3rd Surgical Workshop Of CUGRS (Complex Uro-Genital Reconstructive Surgery) Surgical challenge in patients who underwent failed hypospadias repair: is it time to change? Salvatore Sansalone MD Senior Lecturer in Urology University of Tor Vergata Rome, Italy

UNKNOWN FAILED HYPOSPADIAS POPULATION Incidence Characteristics European Center for Failed Hypospadias Repair

European Center for Failed Hypospadias Repair For many years, failed hypospadias repair was considered a complex chapter in reconstructive urethral surgery, and any book on the urethra includes “hypospadias cripple” or re-operative hypospadias surgery as a special topic Stecker JF, Horton CE, Devine CJ, McCraw JB: Hypospadias cripples. Urol Clin N Amer 1981;8:539-544. European Center for Failed Hypospadias Repair

observational, descriptive survey 1998 – 2007 J Urol 2010 observational, descriptive survey 1998 – 2007 1176 failed hypospadias repair urethral strictures & penile defects European Center for Failed Hypospadias Repair

Center for Reconstructive Urethral Surgery Age range in 1176 patients age (years) N. patients 1 – 16 250 (21.2%) 16 – 20 451 (38.4%) 20 – 40 358 (30.5%) 40 – 60 112 (9.5%) > 60 5 (0.4%) < 16 years 250 (21.3%) > 16 years 926 (78.7%) Center for Reconstructive Urethral Surgery

Primary site of meatus European Center for Failed Hypospadias Repair position n % glandular 193 16.4 penile 702 59.7 penoscrotal 281 23.9 European Center for Failed Hypospadias Repair

Number of operations to repair primary hypospadias in 1176 patients N. operations N. patients 1 130 (11.1%) 2 347 (29.5%) 3 320 (27.2%) 4 159 (13.5%) 5 108 (9.2%) > 5 112 (9.5%) minimum: 1 maximum: 23 mean: 3.3 Center for Reconstructive Urethral Surgery

Number of operations to repair complications following primary hypospadias repair in 1176 patients N. operations N. patients 1 760 (64.6%) 2 280 (23.8%) 3 82 (6.9%) 4 31 (2.7%) 5 9 (0.8%) > 5 14 (1.2%) minimum: 1 maximum: 8 mean: 2.3 Center for Reconstructive Urethral Surgery

Total number of operations to repair primary hypospadias repair and complications in 1176 patients N. operations N. patients 2 102 (8.7%) 3 289 (24.6%) 4 369 (31.4%) 5 – 10 311 (26.4%) 11 – 20 91 (7.7%) > 20 14 (1.2%) minimum: 2 maximum: 23 mean: 5.8 Center for Reconstructive Urethral Surgery

Center for Reconstructive Urethral Surgery In 1176 patients underwent a mean of 5.8 surgical operations to repair primary and failed hypospadias No other congenital abnormality of the body requires a mean of 5.8 surgical operations to be cured ! Center for Reconstructive Urethral Surgery

QUERIES proximal > distal? older techniques > new techniques ? single staged procedures ? NO NO NO European Center for Failed Hypospadias Repair

Failed hypospadias repair may consist in defects of single compartments of the male genitalia (urethra, corpora cavernosa, glans, penile and scrotal skin), or in a combination of them It is a reasonable hypothesis that the outcome of repairing failed hypospadias depends on the number of compartments involved This widespread survey allowed to us to focus on some concepts and concerns, developing a new view of this old problem.

smaller penile size and curvature. The main reason for dissatisfaction was smaller penile size and curvature. European Center for Failed Hypospadias Repair

THE JOURNAL OF UROLOGY Vol. 182, 1736-1743, October 2009 THE JOURNAL OF UROLOGY Vol. 180, 1080-1084, September 2008 ……..we assume that satisfaction with genital self-perception by our patients will decrease with advancing age. European Center for Failed Hypospadias Repair

European Center for Failed Hypospadias Repair

59-year-old patient with 7 previous surgeries - one stage repair

Artificial erection shows severe ventral curvature Elipsoid excision of longitudinal layer of albuginea at several points

Complete penile straightening Running suturing of wounded surfaces (PDS 3-0)

Neourethral reconstruction and “spongioplasty”

Creation of abundant dartos flap for suture line covering Glans wings Dartos flap Dartos flap

Aspect at the end of surgery Outcome after one year Aspect at the end of surgery

34-year-old patient with 6 previous surgeries - one stage repair

Diverticular skin urethra Double - “S” curvature ventral dorsal

Longitudinal tunica excision Ellipsoid excision of longitudinal tunical layer and plication at two points (arrows) Longitudinal tunica excision

Urethral tailoring by external plication

Reconstruction of penile skin using remaining penile skin and scrotal flaps Peno-pubic and peno-scrotal angles are formed by tacking penile base skin to the albuginea (arrows)

Fixation of loose compressive dressing at the base and at subcoronal level European Center for Failed Hypospadias Repair

39-year-old patient with 33 previous surgeries Two stage repair Fixed and elevated testicle

Testicular mobilization Extensive degloving and partial urethral augmentation with buccal mucosa Buccal mucosa inlay Urethral stricture Testicular mobilization

Penile skin reconstruction using scrotal flap Buccal mucosa inlay Scrotal flap Bilateral orchiopexy

Second stage urethroplasty after 6 months - buccal mucosa tubularisation, glans, penis and scrotum plasty

CRIPPLED PENIS: Severe curvature and short, strictured, fistulous neourethra with small, deformed glans Severe curvature and short, strictured, fistulous neourethra and small deformed glans

I-stage: Penile lenghtening by ventral grafting (InteXen® 3x7cm) Graft Meatus

III-stage: Tubularizing urethroplasty Completely straightened and lenghtened penis

Glanular and urethral reposition; skin reconstruction

Outcome after 14 months Before After

Take home message www.failedhypospadias.com Urethral complications in patients with failed hypospadias repair are less frequent than complications involving the corpora cavernosa, and the esthetic appearance of the genitalia. To repair these defects, collaboration between the urethral surgeon and the surgeon who has developed vast experience in plastic and reconstructive surgery of the male genitalia is indeed mandatory www.failedhypospadias.com

MULTI SPECIALIZED SKILLS URETHRAL P E D P I L A A T S R T I C C ANDROLOGICAL