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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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Year : 2017  |  Volume : 22  |  Issue : 3  |  Page : 158-162

Two stages repair of proximal hypospadias: Review of 700 cases

Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication8-Jun-2017

Correspondence Address:
Aditya Pratap Singh
Near The Mali Hostel, Main Bali Road, Falna, Dist-Pali, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9261.207627

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Objective: Surgical repair of hypospadias is challenging and problematic even for the most experienced specialists, and this is especially true when severe and complicated case is confronted. Many operations had been described for the management of this deformity.
Materials and Methods: During the period from May 2004 to December 2015, we performed 700 cases with proximal hypospadias, at our institute in the Department of Pediatric Surgery by a single surgeon. Data were collected retrospectively and included patient's age at operation, degree of the hypospadias, degree of associated chordee, complications, and cosmetic outcome. All patients underwent 2 two-stage procedures with 9–12 months interval in between.
Results: Seven hundred patients with proximal hypospadias were operated upon in a period of 11 years. Byars's 2 two-stage operation was used in all 700 cases. Neither complete disruption nor urethral diverticula occurred 2 two-stage procedures in the 700 patients. 677 (96.7%) patients had no complication. Fistula was present in 21 (3%) patients. There was no case of meatal stenosis in our study.
Conclusion: Two stages procedure using the principles of Byar's technique is a versatile operation that can be used for 2 two-stage procedures the proximal hypospadias. It decreases the rate of fistula formation, disruption, and stenosis and gives a satisfactory cosmetic appearance.

Keywords: Byar's flap, proximal hypospadias, 2 two-stage procedures

How to cite this article:
Shukla AK, Singh AP, Sharma P, Shukla J. Two stages repair of proximal hypospadias: Review of 700 cases. J Indian Assoc Pediatr Surg 2017;22:158-62

How to cite this URL:
Shukla AK, Singh AP, Sharma P, Shukla J. Two stages repair of proximal hypospadias: Review of 700 cases. J Indian Assoc Pediatr Surg [serial online] 2017 [cited 2020 Sep 26];22:158-62. Available from: http://www.jiaps.com/text.asp?2017/22/3/158/207627

   Introduction Top

Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct.[1] The debate over the optimal treatment for severe cases of hypospadias is ongoing, and many surgeons believe that two-stage procedure offers superior functional and cosmetic results with fewer complications.[2] We report long-term results of our series of Byar's two-stage repair for primary cases with proximal hypospadias performed at a single center by a single surgeon with some modification to improve outcome.

   Materials and Methods Top

During the period from May 2004 to December 2015, we performed 700 cases with proximal hypospadias at our institute in the Department of Pediatric Surgery. Data were collected including patient's age at operation, degree of the hypospadias, degree of associated chordee, complications, and cosmetic outcome.

All consecutive patients seen in outpatient department with proximal hypospadias with severe to moderate chordee underwent Byar's two-stage procedure as primary surgery. All were included in this study and were followed up for minimum 1 year after the second stage.

The age of patients ranged from 3 to 12 years. The types of their hypospadias include proximal penile, penoscrotal, and scrotal hypospadias with bifid scrotum. Associated chordee was severe in 560 (80%) cases and moderate in 140 (20%) cases. We included only cases with moderate to severe chordee with proximal hypospadias and excluded cases with mild chordee and mid and distal penile hypospadias. All patients underwent 2 two-stage procedures with 9–12 months interval in-between. The first procedure was to release the chordee using Byar's technique with excising the urethral plate. The second procedure was the urethroplasty.

The procedure

The patients were at least 3 years old to have acceptable size penis. If the penis was relatively small, preoperative aqueous testosterone injection (1–2 mg/kg) was given to enlarge its size. 2–3 injections were given at the 2 weeks interval and operated after 1 month of the last injection. In the first procedure, the Byar's technique was performed. A 4/0 prolene stitch was placed on the glans for traction and a 6 Fr silastic NG tube was inserted. Surgery was performed under general anesthesia with infiltration with 1:100000 lignocaine and adrenaline solution. A circumferential dorsal incision was made about 1/2 cm from the base of the glans. This was advanced ventrally along the urethral plate till it passes to the proximal edge of the urethral meatus. Then it extended vertically in the midline proximal to the meatus. the incision is racket shaped.

