The feasibility of urethral plate preservation in proximal and mid-penile hypospadias: sequential and anatomical approach to the repair

Abstract

BackgroundThe assessment of a child having hypospadias with chordee/ventral curvature (VC) and meatal position that appears to be proximal/mid-penile can be challenging with regard to the choice of chordee correction and type of urethroplasty. The feasibility of preservation of native urethral plate is dependent on these choices. Classically, urethral plate resection of the corpora is performed to correct severe VC, whenever VC is presumed to be due to short urethral plate. But VC is seen to persist in many such cases, in spite of this maneuver that commits the patient to a more complex reconstruction. The aim of the study was to analyze the variation in preoperative and intraoperative assessment of proximal and mid-penile hypospadias, with respect to severity and possible surgical options, in patients treated by a standard protocol of sequential and anatomical approach to repair. The other objective was to ascertain if “extensive ventral urethral detethering” (in all cases) and “urethral plate augmentation” (in select cases) could facilitate more anatomical repair in these cases, with urethral plate preservation and utilization for repair wherever feasible.ResultsFifty-two children who underwent the specific protocol of repair during the 5-year period from January 2014 to December 2018 at a tertiary teaching institution were included in the study. The essential principles adopted for the surgery were as follows: (i) urethral plate preservation in all possible situations; (ii) “extensive ventral urethral detethering” up to the bulb, as a preliminary step, (iii) sequential correction of VC with urethral plate augmentation (in select cases); and (iv) selecting the optimal repair based on the following principles: (a) urethral plate tubularization, (b) urethral plate augmentation, and (c) urethral plate substitution. There was considerable difference in the preoperative and intraoperative assessment of meatal position, with 12 of the apparently mid-penile hypospadias being reclassified as distal penile after preliminary dissection. Three of the penoscrotal variants were regrouped as proximal penile and 6 of the proximal penile were regrouped as mid-penile type. Majority of cases which were deemed to require complex reconstruction on preoperative assessment could be treated by a single-stage procedure.ConclusionThe meatal position is seen to shift distally in select cases of proximal or mid-penile hypospadias after thorough degloving, dartos release, and detethering of Buck’s fascia over ventral urethra. Urethral plate can be preserved for utilization in repair in many of these cases by augmenting the urethral plate, enabling a more anatomical neourethral reconstruction. Resection of urethral plate can be thus restricted to the most severe cases of VC.