Partial Penile Disassembly for Isolated Epispadias Repair

 Pediatric Urology P b E Ib R. OB resen ation prese ME 1 ma re fre ts d the u larize Gla RE app
spad ning CO rest ssem OGY Isolated male epispadias is a rare congenital anomaly ure no typ ba
de the ev vo is t an gla mo mo Ca on wa the complete urethral plate mobilization for better
preserva- From and R Uro dr.y S © All of the external genitalia. It is characterized by dorsal
malposition of the urethra, incomplete closure of the thral plate and dorsal curvature of the corpora
caver- sa. According to the location of the urethral orifice, 3 es of epispadias are described:
penopubic, penile, and lanic. The first type is the most common where the fect starts at or just
distal to the bladder neck. Most of se patients are incontinent. In the other types, the erted urethral
plate begins at the penile shaft or in- lves the glans only.1,2 The ultimate goal of surgical repair of
male epispadias o obtain good cosmetic outcome with a straight penis d a total ventral urethral
opening at the tip of the ns. The evolution of surgical repair, which started re than a century ago,
entailed several techniques and difications and, nevertheless, remains challenging. ntwell3 first
introduced his technique that was based complete mobilization of the urethral plate, which s then
tubularized and transplanted ventrally between corpora. Young4 modified the technique by
avoiding tion of its vascularity thus decreasing the risk of urethral fistula formation. The Young
modification remained the most widely used epispadias repair for several decades. Other
techniques then evolved in which penile and urethral reconstruction was based on the use of
preputial grafts, skin flaps, and full thickness skin and bladder mucosal grafts with variable
results.5–10 A significant advance was achieved in the last 2 decades when Ransley et al.11 and
Mitchell and Bagli12 introduced the tech- niques based on penile disassembly. Variants of this
tech- nique have also been described.13 In the current work we present a preliminary report on our
experience with a modification of Mitchell’s tech- nique of partial penile disassembly for the
surgical treat- ment of isolated cases of epispadias. MATERIAL AND METHODS Epispadias repair
was performed on 11 male patients with iso- lated primary epispadias aged from 4 to 13 years. The
epispadias was penopubic in 2, penile in 6, and balanic in 3. All patients were fresh and continent,
except the penopubic cases. The surgical procedure starts by induction of erection by using
intracorporal injection of prostaglandin E1 into each corpus to facilitate corporal and urethral plate
dissection and assessment of the dorsal chordee for subsequent correction. The skin inci- sion
starts from the epispadiac meatus. It continues distally the Pediatric Urology Unit, Urology
Department, Alexandria University, Alex- ria, Egypt eprint requests: Mohamed Youssif, M.D.,
Pediatric Urology Unit, Department of logy, University of Alexandria School of Medicine,
Alexandria, Egypt. E-mail: oussif@gmail.com ubmitted: March 19, 2007, accepted (with revisions):
September 22, 2007 2008 Elsevier Inc. 0090-4295/08/$34.00 235 artial Penile Disassem pispadias
Repair rahim Mokhless, Mohamed Youssif, Hazem JECTIVES Isolated male epispadias defect is p
Surgical repair of epispadias malform niques adopted. The current study isolated epispadias
repair. THODS Epispadias repair was performed on 1 penile, and 3 glanular. All cases we
performed to the corporal attachmen corporal bodies were separated with blood supply. Urethral
plate was tubu by using corporal rotation technique. up for 6 to 12 months. SULTS The penis had a
satisfactory cosmetic were transformed to subcoronal hypo tip of the glans because of its shorte
repaired at a later stage. NCLUSION Partial penile disassembly technique nents. Our repair of
partial penile disa for isolated epispadias repair. UROL Rights Reserved ly for Isolated Ismail, and
Hosam Higazy t in 10% of cases of epispadias-exstrophy complex. remains debatable as evident
by the different tech- nts our experience in partial penile disassembly for le patients aged 4 to 13
years. Two were penopubic, 6 sh. Extensive disassembly of penile components was own to the
horizontal branches of pubic bones. The rethral plate left attached to 1 corpus to preserve its d and
then transported from dorsal to ventral position nuloplasty was then performed. Patients were
followed earance with no significant dorsal chordee. Two cases ias, as it was difficult to bring the
urethral plate to the . One child had a minute penopubic fistula that was ores the anatomic
relationship of the penile compo- bly is a simple modification of the Mitchell technique 71:
235Ⓚ 238, 2008. © 2008 Elsevier Inc. doi:10.1016/j.urology.2007.09.068
 alo top bor and ure cor the to thr oth vas con ara sup att bra are sui Th cho wh the (Fi gra the win
app Fig tub 23 ng the penile shaft on either side of the urethral plate to the of the glans (Fig. 1). A
transverse incision is made at the der of reflection of the inner preputial layer onto the glans ends
on either side by joining the first incision. The thral plate is dissected from one side and elevated
off the poral body by entering the plane on the tunica albuginea of corpora. The plate should be
dissected as thick as possible develop well-vascularized tissues (urethral wedge). The ure- al plate
is left attached, throughout its entire length, to the er corporal body and hemiglans (Fig. 2). The
urethral plate cularity is based on proximal blood supply and vascularized tralateral edge. Each
 corpus and hemiglans are totally sep- ted and dissected from their mates relying on separate blood
ply. Separation is continued proximally with division of the achment of the suspensory ligament to
the horizontal nches of pubic bones. The pubic attachments of the corpora left intact. The urethral
plate is then tubularized around a table size catheter by using continuous 6-0 PDS sutures (Fig. 3).
