Urethral Mobilization Research Articles

546 AN ALTERNATIVE FOR VENTRAL LENGTHENING IN CHILDREN WITH SEVERE PENILE CURVATURE THAT ALLOWS GRAFT COVERAGE DURING STAGED HYPOSPADIAS REPAIR

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Lower Urinary Tract & Genitalia1 Apr 2011546 AN ALTERNATIVE FOR VENTRAL LENGTHENING IN CHILDREN WITH SEVERE PENILE CURVATURE THAT ALLOWS GRAFT COVERAGE DURING STAGED HYPOSPADIAS REPAIR Bruno Leslie, Bryce Weber, Rodrigo Romao, Walid Farhat, Darius Bagli, Armando Lorenzo, and Joao Pippi Salle Bruno LeslieBruno Leslie toronto, Canada More articles by this author , Bryce WeberBryce Weber toronto, Canada More articles by this author , Rodrigo RomaoRodrigo Romao toronto, Canada More articles by this author , Walid FarhatWalid Farhat toronto, Canada More articles by this author , Darius BagliDarius Bagli toronto, Canada More articles by this author , Armando LorenzoArmando Lorenzo toronto, Canada More articles by this author , and Joao Pippi SalleJoao Pippi Salle toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1271AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Staged repair using preputial grafts has become a popular option for proximal hypospadias with severe curvature. Corporal ventral lengthening (CVL) with autologous, xenogenic or synthetic grafts are often employed, however the initial lack of vascular supply precludes simultaneous superposition of free grafts during first stage urethroplasty. Herein we report preliminary results of a surgical strategy aiming to overcome this limitation, allowing concurrent CVL and preputial grafting for urethroplasty. METHODS The medical records of patients who underwent staged preputial graft urethroplasty (SPGU) for primary repair of perineal or penoscrotal hypospadias with severe curvature were retrospectively reviewed. All patients received pre operative testosterone. The decision to divide the urethral plate was made after complete degloving and urethral mobilization. Multiple deep ventral transverse incisions of the tunica albuginea from 3 to 9 o'clock position were performed in patients with persistent intrinsic curvature after plate transection. An inner preputial graft was then harvested and quilted directly over the incised albuginea, and a tie-over dressing applied. Second stage was done approximately 6 months later, when the graft was tubularized and covered with tunica vaginalis or dartos flap. Prior to tubularization an erection test was repeated and residual curvature addressed with dorsal plication (DP), if necessary. Age, outcomes, need for DP and complications were recorded. RESULTS 30 patients completed the two stages from 2006 to 2010. Mean age at first stage was 18 months (range 10m–11y) and mean interval between stages was 8 months (range 6–11). Mean follow up after the second stage was 16 months (range 6–36). All grafts took well and were suitable for tubularization. DP was required for minor residual ventral curvature in 14/30 (47%) patients. Relevant complications included a long urethral stricture secondary to balanitis xerotica obliterans (1), ventral skin contracture (1), small urethrocutaneous fistulas (2), glans dehiscence (2) and recurrence of mild curvature (2). The remaining 22 cases have no ventral curvature and early excellent cosmetic results, with a slitlike meatus placed in the glans. CONCLUSIONS Our results suggest that the use of deep ventral transverse corporeal incisions for correction of severe curvature allows SPGU and concurrent CVL. The early cosmetic and functional results with this approach are satisfactory with an acceptable complication rate. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e221-e222 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bruno Leslie toronto, Canada More articles by this author Bryce Weber toronto, Canada More articles by this author Rodrigo Romao toronto, Canada More articles by this author Walid Farhat toronto, Canada More articles by this author Darius Bagli toronto, Canada More articles by this author Armando Lorenzo toronto, Canada More articles by this author Joao Pippi Salle toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Parallel Incisions Procedure for Penile Curvature—Short Term Outcomes

Objective: A modified corporotomy technique has been developed in order to overcome the problems of previous techniques such as tissue removal, urethral mobilisation, palpable knots, ‘dog ears’ and leakage on testing after repair. Our objective is to describe the technique and review the outcomes in the short term. Methods: The procedure involves two transverse parallel incisions at the bite points of Allis forceps used to correct curvature. The intervening tunica is buried, sealing the incision and preventing leakage. The incision is closed with 2–0 Polydioxanone sutures and a single 2–0 Polyglycolic to maintain knot burial. Data were collected retrospectively on all patients undergoing this technique from our department. Results: Thirty-two patients underwent daycase surgery. Mean duration of disease was 12.5 months. At three months the cosmetic result was excellent (straight) or good (<20° bend) in 97%. Patient satisfaction was high with 87% being happy with the outcome and 88% able to have pain free intercourse. Complications of note included glans numbness in 1 patient and chronic granuloma related to suture placement requiring excision in 1 patient. Conclusions: The modified parallel incisions procedure is easy to perform and is efficacious in the short term with good cosmetic results and high patient satisfaction. Longer term follow-up is planned in a prospective fashion.

