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Experience with transverse preputial island flap for repair of hypospadias in Ile-Ife, Nigeria Sowande A O, Olajide A O, Salako A A, Olajide F O, Adejuyigbe O, Talabi A O - Afr J Paediatr Surg
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PRACTITIONERS SECTION Table of Contents   
Year : 2009  |  Volume : 6  |  Issue : 1  |  Page : 40-43
Experience with transverse preputial island flap for repair of hypospadias in Ile-Ife, Nigeria


1 Department of Surgery, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria
2 Department of Surgery, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria
3 Department of Community Medicine, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria

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   Abstract  

Objective: To review our experience with the use of transverse preputial island flap in the repair of hypospadias in the paediatric surgical unit of our University Teaching Hospital, Nigeria. Patients and Methods: We reviewed the cases of hypospadias managed by transverse preputial island flap repair over a ten year period (1996 and 2006) in the paediatric surgical unit of our institution. Data was retrieved from the case notes and analysed. Results: Fifty-one patients had hypospadias repair during the period, 22 of whom were by transverse preputial island flap repair. Hypospadisas were in penile shaft in 16 (72.7%), penoscrotal in 5 (22.7%) and perineal in 1 (4.55%). All the patients had intact prepuce at presentation and chordee was present in 18 (81.8%). The commonest complication was urethrocutaneous fistula in five patients, which closed spontaneously in three leaving 2 patients (9.1%) with persistent urethrocutaneous fistular. Conclusion: Transverse preputial island flap urethroplasty remains aviable option in the management of hypospadias especially when the meatal opening is proximal, with associated chordee limiting the options in the repair.

Keywords: Hypospadias, island flap, neourethra, preputial skin

How to cite this article:
Sowande A O, Olajide A O, Salako A A, Olajide F O, Adejuyigbe O, Talabi A O. Experience with transverse preputial island flap for repair of hypospadias in Ile-Ife, Nigeria. Afr J Paediatr Surg 2009;6:40-3

How to cite this URL:
Sowande A O, Olajide A O, Salako A A, Olajide F O, Adejuyigbe O, Talabi A O. Experience with transverse preputial island flap for repair of hypospadias in Ile-Ife, Nigeria. Afr J Paediatr Surg [serial online] 2009 [cited 2014 Mar 11];6:40-3. Available from: http://www.afrjpaedsurg.org/text.asp?2009/6/1/40/48575

   Introduction   Top


Hypospadiology is a field of paediatric urology that is rapidly expanding based on the simple fact that none of the current methods of urethroplasty have been proved superior to the others in terms of achieving the goal of excellent functional and cosmetic results. [1] The transverse preputial island flap repair for hypospadias described by Duckett has gained wide popularity in modern practice. [2],[3] This is mainly because it can be applied to anterior, mid- and posterior penile hypospadias associated with or without chordee. [4] The preputial skin, with its accompanying superficial fascia and vessels, is ideal for the construction of flaps for hypospadias repair [Figure 1]. It is relatively thin and pliable; it has a good blood supply that can be mobilized as a pedicle. It also tolerates prolonged contact with urine better than any tissue other than bladder mucosa. [5] The technique was originally advocated by Asopa [3] but Duckett developed and popularized it. [6],[7]

Reports on hypospadia repair are rare from the subsaharan Africa. However, since we have applied the transverse preputial island flap to treat a number of children with hypospadias in the our centre, we aim to evaluate our experience with this method and to document the outcome and challenges faced in the application of this technique in low resource setting.


   Patients and Methods   Top


This was a retrospective review of all cases of hypospadias managed by transverse preputial island flap repair between January 1996 and December 2006 in the paediatric surgical unit of a tertiary hospital (referral centre) in a semi urban setting of South Western Nigeria. The case notes were retrieved from the medical record department of the hospital and information about the age at presentation, type of hypospadias, presence or absence of chordee, use of stent, urinary diversion and duration as well as outcome were extracted. The data were collected in a proforma and analysed.

