Late chordee correction after tubularized incised plate repair for proximal hypospadias: An underreported problem

Abstract

Background: Repair of proximal hypospadias remains a challenge with no consensus on the best surgical approach. Several reports have shown recurrence of chordee after plate‐preserving techniques. In this report, we present our experience in managing cases who presented with persistent/recurrence of chordee after tubularized incised plate (TIP) repair for proximal hypospadias.

Methods: Between 2015 and 2023, the study included eight patients who presented with ventral penile curvature after previous hypospadias repair in infancy (TIP urethroplasty). Reoperation to correct persistent ventral curvature was performed several years after the primary TIP repair (3–15 years; mean 7.9 years; median 7.5 years). The reoperation was a two‐stage procedure: the first stage comprised transection of the urethra and grafting (lower lip mucosal graft); the second stage (6 months later) was a Thiersch‐Duplay urethroplasty.

Results: Complications included poor taking of the graft after the first stage in one case (12.5%), which was regrafted using buccal (cheek) mucosa. Complications after second stage included urethro‐cutaneous fistulae in five (62.5%) that were successfully surgically treated at a later stage. Follow‐up after second stage ranged between 6 months and 7 years (mean 2.4 years; median 1 year). Satisfaction with reoperation to correct penile curvature was noted by parents as well as older children (adolescents) who appreciated better cosmesis by increasing ventral penile length and improved curvature.

Conclusion: Preservation of the urethral plate in proximal hypospadias may result in shortened penile length, mostly on the ventral aspect. A two‐stage reoperation to increase the length of the penile urethra can successfully reverse this complication.

Graphical abstract

Keywords

complications / hypospadias / proximal / severe / ventral curvature

1 INTRODUCTION

In 1994, Warren Snodgrass popularized the technique of tubularized incised plate (TIP) urethroplasty for managing distal hypospadias[1]. Rapidly, the technique gained widespread acceptance thanks to its simplicity, reproducibility, and low rate of complications[2]. The great success with distal types encouraged several centres to apply TIP repair with more severe forms of hypospadias as well as redo cases[3,4]. However, the ventral curvature associated with proximal hypospadias represented a major concern regarding preserving the urethral plate in TIP repair[5–7]. Some authors argued the role of urethral plate in ventral curvature and that it can be preserved while applying dorsal plication sutures (Nesbit) to correct associated mild to moderate chordee[8].

In this report, we present our experience in managing cases who presented with persistent recurrence of chordee after TIP repair for proximal hypospadias.

2 METHODS

The study included eight cases of proximal hypospadias who presented with persistent chordee after their initial management by TIP repair at our institution several years ago. At follow‐up, these boys reported uncomplicated voiding through a glanular meatus; however, their main concern was the shortened penile length. Data of these boys, which was retained by the author, were retrospectively analyzed. Data included digital photographic documentation of the phenotypic severity of hypospadias at their initial presentation as well as the operative steps of primary TIP repair (Figures 1A–D, and 2). By revising old operative files and photos, all included cases had severe forms of hypospadias at initial presentation (either scrotal or penoscrotal); the degree of chordee was significant (about 40–60°), which was managed by dorsal plication (either midline or Nesbit). At that time, dorsal plication was chosen to treat chordee in order to preserve the urethral plate for TIP urethroplasty. Detailed operative steps of TIP urethroplasty for proximal hypospadias are described in previous reports[9,10].

When these boys returned for follow‐up (several months/years after the initial TIP repair), local examination revealed shortened penile length, which was more pronounced on the ventral aspect. Sometimes the penis appeared buried/hidden (Figure 1E) or with a characteristic “tuna‐can” appearance (Figure 2D). Pelviabdominal ultrasound and urine analysis were ordered to screen for any possible complications, which proved to be normal. Parents were instructed to try to document the voiding pattern of their children as well as morning erections by photos/videos, which would be reviewed by the treating surgeon. During our early experience with such cases, we tried to improve cosmesis by performing some simple procedures that later proved to be of limited value: Penile degloving and skin refashioning, and occasionally repeating the dorsal penile plication. With the growing evidence in the literature on the major role of plate preservation in the recurrence of chordee[5–7,11], and based on our experience as well, we offered a reoperation for these patients with persistent chordee after TIP repair. The reoperation was performed as a two‐stage procedure[12–14] aiming to increase the length of the urethra on the ventral aspect of the penis.

Surgical technique of reoperation to increase ventral penile length and correct persistent chordee: At the first stage, we started by degloving the penile skin. The ventral bending of corpora cavernosa was still significant (about 40–60°) which was made more pronounced by artificial erection test (Figure 3). The urethra together with the surrounding corpus spongiosum was dissected and separated from the dorsal corpora cavernosa (Figure 1E–H). The urethra was then transected most distally at its glanular end. This was followed by the release and straightening of the penile shaft (Figure 4). The mobilized urethra was re‐fixed more proximally to the penile shaft usually at a mid‐penile position. An inner lower lip mucosal graft was used to cover the ventral defect between the urethral meatus at its new mid‐penile position and the tip of the “split open” glans (Figure 4C). The graft was quilted to the underlying penile shaft and further fixed by the tie‐over dressing. In one case with poor taking of the graft, regrafting using buccal mucosa (cheek) was performed before shifting to the second stage (Figure 5). The second stage (Thiersch ‐ Duplay urethroplasty) was usually performed 6 months later (Figures 1I–K and 6). Local dartos flaps were dissected to be used as a second layer of coverage for the urethroplasty.