Complete degloving of the penile shaft was performed till its base and transection, and excision of the urethral plate was done just proximal to the glans in every case. Then, artificial erection was performed to demonstrate any residual chordee. If this persisted, then dorsal tunica albuginea plication was performed. Glanular wings were created by two methods: (1) an incision was made in the midline of the glans and glans wings were created, (2) by inserting the scissor parallel to the shaft of penis under the glans in midline. The meatus was spatulated. The dorsal preputial skin was then incised in the middle and the two flaps were brought ventrally. Preputial skin flap (Byar's flap) sutured to cover the raw area created on retraction of the “glans wings” and on areas created after release of chordee. These were sutured to the glans and to each other in the midline of the shaft [Figure 1]. The catheter was removed after 7 days.
Figure 1: (a and b) Chordee correction

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The second stage was performed 9–12 months later. A traction suture and a 10 Fr silastic NG tube were inserted. Then, the strip of the rotated skin was folded over it to measure the size of future neourethra. The width of this strip was measured according to the catheter circumference. Parallel lines were marked on the ventral side of the penis. Incisions were made along these lines to the tip of the glans. The rotated skin was tubularized around the 8 Fr silastic NG tube to make the new urethra using 6-0 polyglactin edge inverting continuous running suture. This tube must be of a sufficient width to allow the catheter to be removed without tearing the neourethra. A second layer interrupted 6-0 polyglactin sutures were taken from the penile adventitial tissues over 6 Fr NG tube as a “waterproof” layer over the first suture line. Then, we left a 6 Fr silastic NG tube in every case. At last, the penile skin is sutured in two layers [Figure 2]. Simple penile dressing was applied. The dressing was changed after 5–7 days and the catheter was removed after 13 days. If the patient is able to pass urine per urethra after this, he is discharged with the advice to return to clinic at 1 week. We followed our patients at 7 days, 15 days, 1 month, 6 months, and 1 year.
Figure 2: (a-d) Second-stage urethroplasty

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   Results Top

Seven hundred patients with proximal hypospadias were operated on in a period of 11 years. 525 (75%) patients had proximal penile hypospadias, 140 (20%) patients with penoscrotal hypospadias, 35 (5%) patients with scrotal hypospadias with bifid scrotum [Table 1]. The follow-up period ranged from 1 to 10 years.
Table 1: Types of hypospadias

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All patients had two-stage repairs. Byar's technique was used as the first stage. At least 9–12 months later, the urethroplasty was performed in the second stage to create the neourethra from the rotated skin of the first stage. None of the patients needed either skin or bladder or buccal mucosal grafts.

Neither complete disruption nor urethral diverticula occurred in the 700 patients. 677 (96.7%) patients had no complications. Fistula was present in 21 (3%) patients at the subcoronal 2 (0.28%), midpenile 4 (0.57%), penoscrotal 15 (2.14%) region and was repaired 6–9 months later in all cases. No recurrence occurred in all the cases operated on for closure of fistulae. There was no case of meatal stenosis, stricture, and excessive skin on the glans in our study. No recurrence of chordee occurred in any patient in the series. Chordee was present in all patients mainly of moderate to severe types. Most of them were corrected by doing penile degloving with excision of the urethral plate and all fibrosis, but 14 (2%) of them required dorsal plication. There was no case of graft loss in our study. There were two cases of epididymo-orchitis in our study on long-term follow-up [Table 2].
Table 2: Complications

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   Discussion Top

Hypospadias is one of the most common congenital defects of male external genitalia, occurring in approximately 1 in 250 live male newborns, of which proximal hypospadias (penoscrotal, scrotal, and perineal types) account for 20% of all cases.[3],[4]

During the last 10 years, the approach to severe hypospadias has been controversial.[5] This controversy exists with regard to the best approach to proximal hypospadias. There have been many operations described for repair of hypospadias, which reflect the difficulty in getting optimum results from the surgery for this condition.[6] Although one-stage repair has been shown to be successful for some forms of proximal hypospadias, many still favor a more traditional-staged approach when moderate to severe chordee is present to achieve adequate straightening and lengthening of the penis at the time of the first-stage repair. This is achieved either by division of the urethral plate or Byars' flaps are created and mobilized ventrally to cover the ventral shaft of the penis.[7]

Hypospadias is usually accompanied by a band of fibrous tissue that extends from the abnormal meatus to the glans, and this band frequently shortens the ventral aspect of the penis. This chordee produces a downward curvature of the penis, noted during erection.

