Complete Penile Disassembly Research Articles

Redo surgery to improve urinary function, sexual function and cosmesis in male patients with exstrophy–epispadias complex complications. Technical principles and pearls based on case scenarios

The bladder exstrophy-epispadias complex includes some of the most challenging conditions treated by pediatric urologists. They are associated with the need for multiple intricate reconstructive procedures, aimed at restoring the anatomy and function of the bladder, urethra and external genitalia. These patients often endure multiple redo reconstructive procedures to improve urinary function, sexual function and cosmesis throughout the first two decades of life. In this article, we present the 30-year experience of a single surgeon performing redo surgery for males born with epispadias and bladder exstrophy. Through detailed documentation of 6 clinical cases, we highlight technical aspects that may contribute to a successful surgical reconstruction in these patients. The article is focused specifically on patients undergoing redo epispadias repair with or without concomitant continence procedures. We make the case for complete penile disassembly with external rotation of the corpora to correct recurrent dorsal curvature; this approach also allows the surgeon to have access to the proximal urethra and bladder neck after opening the intersymphiseal scar/band. This is useful when additional procedures on the bladder, such as bladder neck tailoring, are necessary. We also highlight the importance of avoiding reverse Byars' flaps when performing skin closure, due to the resulting midline scar. Besides being associated with a poor cosmetic outcome, it can also contribute to recurrent dorsal curvature. The authors advocate for rotational skin flaps to cover the penile shaft. Correction of dorsal curvature and improved cosmesis obtained with complete penile disassembly sometimes comes at the expense of the urethra being left as a hypospadias (figure). This will require further surgeries (usually a 2-stage buccal mucosa graft), much like the treatment of proximal hypospadias. Redo epispadias surgery in males remains a challenge. The systematic approach offered by the case scenarios may help guide surgeons dealing with this difficult condition. Patient with complications after repair of classic bladder exstrophy. A) Stone retrieved from posterior urethra after complete penile disassembly. B) After opening the inter-symphiseal scar, the bladder has been opened and the bladder neck tailored. C) Complete penile disassembly has been completed with corporal bodies and urethra individualized. D,E,F) Final appearance of the repair; abdominal wall was closed with anterior rectus sheath flaps, penile skin was closed with rotational flaps and urethra ended up as a hypospadias.

Long term evaluation of continence after complete primary bladder exstrophy repair

Continence after bladder exstrophy (BE) repair remains a major debatable challenge to pediatric urologists, together with the lack of standard definitions and long-term results in large series. We assessed the long-term urinary continence in 142 toilet-trained cases after one (1-) stage of complete primary repair of bladder exstrophy (CPRE) and consequent procedures to achieve this goal in a single tertiary referral center. The current retrospective study included 123 boys and 19 girls with BE that were repaired by (1-) stage CPRE. The Mean age at (BE) repair was 9.5±2.6 weeks. Complete penile disassembly (CPD) was used for epispadias repair in 42 (34.1%) and modified Cantwell-Ransley repair (MCR) was used in 81 (65.9%) boys. Bilateral anterior transverse innominate osteotomies (ATIO) were applied in all. Urinary continence was expressed in terms of the dry interval (DI). Continence procedures were afforded if CPRE failed to achieve DI≥3h (hrs.), those were in the form of endoscopic bladder neck injection (BNI), bladder neck reconstruction (BNR), and bladder neck closure (BNC) with catheterizable stoma. The mean age at follow up was 12.1±5.2 years. DI≥3h was gained in 23 (16.2%) after CPRE alone, while complementary post-CPRE continence procedures were required to reach this goal in the remaining patients. Deflux injection was reported in 10 (7%), CIC in 8 (5.6%), BNR in 32 (22.5), and BNC with catheterizable stoma alone in 37 (26.1%), or with Charleston pouch in 32 (22.5%). We think that ≥3h DI with voiding represents an appropriate definition of continence after BE repair. According to the results in the current series, we think that successful anatomical closure of BE is achievable, but the functional outcome in terms of continence and its evaluation is tricky. Results of continence were reported to change with age of the child, and it is difficult to evaluate both before toilet training age and long-term follow up. Long-term follow up of CPRE with bilateral ATIO alone or with BNI results in ≥3h DI in a few cases; BNR after CPRE can provide a good chance for continence; otherwise, BNC with catheterizable stoma is a valid option.

