DEFORMITIES OF THE MALE URETHRA

Transcription

1 DEFORMITIES OF THE MALE URETHRA By Sir ARCHIBALD MCINDOE, C.B.E., M.S., M.Sc., F.R.C.S., F.A.C.S. Plastic Surgeon to St Bartholomew's Hospital ; Surgeon-in-charge, Queen Victoria Hospital Plastic Unit, East Grinstead ; Consulting Plastic Surgeon to the Royal Air Force Presented before the Urological Section of the Royal Society of Medicine on 23rd May 1946 RECONSTRUCTIVE surgery is to-day so rapidly growing a specialty that it is not surprising to note its steady advance into fields hitherto closed to it. This invasion is, however, more in the nature of a contribution than a substitution. The plastic surgeon has often been able to solve problems of repair which the specialist regarded as hopeless. He has become, in fact, the specialist's specialist. Thus the particular technique and mental attitude of the plastic surgeon has contributed something to the ophthalmologist, the otolaryngologist, the neurologist, the gynmcologist, and the orthopmdic surgeon. You, as urologists, will probably admit that your specialty offers a fertile field for the plastic surgeon, where reconstructive operations can on the one hand result in doleful disaster, or on the other bring new life and hope to the urologically deformed patient. I need hardly remind you that the man with a defective anterior urethra has a thrice daily reminder of his disability from a urinary standpoint, and while sexually his reminder may not be as frequent, it is no less psychologically potent. Indeed, most of these patients present psychic and sexual inversions of the most surprising kinds, and to them anything which holds a prospect of cure is worth while. It is not the plastic surgeon's province to deal with those urethral conditions involving urinary obstruction, sphincteric control, instrumentation of strictures, and so forth, which are the everyday concern of the urologist. Indeed, it would be presumptuous of him to do so. He can, however, contribute something to the treatment of those partial or complete urethral losses where reconstruction plays a leading part. I propose, therefore, to deal with some of the urethral abnormalities which lend themselves to plastic repair and to indicate the problems which have been most difficult to solve. My experience is fairly limited. In sixteen years I have observed and treated 5o cases, and each one has appeared to present specific difficulties often requiring original methods to deal with unusual situations. As treatment is necessarily prolonged, many of these cases are still unfinished, so that a final analysis would be futile. Rather I would confine myself, firstly, to general principles of repair and, secondly, to the technical details of the methods I have used. The principles are sound ; the methods, however, may in the future be modified or supplanted by others with fewer disadvantages. GENERAL PRINCIPLES I. Anatomieal.--(a) Whatever the cause of the urethral loss, a reconstructed urethra must be regarded as a pipeline of even and adequate calibre sufficient to allow the passage and projection of a normal stream of urine with the patient 29

2 30 BRITISH JOURNAL OF PLASTIC SURGERY standing. A new urethra which produces a spray instead of a stream is a piece of bad plumbing. (b) If the loss of urethral continuity is central and partial, then the anastomosis at each cnd must not contract to produce a stricture. If the loss is terminal, then the proximal anastomosis must be free and the meatal opening must be at the end of the penis--i.e., in the normal position and not below it. This automatically excludes many flap methods of repair. (c) The new urethra must be sufficiently long and elastic to obviate as far as possible penile curvature during erection. It must in effect be the same length as a normal urethra. (d) The lining of the new urethra must not be hair-bearing, otherwise phosphatic deposits occur in later life. (e) Any method used for making a new urethra should not prejudice the cosmetic appearance of the penis. On this point patients are apt to be more than sensitive. This argues against the use of pedicled grafts. (f) The conditions which produce the urethral loss often involve widespread changes elsewhere, l~ecessitating additional repair work. Thus a hypospadiac may have undescended testicles and bilateral hernias which require attention: a penile injury involving the urethra will almost certainly require extensive plastic repair of penis and scrotum, and so on. Thus the anatomical requirements are fourfold. An acceptable repair should overcome penile curvature so that satisfactory sexual intercourse can take place, enable a satisfactory stream to be projected forwards with the patient standing, be devoid of new disabilities such as stricture formation and a growth of intra-urethral hair, and finally be cosmetically satisfactory. 2. Physiological.--Throughout the planning of the repair phase the dual function of the urethra and penis must be kept in mind. Many operations described for urethral repair fail because, while they satisfy the urinary function, they take no account of the sexual aspect. 3. Surgieal.--A well-known textbook of surgery describes hypospadias as an inoperable condition. This is because of the disintegrating effect of urine, and particularly infected urine, on wound healing in the penis. Once the urinary stream bursts through a penile suture line a fistula is bound to develop. Therefore, it can be laid down as axiomatic that during certain crucial stages of urethral reconstruction the urine must be diverted from the operative site. Nevertheless, a suprapubic cystostomy is rarely required, and in this series external urethrostomy is almost the rule. H~ematoma formation and infection are also disastrous, both in operations involving flaps and where free grafts are used. Hence a meticulous technique must be adopted with fine instruments and atraumatic sutures. Nowhere does respect for tissues pay more handsome dividends than in this type of work. Constant attention must be paid during the post-operative phase to the condition of the suture lines, to prevent them from becoming sodden and infected. A "leave-it-alone rtgime" is the prelude to a partial or total breakdown. Each succeeding operation becomes progressively more difficult and hazardous.