Surgical technique

The surgical technique was as described by Duckett.[5],[6] We did not use optical magnification because operation microscope/loupe were not available in our centre during the period under review. A 3/0 silk penile-traction suture is placed at the dorsum of the glans and an artificial erection induced to assess the severity of chordee. A circumferential incision is made 0.5-1.0 cm proximal to the corona, including the hypospadiac orifice. The penis was degloved at the avascular plane between the dartos and Buck's fascia [Figure 2]. Chordee was corrected by sharp dissection of the skin and fibrous tissue until the glistening appearance of the corpora cavernosa was seen. An artificial erection was induced again to reassess the chordee and dorsal placation was applied where necessary to correct residual chordee. A transverse island flap from the inner layer of the prepuce was outlined and dissected, with the length equal to or slightly longer than the distance between the hypospadiac orifice and glans tip as measured with a strip of suture (silk or catgut). The width was measured subjectively (about 12-18mm) based on the age of the patient, the length of the flap and the width of the native urethra. The flap was dissected with its axial vascular pedicle which is mobilized proximally to an extent that allowed ventral transposition of the island flap with no tension [Figure 3]. The island flap was trimmed and then tubularised such that it was slightly loose around a suitable-sized stent, using subcuticular and interrupted 5/0 or 6/0 polyglactin sutures. Then 3-5 mm of the distal end of the native urethra was excised and adequately spatulated ventrally. The neourethra was transposed ventrally and anastomosed to the native urethra using 5/0 or 6/0 vicryl sutures [Figure 4]. We would have preferred 7/0 vicryl as used by most paediatric urologists but this was not available. A glans channel was constructed by excising a central core of glanular tissue, and a meatal opening was fashioned at the tip of the glans. The neourethra was brought through the glans channel and anastomosed to the meatal opening. The distal part of the native urethra and the neourethra were fixed to the corpora cavernosa using 3-5 sutures of 4/0 polyglactin. The dorsal layer of the prepuce was transposed ventrally and the repair covered with skin as cosmetically as possible [Figure 5]. A suprapubic catheter (14-16 F) was placed in the bladder; the stent was left in situ for minimum of 10-14 days and the suprapubic tube was removed a few days after removal of the stent, when micturition per urethra was well established. The patients were followed up in the clinic where the mothers were asked for history of straining; urinary stream was visually assessed (We lack uroflowmetry in our centre.). Where the flow of urine was adjudged poor, we instituted urethral calibration usually as a paediatric day-care procedure. In patients with post-op stricture, urethral dilatation was also done. Follow-up was very poor in our patients because once the problem was over, patients hardly keep clinic appointments. Only those with persistent urethrocutaneous fistula were followed up longer than 6 months; this was the time they were usually repaired.


   Results   Top


Fifty-one patients had surgery for hypospadias during the period. Of the 51 patients, 22 had transverse preputial island flap repair, 16 had repair by perimeatal based (Matthieu) flap, 5 by meatal advancement glanuloplasty, 1 by tubularised incised plate (Snodgrass) and 7 as staged repair. Of the 22 that were repaired by transverse preputial island flap, the age at presentation ranged from birth (patients delivered in our centre) to 15 years (average age: 1.8 year), while the age at repair was between 16 months and 15 years (mean age at repair: 2.10 years).

The hypospadias involved proximal shaft in 16 (72.7%), penoscrotal in 5 (22.7%) and perineal in 1 (4.55%). Chordee was present in 18 (81.8%) patients, and all had intact prepuce at presentation.

All the patients had transverse preputial island flap repair with placement of urethral stent and urinary diversion by suprapubic cystostomy. The mean duration of urethral stent and urine diversion was 15.7 and 18.6 days, respectively. Eight patients had complications [Table 1]. Three of the five patients with urethrocutaneous fistula (UCF) closed spontaneously within the first 6 months of follow up, while the remaining two needed further surgery to close the fistula. Though the frequency of urethrocutaneous fistula reduced with increasing age at repair, there was no statistically significant relationship between age and occurrence of the UCF [Table 2].

Duration of hospital stay ranged between 11 and 48 days (mean duration stay: 22.8 days). Most of the patients were lost to follow up within the first 4 months; only those that had fistula kept their appointments until the problem resolved either spontaneously or by surgery.