Epispadias: recent techniques

Aim: This paper presents the latest surgical approaches for epispadias treatment in the pediatric population, as well as those for adolescent and adult populations after initial failed repair in childhood. Methods: The retrospective study was conducted between March 2005 and May 2020 and included 18 patients with the mean age of 21 months (range 11-48 months) (Group A), who underwent primary epispadias repair and 15 patients with the mean age of 18 years (range 13-29 years) (Group B), who underwent redo surgery after failed epispadias repair in childhood. In Group A, the surgery was performed as a one-stage procedure using complete penile disassembly technique, while, in Group B, the surgery was done as a two-stage procedure and included complete straightening and lengthening of the penis, followed by urethral reconstruction. Penile straightening and lengthening were achieved by tunica albuginea incision and grafting. In Group A, the urethral plate was mobilized, transposed ventrally, and tubularized and augmented with vascularized preputial skin flap where needed. In Group B, the urethra was reconstructed either using the buccal mucosa graft and genital skin flaps or with tubularization of genital skin flaps. Successful treatment was defined as a functional and esthetically acceptable penis without complications. Results: The mean follow-up was 88 months (range 15-197 months). Satisfactory results were achieved in 26/33 patients. Urethral fistula occurred in 4/18 patients from Group A and in 3/15 patients in Group B and was surgically repaired after four months. Skin dehiscence occurred in eight patients, five from Group A and three from Group B. Recurrent penile curvature was observed in 2/18 patients from Group A and required surgical correction and in 2/15 patients from Group B and was mild and did not need surgical repair. Eleven patients from Group B who filled out the International Index for Erectile Function reported satisfying erectile function, sexual desire, intercourse, and overall satisfaction. Conclusion: Primary or redo epispadias repair is challenging even for experienced reconstructive urologists. Only radical surgical approach can lead to complete correction of all deformities and provide successful outcome.

The GUD technique: Glandular urethral disassembly for distal hypospadias repair

We present an alternative procedure for distal hypospadias consisting of urethral mobilization and glandular disassembly, named GUD-technique. After circumcision and exposure of distal dysplastic urethra, it is entirely mobilized from corpora and glans. Glans is deconstructed and incised in midline producing two wings almost not connected to glandular urethra at all. The urethra is then mobilized cranially and sutured to the tip of glans. Glans wings embrace the distal urethra producing a refurbished conical glans. Koff etal. published a technique consisting of extensive urethral mobilization for hypospadias repair. Mitchell & Blagi and Perovic etal. reported on complete penile disassembly for epispadia repair as a way to complete release of the rotation of the penis and treat chordee bringing the urethra to a more functional location. We incorporated these two principles in GUD. The rationale is to avoid suture urethroplasty, simply repositioning the mobilized urethra distally and working aggressively on glans disassembly creating a more conical and cosmetic glans. The aggressive deconstruction of glans makes this technique unique. We are convinced that this operation can be regarded as a genuine alternative to distal hypospadias after performing 100 cases in 3 years of experience.

Penile Disassembly in Complete Primary Repair of Bladder Exstrophy: Time for Re-evaluation?

To explore a series of classic bladder exstrophy (CBE) cases referred to the authors' institution where primary closure with penile disassembly epispadias repair was complicated by penile injury. The penile disassembly technique is frequently combined with bladder closure in patients with CBE undergoing the complete primary repair of exstrophy (CPRE). Penile disassembly has been posited as a risk for penile injury by ischemic mechanisms. A prospectively-maintained institutional database of 1337 exstrophy-epispadias complex patients was reviewed for CPRE cases referred to the authors' institution, and those with injury to the penis were identified. The location, extent of injury, and subsequent management is reported. One hundred and thirteen male CBE patients were referred after prior CPRE. Twenty-six (20%) were identified with penile loss and reviewed. Eighty-one percent were closed in the neonatal period, and 54% had a pelvic osteotomy. Median follow-up time was 9.9 years (range 0.6-21.3). Of 26 patients with penile loss, 77% had unilateral loss and in 23% had bilateral loss involving the glans and/or one or both corpora cavernosa. Three patients were successfully managed with myocutaneous neophalloplasty. Complete penile disassembly during bladder exstrophy closure may lead to penile injury. This major complication questions the continued application of complete penile disassembly in the reconstruction of bladder exstrophy.

Complete penile disassembly in epispadias repair.

