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Hypospadias Repair Techniques
Hypospadias is a condition in which the urethra does not develop completely. This results in an opening that is somewhere on the underside of the penis, scrotum or perineum. Hypospadias is almost always associated with other defects, including penile curvature (chordee) and an incomplete or hooded foreskin. Very mild hypospadias may have few functional implications, but the condition can affect a child’s ability to void standing and eventually to have erections satisfactory for intercourse. It is for these reasons, as well as the obvious cosmetic defect, that most parents elect to have hypospadias repaired.
Repair of hypospadias can take many forms, depending on the severity of the deformity. The first step of any repair is straightening the penis. Almost all hypospadiac penises will have some degree of curvature that needs to be corrected. Often this can be accomplished simply by “degloving” the penis. This involves making an incision circumferentially around the skin of the penis just under the coronal groove. As the skin is separated from the shaft of the penis, tethering bands of tissue are released, straightening the penis. Sometimes this dissection can be carried under the skin of the scrotum and even into the perineum, referred to as a radical mobilization of the urethra. This often will result in straightening of penises formerly thought to require staged surgical repair.
If degloving the penis does not result in sufficient straightening, further measures will be needed. These fall into two general categories. The first includes procedures that create tucks on the topside of the penis in order to correct the disproportion between the top and bottom sides resulting in straightening. This is generally done for relatively mild curvature. The second type of operation involves opening the lining of the erectile part of the penis on its underside, and inserting a graft material, most commonly dermis from the skin of the abdominal wall. This maneuver almost always requires dividing the urethral plate, the tissue that should have tubularized to form the urethra. If this plate can be preserved, the repair of the hypospadias is simplified. On the other hand, if this plate is very short, there is an advantage in the eventual length and appearance of the penis to dividing this plate. This is a decision that generally cannot be made except in the operating room, when the results of the initial dissection are apparent.
A penis with severe curvature that requires grafting on the underside will often be repaired in a staged fashion. The first operation involves straightening the penis as described, and transposing most of the foreskin to the underside of the penis for later use in reconstructing the urethra. Approximately six months later, a second operation is performed to tubularize a urethra from the skin on the underside of the penis.
If the urethral plate can be preserved, most often we will try to tubularize it as a primary repair of the hypospadias. This results in a urethra that is composed completely of tissue that was originally intended to be urethra, rather than using skin or other materials. This technique also gives a very normal functional and cosmetic result. There are several other repairs that can be done with an intact urethral plate and, once again, the decision as to which is most appropriate is made in the operating room. The vast majority of these repairs can be performed on an outpatient basis.
Repair of a severe hypospadias, or a reoperative repair after prior failed surgery, might require a “free graft” of tissue to rebuild the urethra. This can be skin from the penis or inner arm, or “buccal mucosa” - the lining of the mouth. Hospitalization is often required after a free graft repair to allow the graft to heal in place with as little movement of the area as possible.
After surgery, a tube is left in the reconstructed urethra in all but the simplest cases. This tube is referred to as a “stent,” and its purpose is to allow free egress of urine while the tissues are healing. Often there is significant swelling in the penis, and voiding might be difficult for your child. The tube is most commonly managed simply by allowing it to drain into a diaper. In older children, the tube might be attached to a drainage bag that would have to be emptied periodically. These tubes are usually attached to the head of the penis with one or two stitches, which need to be cut before the tubes can be removed. The tubes might be in place for as few as two or three days, or as long as two weeks. Any change in drainage from these tubes, or in their position, should be reported to your doctor immediately.
There often will be a dressing, or bandage around the penis after hypospadias surgery. Most often, this is a clear plastic dressing and is removed at the first postoperative visit in the office. These dressings often will fall off by themselves, and this is not a cause for concern. The only concern would be if the dressing bunches at the base of the penis and acts as a tourniquet. In this case it should be removed, or your physician should be contacted immediately.
Overall, the results of hypospadias repair are excellent. However, it is important to realize that no surgical procedure is perfect. There are a number of complications of hypospadias repair of which you should be aware. The most common is partial breakdown of the urethral reconstruction—usually manifested by a “fistula,” a small opening between the urethra and the skin. A fistula is not an uncommon occurrence, although our techniques are designed to avoid them. If a fistula should occur, we simply watch it for a period of six months. Some of these will close on their own. The ones that do not are repaired in a subsequent surgical procedure that is usually much smaller than the original hypospadias repair. Usually, a fistula does not affect the ultimate functional and cosmetic outcome of the repair.
The goal of hypospadias surgery is to provide a penis that is functionally and cosmetically normal. Whether these goals will be met to your satisfaction depends largely on the original anatomy and the tissues available for reconstruction. Minor cosmetic defects can be found after hypospadias surgery, but often these will not be noticeable to the casual observer. Concerns have been raised, especially on the Internet, about long-term sensation and sexual pleasure in men who have undergone hypospadias repair. The best data indicate that difficulties with erection, sensation or orgasm are very unlikely to result from hypospadias surgery.
Repair of hypospadias is a complex surgery and is somewhat different in every case. Please feel free to ask questions and make sure that you feel well informed before any surgery is performed.
Copyright 2000, Steven G. Docimo, MD
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