failed hypospadias repair - european center - complex … · 2010. 12. 24. · hypospadias repair....
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COMPLEX RECONSTRUCTIONS COMPLEX RECONSTRUCTIONS IN HYPOSPADIAS:IN HYPOSPADIAS:-- Penile straighteningPenile straightening
P il l h iP il l h i-- Penile lengtheningPenile lengtheningGlansGlans and penile skin resurfacingand penile skin resurfacing-- GlansGlans and penile skin resurfacingand penile skin resurfacing
Rados P DjinovicRados P. Djinovic,Belgrade
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Growing number of adult patientsGrowing number of adult patientsMajority had multiple previous surgeriesUnsatisfactory functional andUnsatisfactory functional and esthetic appearance
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LATE OUTCOMES OF HYPOSPADIAS REPAIR
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SOME BIZARRE “FREE-ART” OUTCOMESSOME BIZARRE FREE-ART OUTCOMES…
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CLINICAL AND SURGICAL ASSESEMENT of FAILED HYPOSPADIAS*FAILED HYPOSPADIAS
*Great majority of patients presented with more than one complication
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CAUSES of FAILURESCAUSES of FAILURESHighHigh variabilityvariability ofof anomalyanomaly
InappropriateInappropriate understandingunderstanding ofofInappropriateInappropriate understandingunderstanding ofofanomalyanomaly
SmallSmall andand delicatedelicate structuresstructures ––SmallSmall andand delicatedelicate structuresstructures ––microsurgicalmicrosurgical principlesprinciples
ComplexComplex surgerysurgery::>> 300300 describeddescribedComplexComplex surgerysurgery::>> 300300 describeddescribedtechniquestechniques andand modificationsmodifications
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SurgicalSurgical scarsscars dodo notnot followfollowSurgicalSurgical scarsscars dodo notnot followfollowpenilepenile growthgrowth
InexperiencedInexperienced surgeonssurgeonsInexperiencedInexperienced surgeonssurgeons
PediatricPediatric surgeonssurgeons –– shortshort--termtermfollowfollow--upupfollowfollow upup
AdultAdult urologisturologist –– lacklack ofof properpropertrainingtrainingtrainingtraining
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ComplexityComplexity ofof penilepenile anatomyanatomy ––ComplexityComplexity ofof penilepenile anatomyanatomy ––differentdifferent structuresstructuresii llllinin aa smallsmall spacespace
ProblemsProblems inin adultsadults::E tiE ti-- ErectionErection
-- EjaculationEjaculation-- UrethralUrethral dischargedischarge
Quality of available skin- blood supply, elasticity
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SURGICALSURGICAL TREATMENTTREATMENTSURGICAL SURGICAL TREATMENTTREATMENT
Careful dissectionCareful dissection
R t tiR t tiReconstructionReconstruction
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“In all cases of reparative surgery, in which the defect is g y,congenital, the aim of the surgeon should be to restoresurgeon should be to restore all parts to their normal relations as nearly as possible”relations as nearly as possible”
Frank V Cantwell M.D.
Annals of Surgery 22:689-694 1895. !!!
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Problems that should be faced inProblems that should be faced in salvage procedure
CurvatureCurvature
Urethra
Glans
Penile skin
Scrotum
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CHOICE OF REPAIRCHOICE OF REPAIR
Clinical and intraClinical and intra operative findingsoperative findingsClinical and intraClinical and intra--operative findingsoperative findings
Individual approach Individual approach
Familiarity with all available Familiarity with all available techniq estechniq estechniquestechniques
Preference of the surgeon must not be Preference of the surgeon must not be decisivedecisivedecisivedecisive
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PENILE CURVATUREPENILE CURVATUREPENILE CURVATURE PENILE CURVATURE
One of the most important features of hypospadiasof hypospadias
Curvature checking is mandatory
Corporal disproportion is present in p p p pmajority of hypospadias
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CAUSESCAUSESCAUSESCAUSESShort ventral skinShort ventral skinShort ventral skinShort ventral skin
Subcutaneous tetheringSubcutaneous tethering
Short urethraShort urethraShort urethraShort urethra
Corporal disproportion Corporal disproportion (most (most common)common)
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PENILE STRAIGHTENINGPENILE STRAIGHTENING