To report current results of complete penile disassembly technique in epispadias repair. In ten years, we have preformed 31 complete penile disassembly for proximal epispadias repair. Twenty-four patients had epispadias after primary repair of bladder exstrophy and 7 isolated penopubic epispadias. The age of the patients ranged from 10months to 6years (median 3years). The shortening of urethral plate was found in 30 patients (97% of cases), and this shortening varied between 6 and 16mm. However, in one patient we found a lengthening of the urethral plate of 8mm. The narrowing of urethral plate was found in all patients, and this narrowing varied between 30 and 50% of the width of the plate. Postoperative complications encountered in our patients were dominated by fistulas and dehiscence, particularly in patients who had bladder exstrophy-epispadias complex. After dehiscence and fistulas repair, the cosmetic results were satisfying in 25 patients (80.5% of cases) with conical glans and meatus in orthotopic position without any necrosis of the glans. However, the urinary continence ≥ 1h was observed in 6 patients (19% of cases) and only 3 patients (9.7% of cases) had a urinary continence ≥ 3h. The mean follow-up was 61 months. The complete penile disassembly remains one of the best techniques for epispadias repair. However, we noticed a reappearance of the dorsal curvature of the penis in a large number of patients treated for isolated epispadias and the impact of this technique on urinary incontinence remains uncertain.

Is there a shortening of the urethral plate in complete penile disassembly used in epispadias repair, and what is its impact on the final outcomes?

PurposeTo assess the importance of shortening of the urethral plate that occurred with complete penile disassembly technique in epispadias repair and its impact on cosmetic and functional results (on urinary incontinence). MethodsFrom January 2009 to December 2016, 26 boys underwent complete penile disassembly technique for proximal epispadias repair. Twenty-one patients had epispadias after primary repair of bladder exstrophy, and 5 patients had isolated penopubic epispadias. The age of the patients ranged from 11 months to 6 years (median 3 years). ResultsAfter disassembling the penis in three parts, the shortening and narrowing of urethral plate were found in all patients; the shortening varied between 2 and 16 mm. However, in isolated epispadias, the urethral plate is easily extensible. The cosmetic results (after dehiscence and fistulas repair) were found to be satisfactory in 24 patients with conical glans and meatus in the orthotopic position without any necrosis of the glans. However, 18 patients (81.8% of cases) who initially had a bladder exstrophy presented a dehiscence or fistula. The urinary continence ≥ 1 h was observed in 5 patients (19% of cases), and only 3 patients (11.5% of cases) had a urinary continence ≥ 3 h. ConclusionsThe complete penile disassembly procedure restores the normal anatomy of the penis. Despite the shortening and narrowing of the urethral plate, the cosmetic results were good in the majority of patients. However, its functional outcomes on urinary incontinence, particularly for epispadias with bladder exstrophy, remain uncertain.