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Most cuff erosions occur on the dorsal aspect of the urethra, suggesting missed injury during mobilization of the urethra from tissues behind it as a common etiology. We agree that most early urethral erosions result from inadvertent injury. However, preservation of urethral blood supply by minimizing mobilization is felt to be a positive attribute of this narrower cuff device. Preservation of urethral vascularity is thought to be of prime importance, especially in cases with an initial compromise to the blood flow secondary to radiation, trauma, or previous urethral surgeries. Of course, using meticulous surgical technique during circumferential mobilization of the urethra and being cognizant of the possibility of injury are prudent practices for minimizing early erosion. Editorial CommentUrologyVol. 77Issue 1PreviewIn comparing the tape mechanical occlusive device (TMOD) with the artificial urinary sphincter, the authors mention that the narrow width of the occlusion tape requires less dissection around the bulbar urethra. They believe this might reduce the risk of urethral injury during urethral mobilization, and this, in turn, might encourage more urologists to use this device. Full-Text PDF

In Vivo Biomechanical Assessment of Anterior Rabbit Urethra After Repair of Surgically Created Hypospadias

We studied the in vivo biomechanical properties of the anterior urethra in a rabbit hypospadias simulation model at long-term followup after urethroplasty. A total of 38, 9-week-old white New Zealand male rabbits were randomized into active treatment and control groups. The active treatment group included hypospadias-like simulation and acute repair (sham, mobilization and advancement, tubularized incised posterior urethral plate). After 23 weeks all groups underwent biomechanical investigation using impedance planimetry. Cross-sectional area pressure measurements during bag distention were conducted at 3 different positions along the urethra, and biomechanical (tension-strain) relations were computed. The biomechanical parameters studied were urethral luminal dimension (cross-sectional area pressure relation) and its deformability to luminal pressure (tension-strain relation). The urethral cross-sectional area was significantly larger in the mobilization and advancement group compared to the tubularized incised plate group (p <0.001), shams and controls at the distal distention site (p <0.05), and other groups at the intermediate distention site (p <0.05). The strain-tension curves were not significantly different between the groups. All groups showed a nonlinear cross-sectional area pressure and circumferential wall tension-strain relationships in the 3 distention sites. The urethras exhibited a decreasing ability to be distended with increasing pressures, indicating self-protection against damage. At long-term followup no differences in tension-strain relations were found between groups, despite the fact that the mobilization and advancement group had enlarged urethras. Our hypospadias simulation animal model could be useful to test commonly used or new urethroplasty techniques and their functional (biomechanical) long-term results before clinical use.

Extraordinary muscular structure leads to urethral injury after vaginal delivery in animal study

The aim of this study is to explore causality of birth trauma after vaginal delivery and anatomical findings. A total of 28 virgin mice were studied. Treatment groups received vaginal distention. Specimens were collected and subjected to the following fluorescence stains: progenitor cell (c-kit), smooth muscle (SMA), fibroblast (vimentin), and skeleton muscle (Masson's trichrome). Confocal microscopy was used to screen all of the urogenital tissue to localize the stained cells. Fibroblasts were spread all over perivaginal and urethral surroundings. Progenitor cells appeared at urethral-vagina intersection and urethral circle. They were noticeable only within smooth muscle layer. Two extraordinary skeleton muscle bands appeared on the urethra bilaterally. Our study demonstrates existence of muscle bands at the bilateral urethra. They can limit the mobility of urethra during vaginal delivery and thereby cause urethra injury. Progenitor cells are located only in the smooth muscle of the urethral circle.

