Patient presented with penascrotal hypospadias with severe chordee at 16 years old. What would you do?
Of course two stage repair is the best choice and bucaal mocosa flap insersion after chordee release is my choice
Where has he been these years !? Has he had any prior failed procedures?
I agree with two stage, but I think it's better to save buccal mucosa for failure. In my experience, first of all correction of cordi and a Thiersch-Duplay tubularization later, works well.But it depends on many factors like the amount of penoscrotal skin.
If possible, please operate with laser in the method You have the best results. But laser makes less bleeding and normally postoperative less
kelloidds
Afther appropriate orthoplasty I can use Buccal mucosa as dorsal only graft and pedicled preputial /penile skin flap ro complete urethroplasty in single operation. Our results in this approach are satisfactory
The best choice should be a single operation.
I would try to correct the chordee and then create a neourethra using a pediculed flap if there is enough foreskin.
If there is not enough material, I would plea for a combination of buccal mucosa and penile skin, too.
That could be a nice approach but my patient had a short urethral plate so all attempt to release chordee could not work.This made me to transect it and do two stages.
ِAs we know it is a difficult reconstructive case, it is better to do orthroplasty 1st then creation of neourethra that depends on the donor sites like skin or buccal mucosa and experience of the urologist . Also the judgment of urologist is important to take the decision of one or two stage procedure
The use of method depends of operator s decission. From my expirience , it can be difficuilt to do in one step. So, I prefere two stage procedure
In case you do single stage by creating a neourethra using a pediculed flap @Tobias samuel what is the success rate and reccurrence of chordee?
@John Zakayo: failure and recurrence rates are below 5% (more than 100 cases, FU: 0-11 years)
Agree with staged procedure (Braka) for a redo. Single staged works in very experienced hands, only.
I agree that it is better if You can do it in one stage. But the patient with 16 years old, I think that You have to do in two stages and that is my choice
That case should be repaired by experienced urosurgeon ,as reconstruction of neourethera after removal of choredea could be done by many different methods .I prefer pediculated flap of peinial foreskin and perpetual .it is common to do it as a tow staged procedure from the start but as a rule one is better than tow,that means a good surgeon is the best choice for that case,
I never use scrotal skin for urethroplasty because of the development of intra(neo)urethral hairs in future!
Well mastered two stage Bracka procedure either with buccal mucosa or with inner prepuce when available. Long lasting and stable results.
I think it is early to decide 1 or 2 stage urethroplasty except after complete straightening of the penis. by the way removal of all fibroud band is essential that on both sides and below urethral plate after comoplete degloving of the penis to determine the exact defect length. The avaliable donor tissue is preputeal forskin or buccal mucosal graft or non hairy skin
Orthoplasty Urethroplasty Glanuloplasty - could be done in single stage depending on experience of surgeons and findings upon degloving penis.
There is sufficient local tissue in a fresh case of hypospadias for single stage repair.
At best it would need an additional procedure
Complete breakdown (usually due to an infection) is rare nowadays.
Preferable to day cystoscopy at same sitting to rule out prostatic utricle which is a cause of infection sometimes.
Sigle stage repair is preferable. Curvature corection is posisible by following steps if you procced step by step as shown in the articleIndian journal of urology : IJU : journal of the Urological Society of India. 05/2008; 24(2):188-94.
If you could not open the refence Ventral curvature correction is by following steps
1.Penile Degloving
2.Mobilization of urethral plate
3. Mobilization of urethral plate into glans
4.Proximal urethra up to bulbar region accrding to need
5. Single stitch Dorsal Plication
Pls do not forget Cysto-urethroscopy to rule out "Prostatic Utricle". Its a common cause in severe hypospadias cases and sometimes a cause of infection which may jeopardize the repair.
I think you must remove the chordee then if there is health skin ,urethral plate ,you can go on ,or multistage .
I would do Stage repair. Release of Chordee first. Minimum six months later for urethroplasty. There should be enough foreskin for urethroplasty. Whatever technique you choose, it would be better to have a flap of tissue on the suture lines before skin cover. Graft from buccal mucosa is required if the patient was circumcised before hence foreskin is deficient.
I would agree with DR Dayang Abdul Aziz for staged repair. However I would not wait a whole six months for II stage; may be earlier at four month.
I shall be happy to mange the case in single stage TIPU after correcting the curvature with above mentioned steps
In sever chorde which is not corrected by all means you need to do staged repair with preputial skin graft or mucosal(lip) graft to have a good length penis at the end
Friends: This is a must read for all of us who are doing Hypospadias surgeyr on regular basis. Article is a great leveller from one a pioneer hypospadiologist.
The role of two-stage repair in modern hypospadiology Aivar Bracka.
Indian J Urol. 2008 Apr-Jun; 24(2): 210–218.
PMCID: PMC2684286
Link is as follows:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684286/
Russells Hall Hospital, Dudley, West Midlands, England
For correspondence: Dr. Aivar Bracka, Russells Hall Hospital, Dudley, West Midlands, England. E-mail: [email protected]
I shall advice to go through the article for mdern hypospadialogy
Bhat A: Extended urethral mobilization in incised
plate urethroplasty for severe hypospadias: a
variation in technique to improve chordee correction.