e corpora were then medially rotated (this corrects the dorsal rdee) and sutured dorsal to the
tubularized urethral plate, ich had, by then, occupied a normal ventral position with suture line
facing dorsally toward the approximated corpora g. 4). In cases of dorsoventral length
discrepancies, dermal ft or suturing corporotomies can be used. Glanuloplasty is n performed by
excising excessive irregular skin on the glans gs and refashioning the hemiglans to achieve a
conical earance. Neourethral meatus is advanced to glans tip. The 2 Figure 1. Incision of the
urethral plate. 6 Figure 2. Urethral plate mobilization off 1 corpus. ure 3. Complete splitting of the
corpora and glans with ularization of the urethral plate. UROLOGY 71 (2), 2008
 lay Bya Pat mo RE Th a cu pa dif gla hy for sio fla Bo pe lat CO Ma rep get ve Ca ba wa the co tio
fist mo wa nil me 19 niq the the he blo co cav an rep un dis co som ing Ba bly co wi co co Fig pre
Fig the UR ers of the preputial skin are dissected and split as reversed r♠€ s flaps to cover the
reconstructed penis and urethra (Fig. 5). ients were followed up for a period ranging from 6 to 12
nths. SULTS e mean follow-up was 8.5 months. The penis showed satisfactory cosmetic
appearance with no significant rvature in all cases as reported by the parents. In 2 tients, the
urethral plate was short and it was therefore ficult to bring the external meatus on the tip of the ns.
These 2 cases were transformed to subcoronal pospadias and were managed 6 months later. We
per- med Thiersch-Duplay urethroplasty with dorsal inci- n in 1 patient and by using a tabularized
penile skin p urethroplasty (Mustarde technique) in the other one. th had successful outcomes.
One case had a minute nopubic urethral fistula develop that was repaired at a er stage. MMENT ny
surgical techniques have been described for the air of male epispadias. The aim of surgical repair
is to a cosmetically acceptable and functional penis with a ntrally located urethra opening at the tip
of the glans. ntwell3 was the first one who introduced a technique ure 4. Medial rotation of the
corpora; ventralization of tubularized urethral plate and glanuloplasty. OLOGY 71 (2), 2008 sed on
complete mobilization of the urethral plate that s then tubularized and transplanted ventrally
between corpora. Young4 modified the technique by avoiding mplete urethral plate mobilization for
better preserva- n of its vascularity thus decreasing the risk of urethral ula formation. The Young
modification remained the st widely used epispadias repair for several decades and s the main
technique performed by most centers. Pe- e disassembly techniques presented a real improve- nt
in the results of epispadias repair. Ransley et al.11 in 88 presented their penile disassembly repair.
