A versatile two-stage hypospadias repair

Transcription

1 British Journal ~1 Plasth" Surger.l' (1995) ,~'~ 1995 The Brilish Association of Plastic Surgeons BRITISH JOURNAL OF ( ~ J PLASTIC SURGERY A versatile two-stage hypospadias repair A. Bracka West Midlands Regional Plastic" and Jaw Surgel 3, Unit, Wordsley Hospital, Stourbridge, UK SUMMA R Y. One-stage repair of hypospadias is currently fashionable and is undoubtedly attractive in concept but the methods that are presently available all have inherent limitations and drawbacks. The author presents a two-stage method which offers a unique combination of versatility, reliability and refinement, and can be used for almost any hypospadias deformity, be it primary repair in a child or salvage surgery in an adult. A personal series of 600 cases is analysed. A universally accepted hypospadias repair remains an elusive goal because 11o method as yet can fulfil all the requirements of the ideal operation. Every method compromises on one or more of our principal objectives and the choice will be influenced by the surgeon's perception of where the priorities should lie. Inevitably there will be differences of opinion as to the optimum balance between achieving the most sophisticated result lbr the patient and having an operation which is quick, simple and reliable for the surgeon. Short-term satisfaction can be achieved by the traditional ventralising repairs which create a dystopic meatus on the underside of the glans or corona. These operations used to be popular because of their technical simplicity but adult follow-up studies have shown the long-term outcome to be disappointing. ~ Contemporary surgeons now accept that terminalising repairs, which split or tunnel through the glans to create a true terminal meatus, will function better in the long term and also have the potential for a more natural appearance. How is this best achieved; in one stage or two? Armed with a diyerse array of one-stage repairs such as the MAGPI, distally based "'flip flaps", tubed or onlay preputial island flaps and tubed free mucosal or full thickness skin grafts, one can in principle deal with most hypospadias deformities in a single operation. Conceptually this is most attractive, but in practice many surgeons find that the potential benefits are offset by the drawbacks. For this reason, the author has preferred a twostage repair, and has used such a method successfully on more than 600 patients during the last 10 years. An increasing number of plastic surgeons are now realising that, whilst seemingly outmoded in concept, two-stage repair does offer a realistic alternative which has some very worthwhile advantages. Firstly, there is unrivalled versatility. All single stage repairs have a limited range of application and therefore to deal with the full spectrum of hypospadias one has to master a variety of quite unrelated procedures and all the decision making that goes with them. By contrast, the two-stage method deals with everything from minor coronal hypospadias, through to the most severe proximal cases, even if circumcised or having already been the victim of multiple failed repairs. Two-stage repair also compares favourably on complications and ease of execution. Whilst there are gifted technicians who claim very low morbidity with one-stage methods, the average surgeon may struggle to get a nice result, and a frequent need for revisional procedures often negates the theoretical advantage of these repairs. One-stage tubes have an inherent tendency to stricture, both at the junction with the native urethra and also at the meatus which therefore often finishes up as a puckered orifice rather than a normal slit. Attempts to prevent contraction of the meatus by coring out erectile tissue or turning in triangular glans flaps further compromise the appearance of the glans. Two-stage repair avoids this problem, producing a natural slit-shaped terminal meatus and an overall sophistication of result which is hard to match with the one-stage techniques. Principles of repair The use of full thickness grafts of preputial skin in hypospadias repair is long established; it was described by Humby in 1941.'-' This concept is however widely associated with Cloutier, who modified the first stage of the Denis Browne repair by splitting the glans and lining it with a Wolfe graft of inner preputial skin to allow subsequent terminalisation of the meatus. :~ This theme was then developed by others, notably Nicolle 4 who preferred to tube the urethra at the second stage, using the method described by Byars) More recently Turner-Warwick ~ and Rabinovitch ~ have advocated similar principles. The technique described here is but a further refinement and evolution of existing concepts and therefore does not claim substantial originality. What is the ideal age at which to operate? Many surgeons now recommend early intervention during the first year of life, on the basis of rather contentious paediatric psychology theories. With improving standards of paediatric anaesthesia this may be a reasonable option, provided that one can be confident of 345