V09-04 THE MITCHELL COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR

You have accessJournal of UrologyPediatric Urology1 Apr 2018V09-04 THE MITCHELL COMPLETE PENILE DISASSEMBLY FOR EPISPADIAS REPAIR Joshua Chamberlin, Ahmed Abdelhalim, Zhan Tao Wang, and Antoine Khoury Joshua ChamberlinJoshua Chamberlin More articles by this author , Ahmed AbdelhalimAhmed Abdelhalim More articles by this author , Zhan Tao WangZhan Tao Wang More articles by this author , and Antoine KhouryAntoine Khoury More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2176AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Epispadias repair aims to restore normal penile anatomy, achieve straight erections with excellent cosmesis and improve urinary continence. The complete penile disassembly technique allows for ventral positioning of the urethra and correction of severe dorsal chordee, however the resultant hypospadic meatus requires further reconstruction. We describe the technical refinements of the complete penile disassembly technique for epispadias repair with the use of buccal mucosal graft and ventral skin flap. METHODS After penile degloving, the urethral plate was dissected and detached from the corpora cavernosa which were separated. The urethra was tubularized and ventrally positioned. A buccal mucosal graft was harvested and quilted to the corpora cavernosa distal to the neomeatus. Skin coverage was achieved with a ventral preputial transverse island flap rotated dorsally. The buccal graft was tubularized 6 months later. RESULTS The technique was successful to achieve an excellent aesthetic outcome with an orthotopic meatus and a conical glans in 2 stages. The patient eventually had straight erections and improved continence. Neither procedure had complications. CONCLUSIONS Excellent cosmetic and functional outcome can be achieved with complete penile disassembly for epispadias repair. Buccal mucosal graft urethroplasty is a feasible option to correct the resultant hypospadias. A ventral preputial island flap allows for adequate skin coverage while avoiding a dorsal midline scar. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e904 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Joshua Chamberlin More articles by this author Ahmed Abdelhalim More articles by this author Zhan Tao Wang More articles by this author Antoine Khoury More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP25-02 PENILE DISASSEMBLY IN EXSTROPHY: TIME TO REEVALUATE?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II1 Apr 2018MP25-02 PENILE DISASSEMBLY IN EXSTROPHY: TIME TO REEVALUATE? Matthew Kasprenski, Mahir Maruf, John Jayman, Karl Benz, Jason Michaud, Emily Dunn, and John Gearhart Matthew KasprenskiMatthew Kasprenski More articles by this author , Mahir MarufMahir Maruf More articles by this author , John JaymanJohn Jayman More articles by this author , Karl BenzKarl Benz More articles by this author , Jason MichaudJason Michaud More articles by this author , Emily DunnEmily Dunn More articles by this author , and John GearhartJohn Gearhart More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.839AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Epispadias repair, using the complete penile disassembly technique, is frequently combined with primary bladder closure in patients with classic bladder exstrophy (CBE). Yet, penile disassembly has been posited as a risk for penile injury by ischemic mechanisms. Herein, the authors present all CBE cases referred to their institution where primary closure with penile disassembly epispadias repair was complicated by penile injury. METHODS A prospectively-maintained institutional database of 1311 exstrophy-epispadias complex patients was reviewed for complete primary repair of CBE cases referred to the authors' institution, and those with injury to the penis were identified. The location, extent of injury, and subsequent management is reported. Triplanar magnetic resonance imaging (MRI) of the pelvis with volumetric analysis was used for penile compartment quantification. RESULTS Of the 170 CBE patients referred after a prior complete primary repair, 22 (13%) were identified with penile loss. A majority (82%) were closed in the neonatal period, and 55% had a pelvic osteotomy. Eight patients (38%) had a failed primary closure. Median follow-up time was 10 years (range 3-21). Penile injury was often unilateral (82%), and involved the glans and/or corpora cavernosa. MRI of the pelvis confirmed anterior corporal deficiency that resulted from primary closure. Three patients were successfully managed with myocutaneous neophalloplasty between the ages of 15 and 16 years old. CONCLUSIONS As a part of the primary bladder closure, penile disassembly for epispadias repair may lead to penile ischemia. In addition to reconstructive planning, MRI may be used to quantify penile injury. CBE patients with penile injury can be managed with myocutaneous phalloplasty. Because of the soft tissue loss with complete penile disassembly, it may be time to reevaluate the application of this technique in the reconstruction of bladder exstrophy. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e326 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Matthew Kasprenski More articles by this author Mahir Maruf More articles by this author John Jayman More articles by this author Karl Benz More articles by this author Jason Michaud More articles by this author Emily Dunn More articles by this author John Gearhart More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Modified complete penile disassembly for epispadias repair: a case report

Modified complete penile disassembly for epispadias repair: a case report

Functional and cosmetic outcome of partial penile disassembly repair in isolated male epispadias patients

IntroductionEpispadias is a rare congenital anomaly and requires a carefully constructed and well-planned approach for the management. Modified Cantwell-Ransley technique and Mitchell's complete penile disassembly are commonly used technique and these may require multiple surgeries in majority of the patients to achieve the goals of cosmesis and continence. ObjectiveTo evaluate the functional and cosmetic outcome of single stage partial penile disassembly repair in isolated male epispadias. Patients and methodsA retrospective analysis of 43 cases of primary epispadias repair, performed during July 1998 to March 2013. Patients were classified on the basis of type of epispadias, urinary incontinence, presence/degree of chordee and penile rotation. TechniquePenile de-gloving with mobilization of urethral plate from ventral to dorsal aspect with preservation of blood supply at both ends, distally up to the level of mid-glans and proximally up to pubic symphysis with division of peno-pubic ligament to lengthen the penis and position the urethra ventrally. Tubularization of urethral plate followed by spongioplasty, corporoplasty with medial rotation of corporeal bodies (without any corporotomy) and glanuloplasty with meatoplasty is done to bring the meatus ventrally. Skin cover with rotation of ventral flaps and z-plasty when required. ResultsAge of the patients varied from 6 months to 26 years with a mean of 9 years. Ninety three percent of the patients had excellent cosmetic outcome while seven percent had minimal residual chordee/torque but did not require any surgery. None of the patients developed complications like fistula or stricture. All the 12 patients in the postpubertal group reported normal erections and successful ejaculations after the surgery. Postoperative follow up ranged from 2 to 10 years with a mean of 4 years. ConclusionsThe technique incorporates all the benefits of Cantwell-Ransley repair, can be done with less extensive dissection than total penile disassembly. Both functional and cosmetic results are good with low complication rate. Spongioplasty reconstructs near normal urethra and corporoplasty with spongioplasty also helps in prevention of urethral fistula.

