hypospadias and its complications

Transcription

1 Ann R Coll Surg Engl 1998; 80: Newer concepts in the mngement of hypospdis nd its complictions H S Asop MS FRCS Consultnt Surgeon Asop Hospitl, Agr, Indi Key words: Hypospdis; Complictions of hypospdis; Urethrl construction; Preputil flp; Urethr Hypospdis is common condition, estimted to occur once in 300 mle live irths (1). The urethrl metus my e situted nywhere etween the norml position, t the tip of glns to the perineum, on the ventrl spect of the penis. It is commonly, ut not lwys, ssocited with ventrl curvture of the penis termed chordee. There is hooded prepuce nd deficient ventrl penile skin in most cses. History of hypospdis surgery mkes fscinting reding nd gives n insight into the ingenuity s well s frustrtion of surgeons owing to imperfect results of surgery. This in turn hs resulted in plethor of techniques since the first unsuccessful ttempt t repir y Dieffench in 1838 (2) nd the first successful repir y Anger in 1874 (1). Since then well over 200 techniques hve een descried, ut most of these hve een minor modifictions of techniques nd principles enuncited in the lter prt of the nineteenth nd erlier prt of the twentieth century. Multistge procedures were in vogue nd refinements of some of the sic principles were the minsty of different techniques. These included: (1) Ventrl tue or strip of skin (1); (2) Perimetl flps (3); (3) Free grfts (1,4); (4) Penile or scrotl tissue for the tue nd urying the penis in the scrotum (3); (5) Urethrl moilistion for distl hypospdis (3) nd (6) Buttonhole in preputil hood to trnsfer skin ventrlly (1) Ḋuring the lst 30 yers newer surgicl techniques hve evolved, with proper understnding of vsculrity nd heling of flps. Advnces in suture mterils, ctheters, dressings, hemostsis nd mgnifiction hve ll resulted in etter cosmetic nd functionl results in lrge percentge of cses in single opertion. Bsed on Hunterin Lecture delivered during the nnul conference of the British Assocition of Urologicl Surgeons, held in Bournemouth on 24 June 1997 Correspondence to: Dr H S Asop MS FRCS, Consultnt Surgeon, Asop Hospitl, Delhi Gte, Agr , Indi Tle I. Age incidence No. of new No. of filed Totl Age in yers cses (%) cses (o%) (%) (16.11) 3 (1.46) 52 (10.21) (46.38) 56 (27.31) 197 (38.70) (20.06) 52 (25.36) 113 (22.20) (8.88) 34 (16.58) 61 (11.98) (5.26) 26 (12.68) 42 (8.25) >20 10 (3.28) 34 (16.58) 44 (8.64) Totl 304 (59.72) 205 (40.27) 509 During the lst 5 yers we hve treted 304 (59.72%) cses of hypospdis nd 205 (40.27%) cses of complictions of operted hypospdis (Tle I), which include our own cses nd those referred from other centres, y different techniques nd in this rticle we descrie the present trend nd our own preferences. Glnulr nd coronl hypospdis (cosmetic ppernce) Until recently, it ws suggested y mny tht glnulr nd lnitic hypospdis required no correction s there is no functionl deformity (1). In fct coronl position of the metus fter hypospdis opertion ws considered stisfctory (5). Cosmetic ppernce ws considered secondry nd usully of more concern to the prents thn the ptient (1). Such views were justifile then, s there ws no stisfctory one-stge repir technique to correct glnulr or coronl hypospdis nd ttempts to ring the metus to the tip of the glns filed in lrge numer of cses. Tody these cses cn e corrected in one stge s dy cse, which tkes little more time thn circumcision-metl dvncement nd glnuloplsty (MAGPI-Duckett) (6). In our series, over the lst 5 yers, 52 (17.11%) cses hve enefited y this technique with stisfctory

