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

M Bhat,K Sabharwal,A Bhat,R Kumar

doi:10.1016/j.afju.2016.04.007

Abstract

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 5–8mm 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 5cm and flap tube varied from 5.5 to 13cm (average 7.5cm). 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 5–8mm 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.

Highlights

The management of severe or proximal hypospadias is still the ‘Holy Grail’ of hypospadiology
We reviewed the case sheets, operative photographs and videos of 21 cases of severe hypospadias treated with the modified
14 had a wide urethral plate and a good spongiosum, enabling correction of the curvature with preservation of the urethral plate, so TIPU repair was done. These patients were excluded from the study, leaving the remaining 21 cases with a narrow and/or poorly developed urethral plate and severe curvature which persisted after penile de-gloving and urethral mobilization as a patient cohort for this study. They were treated with a combined approach using proximal tubularized incised plate (TIP) urethroplasty and a distal Duckett tube constructed from the inner prepuce after transection of the urethral plate at the corona

Summary

Introduction

The management of severe or proximal hypospadias is still the ‘Holy Grail’ of hypospadiology. The accepted modern approach in any kind of hypospadias repair includes preservation of the urethral plate, if possible [1]. The urethral plate was resected to correct chordee in proximal hypospadias, and tube, flap or graft urethroplasty was done. Over the last few years, tubularized incised plate (TIP) urethroplasty has become the most commonly performed surgery for distal hypospadias [2], but its use is limited in proximal hypospadias cases due to severe ventral curvature [3]. Severe hypospadias is managed by applying two- or three-stage procedures. In many cases of perineal and perineo-scrotal hypospadias, the preputial flap falls short, forcing the surgeon to go for a two-stage repair. The advantages of one-stage repair on the other hand are a healthy unscarred skin in primary repair cases, cost effectiveness of the procedure, a decreased anesthesia risk, better psychological impact and decreased separation anxiety, all of which offer a greater convenience to the patient and parents, as well as to the surgeon [4,5]

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Conclusion