3 RESULTS

Between 2015 and 2023, the study included eight patients who presented with ventral penile curvature after previous hypospadias repair in infancy (TIP urethroplasty)[10]. Their age at primary TIP repair ranged between 6 and 15 months (mean 11.5 months; median 12 months).

The reoperation to correct persistent ventral curvature was performed several years after the primary TIP repair (3–15 years; mean 7.9 years; median 7.5 years). The reoperation was a two‐stage procedure as previously described in the methods: The first stage comprised transection of the urethra and grafting (lower lip mucosal graft); the second stage (6 months later) was a Thiersch–Duplay urethroplasty. Complications included poor taking of the graft after the first stage in one case (12.5%), which was regrafted using buccal (cheek) mucosa (Figure 5). Complications after the second stage included urethro‐cutaneous fistulae in five cases (62.5%) that were successfully surgically closed at a later stage. Follow‐up after the second stage ranged between 6 months and 7 years (mean 2.4 years; median 1 year). Satisfaction with reoperation to correct penile curvature was noted by parents as well as older children (adolescents) who appreciated better cosmesis by increasing ventral penile length and straightening of the penis (Figures 1K and 6A–C).

4 DISCUSSION

Repair of proximal hypospadias remains a challenge with no consensus on the best surgical approach[5]. After penile degloving, a critical decision is whether to preserve or transect the urethral plate that would essentially depend on the degree of associated chordee[15]. Preserving the plate will eventually simplify the procedure through a single stage repair with a low rate of early postoperative complications[15]. However, several reports have shown recurrence of chordee after plate‐preserving techniques, and the threshold for scarifying the urethral plate has been lowered worldwide (starting from 30°)[5,11].

Persistence/recurrence of chordee after hypospadias repair may be underreported in the literature[5]. Primary hypospadias repair is usually performed in infancy or early childhood. The rate of penile growth remains very slow (almost plateau) till puberty when it rapidly increases in size (several folds). Some surgeons may prefer to wait after puberty when it becomes easier to assess the final penile length and degree of curvature. However, there is growing evidence that the ventral hypoplastic tissues (urethral plate with deficient spongiosum) do not grow at the same normal rate of dorsal penile tissues[16,17]. This may eventually increase the ventral curvature after puberty. In a previous report, we studied the effect of hormonal stimulation (local testosterone) on the penile length in a group of hypospadiac patients[18]. Interestingly, we have reached to a similar conclusion when we found that the ventral penile length distal to the meatus differentially grew at a slower rate than that proximal to the meatus[18]. In other words, the hypospadiac plate with deficient spongiosum responded less to hormonal stimulation compared to healthy proximal urethra.

The decision of reoperation to bring the meatus back again to a hypospadiac position after years of completing the primary repair is not easy for both surgeons and families. However, persistence of significant chordee may affect the sexual function of these boys in the future. Moreover, from the cosmetic point of view, the penile length seems to be more important, while the shape and position of meatus may be ranked very last[19]. Early during the study period, we were rather hesitant to reoperate on these children hoping that their penile length would improve with time. However, as these boys grew older approaching puberty, they got more and more concerned with their penile length. The aim of reoperation was to increase the length of their shortened penile urethra on the ventral aspect. Since there were no obstructive symptoms/strictures, we made use of the former tubularized urethral plate while adding extra length to the penile urethra distally using buccal grafts (Bracka technique)[14]. The technique was successful in increasing the penile length immediately after the first stage, which was quite appreciated by teenage patients and their parents even before completing the second stage. Apart from graft failure after the first stage in one case, the complications after the second stage were considered minor and were quite accepted by referring to the benefits of reoperation.

In the period 2007 to 2015, TIP urethroplasty was a popular technique at our institution to manage cases of proximal hypospadias (more than 75% of cases with proximal hypospadias)[9,11]. Due to the growing evidence in the literature as well as our experience with plate preservation in proximal hypospadias, this percentage has sharply dropped to less than 10% nowadays. Currently, the two‐stage repair has become the preferred technique which has replaced TIP in management of proximal hypospadias at our institution as well as for different centres all over the world[20,21]. The study is limited by the small number of cases, and lack of data referring to the actual percentage of this complication (recurrent curvature) after TIP for proximal hypospadias. However, the report may be speculiar in presenting long‐term follow‐up of these cases while referring to their initial phenotypic severity. Another limitation in this report is using a single technique (urethral transection) to correct penile curvature without discussing other options for performing penile orthoplasty (ventral lengthening procedures)[21]. Also, the way of describing the outcomes was subjective lacking precise measurements for the degree of chordee (goniometer) before and after reoperation. However, we have tried to overcome the latter limitation by including a detailed digital photographic demonstration for the degree of penile curvature, operative steps, and follow‐up.

5 CONCLUSION

Preservation of the urethral plate in proximal hypospadias may result in shortened penile length, mostly on the ventral aspect. A two‐stage reoperation to increase the length of the penile urethra can successfully reverse this complication.

References

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2024 The Author(s). UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.