2 162 H S Asop Tle II. Opertive procedures nd results of primry surgery for hypospdis Opertive technique No (%) Filure % 1 Chordee without hypospdis () Skin nd drtos chordee 8 (2.63) (with dorsl pliction) (3) 2 () Congenitl short urethr 2 (0.66) MAGPI repir 52 (17.11) (with dorsl pliction) (2) 3 Perimetl flp 4 (1.31) Inner trnsverse preputil ptch 119 (39.14) (with dorsl pliction) (13) 5 Inner trnsverse preputil tue 107 (35.20) (with dorsl pliction) (7) 6 Byrs' two-stge 12 (3.95) Totl outcome in 47 (90.39%) (Tle II). A vrition of MAPGI, the Arp procedure (7) uses midline suture of fringe of skin proximl to the coronl metus fter circumcoronl incision. The glnulr tissue is then rought together. We hd found no dvntge of this procedure over stndrd MAPGI nd filure rte is higher. Trnsverse preputil skin ptch/tue The inner lyer of the prepuce is in texture nerest to the distl urethr nd when used in the trnsverse xis gives n dequte length to form the distl urethr in hypospdis, s tue or ptch, except in the most severe proximl hypospdis. The inner trnsverse prepuce ws used s free grft to mke tue (4) for repir of hypospdis with chordee in one stge. Trnsverse preputil flp urethroplsty, sed on the superficil dorsl vessels of the penis, hs stood the test of time. Since it ws first used y Asop et l. (8), its vrious modifictions nd refinements re the minsty of onestge repir of hypospdis, s heling is etter, ecuse the trnsferred skin crries its own lood supply. Inner preputil islnd flp The inner prepuce cn e seprted from the outer prepuce nd penile skin with its own lood supply y the superficil dorsl vessels s shown y Duckett (9) nd cn e trnsferred ventrlly s n islnd tue or ptch. The rw re is covered in Byrs' fshion (10). Doule-fced preputil islnd flp It ws relised tht the superficil dorsl vessels supply oth inner nd outer lyers of the prepuce where its rnches fn out trnsversely etween the two lyers of c Figure 1. Inner trnsverse preputil ptch urethroplsty. () Showing inner trnsverse preputil ptch, urethrl plte nd olique cut in outer preputil skin on left side protecting the vsculr pedicle. () Inner trnsverse preputil ptch stitched to the urethrl plte on oth sides. (c) Spirlling the penile skin to cover the ventrum. (d) Finl result. d

3 Mngement of hypospdis 163 c d e f g Figure 2. Inner trnsverse preputil tue urethroplsty. () Incision (rchet shped). () Rising the inner trnsverse preputil flp. (c) Chordee corrected. (d) nd (e) Tue is mde from inner trnsverse preputil flp. (f) Olique cut in outer preputil skin on left side protecting the vsculr pedicle. (g) Finl result. the prepuce nd when the penile skin is rised over the vsculr pedicle, the inner preputil tue cn e trnsferred ventrlly with the outer prepuce covering it (3,11). The penile skin, when stitched round the coron nd outer prepuce, gives n excellent cosmetic result. The islnd flp nd doule islnd flp give excellent cosmetic results, looking similr to norml circumcised penis. The compliction rtes vry considerly nd the good results otined y some (3) re not duplicted y others (12,13). Compliction rtes vry from 3.7% to 69% (12,13), proly owing to the seprtion of the islnd. On the other hnd, vsculrised trnsverse preputil flp ttched to the outer prepuce ut not freed s n islnd flp is more secure thn islnd flps (14). The cosmetic ppernce cn e improved considerly y spirlling the flp round to the ventrum y n extended olique cut in the skin etween the penile skin nd outer prepuce on one side (14-16). The cut cn e extended up to the midpoint of the penile skin, voiding the dorsl vein nd rtery (Fig. 1, Fig 2). This gives symmetricl skin cover nd overcomes the torsion which is considerle if the olique cut is incomplete. This, to some extent, is n incomplete doule-fced islnd nd hels etter thn doule-fced islnd flp. We hve used this s ptch or tue in penile, penoscrotl nd perinel hypospdis, with stisfctory cosmetic results.