Penile skin deglovingPenile skin degloving
Excision of fibrotic dartos andExcision of fibrotic dartos and
Buck’s fasciaBuck s fascia
Urethral/urethral plateUrethral/urethral plate
mobilizationmobilization
Urethral/Urethral plate divisionUrethral/Urethral plate division
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SHORTENING PROCEDURESHORTENING PROCEDURE
PlicationalPlicational oror excisionalexcisional techniquetechniquePlicationalPlicational or or excisionalexcisional techniquetechnique
Indications: Normal penile size and small curvature glans tiltcurvature, glans tilt
Multiple small incisions/excisions - better corporal sculpturing p p g
Continuous suture (PDS Maxon) 3-0 inContinuous suture (PDS, Maxon), 3-0 in adults and 5-0 in children
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Residual chordee – Incomplete disassembly with incisional corporoplasty
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LENGTHENING PROCEDURESLENGTHENING PROCEDURESLENGTHENING PROCEDURESLENGTHENING PROCEDURES
VentralVentral albuginealalbugineal graftinggraftingVentral Ventral albuginealalbugineal graftinggrafting- Severe curvature and small penis
TunicalTunical attenuationattenuationTunicalTunical attenuationattenuation
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Severe ventral curvature with short neourethra – III stage repairneourethra – III stage repair
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Ventral grafting with InteXen®
(4x8cm) for penile lenghtening(4x8cm) for penile lenghtening
GraftGraft
Tunical defect
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Appearance at the end of surgery ith h di t with hypospadiac meatus
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Urethroplasty – 3rd stageU et op asty 3 stage
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Urethral tubularization
“Spongioplasty” tubularization
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Penile skin reconstruction using asymmetrical flaps to avoid overlapping of suture linesflaps to avoid overlapping of suture lines
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URETHROPLASTYURETHROPLASTYComplex structure (very delicate
URETHROPLASTYURETHROPLASTYComplex structure (very delicate
epithelium) and function of the urethra
U eth al plate (if s fficient) is the bestUrethral plate (if sufficient) is the best available tissue for reconstruction
Buccal mucosa is the best urethralBuccal mucosa is the best urethral substitute (estimate graft shrinkage)
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Penile/praepucial skin flap is the third choicethird choice
Scrotal skin – never!
Tension-free urethroplastyTension-free urethroplasty
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Avoidance of suture-line overlapping
Urethral stenting and suprapubicUrethral stenting and suprapubicurinary drainage
Glanular stricture and coronal fistula
L dLong endurance
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Urethral Urethral plate/urethral mobilization with plate/urethral mobilization with ventral ventral onlayonlay flap flap urethroplastyurethroplasty
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Urethral Urethral stenosisstenosis 20 years after 20 years after tubularizedtubularized flapflap urethroplastyurethroplasty –– DorsalDorsaltubularizedtubularized flap flap urethroplastyurethroplasty –– Dorsal Dorsal
inlay inlay buccalbuccal mucosa graft mucosa graft urethroplastyurethroplasty
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RECURENT PENDULAR URETHRAL S C l b lSTRICTURE – Ventral buccal mucosa
onlay quilted on dartos fasciaonlay quilted on dartos fascia
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Urethral stricture -D l b l lDorsal buccal mucosa onlay
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Urethral stricture - Dorsal buccalmucosa onlay combined withmucosa onlay combined with
submeatal flap
SubmeatalSubmeatal flapflap
Lateral approachLateral approachLateral approachLateral approach
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Completed urethroplasty and glansireconstruction
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Distal urethral stricture – two-stage repairrepair
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GLANS PLASTYGLANS PLASTYGLANS PLASTYGLANS PLASTY
The most important for esthetic appearanceappearance
Often damaged
Proper layer of incision and wide l i bili i i hglans wings mobilization without
impairment of vascularityp y
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Tension-free closure – beware of stricture!stricture!
