Mobilization Of Urethral Plate Research Articles

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.

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

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.

Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period

The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled. To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias. Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later. A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR. Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes.

Incised plate urethroplasty in perineal and perineo-scrotal hypospadias

ObjectiveThe ideal replacement of the urethra is the urethra itself. However, when the urethra is not available, flaps or tubes are used as substitutes in hypospadias repair. The urethral plate, when preserved, is an excellent tool for tubularization and urethral reconstruction. Tubularized incise plate (TIP) repair has become increasingly popular for the treatment of proximal hypospadias, with encouraging results. The objective of this study was to assess the feasibility and results of TIP in perineal and perineo-scrotal hypospadias. Subjects and methodsOut of a total of 262 hypospadias cases treated at our clinic between January 2006 and June 2010, 35 patients had perineal and perineo-scrotal hypospadias. Of these, 21 cases with a narrow and/or poorly developed urethral plate and residual curvature after penile degloving and urethral mobilization underwent hypospadias repair using proximal TIP combined with a distal Duckett tube made from the inner prepuce after transection of the urethral plate at the corona. The present study was conducted on the remaining 14 cases treated with TIP alone. We retrospectively reviewed their case sheets, operative photographs and videos. Chordee was corrected by penile degloving and mobilization of the urethral plate with the corpus spongiosum, followed by proximal urethral mobilization with or without single-stitch dorsal plication. After incision of the urethral plate and tubularization, the neourethra was covered with a dorsal dartos/tunica flap. Two glanular wings were raised for glanuloplasty. Scrotoplasty was performed to cover the proximal urethra. ResultsThe patients’ age ranged from 1 to 23 (mean 13) years. Of the 14 cases studied, 4 had perineo-scrotal and 10 perineal hypospadias. Correction of the curvature was possible by penile degloving and urethral plate mobilization in 12 patients, while two required single-stitch dorsal plication. The length of the urethral plate varied from 5 to 16 (average 9)cm. The neourethra was covered with a dorsal dartos flap in nine and with a tunica vaginalis flap in six cases. None of the patients had residual curvature or stricture. Two patients developed a fistula which required re-do surgery. ConclusionsTubularized incised plate urethroplasty is an effective method for the repair of perineal and perineo-scrotal hypospadias with an acceptable complication rate.

Double breasting of bladder neck and posterior urethra for continence in isolated peno-pubic epispadias.

The objectives of surgical repair of epispadias include the achievement of urinary continence, cosmetically acceptable genitalia with correction of curvature and normal genital function. To achieve all the aforementioned objectives, patients usually undergo two- or multiple-stage surgeries. Traditionally, the patients undergo epispadias repair in the first stage through modified Cantwell-Ransley or Mitchell-Bagli procedure. Subsequently, in the second stage, bladder neck repair is performed to achieve continence, the most common procedure being modified Young-Dees-Leadbetter. There is no reported single-stage technique of epispadias repair achieving both cosmesis and continence in isolated incontinent epispadias. The objectives of the study were to assess continence and cosmesis with partial penile disassemble and double breasting of bladder neck and posterior urethra in isolated peno-pubic epispadias. A retrospective analysis of surgical outcome of seven cases of primary isolated incontinent peno-pubic epispadias repair from July 2008 to July 2012 was carried out. Patients' age varied from 10 months to 16 years. Penile de-gloving is done with mobilization of urethral plate from ventrum to dorsum, distally till mid-glans and proximally up to pubic symphysis with preservation of blood supply at both ends. Partial mobilization of corporal bodies from its attachment and division of peno-pubic ligament are done to lengthen the penis. A mucosal strip of 5-7 mm is excised to denude the mucosa for double breasting. Tubularization of urethral plate with double breasting from the region of bladder neck to posterior urethra is done to increase the outlet resistance and then tubularization of distal urethral plate. Approximation of mobilized pelvic floor muscles is done to complete sphincteroplasty. Spongioplasty along the entire length and corporoplasty with medial rotation of corporeal bodies is done. Glanuloplasty with meatoplasty is done to bring the meatus ventrally and then skin cover to penis is done with rotation of ventral flaps or z plasty. Preoperatively, three patients (42.8%) had moderate and four (58.2%) had severe chordee. Three (42.8%) of the seven patients had mild torque toward right. Six patients became fully continent and had excellent cosmesis postoperatively, while one was partially continent with a dry interval of 2 h and required anticholinergics. None of the patients developed fistula, stricture, wound dehiscence or necrosis in a follow-up period of 1-5 years; however, one patient had mild residual chordee but did not require any additional surgery. Double breasting of bladder neck and posterior urethra with sphincteroplasty and partial penile disassembly produces a reliable tubularized neourethra with complete chordee correction with emphasis on achievement of continence and near-normal-appearing penile morphology through a single-stage surgery. Mobilization of urethral plate and proximal urethra up to bladder neck helps correction of chordee as well as torsion. Partial penile disassembly keeping the urethra attached to glans maintains the dual blood supply, thus preventing stricture and fistula. This small series is a preliminary study, and more studies at different centers may authenticate it by reproducing the results.

Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: A prospective study

Introduction:Additional cover after neourethra formation to decrease the fistula rate, has been described using the dartos, tunica, denuded skin and corpus spongiosum. The use of corpus spongiosum alone to cover the neourethra is infrequent. The objective of this study was to evaluate the efficacy of spongioplasty alone as an intervening layer in the prevention of urethral fistula following tubularized incised plate urethroplasty (TIPU).Materials and Methods:A prospective study was performed including 113 primary hypospadias cases undergoing TIPU with spongioplasty from June 2010 to March 2012. Correction of chordee was carried out by penile degloving alone in 5, mobilization of urethral plate with spongiosum in 22 and combination of both in 45 cases. Intra-operatively, spongiosum was taken to be poorly developed if it was thin and fibrous, moderate if good spongiosal tissue with good vascularization and well-developed if healthy robust spongiosum, which became bulkier than native spongiosum after tubularisation. Spongioplasty was done in a single layer after mobilization of spongiosum, starting just proximal to the native meatus and into the glans distally.Results:The mean age of the patients was 11.53 years. The type of hypospadias was distal, mid and proximal in 81, 12 and 20 cases respectively. Spongiosum was poorly developed in 13, moderate in 53 and well-developed in 47 cases. The mean hospital stay was 8-10 days and follow-up ranged from 6 months to 2 years. Urethral fistula was seen in six patients (11.3%) with moderate spongiosum (distal 1, mid 1 and proximal 4), and three (23.03%) with poorly developed spongiosum (one each in distal, mid and proximal) with an overall 7.96% fistula rate. None of the patients with well-developed spongiosum developed a fistula. Poorer spongiosum correlated with a greater number of complications (P = 0.011). Five out of thirteen cases with poor spongiosum (38.46%) had proximal hypospadias, i.e. more proximal was the hypospadias, poorer was the development of the spongiosum (P = 0.05). Meatal stenosis was seen in two patients (1.76%) with proximal hypospadias, one with moderate and the other with poorly developed spongiosum. More proximal was the hypospadias, greater were the number of complications (P = 0.0019).Conclusion:TIPU with spongioplasty reconstructs a near normal urethra with low complications. Better developed and thicker spongiosum results in lower incidence of fistula and meatal stenosis. More proximal hypospadias is associated with poorer spongiosum. We recommend spongioplasty to be incorporated as an essential step in all patients undergoing tubularized incised-plate repair for hypospadias.