4 164 H S Asop Chordee Though one-stge repirs of hypospdis hve een undertken since 1960, rtificil erection on the tle, introduced y Gittes nd McLughlin (17), infused confidence in correction of hypospdis with chordee in one stge. It hs lso improved our understnding of the extent nd incidence of chordee in hypospdis nd in chordee without hypospdis. Alterntives to rtificil erection y injection of sline into the corpor, which we commonly use, re (1) pulling the glns y n nchor suture or etween thum nd index finger nd feeling the tightening of the urethr, the corpor cvernos nd the dorsl nerves. If chordee is present the corpor will e lx; (2) Blood cn e pushed into the penile corpor y compressing the two crur of the penis nd squeezing the lood into the penile corpor with the thum nd index finger. In most cses this cn produce n rtificil erection, enough to show the presence nd extent of chordee in penile hypospdis. Using these mnoeuvres, it hs een relised tht high percentge of cses of distl penile hypospdis nd some cses of proximl hypospdis hve no chordee, or only drtos chordee which cn e corrected when penile skin is rised over the shft of the penis. These cses cn e mnged y trnsverse preputil ptch over the urethrl plte with or without dorsl pliction (18). Cses with considerle chordee require division nd moilistion of the urethrl plte proximlly, eyond the metus, nd distlly deep to the glns. Urethroplsty is performed y ridging the gp with trnsverse preputil skin tue. A long sptulted nstomosis is mde proximlly nd the distl end is rought out to the tip of the glns through tunnel or glns split. It hs een oserved tht in spite of extensive moilistion of the divided urethrl plte, some cses still hve considerle chordee. These re corrected y dorsl pliction (18). Moilistion of the urethrl plte Following the use of moilised urethrl plte without dividing it in epispdis (19), interest ws roused for similr technique in hypospdis (20,21). The urethrl plte is dissected free from the tunic lugine nd the firosed corpus spongiosum excised. It is reported tht chordee cn thus e corrected in even the most severe forms of hypospdis (21). After few ttempts, we hve not een convinced out this clim. The thin strip of mucos, with length of out 4 to 6 times its width, seems unlikely to hve vile vsculrity. The good results reported re in ll proility owing to the good vsculrity nd heling potentil of the trnsverse preputil skin ptch. Similr views re shred y others (18). Two-stge repirs Though some surgeons use one-stge repirs, even in the most severe perinel hypospdis, others hve continued or reverted ck to two-stge procedures. We reserve twostge repirs for severe forms nd fvour Byrs' two-stge (10) technique. Other commonly used techniques re Durhm Smith (22) nd Fuqu (23). Mterils nd methods During the lst 5 yers, 304 fresh cses, vrying in ge from 1 to 36 yers (Tle I), of hypospdis of different grdes hve een operted upon t our centre, including 10 (3.28%) cses of chordee without hypospdis, using pproprite techniques (Tle II). In ll 52 (17.11%) cses of glnulr nd coronl hypospdis were treted y metl dvncement nd glnuloplsty. A perimetl flp ws used in 4 (1.31%) cses only. Inner trnsverse preputil skin ptch over the urethrl plte ws used in 119 (39.14%) nd n inner trnsverse preputil skin tue ws used in 107 (35.20%) cses. Only 12 (3.95%) cses required two-stge procedures; 25 (8.22%) cses required dorsl pliction (Tle II). The ldder ws drined y per urethrl ctheter which ws removed fter 1 dy in cses undergoing MAGPI. Results The overll compliction rte ws 12.50% nd the rekdown is depicted in Tle II. Discussion The overll ge t opertion ws higher thn in other reported series s ptients reported lte, though our preferred ge for surgery is 1.5 yers. The oldest ptient ws 36 yers of ge (Tle I). Fifty-two cses (17.11%) were corrected y MAPGI (Tle II); most centres perform MAGPI in higher percentge of cses. The smller percentge of MAGPI in our work my e ecuse lrge numer of our cses re referred from other centres, nd cses of glnulr nd coronl hypospdis re delt with elsewhere. Minor defects without chordee my not report for surgery in developing countries. I feel nything proximl to the coron is not suitle for MAGPI nd we prefer to use trnsverse preputil ptch repir. A vsculrised inner trnsverse preputil tue or ptch is the most commonly used flp for urethrl reconstruction in one-stge repir of hypospdis (3). The islnd flps give good cosmetic results ut the reported compliction rte is vrile nd up to 69% (13). The vsculrity of the outer prepuce is often compromised nd this hs to e excised (14). On the other hnd, flp urethroplsty, in which the two lyers of the prepuce re not seprted nd the penile skin flp with the inner lyer of prepuce, still ttched to the outer lyer, is trnsferred ventrlly, is more secure nd less likely to hve compromised vsculrity. The compliction rte vries from 5% (24) to 21% (14). Our series hs compliction rte of 10.92% in cses corrected y inner trnsverse preputil ptch nd 16.82% in cses in which n inner trnsverse preputil tue ws used for hypospdis repir (Tle II).