Straightening Ventral Curvature While Preserving the Urethral Plate in Proximal Hypospadias Repair

We report the efficacy of an expanded algorithm for penile straightening in proximal hypospadias surgery to preserve the urethral plate for urethroplasty. We also compared ventral corporotomy with grafting to multiple superficial ventral corporotomies without grafting for straightening greater than 30-degree ventral curvature. The need for urethral plate transection was compared in 2 groups comprising consecutive patients with proximal shaft to perineal hypospadias repair done by one of us (WS). The 47 patients in group 1 underwent surgery from 2000 to 2005 and had ventral curvature greater than 30 degrees after degloving, leading to urethral plate transection, while in 23 in group 2 from 2006 to 2008 mobilization of the corpus spongiosum/urethral plate and proximal urethra were also performed before urethral plate transection. Patients in group 1 with greater than 30-degree ventral curvature after urethral plate transection underwent ventral corporotomy with grafting (7) or multiple transverse corporotomies without grafting (4), while those in group 2 with greater than 30-degree ventral curvature after corpus spongiosum/urethral plate and urethral mobilization underwent multiple transverse corporotomies without grafting. Excluding 10 group 1 and 3 group 2 boys without ventral curvature after degloving the rate of urethral plate transection significantly decreased from 54% to 15% using the expanded algorithm (p = 0.005). At a mean followup of 11 months in those with corpus spongiosum/urethral plate and urethral mobilization there was no recognized recurrent ventral curvature. Seven patients with greater than 30-degree ventral curvature underwent ventral corporotomy with grafting, while 11 underwent multiple transverse corporotomies without grafting. At a mean followup of 27 and 19 months, respectively, no patient had recurrent ventral curvature. Mobilization of the corpus spongiosum/urethral plate and the urethra in proximal hypospadias cases with greater than 30-degree ventral curvature after penile degloving decreases the need for urethral plate transection. Ventral lengthening to correct corporeal disproportion can be achieved by corporotomy with grafting or by multiple transverse incisions without grafting.

Double-Cross Flap Protection: New Technique for Coverage of Neourethra in Hypospadias Repair

We analyzed a new urethra preserving approach, double-cross flap protection, during tubularized incised plate urethroplasty. We compared the results of 57 patients treated with this new procedure and 80 patients treated with 2 different techniques. We studied 137 patients with hypospadias between October 2002 and March 2008. Patients were divided into 3 groups. Group 1 consisted of 40 patients (mean age 50 months) undergoing tubularized incised plate urethroplasty. Group 2 included 40 patients (mean age 48 months) undergoing tubularized incised plate urethroplasty with dorsal subcutaneous flap. Group 3 consisted of 57 patients (mean age 39 months) undergoing tubularized incised plate urethroplasty with 2 de-epithelialized preputial flaps twisted ventrally and sutured individually over the neourethra. All patients were operated on by the same surgeons. Statistical analysis of postoperative complications was performed by ANOVA and chi-square test. In Group 1 fistula developed in 6 patients (15%) and was associated with stenosis of the neourethra in 4 (10%). In Group 2 fistula developed in 4 patients (10%). In Group 3 no fistula was observed, but mild stenosis of the neomeatus developed in 3 patients (5.3%), which was treated with dilation. Thus, the incidence of fistula in group 3 was significantly less (p = 0.015). Double-cross flap protection is safe and significantly reduces the incidence of postoperative fistula.

The importance of patient selection in the treatment of distal hypospadias using modified Koff procedure

We present our experience in the treatment of distal hypospadias using a modified Koff procedure, emphasizing the importance of patient selection for a good outcome. In 2003-2008, 90 patients, mean age 52.1 months, underwent surgical repair of distal hypospadias using urethral advancement according to Koff, modified with a Ψ incision on the tip of the glans. Meatal defect was glanular in six (8%), subglanular in 24 (26%) and coronal in 60 (66%) cases. Mild chordee was present in 19 patients (21%). Follow-up was 8-66 months. All patients were evaluated in terms of cosmetic results, and early and late postoperative complications. All patients showed excellent cosmetic results with urethral meatus on the tip. There was only one postoperative fistula due to extensive use of electrocautery during urethral mobilization that was surgically corrected 8 months after appearance. One patient had a postoperative meatal stenosis treated conservatively. No cases of residual chordee were detected. Successful use of the modified Koff procedure depends on careful selection of patients. Good candidates are those with distal or mid-shaft hypospadias, presenting with: (1) absence or low degree of ventral chordee; (2) distal plate of urethra well developed; (3) distance between meatus and tip of glans at most 10-12 mm; and (4) glanular morphology preserved.

