A DE-EPITHELIALISED OVERLAP FLAP TECHNIQUE IN THE REPAIR OF HYPOSPADIAS

British ffournal of Plastie Surgery (I973), 26, :ro6-xi 4 A DE-EPITHELIALISED OVERLAP FLAP TECHNIQUE IN THE REPAIR OF HYPOSPADIAS ]3y DURHAM SMITH, M.D., F.R.A.C.S., F.A.C.S. Royal Ghildren's tlospital, Flemington Road, Melbourne, 3052, Australia THAT over 15o different techniques of hypospadias repair have been described acknowledges that none has been completely free of complications. Study of the reviews of Creevy (z958), Backus and de Felice (z96o), Kennedy (1961), Smith (I967) and Culp and McRoberts (x968) shows that the major complications which bedevil results are fistula formation, the new meatus not at the tip of the glans or stenosed or retracted, stricture in the new urethra and persistance of chordee. The author, using the techniques of Denis Browne or of Byars (1955) experienced the same complications and evolved the present technique to avoid them. It produces a repair in which the urethral orifice opens at the tip, the cosmetic appearance is that of a normal circumcised penis and fistulae can probabl; be avoided altogether. There are 2 stages. later. METHOD The first is undertaken at age 3~} to 4 years, the second 6 months First Stage. A rubber catheter around the base of the penis acts as a tourniquet; it is released every IO minutes. The prepuce is split longitudinally on the dorsal surface as far as the coronal groove to create z lateral flaps (Figs. I.I and 1.2). On the ventral surface the inner layer of preputial skin is excised up to the coronal groove leaving inch (3.2 mm.) of everted mucosa in the groove. The epithelium of the glans is similarly excised in continuity with that of the prepuce, from the coronal groove to beyond the tip of the glans (Fig. z.3). The central blind groove on the glans is preserved. The skin of the penile shaft between the a denuded areas is divided transversely to release the skin adhesion which contributes to chordee, and to provide access for excision of any central chordee band. The denuded surface of the lateral flap is then applied to that of the glans, carrying preputial skin beyond the tip of the glans, and sutured with 5/o chromic catgut. The meatus is enlarged and the remaining edge of the lateral preputial flap sutured around the lateral and dorsal edge of the coronal groove (Figs. 1.4 and 1.5). No catheter or dressing is used and the patient leaves hospital on the 5th day. A healed result is shown in Figure 2. Apart from adequate chordee correction the main purpose of this preliminary stage is to advance to the margins of the ventral groove sufficient preputial skin not only for the formation of a sound urethral tube right to the tip of the penis but for second layer cover. The blind ventral groove is preserved to ensure a smooth floor to the skin tube when buried deeply in the glans. Care should be taken to denude completely the lateral preputial flaps near the coronal groove; in 3 early cases fistulae developed in this situation along epithelium lined tracks. Second Stage. A perineal urethrostomy drainage catheter is inserted and a rubber tourniquet applied as before, unless the urethral orifice is peno-scrotal. An incision is made from proximal to the urethral meatus, through the mobilised ventral prepuce io6

DE-EPITHELIALISED OVERLAP FLAP TECHNIQUE IN HYPOSPADIAS IO 7.... :..,,,.,.,.,., :" r,,',: :,:,~.,,3C j,.,., ~' ' " " " '. ' ', " ', ' " ', c,' "~,:'-",~, ". "',, 5";.... ' " '.' ' ~ ~' ' - - ". " " '.",' '~."._:.,,,I,,::"2:. : :,,'? "..,,.',.2.;,,.",":~'!', :~':L,,~-,:'3,".,,:?, :i,i'.i.:,~'2i :',I!,:,.:,.::.xx~.s~ ', '?.,,2,,.?,,, ~:ie'..:."-: :Y..,, :,: ;.:.~".V~,, ',-?,.Y?,:',.~;:"..: '... ~ -... :,.. ' I ~ STA~E"., : '"" :.,,,,e " ' " '. /,...::!~-?;:,, ;,, '.1 ~.:"' ~.."i ' : : ".,,',.:... ' ",. ", '.' "-"?'",i','" -','-, ' ' '.. '," \ " ", ~,~;--.," ' ",,.,~' '.'; :, "~,k-.;,&., '.~ ".','~ ', t~,.,'~.~ ";,-,k ',;..', - ~:,, ' ".. ~ "~-i,'~',' ',', "', :,, ' " ";."':" " "" '""-~""" ":'.;",'~'".: ", "-'."i~;;'"'~",,"~-",~..","~"~."-',~; ~''L'-' :"";-",' FIG. I. First-stage repair. I, Dorsal prepuce cut longitudinally to coronal groove. 2, Preputial flaps rotated from dorsal to ventral side~ and sutured dorsally and laterally (B and C) into coronal groove. 3, Ventral surface of preputial flaps, and of glans, denuded of epithelium (dark area). Chordee fibrous band excised~ and ventral penile skin released. 4~ Preputial flaps applied ventrally to glans and sutured to tip of penis, A-A t, E-EI~ etc., preserving the central blind groove. Meatotomy. 5~ To show extent of mobilised and sutured prepuce. to beyond the glandular tip. The lateral cuts are about ] inch (Io ram.) apart (Figs. 3.I and 4). A complete inner skin tube is fashioned by inverting the medial edges of the incised skin right to the tip of the glans. A size 6 English catheter is laid in the tube as a guide to lumen size during suturing with continudus 4/0 nylon; it is removed at the end of the operation (Figs. 3.z, 5 and 6). A few supporting 5/0 chromic catgut sutures bring fascial tissue over the nylon suture line (Figs. 3.3 and 7). The lateral skin edges are undermined keeping close to the corpora to preserve blood supply to

