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Source publication
Purpose
We reviewed our experience and efficacy of reconstruction of a forked corpus spongiosum (FCS) to correct glans droop in distal/midshaft hypospadias repair.
Methods
Eighty-five consecutive patients who underwent distal/midshaft hypospadias repair by the same surgeon in our center from October 2015 to June 2018 were retrospectively analyzed....
Similar publications
We reviewed our experience in reconstructing forked corpus spongiosum (FCS) in distal/midshaft hypospadias repair and analyzed the efficacy of this surgical technique. From August 2013 to December 2018, 137 consecutive cases of distal/midshaft hypospadias operated by the same surgeon in Urology Department, Children's Hospital of Fudan University (S...
Citations
... 1 Glans droop is often both a cosmetic and pain concern for hypospadias patients, and the degree of glans droop may be closely associated with the development of a forked corpus spongiosum (FCS) due to fibrotic tension on the penile head. 2 Functional complications after distal/midshaft hypospadias repair include fistula and urethral stricture formation that may require reoperation, which occur at a rate of about 16%. 3 In the accompanying article, Zhang et al. 4 describe a new hypospadias repair technique that includes reconstruction of the FCS during tubularized incised plate (TIP) and onlay island flap (ONLAY) repair for distal and midshaft hypospadias. The authors describe their technique briefly and provide some nice intraoperative photos. ...
Introduction:
Anatomical studies of hypospadias show failure of zipping-up of histologically normal urethral plate and corpus spongiosum. With the commonly utilized substitution urethroplasties for proximal hypospadias, a reconstructed urethra of just an "epithelial-lined tube" with no spongiosal support, is apt to long-term urinary and ejaculatory dysfunctions. We completed a one-stage anatomical reconstruction in children with proximal hypospadias whenever the ventral curvature could be reduced to <30° and evaluated the post-pubertal outcomes.
Method:
This is a retrospective analysis of prospectively maintained data on one-stage anatomical repair of proximal hypospadias between 2003 and 2021. In children with proximal hypospadias, the corpus spongiosum, bulbo-spongiosus muscle (BSM), Bucks', and Dartos' layers of the shaft were anatomically re-aligned prior to assessing the ventral curvature visually. When the curvature was >30°, the urethral plate was divided at the glans for a 2-stage procedure, and those patients were excluded from the study. Otherwise, the anatomical repair was continued (this series). The Hypospadias Objective Scoring Evaluation (HOSE) and the Paediatric Penile Perception Score (PPPS) were used for post-pubertal assessment.
Results:
Prospective records provided details of 105 patients with proximal hypospadias who had complete primary anatomical repair. The median age at surgery was 1.6 years, and 15.9 years at the post-pubertal assessment. Forty-one (39%) had complications that necessitated re-operations. Thirty-five (33.3%) patients had complications involving the urethra. For fistula and diverticula, eighteen cases required only one corrective procedure, while one required two. Other 16 patients required an average of 1.78 corrective operations for severe chordee and/or breakdown, with 7 requiring Bracka's 2-stage procedure.
Results of pubertal review:
Fifty patients (47.6%) were over 14 years old; 46 (92.0%) had pubertal reviews and scoring, while four were lost to follow-up. The mean HOSE score was 14.8/16, and the mean PPPS score was 17.8/18. Five patients had residual curvature of >10°. 17 and 10 patients, respectively, were unable to comment on glans firmness and ejaculation quality. During erections, 26/29 (89.7%) patients reported a firm glans, and 36/36 (100%) reported normal ejaculations.
Conclusion:
This study proves the need for reconstruction of normal anatomy for normal post-pubertal function. In all proximal hypospadias, we strongly recommend anatomical reconstruction (zipping up) of the corpus spongiosum and BSM. When the curvature can be reduced to <30°, a complete one-stage reconstruction is possible; otherwise, anatomical reconstruction of the bulbar and proximal penile urethra is recommended, reducing the length of the epithelial-lined substitution tube for the distal shaft and glans.
