1. FAILED HYPOSPADIAS REPAIR PRESENTING IN ADULTS: A NEW OUTBREAK? THE ADULT UROLOGIST POINT OF VIEW Sava V. Perovic

2. Number of patients: 305 Period:1998-2008 Mean age: 27 years (19–68) PATIENTS CHARACTERISTICS

3. AGE DISTRIBUTION

4. Minimum: 1 Maximum: 33 Mean: 4.4 NUMBER OF PREVIOUS SURGERIES

5. NUMBER OF PLANNED STAGES Three-stages means: 1.Ventral grafting 2.Buccal mucosa inlay 3.Urethral tubularization, glans and penile skin reconstruction

6. Minimum: 1 Maximum: 4 Mean: 1.6 NUMBER OF PERFORMED STAGES AFTER FAILED HYPOSPADIAS REPAIR

7. Minimum: 2 Maximum: 35 Mean: 7.4 TOTAL NUMBER OF PROCEDURES PER PATIENT

8. CLINICAL AND SURGICAL ASSESEMENT* *Great majority of patients presented with more than one complication

9. CHOICE OF REPAIR Clinical and intra-operative findingsClinical and intra-operative findings Individual approachIndividual approach Familiarity with all available techniquesFamiliarity with all available techniques Preference of the surgeon is important but must not be decisivePreference of the surgeon is important but must not be decisive

10. SPECIFIC PROBLEMS IN ADULTS Erection Nocturnal ejaculation Quality of available skin –blood supply??, elasticity Urethral secretion

11. 59-year-old patient with 7 previous surgeries - one stage repair

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

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

14. Neourethral reconstruction and “spongioplasty” (arrow)

15. Creation of abundant dartos flap for suture line covering (arrows) Glans wings Dartos flap

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

17. 34-year-old patient with 6 previous surgeries - one stage repair

18. Diverticular skin urethra with double - “S” curvature (arrows) ventral dorsal

19. Elipsoid excision of longitudinal tunical layer and plication at two points (arrows) Longitudinal tunica excision

20. Urethral tailoring by external plication Glans and penile skin plasty

21. Aspect at the end of surgery

22. 26-year-old patient with short penile skin and residual curvature

23. Curvature correction

24. Urethral “spongioplasty” (arrows)

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

26. Fixation of loose compressive dressing to the penis

27. Urethral stricture - Dorsal buccal mucosa onlay

28. Urethral stricture - Dorsal buccal mucosa onlay combined with submeatal flap Lateral approach Submeatal flap

29. Completed urethroplasty and glans reconstruction

30. 33-year-old patient with short penile skin

31. Penile skin reconstruction using remaining penile and scrotal skin Scrotal skin Penile skin

32. Outcome after 1 year

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

34. Testicular mobilization Extensive degloving and partial urethral augmentation with buccal mucosa Urethralstricture Buccalmucosainlay

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

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

37. 19-year-old patient with 12 previous surgeries - III-stage repair Severe curvature and short, strictured, fistulous neourethra and small deformed glans

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

39. II-stage: Excessive buccal mucosa graft quilting

40. III-stage: Tubularizing urethroplasty Completely straightened and lenghtened penis

41. Glanular and urethral reposition; skin reconstruction

42. Outcome after 14 months Before After

43. Severe ventral curvature with short neourethra – III stage repair

44. Ventral grafting with InteXen ® (4x8cm) for penile lenghtening Tunical defect Graft

45. Appearance at the end of surgery with hypospadiac meatus

46. 26-year-old patient with short penile skin and residual curvature

47. Penile skin reconstruction covering graft Ventral grafting with InteXen ® (4x8cm) for penile lenghtening

48. Urethroplasty – 3 rd stage

49. Urethral tubularization “Spongioplasty”

50. Penile skin reconstruction using asymmetrical flaps to avoid overlapping of suture lines

51. Ventral grafting using buccal mucosa graft (4x6cm)

52. TAKE-HOME MESSAGE Proper clinical and surgical assessment is crucial for appropriate treatment of failed hypospadias Urethroplasty is important but not the only goal of repair - equally important is creation of long and straight penis to avoid psychosexual trauma

53. Our goal is creation of functionally and esthetically “normal” penis to enable unobstructed voiding as well as normal sexual life Reconstruction of penile skin is often the most difficult and major limiting factor for successful treatment