3 DEFORMITIES OF THE MALE URETHRA 3I TYPES OF URETHRAL Loss The 52 cases comprising this report were of the following types :-- (a) Penile injury with urethral loss in continuity, resulting in fistula formation of greater or lesser degree--6 cases. (b) Penile amputation-- 3 cases. (c) Congenital short urethra--2 cases. (d) Epispadias--6 cases. (e) Hypospadias~35 cases. THE BASIC PLAN FOR URETHRAL REPAIR All urethral repairs must begin by returning those portions of the urethra left behind to their normal position. The full defect must be established. Hence a preliminary operation to remove scar tissue, congenital as with the urethral cord in hypospadias, acquired as in traumatic lesions, must often be undertaken. The ends to be anastomosed must not be stenosed or fibrosed. It is often easier to insert 5 cm. of new urethra in good tissue than to remake I cm. in bad, and the effect on penile efficiency is correspondingly greater. Of all the methods of reconstructing the urethra, associated with the names of Marion-Duplay, Bucknall, Beck, Ombr4danne, Blair, Nov4 Josserand, Rochet, Mayo, Young, Edmunds and Mclndoe, two have been consistently used by me with satisfactory results. With increasing experience I have found that small defects up to 2. 5 cm. in the course of the urethra are best dealt with by variations of the Marion-Duplay flap method, sometimes called Cantwell's operation, while greater losses give better results with my own free-graft inlay technique, Special situations demand special methods. URINARY DIVERSION As mentioned earlier in almost all cases and at some stage, the urine must be completely diverted from the operative field. The right time for this is at that stage when the continuity of the urethra is finally established and it must be used as a pipeline. Reconstructions over a catheter, using the catheter as a drain, are almost bound to fail. Inevitably the overlying suture line becomes infected, undesirable tension occurs, and breakdown follows. Suprapubic cystostomy does not keep the urethra dry, for the drainage is not dependent and some urine is bound to seep through. Furthermore, it is undesirable to perform suprapubic cystostomy in a child when other methods are available. Almost always I have performed external urethrostomy well behind and below the operative site, passing a catheter into the bladder and so obtaining good dependent drainage for the time necessary for healing to occur. One extra precaution which has been advised, but which I have not used, is to pass a silkworm gut ligature subcutaneously round the urethra just distal to the urethrostomy to ensure perfect dryness. One great advantage of external urethrostomy is that after removal of the catheter the scrotal or perineal fistula closes spontaneously without any trouble, provided it has not been present for more than fourteen to twenty-one days. Incidentally one might point out that the reason why a penile fistula persists is due to the rapid epithelialisation of the thin fistulous edges. In the deeper perineal fistula healing anticipates epithelialisation. At the penoscrotal angle most difficulty is experienced, probably due to the added factor of movement.