108 BRITISH JOURNAL OF PLASTIC SURGERY the skin. At the glans this undermining is extended well into the cavernous tissue by a longitudinal cut to a depth of about ~ inch (3"2 ram). on either side; this results in the skin tube being buried into the substance of the glans when the lateral edges of the incision are brought together. This completed skin tube obviates the redundancy, sacculation or stricture which may result from irregular healing of a buried skin strip. A strip of skin ] inch-~ inch (3"2-4"8 mm.) wide is then de-epithelialised on one side to provide a raw surface of deep dermis (Figs. 3.4 and 8). This is achieved by cutting 2 or 3 fine longitudinal strips with a pair of small curved-on-the-flat scissors. ~;~,~-~ ~ ~'~ ~ ~ FiG. 2. Completion of first stage. A, Correction of chordee, adequate meatus at peno-scrotal junction and prepuce well forwards on glans. B, Ventral groove preserved, and prepuce advanced to the tip of the glans ventrally. C, Transfer of dorsal prepuce to ventral surface of glans, The medial edge of the shaved flap is brought across the buried skin tube, and sutured with 5/o chromic catgut to fascial tissue beneath the other flap (Figs. 3.5 and 9). The latter is then sutured with 5/0 chromic catgut to the edge of the de-epithelialised strip (Figs. 3.6, Io and r~). Commence the closure distally. Beads and stops are applied to the ends of the nylon suture (Figs. 3.6 and 12) and a dorsal relieving incision is made if there is any tension (Figs. 3-7 and I3). No dressing is applied to the penis; the nylon suture pulls out easily on the 8th day, and the perineal catheter on the I2th day. RESULTS Fifty-one urethroplasties have been performed by this technique for all degrees of hypospadias from perineal to distal penile shaft. One ventral fistula occurred in

~/:,~.,~., DE-EPITHELIALISED OVERLAP FLAP TECHNIQUE IN HYPOSPADIAS IO 9,,, :':',,",.:,.:., -,..,,.,, f,,,,... " ~ : " i ~, ' " ',, ~ " : if, (,..:../: '.. Llrethro~lasty.".,..,.~,~.--. ~,.--...,. "............ :...:...! A i ~- t - : T,". 7 2 ' ' " " :~." '-' -'" i. ~ i:~i,-,":~:'.: '-.'." ' " "'":" "... ~ ' " ' FZG. 3. Second-stage repair, z, Ventral incision from orifice to tip. ~, ]Fashioning of skin tube with a continuous inverting suture of 4]o nylon over a temporary catheter. 3, Supporting chromic catgut sutures over skin tube, undermining of latei:al skin flaps and longitudinal deep cuts into glandular tissue. 4, A de-epithelialised strip ~--f~- inch (3-9.-4.8 ram.) wide prov/des a raw area on one flap. 5, Medial edge of shaved skiu sutured beneath opposite flap. 6~ Opposite flap swung over raw area and sutured. 7~ Dorsal relieving incision if tension.

IIO BRITISH JOURNAL OF PLASTIC SURGERY FIG. 4 Fro. 5 FIG. 4. FIG. 5. Lateral incision from orifice to tip to provide skin for inner tube. (Note tourniquet on base of penis.) Fashioning the inner tube over a catheter with continuous nylon. /./ / FIG 6. FIG. 7 Fro. 6. Comp!etion of the inner skin tube to the tip. FIG. 7. Strengthening the skin tube with an extra layer of fascia using catgut.

DE-EPITHELIALISED OVERLAP FLAP TECHNIQUE IN HYPOSPADIAS III FI~. 8 FIG. 9 Fit. 8. Fm. 9. The "shaved" lateral flap (the artery forceps were only used to obtain the photograph). The medial edge of the shaved skin is sutured beneath the opposite lateral flap.,. ' " '.,[, "'i FIG. Io FIG. IX FIG. IO. The outer lateral flap is drawn across the shaved raw area and sutured to the lateral border of the shaved strip. Fro. II. Completion of the outer suture layer. Sucker at the new orifice on the 6p.