5 The superficil dorsl vessels fn out etween the outer nd inner lyers of the prepuce nd supply oth these lyers. This cn e seen during dissection etween the two lyers. Tht n inner preputil islnd (9), outer preputil islnd (25) or doule-fced islnd (11), ll survive on the superficil dorsl vessels lone, is mple proof of this. The extended olique cut mintins symmetry nd voids torsion, nd thus gives good cosmetic results (Fig. 1, Fig. 2). In cses where the urethrl plte is used to form prt of the circumference of the urethr without chordee or when mild chordee is corrected y dorsl pliction, the compliction rte ws lower, 10.92%, compred with when the urethrl plte hd to e divided 16.82% (Tle II). Similr difference ws reported y Duckett (18). When there is no chordee or when only drtos chordee is present, the urethrl plte does not need to e trnsected or moilised. Keeping the urethrl plte intct hs the dvntge tht the lood supply is not interfered with nd the urethr does not hve to e fixed to the tunic lugine. Dorsl pliction will correct mild chordee, nd the urethrl plte cn e used with dvntge. We hve resorted to the ove techniques in 119 cses nd the results, when the urethrl plte is utilised to form prt of the circumference of the urethr, re 10.9% (compliction rte) compred with 16.8% when the urethrl plte ws trnsected nd the whole tue ws formed y inner prepuce (Tle II). Some cses of curvture persist fter excision of the ventrl chordee nd these cses require dorsl pliction (18) or ventrl incision with derml or tunic vginlis testis grfting (3). Our preference hs een dorsl pliction; this ws required in 25 cses (8.22%) (Tle II). Conclusion The im of hypospdis repir is to provide good cosmetic nd functionl result with the ptient le to pss urine from the pex of the glns, preferly in single opertion. Newer surgicl techniques hve mde it possile to chieve these gols with first opertion filure rte of round 10%. In one-stge repir, when the urethrl plte is used to form prt of the circumference of the neourethr, the compliction rte is much lower thn when the urethrl plte hs to e trnsected. The technicl dvnces y wy of fine sorle suture mterils, opticl mgnifiction, soft silstic ctheters nd dressing mterils hve dded to the confidence in providing etter results. Mny centres operte round 6 to 18 months of ge s dy cse procedure. The results my improve further with the expected use of lser welding nd tissue dhesives (21). Complictions Common complictions of hypospdis re fistul, stricture, recurrent or residul chordee, diverticulum nd retrusive metus. These re voided y selecting the pproprite procedure for ech cse, ttention to detil, Mngement of hypospdis 165 creful hndling of tissues nd the use of fine sorle suture mterils. Though the compliction rte hs come down in recent yers with the newer techniques, complictions, especilly fistul, re likely to continue for mny yers (3); reported rtes vry from 0% to 69% (12,13). Once fistul develops, one should wit for t lest 6 months for inflmmtion nd indurtion to resolve (26,27). Though this sttement is true for two-stge repirs when the skin suture line is in the midline, overlying the neourethr, when flp is used for tretment of hypospdis or its complictions we hve een resuturing the skin flp, if moderte sized fistul is detected during chnge of dressing, etween the 7th nd 12th postopertive dy. The flp is rised nd dvnced few millimetres nd resutured overlpping the fistulous opening in the urethr. There ws rpid nd stisfctory heling in 21 of 26 cses of primry hypospdis repir with flp nd when flp ws used for postopertive complictions, thus voiding repet surgery. Fistul my e ssocited with stricture, diverticule or chordee nd these should e corrected t the time of fistul closure. Mterils nd methods