Correction of penile torsion by mobilization of urethral plate and urethra

To assess the feasibility of correction of torsion by mobilization of the urethral plate with the corpus spongiosum and the proximal urethra. Of 27 cases of congenital penile torsion, 18 had hypospadias, seven were chordee without hypospadias, and two were isolated penile torsion. Age of patients varied from 2 to 26 years (mean 6 years, 8 months). Correction of torsion was performed: (1) penile skin de-gloving; (2) mobilization of the urethral plate with the corpus spongiosum up to the corona; (3) mobilization of the proximal urethra up to the perineum; and (4) mobilization of the hypoplastic urethra/urethral plate into the glans. Tubularized incised plate urethroplasty with spongioplasty was done in cases of hypospadias, as compared to spongioplasty alone in cases of chordee without hypospadias. Degree of torsion varied from 45 to 180 degrees (mean 68.70); 74% of the patients had left and 26% had right penile torsion. Correction of torsion was possible by penile de-gloving (4%), mobilization of urethral plate and spongiosum (26%), mobilization of proximal urethra (22%), and mobilization of urethral plate/hypoplastic urethra with spongiosum into glans (48%). Extended urethral mobilization corrected penile torsion in almost all cases. The technique is simple, safe, reproducible and effective for correction of both torsion and chordee.

Modified annular penile skin flap for repair of pan-anterior urethral stricture

To review our experience with a zigzag shape annular penile fasciocutaneous flap (modified McAninch flap) for reconstruction of pan-anterior urethral strictures. From 2003 to 2006, 30 male patients with pan-anterior urethral stricture were repaired by single-stage urethroplasty using a modification of the annular penile flap of McAninch for augmentation of a long anterior urethral stricture (zigzag annular penile fasciocutaneous flap). The procedure was total bulbopenile urethral mobilization, stricturotomy, and ventrally positioned zigzag annular penile island fasciocutaneous flap. Age of patients ranged from 20-60 years. Range of stricture length was 15-20 cm. All strictures were bulbopenile post inflammatory or post catheter with exclusion of BXO in all cases by clinical picture and pre-operative biopsy. Follow up period was 24 months. Urethral patency was documented clinically, urodynamically, by RUG, and by urethroscopy for 26 male patients for whom repair was performed by use of this technique. Re-stricture occurred in four patients, fistula in one patient, and post voiding dripping in two patients. A meticulously fashioned zigzag annular penile skin flap could be raised to bridge a urethral defect up to 20 cm long and has the advantage of one-stage repair. No additional grafts are needed. Cosmetic outcome included a straight penis in all cases.

Supracrural rerouting as a technique for resolution of posterior urethral disruption defects.

Selection of an acceptable method for the treatment of posterior urethral disruption defects would be highly desirable. We determined the efficacy and success rate of some techniques including supracrural rerouting for removing of these defects among our patients. Records of 200 consecutive men treated with anastomotic urethroplasty for traumatic posterior urethral strictures were reviewed at our teaching hospital. Prior treatment, surgical approach, and ancillary techniques required during reconstruction were evaluated. Success rate due to posterior urethral reconstruction was achieved in 78.0% of cases. Supracrural urethral rerouting was performed in 11 patients (5.5%), of whom 7 sustained recurrent stricture requiring intervention. The highest success rate of defect resolving was reported by urethral mobilization (92.4%). Supracrural rerouting is not an acceptable technique and can result in postoperative complications such as recurrent stricture in most of the patients with posterior urethral disruption defects.

Dorsolateral onlay urethroplasty for anterior urethral strictures by a unilateral urethral mobilization approach

Context:For management of long segment anterior urethral stricture, dorsal onlay urethroplasty is currently the most favored single-stage procedure. Conventional dorsal onlay urethroplasty requires circumferential mobilization of the urethra, which might cause ischemia of the urethra in addition to chordee.Aims:To determine the feasibility and short-term outcomes of applying a dorsolateral free graft to treat anterior urethral stricture by unilateral urethral mobilization through a perineal approach.Settings and Design:A prospective study from September 2005 to March 2008 in a tertiary care teaching hospital.Materials and Methods:Seventeen patients with long or multiple strictures of the anterior urethra were treated by a dorsolateral free buccal mucosa graft. The pendulous urethra was accessed by penile eversion through the perineal wound. The urethra was not separated from the corporal bodies on one side and was only mobilized from the midline on the ventral aspect to beyond the midline on the dorsal aspect. The urethra was opened in the dorsal midline over the stricture. The buccal mucosa graft was secured on the ventral tunica of the corporal bodies.Statistical Analysis Used:Mean and median.Results:After a follow-up of 12-30 months, one recurrence developed and 1 patient needed an internal urethrotomy.Conclusions:A unilateral urethral mobilization approach for dorsolateral free graft urethroplasty is feasible for panurethral strictures of any length with good short-term success.