2 346 British Journal of Plastic Surgery avoiding the need for hospitalisation during the developmentally difficult phase that children start at around 18 months. The author therefore prefers to delay treatment until the age of 3 years, by which time the child should be out of nappies and improved levels of co-operation and maturity make for a happier and more manageable patient. An adult follow-up study showed that, provided treatment is completed by school age, unpleasant memories ofhospitalisation are not a significant problem and that the subsequent psychosexual adjustment is determined more by the quality of the repair, rather than how or when it was achieved. 1 Stage 1 Surgery is performed under general anaesthesia but supplemented with a bupivacaine local anaesthetic caudal block or penile block. This ensures a quiet painfree recovery, allowing for a lighter anaesthetic without the need for intraoperative opiates, and thereby minimises the risks of postoperative vomiting and bleeding. The patient is positioned at the lower end of an ektended operating table, allowing the surgeon and assistant to sit comfortably with their legs under the table and with their forearms and wrists adequately supported for optimum control of fine movements. The use of small "supercut" scissors and delicate ophthalmic or microsurgical toothed forceps ensures accurate and atraumatic tissue handling. I have not found a'need for optical magnification but some may find that loupes are helpful. Vasoconstrictor infiltration has not been employed ; most of the surgery is performed under tourniquet using a length of soft latex catheter clipped around the base of the penis. The tourniquet should not be so tight as to obstruct the passage of a urethral catheter. Tourniquet times of up to 90 rain in difficult salvage cases have so far caused no problems. Figure I A shows a straightforward distal hypospadias which will be used to illustrate a routine repair. Unless a natural erection has already been observed, a preliminary saline erection test is essential to assess the degree of chordee, which can often be far greater or sometimes much less than one would expect from the feel and appearance of the penis. An axial line is drawn from the proposed dorsal limit of the new meatus down to the ectopic meatus. So as not to extend the midline glans split too far dorsally, it is important when planning the markings to pull a ventrally tethered glans up into its normal alignment. Lateral incision lines extending from the midline are drawn in the subcoronal region. To facilitate surgery, 4/0 nylon stay sutures are placed superficially on either side of the midline just below the proposed ventral limit of the meatus. A third shorter suture takes a deep bite of the dorsal glans and is used for traction purposes. At this stage, although the defect has not yet been created, it is often easier to take the preputial Wolfe graft, whilst the glans is still intact. With the preputial hood stretched out, the required donor area is marked, erring on the generous side (Fig. 1B). Many hypospadic penises still have residual adhesions between the foreskin and proximal glans and when these have been peeled apart it is better to discard any flimsy, raw areas within the donor site if there is plenty of intact skin available. The marked area of skin is incised, dissected offwith scissors, and then carefully thinned out over a finger to remove all surplus areolar connective tissue. This should leave a translucent membrane which is stored in a saline-moistened swab for later use. Returning to the ventral aspect of the penis, a proximal (ventral) meatotomy is performed if the meatus will not readily accept a size 14/18F Clutton sound. With incisions through the marked midline and lateral lines, clefting of the glans using a No. 15 blade and sharp dissecting scissors is a relatively bloodless