Complete Penile Disassembly for Epispadias Repair in Isolated Epispadias in a Postpubertal Patient: A Case Report

Complete Penile Disassembly for Epispadias Repair in Isolated Epispadias in a Postpubertal Patient: A Case Report

Complete Primary Repair of Bladder Exstrophy Is Associated With Detrusor Underactivity Type of Neurogenic Bladder

To test the hypothesis that complete primary repair of bladder exstrophy (CPRE) is associated with detrussor underactivity. For this purpose, we review (1) our experience, (2) the results of the published literature as it pertains to bladder function, and (3) the known anatomic basis on which the mechanism of the observed outcome can be understood. The medical records of all patients who underwent CPRE by the author between 2004 and 2010 were reviewed. Attention was focused on the clinical, imaging, and urodynamic findings. Four men and 2 women underwent CPRE. Follow-up ranges from 2 to 8 years. Four underwent bilateral ureteral reimplantation combined with bladder neck repair in 3. Detrusor activity (or overactivity) was not recorded in the 5 patients who underwent urodynamic studies. Four patients achieved short periods of urinary continence. The percent predicted bladder capacity, adjusted for age, ranged from 25 to 70, with a median of 60. Of the 68 publications on CPRE since 1999, none reports the presence of detrusor activity. A description of the pelvic plexus anatomy by Walsh and Donker provides a basis for the mechanism of injury resulting in the previously mentioned results: (1) complete penile disassembly eliminates the distal fixation point of the bladder-urethral plate, (2) the subsequent dissection and mobilization result in shearing injury to the microscopic pelvic plexus branches to the bladder, external sphincter, and prostatic urethra. CPRE results in disruption of the branches of the pelvic plexus and a neurogenic bladder (detrussor underactivity).

COMPLETE PENILE DISASSEMBLY FOR ISOLATED EPISPADIAS REPAIR WITH MITCHELL-CAIONE TECHNIQUE: TWO CASES

Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Many surgical technique have been described for repair of male epispadias. The aim of surgical repair is to get cosmetically acceptable and functional penis with a ventrally located urethra opening at the tip of the glans and moreover to give the patient a urinary continence. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. We present two cases of our experience where we used the complete penile disassembly tecnique by Mitchell-Caione in wich we acts on the voluntary control of urination by the reapproximation of the muscular plane of pelvic diaphragm and elevator muscle around the posterior urethra reconstructed. Epispadias repairs was performed on two incontinent male epispadias patient, aged 2 to 3 years. Both cases were untreated. Complete disassembly of penil components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies and the glans were split on the sagittal plane according to Grady-Mitchell. The central portion of the urethral plate was preserved intact. An electric stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. “Z plasties” were necessary according to initial urethral length and width: the urethra was reconstructed over a double catheters, using 5/0 polyglicolic acid interrupted sutures in a single layer. In one patient we sutured symphisis pubis opened precedently, using 1/0 polyglicolic acid. The urethra was placed ventrally in the reconstructed shaft under the two corpora as Mitchell technique. Glanduloplasty was then performed. Patients were followed up for one month (June 2012). The penis of the two patients had a satisfactory cosmetic appearance with no dorsal chordee. Morover, our patients obtained urinary continence. The limitation of our study was the low follow-up. The electric stimulator used to identify pelvic muscle components in the sagittal plane for reapproximate the posterior tabularized urethra to form the periurethral muscle complex and the “Z-plasties” that elongated the urethra significantly.This procedure seems to be satisfactory for the repair of cases of isolated male epispadias because we have good results in cosmetic appearance and in urinary continence. Our study is a preliminary report and a longer follow-up with a larger number of cases is needed to document further the success of the procedure.

