What kind of repair you will propose?

• 09 Feb 2021 11:58:51 AM
• |Pediatic Urology

3 years child with mid penile location of meatus with significant chordee. Ureteal plate is fairly good. 

Comments(7)

• 

  Dr. Ashvinkumar Motilal Gami

  09 Feb 2021 09:47:24 PM

  May requires one or might two stage repair. During chordee correction if urethral plate has to excise then two stage repair. I follow following steps

  1. Chordee Correction,  after Y incision keeping 8 mm urethral plate, deglove penis, 

  Dorsal midline stiches, urethral plate desembly or may requires to cut urethral plate.

  2.A Urethroplasty, I will prefer to do Ventral onlay prepucial pedical flap. With acentric skin closer.

  2.B tissue transfer Byer's flap, and second stage after 6 months , Urethroplasty.

  
  

  Here I post similar case done by me few days back.

  

• 

  Jaideep Mahajani

  09 Feb 2021 10:51:58 PM

  In patient with severe coffee, I always do Braka's repair. Many times even after correction of chordee by excising fibrosis, there is significant curvature of penis, and you need to do Nesbit plication. 

  Results of ventral only are good initially, but long-term results are not very good. There are chances of diverticulum as the flap is not supported as well as stricture at the proximal end. Cosmetic results of Braka's repair are also excellent, with slit like meatus right at the tip of glans, which no other procedure can achieve. Due to that the stream is straight without spraying.

  Only difficult part is during elevation of neurovascular bundle during Nesbit's plication. You should be in the correct plane.. One has to be very careful to avoid damage to vessels and nerves.

• 

  Christopher Long

  10 Feb 2021 01:38:12 AM

  Hello,

  
  

  Given the appearance of the urethral plate and the penoscrotal webbing I would be quite concerned about the need for a 2-stage repair.  I would defer the definitive plan until in the operating room and the penis has been degloved.  If the webbing resolves, the curvature is <30 degrees and responsive to plication, and the plate is sufficient for tubularization then I would consider a 1 stage repair, either with an island onlay or Thiersch Duplay, depending on the quality of the plate.

  
  

  I do suspect, however, that this will be a more severe variant and will require a corporal lengthening procedure and subsequent 2 stage repair.  I think the plate looks hypoplastic and will need to be replaced in order to prevent recurrent penile curvature in the future.  I typically use a Byars flap or island flap from the preputial skin to resurface the ventral aspect of the penile shaft. 

• 

  Dr. Anil Takvani

  10 Feb 2021 12:48:38 PM

  On behalf of Ashwin posting all  pictures 

  

• 

  Dr. Ashvinkumar Motilal Gami

  11 Feb 2021 09:42:29 AM

  Thank you Anilbhai, I am doing prepucial only flap since 15 years.  But fortunately I have not seen stricture and divericulm with this technique. Yes fistula arise but easily managed, because we have good skin available. One patient developed delayed fistula and stricture after 6 years because of ?  BXO changes in prepucial skin.

  Thanks

• 

  aditya gupta

  11 Feb 2021 11:04:30 PM

  Looking at the photo, I feel once chorded is corrected this will become a more proximal hypospadias. So would consider a two stage repair. Byars flap would be better for me bcoz of the flaps better blood supply than a graft..

• 

  Tariq Abbas

  19 Aug 2021 01:39:55 AM

  Three critical questions are to be answered sequentially to guide my approach for such cases;

  1. What is the extent of the Urethral hypoplasia, as a surrogate of severity, and not the meatal position. To objectively assess this, I measure the distance between the glandular knobs (b points) to the bifurcation of the spongiosa after degloving decided by the stretched penile length. If the ratio indicates the hypoplasia is less than half of the suprapubic penile shaft, I would go for the next step (curvature assessment) otherwise staged repair (proximal hypospadias).
  2. Curvature assessment using mobile application like angle meter 360 and not goniometer. If less than 50 degrees will use dorsal plication and proceed to the next step to decide about what type of a single stage (either TIP or dorsal inlay TIP) based on Urethral plate quality. If curvature is more than 50, for 2 stage. 
  3. Urethral plate quality assessment using the POST score. If favorable, will do TIP other wise, dorsal inlay TIP. (Abbas TO, et al. Plate Objective Scoring Tool (POST); An objective methodology for the assessment of urethral plate in distal hypospadias. J Pediatr Urol. 2020 Oct;16(5):675-682.)