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The age of presentation of congenital genital anomalies in developing countries is older than the age in developed countries because of ignorance, illiteracy, unavailability of medical care, and unaffordability. 1 Bhat A. Extended urethral mobilization in incised plate urethroplasty for severe hypospadias: variation in technique to improve chordee correction. J Urol. 2007; 178: 1031-1035 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar The technique differs not merely in the use of double breasting, but also because it includes perineal urethroplasty, pelvic floor repair, and genitoplasty in a single stage, is the least morbid, and uses urethral factors for continence. The functional length of the female urethra is 2.4 to 2.8 cm and covers the proximal two thirds of the urethra. To maintain continence, the urethral lumen must be completely sealed. Continence is not only a function of the bladder neck alone. Properties of the urethral wall undoubtedly play a significant role. Urethral wall tension develops within the outer layers of the urethra and is a product, not only of active characteristics of the smooth and striated muscle, but also of the passive characteristic of the elastic tissue and collagenous tissue. 2 Arsdalen K.V. Wein A.J. Physiology of micturition and continence. in: Krane R.J. Siroky M.B. Clinical Neurourolgy. 2nd ed. Little Brown, Boston1991: 25-82 Google Scholar In our procedure, the denuded area was 10 mm in the bladder neck and tapered lower down to 5 mm at the neomeatus. Urethral double breasting helps to keep the symmetry of the bladder neck and urethra, as well as in maintaining the lumen and pressure in the proximal urethra. Thus, it maintains the functional urethral length. Double breasting of the urethra also helps to keep the urethroplasty intact. Thus, double breasting of the bladder neck and urethra both help in achieving continence. We had the advantage of having slightly older patients, but the technique is feasible even in younger patients because the area of double breasting (10 mm) lies in the bladder neck and proximal urethra and then tapers distally. The puborectalis and bulbocavernous are approximated in the midline by partial detachment from the pubic rami, which helps in continence without osteotomy. Osteotomy will definitely help in the proper approximation of the pelvic floor muscles and continence. Pubic diastasis (measured 5.5 cm) is in an adult female, and is measured in plane X-ray; therefore, it is slightly more (approximately 10% magnification in X-ray) 3 Curry III, T.S. Dowdey J.E. Murry R.C. Geometry of radiographic image. in: Christen's Introduction to Physics of Diagnostic Radiology. 3rd ed. Lea & Febiger, Philadelphia1984: 152-160 Google Scholar than the real one. The results were that 2 of the patients became fully continent and another patient who had nocturnal incontinence responded to anticholinergics and became continent. Thus, 3 patients became continent after the single-stage procedure, and the fourth patient who had undergone the Young-Dees procedure earlier was partially incontinent. She became continent after double breasting. Thus, all patients achieved continence. We agree with the editorial comment that bladder neck elevation can be done without more mobilization, which will again help in continence, and we plan to add this maneuver to our procedure to enhance continence in the future. The bladder capacity and voided volumes varied from 150 to 250 mm in the younger patients and 250 to 400 mm in the adults, as shown in the ultrasound scan. The rarity of the condition and a lack of awareness among general practitioners and the referring doctors about the condition and the possible surgical treatment made it difficult to have a larger series. More publications and discussions on the subject will make family physicians more aware of the condition, which will help in having larger series. Hopefully, a combined study will be done at multiple centers to resolve the problems of female epispadias in the future. We thank the learned editor for the compliments about the figures and overview of the published data.

Urethral Mobilization and Advancement With Distal Triangular Urethral Plate Flap for Distal and Select Cases of Mid Shaft Hypospadias: Experience With 251 Cases

All urethral reconstruction for hypospadias involving use of local tissue, flaps or substitution has an inherent incidence of complications, including fistula, meatal stenosis and urethral restenosis with time, and recurrence of chordee. To avoid these complications, we developed a technique for urethral mobilization and advancement with distal triangular urethral plate flap to repair distal and select cases of mid shaft hypospadias with or without chordee. We present a description of the procedure and results based on a 10-year experience. A total of 251 boys 2 to 16 years old underwent repair of glanular (62 patients), subglanular (128), mid shaft (28) and recurrent (33) hypospadias. Ventral curvature was present in 201 patients. Followup ranged from 6 months to 10 years (mean 7.4 years). No patient had a urethrocutaneous fistula or meatal stenosis. There were 2 cases of recurrent curvature in mid shaft hypospadias, due to inappropriate case selection. One patient had a hematoma that resolved after emptying under general anesthesia. Cosmetic results were excellent. This procedure is one of the most appropriate and preferable operations in all distal and select cases of mid shaft hypospadias with or without chordee, due to the minimal complications and excellent cosmetic results.