procedure under tourniquet. It should be deep enough so that the distal ends ofthe two corpora cavernosa are clearly demarcated. Release of chordee may entail dividing quite well formed vascular bands of laterally diverging aberrant corpus spongiosum (Fig. I C), and the lateral incisions will often be in continuity with the skin graft donor site on the inner prepuce. Although not illustrated here, more recently it has become usual practice to extend the midline incision right back into the dorsal margin of the meatus, thereby allowing a V- shaped inset of the graft and reducing the likelihood of a junctional stenosis. The erection test can be repeated and if there is still any inherent residual curvature in the corpora despite complete clearance of the restricting chordee tissue then transection of the ventral tunica albuginea may produce some further straightening. Otherwise, minor residual chordee can be dealt with at the second stage using a dorsal Nesbit procedure. With the lateral stay sutures holding the glans open, the preputial graft is accurately tailored into the defect using 7/0 plain catgut (Fig. I D). Whenever possible, sutures should be limited in the proposed meatal area to one in the midline of the cleft and one at each ventral extremity, so as not to mark the meatal margins. The dimensions of the graft should not be overgenerous; it should fit snugly on the stretched out defect and should not heap up into folds when the tension is released. If the graft is of significant length, a few midline 7/0 plain catgut quilting sutures along the shaft, and one in the base of the glans split will help to avoid shearing of the graft on the wound bed. A firm "tie-over" dressing will usually ensure that no haematoma can collect under the graft. For this purpose a small roll of tulle gras or similar material is used, ensuring that it is wide enough to keep the edges of the glans well separated, so as to facilitate subsequent removal of the dressing. The two lateral stay sutures are used to make the first tie-over. Further looped 4/0 nylon sutures pick up the graft/skin margins and tunica on either side, and are tied snugly over the bolus dressing, with the knots in the midline for subsequent easy removal (Fig. 1E). An 8F Foley urethral catheter is passed (as a precaution against reflex urinary retention in the early postoperative period), the traction stitch removed, and only then is the tourniquet released to allow hae-

3 A versatile two-stage hypospadias repair 347 Fig. I Figure I--Stage I. {A) Preoperative markings. (B) Wolfe graft donor site marked on the inner prepuce. (C) Defect produced after clefting of the glans. (D) Defect resurfaced with preputial graft. (E) "Tie-over'" dressing in place, before release of the tourniquet. mostasis and closure of the preputial donor site with a few 7/0 plain catgut sutures. The catheter is taped to the abdominal skin and the penis immobilised against the abdominal wall with a non-stick absorbent dressing and Micropore(3M) tape. Despite minimal intraoperative haemostasis, prolonged bleeding requiring further intervention has been exceptionally rare. Trimethoprim antibiotic prophylaxis is started preoperatively. After the catheter has been removed in the bath, usually on the second day, antibiotic prophylaxis is discontinued and the child is allowed to mobilise more. Although the "tie-over" dressing will then get soaked on micturition, this does not matter. On the 5th day, the surgeon removes the "tie-over" dressing on the ward and this is facilitated if the patient has been sedated and the penis wrapped up with EMLA, a local anaesthetic cream, for an hour or so beforehand to provide topical analgesia. It is rarely necessary for a 3-year-old of normal maturity to require general anaesthesia for this procedure, whereas in younger or developmentally immature patients compliance is often poor. After removing support from the graft, strict bed rest is encouraged for the rest of the day to minimise the chances of a secondary bleed and the patient can then go home. The parents are instructed on the use of a cotton bud and some antiseptic ointment to make sure that the glans margins do not stick together in the early postoperative period. Although we find it convenient to keep patients in hospital for 6 days after their operation, if pressure on beds or other factors dictate then many could probably go home after the catheter comes out and return as day cases for removal of the '" tie-over" dressings.