4 3 2 BRITISH JOURNAL OF PLASTIC SURGERY PENILE INJURY WITH URETHRAL LOSS IN CONTINUITY RESULTING IN FISTULA FORMATION OF GREATER OR LESSER DEGREE The most frequent cause of this is a sniper's bullet. (I do not include here ruptured urethra from falls or blows--a purely urological condition). It is surprising how few cases occurred during this war (Fig. I). When healed, the pauent presents himself with chordee due to scarring of the corpora cavernosa.or corpus spongiosum and a urethral fistula of anything up to 2.5 cm. in length. FIG. I A, Bullet wound of penis with partial urethral loss 4 cm. in length. B, Repair by Marion-Duplay flap method. There may be fairly extensive loss of erectile tissue of the penis, so that a permanent chordee is certain. Usually, however, careful excision of all scar tissue and establishment of the full urethral defect reduces this to a minimum. This can be done without urinary diversion. Three months later the urethra is reconstructed by longitudinal overlapping flaps, the inner to form a urethral lining, the outer to cover the inner tube. Care is taken to see that the flaps are cut longer on one side than the other so that the suture lines are not directly over each other. Sutures are interrupted 6-o plain catgut on atraumatic needles. Success depends on a meticulous technique, careful reinforcement of the inner row of sutures with a layer of subcutaneous tissue interposed between urethral lining and external skin, and thoroughly efficient diversion of urine by external urethrostomy maintained for fourteen days. In one case both testicles were shot away and the patient :suicidal. Implantation of 800 mg. testosterone propionate, subcutaneously in divided doses, has completely cured this. In another case, reported elsewhere (McIndoe, I937), a most extensive loss occurred well back in the perineum, involving the rectum so that suprapubic cystostomy and colostomy were necessary. The patient had been in hospital for nineteen years. Repair was effected by local lining flaps, rotating gluteal flaps, and reimplantation of the rectum and anal canal.

5 DEFORMITIES OF THE MALE URETHRA 33 FIG. 2 A, Extensive loss of perineal floor, exposing apex of prostate and urethra. The middle third of the urethra is lost. B, (:Edematous rectum projecting between the scarred ischiorectal fosse. C, Repair by lining flaps and rotating gluteal flaps. Closure of suprapubic drain and colostomy. D, Urethra reconstructed. Rectum reset in perineum. Complete sphincteric control. IC

6 34 BRITISH JOURNAL OF PLASTIC SURGERY Subsequently the urinary and intestinal continuity were restored and the patient cured (Fig. 2). PENILE AMPUTATION This, of course, means complete loss of the penile urethra, and repair is a considerable undertaking. Excluding operative amputation for cancer or disease, the condition may be congenital, when it is presumably due to intra-uterine amputation, or acquired as the result of injury. I have seen one example of the former, now beautifully repaired by Sir Harold Gillies, and two of the latter. One of these occurred in a pilot returning from a raid on Germany. A piece of flak penetrated the floor of the aircraft, passed between his legs, and amputated penis, testicles and scrotum (Fig. 3). Otherwise he was uninjured. By a remarkable A, " Flak" wound with complete loss of urethra. Penis, testicles, and scrotum amputated. Suprapubic drain inserted. B, Healed condition ready for penile reconstruction. coincidence repair was unnecessary in this case and, indeed, the patient refused it. He happened to belong to that intermediate sex with a distinctly feminine habitus which would consider male external genitalia superfluous. Nevertheless, when healed, he returned to flying operations and completed another term of duty, for which he was decorated. Those who philosophise upon the anatomy of courage would find difficulty in supporting a theory based on testicular hormones. The third case was the subject of a Japanese atrocity. Intervening between a Japanese naval rating and a Chinese child whom the Jap proposed to rape, he was arrested, removed by a gang to a basement room, pinned to a table through the thighs by bayonets and branded with red-hot cigarette tins. As a final gesture his penis was amputated at the symphysis. Oddly enough the scrotum and testicles were left behind. The condition eighteen months later is shown. Repair was decided upon. An abdominal pedicle I8 cm. long, lined with an inlaid epithelial tube, was constructed from the level of the amputation to the umbilicus. This was allowed

7 DEFORMITIES OF THE MALE URETHRA 35 to resolve and the inlaid tube maintained open with a dilator (No. ISF) for six months. At the end of this time the lower end of the pedicle was joined to the stump of the penis and the urethra, and the new inlaid one anastomosed. Urinary diversion by external urethrostomy was laid on at this time. Three weeks later the upper end of the pedicle was detached and the end shaped to resemble a glans FIG. 4 3-Stage repair of penis and anterior urethra A, Full thickness flap mapped out on abdomen. B and C, Tubed pedicle with free-grafted urethra inlaid along it. D, The same six months later. E, Anastomosis between new and old urethrm. F, Detachment of upper en d of new penis. penis. The new penis functioned perfectly as a urinary passage. The Russian addition of a cartilage graft projecting into the bulbocavernosus was not considered necessary as the patient was satisfied with what had already been accomplished (Fig. 4). He is now back in China and has, I believe, managed to obtain an interview with those responsible for his original condition.