Commentary to ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’

Mobilization of the urethral plate (UP) and native urethra is one of the manoeuvres that can be performed in order to straighten the penis while preserving UP continuity in severe hypospadias repair [1]. The authors of the present paper advocated it in conjunction with tubularized incised plate (TIP) urethroplasty in the recent past (see Ref. [2] in text). In the present series, they confirm that this combination is effective for penile straightening, as it allowed avoiding UP transection in some 25% of their cases with a 5% rate of recurrent curvature after a mean follow-up of 21 months. However, they also suggest that this combination is possibly hazardous and might predispose to stricture formation in the reconstructed urethra. The development of urethral strictures after TIP urethroplasty in patients undergoing UP/urethral mobilization is consistent with the concern that the latter might cause partial de-vascularization and ischemia in a UP that furthermore requires to be halved into two strips for tubularization. The 17% stricture rate is therefore a warning, but perhaps deserves some qualification. To begin with, this is a single-surgeon experience and, as the same authors acknowledge, other series of similar procedures did not include any such complication (see Refs. [3,4] in text). This cannot be attributed to the follow-up investigations performed, as the strictures reported in the present study were all symptomatic and none was diagnosed after a particular investigation in an otherwise asymptomatic patient. Moreover, it is worth noting that the stricture was very short, 1-mm to 3-mm long, in 3 of the 5 patients with this complication, and was associated with recurrent curvature due to contracture of the UP in only 1 case. In contrast, contracture of the UP was reported to be the cause of recurrent curvature in 2 of the 3 patients experiencing this complication in the group treated without mobilization. Yet, it is quite surprising that none of the patients undergoing mobilization developed any fistulas, as one would expect a higher rate of healing complications in the presence of ischemic tissues. According to the authors, technical refinements could account for the lower fistula rate in patients undergoing mobilization. This, however, points out that this study compares two series that were not contemporary, which is always a source of variability, and makes one wonder whether results in the patients undergoing TIP repair after UP/ urethral mobilization might improve as well with increasing experience. The latter might also include improvement in patient selection. Consistently, the authors suggest that TIP urethroplasty might still be an option in patients requiring mobilization of the UP, without mobilization of the native urethra or additional ventral lengthening procedures. Other possible criteria could be a UP wide enough after mobilization to make tubularization around a 10 Fr catheter possible (a 6 Fr was used in the present series), or a UP supported by thick spongiosum, especially if no injury to the latter and subsequent bleeding occurs during mobilization. Criteria for patient selection cannot be determined based on the data provided, but might account for the different results among series and deserve further enquiry. Finally, even fully accepting the authors’ conclusions, how can we incorporate them in our practice? Should we fully abandon UP mobilization, avoid combining it with a TIP repair, inlay graft the incised plate before tubularization, or always combine this maneuver with a flap urethroplasty?

Surgical Management of Primary Severe Hypospadias in Children: Systematic 20-Year Review

We systematically reviewed the literature published during the last 20 years on the treatment of primary proximal hypospadias associated with severe ventral curvature. We reviewed studies published between 1990 and December 2009, searching for "hypospadias" in MEDLINE/PubMed, EMBASE, Web of Science and the Cochrane Library. The search yielded 69 pertinent studies. These studies were generally of low quality (69.5% surgical series). Based on the literature, curvature should be addressed stepwise starting with ventral dissection that extends underneath the urethral plate (urethral plate mobilization). Contrary to former practice, urethral plate division seems to have more of a role if significant curvature persists. Dorsal plication seems sufficient to correct only minor degrees of curvature, while a minority of cases require ventral lengthening. No urethroplasty techniques appear to be definitively superior. After urethral plate division a staged urethroplasty has lower complication rates but a second operation is required, which might otherwise be avoided in approximately 70% of cases. The present systematic review shows the weak evidence backing current management of primary severe hypospadias. We even lack a clear-cut definition of severe hypospadias and associated curvature. Hence, while we developed general recommendations for treatment based on our review of available evidence, we emphasize the need to establish shared criteria for accurate preoperative or introperative patient stratification, and to define objective outcome measures and followup intervals for data reporting to make comparison of surgical approaches reliable.

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-Mathieu's technique: a variation of the classic procedure for hypospadias surgical repair.

Distal penile curvature associated with anterior hypospadias can be corrected by urethral plate mobilization. The authors present 11 cases, in which this procedure was performed modifying the classic Mathieu's technique in the surgical treatment of coronal and distal shaft hypospadias associated with chordee. Performing this modified-Mathieu's technique, excellent results, both functional and cosmetic, are obtained without any complication.