4 348 British Journal of Plastic Surgery Stage 2 Re-admission is usually 6 months after the first stage by which time the graft will be soft and mature and unlikely to undergo any contraction. Six months is a convenient time scale on which to plan, though in many of the minor cases it would be perfectly feasible to proceed several months earlier, and conversely in some of the more extensive adult salvage cases requiring grafts of non-preputial skin it may be wise to wait a few months longer. Figure 2A shows the smooth supple graft bed from which the neourethra will be tubed. The edges of the resurfaced glans split are well demarcated, mature and unmarked by sutures so that, unlike with one-stage methods, a slit shaped meatus can be accurately designed, which will neither contract nor stick together in the postoperative period. If the glans split is ill defined or contains a surplus of loose wrinkled skin, this suggests that either the defect has been overfilled with graft, 6r that the underside of the graft had not been adequately cleared of areolar tissue, or thirdly it may be the result of an organised haematoma under the graft. Anaesthesia is as before, and if any chordee release was necessary at the first stage, a repeat erection test is performed to confirm that correction is adequate. If some curvature should remain, one has the choice of a further stage 1 operation, or of proceeding with stage 2 and incorporating a dorsal Nesbit correction. A U-shaped strip of skin is marked out from the anterior limits of the new meatus and skirting closely around the old meatus. About 1.5 cm width is sufficient (up to 2.5 cm in an adult). A size 8F all silicone Foley catheter (up to 12F in adults) is then passed (Fig. 2B). If possible, the operation is done under tourniquet and the tourniquet should not be so tight as to obstruct passage of the catheter. After incising the edges of the ventral strip, any surplus graft laterally can be excised from the glans margins and shaft, and the incision continues around the dorsal surface of the penis at a subcoronal level to allow mobilisation of the skin envelope along the Buck's fascia plane down to a level proximal to the ectopic meatus. The isolated graft strip will usually tube comfortably around the catheter without the need for significant undermining of the edges. The meatus is reconstructed first, by joining the ventral points with a 7/0 vicryl suture. The rest of the urethra is then tubed with a combination of interrupted and continuous inverting extraluminal 7/0 vicryl (Fig. 2C). A potential problem with this Byars repair is that the urethral suture line faces the overlying skin closure and is therefore at significant risk of fistula formation. This was indeed the case in the early part of the series with 5 fistulae arising in the first 24 cases. However gradual evolution of the operative technique and aftercare, particularly with greater emphasis on "'waterproofing" manoeuvres, has largely eliminated the fistula problem. The account given here describes the operation as currently practised. If the meatus is very distal and there is no shortage of ventral skin, then a tongue of subcutaneous tissue pulled up and anchored inside the base of the glans split will ensure that the critical coronal junction is protected once the glans and skin are closed. Durham Smith similarly used a de-epithelialised area of a ventral flap to overlap the urethral suture line." When the meatus is more proximal, and a midline ventral skin closure is required, separation of the urethral suture line from the overlying skin can usually be achieved by covering the urethroplasty with a proximally based flap of preputial subcutaneous tissue, transposed around the shaft to the ventral surface. This has been by far the most frequently used "'waterproofing" manoeuvre and is therefore the method that is illustrated. Where. in a severe hypospadias oz" in a "'salvageplasty" situation, there is insufficient penile subcutaneous "" waterproofing'" tissue available, and particularly if there is any rotation deformity to correct, then twisting the skin envelope to offset the axial suture line laterally is helpful. Alternatively, extending the skin incision proximally along the scrotal raphe, exposes the midline lilscial septum. An anteriorly based longitudinal flap of this vascular fascia can be turned up to provide subcutaneous cover for at least the proximal penile shaft and sometimes the whole repair if the penis is short. In the rare situation where there is insufficient penile skin to effect a safe closure, the flap can also carry with it an island of midline scrotal skin. Augmenting the ventral skin closure is cosmetically preferable to making unsightly dorsal releasing incisions. Figure 2D shows a "'waterproofing" flap marked out on the subcutaneous aspect of the mobilised dorsal skin. The pedicle is dissected well proximally so that the flap can be transposed to cover the whole neourethra without creating torsion or tension (Figs 2E, F). The flap is sutured in place with 7/0 vicryl. The glans is closed over the flap using 7/0 vicryl for deep approximation and small sutures of 7/0 catgut for the skin. Only when the glans has been repaired and surplus skin excised is the tourniquet released to allow haemostasis before completing the skin closure with 7/0 catgut (Fig. 2G). 