The corpus spongiosum is a spongy tissue that surrounds the urethra. Historically, spongiosum in hypospadias was considered as fibrous tissue and one of the causes of chordee. Traditionally, spongiosum was resected to correct the chordee with or without dorsal plication in moderate to severe hypospadias. However, with TIPU’s increasing popularity as the most commonly performed procedure, various healthy tissues have been interposed. The tissues are dorsal/lateral/ventral based dartos flap, scrotal dartos, de-epithelized local penile skin, inner prepucial dartos flap, preputial flap, paraurethral tissue, spongiosum, and tunica vaginalis flaps. Although the spongiosum is a healthy vascular tissue and spongioplasty reconstructs the near-normal urethra with minimal complications, but it is still less frequently used. Spongioplasty improves the results of hypospadias repair including re-operative cases and flap urethroplasty. Since the spongiosum is part of the urethra, so attempts should be made to preserve and utilize the spongiosum in hypospadias repair.KeywordsHypospadias repairHealthy interposing tissueSpongiosumSpongioplastyDartos flapsComplications of hypospadias repairTIPUModified TIPUUrethroplastyDouble breasting spongioplastyReconstructive surgery
Hypospadias surgery is one of the most demanding ones, a pediatric surgeon/urologist has to perform. The surgeon needs to achieve both functionally and cosmetically acceptable results. The surgical outcome depends on the various factors related to the patients, surgical skill, and surgical environment. The patient-related factors are the hypospadias type, chordee severity, urethral plate and spongiosum development, type of urethroplasty, age at surgery, penile torsion, caudal analgesia, penis and glans size, application of a tourniquet, use of testosterone, and learning curve. Among these, the type of hypospadias, severity of chordee, poor development of the urethral plate and spongiosum, age of the patients are the most important variables that affect the results and play a crucial role in decision making. The presence of more than three variables in a patient results in poor outcomes in TIPU repair. In TIPU cases, these patients may need to add supporting tissue like tunica vaginalis or change the technique to augmented/replacement urethroplasty or two-stage repairs. They should also be counseled about the results before surgery.KeywordsHypospadias repairtype of hypospadiasChordee Urethral plateLearning CurveAge development of spongiosumComplications of hypospadias surgery
We reviewed our experience in reconstructing forked corpus spongiosum (FCS) in distal/midshaft hypospadias repair and analyzed the efficacy of this surgical technique. From August 2013 to December 2018, 137 consecutive cases of distal/midshaft hypospadias operated by the same surgeon in Urology Department, Children's Hospital of Fudan University (Shanghai, China), were retrospectively analyzed. Sixty-four patients who underwent routine tubularized incised plate (TIP) or onlay island flap (ONLAY) surgery were included in the nonreconstructing group, and 73 patients who underwent reconstructing FCS during TIP or ONLAY surgery were included as the reconstructing group. Thirty-eight cases underwent TIP, and 26 underwent ONLAY in the nonreconstructing group, with a median follow-up of 44 (range: 30-70) months. Twenty-seven cases underwent TIP, and 46 underwent ONLAY in the reconstructing group, with a median follow-up of 15 (range: 6-27) months. In the nonreconstructing/reconstructing groups, the mean age at the time of surgery was 37.55 (standard deviation [s.d.]: 29.65)/35.23 (s.d.: 31.27) months, the mean operation duration was 91.95 (s.d.: 12.17)/93.84 (s.d.: 14.91) min, the mean neourethral length was 1.88 (s.d.: 0.53)/1.94 (s.d.: 0.53) cm, and the mean glans width was 11.83 (s.d.: 1.32)/11.56 (s.d.: 1.83) mm. Twelve (18.8%)/5 (6.8%) postoperative complications occurred in the nonreconstructing/reconstructing groups. These included fistula (5/2), glans dehiscence (3/0), diverticulum (1/2), residual chordee (3/0), and meatus stenosis (0/1) in each group. There was a significant difference in the overall rate of complications (P= 0.035). These results indicate that the technique of reconstructing FCS provides excellent outcomes with fewer complications in distal/midshaft hypospadias repair.