Over the lst 5 yers we hve operted on 205 cses of filed hypospdis (Tle I), these include our own nd cses referred from elsewhere. We group these cses ccording to the site nd numer of fistuls, ssocited prolems, such s stricture, retrusive metus, diverticulum chordee, nd the type of surgery contemplted. Simple fistul in proximl penile prt without stricture diverticulum or chordee These cn e treted s dy cse procedure, with locl flp. The fistulous trct is excised down to the urethr nd the reolr tissue round the fistulous opening in the urethr is closed with 6/0 Vicryl 'l, the skin or mucos is not repired. A proximl or distl sed locl flp covers the fistul site so tht the skin suture line is some distnce wy from the fistul site (Fig. 3). This is ssured y suturing sucutneous tissue of the flp to the tunic lugine. Urinry dringe is not usully required. Multiple fistuls without chordee or stricture nd coronl fistul A circumcoronl incision is mde nd the penile skin rised, fter circumscriing the fistulous openings. The fistulous trcts re excised down to the urethr nd ridges of skin etween the fistuls re cut open to communicte the fistuls. The reolr tissue round the urethr (Fig. 4) is closed with 6/0 Vicryl. The penile skin is rotted round the shft of the penis y out 10 so tht the lterl penile skin covers the site of the fistuls nd the skin suture line lies lterlly wy from the suture line of the fistul closure.

6 166 H S Asop Figure 3. Closure of urethrl fistul (fter hypospdis surgery) y locl flp dvncement. () Incision. () Locl flp is dvnced to cover the stitched fistul site. chordee there is not enough skin to cover the rw re on the ventrum. We hve evolved two-stge opertion for such cses. After chordee correction, skin tue is mde from the medin rphe of the scrotum, nd the penis is uried in the scrotum s first stge (Fig. 5). The scrotl tue is nchored to the tunic lugine nd penile skin is stitched to the scrotl flps. After 3 to 4 months the penis is relesed from the scrotum (Fig. 6). Retrusive metus lone or ssocited with ove defects Metl dvncement nd glnuloplsty, or perimetl flps, re used for retrusive metus, with or without the ove opertive techniques, s indicted. A.,.?.f, Figure 4. Closure of multiple urethrl fistuls fter hypospdis surgery. () Penile skin rised fter circumcoronl incision. () Fistul site is stitched nd penile skin is rotted y 10, so tht skin suture line does not overlp the stitched fistul site. Figure 5. Two-stge repir of hypospdis cripples- Stge I. () Scr nd chordee excised (note deficient penile skin on ventrum), glnulr flps rised nd neourethr is constructed from medin rphe of the scrotum. () Penis is uried in scrotum, stitching the penile nd scrotl skin. Fistuls with stricture ndlor chordee with intct prepuce Penile skin is rised with the prepuce, preserving the superficil dorsl vessels of the penis. The urethr is lid open proximl nd distl to the fistul. The chordee, if present, is corrected. A trnsverse preputil ptch/tue is utilised to refshion the urethr s necessry. Fistuls with chordee or stricture without prepuce These re est treted in two stges. The penile skin is rised fter circumcoronl incision. The chordee is corrected nd the penile skin is redistriuted in Byrs' fshion (10). After 4 to 6 months the urethr is constructed in the midline nd lterl flps re used to cover the constructed urethr or uried skin strip. Fistuls with chordee with scrring of tunic nd shortge of skin These very complex cses hve een clled hypospdis cripples. After excision of scr tissue nd correction of Figure 6. Two-stge repir of hypospdis cripples- Stge II () Penis with neourethr is relesed from the scrotum, giving n incision in the scrotum protecting the neourethr, 3-4 months fter stge I opertion. () Finl result.