7/0 catgut is greatly preferred to the more widely available and cheaper 6/0, because the likelihood of suture tunnels and unsightly marks in the skin is reduced. Whilst hitherto this has only been available on special order, Ethicon Ltd have now added it to their standard range. Should the foreskin be reconstructed'? Whilst in our society this may be deemed as aesthetically desirable, in practice it is difficult to combine natural appearance with normal function. Some refashioned foreskins may look good, but I have found that they often have to be removed later because of discomfort or difficulty with retraction during sexual activity. In the majority of cases it is better to settle for a tidy circumcision, particularly as this method of hypospadias repair can achieve a natural looking glans. Figure 2H shows a dressing of tulle gras and circumferential polyurethane sponge which can be left in place for several days. Whilst I am not convinced that the choice of dressings is particularly important,

5 A versatile two-stage hypospadias repair 349 ". i; - " '~.". L Fig. 2 Figure 2--Stage 2. (A) Well defined margins of glans cleft 6 months after 1st stage. (B) Preoperative markings. (C) Tubing of neot, rethra completed (DI Design of oblique, proximally based "'waterproofing" flap on the subcutaneous aspect of the mobilised preputial hood. (E. F) Flap transposed ventrally to cover entire urethroplasty, with a tip of the flap extending up into the ghms. (G) Surplus tissue excised and skin suturing complete. (H) Dressi,lg and fixation of catheter. (I) The healed result 2 months later

6 350 British Journal of Plastic Surgery IIIXI~ l ~'~Ilt:i.t'i~:~lal Fig. 3 Figure 3--(A) Proximal hypospadias with severe ventral tethering. (B) After Ist stage repair with long preputial Wolfe graft. (C) Healed result to show natural appearance of the glans. having used a variety of techniques with similar success, there are several features of the management which I think do contribute to a reduction in the postoperative morbidity. Firstly, tile use of a small gauge Foley catheter through the repair. This splints the urethra and provides more complete diversion and less bladder spasm than suprapubic drainage. For paediatric use in particular, the extra expense of an all silicone catheter is justifiable, as it will have a larger and more rigid drainage channel than an equivalent gauge latex coated catheter. Secondly, tile use of purpose designed paediatric urine drainage bags rather than the more readily available adult bags. The latter, with their very wide connecting tubes, do not effectively provide siphon drainage and are prone to develop airlocks that lead to pseudo-obstructions and bypassing of urine around the catheter. Thirdly, the catheter is strapped securely up on the abdominal wall so that if the child has an erection or inadvertently tugs on his penis, the catheter will more likely pull on the intact posterior margin of the meatus and not disrupt the ventral reconstruction. In a routine case the catheter can be removed on the 5th or 6th day, though there should be no hesitation about leaving it in longer after a difficult closure or in the presence of excessive bruising and swelling. Because 2 fistulae early in the series were attributable to Bacteroides wound infections, antibiotic prophylaxis with co-amoxiclav (Augmentin*') is used for the second stage in preference to trimethoprim and continued until the catheter is removed. Trimethoprim, with its lower cost and more convenient dosage, however remains the antibiotic of choice for the first stage. Postoperative erections do not seem to be a significant problem for a small child but in the young adult they are at best unpleasant and at worst may damage tile repair. For tile adult, high dosage antiandrogen treatment with cyproterone acetate, 300 mg daily, started at least 10 days preoperatively is helpful in decreasing libido and postoperative erections. If control is still inadequate, desipramine, up to 150 mg daily, is a worthwhile adjunct. It has a more rapid onset of action but with effective dosage there may also be anticholinergic-type side effects. As a