SNODGRASS Surgical Atlas Snodgrass technique for hypospadias repair

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1 Originl Article SURGICAL ATLAS SNODGRASS Surgicl Atls Snodgrss technique for hypospdis repir WARREN T. SNODGRASS Deprtment of Peditric Urology, Children's Medicl Center of Dlls nd University of Texs South-western Medicl Center t Dlls, TX, USA ILLUSTRATIONS y STEPHAN SPITZER, INTRODUCTION Options for urethroplsty in children with hypospdis cn e clssified s tuulriztions of the urethrl plte, skin flps nd grfts. Throughout the history of surgery for this condition flps hve een most commonly used, ut in the pst 10 yers incision nd tuulriztion of the urethrl plte (tuulrized incised-plte, TIP) hs rpidly gined populrity for correcting distl, proximl nd re-opertive hypospdis. TIP potentilly simplifies oth decision-mking nd surgicl technique, nd hs low compliction rte with etter cosmetic results. However, creful ttention to surgicl detils nd wreness of contrindictions to the procedure re needed to chieve optiml results. PATIENT SELECTION Essentilly ll ptients with midshft nd more distl hypospdis cn undergo TIP of the urethrl plte. Those whose pltes re deeply grooved to ner the underlying corpor cvernos do not need midline plte incision, except to remove ny trnsverse wes tht might deflect the urinry strem, wheres most with flt or only modertely grooved plte enefit from the relxing incision to crete n dequtely sized neourethr. Mny cses of proximl hypospdis cn lso e corrected y TIP, ssuming ny ssocited ventrl curvture is strightened without trnsecting the urethrl plte, nd tht the incised plte ppers supple. Similrly, TIP is n option for reopertions if the urethrl plte hs not een excised previously nd still ppers helthy without gross scrs. In otherwise helthy infnts orn full-term hypospdis cn e repired, s n outptient procedure, s erly s 3 months of ge, nd is proly est completed efore the child develops genitl wreness t 18 months old. Preopertive hormonl stimultion is given when the glns ppers smll, which is most common in oys with proximl defects. Specific instruments nd mterils used for hypospdis repir include: Opticl mgnifiction (loupes); Mrking pen; 0.5 Cstro-Viejo forceps; Cstro-Viejo needle driver; 69 Bever sclpel; Tenotomy scissors; 6 F silicone stent; 5 0 polypropylene suture; 6 0 polydioxnone; 6 0 nd 7 0 polyglctin sutures; 1 : 1000 nd 1 : nordrenline. Ptients re positioned supine for surgery. In distl repirs either dorsl penile or cudl nerve lock is given efore eginning the opertion, while cudl lock is preferred for proximl cses BJU INTERNATIONAL 95, doi: /j x x 683

2 SNODGRASS Figure 1 A 5 0 polypropylene suture is plce into the glns for trction nd to lter secure the urethrl stent. The initil skin incision depends upon whether the fmily prefers circumcision or foreskin reconstruction, s either cn e performed. When circumcision is the desired result cre is tken to preserve sufficient inner prepuce so tht so-clled mucosl collr cn e pproximted in the ventrl midline fter glnsplsty. Then the penis is degloved to ner the penoscrotl junction. If the foreskin is to e reconstructed the skin incision extends from the corners of the dorsl preputil hood to 2 mm proximl to the metus. Ventrl shft skin is relesed until norml drtos tissues re encountered. An rtificil erection confirms the sence of ventrl curvture, ut if there is significnt ending midline dorsl pliction is done using single 6 0 polydioxnone suture plced in the tunic lugine of the corpor cvernos directly opposite the point of mximum curvture BJU INTERNATIONAL

3 SURGICAL ATLAS Figure 2 Next, longitudinl incisions re mde long the visile junction of the glns wings to the urethrl plte. Proposed lines for incision re first infiltrted with 1 : nordrenline or tourniquet is used round the se of the penis for hemostsis. After mking the skin incision with the 69 Bever sclpel, I prefer to complete the dissection nd glns wings moiliztion using tenotomy scissors, tking cre oth to preserve vsculrity to the urethrl plte nd sufficient thickness for the wings to e securely pproximted BJU INTERNATIONAL 685

