Experience
With the Van Der Meulen One-Stage Hypospadias Repair By M. Gipson and A. M. K. Rickwood Sheffield,
l The van der Meulen one-stage hypospadias repair for distal hypospadias with minimal or no chordee is described. It has been used in 65 cases and the results were good or excellent in 50 patients. There were no instances of postoperative urethral fistula.
INDEX WORDS: Hypospadias.
HE MULTIPLICITY OF methods of repairing hypospadias suggests that no one method is universally satisfactory. Until recently, the Crawford two stage repair’,’ has been the method of choice at the Children’s Hospital, Sheffield, and is still used for those cases with significant chordee. However, in most cases of hypospadias3 the meatus lies at or near the corona and chordee, if any, is not severe. The question of correcting any chordee in such cases is controversial. Some authorities4” maintain that almost all cases of hypospadias have a significant degree of chordee requiring correction before advancement of the meatus can be undertaken. On the other hand, van der Meulen6 states that only 20% of cases of hypospadias have inadequate erection due to chordee and our experience confirms this. It is frequently seen, examining babies with apparent chordee, that when a spontaneous erection takes place the penis is quite straight and the chordee is therefore of no functional significance. This apparent chordee is due to skin shortage rather than deep bands in the corpora cavernosa. In a few cases where there is no chordee, a straight urinary stream and the meatus is penoglandular or distal to this, cosmetic circumcision is all that is required. However, in the majority, the stream is directed downwards and a urethral reconstruction is necessary. Following a visit of one of us (M.G.) to van der Meulen’s clinic in 1974, his one stage repair has become our method of choice for dealing with most cases of hypospadias, and our results are described in this paper.
T
MATERIALS
AND
METHODS
The van der Meulen repair is a simple procedure taking some 30 min to perform. The steps are shown in Figs. 1-8. JownaloffedianicSwgery.
Vol. 14, No. 2 (April), 1979
England
Any meatal stenosis can be corrected by a meatotomy prior to commencing the repair proper. The circumferential incision made in the prepuce (Fig. 1) is at the level of the two dimples that can usually be seen on the dorsal surface of the prepuce. It is important not to incise distal to these dimples as this includes skin which derives its blood supply from the prepuce and may therefore necrose. The incision is carried round ventrally immediately proximal to the urethral meatus (Fig. 2). and this enables the skin to be mobilised off the shaft of the penis along its entire length, like lifting a jacket sleeve off the arm (Fig. 3). Some patients with hypospadias have very thin skin overlying the distal penile urethra, and such cases are not suitable for this type of repair. Two small triangular areas are bared on the ventral surface of the glans penis (Fig. 4) up to the site of the proposed meatus leaving a strip of skin in continuity with the urethral meatus. This strip, when buried, will tubularize itself as in the Denis Browne repair? It is essential not to make the strip too narrow, although it is an advantage to make the meatus slightly narrower than the remainder in order to avoid spraying. The strip is roofed over by rotating the long dorsal surface of the skin sleeve ventrally (Figs. 5 and 6). In order to facilitate rotation, it may be necessary to perform an oblique back cut although this is not done routinely. The flap is sutured with subcutaneous sutures (Xs in Fig. 7) to attach it around the buried strip and onto the bare triangular surfaces on the glans penis (Fig. 8). The remaining skin edges are approximated with interrupted 4-o Dexon a sutures. The dorsal surface of the defect is closed using the preputial skin left distal to the original circumferential incision (Fig. 9). It is usually necessary to trim the skin in order to achieve a neat ‘fit’; if this is not done then a further minor trimming procedure may be required at a later date. A short length of catheter (8F-infant feeding tube) may be left 2 or 3 cm inside the penile urethra for 48 hr postoperatively, but this is not strictly necessary. A paraffin tulle and gauze dressing is applied and then removed after 48 hr. The patient is usually able to be discharged home after 4 days. The sutures are allowed to separate spontaneously. The procedure leaves a twist on the shaft of the penis that resolves over a period of 3 to I2 mo. RESULTS
This patients ranged ated on
procedure has been performed on 65 with a 6 to 18 mo follow-up. Their ages from 3 to 11 yr; 58 patients were operbetween 3 and 6 yr of age. The preopera-
From the Children’s Address Children’s 0 I979
reprint Hospital.
Hospital,
requests
She@eld.
10 M.
England.
Gipson.
F.R.C.S..
The
She@ield 10 England.
by Grune & Stratton,
Inc.
0022-3468/79/1402-0014$01.00/0
177
GIPSON AND RICKWOOD
178
Fig. 1.
The dorsal skin incision marked.
Fig. 2.
The ventral skin incision marked.
Fig. 4. Triangular areas bared on the glans penis: the urethral strip is clearly seen.
Fig. 5.
Fig. 3. penis.
Ventral rotation of the dorsal skin flap.
Mobilization of the skin off the shaft of the
tive assessments of the patients are shown in Table 1. There were no immediate postoperative complications in 60 cases. In one patient there was infection of the wound, and in 4 patients there was necrosis of the tip of the skin flap resulting in slight retraction of the meatus. There were no cases of fistula formation. The
Fig. g. Ventral view of the dorsal skin flap. A urethral catheter has been inserted.
results at 6-18 mo postoperatively Table 2.
are shown in
DISCUSSION
In most cases of hypospadias the meatus is situated at or near the corona, and in these cases
VAN
DER MEULEN
ONE-STAGE
HYPOSPADIAS
REPAIR
179
Table 1. Preoperative
Assessment
Coronal-45
Position of Meatus
19
Penile-
t
With the Van Der Meulen One-Stage Hypospadias Repair By M. Gipson and A. M. K. Rickwood Sheffield,
l The van der Meulen one-stage hypospadias repair for distal hypospadias with minimal or no chordee is described. It has been used in 65 cases and the results were good or excellent in 50 patients. There were no instances of postoperative urethral fistula.