further measure, a sharp icy blast from a can of PR Freeze spray (a proprietary cold spray used for the symptomatic relief of minor musculo-skeletal injuries) can reverse unwanted erections. This is kept on the bedside locker for emergency use. Usually the patient stays in hospital until the catheter has been removed and urine passed satisfactorily from the new meatus. Again if circumstances dictate and available home care is of acceptable standard, it is reasonable to allow the patient home 48 hours postoperatively and for him to return as a day case for removal of the catheter. Results Figure 2I shows the early appearance at 2 months. Most patients are seen again once or twice in tile next 2 years and then every few years through to physical maturity. Whilst this creates a significant clinical workload, the true merits of a repair cannot be reliably assessed in childhood, as is very clear from adult follow-up studies. ~" "-' ' Although illustrated on a minor hypospadias, the technique is just as applicable to the severe proximal and perineal cases as seen in Figure 3A. Figure 3B shows the extensive release that has been achieved and the long smooth strip of supple hairless skin that will be excellent material from which to tube a new urethra, and the healed result in Figure 3C. The method is unsurpassed for salvaging the circumcised and skin deficient adult hypospadias "cripple",

7 A versatile two-stage hypospadias repair 351 Fig. 4 Figure 4---(A) Adolescent with unsatisl:,,tctory result from Denis Browne repair. (B) After I st stage salvage with postauricular Wolfe graft. (C) Final result showing the excellent cosmesis that is possible with two-stage salvage surgery. as skin can be imported from a variety of donor sites. Postauricular Wolfe grafts are the best source of extragenital skin, being thin, pliable and non-hairy. Transferring groin or inner arm skin to a vascular glans bed can stimulate latent hair growth, and in my experience these sites are best avoided. Figure 4A shows a 14-year-old in whom a Denis Browne repair has left a distal shaft spraying meatus and no spare skin. A postauricular Wolfe graft was put in at the first stage (Fig. 4B) and the completed repair combines excellent function with normal appearance (Fig. 4C). Complications I have used this two-stage principle of repair as the mainstay of my hypospadias surgery since 1984, though during that time the operative technique and postoperative care have evolved in response to the problems that have been encountered. The method described herein represents current practice, though analysis of results relates to the first 600 cases starting from the very outset and including all the variants which have now been superseded. Follow-up ranges from between 6 months and 10 years. As shown in the Table, this series contains an unusually high proportion of salvage surgery, with more than a third of patients having already had Table 600 two-stage hypospadias repairs CI]ildren Adults 369 primary 88 secondary 457 total 22 primary 121 secondary 143 total previous operations for their hypospadias, and almost a quarter of the patients being adult. The salvage of many hypospadias "'cripples" (one claimed to have undergone 67 previous procedures) is reflected in the complication rates. Fistulae 34 patients required readmission for repair of a fistula, representing a gross fistula rate of 5.7 %, but it is worth noting that 20 of the fistulae occurred during the first 3 years whilst the operation was still evolving. Subsequently, fistulae have averaged at only 2 per year and the vast majority have been minor "'pinhole" leaks, easily repaired with one further procedure. One might expect more complications from the salvage surgery than from the primary cases and this was indeed so. The overall fistula rate for primary repairs was only 3 % whereas for the often more challenging salvage surgery it was 10.5 %. Whilst increasing familiarity and experience with the repair may account for some of the progressive reduction in morbidity, other factors are also relevant. The use of specific subcutaneous waterproofing flaps evolved in response to the relatively high fistula rate at the beginning of the series. The progression from 6/0 to 7/0 suture materials may also be significant. In the early years, urinary diversion was usually discontinued by the 4th day and sometimes earlier because the use of coated latex catheters and adult drainage bags often led to catheter irritation and blockages. With the change to all silicone catheters and paediatric drainage bags, catheters are now left in for longer and have been far less troublesome. Strictures The overall stricture rate in this series was 7 %, which seems disconcertingly high for a two-stage rgpair.