8 3 6 BRITISH JOURNAL OF PLASTIC SURGERY CONGENITAL SHORT URETHRA This is a very rare condition, though I have seen it twice. At first sight it resembles hypospadias, for the penis is short, ventrally curved and bound down. Normal erection is impossible. The distinguishing feature is that the urethra emerges from the meatal dimple in the normal way and not on the ventral surface of the penis as in hypospadias (Fig. 5). Actually the corpus spongiosum and urethra are complete, but are too short when compared with the corpora cavernosa. I believe there is only one sound treatment for this troublesome condition, and B t E F FIG. 5 A, Congenital short urethra, showing intact prepuce and ventral curve. B, The penis is apparently normal but the urethra is short. C, Note difference between hypospadias and congenital short urethra. D, A Ventral fistula resulted from an attempt to stretch the urethra. E, Urethra allowed to assume normal position, establishing gap of 5 cm. Anterior end buried. F, Urethral inlay subsequently anastomosed to posterior end. Result. Full function. that is boldly to divide the urethra and corpus spongiosum ventrally at the level of the corona to straighten the penis fully and to establish the urethral defect, however great it may be, as a partial urethral loss in continuity. The gap, when established, may be 2.5 cm. or it may be more. If it is the former, then a flap reconstruction as for a traumatic defect is indicated ; if the latter, then an inlaid urethral reconstruction, as will be subsequently described for hypospadias, will give the best result. A double anastomosis proximally and distally will, of course, be necessary.

9 DEFORMITIES OF THE MALE URETHRA 37 ]~PISPADIAS Like congenital short urethra, epispadias is a rare condition. It is said to be ten times less common than hypospadias. Many observers would regard epispadias as closely allied developmentally to hypospadias, but this is, I think, a mistake. There are good reasons for such a belief. Epispadias is a failure of the urethra to unite dorsally, and is therefore a midline anastomotic defect allied to cleft lip and palate. Clinically there are three varieties : (a) the urethra is laid open dorsally FIG. 6 A, Ventral surface of penis. B, Dorsal surface showing split urethra. C, Simple repair by local flaps. from the tip of the glans, for a varying degree, as far as the urethral sphincter--the patient is continent ; (b) the urethra is laid open dorsally beyond the urethral sphincter, in which case the patient is incontinent ; (c) the urethra, symphysis, sphincters, and bladder are laid open. The condition is then known as ectopia vesicm. There is a world of difference, to wit continence, between the first and the other two. I should like to quote Keyes, who wisely says of the latter two conditions : " Every urologist must prove at least once that he is unable to close the anterior bladder wall, make a new sphincter, penis and urethra, and close

10 3 8 BRITISH JOURNAL OF PLASTIC SURGERY the symphysis before he is satisfied to accept uretero-intestinal anastomosis as the cure of extrophy. Plastic operations may close the bladder wall, but they do not repair the sphincter, and the stinking patient remains aware of the wit of those elder anatomists who dubbed the sphincters along with the heart and diaphragm, ' the royal muscles.'" As a former assistant of both Hugh Cabot and Charles Mayo, and having helped them in many ureteral transplants for the incontinent epispadiac, I can testify to the value of this operation. The incontinent epispadiac is still best treated by ureteral transplantation. I do not therefore propose to consider epispadias in any other ferm than that of the condition established without incontinence--the sphincters are intact. Here the urethra lies open as a groove along the dorsum of the short spade-like penis. The corpus spongiosum is absent and the two corpora cavernosa are short and loosely attached to each other. The distribution of the prepuce is normal, quite unlike hypospadias. The only resemblance between the two conditions is that while the urethra runs the whole length of the penis it is relatively short and produces acute dorsiflexion during erection, just as the short urethra produces ventral fexion in the hypospadiac. The usual method of treatment, therefore, is to close the ectopic urethra by a simple flap method extending from the tip of the penis to the epispadiac meatus (Fig. 6). This is Cantwell's operation, resembling the Marion-Duplay procedure, and presents little difficulty, but it has one obvious disadvantage. The urethral shortness remains and consequently the acute penile sected and formed into a tube and brought out ventrally between the corpora cavernosa. The patient is now a hypospadiac. dorsiflexion is not corrected. Obeying the general principle of establishing the defect as for congenital short urethra, I now attack the problem in a different way. After dissecting out the ectopic urethra from the tip of the penis to the posterior meatus, I form it into a tube and bring it down ventrally between the corpora Cavernosa as far back as possible, thus converting the epispadias into hypospadias (Fig. 7). This suggestion was made to me by my colleague, Colonel Koch of the Netherlands Army. The effect of this mangeuvre is to lengthen the penis and