COMPLETE PENILE DISASSEMBLY FOR ISOLATED EPISPADIAS REPAIR WITH MITCHELL-CAIONE TECHNIQUE: TWO CASES

Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Many surgical technique have been described for repair of male epispadias. The aim of surgical repair is to get cosmetically acceptable and functional penis with a ventrally located urethra opening at the tip of the glans and moreover to give the patient a urinary continence. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. We present two cases of our experience where we used the complete penile disassembly tecnique by Mitchell-Caione in wich we acts on the voluntary control of urination by the reapproximation of the muscular plane of pelvic diaphragm and elevator muscle around the posterior urethra reconstructed. Epispadias repairs was performed on two incontinent male epispadias patient, aged 2 to 3 years. Both cases were untreated. Complete disassembly of penil components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies and the glans were split on the sagittal plane according to Grady-Mitchell. The central portion of the urethral plate was preserved intact. An electric stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. “Z plasties” were necessary according to initial urethral length and width: the urethra was reconstructed over a double catheters, using 5/0 polyglicolic acid interrupted sutures in a single layer. In one patient we sutured symphisis pubis opened precedently, using 1/0 polyglicolic acid. The urethra was placed ventrally in the reconstructed shaft under the two corpora as Mitchell technique. Glanduloplasty was then performed. Patients were followed up for one month (June 2012). The penis of the two patients had a satisfactory cosmetic appearance with no dorsal chordee. Morover, our patients obtained urinary continence. The limitation of our study was the low follow-up. The electric stimulator used to identify pelvic muscle components in the sagittal plane for reapproximate the posterior tabularized urethra to form the periurethral muscle complex and the “Z-plasties” that elongated the urethra significantly.This procedure seems to be satisfactory for the repair of cases of isolated male epispadias because we have good results in cosmetic appearance and in urinary continence. Our study is a preliminary report and a longer follow-up with a larger number of cases is needed to document further the success of the procedure.

Penile Repair in Patients with Epispadias-Exstrophy Complex—Can we Prevent Resultant Hypospadias?

Male genitalia reconstruction in patients with exstrophy-epispadias complex often leads to secondary hypospadias, thus requiring additional surgery and resulting in possible complications. We describe a technique of male epispadias repair to prevent resultant hypospadias. The complete penile disassembly technique is modified by multiple Z-plasties, which enable creation of a funnel-like bladder neck and urethral plate lengthening. A total of 29 patients 2 months to 12 years old presenting with pure epispadias and bladder exstrophy were treated with this technique between 2004 and 2011. These patients were compared to 19 patients 1 day to 11 years old with exstrophy-epispadias treated with the standard penile disassembly technique between 2000 and 2004. Outcome measures were urethral orifice position, penile length and complications. There was no statistically significant difference between the 2 groups regarding penile length or complications. In the study group the urethra reached the tip of the glans in all patients, whereas the creation of intentional hypospadias was necessary in 6 patients (31.5%) in the control group (p <0.05). The modified technique was effective in obtaining appropriate meatal location without decreasing the penile length. The complication rate was not changed. Creation of resultant hypospadias at genitalia reconstruction in male epispadias should strongly be prevented.

Editorial Comment

The authors present an impressive case series. This technique is not for the faint of heart in adult patients. The authors are to be commended for their excellent outcomes. I would urge them to use validated patient self-report tools in the future, as they continue to follow-up this group of adults. I would also offer a word of caution. This technique must be used judiciously in patients who have undergone previous extensive surgery on the penis. Complete Penile Disassembly for Epispadias Repair in Postpubertal PatientsUrologyVol. 78Issue 6PreviewTo present the outcomes of complete penile disassembly in 14 postpubertal patients. Complete penile disassembly is widely used for epispadias repair. Full-Text PDF