New concept in urethral advancement for anterior hypospadias

Objective We report on our experience with urethral mobilization and advancement as a treatment for anterior hypospadias. Patients and methods From January 2004 to March 2007, 55 out of 160 children with anterior hypospadias were managed by urethral mobilization and advancement; 46 had a mean follow-up period of 25 months (range 6–38) and are the subjects of this report. Their ages ranged from 2.5 to 12 years with mean age 4.5 years. The dissection began proximally in the avascular plane above the tunica albuginea covering each corpus cavernosum medially until reaching beneath the corpus spongiosum up to the hypospadiac meatus. Tension-free urethral anastomosis was achieved. The ventral glans was incised deeply at the interballanitic groove. The two glans wings and ventral glanular mucosal flaps were mobilized laterally. Interrupted sutures were placed through the tunica albuginea of corpus spongiosum to the corpora cavernosa. The mobilized urethra was wrapped by dartos fascia. The urethral stent was removed 24 h postoperatively. Results Three-fold urethral mobilization was sufficient to achieve tension-free urethral anastomosis. A slit-like orthotopic meatus, with conically shaped glans and straight penis, was achieved in all but one subcoronal case with mid-glans meatal retraction during our early experience. Postoperative urethral fistula was not recorded in any patient. Satisfactory urinary stream for parents and child was reported in 42/46. Peak flow rate was within normal range (upper 50% percentile) in all. Conclusion Urethral mobilization should begin proximally. Three-fold penile urethral mobilization, deep interballanitic incision and wide dissection of the glans can provide a slit-like orthotopic meatus with conical glans and straight penis in cases of anterior hypospadias without hypoplastic distal urethra and persistent ventral curvature after penile skin degloving, regardless of the presence of unhealthy, narrow urethral plate, shallow glanular groove, and flat or small glans.

Evaluation of the results of eccentric circummeatal-based flap with combined limited urethral mobilization technique for distal hypospadias repair

Objective To evaluate the outcome of patients with distal hypospadias who are operated using the eccentric circummeatal-based flap (ECBF) with combined limited urethral mobilization (LUM) technique. Patients and methods We retrospectively reviewed the medical records of all patients who underwent distal hypospadias repair at our institution between January 2000 and December 2005. Seventy-one patients with distal hypospadias were operated. Eighteen cases were operated with glanular approximation and 11 cases using the Snodgrass procedure. Forty-two cases of distal hypospadias without a thin distal urethra were operated using an eccentric circummeatal-based flap with combined limited urethral mobilization. We reviewed these 42 patients according to age at surgery, position of meatus, presence of ventral curvature or glanular tilt, previous operations, duration of catheterization and hospitalization, and early and late postoperative complications. Results The mean age at operation was 5.9 ± 3.1 years. The position of the meatus was coronal in 29 patients (69%), glanular in seven (16.7%) and subcoronal in six (14.3%). Two patients had ventral curvature. Five patients had undergone previous unsuccessful hypospadias repair and five had undergone circumcision. The average length of catheterization was 4.64 ± 1.07 days. All patients were discharged after stent removal. At follow up of 1–31 months (median 6 months, 22 patients over 6 months), three patients had a slightly glanular urethral meatus and six patients had a decrease in calibration during urination which responded to meatal dilatation. No fistula had occurred. All patients achieved a normally situated vertical slit-like glanular meatus. Conclusion This technique is simple with satisfying cosmetic results, and can also be applied to patients who have undergone previous failed operations. The absence of fistula formation and short duration of hospital stay are additional advantages.