11 DEFORMITIES OF THE MALE URETHRA 39 overcome the dorsal shortness. down for hypospadias. The treatment from there on follows that laid HYPOSPADIAS Hypospadias, by far the most common urethral abnormality, presents itself clinically as balanitic, penile, penoscrotal, scrotal and perineal (Fig. 8). At one end of the scale are those mild urethral deficiencies which have little but an a~sthetic significance and which can safely be left alone. At the other end are those FIG. 8 A, Penile hypospadias (almost balanitic), no ventral curvature. Suitable for preputial repair. B, Peno-scrotal hypospadias (pseudo-penile). Most common type. C and D, Pseudo-hermaphrodism. Ventrally fixed small penis, split scrotum, perineal meatus. Undescended testes and bilateral hernim. vulviform types which, with bilateral hernias and undescended testicles, entail multiple operations for their cure and so closely resemble the female genitalia as not infrequently to include a change of sex as part Qf the treatment. These are the pseudo-hermaphrodites. Between these two extremes come the majority of patients with penile, penoscrotal, and scrotal hypospadias, all of whom have from the practical standpoint two essential defects in common ; namely, the dorsal preputial apron with unequal distribution of the dorsal and ventral penile

12 4o BRITISH JOURNAL OF PLASTIC SURGERY skin and a greater or lesser degree of approximation of the glans to the hypospadiac meatus, due to the shortness of the urethral cord replacing the absent portion of the urethra. Developmentally it is clear that the lesion is an obliteration of the corpus spongiosum in its distal portion, for a greater or lesser distance, and its replacement by a fibrous cord. The farther back the process goes the more is the scrotum split to receive the urethra, but never does the process go farther than the sphincter. The hypospadiac is always continent, the epispadiac usually incontinent. The urethra is obliterated distally in the hypospadiac, it is longitudinally and dorsally split in the epispadiac. When the parts are carefully dissected free from the fibrous band or urethral cord which holds them together, so that the penis can be fully extended and the urethra allowed to retreat posteriorly, a high proportion of the penile cases become penoscrotal, the penoscrotal become scrotal, and the scrotal perineal. It is necessary to establish this urethral defect to its widest limits and to make the penis and urethra occupy their normal relationships before attempting to reconstruct the missing portion of the urethra. This part of the problem should be attacked at an early age (2 to 3 years) to enable normal development to proceed. The problem of hypospadias falls thus into two parts. Firstly, the establishment of the urethral defect and the redistribution of the penile skin. Upon the success of this the sexual future of the patient depends. Secondly, the construction of a new urethra which will render the patient potent and able to micturate efficiently. The well-known Ombr6danne procedure entirely neglects these principles. TREATMENT OF ASSOCIATED CONGENITAL DEFECTS As a preliminary to the attack on the hypospadias itself, associated defects must be treated--two in particular: undescended testes and hernias. While injections of testicular hormone will help the former, only operation will cure the latter. It has therefore been iny practice to carry out bilateral herniotomy wherever required and at the same time to anchor the testes to the fascia lata of the thigh by the well-known Meyer-Torek procedure. They are released after six months' traction has established them in the bottom of the scrotum. The hypospadias itself is then dealt with. ESTABLISHMENT OF THE COMPLETE URETHRAL DEFECT AND REDISTRIBUTION OF THE PENILE SKIN The importance of this step cannot be fully realised by those who are satisfied with the effects of ventral transverse incisions, for such a method cannot possibly cure what is, after all, a very complicated defect, and one which lends itself extraordinarily well to the application of correct plastic principles. No operation has been devised which equals that of Edmunds. The criticism has been levelled at it that it requires special technical ability and dressmaking knowledge to accomplish it (Browne) : surely poor reasons for not performing it. Three steps carried out in two operations are essential. Firstly, a tubed pedicle is prepared from the dorsal preputial apron in order to increase its blood supply so that all of this skin may be safely utilised in reconstructing the ventral skin loss. This is done at 2 years of age. One month later the urethral cord and the remains of the corpus spongiosum are completely removed without damage to the corpora cavemosa, and at the same time the hypospadiac meatus and urethra are thrown