Two-layer delicate closure
Tension should be controlled by ysubcutaneous, short-time
resorbable sutureresorbable suture
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Failed Failed hypospadiashypospadias repairrepair –– DuplayDuplayrepair withrepair with spongioplastyspongioplastyrepair with repair with spongioplastyspongioplasty
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Failed Failed hypospadiashypospadias repairrepair –– Double Double faced flapfaced flap urethroplastyurethroplastyfaced flap faced flap urethroplastyurethroplasty
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PENILE SKIN PENILE SKIN RECONSTRUCTION RECONSTRUCTION
Thin, elastic epithelium and dartosfasciafascia
Usually significantly reduced and scaringscaring
Wide degloving and mobilization of penile skin with preservationpenile skin with preservation
of its vascularization
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Scrotal skin is the second choice
– Proper flap mobilization and separation fromProper flap mobilization and separation from testicular fascia Understanding and preserving of scrotal skin– Understanding and preserving of scrotal skin vascularityS t l h i ll i bl– Scrotal hair – usually minor problem
Formation of proper peno-scrotal and peno pubic anglepeno-pubic angle
Tension control by subcutaneous sutures
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Residual curvature with short penile skin – one stage repair
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Trapped Trapped Penis Penis –– Dorsal webbing after Dorsal webbing after hypospadiashypospadias repairrepairhypospadiashypospadias repairrepair
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33-year-old patient with short il kipenile skin
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Penile skin reconstruction using remaining il d t l kipenile and scrotal skin
Penile skinPenile skin
Scrotal skinScrotal skin
Scrotal skin
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Outcome after 1 yeary
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COMPLEX COMPLEX RECONSTRUCTIONRECONSTRUCTIONRECONSTRUCTIONRECONSTRUCTION
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59-year-old patient with 7 previous surgeries - one stage repairsurgeries - one stage repair
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Artificial erection shows severe ventral
Elipsoid excision of longitudinal layer of shows severe ventral
curvature albuginea at several points
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Running suturing of wounded surfaces
Complete penile straighteningwounded surfaces
(PDS 3-0) straightening
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Neourethral reconstruction and “spongioplasty” (arrow)“spongioplasty” (arrow)
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Creation of abundant dartos flap for suture line covering (arrows)line covering (arrows)
Glans wingsGlans wings
Dartos flap
Dartos flapDartos flap
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Outcome after one year
Aspect at the end of surgery yearof surgery
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34-year-old patient with 6 previous i t isurgeries - one stage repair
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Diverticular skin th
Double - “S” curvature (arrows)urethra curvature (arrows)
ventral
dorsal
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Ellipsoid excision of longitudinal tunicallayer and plication at two points (arrows)layer and plication at two points (arrows)
Longitudinal tunica excision
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Urethral tailoring by external plicationexternal plication
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Reconstruction of penile skin using remaining penile skin and scrotal flapsremaining penile skin and scrotal flaps
Peno-pubic and peno-scrotal angles are formed by tacking penile base skin to the albuginea (arrows)
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Fixation of loose compressive dressing at p gthe base and at subcoronal level
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39-year-old patient with 33 previous surgeries - Two stage repairsurgeries - Two stage repair
Fixed and elevated testicleelevated testicle
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Extensive degloving and partial urethral augmentation with buccal mucosaaugmentation with buccal mucosa
Urethral Urethral stricturestricture
BuccalBuccalmucosa mucosa
inlayinlayinlayinlay
Testicular mobilization
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Penile skin reconstruction using scrotal flap
Scrotal flap
Scrotal flap Buccal mucosa inlay
Bil t lBilateral orchiopexy
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Second stage urethroplasty after 6 months b l t b l i timonths - buccal mucosa tubularisation,
glans, penis and scrotum plasty
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CRIPPLED PENIS: Severe curvature and short, strictured, fistulous neourethra with small,
d f d ldeformed glans
Severe curvature and short, strictured, fistulous neourethra and small deformed glans
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I-stage: Penile lenghtening by t l fti (I t X ® 3 7 )ventral grafting (InteXen® 3x7cm)
Graft
MMeatus
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II-stage: Excessive buccal mucosa ft iltigraft quilting
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III-stage: Tubularizing urethroplasty
Completely straightened and lenghtened penis
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Glanular and urethral reposition; skin reconstructionskin reconstruction
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Outcome after 14 months
BeforeBefore
After
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TAKETAKE--HOME MESSAGEHOME MESSAGE
Treatment of failed hypospadias isTreatment of failed hypospadias is both surgery and an art with creativity and flexibility being key component for successful outcomecomponent for successful outcome
Proper clinical and surgical assessment is crucial forassessment is crucial for
appropriate treatmentpp p
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Urethroplasty is important but notUrethroplasty is important but not the only goal of repair - equally important is creation of long and straight penis to enablestraight penis to enable unobstructed voiding and normal
l lifsexual life
Reconstruction of penile skin is often the most difficult and major problem for successful treatmentproblem for successful treatment
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This isThis is complexcomplex surgery,surgery,This is This is complex complex surgery, surgery, and is and is best to best to be be
undertaken only in an undertaken only in an i t i ti t i tappropriate environment appropriate environment
by skilled surgeons fullyby skilled surgeons fullyby skilled surgeons fully by skilled surgeons fully educated and trained educated and trained in in
the the techniquetechnique