7 Tle III. Opertive procedures nd results of first ttempt fter primry surgery filure Mngement of hypospdis 167 Opertive technique No. (%) Filure (%) 1 Metl dvncement lone 10 (4.88) Perimetl flp 23 (11.22) (with dorsl pliction) (1) 3 Locl flp for shft fistul 67 (32.68) (with metl dvncement) (10) 2 (with perimetl flp) (4) (with dorsl pliction) (2) 4 Penile skin rottion 13 (6.34) (with metl dvncement) (0) (with perimetl flp) (1) (with dorsl pliction) (2) 5 () Inner trnsverse preputil ptch 24 (11.71) (with dorsl pliction) (1) () Inner trnsverse preputil tue 22 (10.73) Two-stge Johnson repir 23 (11.22) (with dorsl pliction) (1) 7 Scrotl rottion flp 7 (3.41) (with metl dvncement) (1) (with perimetl flp) (1) 8 Scrotl ury 16 (7.80) Totl Results The rekdown of cses ccording to the procedures performed nd the results re depicted in Tle III. Discussion Surgery for hypospdis complictions hs high filure rte (3,26). Our series, which hs lrge numer of complex fistuls with ssocited complictions, referred from elsewhere, hd filure rte of 11.70% (Tle III). Some uthors hve reported excellent results (28), when urethr nd skin were closed t right ngles to ech other. Others hve reported good results in smll series, using Y-V dvncement flp (29). De-epithelilised 'pnts over vest' hs lso given good results in midshft fistuls (30). Most reports with good results hve used flps in such wy tht suture lines of urethr nd skin do not overlp. These results hve een otined in simple fistul using single technique. We hve used ssorted techniques for ll complictions of hypospdis surgery ssocited with hypospdis fistuls. The results re etter when flp is used to seprte the suture lines of urethr nd skin y good mrgin (Tle III). Cses operted for complictions of hypospdis surgery, either t our centre or elsewhere, vried in ge from 2 yers to 35 yers (Tle I). Most of the cses eing referred for complictions from other centres presented lte (Tle I). A perimetl flp cn e used for retrusive metus or when the metus hs een left just proximl to the coron; we do not moilise the flp extensively. Two groups of cses re unique in our series. A lrge numer of cses (22%) hd n intct prepuce which we lwys used, utilising the inner prepuce s ptch or tue. This ws not only secure ut lso improved the cosmetic ppernce nd the metus could e creted t the tip of the glns. The high incidence of n intct prepuce in our referred cses is ecuse mny surgeons in Indi use two-stge opertion, without ventrl trnsfer of preputil skin in the first stge. Hypospdis cripples which hve multiple fistuls, strictures, recurrent or residul chordee nd shortge of penile skin cn e treted y excision of scr tissue, correction of chordee nd, if necessry, dorsl pliction. In these cses, the penile skin cnnot e closed t the initil opertion (Fig. 5). Prtil thickness skin, ldder, or uccl mucos cn e pplied on the ventrl surfce of the rw re, nd tue constructed from this in the second stge. The filure rte is very high (31). We construct tue from the medin rphe of the scrotum in the first stge nd ury the penis in the scrotum. As these ptients re dolescents or dults nd hd severl ttempts t repir, they re very nxious. We feel tht if they cn pss urine from the tip of the glns fter the first opertion, it provides gret morl oost. After 3 to 6 months the penis is relesed from the scrotum. This hs given us excellent results (Fig. 6). The medin rphe hs very few hirs, nd the hir-ering urethr is in the pendulous prt of the penis, hence pooling of urine does not occur, unlike when scrotl skin is used in the ulr urethr. We hve not encountered stone formtion or hir lls since we strted using this technique 15 yers go. The long-term results during the lst 15 yers hve een encourging (Tle III). I wish to thnk my surgicl ssocites, Dr Mukul Grg, Dr G G Singhl, Dr Kishore Pnjwni, Dr Anil Ydv, Dr Lkhn Singh nd the nesthesiologists Dr Smit Sne, Dr Yogesh Kumr Singh nd Dr Vnml Ydv for their help in mnging these ptients.