13 DEFORMITIES OF THE MALE URETHRA 41 back to that point in the penis, scrotum, or perineum which they would normally occupy. Next the tubed dorsal prepuce is divided medially, unfolded, and the flaps so formed incorporated into the ventral length. The result of these two operations should be overcorrection of the ventral curvature and thorough A B C D FIG. 9 ISt Stage, Edmunds' operation A, The dorsal prepuce is tubed. B and C, The pedicle is divided centrally and opened out. D, The urethral cord is dissected from the corpora cavernosa, so lengthening the penis. E, The dorsal prepuce is transposed to the ventral surface. establishment of the real, as against the apparent, urethral defect (Fig. 9). No further operations are undertaken until the child is 7 to 8 years of age, when the development of the parts warrants urethral reconstruction. In the adult, of course, the operations may follow each other in quick succession, governed only by surgical considerations. E

14 4 2 BRITISH JOURNAL OF PLASTIC SURGERY THE URETHRAL RECONSTRUCTION This is done by the epithelial inlay method described in I935. A thin razor graft is cut from the hairless inner side of the arm and carefully applied, raw surface outwards, like a cigarette paper to a piece of gum-elastic catheter which just fits in width and length the barrel of a special carrier trocar designed in various sizes for the purpose. The graft on its piece of catheter is inserted into the instrument and the cutting point and handle screwed into position. C A B FIG. io Author's operation for urethral repair A, The introducer is loaded with a piece of skin-covered catheter. B, It is passed along the penis. C, The introducer is withdrawn, leaving the graft in situ. With the patient in the lithotomy position a small stab wound is made just distally to the hypospadiac meatus and another at the dimple always present at the tip of the glans. The trocar is then thrust subcutaneously along the penis from the posterior stab incision until the point emerges from the penis. The maneeuvre, which is not easy, can be facilitated by introducing a long slender pair of scissors with Mayo points (McIndoe) in order to divide any fibrous bands which may obstruct the onward passage of the instrument. When it emerges the cutting point is unscrewed and the end of the skin-covered catheter is gripped firmly with a pair of forceps. The barrel of the instrument is carefully withdrawn through the posterior opening, leaving the catheter in place and its skin covering undisturbed. One inch gauze tape soaked in Whitehead's varnish is then bandaged round the penis fairly firmly so that when the dressing sets an efficient casing results which maintains even pressure on the graft and prevents erection of the organ. A catheter is placed in the bladder for forty-eight hours through the

15 DEFORMITIES OF THE MALE URETHRA 43 hypospadiac meatus in order to prevent urine coming in contact with the graft (Figs. IO and II). FIG. II Author's method of repair of hypospadias A, Penis has been straightened by Edmunds' operation. B, Introducer passed along penis to emerge at meatal dimple. C, The ends are unscrewed. D, The skin-covered catheter is slipped into the barrel. E, The barrel is withdrawn and the penis bandaged : catheter in bladder. F, Six months later. Dilator in position and ready for anastomosis. At the end of ten days the casing is removed, the gum dastic catheter is withdrawn, and the skin-lined urethra is syringed through with saline or halfstrength eusol. A permanent dilator of suitable size is then introduced into the new urethra, and at no time is this left out for more than the five or ten minutes required to cleanse the canal It is necessary to make this point absolutely clear to the patient and the parents, for twenty-four hours without the catheter will

16 44 BRITISH JOURNAL OF PLASTIC SURGERY cause hopeless stenosis of the cavity in the early stages. These dilators are made in various sizes with screw-on ivory ends to prevent them slipping out (Fig. 12). FIG. IZ The author's skin graft introducers and dilators The former will carry in the barrel thin skin-covered catheters from 5E to IIE. The dilators are of gum elastic and have " screw on " ivory ends so that they will not slip out. When reinserting them a small olive point is substituted for the ivory end. After six months the contractile phase should be over and the dilator can be safely left out. Anastomosis of the posterior end of the new urethra and the hypospadiac meatus is then performed after urinary diversion by external urethrostomy. The earlier use of a catheter for this anastomosis has now been abandoned. The nearer the perineum the anastomosis is made, the easier it is to perform, for more reinforcing tissue can be got over the opening. If possible, anastomosis is avoided in the penoscrotal angle, a point where end-to-end union is very difficult. Closure is attained by the flap method as described for urethral fistula (Fig. 13). The result of such a series of operations is highly gratifying, and the patient can almost be guaranteed that a normal condition of affairs will be produced

