A new technique for distal hypospadias repair: advancement of a distally deepithelialized urethrocutaneous flap

Urethral advancement for recurrent distal hypospadias fistula treatment

Hypospadias fistula may be persistently recurrent in some patients. In distal hypospadiac fistula cases, carrying the fistulous opening to the glans tip may be possible with extensive urethral mobilization and advancement. In 9 patients who were operated for urethrocutaneous fistula, we used the urethral advancement technique. Patient ages ranged from 5 to 14 years (mean, 8 years). In all of the cases, the urethra was mobilized proximally to at least penoscrotal junction, and in some cases, the bulbar urethra was mobilized partially. Follow-up ranged from 6 months to 16 months. In all but 1 child, a straight penis with the neomeatus at the glans tip was maintained without any urethrocutaneous fistula. In 1 child, chordee, which was already present, could not be prevented.Urethral advancement technique may effectively solve the problem of persistently recurrent hypospadias fistula. We recommend the technique to plastic surgeons' armamentarium.

What Is New in the Treatment of Hypospadias?

Hypospadias is a congenital anomaly characterized by a ventrally placed urethral meatus in a more proximal position on the midline than its normal position in the glanular part of the penis. In 1961, C. E. Horton and C. J. Devine, Jr., developed single-stage modern surgical techniques, namely, local skin flaps and free skin grafts, for urethra reconstruction in hypospadias repair, which may be applied to almost any case with different localizations of the meatus. Later, two new methods, advancement of the urethra and preputial island flap techniques, were added to the surgical algorithm. Because acceptable results were observed, the authors have insisted on using these four techniques for all hypospadias cases since 1972. Complication rates (mainly fistula formation) were quite high (50 percent) in their early series of adults as a result of erection and hematoma formation. The complication rate of their patient population, which is now mainly composed of preschool children, has decreased to 7 to 8 percent, primarily as a result of careful selection of appropriate techniques for each individual case, the development of better surgical materials and equipment, and taking necessary precautions for postoperative care. A brief summary of modern hypospadias repair techniques is presented in four major classes. The results of the authors' 30-year experience and the precautions necessary to avoid postoperative complications are evaluated. The authors conclude that the four modern techniques and their modifications should be performed meticulously for successful hypospadias repair.

T-incision technique in distal hypospadias: a modification of meatal advancement and glanuloplasty

Hypospadias is among the most common of the congenital anomalies. Distal hypospadias refers to an orifice in the distal third of the penile shaft. Correction of distal hypospadias requires different techniques, depending on the location of the meatus. Simple advancement techniques can be used for most distal hypospadias, whereas hypospadias with chordee requires reconstruction of a urethra. The meatoplasty and glanuloplasty procedures developed by Duckett have become standard operations to correct these lesions. Complications such as meatal stenosis, meatal retraction, and fish mouth-like meatus can be seen after meatal advancement and glanuloplasty ("MAGPI"), though it usually yields good results. In an attempt to avoid the complications associated with the meatal advancement and glanuloplasty procedure, the authors added a modification to the procedure for those hypospadias cases located in the coronal sulcus or its distal part. As an addition to conventional meatal advancement and glanuloplasty, a transverse incision on top of the vertical incision was made so that the urethra was supported by lateral triangle flaps created on the glans. Lateral triangle flaps of the glans were sutured to the dorsal aspect of the urethra advanced from the previous position. Thus, stress on the urethra was lessened and meatal retraction was prevented. When closure was performed with a T incision, an M-shaped, zigzag incision line was placed instead of a circular incision line. Therefore, stenosis was prevented and a vertical meatus with good cosmetic appearance was obtained. Fifty-three boys aged 4 to 7 years were operated on with this technique and were followed for 2.4 years. Good functional and cosmetic results were achieved in most of the cases.

Hypospadias

The incidence of hypospadias is increasing. Decreased androgen sensitivity, 5alpha-reductase deficiency and chromosomal abnormalities are causes of the disease. Nonirritant suture material, coverage of the urethral reconstruction by additional tissue and perioperative care positively influence the outcome. Complication rates after repair of distal hypospadias are low. For severe hypospadias staged procedures provide good results. Buccal mucosa is promising for initial repair and repeat cases. Psychosocial function in patients with severe hypospadias is normal.