Failed repair with iatrogenic penile rotation

• 26 Jan 2021 11:16:53 AM
• |Pediatic Urology

Dear Friends, 

Comments(12)

• 

  Amilal Bhat

  26 Jan 2021 09:46:54 PM

  Problems 

  1.Torsion 90 degree,  cause uncorrected primary torsion associated with hypospadias Devian of median Raphe is suggestive of it.  

  Other postoperative , dorsal dartos cover over the neo-urethra causing traction and torsion 

  Tunica vaginalis flap cover causing traction and Torque 

  2.   Laid open urethra 

  3. Deformed Glans and dorsal hood 

  4. Glans scars 

  5. Poor urethral plate with scars 

  Management 

  
  

  Correction of torsion by penile de-gloving ,Mobilization of urethral plate and urethra, still persist de-torque by dartos flap after urethroplasty

  Urethroplasty.  TIPU with dorsal inlay from inner prepucial graft / buccal mucosa 

  Another option onlay flap urethroplasty.

  
  

  
  

  
  

• 

  Venugopal P

  27 Jan 2021 11:18:17 AM

  Dear All,

  I am providing an article from Laurence Baskin addressing ‘What is Hypospadias’. It is an article worth reading and understanding.

  https://journals.sagepub.com/doi/pdf/10.1177/0009922816684613

  With warm Regards,

  Venu

   

• 

  Dr. Ashvinkumar Motilal Gami

  27 Jan 2021 09:00:20 PM

  For Torsion 1. deglove, 2 urethral disembly and realignment, 3 acentric skin cover

  For urethra  ventral onlay prepucial flap, with acentric skin cover.

• 

  Gyanendra Sharma

  28 Jan 2021 08:59:13 AM

  I would agree with the views of Dr. Amilal Bhat

  However  the option of chordee correction & scar excision and then later on urethroplasty (after 6months)would also be there in my mind

• 

  Luis H. Braga

  28 Jan 2021 10:22:43 AM

  In cases of failed hypospadias repair like this one, I usually tend to go back to square one and redo it using buccal mucosa graft. In this case, I would start by degloving the penis beyond the PS junction to correct the penile torque and then assess the UP. In most redo cases, the UP is not salvageable, then I prefer to excise the UP and lay a buccal mucosa graft on the corpora after excising all the scar tissue (I would use lower lip or cheek depending on the size of the gap) as part of a 1st stage repair. I would make sure that there is no residual curvature that could have been the cause for the dehiscence. Correct that with DP if less than 30 degrees or with ventral corporotomies if greater than 30.

  If I felt that the UP was supple and wide, surrounded by good spongiosum (rare cases), I would do a dorsal inlay graft using a small piece of upper lip graft. 

• 

  Lalit Shah

  28 Jan 2021 11:15:05 AM

  Would agree with most of things mentioned above.

  I would be more conservative and would stage the procedure.

  I might even consider compromising for bringing  meatus to glans tip,

  My aim now would be 

  1/- no chordee/ no significant chordee

  2/-no torque/ no significant torque

  3/-meatus to at least till corona

  4/- if possible n looks reasonably promising for success on table , meatus at glans tip

  
  

  
  

• 

  aditya gupta

  28 Jan 2021 11:53:35 AM

  penile rotation post surgery - causes: if TIP done than probability of surgery induced rotation should be rare. however as seen in images ,median raphe almost goes dorsally, so i feel after circumscision during reapproximation there might have been an issue, or during construction of a newer urethral plate using prepucial skin- proper mobilization was not done. same with dartos flap for reinforcement.

  treatment of this: 2 problems: managing penile rotation and hypospadias.

   this being a redo case will like to do it in staged reconstruction. penile degloving , chordee correction if needed , excision of abnormal urethral plate and placement of buccal mucosal graft in first stage. and then closure in second.

• 

  Mallikarjuna Reddy N

  28 Jan 2021 09:20:17 PM

  Unfortunately we have to go to stage 1. Degolve, excise all the scar tissue. lay in buccal mucosa and reconstruct in stages. Short of this we will be not doing justice to the patient

• 

  Christopher Long

  29 Jan 2021 09:08:36 PM

  Greetings,

  
  

  I am delayed in my response but I have to agree with a lot of what has already been stated.

  
  

  Torsion: as above he would need to be completely degloved to determine if this corrects the torsion.  If not then I would place PDS sutures at the 12, 5, and 7 o'clock positions to anchor the base of the penis.  If this doesn't completely correct the torsion then I would use a dorsal based dartos flap as has already been mentioned above.  I think this was simply not addressed at the first procedure as opposed to being secondary to the initial repair.  

  
  

  Hypospadias- concerns include the poor urethral plate, loss of glans tissue, and scarring of the glans. In this scenario I would excise the plate, place a buccal graft (inner lip would be the preference) and perform a 2-stage repair closure.  I typically wait 9-12 months between stages to ensure that the graft has healed appropriately. 

  
  

  Also as mentioned I would counsel the family that there is a good chance that the meatus will not be in the distal glans given the loss of glans tissue. 

• 

  Dr. Roy Chally

  29 Jan 2021 09:51:35 PM

  The urethral plate surface looks modular. I agree that in this case unlikely to see good spongy tissue and will need excision. There are scars on the glans that has to be excised. Two stage repair as stated by others is my choice after correcting chordee if needed. Should preserve blood supply to glans in redo cases when devolving. The wide glans will allow us to take the meatus to the tip of glans in 2 stage repair. Here creation of a split meatus is possible. 

• 

  Douglas Canning

  01 Feb 2021 08:05:06 PM

  I agree with Luis and all of you really.  I would deglove, check the curvature, assess whether there is adequate skin for urethral closure and close to the proximal glans as Chris notes.  If there is not enough skin, I would consider rotating flaps from the mid shaft into place and bury the penis in the scrotum (Cecil repair).  Or I would do as Luis says and place buccal mucosa (as long as adequate dartos is present to assure good take of the buccal graft) and stage it

• 

  Kalpana

  02 Feb 2021 04:25:21 PM

  In my opinion and practice this case can be addressed from cosmetic and functional aspects. Based on my experience practice and where  I am based I would suggest the following:

  Manage parental and patient expectations first. Ensure that both of them come along with you in both the stumbles and successes. In my opinion this is very important.
  

  1. Cosmesis:

  Adequate amount of penile skin and more importantly reasonable amount of prepuce as seen on pictures attached

  Urinary meatuses situated at the corona

  The urethral plate is not well visualised but assuming TIP was done usually unsalvegable

  Glans wide and good but will need addressing and edges repaired give a vertical smooth external urinary meatus

  Median raphe to patient's right resulting in torsion.

  
  

  2. Function

  I don't have the information as to how he pees but I think he may be peeing straight in front of him in a straight but stream deviated to his left

  
  

  I would suggest a 2 stage repair using the inner prepuce as a free ventral graft after erection test to rule out any chordee. All scar tissue needs excision.

  I would leave the skin revision during the second stage but would do the glans refining excise the irregular edges during the first stage.

  
  

  This 2 stage repair would address the above mentioned problems.

  
  

  I do not trust the tissues to give a robust outcome in all cases following a redo hypospadias repair as this depends on the age of the patient as they enter puberty there are changes in the local tissues.

  Keeping this in mind we,  the parents and the patient have to be prepared to plan further surgery for the aspects that didn't work. 

  
  

  Hope this helps?

  Thank you.