17 DEFORMITIES OF THE MALE URETHRA 45 (Figs. I4 and I5). The appearance from a cosmetic standpoint is much superior to that by any other method, particularly at the meatus, which is placed at its! i '' C Fit. 13 Anastomosis of new urethra to hypospadiac meatus A, Lining flap outlined. B, Lining flaps sutured. C and D, Subcutaneous tissue and skin sutured. correct anatomical position at the tip of the glans. Thus the urinary stream is likely to be better projected than following operations of the flap type, where the meatus is more ventrally placed and spraying is common. Another important advantage is that hair is not included in the urethral lining. D

18 46 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 14 A, Complete perineal hypospadias with bilateral undescended testes and split scrotum (pseudo-hermaphrodism). Child 7 years old. B, Showing perineal meatus. C, Bilateral hemiotomy, attachment of testes to thighs~ straightening of ventral curvature and urethral inlay have been performed in four operations. D, 13etachment of testes, anastomosis of urethral graft. Note normal meatus. E, Split scrotum united. Early condition. F, Present condition at 16 years of age. Normal function. FIG. 15 A, Primary adult scrotal hypospadias. Marked fixation of the glans. B, After Edmunds' operation and author's urethral inlsy. C, Lateral view to show correction of ventral curve. I3, Anastomosis performed. Note the normal appearance of the meatus. patient not only micturates perfectly, but is sexually efficient. The

19 DEFORMITIES OF THE MALE URETHRA 47 The total time taken to make a functioning urethra is rather longer than with other methods, owing to the prolonged period of continuous dilatation necessary, somewhere between nine to twelve months elapsing from start to finish. On the other hand the actual period of hospitalisation is relatively short, five to six weeks, while between operations the patient is perfectly able to conduct a normal life. From the surgeon's point of view, one is freed from the tiresome and irritating business of closing and reclosing the fistulm which so often develop in adult patients along the suture line of the flap operation. These, then, are the contributions which the plastic surgeon can make in a fairly uncharted urological sea. Much remains to be done, and I am still hopeful that that terrible congenital deformity of ectopia vesicm, about which I have said nothing, may yet yield to the application of some of the reconstructive principles which I have described herein. REFERENCES BECK, C. (I898). " A New Operation for Balanic Hypospadias," New York reed. ft., 67, i47, -- (1899). " Beck's Operation for Hypospadias," New York reed. ft., 7 o, (1917). " Hypospadias and its Treatment," Surg. Gynec. and. Obstet., 24, 5rI. BLAIR, V. P. (I929). " Hypospadias and Epispadias: Indications for and Technique of their Operative Correction," Trans. South S.A., 42, I63 (I93O). BROWNE, DENIS (I936). Lancet, I, I4I. BUCKNALL, R. T. H. (I9o7). 1bid., 2, 887. CaNTWELL, F. V. (I9O3-5). " Cantwell's Operation for Complete Epispadias," Trans. med. Soc. N. ffersey, p. 2o6 ; Internat. ft. Surg., r8, 69 (19o5). DUPLaY, SIMON (1886). " Ashhurst," Int. En. of Surg., 6, 488. EDMONDS, ARTHUR (1926). Lancet, I, 323. KEYES, E. L. (1923). " Textbook of Urology." D. Appelton & Co. MClNDOE, A. H. (I937). Brit. med. ft., 2oth Feb., vol. i, p. 385 ; Amer. ft. Surg., vol. xxxviii, x, 176 to 185. MAYO, C. H. (19Ol). ft. Amer. med. Ass., 36, NOV~-JOSSERAND, C. J. (1914). d'urol, med. Ghir., Paris, 5, 393. OMBRI~DANNE, L. (1923). " Precis Clinique et Operative de Chirurgie Infantile, Paris," p Masson et Cie. ROCHET (1899). " Nouveau procdd6 pour refaire le canal penmen dans l'hypospadias," Gaz. Hebd. d. mdd., 4, 673. YOUNG, H. H. (1918). " New Operation for Epispadias," ft. Urol.~ 2, 237