Distal hypospadias

• 28 Jan 2021 10:43:10 AM
• |Pediatic Urology

How would people manage this child with distal hypospadias? the UP was wide and there was a deep glans groove, but chordee after degloving was about 50 degrees. 

Comments(11)

• 

  aditya gupta

  28 Jan 2021 12:03:26 PM

  dorsal plication would further lead to penile shortening. also with increase in age recurrence of curvature chances are there.

  corporal lengthening with corporotomies and grafting in adults have erectile dysfunction chances but in children this incidence is very less..

  so in this case Staged Tubularized Autograft Repair would be my choice.

• 

  Dr. Anil Takvani

  28 Jan 2021 06:21:35 PM

  Dear Dr.Luis,

  Thank you very much for sharing an excellent case. Beautiful images.

  You have raised age old debate of correcting severe chordee(>30 degree) after de-gloving by dorsal plication and mobilization of urethra or by transecting the plate and doing ventral corporotomies just deep to the transverse layer of tunica albugenia of the corpora cavernosa.

  In the case posted by you I would have preferred what exactly you have done. But in my case it would have been less aesthetic in comparison  to your dissection!

  In few cases of distal most hypospadias I try to do advancement of uretrhal tube after adequate mobilization till penoscrotal junction. Once the uretrhal plate is lift from the tunica albugenia of the corpora cavenosa, small transverse cuts deep to the transverse layer done sparing circular layer of the tunica albugenia for correction of chordee.

  Urethral mobilization along with the corpus spongiosum and cuts on ventral surface of the tunica albugenia corrects the chordee in few of the cases. Mobilized urethral plate is than brought to tip in glans and rest of the ganuloplasty and skin covering done.

  I am sure Dr. Amilal Bhat might come out with different methodology to treat your case...

• 

  Chandra Singh J

  28 Jan 2021 09:06:12 PM

  I would agree with staged Braka's repair, dividing the plate and graft ventrally. If the chordee persists, ventral corporotomies will be required. This is better than addressing persistent chordee at a later stage with well reconstructed tube.

• 

  Mallikarjuna Reddy N

  28 Jan 2021 09:16:38 PM

  Hi all

  I was trained to correct chord by incising or excising the atretic urethral plate. I later realised that the blood supply to it is different from the skin. ventral chordee release will always keep the length of penis. I would do the same in this case. The preoperative assessment is the most important here

• 

  Amilal Bhat

  29 Jan 2021 08:25:27 AM

  I would like to go step by step aproch for chordee correction penile de-gloving mobilization of urethral plate and proximal urethra and mobilization of urethral plate into glans.in this case possibly chordee will be corrected. Dorsal inlay and TIPU / onlay flap urethroplasty. I prefer going one stage.In spite of all efforts in two do have complications that converts the produce three or more means money and trauma to the child and parents. Another important issue is preservation and utilisation of spongiosum. Urethra is not a simple tube and we should also aim not to reconstruct a tube but try to reconstruct a urethra . Tubularization with spongioplasty reconstruct near normal urethra. This should be tried most of the distal Hypospadias it is possible to utilise the spongiosum.

  Reason for going grafting and two stage ,how do you feel comfortable and confident with particular technique in your practice.

• 

  Dr Sanjay Balwant Kulkarni

  29 Jan 2021 11:19:59 AM

  Hypospadias repair still remains a unresolved mystery.

  The perfect repair is yet to be invented and there  is scope of improvement.

  Amongst us, I respect Dr Amilal Bhat's views as he has devoted his life for one cause.

  Importance should be meticulously given to correction of chordee.

  I would propose my thoughts:

  1.Preferabaly a single stage urethroplasty. 

  2.One can perform dorsal inlay and plications on the opposite side. But if you are going to transect the urethral plate and perform multiple ventral corporotomies then do not perform mobilisation of neurovascular bundle in the same sitting as it can lead to glans devascularisation.

  3.Staged buccal graft urethroplasty has a chance  of graft contracture. In adults ,we see this in over 39% across the high volume centres.

  If you choose option 3, and in order to prevent graft contraction, vacuum physiotherapy is recommended between the two stages of surgery. Vacuum is also very useful when ventral corporotomies are performed, like you did in your in this case. Indeed, Vacuum increase the blood supply to the distal part of the penis and reduces the fibrosis process after corporotomies, preventing curvature recurrence and ED, but also as I said it avoids buccal graft shrinkage. If any curvature is residual at the time of second stage (6months later), then it is possible to go for dorsal plications. 

  The case you presented has also another important aspect that needs to be discuss: Penile skin. Hypospadias is all about aesthetic results, in this case the penile-scrotal angle and the pubic-penile angle need to be reconstructed. Also, pubic fat hypertrophy should be evaluated, but such is not visible from your pictures.

  Very interesting case with a lot of points for discussion. Thank you very much for sharing.

  
  

  
  

• 

  Dr. Roy Chally

  29 Jan 2021 11:53:52 AM

  The glans grove is very narrow for a one stage repair. If excising the urethral plate is not correcting the chordee what is illustrated, incisions not deep to expose the corporal tissue is a very nice step. With this mobilisation of glans any dorsal incisions on the corpora to correct the chordee can compromise the blood supply to glans. The winged glans has to stay like this for the next surgery. Any special dressing after surgery to prevent skin graft contracture?  How soon the next surgery ? 

• 

  Virender Sekhon

  29 Jan 2021 12:41:55 PM

  I follow Dr Bhat's algorithm of a step-by-step approach and would aim for a single stage urethroplasty in this case. My visual impression after looking at the images is that the chordee may be correctable after lifting the urethral plate / proximal tube from the underlying corpora right upto the glans, with/ without adding transverse corporotomies. 

  - Dr Braga, what was the chordee assessment after you transected the urethral plate?

  - Dr Kulkarni may kindly share his experience on vacuum physiotherapy in children.

• 

  Luis H. Braga

  30 Jan 2021 10:26:30 AM

  The curvature after division of UP was 48 (almost 50 degrees) as shown in the photo.

  We normally leave a tie-over dressing for 4-5 days and do the 2nd stage 6 months later. 

  We start applying vitamin E, stretching the penis 1 week after we remove the dressing for 8-10 weeks. This has helped prevent graft contraction (anecdotal, as we have not done any randomized study - learned from a plastic surgeon). 

  It is nice to see so many comments from experienced surgeons. I think we can conclude that there is more than one way to skin a cat. 

• 

  Dr. Anil Takvani

  30 Jan 2021 06:38:46 PM

  Dear Dr. Luis, 

  I would like to request, how exactly you put these cuts on the tunica albuginia sparing spongy tissues of the corpora cavernosa?

  Please write little bit of anatomical details in interest of our urology residents.  Thanks. 

  

• 

  Douglas Canning

  01 Feb 2021 07:57:32 PM

  I would lengthen the ventrum with a tunica vaginalis graft.  For many years we did dorsal plications.  But I now think ventral lengthening is the way to go.  Luis convinced me with his Toronto paper