4 SNODGRASS Figure 3 The key step in the procedure is midline incision of the urethrl plte. This mnoeuvre is fcilitted y counter-trction mintined y the surgeon nd ssistnt long opposite mrgins of the plte. Using tenotomy scissors, the relxing incision is mde from within the metus to the tip of the urethrl plte. It should not e crried further distlly into the glns. The depth of incision depends upon whether the plte is grooved or reltively flt, ut in ll cses extends down to ner the corpor cvernos. Figure 3c: A 6 F Silstic stent is pssed into the ldder nd secured to the glns trction suture. Then the urethrl plte is tuulrized eginning t the neometus, using 7 0 polyglctin suture. The first suture is plced through the epithelium t point just distl to the midglns so tht the metus hs n ovl, not rounded, configurtion. Tuulriztion is completed with running two-lyer suepithelil closure, turning ll epithelium into the neourethrl lumen. c BJU INTERNATIONAL

5 SURGICAL ATLAS Figure 4 A drtos pedicle flp is dissected from the preputil hood nd dorsl shft skin in ptients undergoing circumcision, then utton-holed nd trnsposed ventrlly to cover the entire neourethr. When the foreskin is reconstructed this lyer is not ccessile, yet there hs een no incresed incidence of fistul in my experience BJU INTERNATIONAL 687

6 SNODGRASS Figure 5 Glnsplsty is key determinnt of the finl cosmetic outcome. Over the yers my technique hs developed, nd currently egins with 7 0 polyglctin suture through the epithelium t the desired point for the ventrl lip of the metus. A second 7 0 suture is plced suepithelilly in this sme loction to further uttress the neometus nd hopefully prevent prtil dehiscence tht would result in lrger thn norml metus. No ttempt is mde to secure the glns to the underlying neourethr. The reminder of glns pproximtion is then done using interrupted 6 0 polyglctin suepithelil sutures proximlly to the coron. It is not necessry to plce sutures through the epithelium of the glns, nd I hve seen few ptients develop suture trcks when second lyer ws creted BJU INTERNATIONAL

7 SURGICAL ATLAS Figure 6 Skin closures lso use suepithelil 7 0 polyglctin sutures to minimize the risk of suture trcks. During circumcision the dorsl hood is incised down the midline to the level of the sucoronl collr of the inner prepuce. This point is sutured, nd then the ventrl shft skin is pproximted up the midline, simulting the norml medin rphe. Excess skin is next excised nd remining edges sutured. When the foreskin is reconstructed the inner prepuce is first closed with interrupted sutures, then drtos is pproximted, nd finlly the outer shft skin is sewn, giving three-lyer closure. A Tegoderm dressing is pplied nd the stent is left open dripping into diper BJU INTERNATIONAL 689

8 SNODGRASS Figure 7 I recommend initilly mintining the urethrl plte in ll proximl hypospdis repirs, s even pprently severe ventrl curvture sometimes cn e strightened without trnsecting the plte. The skin incision should e mde immeditely next to the plte to minimize the risk of incorporting hir follicles into the neourethr. Similrly, the foreskin lso cn e preserved t the eginning of surgery s curvture is ssessed, lthough in mny ptients it will e necessry to completely deglove the penis nd ultimtely circumcise it. My experience with foreskin reconstruction in oys with proximl defects is limited, nd desire to void circumcision should not outweigh the need to correct significnt ventrl curvture tht might lter impir sexul function. After degloving, the corpus spongiosum longside the urethrl plte is dissected off the underlying corpor cvernos. This tissue lter will e pproximted over the neourethr s rrier lyer ginst fistul, nd its moiliztion sometimes lso lessens the extent of ventrl penile ending. Then n rtificil erection is creted; persistent mild curvture is corrected y midline dorsl pliction, s descried ove. More severe ending next leds to dissection under the entire urethrl plte, nd if it still persists, to trnsection of the plte nd, in my hnds, stged urethroplsty BJU INTERNATIONAL

9 SURGICAL ATLAS Figure 8 A midline incision of the penile spect of the urethrl plte is mde to ssess the helth of this tissue. In very few cses the incised plte hs ppered less supple nd poorly developed, nd this finding hs led to excision of the unhelthy plte nd stged repir. Note tht the glns is left undistured until this point, s even when the penile urethrl plte hs seemed undesirle for urethroplsty, the glndulr spect hs een supple nd could still e incorported into the neourethr. When the incised plte is stisfctory, glns wings re next dissected from the urethrl plte s descried for distl repirs. This spect of the plte is then incised in the midline in preprtion for tuulriztion. c 2005 BJU INTERNATIONAL 691

