Hypospadias Cripple

• 29 Mar 2020 09:27:47 PM
• |Reconstructive Urology

24 years male presented after 5 times failed Hypospadias surgery

Comments(15)

• 

  Jaideep Mahajani

  30 Mar 2020 08:45:53 AM

  Is karyotyping done?

  If not, then it is mandatory. 

  Whether breast are examined?

  Criteria for ambiguity are:

  1. Unilateral undiscended testis with hypospadias. 

  2. Bilateral undiscended testis (with or without hypospadias).

  3. Perineal hypospadias (with or without undiscended testis).

  If he male : He needs left orchidectomy and repair of hypospadias in two stage. I will prefer post auricular skin, (provided he doesn't have tendency of producing hypertrophy scar or keloid). 

  
  

• 

  Dr. Anil Takvani

  30 Mar 2020 09:43:46 AM

  I agree with Jaydeep.

  Remove left iliac testis. In same anesthesia do first stage of crippled hypospadias.

  Remove all scared skin and hair bearing urethra till penoscrotal junction.

  Use buccal or lip mucosa or postauricular skin to cover penis ventrally to prepare bed for future urethral tube after six months to one year.

  We have many national and international reconstructive urologist in group, I request them to share their experience...

  Thanks

• 

  Rahul Kapoor

  30 Mar 2020 10:08:26 AM

  Sir

  Is karyotyping necessary now, he is 24 years old, secondary sexual characters are normally developed. He gets erection. 

  No gynecomastia. 

  Left testis is almost normal size. Can we just bring it down. 

  
  

• 

  Dr. Anil Takvani

  30 Mar 2020 10:19:58 AM

  I will not ask for karyotyping at this stage as that will not change my treatment plan,

  But please send left testis for histopathology on removal of it.

• 

  Jaideep Mahajani

  30 Mar 2020 10:21:33 AM

  If he turns out to be ambiguous, then he needs right testicular biopsy to rule out ovotestis.

  In that case he also needs right orchidectomy also along with androgen supplement lifelong. 

• 

  Venugopal P

  30 Mar 2020 10:39:13 AM

  Hypospadias Cripples

  Dear All,

  (Posted in Uroacademy on 13-1-2020). I am not able to land on this write up on our site and hence I am resending but have added an additional material by Sanjay

  Much has been written on Techniques to Repair Hypospadias be it single stage or two stage repair. There are as many techniques available as the number of surgeons involved in the repair. It only means that no one technique is perfect.

  Dina Manasherova* et al (2019, Published online Dec 30^th) have found that the use of Prepucial graft resulted in Complications in 31% while using BMG resulted in Complications in 20%. Hence which ever method is used for repair of Hypospadias, a good number will have complications like fistulas, defects of urethra, and scar contraction of grafts needing subsequent repairs. In the management of scarred Urethral plate, controversy exists whether they could still be used or have to be completely excised during subsequent repair. I am providing link for an article by Min Wu, Fang Chen* et al (2018) where they have discussed on ‘management of failed hypospadias repair’.

  https://link.springer.com/content/pdf/10.1007/s11255-018-1962-2.pdf

  Every Hypospadiologist have their own tricks up their sleeves when considering repair for failed Repairs.

  It would be nice to hear from them as to what their options are. Will these patients need staged procedures in subsequent repairs or can they have successful outcome with single stage revision.

  I would urge all involved in such repairs to throw in their weight to enlighten us.

  I am additionally providing some more materials and one is from Sanjay and Pankaj (2018) on ‘Redo Hypospadias Surgery Current and Novel Techniques’

  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6167977/pdf/rru-10-117.pdf

  https://www.dovepress.com/redo-hypospadias-surgery-current-and-novel-techniques-peer-reviewed-article-RRU (Video available)

  Likewise there was a symposium in IJU in 2008 with Guest Editor being Amilal Bhat in which many aspects on Hypospadiology have been discussed, some by the Pioneers. I am providing the link for the issue from which you can access all the articles published in the symposium.

  http://www.indianjurol.com/showBackIssue.asp?issn=0970-1591;year=2008;volume=24;issue=2;month=April-June

  With warm Regards,

  Venu

   

• 

  PANKAJ JOSHI

  30 Mar 2020 11:08:26 AM

  Greetings

  1.Testes can be dealt with as per guidelines.

  2.Staged Uplasty with inserting buccal graft in first stage fails in 39% cases-graft contracture-redo-reredo-surgery 

  3.Plan:Lay open as Johansons Stage 1-wait for 6 months-Insert BMG as dorsal inlay-Tubularise

  
  

  Details are available on IJU 

  Attaching some images.

  
  

  We thank Venugopal sir for citing our article published in Dovepress on Failed hypospadias 

  View Document

• 

  Amilal Bhat

  30 Mar 2020 11:52:31 AM

  Pelvic MRI for site size of testis, internal rudimentary internal female organ, RGU for vagina/ Prostetic Uricle. 