Extended Urethral Mobilization in Incised Plate Urethroplasty for Severe Hypospadias: A Variation in Technique to Improve Chordee Correction

Extended Urethral Mobilization in Incised Plate Urethroplasty for Severe Hypospadias: A Variation in Technique to Improve Chordee Correction

A new algorithm for management of chordee without hypospadias based on mobilization of urethra

Objective To assess the feasibility of chordee correction by mobilization of urethra with corpus spongiosum, and define the guidelines for management of chordee without hypospadias. Patients and methods We reviewed 25 cases of chordee without hypospadias, managed in 1992–2005. Age of patients ranged from 3 to 28 years (mean 14.4 years). Chordee correction was performed on a case-by-case basis by skin de-gloving, mobilization of divergent corpus spongiosum, mobilization of hypoplastic urethra, mobilization of proximal urethra up to bulbar urethra, dorsal plication and division/resection of hypoplastic urethra with main emphasis on mobilization of urethra, and confirmed by Gittes test. Results Chordee correction was possible by mobilization of urethra after penile degloving in 76% of cases and dorsal plication after urethral mobilization in 8%. Only 16% required division/resection of hypoplastic urethra. None of them had residual chordee in follow-up period of 6 months–3 years (mean of 26 months). After fistula repair and internal urethrotomy in one patient each, a second surgery had 100% success. Conclusions We propose an algorithm based on mobilization of urethra that defines the etiology and guidelines for the management of chordee without hypospadias.

Extended Urethral Mobilization in Incised Plate Urethroplasty for Severe Hypospadias: A Variation in Technique to Improve Chordee Correction

The feasibility of tubularized incised plate urethroplasty in proximal hypospadias with severe chordee was studied after correction of chordee by extended urethral mobilization. Boys with severe hypospadias who underwent tubularized incised plate urethroplasty were included. A total of 34 patients (28 with proximal penile/penoscrotal hypospadias and 6 with scrotal hypospadias) 18 months to 13 years old (mean 5 years) with severe hypospadias underwent tubularized incised plate urethroplasty between January 1999 and March 2006. A Gittes test was performed to assess the chordee after penile degloving and preservation of the urethral plate. Subsequently, the urethral plate with divergent corpus spongiosum and proximal healthy urethra were mobilized up to the bulbar urethra. Glanular chordee was corrected by mobilizing the urethral plate into the glans. The urethral plate was tubularized with or without incision and spongioplasty to complete the urethroplasty. Chordee correction was possible by mobilization of the urethral plate with corpus spongiosum from the meatus to the glans and the proximal urethra up to the bulbar region in 88% of the cases. Mean followup was 23 months (range 6 months to 3 years). Overall complication rate was 12% (fistula in 3 patients, meatal stenosis in 1). Two patients (6%) required dorsal plication, and in 2 (6%) the urethral plate had to be divided to correct the chordee. No patient had residual chordee during followup. The technique of chordee correction by mobilization of the urethral plate and proximal urethra with preservation of the urethral plate is simple and effective, and enlarges the scope of tubularized incised plate urethroplasty in severe hypospadias.

Simplified Reconstruction of Posterior Urethral Disruption Defects: Limited Role of Supracrural Rerouting

We present our combined experience with a simplified posterior urethroplasty technique to determine the necessity and usefulness of ancillary reconstructive maneuvers. We reviewed the records of 135 men and 7 boys who underwent reconstruction of traumatic posterior urethral defects with greater than 1 year of followup from 5 tertiary teaching hospitals. Prior treatments, surgical approach and ancillary techniques required during reconstruction were compiled. Direct anastomosis following scar excision and urethral mobilization alone was performed in 95 of the 142 males (67%). Formal corporal splitting was performed in 24 patients (17%) and inferior pubectomy in was done in 14 (10%). Supracrural urethral rerouting was performed in only 4 patients (3%), of whom 3 (75%) experienced recurrent stenosis. Abdominoperineal reconstruction, which was reserved mainly for salvage and pediatric cases, was required to reconstruct complex defects in 5 of the 142 cases (4%) and it was successful in 4 (80%). Early urethral realignment was associated with successful subsequent reconstruction in all patients in whom this maneuver was achieved (17 of 17 or 100%). This maneuver tended to be straightforward. Overall successful posterior urethral reconstruction was achieved in 130 of 142 cases (92%). Eight failures were successfully salvaged by internal urethrotomy (3) or repeat urethroplasty (5). Ancillary maneuvers such as corporal splitting or inferior pubectomy are seldom required for successful posterior urethral reconstruction. Urethral rerouting appears to be inferior to the abdominoperineal approach as a salvage maneuver for complex cases. Primary realignment appears to promote more simplified and successful surgical repair.