INDEX WORDS: Hypospadias.
HE MULTIPLICITY OF methods of repairing hypospadias suggests that no one method is universally satisfactory. Until recently, the Crawford two stage repair’,’ has been the method of choice at the Children’s Hospital, Sheffield, and is still used for those cases with significant chordee. However, in most cases of hypospadias3 the meatus lies at or near the corona and chordee, if any, is not severe. The question of correcting any chordee in such cases is controversial. Some authorities4” maintain that almost all cases of hypospadias have a significant degree of chordee requiring correction before advancement of the meatus can be undertaken. On the other hand, van der Meulen6 states that only 20% of cases of hypospadias have inadequate erection due to chordee and our experience confirms this. It is frequently seen, examining babies with apparent chordee, that when a spontaneous erection takes place the penis is quite straight and the chordee is therefore of no functional significance. This apparent chordee is due to skin shortage rather than deep bands in the corpora cavernosa. In a few cases where there is no chordee, a straight urinary stream and the meatus is penoglandular or distal to this, cosmetic circumcision is all that is required. However, in the majority, the stream is directed downwards and a urethral reconstruction is necessary. Following a visit of one of us (M.G.) to van der Meulen’s clinic in 1974, his one stage repair has become our method of choice for dealing with most cases of hypospadias, and our results are described in this paper.
T
MATERIALS
AND
METHODS
The van der Meulen repair is a simple procedure taking some 30 min to perform. The steps are shown in Figs. 1-8. JownaloffedianicSwgery.
Vol. 14, No. 2 (April), 1979
England
Any meatal stenosis can be corrected by a meatotomy prior to commencing the repair proper. The circumferential incision made in the prepuce (Fig. 1) is at the level of the two dimples that can usually be seen on the dorsal surface of the prepuce. It is important not to incise distal to these dimples as this includes skin which derives its blood supply from the prepuce and may therefore necrose. The incision is carried round ventrally immediately proximal to the urethral meatus (Fig. 2). and this enables the skin to be mobilised off the shaft of the penis along its entire length, like lifting a jacket sleeve off the arm (Fig. 3). Some patients with hypospadias have very thin skin overlying the distal penile urethra, and such cases are not suitable for this type of repair. Two small triangular areas are bared on the ventral surface of the glans penis (Fig. 4) up to the site of the proposed meatus leaving a strip of skin in continuity with the urethral meatus. This strip, when buried, will tubularize itself as in the Denis Browne repair? It is essential not to make the strip too narrow, although it is an advantage to make the meatus slightly narrower than the remainder in order to avoid spraying. The strip is roofed over by rotating the long dorsal surface of the skin sleeve ventrally (Figs. 5 and 6). In order to facilitate rotation, it may be necessary to perform an oblique back cut although this is not done routinely. The flap is sutured with subcutaneous sutures (Xs in Fig. 7) to attach it around the buried strip and onto the bare triangular surfaces on the glans penis (Fig. 8). The remaining skin edges are approximated with interrupted 4-o Dexon a sutures. The dorsal surface of the defect is closed using the preputial skin left distal to the original circumferential incision (Fig. 9). It is usually necessary to trim the skin in order to achieve a neat ‘fit’; if this is not done then a further minor trimming procedure may be required at a later date. A short length of catheter (8F-infant feeding tube) may be left 2 or 3 cm inside the penile urethra for 48 hr postoperatively, but this is not strictly necessary. A paraffin tulle and gauze dressing is applied and then removed after 48 hr. The patient is usually able to be discharged home after 4 days. The sutures are allowed to separate spontaneously. The procedure leaves a twist on the shaft of the penis that resolves over a period of 3 to I2 mo. RESULTS
This patients ranged ated on
procedure has been performed on 65 with a 6 to 18 mo follow-up. Their ages from 3 to 11 yr; 58 patients were operbetween 3 and 6 yr of age. The preopera-
From the Children’s Address Children’s 0 I979
reprint Hospital.
Hospital,
requests
She@eld.
10 M.
England.
Gipson.
F.R.C.S..
The
She@ield 10 England.
by Grune & Stratton,
Inc.
0022-3468/79/1402-0014$01.00/0
177
GIPSON AND RICKWOOD
178
Fig. 1.
The dorsal skin incision marked.
Fig. 2.
The ventral skin incision marked.
Fig. 4. Triangular areas bared on the glans penis: the urethral strip is clearly seen.
Fig. 5.
Fig. 3. penis.
Ventral rotation of the dorsal skin flap.
Mobilization of the skin off the shaft of the
tive assessments of the patients are shown in Table 1. There were no immediate postoperative complications in 60 cases. In one patient there was infection of the wound, and in 4 patients there was necrosis of the tip of the skin flap resulting in slight retraction of the meatus. There were no cases of fistula formation. The
Fig. g. Ventral view of the dorsal skin flap. A urethral catheter has been inserted.
results at 6-18 mo postoperatively Table 2.
are shown in
DISCUSSION
In most cases of hypospadias the meatus is situated at or near the corona, and in these cases
VAN
DER MEULEN
ONE-STAGE
HYPOSPADIAS
REPAIR
179
Table 1. Preoperative
Assessment
Coronal-45
Position of Meatus
19
Penile-
t