  Then orchiopaxy with testiclar biopsy or orchidectomy. Excise scared / hairy skin n put BMG graft n tubularization in second stage

  Amilal Bhat

• 

  Dr. Ashvinkumar Motilal Gami

  30 Mar 2020 12:30:54 PM

  First I deal with testis and do left side laparoscopic orchiopaxy.

  Second 1. if no chordee - I would put BMG on dorsal side, after splitting urethral plate. Excise hair bearing skin.  Do ventral closer with urethral plate. Cover it with acentric skin closer. 

               2. If chordee - do Johnson 1 and after 6 months dorsal  BMG Urethroplasty.
  

  
  

• 

  Gyanendra Sharma

  30 Mar 2020 03:15:39 PM

  I would deal with the testis by Laparoscopic orchidectomy

  As regards the Hypospadias--I would agree with Dr. Pankaj Joshi and lay open the urethra. Buccal Mucosa can be used as dorsal inlay in the second stage, which I would do not earlier than 6 months after the First stage

  Contraction of Buccal mucosa is certainly an issue.

  However it would be interesting to know the experience of all those who have used post auricular graft in the first stage

  
  

• 

  Jaideep Mahajani

  30 Mar 2020 03:48:43 PM

  Post auricular skin workers very well as long as patient doesn't develop keloid. But if he develops keloid or hypertrophic scar, then it is very difficult to manage. If used as inlay graft (snodgraft procedure), it is very good. If used for DOG, it is very good option in circumcised patients who have trismus (when BMG is not healthy). 

  In my experience as long as post auricular skin is not exposed to air, chances of developing keloid is minimal.

• 

  Dr. Anil Takvani

  30 Mar 2020 03:50:36 PM

  I learned post auricular skin graft in hypospadias cripple from Dr. Jaydeep,

  In last couple of years used in 4 to 5 cases like this case as first stage. 

  In those cases results are good. I will dig out few images from my collection to post on website.

  I request Jaydeep to share his experience...

  I agree with Pankaj and Gyanendra for dorsal inlay as better option but have seen Dr. Amilal and many more experts to do differently.

  I request Prof. Amilal to share images of appropriate case. And also to Pankaj Joshi.

  Thanks

• 

  Ramesh Babu

  30 Mar 2020 09:30:16 PM

  This patient is a clear candidate for BMG two stage repair. I would excise all scar tissue until normal urethra reached. Quilt BMG +/- Labial mucosa also (may need a proper width). Then plan second stage urethroplasty later (Alas he cant have a Tunica Vaginalis flap at that time) 

  
  

  Testis, one can argue for and against removal. It is becoming controversial these days with legal stands. Patient has to give informed consent if orchidectomy is planned. (I would focus on hypospadias first)

• 

  RAJIV N KORE

  30 Mar 2020 11:21:48 PM

   

  Hello, everyone.

  Very interesting discussion on this complex issue which as Reconstructionist we come across quite often!

  The hypospadias part of this case:

  Two main issues while facing this situation are

  A.      1.Correction of chordee:

  If the chordee is not corrected adequately, no matter what repair you do the chances of failure are exceedingly high. If in this case the on table erection shows chordee more than 30 degrees I will take all the steps to correct including skin, fascia and if required urethral plate transection. If required three ventral corporotomies. This will then proceed to appropriately placed urethrostomy and distal cover with Bayr’s flap. (Snodbush repair)This will be stage one. After a year a supple urethral plate with a corrected chordee will help tubulerise, with additional inlay for the narrow glans in this case. If the chordee is less than 30 degrees then dorsal plication should suffice.

   

  B.    2.  If there is no chordee I would go ahead with excision of multiple fistulae and fibrosis and laying it open ventrally (using Denis Brown principle of buried epithelium). This will be tubulerised in the second stage between 6 to 12 months

• 

  Dr. Roy Chally

  31 Mar 2020 10:27:58 PM

  I agree with Amilal Bhat. After excising all scared penile skin and the distal scared skin tube, put a wide BM graft on the corpora and laterally on the subcutaneous tissue to permit this part to be lifted to form a hairless tube.  If the graft is seen taken at 1 month take him for second stage repair. If one waits longer the graft will shrink. There is going to be a problem of lack of penile skin for cover. How best to manage this problem? Scrotal burry / rotating a scrotal skin flap / mobilising penile skin with dorsal cut and skin graft. They must have mobilised the penile multiple times earlier. The penile skin vascularity is likely to be comprised and I would not opt for this.

     Here I would like to aim for a meatus at coronal sulcus only. With multiple repairs earlier even the glans vascularity will be comprised to get a meatus at the tip of glans. One should accept this compromise.