A combined retrospective and prospective analysis of children operated during the 5-year period from January 2014 to December 2018 was done for the study. The cases with preoperative diagnosis of mid-penile/proximal penile/penoscrotal hypospadias only were included in the analysis. In the past, a significant proportion of these patients would have been treated by staged correction after urethral plate resection, based on preoperative assessment. All the cases were operated by a single surgeon. Exclusion criteria were as follows: (1) distal penile hypospadias, (2) perineal hypospadias, (3) previous hypospadias surgery (reoperative cases), (4) severe pre-penile scrotum, and (5) disorders of sexual differentiation. The preoperative, intraoperative, and postoperative follow-up records of all patients who underwent the specific protocol of repair were studied in detail to analyze the cardinal observations in decision-making and results. The preoperative assessment of type, severity, and suitable procedure were compared with the intraoperative assessment. The postoperative outcome was reviewed in detail. Ethics approval and standard informed consent were obtained as per institutional protocol.
In preoperative assessment, the factors considered were as follows: (1) meatal position, (2) severity of VC (mild/moderate/severe), (3) the possible maneuver required for correction of VC (degloving and detethering/auxiliary procedures like midline dorsal plication/urethral plate resection/ventral corporotomies), (4) size of phallus, (5) quality and width of urethral plate, (6) glandular groove and glans width, (7) associated issues like pre-penile scrotum/undescended testes, and (8) type of procedure likely to be required (urethral plate tubularization/augmentation/substitution). These were essentially noted for comparison with the intraoperative observations including meatal position after correction of VC, final mode of correction of VC, and type of urethroplasty done. The definitive observations and final decisions regarding the severity of hypospadias and ideal operative procedure were made only intraoperatively.
The algorithm followed for hypospadias repair in the present series is summarized in Fig. 1. Intraoperatively, a sequential and anatomical approach to repair was adopted. After catheterization and marking the incision, the initial step was a circumferential incision (circumcoronal), which was carried proximal to the meatus by a U-shaped extension near the meatus in all cases. Even in apparently proximal hypospadias, the incision was not carried distal to the meatus. The initial dissection on the ventral surface of urethra close to the meatus to separate the native urethra from overlying thin skin was tedious, but became easier as the dissection proceeded proximally. This was essentially aimed at preserving the urethral plate and native urethra, in all but the most severe instances of VC, or preserves the plate in other cases, till such a stage were all other options to correct VC had been exhausted [1,2,3].
The next step was thorough degloving of the phallus till base with release of phallic and scrotal Dartos, as classically described. This was combined with “extensive ventral urethral detethering” of the deeper Buck’s fascia surrounding the urethra and aborted corpus spongiosum. The dissection was neither circumferential, nor it lifted the urethra from the corpora, but extended to free the ventral surface of urethra till the bulb. Though similar dissection has been previously described as an ancillary maneuver to correct severe VC, it has been employed in the present series as a basic, mandatory, and preliminary step [4, 5] The phallus being tethered to scrotum is a common observation in proximal hypospadias or severe VC (referred to here as penoscrotal fusion). After the thorough degloving, dartos release, and detethering of ventral urethra (the 3Ds of preliminary dissection in hypospadias), the normal relation between penis and scrotum was observed to be restored. This has been referred to here as penoscrotal realignment (Figs. 2 and 3). The final position of meatus in relation to the phallus, severity of VC, the suitability of urethral plate for use in reconstruction, and the optimal method for creation of neourethra/necessity for a staged procedure were assessed at this stage. The hypospadias was reclassified based on the meatal position in relation to the glans and base of the penis. If the meatal position was in the distal third, mid-third, proximal-third, and penoscrotal junction, the hypospadias was reclassified as distal penile, mid-penile, proximal penile, and penoscrotal types respectively.
VC was reassessed afterwards by artificial erection (classical Gittes test) and if seen to persist, midline dorsal plication (Baskin) was performed. The patients with persistent VC after midline dorsal plication were classified as those suitable for urethral plate augmentation or those requiring urethral plate resection and substitution. Urethral plate augmentation was started by a single Z-plasty incision on the urethral plate at the site of maximum VC, to divide the short urethral plate, preserving the vascular plexus deep to the urethral plate (Fig. 4). This is supplemented by an onlay flap of inner prepuce. The incision was made to divide the urethral plate and combined with midline dorsal plication to correct VC. It is used along with the classical midline incision for tubularization, where necessary. Severe VC associated with poor urethral plate or short ventral corpora required urethral plate resection. This was combined with ventral corporotomies and midline dorsal plication wherever necessary. The adequate and complete correction of VC was given paramount importance. Urethral plate resection has been employed as the last resort to correct VC in the present series. The construction of neourethra is based on the one of the following principles:
(A) Urethral plate tubularization: if there was no residual VC and urethral plate was adequate, a single-stage urethroplasty is done [classical tubularized incised plate (TIP) urethroplasty] [6]. A modification employed in select cases was to “stagger” one lateral incision of the urethral plate more laterally and to create unequal sections of urethral plate, but with total caliber more than 3 times that of the catheter used. The suture line of reconstruction of the neourethra was thus taken away from the midline on ventral surface, to lie more laterally and closer to the dorsum. (B) Urethral plate augmentation: inadequate length and width of an otherwise sufficient urethral plate was overcome by a Z-plasty incision on the plate, along with a graft to augment the plate (G-TIP/grafted TIP repair) [7]. The use of urethral plate division along with onlay (or inlay) flaps helps to utilize the available urethral plate, in cases with feasibility of a single-stage reconstruction of neourethra. The preferred method in this series was the use of an onlay flap of pedicled inner prepuce, wherever native urethral plate was deemed inadequate for tubularization, but did not require resection. (C) Urethral plate substitution: if urethral plate resection was deemed necessary, the surgical options preferred were staged Braca’s procedure (using a pedicled inner prepucial flap as a graft to substitute the urethral plate), the classical Thiersch-Duplay procedure (with first stage transfer of Byar’s flaps of prepucial skin), or STAG repair (staged tubularized autograft, with tubularization of neourethral plate of prepucial autograft) [8,9,10]. In cases requiring urethral plate substitution, two-stage procedures using native tissue or pedicled local graft were always preferred to complex reconstruction using non-native tissue or free grafts.
The divergent corpus spongiosum was mobilized and approximated in the midline over the neourethra whenever feasible. The most commonly used cover for the reconstructed neourethra was the pedicled inner prepucial flap. The other options used for cover were corpus spongiosum, local dartos flap and tunica vaginalis flap. The pedicled tunica vaginalis flap was used liberally even in primary hypospadias repair, especially for proximal and mid-penile hypospadias with severe VC, where judicious use of prepucial skin to cover the ventral surface was necessary. A 6 Fr/8 Fr Silicone Foley’s catheter was used for urinary drainage for 7–10 days postoperatively. Urethral calibration with a small metal dilator was started 2 weeks postoperatively.