Complete Penile Disassembly for Epispadias Repair in Postpubertal Patients

To present the outcomes of complete penile disassembly in 14 postpubertal patients. Complete penile disassembly is widely used for epispadias repair. From July 2001 to May 2008, a total of 14 postpubertal patients underwent complete penile disassembly epispadias repair. The median age at surgery was 18 years (range 14-34). Of the 14 patients, 3 patients had isolated penopubic epispadias (all with failure of previous repairs) and 11 had bladder exstrophy with no previous attempts at epispadias repair. Of the 11 patients with exstrophy, 6 had undergone previous cystectomy and rectal diversion and 5 had undergone bladder neck closure, ileocystoplasty, and creation of a continent outlet. A urethral stent was used only for patients with isolated epispadias. The first postoperative follow-up examination was at 6 weeks. Later, the patients were followed up every 3 months for 1 year. All patients had an orthotopic meatus. However, the short urethral plate was lengthened with a penile skin flap in 5 (36%) of the 14 patients to achieve an orthotopic meatus. No patient had glans/corporal ischemia. All patients had normal conical symmetric glans/corpora. Of the 3 patients undergoing redo surgery, 1 had sloughing of the distal neourethra and ended up with a coronal hypospadias. All 11 de novo patients had an orthotopic meatus with no fistula, stenosis, or dehiscence. All neourethras were easily calibrated with a 14F sound. All patients had normal straight erections with normal forward ejaculation. Complete penile disassembly is safe and effective surgery for epispadias repair in postpubertal patients. Lengthening of the urethral plate with a penile skin flap was required in one third of patients. The erection/ejaculatory functions were preserved in all patients.

922 THE RESULTS OF PENILE DISASSEMBLY FOR EPISPADIAS REPAIR IN 108 PATIENTS

You have accessJournal of UrologyPediatrics: Reconstructive Surgery1 Apr 2010922 THE RESULTS OF PENILE DISASSEMBLY FOR EPISPADIAS REPAIR IN 108 PATIENTS Hisham Hammouda, Mohamed Elgammal, Ahmed Safwat, and Hazem Orabi Hisham HammoudaHisham Hammouda More articles by this author , Mohamed ElgammalMohamed Elgammal More articles by this author , Ahmed SafwatAhmed Safwat More articles by this author , and Hazem OrabiHazem Orabi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1713AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated the Complete penile disassembly (CPD) technique described by Mitchell and Modified penile disassembly (MPD) technique which preserves the 2 hemiglans integrity together and which was reported by Grady for Epispadias repair. METHODS A total of 108 patients with their age ranged between 3 weeks and 22 years and who had repair of Epispadias between 1998 and 2008 were included. Cases were divided into two groups; group I included 80 cases of complete Epispadias as a part of one stage closure of Bladder Exstrophy (17 of them had prior continent urinary diversion) and group II included 28 cases of complete Epispadias alone (22 primary and 6 secondary cases). Complete penile disassembly was performed in 79 (61/80 in group I &18/28 in group II) patients and MPD was performed in 29 (19/80 in group I & 10/28 in group II) patients. Urethra was closed using interrupted absorbable 6/0 or 7/0 sutures in our series, with maintaining the attachment of the urethral plate (UP) to the ventral skin (our reported modification of CPD) in 55/79 (45/61 in group I &10/18 in group II) patients and no maintaining of this attachment in 24/79 cases of CPD (16/61 in group I &8/18 in group II ) in addition to 29 cases of MPD (19/80 in group I &10/28 in group II). RESULTS Mean follow up was 48.5 months (range 12-86). Ischemic changes at glans penis was recorded in 5/79 cases which was irreversible in two cases (2.5%) during our initial experience with CPD,while this complication was not reported with MPD. Ventral orthotopic urethral meatus was achieved in all 55 cases of CPD with maintaining the attachment of the UP to the ventral skin,while it was hypospadiac in 10/24 cases of CPD (7/16 in group I & 3/8 in group II ) and 17/29 cases of MPD (11/19 in group I & 6/10 in group II) with no maintaining of UP attachment in both. Conical glans was reported in 104/108 (96.6%), straight shaft in 70/79 (85.2%) after CPD and in 26/29 (89.6%) after MPD. Urethral fistula was recorded in 4/108(3.7%) cases. Insignificant decrease for cosmetic penile length with maintaining UP attachment with ventral skin was observed. There were no reported cases of dehiscence,meatal stenosis or urethral stricture. Erectile function was preserved in all patients. CONCLUSIONS Either CPD after a considerable learning curve or MPD are safe procedures for Epispadias repair,which can provide satisfactory cosmetic and functional outcome. Keeping of UP attachment with ventral skin helps in achieving orthotopic ventral urethral meatus, however it is accompanied with insignificant decrease in cosmotic penile length. Assiut, Egypt© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e359 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hisham Hammouda More articles by this author Mohamed Elgammal More articles by this author Ahmed Safwat More articles by this author Hazem Orabi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Penile loss following complete primary repair of bladder exstrophy

The complete penile disassembly technique is increasingly employed during the surgical repair of classic bladder exstrophy. We describe the complication in a newborn boy of loss of the glans penis following complete primary exstrophy repair. The possible causes and prevention of this injury are discussed.