Urethroplasty using diverticular tissue

Repair of stenosed neourethra using the proximal neourethral diverticulum - A technique in redo hypospadias surgery

Neourethral diverticulum secondary to distal neourethral stenosis is not uncommon after proximal hypospadias repair. We describe a technique using the neo urethral diverticular roof and overlying skin as a composite flap to reconstruct the urethral stenosis distal to the diverticulum. The composite flap is advanced distally for reconstruction of the stenosed urethra either as a tube or as an onlay. Urethra at the diverticular bed is tubularized to reduce its caliber. This technique has yielded excellent results in three children. The tissue expansion caused by the obstructed urinary stream has been utilized to correct both neourethral diverticulum and stenosis.

Urethroplasty Using Diverticular Tissue for Hypospadias

CASE

The patient was a 3-year-old with hypospadias. Urethroplasty was performed as a two-stage procedure, but a severe urethral stricture occurred due to a postoperative infection and the patient was virtually in urinary retention. An emergency cystostomy was performed, and thereafter urethral reconstruction was performed. A large urethral diverticulum had formed in the scrotum. The inner wall of the diverticulum was found to be completely epithelialized and well vascularized. Therefore, it was elevated as a skin flap and a neourethra was reconstructed up to the glans region using the diverticular tissue.

OUTCOME

Postoperative complications were not observed, and micturition was satisfactory.

CONCLUSION

A urethral diverticulum is one of the often encountered complications of hypospadias surgery. However, there are only a few literature reports related to the treatment of urethral diverticulum. In addition, there are almost no reports on reconstructions using urethral diverticular tissue. In this report, we describe such a treatment experience.

Management of urethral diverticulum complicating hypospadias repair

BACKGROUND

Urethral diverticula can occur after hypospadias repair, and may lead to stone formation, incomplete voiding, infection, postvoid dribbling, haematuria and other problems. We previously reviewed our experience with hypospadias complications. We separately analyzed those patients who developed urethral diverticula to attempt to identify predisposing factors and appropriate management strategies.

PATIENTS AND METHODS

We reviewed the available medical records and charts of 123 patients undergoing re-operation for hypospadias complications at The Children's Mercy Hospital from 1 May 1984 until 1 January 2003. Hypospadias cripples, traumatic fistulae, complications after circumcision and true intersex patients were excluded.

RESULTS

Diverticula accounted for 11% of all complications (13 patients). The patients with diverticula were more likely to have perineal/proximal hypospadias. The initial repair was island tube urethroplasty in five, island onlay urethroplasty in seven and bladder mucosal graft in one child. The repair of the diverticulum in one stage was successful in 10 of the 13 patients. There was one recurrent diverticulum and two fistulas. A stricture was present in only one of the 13 patients but was detected overall in 14 of the 123 patients (11%).

CONCLUSION

Diverticula are uncommon after hypospadias repair, accounting for 11% of all complications in the present series. The stricture was not causative in 12 of 13 children. Repair of the diverticulum was successful after one attempt in 10 of 13 patients. The management of this complication is discussed.

'Pseudospongioplasty' in the repair of a urethral diverticulum

OBJECTIVES

To describe a technique for repairing urethral diverticula which includes neourethral reconstruction and increasing the mechanical support of the neourethra.

PATIENTS AND METHODS

Between February 1995 and May 2000, 267 patients with proximal hypospadias underwent a one-stage penile skin longitudinal flap urethroplasty. The overall postoperative complication rate was 20%; a diverticulum formed in 24 patients (9%) and in all it was repaired. Diverticulectomy was carried out by de-epithelialization of excess diverticular skin, so that two subcutaneous vascularized tissue wings could be created. After re-establishing distal urethral patency and neourethral closure, the de-epithelialized diverticular wings were folded and overlapped to form a mechanical support for the neourethral ventral wall; this procedure was termed 'pseudospongioplasty'.

RESULTS

There were no recurrences of diverticulum or any fistula formation. The only complication was urethral stenosis in two cases, which was successfully resolved by internal urethrotomy.