Notwithstanding the dispute on single-stage versus two-stage repairs, agreement exists that procedure assignment in hypospadias repair is based on the patient's individual anomaly and on the surgeon's experience and preference. However, the ultimate surgical goal is common and that is to reconstruct a normal or near-normal appearance of penis mimicking that of postcircumcision one, to have adequate caliber, water-proof neourethra extending to the apex of glans for upright voiding with normal urine stream, to create a straight penis adequate for sexual intercourse, and to prevent complications.[8]

Over the years, so many techniques have evolved and these range from a one-stage technique, where correction of chordee and creation of neourethra are done simultaneously to a two-stage operation, where creation of the new urethra is performed as a second-stage procedure after an earlier operation for chordee correction. Creation of this urethral tube ranges from using buried skin strip as in the Dennis Brown operation to using skin graft either from preputial skin or thick split-thickness skin graft.[7] Other techniques use vascularized skin flaps either pedicled on the subcutaneous adventitial tissue of the penis [9],[10] or as a transposed skin flap as in Byar's operation.[11] Single-stage procedures are often associated with complications such as fistulae, stricture, metal stenosis, and require reoperations.[12],[13],[14] There has been a resurgence of the two-stage procedure for such severe proximal hypospadias cases in recent years.[15] No single surgical procedure is ideal and the quest for such a procedure continues.[16]

In our institute, the author prefers to perform surgery when the child is 3 years of age so that all operations and the treatment of complications would be completed by the time the child goes to school. Furthermore, at 3 years of age, the penis is of acceptable size to make surgery relatively easier and children are more cooperative. The second stage of the surgery is done 12 months later to allow time for adequate scar maturation and the surrounding tissue to be supple enough for further handling and surgery. The range of patients in our study was 3–12 years. After 12 years, there was more chance of the infection in initial experience of the Byar's technique in our institute. We did not include patients after the age of 12 years.

Byar's two-stage operation is the most common operation performed in our department. It was performed on 700 patients. Being a vascularized skin flap, it is very reliable when used in the first stage, and at the same time, there is abundant vascularized skin available to resurface the raw area that has been created as a result of chordee correction. This need for a large vascularized flap to cover this raw area is especially seen after release of chordee in penoscrotal hypospadias. The other advantage of Byar's operation is that on completion of the procedure, there is no need to do a circumcision which can be a big advantage to a Muslim patient.

In our technique, there are some modifications: (1) skin leaves thin during degloving of penis which acts like as principle of bucccal mucosa, (2) first deglove around the ectopic meatus with leaving some tissue with urethral wall to prevent urethral injury, (3) we usually either mobilize the urethra and suture it with the Byar's flap or after spatulating it suture with the penile shaft.

There were no cases of meatal stenosis, diverticulae, and urethral stricture. This could be attributed to the size of the new urethra, which was deliberately made wide using the 10 Fr silastic NG tube circumferences as a guide to the urethra size. We also formed neourethra in two layers; it also formed a tough tissue. In our opinion, tough tissue prevents the diverticulae formation in our study. It is very important to measure the size of the strip in Byar's technique because if it will keep large then leads to diverticulae formation and small leads to stricture and meatal stenosis; further, it will complicate by fistula formation and complete disruption of the repair.

The size of the neourethra is of utmost importance; it must be adequate enough to prevent tearing of the urethra when the catheter is removed. Tears in an already fragile tissue often lead to fistula formation. The diameter of this new urethra must be of adequate size to allow the penile catheter to be withdrawn without causing a tear to this urethra, so we measured the neourethra over 10 Fr NG tube, created neourethra over 8 Fr, and replaced it with 6 Fr tube in every case. We did not use any suprapubic catheter in our study. In our view, it is more invasive and increases the morbidity in patients. The second layer is also important in providing an extra layer to prevent fistula formation. Hence, we had only 3% case of fistula in our study. We got this success with simple penile dressing using only tulle grass, gauze piece, and adhesive tape and without any magnifying loupe in our study with better results. In our view, we prefer not to use costly dressings and magnifying loupes, especially in developing countries such as India. This makes surgery more costly.