10 SNODGRASS Figure 9 A 6 F stent is pssed into the ldder; occsionlly there my e difficulty negotiting the ctheter pst n enlrged utricle, nd in this sitution cystoscope is introduced under vision into the ldder nd wire plced over which the stent cn e mnoeuvred. To crete the longer neourethr in proximl repirs, I prefer two-lyer, 7 0 polyglctin suepithelil closure, the first using interrupted sutures nd the second running suture. Cre is tken to turn ll visile epithelium into the neourethrl lumen. Then the previously moilized corpus spongiosum is closed, followed y coverge of the repir y drtos pedicle flp. Glnsplsty follows nd then skin closure. Significnt penoscrotl trnsposition is lso corrected t this point. Next Tegoderm dressing is pplied. After proximl repirs I further immoilise the penis with mild compression dressing consisting of smll guze squre plced onto the ventrl spect of the penis tht is held in plce y second, lrger Tegoderm dressing ginst the lower domen BJU INTERNATIONAL

11 SURGICAL ATLAS POSTOPERATIVE CARE Dressings fll off spontneously within few dys. Sponge thing nd ntiiotic therpy with sulphmethoxzole-trimethoprim re dvised until the stent is removed, which is usully week fter surgery. Children ged <2 yers cn e mnged with cetminophen nd iuprofen, while older ptients re dditionlly prescried hydrocodone for pin. Oxyutynin is lso provided to oys ged >2 yers to prevent ldder spsms from the stent. When the foreskin hs een reconstructed prents re dvised not to ttempt to retrct it until the surgeon hs determined tht oedem nd tissue rection hve sufficiently susided. SURGEON TO SURGEON As with other techniques, the most common compliction from TIP urethroplsty is fistule. These cn e lrgely prevented y turning epithelium into the neourethr, using sufficient rrier lyers, nd voiding metl stenosis. My incidence of fistule with distl repirs is 2%, ut initilly ws much higher with proximl TIP. At tht time I ws closing the neourethr with single running suture through the epithelium. Since dopting two-lyer suepithelil closure nd dding corpus spongiosum s n dditionl rrier lyer, the numer of fistule fter proximl urethroplsties hs diminished y more thn hlf. After TIP re-opertions fistule hve occurred most often when drtos flp ws not used, nd the tempttion to simply pproximte djcent drtos in the midline over the neourethr should e resisted. Consequently, now I crete ventrl drtos flp to cover the neourethr, nd if tht tissue is not ville, tunic vginlis is used. Metl stenosis hs een noted in some reports of TIP, ut is rre postopertive finding in my ptients. Proly most importnt in voiding this compliction is tking cre not to tuulrize the neourethr too fr distlly. As mentioned ove, the neometus should e ovl nd not round. Other key mnoeuvres include incising the plte deeply to ner the corpor cvernos, so the neourethr will hve n dequte dimeter, nd resisting the tempttion to extend the relxing incision into the glns, s this will lso led to tuulrizing the plte too fr distlly. Metl dilttion fter surgery is not necessry. During the pst decde I hve repired ll midshft nd distl hypospdis y tuulrizing the urethrl plte, nd conclude tht this technique cn e used regrdless of metl configurtion or urethrl plte width nd depth. The min limittion to TIP in more proximl hypospdis is the occsionl need to trnsect the plte to strighten curvture. Rrely the urethrl plte cn e preserved ut its incised ppernce is unhelthy, seeming thin nd inelstic. Twice when confronted with this sitution I nevertheless tuulrized the plte, resulting in complete dehiscence once nd contrcture of the neourethr with ventrl curvture in the other. TIP should only e considered when the penis is redily strightened with no tension on the urethrl plte, nd the incised plte resemles tht in distl repirs. Similrly, TIP is n option for reopertions when the plte remins supple, even fter previous incision, ut otherwise should e voided. Within these limittions TIP urethroplsty is verstile procedure with no more complictions thn other procedures used in hypospdis surgery. However, its widespred cceptnce hs risen from the oservtion tht tuulriztion of the urethrl plte most relily cretes verticl slit-like neometus. Consequently, currently it is the gol of hypospdis repir oth to restore good function nd norml ppernce to the penis. Correspondence: Wrren T. Snodgrss, Deprtment of Peditric Urology, Children's Medicl Center of Dlls nd University of Texs South-western Medicl Center t Dlls, Dlls, Texs, USA. e-mil: wrren.snodgrss@childrens.com wrren.snodgrss@childrens.com 2005 BJU INTERNATIONAL 693

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