Can We Preserve the Urethral Plate in Proximal Hypospadias Repair?

Abstract

The essential factor responsible of curvature associated with proximal hypopsadias is the fibrosis tissue present on the ventral side of the penis. However, in the severe forms, a short urethral plate must be transected to obtain a complete correction of the chordee.

Commentary: Results of Onlay Preputial Flap Urethroplasty for the Single-Stage Repair of Mid-and Proximal Hypospadias

“…The proximal forms of hypospadias represent approximately a third of cases of this urogenital malformation. These forms are very often associated with curvatures ( 2 ). Thus, the treatment of proximal hypospadias includes two surgical stages: correction of the curvature and urethroplasty.…”

Commentary: Management of High-Grade Penile Curvature Associated with Hypospadias in Children

“…We conducted a scientific study on a large number of patients to know the causes of curvature associated with proximal hypospadias; this study that lasted more than 20 years and whose results were published successively ( 1 , 5 , 6 ) clearly shows the essential factor responsible for the formation of the curvature associated with proximal hypospadias is the fibrosis tissue present on the ventral side of the penis. The release of the skin and dartos fascia continued widely upstream of the meatus gives a significant correction (ranging from 20 to 100°).…”

“…However, the curvature of the penis is an anomaly very often present in the proximal forms of hypospadias. In a recent study (182 patients) ( 6 ), the saline erection test performed at the beginning of the operation showed that only 14% of patients had a curvature (≤45°), 54% (45–90°), and 31% (≥90°). This is completely different from the findings reported by Snodgrass and the authors who report “an absence or mild curvature (<30°) in 50% of patients with proximal shaft to perineal hypospadias” ( 7 ).…”

“…One of the two main reasons for dissatisfaction of penile appearance at the adult age of patients who underwent hypospadias surgery in childhood was residual or recurrent curvature of the penis ( 8 ) and I think that in the future the real challenge for pediatric urologists will be the management of curvature associated with proximal hypospadias. For more than 20 years, we have been using a dorsal plication technique by excision of a diamond shape at the point of the maximum bend dorsally after complete separation of the dorsal neurovascular bundle from the corpus cavernosum ( 1 , 5, 6 ). A procedure of dorsal plicature that seems more physiologic than others.…”

“…When the preservation of urethral plate is possible; the surgical repair of proximal hypospadias by onlay island flap or tubulization of urethral plate in the manner of Thiersch–Duplay becomes simpler, more facile, and gives excellent results. However, a significant number of adults and adolescents who we continue to follow and who have benefited during their young age an onlay island flap urethroplasty with or without mobilization of urethral plate and dorsal plication report the presence of curvature during erection ( 6 ). Thus, it is clear that there are cases where it is impossible to preserve the urethral plate in the curvature correction and it is difficult to say that the treatment in one stage of severe forms of this urogenital malformation, especially when the urethral plate was resected, is better than that realized in the two stages.…”