As for all other techniques, major complications of the staged repair include fistula formation, metal stenosis, suture line dehiscence, stricture, and diverticulue formation. Most of the urethroplasty complications tend to occur in the first 12 months after the second stage.[17]

Other complications of surgery for hypospadias are complete disruption, postoperative bleeding, and recurrence of chordee or excess skin at the glans. The most common complication is fistula formation. The incidence of fistula formation is reported to be from 3% to 50%, and it is higher in the more proximal hypospadias.[11] In this series, the fistula rate was 3% (21 out of 700 patients). We did not have any excess skin at the glans in our study. It looked like a circumcised penis.

Telfer et al.[18] reported a 63% fistula rate in cases operated without and a 4.5% rate in those operated with such an additional layer. We created neourethra in two layers. Additional layer provides waterproofing in our study.

Simple dorsal plication was reported to be associated with a recurrence rate of 37% compared with no curvature recurrence after simultaneous dorsal plication and urethral plate transection in patients who had proximal hypospadias with severe ventral curvature.[19] We transected and excised urethral plate in every case in our study. Transection and excision of the urethral plate may reduce the recurrence rate of chordee, especially in cases of proximal hypospadias with severe chordee. In our study, no recurrence of chordee was found after nearly 10 years of follow-up. Furthermore, all of our patients or their parents were satisfied with cosmetic appearance and the penile length after chordee correction and urethroplasty. Cosmetic appearance was judged by circumcised penis, opening at the tip, and less scarring in our study. Satisfactory cosmetic results were achieved in all cases. According to Bracka, one of the major advantages of staged repair is the possibility to achieve a good cosmetic result with placement of the urethra deep in the glans and creation of a natural slit-like meatus. Accordingly, most series report an excellent cosmetic result and patient satisfaction.[7],[8],[16],[20],[21] In our series, all patients had meatus at the tip, passing urine in good single stream. In severe chordee cases during which a poor urethral plate must be transected, these techniques usually cannot reconstruct the neourethra in one-stage. In recent years, there has been renewed interested in treating those severe cases with two-stage repair.[22],[23] Although the two-stage procedures are more time-consuming and more costly, they usually provide a healthier urethral bed and tough tissue around the urethra. Penoscrotal transposition cases were managed as three stages in our study.

There were two cases of epididymo-orchitis cases in our study. These may be due to long-term catheterization for 13 days in our study. We kept follow-up at 1 week, 2 weeks, 1 month, 6 months, and 1 year. In our view, it is very long follow-up in Byar's technique. On follow-up, we recommended urinary antibiotic on empirical basis without any culture. It helped us prevent urinary tract infection after using NG tube for 13 days.

In our study, there were no graft contraction and graft loss problems as seen with Bracka technique. We used preputial-based flap, it leads to no stricture formation in our study. It is because neourethra was formed of adequate size with no problem of graft contraction.

There are complications with Bracka technique related to donor site such as scarring and sensory loss. It is also a technically challenging and invasive technique while Byar's technique does not have these problems and it is a simple technique.

   Conclusion Top

Two-stage procedure using the principles of Byar's technique is a versatile operation that can be used for the proximal hypospadias. It decreases the rate of fistula formation, disruption, and stenosis and gives a satisfactory cosmetic appearance. In our view, the key to success of the repair depends on the urethral strip measurement in the second stage of Byar's technique.

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Conflicts of interest

There are no conflicts of interest.

