Bhat’s modifications of Glassberg–Duckett repair to reduce complications in management severe hypospadias with curvature
Objective: Disadvantages of two-stage hypospadias repair are the necessity of 2 or 3 surgeries, loss of time/money, complications like splaying of the stream, dribbling of urine or ejaculate and milking of the ejaculate due to a poor-quality urethra. The current article details our modifications of flap repair allowing to manage such patients in one stage and reducing the complications.
Subjects and methods: Twenty one patients (aged 2–23 years, between January 2006 and June 2012 mean 11.5 years) of severe hypospadias were managed with flap tube urethroplasty combined with TIP since June 2006 and June 2012. Curvature was corrected by penile de-gloving, mobilization of urethral plate/urethra with corpus spongiosum and transecting urethral plate at corona. Buck’s fascia was dissected between the corporeal bodies and superficial corporotomies were done as required. Mobilized urethral plate was tubularized to reconstruct proximal urethra up to peno-scrotal junction and distal tube was reconstructed with raised inner preputial flap after measuring adequacy of skin width. Both neo-urethrae were anastomosed in elliptical shape and covered with spongiosum. Distal anastomosis was done 5–8 mm proximal to tip of glans preventing protrusion of skin on glans. Tubularized urethral plate was covered by spongioplasty. Skin tube was covered by dartos pedicle and fixed to corpora. Scrotoplasty was done in layers, covering the anastomosis.
Results: Type of hypospadias was scrotal 10, perineo-scrotal 5, penoscrotal 4 and proximal penile in 2 cases. Chordee (severe 15 and moderate 6) correction was possible penile de-gloving with mobilization of urethral plate with spongiosum after dividing urethral plate at corona 8, next 5 cases required dissection of corporal bodies, superficial corporotomy 5 and 3 cases lateral dissection of Buck’s fascia. Length of tubularized urethral plate varied from 3 to 5 cm and flap tube varied from 5.5 to 13 cm (average 7.5 cm). Complications were fistula 2, meatal stenosis 1, and dilated distal urethra1 with overall success rate of 81%. None of them had residual curvature, torsion, splaying or dribbling urine in follow up of 10–36 (average 18) months.
Conclusions: TIPU with spongioplasty of proximal urethra and dartos cover on skin tube reconstructs functional urethra. Distal end skin sutured to glans mucosa 5–8 mm proximal to the tip of glans reconstructs a cosmetically normal looking meatus. An exact measurement of the width and length of the stretched dartos, fixation of the skin tube to the corpora and covering the skin tube with dartos helps in prevention of diverticula. Elliptical anastomosis covered with spongiosum prevents fistula and stricture at anastomotic site.
Keywords: Severe hypospadias; Complications of hypospadias repair; Fistula; Diverticula; Single stage and two stage hypospadias repair; Duckett repair; Inner preputial flap repair; Tubularized incise plate urethroplasty