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ORIGINAL ARTICLE |
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| Year : 2006 | Volume
: 22
| Issue : 4 | Page : 326-328 |
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Preservation of urethra devoid of corpus spongiosum in patients undergoing urethroplasty
YK Sarin, V Manchanda
Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi - 110 002, India
Correspondence Address:
Y K Sarin
Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi - 110 002
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-1591.29115
 Abstract | | |
Introduction: Hypospadias repair is done in many centers using tubularized incised plate urethroplasty technique. A varying length of distal urethra in almost one-fourth of patients is devoid of corpus spongiosum. Traditionally, this segment is incised proximally till 'healthy' urethra is reached. It makes hypospadias more proximal and thus increases chances of failure. Materials and Methods: We tried to preserve this thin so-called "hypoplastic" urethra in nine patients. The meatus was distal penile in four, mid-penile in four and proximal penile in one patient. Another patient with chordee without hypospadias with hypoplastic urethra underwent chordee correction without sacrificing any length of urethra. Results: No residual chordee was seen in any of the patients. Only two patients (22%) developed subcoronal fistulas needing secondary repair. No patient had urethral diverticulum or stricture. Conclusions: We thus recommend preservation of hypoplastic urethra whenever possible.
Keywords: Chordee, corpus spongiosum, hypoplastic urethra, hypospadias, tubularized incised plate urethroplasty
How to cite this article:
Sarin Y K, Manchanda V. Preservation of urethra devoid of corpus spongiosum in patients undergoing urethroplasty. Indian J Urol 2006;22:326-8 |
Hypospadias is a common congenital anomaly of the genital tract with a reported incidence of about four per 1000 live births. Various methods have been described in the literature for hypospadias repair. The most commonly used method of tubularized incised plate (TIP) urethroplasty was first suggested by Snodgrass in 1994[1] for distal hypospadias. Its use was extended to more proximal hypospadias in the following years.[2] We, at our center, employ this technique for most of the primary hypospadias repair.
Occasionally, the distal most segment of the urethra is found devoid of corpus spongiosum cover, sometimes called 'hypoplastic urethra'. Traditionally, this hypoplastic urethra is spatulated till the 'healthy' urethra with spongiosum cover is obtained and the urethroplasty is commenced. This step creates a more proximal hypospadias, thus increasing the chances of postoperative fistula. We tried to preserve this hypoplastic urethra in order to achieve better outcome.
| Materials and Methods | |  |
In the year 2005, 44 patients underwent primary repair for their hypospadias in our department. About one-fifth of these patients (n=9) had at least 1cm of the distal most urethra devoid of corpus spongiosum [Figure - 1][Figure - 2]. These nine children varied from eight months to six years in age (mean 3.2 years) and the length of hypoplastic urethra ranged from 1 cm to 2.5 cm (mean 1.92 cm). The meatus was distal penile in four, mid-penile in four and proximal penile in one patient. The chordee in these patients was mild to moderate and the straightening of the penis was achieved in all by degloving only (none of these patients required Nesbitt's plication). Another patient, operated for chordee without hypospadias and hypoplastic urethra 2.5 cm long was included in the study.
The urethra devoid of spongiosum was preserved in nine patients with hypospadias with hypoplastic urethra. All the patients underwent TIP urethroplasty by interrupted 6-0 polydiaxonone sutures [Figure - 3]. The repair was reinforced by a de-epithelialized rotation prepucial flap[3] [Figure - 4]. In one patient, the urethral tube was additionally supported by approximating the flayed spongiosum (Y-to-I wrap) prior to this step.[4] The prepucial skin was rearranged as Byar's flaps to give the penis a circumcised look after the procedure. All the patients received the standard posturethroplasty care in the postoperative ward. The dressing was opened on the fifth postoperative day and the catheter was removed on the seventh to tenth day. The results were evaluated for the occurrence of urethro-cutaneous fistula, stricture formation, diverticula formation and residual chordee.
| Results | | |
The patients were followed up for a period of three months to six months (mean 4.2 months). No residual chordee was seen in any of the patients. Among the patients where the urethra devoid of corpus spongiosum was preserved, only two patients (20.5%) developed subcoronal fistulae needing secondary repair. No patient had urethral diverticulum or stricture.
| Discussion | | |
Snodgrass urethroplasty was first published in 1994.[1] The technique has been used all over the globe and surgeons have obtained good results. The success rate for distal hypospadias has been reported to be 90 to 100%,[1],[5],[6] and that for proximal hypospadias 88 to 89%.[2],[5] Our experience has been similar.
Significantly thin distal urethra devoid of spongiosum has been noticed in about one-fourth of patients undergoing urethroplasty in previous studies.[5] In our study group, we found such urethra in 22% of the subjects undergoing surgery on urethra. It is well established that the success of hypospadias repair, regardless of the type of repair used, is associated with the position of the original meatus in addition to the expertise of the surgeon, the nature of the urethral plate and the dimensions of the urethral plate. The more proximal the meatus, the higher is the rate of postoperative fistulas noted previously.[5] Incising the distal hypoplastic urethra will lead to longer suture line and a higher incidence of postoperative fistula formation. We recommend preserving the hypoplastic urethra and incorporating it in the repair. We also advocate the use of de-epithelialized prepucial dartos flap[3],[7] to reduce the risk of urethro-cutaneous fistula. We also recommend a Y-to-I spongiosum wrap to support the hypoplastic urethra (decreases the chances of urethral diverticulum) and the urethral tube (decreases the fistula rate).[4]
| Conclusion | | |
The urethra devoid of corpus spongiosum is found in a significant number of patients undergoing urethroplasty. Such urethra could be preserved and included in the urethral reconstitution. The hypoplastic urethra and the reconstituted urethral tube should be covered by de-epithelialized prepucial dartos flap and with Y-to-I spongiosum wrap, if possible.
| References | | |
| 1. | Snodgrass W. Tubularized incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.  [PUBMED] |
| 2. | Chen SC, Yang SS, Hsieh CH, Chen YT. Tubularized incised plate urethroplasty for proximal hypospadias. BJU Int 2000;86:1050-3. [PUBMED] [FULLTEXT] |
| 3. | Retik AB, Borer JG. Primary and reoperative hypospadias repair with the Snodgrass technique. World J Urol 1998;16:186-91. [PUBMED] [FULLTEXT] |
| 4. | Yerkes EB, Adams MC, Miller DA, Pope JC 4th, Rink RC, Brock JW 3rd. Y-to-I wrap: Use of distal spongiosum for hypospadias repair. J Urol 2000;163:1536-9. [PUBMED] |
| 5. | Yang SS, Chen YT, Hsieh CH, Chen SC. Preservation of the thin distal urethra in hypospadias repair. J Urol 2000;164:151-3. [PUBMED] |
| 6. | Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair: Results of a multicenter experience. J Urol 1996;156:839-41. [PUBMED] |
| 7. | Djordjevic ML, Perovic SV, Vukadinovic VM. Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair. BJU Int 2005;95:1303-9. [PUBMED] [FULLTEXT] |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
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Preservation of urethra devoid of corpus spongiosum in patients undergoing urethroplasty |
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