CONCLUSION

Re-establishing patency and providing mechanical support are essential when repairing a urethral diverticulum. Our technique with pseudospongiosal tissue reconstruction during the repair represents a good alternative or addition to other techniques.

Urethral reconstruction in spinal cord injury patients

PURPOSE

Bladder management programs for patients with spinal cord injury and neurological disease (SCIND) include intermittent catheterization and sphincterotomy with external catheter drainage. These programs depend on maintaining a patent urethra. Once urethral stricture, erosion, diverticulum or urethrocutaneous fistula occurs, the only treatments available are urethral reconstruction and urinary diversion. We evaluate the role of urethral reconstruction in this subset of patients.

MATERIALS AND METHODS

The charts of 18 patients with SCIND (spinal cord injury 16, cerebral palsy 1, meningomyelocele 1) were retrospectively analyzed. Different surgical procedures had been performed according to the presenting pathology and tissue availability.

RESULTS

Urethral reconstruction was performed in 17 patients with a mean age of 42.2 years (range 27 to 60). Of the patients 13 are paraplegic and 4 are quadriplegic. Urethral defects included urethral stricture in 6 cases, urethral erosion in 4, urethrocutaneous fistula in 3, urethral diverticula in 1 and combined defects in 3. Mean followup is 3.7 years (range 1 to 13) and the mean number of reoperations was 1.4 (range 0 to 4). Of the 17 patients 11 (64.7%) who underwent urethral reconstruction eventually required urinary diversion for end stage urethral pathology (incontinent ileovesicostomy 5, right colon pouches 2, other procedures 4). The mean time from first urethral reconstruction to eventual urinary diversion was 3.3 years (range 0.7 to 7). Four patients maintain a patent urethra while 1 patient was lost to followup.

CONCLUSIONS

Patients with SCIND in whom urethral reconstruction is considered should be advised that urethral surgery carries a high risk of reoperation and eventual need for urinary diversion. Clearly, many patients with neurological disease and severe urethral pathology are best treated with urinary diversion.

Megalourethra and urethral diverticula

Megalourethra and urethral diverticula encompass a diverse group of congenital and acquired urethral defects. The appropriate management of these anomalies relies on a keen appreciation of phallic anatomy and an understanding of urethral embryology. A thorough history and physical examination--including a careful evaluation of the urinary tract--is necessary to identify associated congenital anomalies. Finally, satisfactory surgical management demands meticulous attention to surgical technique.

Repair of urethral diverticulum by plication

OBJECTIVES

To develop a new technique to repair congenital and acquired megaurethra without opening the enlarged urethra.

METHODS

A urethral plication similar to the Starr ureteral plication was developed, which allows the urethra to be plicated without opening into the lumen. This technique also allows the operation to be done in conjunction with hypospadias repairs.

RESULTS

Eight of 10 patients had uneventful recoveries. One had obstruction and infection that resolved with drainage and antibiotics. A coronal margin fistula developed in a patient who had urethral plication as well as urethral advancement.

CONCLUSIONS

This new urethral plication eliminates the need for opening the urethra and its associated complications while preserving urethral blood supply and allowing associated hypospadias repairs to be simultaneously performed.

Repair of the complications of hypospadias surgery

In 1992 a retrospective review was conducted of 190 patients evaluated and treated for complications of hypospadias surgery during 1979 through 1990 at the Devine Center for Genitourinary Reconstructive Surgery of Sentara Norfolk General Hospital and Children's Hospital of the King's Daughters. We could not contact 13 patients and 8 are awaiting a second stage procedure. Of the 177 patients 167 (94.35%) have had a successful outcome, defined as a controllable urinary stream, functional erection and an acceptable cosmetic appearance, and 2 (1.13%) are considered failures. Details of presenting problems, surgical techniques and recent modifications of these procedures are presented.

Surgical correction of anterior urethral diverticula after hypospadias repair in children

We present a new surgical technique to correct acquired anterior urethral diverticula after hypospadias repair. The correction involves a degloving circumferential skin incision, excision of the diverticulum, and closure of the urethra incorporating overlapping suture lines.