodgrass. RESULTS: The intraoperative meatal position before urethroplasty was subcoronal in 95 cases, penile/midshaft in 11 and penoscrotal in 5. The majority of patients (90 of 111) were younger than 12 months at surgery. Ages ranged from 5 months to 16 years (mean 21.1 months). Of the 111 patients reconstruction using the ventral based vascularized dartos pedicle to cover the urethroplasty was successful in 109 (98.2%), and at followup they have an acceptable cosmetic result with no evidence of urethrocutaneous fistula. In 1 patient with distal hypospadias a urethrocutaneous fistula developed, which was recognized 20 months postoperatively. Another patient with penoscrotal hypospadias had a proximal fistula at 6 months. There were no recognized intraoperative urethral injuries or complications. Followup ranged from 3 to 38 months (mean 19.1). CONCLUSIONS: The ventral based vascularized dartos pedicle urethral coverage procedure is an easy and reliable technique to harvest adequate vascularized tissue to cover a hypospadias urethroplasty. In this small single surgeon series, this technique appears to have contributed to a low rate of urethrocutaneous fistulas after hypospadias repair.     

The effect of oestrogen and testosterone on the urethral seam of the developing male mouse genital tubercle

OBJECTIVES: To describe the effects of exogenous oestrogens and androgens on urethral formation in the mouse, as the development of the mouse and human urethra have significant similarities, and understanding normal male urethral development may help to identify the causes of abnormal development, e.g. hypospadias. MATERIALS AND METHODS: Timed-pregnant C57/6 mice were exposed to synthetic oestrogens and androgens. The morphology of the genital tubercles was examined histologically and with three-dimensional computer reconstruction. Specific attention was focused on the developing urethral seam. RESULTS: Microscopic serial analysis confirmed the presence of an arrest in seam formation in about half of oestrogen-treated male fetuses. In contrast, there was acceleration of urethral fold fusion and a longer urethral tube in those treated with androgens. Oestrogen-treated fetuses had a thin periurethral spongiosa, in contrast to androgen-treated fetuses which developed a thicker periurethral spongiosa. The effect of oestrogens on seam area formation did not depend on the dose, but in contrast, in the androgen-treated fetuses it was. CONCLUSION: Oestrogens and androgens have a direct effect on the fusion of the urethral fold that leads to seam formation. Normal urethral development depends on the delicate balance of these complementary hormones.     

Urethrocutaneous fistula repair after hypospadias surgery

OBJECTIVE: To evaluate and compare the success rates of simple and layered repairs of urethrocutaneous fistulae after hypospadias repair. PATIENTS AND METHODS: The charts of 72 children who developed fistulae after hypospadias repair were reviewed; 39 had a simple closure of the fistula, whereas 32 had a 'pants over vest' repair, in all cases after excluding an impairment of urine outflow. RESULTS: The success rate at the first attempt was 74% for simple closure and 94% for the layered repair; at the second attempt it was 80% and 100%, the difference being statistically significant for both repairs. CONCLUSIONS: Although probably far from an optimal technique for repairing urethrocutaneous fistulae, the pants-over-vest repair allows a good success rate for penile shaft fistulae.     

小儿先天性单纯性阴茎弯曲的误诊和误治并发症的处理

本文报道６例先天性单纯性阴茎弯曲的误诊和误治,在讨论该病的病因和病理学特点的基础上,总结发生原因,针对其尿道皮肤瘘等并发症,提出了进一步行尿道松解、瘢痕切除、瘘口修补或尿道成形等处理措施。     

尿道下裂手术适应症的选择及阴囊隔岛状皮瓣解剖学的研究

本文报道应用阴囊隔神经血管蒂岛状皮瓣一次修补尿道下裂63例,获得满意效果。由于发现了阴囊隔血管丛,并为解剖学研究证实,这与过去应用阴囊任意皮瓣有原则的不同。又对皮瓣设计因型而异进行了讨论。     

Novel technique for correcting penile curvature with severe hypospadias; Ventral lengthening with tunica vaginalis flap patching

The adequate correction of penile curvature is essential for successful hypospadias surgery. We describe a novel technique to correct severe penile curvature with a tunica vaginalis flap on the penile ventrum. We applied a tunica vaginalis flap to lengthen the ventral aspect of the tunica albuginea in two boys with significant curvature and proximal hypospadias. Tunica vaginalis flap patching to the ventral aspect of the penis is safe and technically feasible. If penile curvature is severe or the penis is small in hypospadiac patients, lengthening the ventral aspect using a tunica vaginalis flap is likely to expand instead of dorsal plication or ventral graft.     

The repair of penile hypospadias by the van der Meulen technique

Summary During the years 1980–1985, 80 children with penile hypospadias underwent repair using a slight modification of the van der Meulen technique. All the children had mid or distal shaft hypospadias excluding those with glandular or penoglandular position. All patients except 10 had chordee which necessitated a release at a previous operation. Two children had previously unsuccessful repairs by the Denis Browne technique. The overall hospitalization was at the mean of 4.6 days per child. In 10 children (12.5%) some complications occurred, of which 3 (3.75%) had fistula and in six (7.5%) meatal or neo-urethral strictures developed. In a small number of patients there was some degree of torsion, mostly temporary, and in no case did it cause any functional disturbance.     

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.     

Psychosexual adjustment and age factors in 130 men undergone hypospadias surgery in a Chinese hospital

The study investigated the psychosexual status and sexual function in adults who had hypospadias surgery at different ages. A detailed questionnaire was mailed to 130 patients who underwent hypospadias surgery between January 1988 and December 2007, and 50 healthy males who served as the control group. The patients were divided into three groups based on their age at which surgery was completed: group A (n=32; <10 years); group B (n=45; 10-18 years); and group C (n=53; >18 years). The Zung Self-Rating Anxiety Scale and The Zung Self-Rating Depression Scale were used to assess psychosexual status; a designed questionnaire and the International Index of Erectile Function-5 were used to assess sexual function. The incidence of anxiety and depression was significantly higher in patients than that in controls (P < 0.001), and was correlated with the age at which surgery was completed. The length and circumference of penises in patients were shorter than those of control groups with statistically significant differences (P < 0.01). There were no significant differences between patients and controls regarding libido strength, overall sexual satisfaction and erectile function (P > 0.05). In conclusion, difference existed in certain aspects of psychosexual and penile development between patients and controls. Hypospadias surgery should be performed early.