J Urol 2007; 178: 1031.
A Farewell to Chordee THE JOURNAL OF UROLOGY .
Vol. 178, 753-754, September 2007
Straightening ventral curvature while preserving the urethral plate in proximal
hypospadias repair by snodgrass Journal of Urology 182, 4 ,1725; 2009
I think Prof.Sava Perovic method of Perovic foundation,Serbia will be a good alternate one stage repair.
Quote from the Aivar Bracka's paper:
Quote:
Whilst a variety of technically more intricate one-stage flap repairs can produce decent results in the hands of a few gifted individuals, a measure of the worth of this particular method is that it can be mastered by hypospadias surgeons of average ability and by trainees.[8] It can be used safely not only by paediatric surgeons working in specialised children's hospitals,[9,10,13] but also by alternative specialists working in general hospitals[11] and likewise in less sophisticated third world environments.[12]
Unquote:
That is why it becomes versatile. Of course one should not be doing hypospadias in the first place if one does not have sufficient training and more importantly exposure to same in practise. But as we all know sometimes parents of children have no access to such expertise and local surgeons may be forced to take upon such cases.
Recently in a article ,Prof.Snodgrass discourage not to elevate urethral plate and proximal urethra for correction of chordee if it is more than 30degree after complete degloving of penis which he previously recommend to preserve the urethral plate for TIPU in proximal hypospadias,because there is chance of ischaemia which can cause urethral stricture due mobilization of urethral plate,in that case two stage BRACKA's method is a good option.
Two stage hypospadias repair is good option; preceeded by cystourethroscopy to rule of prostatic utricle - make sure its not stenosed and is self emptying to avoid infection post-op. MCU is not required if you plan scopy.
What did you do finally?
In our reconstructive center we first repair his chordee and about 6 months later his hypospadiasis. According to his penoscrotal hypospadiasis, two stage repair with use of buccal graft maybe the best choice.
Dr Alireza At what AGE do you the orthoplasty? And to all hypospadiologist: What would be recommended age for surgery on severe penoscrotal hypospadias with severe chordee? Esp if there was meatal stenosis?
Its better to repair the patient with chordee and hypospadiasis at 6 months of age. Chordee should be repaired first and six months later repair of hypospadiasis should
be done. If the surgery is done in single stage, the risk of failure is high.
I agree / do you use testerone cream locally or injections?
whats your choice of sutures? Stent vs no stent? / dressing?
How long do you keep catheter for I stage meatoplasty?
How many days hospital stay - I Stage / II stage?
No we don't use testosterone routinely. We use simple sutures with 5-0 vicryl. We use foley catheter and keep it for 2 weeks. We use dressing and don't change it for 3 days. Hospital stay is 4 days for the first stage (specially when we use buccal graft) and 3 days for the second stage.
Proximal hypospadias with chordee is a difficult malformation to repair that should be operated on only by experienced surgeons since the final outcome often depends on the first operation. All these children should be referred to specialized centers. To do otherwise is a disfavor to children.
Bracka´s technique gained popularity because of the apparent simplicity of the first stage. Little is written about the complications of the second (and third and often fourth) operations.
Choosing to do it in 1 or 2 stages is a matter of surgeon´s preference but does not imply that the 2 stage procedure should be undertaken by beginners or surgeons who only occasionally repair hypospadias.
I use preoperative testosterone (injectable) only to increase the diameter of a small glans before the urethroplasty.
In short refer the child to a center with experienced surgeons.
several options are open. depends on one's personal choice and expertise. I have been doing single stage Duckett's tube for children less than 12 years. For a 16 year old, phallic size should be considered while deciding this procedure, although few authors have demonstrated that a long tube can be constructed from the prepuce.
Agree with two stage repair - at four to six month intervals at appropraite age anytime in the early second year of life. Best to use local tissue aka Prepucial flaps rather than buccal grafts - hence the importance not to circumcise which is universal. Buccal mucosal graft is mainly for salvage repairs.
At 16 years penoscrotal Hypo.No need for tester one creams as the penile skin is already exposed to testosterones. It will be a 2 stage procedure in my hands.
Agree with two stage repair - at four to six month intervals at appropraite age anytime in the early second year of life. Best to use local tissue aka Prepucial flaps rather than buccal grafts - hence the importance not to circumcise which is universal. Buccal mucosal graft is mainly for salvage repairs.
I totally agree with two stage repair. As many adolescent urologists using buccal mucosae, I would like to limit the retraction of the flap on the grafted urethral plate : have you suggestions about that problem ?
Better go step by step to step to correct the curvature
Step1- Penile skin de-gloving
Step2- Mobilization of divergent corpus
spongiosum with urethral plate
Step3- Mobilization of proximal urethra
Step4- Mobilization of urethral plate
into glans
Step5- Single Stitch Dorsal plication
Step6- Ventral grafts
Step7- Division / resection of urethral plate
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