The tech- ue was based on dissection of the urethral plate from corpora with separation of the 2
corporal bodies with exception of the distal part of the corpora and miglans that are left
undissected to ensure a better od supply and prevent plate shortening. The dissected rpora are
medially rotated and secured in position by ernosocavernostomy. The urethral plate is tubularized
d transformed ventral to the rotated corpora. This air is a good one; however, it was noted that the
dissected distal corpora and urethral plate make the tal part of the urethral tube unsupported
dorsally by rpora. Moreover, the incomplete distal disassembly etimes prevents ideal corporal
rotation and, accord- ly, urethral tube ventralization.13,14 Mitchell and gli12 in 1996 introduced the
complete penile disassem- technique. This entails the complete splitting of the rporal bodies and
the hemiglans into separate halves th complete dissection of the urethral plate off the rpora. This
procedure provides free mobility of the rpora and urethral plate. Although this technique is ure 5.
Skin coverage of the penis with reversed Byar’s putial flaps. 237
 used with good results for the repair of isolated male epispadias, it is really more ideal for
epispadias cases ass pu cas pla pe wi iso ma co sho ure pa ba era Ca lie the sep of ize co the no
scr pro of gla be co im tag car co dis att po sho de po ure reg ure ma of pla bro sub stu ure tra tin
bic rec ne cent data reported that bladder neck reconstruction was needed in 72% of females and
86% of males to achieve co ful ex ini ab ten to as de Mi du iso an ne Re 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15. 16. 17. 18. 19. 23 ociated with bladder exstrophy and incontinent peno- bic
epispadias. The complete penile disassembly, in es with associated exstrophy, allows more
posterior cement of the bladder neck and urethra into the lvis. This enhances the normal growth of
the bladder th better continence. This technique is also used for lated epispadias repair with good
results.15–17 The in disadvantages of the Mitchell technique are that mplete urethral plate
dissection is usually followed by rtening and retraction, and there is always the risk of thral plate
devascularization especially in its distal rt.13,15,18 In the current study we followed a surgical
technique sed on partial penile disassembly, taking into consid- tion the merits and the weak points
of both the ntwell-Ransley and the Mitchell techniques. We be- ved that complete splitting of the
corporal bodies and glans (as described by Mitchell and Bagli12) into arate halves is essential to
obtain easy medial rotation the corpora with proper ventralization of the tubular- d urethral plate.
Corporal rotation leads to satisfactory rrection of the dorsal chordee. Complete splitting of corpora
and glans allowed easy medial rotation with need to do a securing cavernosocavernostomy de-
ibed by Ransley et al.11 in their technique. The current cedure, on the other hand, is in accordance
with that Mitchell and Bagli in the complete splitting of the ns and corporal bodies with 2
differences. First, we lieved that in treating cases of isolated epispadias, mplete disassembly with
dissection of the corpora prox- al to the penopubic region will not add real advan- es, unlike cases
of associated exstrophy, as this will ry the risk of injury to the neurovascular bundle and rporal
devascularization. The second point is that we sected the urethral plate from only 1 corpus, leaving
it ached, throughout its entire length to the other cor- ral body. This is intended to prevent retraction
and rtening of the urethral plate and prevent its possible vascularization especially in its distal part.
The weak int in the current technique is that the tubularized thral plate is unsupported dorsally in
the penopubic ion (Fig. 4); hence we had a case of a penopubic thral fistula. The incidence of
fistula in this situation y be reduced by dissection and approximation of layers soft tissue to cover
this part of the tubularized urethral te. Cases with a short urethral plate that cannot be ught to the
tip of the glans are either transformed into coronal hypospadias (as was performed in the current
dy), or maybe treated by incision on the middle of the thral plate with interposition of an island
pedicled nsverse skin flap as reported in other studies.9,10 Con- ence is the functional concern
after repair of penopu- epispadias or exstrophy epispadias complex. There is ent data discussing
the long-term outcome of conti- nce in the single-stage Mitchell technique. These re- 8 ntinence.
Bladder neck reconstruction is more success- in those in whom complete primary repair of bladder
strophy was successful. As in all types of repair, failed tial closure usually results in a bladder that
is unsuit- le for bladder neck reconstruction. These patients of- require bladder augmentation and a
continent stoma be dry.19 In conclusion, the partial penile disassembly technique described in the
current work is based on procedures scribed by Cantwell and Ransley et al., as well as tchell and
Bagli with some modifications. This proce- re seems to be satisfactory for the repair of cases of
lated male epispadias. Our study is a preliminary report d a longer follow-up with a larger number
of cases is eded to document further the success of the procedure. ferences Duckett JW Jr:
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Epispadias Repair MATERIAL AND METHODS RESULTS COMMENT References