Two-Stage Urethroplasty for Severe Primary Hypospadias 11 stage I, graft take should be unquestionable, or else additional tissue should be involved in urethral reconstruction. To guarantee a water proofing neourethra, an additional vascularized coverage is of great importance. Relocation of meatus is optimally made on the apex of the glans and be slit-like. In stage II, a cornical and plump glans is realigned following meatoplasty. Skin coverage of the penile shaft is required to be smooth in surface, even in axial view, and adequate in length. Bifid scrotum and penoscrotal transposition are frequently associated with severe hypospadias. Such associated deformities desire correction, usually accomplished in stage II hypospadias surgery. Elemination of scrotal bifida is usually out of problem. While satisfactory correction of severe translocation necessitating radical dissection and may threaten reliability of urethral replacement, thus to leave penoscrotal correction to a future surgery is rational in some cases. 2.3 New concept of two-stage repair Indeed that the aim of sgate I surgery should be to prepare optimal local anatomic status for stage II other than doctrinal orthoplasty, urethra bed preparation and glans/groove augmentation. Shall we do more in stage I than leave behind so many problems awaiting future resolution? In popular two-stage repair procedures, stage II surgery still bears high risk of complications (Bracka , 2011). This can be explained with the facts that: (1) long segment urethral reconstruction is associated with high risk of fistula, stenosis/stricture, diverticulum/dilatation, and curvature recurrence; and (2) extensive coverage of neourethra as well as correction of bifid scrotum and penoscrotal transposition denotes radical trauma, underlying infection, fascia tethering curvature, and threatened vascularity. Another usual problem of such radical reconstruction, concerning complicated plastic contents vs limited local tissue, is the sacrfice of cosmesis, which has profound psychological disturbance. Some authors tried modifications of the stage I procedure with partial urethroplasty especially in cases owning a relatively long and healthy urethral plate (Schumacher et al, 1997; Cheng et al, 2003). Partial urethroplasty and additional correction of anatomical alterations achieved in stage I surgery might aleviate the reconstructive burden in stage II. We further advocate a new concept of two-stage hypospadias repair, that two-stage strategy can be either more radical or more conservative (article in press). With technical development and individual experience gathering, one-stage repair of severe hypospadias is advocated by quite a number of specialists, let alone by patients. Our concept of “conservative” denotes that two-stage repair be indicated in those who could be repaired in single-stage, while complicated correction is anticipated with high risk of complications and poor appearance. The concept of “radical” denotes that when two-stage is indicated, much more can be done in stage I to diminish the risks in stage II surgery. In addition to sufficient orthoplasty, partial urethroplasty is achieved distal to the penoscrotal junction, and in some cases extended to the subcoronal area. The defect between neomeatus and the glans tip is substituted with skin flap as urethra bed, meanwhile glans/groove augmentation is accomplished. Stand voiding can be expected with such management. With partial urethroplasty carried out, scrotal bifida is eliminated, penoscrotal transposition resolved in a degree, and penoscrotal angle created. At completion of these steps in stage I surgery, the anomaly becames a much milder variant of hypospadias. Thus reconstruction of stage II surgery is much more easier and much less risky. With twice chances of cosmetic tailor, good appearance can be
Posted on: Tue, 28 Jan 2014 09:03:15 +0000
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