   Discussion   Top


The specialty of hypospadiology has evolved over the years. Due to the technical challenges and often poor outcome associated with hypospadia repair, a variety of technique has developed over the years to tackle the problem. The transverse preputial island flap technique allows for one stage repair of hypospadias especially the proximal types. Reports on outcome of hypospadia repair from sub-Saharan Africa are rarely found in the literature. In Nigeria, the author is not aware of any.

When hypospadias is associated with severe chordee and resection of the urethral plate is mandatory for orthoplasty, the tubularized preputial island flap is the technique of choice, provided that the prepuce is not removed or used in a failed previous repair. [6],[7] The inner preputial skin provides one of the most suitable epithelial structures for creating a neourethra up to 6-7 cm long. Its vascular pedicle can be dissected proximally to be adapted to different varieties of hypospadias. [2] The commonest complications associated with hypospadia repair generally is fistula formation and the incidence of fistula formation varies from the various reports on this procedure. [8],[9],[10],[11] Duckett himself reported an incidence of 10%. [6],[7] The wide variability in fistula rates among these studies can be explained by the technical differences, the severity of hypospadia and the length of the neourethra. The difficulty encountered during the repair underlies the high fistula rate (22.7%) in the present report. Most of the instruments are not refined for the repairs and there was no magnification used during the procedures. For this reason, we usually delay the repair until the child is at least 18 months old when the tissues would be easily visualised. Our fistula rate is however lower than that of Dewan who reported 34% fistula formation among his patients treated by same method. [11] Only 2 of the patient with post operative fistula in this study required further surgery to close the fistula, the remaining 3 closed spontaneously.

The post operative stricture complicating this procedure responded to few sessions of urethral dilatation while wound infection responded fairly well to wound dressing and antibiotics.


   Conclusion   Top


Transverse preputial island flap urethroplasty remains a viable option in the management of hypospadias even in a low resource economy. It offers a good functional and cosmetic advantage for proximal hypospadias with an acceptable complication rate.

 
   References   Top

1. Gangopadhyay AN, Sharma S, Mongha R. Onlay preputial graft for mid and distal penile hypospadias. J India Assoc Pediatr Surg 2005;10:244-7.  Back to cited text no. 1    
2. Elder JS, Duckett JW. Urethral reconstruction following an unsuccessful one-stage hypospadias repair. World J Urol 1987;5:19-6.   Back to cited text no. 2    
3. Asopa HS, Elhence EP, Atri SP, Bansal NK. One-stage correction of penile hypospadias using a foreskin tube: A preliminary report. Int Surg 1971;55:435-40.   Back to cited text no. 3    
4. Elbakry A. Complications of the preputial island flap-tube urethroplasty. BJU Int 1999;84:89-94.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5. Hinman F Jr. The blood supply to preputial island flaps. J Urol 1991;145:1232-5.  Back to cited text no. 5  [PUBMED]  
6. Duckett JW Jr. Transverse preputial island flap technique for repair of hypospadias. Urol Clin N Amer 1980;7:423-30.   Back to cited text no. 6    
7. Duckett JW. The island flap technique for hypospadias repair. Urol Clin North Am 1981;8:503-8.   Back to cited text no. 7  [PUBMED]  
8. Monfort G, Jean P, Lacoste M. Correction des hypospadias posterieurs en un temp par lambeau pedicule transversal (intervention de Duckett). Chir Pediatr 1983;24:71-4.   Back to cited text no. 8  [PUBMED]  
9. Jayanthi VR, Mcloire GA, Khoury AE, Churchill BM. Functional characteristics of the reconstructed neourethra after island flap urethroplasty. J Urol 1995;153: 1657-3.   Back to cited text no. 9    
10. Wiener JS, Sutherland RW, Roth DR, Gonzales ET Jr. Comparison of onlay and tubularized island flaps of inner preputial skin for the repair of proximal hypospadias. J Urol 1997;158:1172-4.   Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11. Dewan PA, Dinnen MD, Winkle D, Duffy PG, Ransley PG. Duckett pedicle tube urethroplasty. Eur Urol 1991;20:39-42.  Back to cited text no. 11    

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Correspondence Address:
A O Olajide
Department of Surgery, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State
Nigeria
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DOI: 10.4103/0189-6725.48575

PMID: 19661665

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