II2 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 12 FIG. 13 FIG. 12. The dorsal appearance on completion, with beads and stop on the nylon suture. Fro. 13. Dorsal relieving incision. FIG. I4 Fro. I5 FIG. I4. The usual end result 3 weeks after repair, with no excess prepuce, straight penis, orifice on tip. FIG. I5. End result t~ show orifice on tip of glans.

DE'-EPITHELIALISED OVERLAP FLAP TECHNIQUE IN HYPOSPADIAS II 3 the 3rd case, due to too radical de-epithelialisation but the last 48 patients have healed in the expected time without complications. As noted above, 3 early cases developed a tiny leak in the coronal groove laterally from faulty teclmique in the first stage; one closed spontaneously, the others required a single suture. One patient required a meatotomy and 4 early patients have required a secondary trimming of excess skin rags. The end result is shown in Figures 14-16. FIG. I6. Straight stream one month after surgery. The ventral flaps will regress further with time. DISCUSSION The author had performed over 30 of these urethroplasties before finding out that the idea of skin shaving had been described previously, although not in the manner at present used. Pers (I965) shaved a central strip of penile skin, apposing the raw edges by the Browne technique; he reported 5 fistulae in 41 repairs. Pers mentioned that Crawford had used skin shaving in 1961 without apparently publishing the'results. Fistula Prevention. The principal contribution of the new repair is that skin closure is achieved by the apposition of 2 raw surfaces. Tissue adhesion is very rapid and firm and the strength of the union is assured at an early stage, even apart from the sutures. No suture lines are superimposed; thus further strengthening the repair and lessening the risk of fistulae. A Stable Orifice on the Tip of the Glans. In many repairs the orifice is short of the:tip, or retracts later or stenoses. The first stage of the present technique brings preputial skin beyond the blind groove thus ensuring ample thick skin flaps of sound

114 BRITISH JOURNAL OF PLASTIC SURGERY viability well forwards over the tip of the glans from which to construct a stable, nonretracting, non-stenosing urethra. It is often not appreciated that in hypospadias the ventral glans is "explicated", i.e., splayed out on either side of the blind groove. The deep cuts deliberately made laterally into the glandular tissue allow the explicated cavernous tissue to be brought to the midline, thus burying the urethra in the substance of the glans with its meatus right at the tip. Perineal Urethrostomy. In the 5I cases reported, the second-stage repair has been safeguarded by proximal urinary diversion. However~ such is the strength of the repair that a trial without catheter drainage seemed justified. An additional 7 patients have been so managed; one developed a fistula, the others healed soundly. With further experience I believe catheter drainage will become unnecessary. Indications. This repair is applicable to all degrees of hypospadias requiring urethral reconstruction, including orifices as far back as the perineum. For many years I accepted the Denis Browne thesis that glandular orifices, even those in the coronal groove, only need distal meatotomy. Time has proved, however, that an orifice on the ventral surface of the glans is often lmacceptable in adult life. I now prefer to do a formal urethral reconstruction for any orifice from the coronal groove to the proximal half of the glans, reservhag meatotomy and hemi-circumcision for those on the distal half. SUMMARY A new technique of hypospadias repair is described using the principle of one penile skin flap overlapping a similar but de-epithehalised flap. The repair depends on tissue adhesion over a wide area rather than edge-to-edge healing. None of the suture lines are superimposed. Only one fistula resulted from 51 repairs, the last 48 consecutive cases being without fistulae. Other features of the repair ensure a urethral tube of uniform lumen, an orifice on the tip of the glans, and a cosmetic appearance of a normal circumcised male. REFERENCES BACKUS, L. H. and DE F~,LICE, C. A. (196o). Hypospadias--then and now.,plastic and Reconstructive Surgery~ 25., I46-I6o. BYARS, L. T. (1955). A technique for consistently satisfactory repair of hypospadias. Surgeo,, GynecoIog Z and Obstetrics, Ioo, I84-I9o. CREEVV, C. D. (1958). ~ Fhe correction of hypospadias: a review. Urologic S~trgery, 8, 2-47. CuLl', O. S. and McROBERTS, J. W. (I968). Hypospadias. In "Encyclopaedia of Urology", pp. 307-344. Berlin: Springer-Verlag. KENNEDY, P. A. (x96i). Hypospadias: a 2o-year review of 489 cases, ffournal of Urology, 85, 814-817. PERs, M. (1965). "Skin-shaving" in the treatment of hypospadias and other defects of the lower urinary tract. Acta Chirurgica Scandinavica. Supplement 343-346, PP. 209. SMITH, D. R. (I967). Repair of hypospadias in the pre-school child: a report of I5o cases. Journal of Urology, 97, 723-730.