Urethral pull-up operation for distal and mid-penile hypospadias: a new safe method

Introduction

There are many operative techniques described for hypospadias but very few of them can be considered as the ideal operation option. Complications are fairly frequent, up to 50%. ¹ An ideal surgery should have few complications, especially fistula and normal urethra anatomy. Less operating time would be preferable. The modified technique that we describe comes close to achieving these objectives.

Material and methods

The data of patients operated on from October 2015 at Jawale Institute of Pediatric Surgery at Jalgaon, India who had a follow-up of one year on average were reviewed. Their ages were in the range of 11 months to 17 years. Coronal hypospadias was found in 23 patients (45%), sub-coronal hypospadias in 26 (51%) and mid-penile hypospadias in 2 (4%). Forty out of 51 patients had chordee (78.5%). De-gloving of the penis was sufficient to correct the chordee in three patients while urethral plate incision was necessary in the remaining 37 patients. The new meatal location was coronal in three patients (6%), sub-coronal in 23 (45%) and mid-penile in 25 (49%).

The technique used was as follows. With catheterisation and a tourniquet, the penis was de-gloved and chordee correction was carried out if necessary. The urethral plate was incised near the meatus to let it drop down (Figure 1). The distance between the regressed urethral meatus and the tip of the glans penis where the neo-meatus will be located is measured in centimetres with a stainless-steel ruler. The author describes the ‘rule of two’, where the urethra is dissected proximally twice the distance between the proposed neo-meatus and the actual meatus (Figure 2). The urethra, along with the corpus spongiosum, is dissected off the Buck’s fascia corpus cavernosum (Figure 3). The glans wings are raised on both sides and the tourniquet is released with good bleeding suggesting adequate vascularity. The distal 5 mm of the dissected urethral tube is excised to get healthy urethral tube for implanting at the site of the neo-meatus (Figure 4). The urethral tubes are anchored to the glans wings and to the Buck’s fascia at the levels of the corona and mid-penis (Figure 5). The skin could be either rotated or closed using Byar’s method. ² OPEN IN VIEWER

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Figure 2.

The dissected urethra that could be stretched well beyond the glans penis.

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Figure 3.

(a) The urethra before stretching. (b) Displaying the elasticity of the urethra.

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Figure 4.

Cutting off the less vascular portion.

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Figure 5.

The final result after fixing the stretched urethra.

Intravenous amino acid solution 10% was given in dosages of 10 mL/kg over 4 h daily for three days Essential amino acids are lacking in the diet of rural Indian children. The correlation between amino-acid infusions and wound healing is well documented; however, its use in hypospadias surgery is documented for the first time in this case series. Further studies are recommended to assess the overall outcome

Results

Only one patient (2%) developed meatal regression. Two patients (4%) had infection and wound dehiscence at the sub-coronal level ventrally. The wound healed on conservative management after two weeks without any other complication. Two patients developed subcutaneous haematoma (4%) that was drained. Both patients later had successful outcome. None developed urethral fistula. No patient required urethral dilatation under local or general anaesthesia. No patient had a residual chordee or meatal stenosis. Urinary flow rate (UFR) was done manually with stopwatch method at six weeks postoperatively. All patients had a urinary flow rate within the normal range. The average UFR was 10.62 mL/s with the highest of 15 mL/s and lowest of 8 mL/s. The cosmetic appearance was evaluated at the end of six weeks postoperatively on a scale of excellent, good, average and poor. Forty-three patients (84%) were in the excellent category and the remaining eight patients (16%) in the good category with none in the average and poor categories.

Discussion

The results of tabularised incised plate urethroplasty (TIP; also known as the Warren Snodgrass repair) had a mean meatal stenosis rate of 2.1% (range = 0–17%). ¹ In another review of 16 studies, ³ the mean meatal stenosis rate was 3.6% (range = 0–6%). ⁴ The results of Duckett’s transverse island urethroplasty and on lay flap operations^3,5 are as follows: necrosis and sloughing of the neo-urethra occurred in five patients (7%); urethra cutaneous fistula in 17 patients (23%); strictures in seven patients (9%); and diverticula in three patients (4%). Mathew’s flip-flap operation ⁶ had urethra cutaneous fistula due to wound dehiscence (7.7%), and a redo operation rate of 3.3%

The corpus spongiosum and urethra are supplied by a pair of bulbourethral arteries, one on either side, which are the branches of the internal pudendal arteries. ⁷ Hence the urethra with corpus spongiosum can be safely mobilised to the level of the penoscrotal junction without fear of de-vascularisation.

Urethral mobilisation and advancement surgery have been described elsewhere. ⁸ However, the problem was meatal regression. The modifications that were made to give better results are as follows:

Dissection only up to twice the distance between the original and new meatus;

The other advantages are: a shorter operating time; single stage correction of chordee is possible; the mucosal integrity of the urethra is not breached; and there is less meatal regression.

The technique is ideal for distal hypospadias. However, with mid-penile hypospadias after the dissection, the orifice shifts to the penoscrotal junction. The number of interventions done thus far are insufficient currently to recommend this procedure for mid-penile hypospadias. However, it could be said that the urethra could be stretched easily (Figure 3b) as it has an intramural blood supply (like the ureter) and a normal urethra can stretch up to fivefold in length during an erection.