8 168 H S Asop References 1 Bckus LH, Defelice CA. Hypospdis: then nd now. Plst Reconstr Surg 1960; 25: Dieffench JF. Guerision des fenles congenitles del Verge, de Hypospdis. Gz hed de med 1837; 5: Duckett JW, Hypospdis. In: Wlsh PC, Retik AB, Stmey TA, Vughn ED, eds. Cmpell's Urology, 6th Edition. Phildelphi: WB Sunders Co, 1992: Devine CJ Jr, Horton CE. A one stge hypospdis repir. J Urol 1961; 85: King LR. One stge repir without skin grft, sed on new principle: chordee is sometimes produced y skin lone. J Urol 1970; 103: Duckett JW. MAGPI (metoplsty nd glnuloplsty): procedure for sucoronl hypospdis. Urol Clin North Am 1981; 8: Arp S, Mitre AI, DeGoes GM. Modified metl dvncement nd glnuloplsty repir of distl hypospdis. J Urol 1984; 131: Asop HS, Elhence IP, Atri SP et l. One stge correction of penile hypospdis using foreskin tue: preliminry report. Int Surg 1971; 55: Duckett JW. The islnd flp technique for hypospdis repir. Urol Clin North Am 1981; 8: Byrs LT. Technique of consistently stisfctory repir of hypospdis. Surg Gynecol Ostet 1955; 100: Asop R, Asop HS. One stge repir of hypospdis using doule islnd preputil skin tue. Indin J Urol 1984; 1: El-Ksy AW, El-Beily H, El-Hly R, Nowier A, Mged A. Urethroplsty using trnsverse penile islnd flp for hypospdis. J Urol 1986; 136: Prsons K, Aercomie GF. Trnsverse preputil islnd flp neo-urethroplsty. Br Jf Urol 1984; 25: Frey P, Binchi A. One stge preputil pedicle flp repir for hypospdis: experience with 100 ptients. Prog Peditr Surg 1989; 23: Asop HS, Elhence IP, Asop R. One stge repir of hypospdis using foreskin tue. Ann Peditr Surg 1984; 1: Hodgson NB. Use of vsculrised flps in hypospdis repir. Urol Clin North Am 1981; 8: Gittes RF, McLughlin AP III. Injection technique to induce penile erection. Urology 1974; 4: Duckett JW. The current hype in hypospdiology. Br J Urol 1995; 76: Rnsely PG, Duffy PG, Wollin M. Bldder exstrophy closure in epispdis repir. Opertive Surgery-Peditric Surgery, 4th Edition. Edinurgh: Butterworths, 1989: Mollrd P, Mouriqund P, Felfel T. Appliction of only islnd flp urethroplsty in penile hypospdis with severe chordee. Br J Urol 1991; 68: Mouriqund PDE, Persd A, Shrm S. Hypospdis repir: current principles nd procedures. Br J Urol 1995; 76: Smith ED. Durhm-Smith repir of hypospdis. Urol Clin North Am 1981; 8: Fuqu F. Renissnce of urethroplsty: the elt technique of hypospdis repir. J Urol 1971; 106: Wcksmn J. Use of the Hodgson XX (modified Asop) procedure to correct hypospdis with chordee: surgicl technique nd results. J Urol 1986; 136: Stndoli L. One stge repir of hypospdis: preputil islnd flp technique. Ann Plst Surg 1982; 9: Erdley I, Whitker RH. Surgery for hypospdis fistul. Br J Urol 1992; 69: Horton CE Jr, Horton CE. Complictions of hypospdis surgery. Clin Plst Surg 1988; 15: Goldstein HR, Hensle TW. Simplified closure of hypospdis fistule. J Urol 1981; 18: Sd MH, Khoo CTK, Lochilis AS. A simple technique for repir of urethrl fistule y Y-V dvncement. Br Jf Plst Surg 1980; 33: Geltzeiler J, Belmn AB. Results of closure of urethrocutneous fistule. Jf Urol 1984; 132: Keting MA, Crtwright PC, Duckett JW. Bldder mucos in urethrl reconstruction. J Urol 1990; 144: Received 16 July 1997