【Abstract】Objective To summarize the clinical results of staged surgery for perineal hypospadias. Methods Retrospective analysis of the clinical data of 18 cases of perineal hypospadias: Stage I surgery was performed to completely straighten the penile corpus cavernosum, and the urethra was reconstructed to the penile scrotal junction by applying a longitudinal flap of the perineal septum to roll the tube; Stage II surgery was performed to reconstruct the urethra of the penile segment, and cystourethrography was performed before surgery, using Dupaly or Snodgrass surgical methods. The success rate of the operation was 68% (12/18), the incidence of urethral fistula was 28% (5/18), the incidence of urethral stricture was 17% (3/18), and the urethral fistula and stricture were cured by urethral repair and urethral dilatation; the perineal septum longitudinal flap urethra No dilatation, no stricture, and little urethral sebum. Conclusion: Staged surgical treatment of perineal hypospadias can repair longer urethral defects, and the perineal septal longitudinal flap is an ideal material for repairing the urethra of the scrotal segment with more satisfactory postoperative results, which can be an effective and reasonable surgical mode. Li Shoulin, Department of Urology, Shenzhen Children’s Hospital
【Key words】Suburethral cleft; urological surgery
Hypospadias is a common congenital malformation in pediatric urology, which is usually divided into 4 types according to the location of the opening of the external urethra, namely type I: penile head and coronal groove type; type II: penile body type; type III: penile scrotum type; and type IV: perineum type. Among them, perineal hypospadias is difficult to operate and has many postoperative complications due to the combination of severe penile dysplasia and other malformations. Failure to adopt a suitable treatment plan can have considerable psychological and physiological effects on the child. From January 2009 to September 2011, 18 cases of perineal hypospadias were treated in our hospital by staged surgery with definite results and satisfactory appearance. The results are reported below.
Data and methods
I. Clinical data
All 18 cases of perineal hypospadias were hospitalized in our hospital, aged 1-5 years, with a median age of 3.5 years. The sex chromosome examination was 46XY in all cases, and no female internal genitalia were seen on ultrasound; 7 cases had unilateral or bilateral cryptorchidism, 4 cases had gonadal dysplasia, 2 cases had traffic syringomyelia, and 2 cases had inguinal hernia. In all cases, the vulva was characterized by short penile development, hypospadias, and in some cases, it resembled the clitoris; the scrotum was divided and the scrotal septum skin was mucous-like, with different degrees of penile-scrotal transposition; the external urethral opening was located at the junction of the scrotum and perineum.
II. Method
Before the age of 2 years, testicular fixation or gonadal exploration is performed for those with cryptorchidism or gonadal dysplasia, and syringomyelia or high ligation of the hernia sac is performed for those with syringomyelia or inguinal hernia; urethral repair surgery is performed after the age of 2 years and is completed in two sessions, with more than 6 months between the two surgeries. 1. Phase I surgery: correction of penile curvature, repair of the urethral orifice to the penile scrotal junction or the proximal end of the penile body by applying the perineal septum longitudinal flap method. The cystostomy was performed at the same time, and a short silicone stent tube was left in the urethra. The cystostomy tube was removed 12-14 days after surgery and the urethral stent tube was retained and removed during the outpatient review 1 month after discharge; for short penile corpus cavernosum, 1000 IU of chorionic gonadotropin (hCG) was given intramuscularly 1 to 2 months before the second surgery, twice/week, four times in total, to stimulate the development and enlargement of the corpus cavernosum. 2. Phase II surgery: The urethra of the penile segment was reconstructed according to the Duplay method or Snodgrass method, and the stent tube was left in place for the same period as the phase I surgery.
Results
Five cases had urethral fistula due to flap necrosis with diameters between 1 and 3 mm, all of which were located in the urethral area of the penile segment reconstructed in the second stage, and improved after reoperation six months later. The urinary flow rate Qmax was 5-8 ml/s. After hCG treatment for penile corpus cavernosum abnormalities, the penile outer diameter and length were changed to different degrees.
DISCUSSION
Hypospadias is a more common phenomenon among male external genital anomalies, mainly manifested as a ventral bending deformity of the head and body of the penis, with ectopic opening of the urethra in any part of the ventral urethra, even in the scrotum and perineum. The most serious type of hypospadias is the perineal hypospadias, in which the penis is obviously short and bent ventrally, and may be accompanied by cryptorchidism or testicular hypoplasia, and traffic testicular syringomyelia or reducible inguinal hernia. The majority of these cases are associated with penile scrotal transposition or scrotal splitting, which resembles the female vulva and even leads to incorrect gender confirmation after birth. It has been reported that up to 34.7% of cases of perineal hypospadias are combined with hermaphroditism. The presence of vagina, uterus and ovaries can be identified clinically by chromosome, ultrasound and retrograde urography. However, no significant gender abnormality was found in this group of cases.
There are various but not perfect surgical options to correct perineal hypospadias. Since the flexion deformity of the penile corpus cavernosum in perineal hypospadias is more pronounced than in other types of hypospadias, the corpus cavernosum is less developed, and the urethra to be reconstructed is longer, the formulation of the surgical method, the correction of the morphology and the selection of alternative materials should be considered comprehensively. At present, most scholars at home and abroad believe that instead of pursuing a higher success rate of one-stage surgery, it is better to improve the long-term therapeutic effect, so for perineal hypospadias, especially in combination with penile dysplasia or severe penile curvature, it is appropriate to operate in stages.
Through the treatment of this group of cases, the author has the following experiences: (1) the surgical complications are significantly reduced in staged surgery compared with phase I surgery, mainly due to the fact that staged surgery has less material taken each time compared with phase I surgery, blood flow is easily secured, and the chance of flap necrosis or infection is reduced; (2) staged surgery effectively reduces passive reoperation because of the reduced complications compared with phase I surgery, thus reducing the pain of the child and making it easy for parents to (3) the mucosalized perineal mediastinal flap is easy to retrieve and has fewer complications. In this group, no urethral fistula or urethral stricture occurred during the first-stage urethral repair; (4) the short silicone tube was left in place for a longer period of time (1-1.5 months), which is equivalent to continuous urethral dilation and reduces the occurrence of urethral stricture.