Chapter 2 Continued (part 3)
- Conclusion
The understanding of the etiology and the surgical treatment of hypospadias (or hypospadiology), remain two very active fields in medical research and literature.
Hundreds of surgical procedures developed over a century and half bear witness to the interest of surgeons, and more recently pediatric urologists, in this condition. One of the principle objectives of surgery for hypospadias has always been to improve the functional aspects of the penis: to permit urination standing up and satisfactory sexual relationships.
For several years now, specialists in this surgery have also tried to give the penis an appearance which comes as close as possible to the aesthetic norm. This is realized in those techniques which allow the creation of a urethral meatus in a terminal position and also result in a penis of a circumcised appearance.
Another important change concerns the required age for surgical treatment. Current practice is to advise that the operation should take place as soon as possible in order to avoid emotional consequences of awareness of a congenital deficiency and the experience of surgery.
In the same context, it’s now seen as important that the parents accompany the child during the pre- and post-operative processes. Another principle objective is to prepare the parents for the child’s surgery, giving them information on surgical procedures, the duration of hospitalization, the possible complications and the required post-operative care.
A review of the medical literature shows that hypospadias is much studied from a surgical position, but research on the psychological, psychosocial and psychosexual effects of hypospadias and its surgery is very much less represented in the literature. This is the subject of the next chapter.
Footnotes to text of Chapter 2
[21] It is notable that only a small number of publications have dealt with the physical consequences of unoperated hypospadias, regarding sexuality and reproduction as an adult (see, for example, Moudouni, Tazi, Nouri et al., 2001; Viville, 1993).
[22] In simple cases of hypospadias, an aesthetic correction should only be planned after first discussing the psychological aspects linked to hypospadias as well as clarification of any functional difficulties.
[23] The earliest forms of treatment date back to the !st and 2nd centuries BC, when surgeons amputated the penis at the level of the meatus and cauterized the wound with a hot iron! (De Sy & Hoebeke, 1996; Smith, 1997; Zaontz & Packer, 1997).
[24] I cite in this regard the use of scrotal skin (Cecil, 1932, cited by Horton & Devine, 1972), vesicle mucosa (Marshall & Spellman, 1955, cited by Coleman, 1981) or even skin from the penis (Denis Browne, 1949, cited by Gearhart & Witherington, 1979) to carry out urethroplasty.
[25] In fact, according to Paparel et al. (2001), replacement of the missing urethra using different skin grafts often produced unsatisfactory results and too high a number of repetitive operations (repetitive failures). This period was known as the ‘dark age of hypospadias surgery‘, since so many ‘disasters’ occurred!
[26] The reason for waiting was mainly ‘strategic’: surgeons had to have a reserve of skin sufficient to carry out reconstruction of the urethra. This did not happen until the age of around 3 years, or even later (AAP, 1975).
[27] When reconstructions in multiple stages were the rule (AAP, 1975), these were usually separated at intervals of 6 to 12 months, and children stayed in hospital a number of days (between 5 to 14 days) after each operation; very often rooms for parents to stay in were not provided. According to the AAP (1996), the need for several days of post-operative hospitalization is tending to be replaced by outpatient procedures, permitting patients to go home the same day. If a stay is required, many pediatric centers take care to minimize the separation time and offer rooms adapted to allow for this.
[28] MAGPI: Meatal Advancement and Glanuloplasty Incorporated. A surgical procedure consisting of opening the glans by a longitudinal incision, then vertically suturing the two sides. This maneuver creates a flattening of the glans and repositioning of the urethral meatus to the level of the glans apex (Sheldon & Duckett, 1987).
[29] In fact, many authors have confirmed a regression or secondary recoil of the meatus after using MAGPI (Paparel et al., 2001).
[30] GAP : Glans Approximation Procedure. This technique pulls the sides of the glans together. Its indication is limited to hypospadias where the meatus is wide and deep (Gites et al., 1998).
[31] The principle of this intervention is to use the elasticity of the urethra to bring it forward into a good position on the apex of the glans (Atala, 2002).
[32] Tubularization: creation of a new urethral canal (or neo-urethra) by rolling the tissue around a urethral catheter and suturing it in the form of a tube (Wilcox & Ransley, 2000).
[33] Embryologically, the urethral plate creates the penile urethra. In the case of a hypospadic penis, the urethral plate represents an important anatomic entity: it is a smooth urethral mucosa of variable dimensions which extends from the hypospadic meatus as far as the glans (Perovic et al., 1999). Anatomical studies have demonstrated that its use works well in the fabrication of a neo-urethra: this structure is free from hair, is richly vascularised and nerve-free, and it possesses good muscular and connective tissue components (Erol, Baskin, Li & Liu, 2001).
[34] TIP: Tubularized Incised Plate Urethroplasty.
[35] Mathieu’s technique (1932) was for a good part of the 20th century considered a model technique in repairing anterior hypospadias (the limit of its use is median hypospadias). Its method is as follows: a piece of skin, taken in advance from the ventral side of the penis, is freed, moved forward and stitched between the flanks of the urethral canal to create a new conduit (Ravasse, Petit & Delmas, 2000).
[36] The technique, the preputial pedicle flap is more often known as the ‘Onlay-Island Flap’. Its general principle is as follows: a flap of preputial skin is dissected and moved onto an isolated pedicle in the subcutaneous tissue of the dorsal side of the penis. It is then turned over onto the ventral side and sutured as a patch on the urethral canal to constitute a new canal as far as the glans apex (De Sy, 1996b). See also: Braz J Urol, 26: 621-629, 2000 online at http://www.brazjurol.com.br/novembro/Baskin_621_629.htm
[37] This technique, better known as ‘Tubularized Transverse Preputial Island Flap’, is employed when the urethral plate has had to be dissected to straighten the penis. It utilizes the inner portion of the foreskin, retaining its own blood supply. The remaining outer portion of foreskin resurfaces the front of the penis. (See also: Hayashi et al., 2003).
[38] Buccal mucosa: mucosa taken in advance from either the inside of the cheek or from the inside upper lip.
[39] I note here that certain new techniques such as GRAP (Glanular Reconstruction and Preputioplasty) (Gray & Boston, 2003), allow a combined reconstruction of the glans and the prepuce (preputioplasty) in the case of anterior hypospadias repair. Reconstruction of the prepuce may be carried out for many reasons: aesthetic, personal convenience or even cultural (Bruézière, 1996 ; Klijn, Dik & de Jong, 2001).
[40] In English medical literature this term is known as ‘hypospadias cripples’ (Stecker, Horton, Devine & McCraw, 1981).
[41] These numerous operations are the result of an accumulation of technical faults, traumatic dissections, use of poorly vascularised skin, bad sutures or even post-operative infections (Paparel et al., 2001).