8 352 British Journal of Plastic Surgery However, 28 out of the 41 strictures were of the late onset type presenting between 2 and 5 years after hypospadias repair. These were mostly "'salvageplasty" cases and all of them had histological evidence of balanitis xerotica obliterans (BXO). This little understood disease is the most important cause of late onset stricturing and can be very difficult to manage. Repair with local genital skin inevitably leads to recurrence. Postauricular Wolfe grafts fare much better but still have a significant recurrence rate. Current experience suggests that in these patients salvage is best achieved with buccal mucosa or a combination of buccal and bladder mucosa when there is very proximal urethral disease. Only 13 patients (2 %) had strictures which might be regarded as true surgical complications. Of these, 9 were cured by a single dilatation and in the remaining 4 the strictures were considered sufficiently tight to warrant surgical repair with free patch grafts of full thickness skin (though now I would prefer to use buccal mucosa). achieved primarily and subsequent debulking and tidying up procedures are rarely required. Fears that grafted urethras may not grow adequately have so far been unfounded. Those children who have been followed through their adolescent growth spurt have maintained excellent repairs with no late onset ofchordee or stricturing. Given a smooth urethra with a normal shaped meatus, then misdirection or spraying of the urinary stream are rare. The occurrence of such symptoms would suggest that a stricture has developed and merits further investigation. Traditionally, success has been judged mainly on short-term functional parameters such as fistula and stricture rates. "'Quality" factors such as cosmesis, whilst more subjective and harder to quantify, are nevertheless important for the patient's long term socio-sexual adjustment. A two-stage operation is an acceptable price to pay for a repair that offers the best combination of function, versatility, reliability and aesthetics. Other rerisional surgert" 22 patients (3.7 %) underwent revision of the first stage of their repair, either for further chordee correction and grafting, or improving the definition of the glans split, or enlarging a small meatus. 33 patients (5.5%) underwent further cosmetic adjustments after completion of their repairs. These consisted of tidying up skin irregularities, deroofing suture tunnels, correcting residual rotation deformities or adjustments to the meatus. Many of these procedures might be deemed unnecessary as they were often of no functional consequence and were not a.lways requested by the patient or family. However, having reviewed ~ and treated many young adult hypospadiacs, I have a low threshold for adjusting cosmetic imperfections that are likely to become a source of embarrassment in later life. Discussion Two-stage repair of hypospadias, reconstructing the new urethra with a free Wolfe graft, has proven to be reliable and extremely adaptable and can consistently produce sophisticated results. Reliability means that the desired appearance can be confidently tailored without the need to retain surplus soft tissue (on the assumption that this tissue might come in handy for subsequent fistula or stricture repair). Unlike many other methods of repair, the optimal result is usually References I. Bracka A. A long-term view of hypospadias. Br J Plast Surg 1989: 42: Humby G. A one-stage operation for hypospadias. Br.I Surg 1941: 29: Cloutier AM. A method for hypospadias repair. Plast Reconstr Surg 1962: 30: Nicolle F. Improved repairs in 100 cases of penile hypospadias. BrJ Plast Surg 1976: 29: Byars LT. A technique for consistently satisfactory repair of hypospadias. Surg Gynecol Obstet 1955; 100: Turner-Warwick R. Observations upon techniques for reconstruction of the urethral meatus, the hypospadic glans deformity, and the penile urethra. U rol Clin North Am 1979: 6: Rabinovitch H H. Experience with a modification of the Cloutier technique for hypospadias repair. J Urol 1988 : 139: I Smith D. A de-epithelialised overlap flap technique in the repair of hypospadias. Br J Plast Surg 1973: 26: Sommerlad BC. A long-term follow-up of hypospadias patients. Br J Plast Surg 1975: 28: Farkas L, Hynie J. After effects of hypospadias repair in childhood. Postgraduate Medicine 1970: 47: I. Svensson J. Berg R. Micturition studies a,~d sexual function in operated hypospadias. Br J Urol 1983: 55: The Author Aivar Braeka, FRCS, Consultant Plastic and Genital Surgeon, West Midhmds Regional Plastic and Jaw Surgery Unit. Wordsley Hospital, Stourbridge, West Midlands, DY8 5QX, UK Correspondence to the author. Paper received 9 December Accepted 28 March after revision.