   References Top

DeFoor W, Wacksman J. Results of single staged hypospadias surgery to repair penoscrotal hypospadias with bifid scrotum or penoscrotal transposition. J Urol 2003;170(4 Pt 2):1585-8.  Back to cited text no. 1
Gershbaum MD, Stock JA, Hanna MK. A case for 2-stage repair of perineoscrotal hypospadias with severe chordee. J Urol 2002;168(4 Pt 2):1727-8.  Back to cited text no. 2
Baskin LS, Ebbers MB. Hypospadias: Anatomy, etiology, and technique. J Pediatr Surg 2006;41:463-72.  Back to cited text no. 3
Duckett JW. Successful hypospadias repair. Contemp Urol 1992;4:42-55.  Back to cited text no. 4
Shapiro SR. Fistula repair. Reconstructive and plastic surgery of the external genitalia: Adult and paediatric. London: WB Saunders; 1999. p. 132-6.  Back to cited text no. 5
Arshad AR. Hypospadias repair: Byar's two stage operation revisited. Br J Plast Surg 2005;58:481-6.  Back to cited text no. 6
Bracka A. Hypospadias repair: The two-stage alternative. Br J Urol 1995;76 Suppl 3:31-41.  Back to cited text no. 7
Fathi K, Burger AE, Kulkarni MS, Mathur AB. Duckett versus Bracka technique for proximal hypospadias repair: A single centre experience. J Pediatr Surg Spec 2008;2:11-3.  Back to cited text no. 8
Broadbent TR, Woolf RM. Hypospadias: One stage repair. In: Horton CE, editor. Plastic and Reconstructive Surgery of the Genital Area. Boston, MA: Little, Brown and Company; 1973. p. 264-7.  Back to cited text no. 9
Duckett JW. The island flap technique for hypospadias repair. In: Duckett JW, editor. The Urologic Clinic of North America. Vol. 8. London: WB Saunders; 1981. p. 503-11.  Back to cited text no. 10
Byars LT. A technique for consistently satisfactory repair of hypospadias. Surg Gynecol Obstet 1955;100:184-90.  Back to cited text no. 11
Glassberg KI, Hansbrough F, Horowitz M. The Koyanagi-Nonomura 1-stage bucket repair of severe hypospadias with and without penoscrotal transposition. J Urol 1998;160 (3 Pt 2):1104-7.  Back to cited text no. 12
Demirbilek S, Kanmaz T, Aydin G, Yücesan S. Outcomes of one-stage techniques for proximal hypospadias repair. Urology 2001;58:267-70.  Back to cited text no. 13
Castañón M, Muñoz E, Carrasco R, Rodó J, Morales L. Treatment of proximal hypospadias with a tubularized island flap urethroplasty and the onlay technique: A comparative study. J Pediatr Surg 2000;35:1453-5.  Back to cited text no. 14
Snodgrass WT. Re: Skin graft for 2-stage treatment of severe hypospadias: Back to the future? J Urol 2003;170:193-4.  Back to cited text no. 15
Johal NS, Nitkunan T, O'Malley K, Cuckow PM. The two-stage repair for severe primary hypospadias. Eur Urol 2006;50:366-71.  Back to cited text no. 16
Hensle TW, Kearney MC, Bingham JB. Buccal mucosa grafts for hypospadias surgery: Long-term results. J Urol 2002;168 (4 Pt 2):1734-6.  Back to cited text no. 17
Telfer JR, Quaba AA, Kwai Ben I, Peddi NC. An investigation into the role of waterproofing in a two-stage hypospadias repair. Br J Plast Surg 1998;51:542-6.  Back to cited text no. 18
Braga LH, Lorenzo AJ, Bägli DJ, Dave S, Eeg K, Farhat WA, et al. Ventral penile lengthening versus dorsal plication for severe ventral curvature in children with proximal hypospadias. J Urol 2008;180 4 Suppl: 1743-7.  Back to cited text no. 19
Ferro F, Zaccara A, Spagnoli A, Lucchetti MC, Capitanucci ML, Villa M. Skin graft for 2-stage treatment of severe hypospadias: Back to the future? J Urol 2002;168 (4 Pt 2):1730-3.  Back to cited text no. 20
Ramanathan C. Three-year experience of hypospadias surgery: Bracka's method. Indian J Plast Surg 2006;39:130-5.  Back to cited text no. 21
  [Full text]  
Bracka A. The role of two-stage repair in modern hypospadiology. Indian J Urol 2008;24:210-8.  Back to cited text no. 22
[PUBMED]  [Full text]  
Castellan M, Gosalbez R, Devendra J, Bar-Yosef Y, Labbie A. Ventral corporal body grafting for correcting severe penile curvature associated with single or two-stage hypospadias repair. J Pediatr Urol 2011;7:289-93.  Back to cited text no. 23


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