SURGICAL TECHNIQUE O shaped circular incisions were taken on both scrotal halves.Subcutaneous dissection was performed on both sides till adequate mobilization of both scrotal aps.T shaped incision was taken at intervening skin just proximal to hypospadiac urethral meatus and subcutaneous tissue dissection done till adequate margins raised.Then both the scrotal aps were brought posterior to penis and more caudal [Figure 1, 2,3] All incisions were closed primarily with good tissue approximation [Figure 4].Urinary diversion and pressure dressing were given for 5 days. Hypospadias repair was done after 6 months. No patient had any complications like penile lymphoedema,ap necrosis or infection. Satisfactory anatomical, cosmetic and functional results were obtained in most of the patients. The follow up period ranged from 6 to 18 months. Complications include only urethral stulas in 2 patients (9%) that was successfully treated with repeated dilatations and no patient required redo surgery. In this technique, no circumferential incision of the skin around the penile base was taken. In fact, whole penile skin left attached to skin of mons pubis. There was almost nil post operative edema and rapid wound healing. FIGURES Figure 1 Figure 2 PENOSCROTAL TRANSPOSITION WITH HYPOSPADIAS: HAMBARDE`S TECHNIQUE OF O-T-O PLASTY Original Research Paper Dr. sandeep R. Hambarde* Paediatric Surgeon, Ramkrishna Hospital, N 5, Cidco,Aurangabad, India *Corresponding Author X 123GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Surgery BACKGROUND/ PURPOSE: Penoscrotal transposition , partial or complete is result of positional exchanges between the penis and the scrotum. Earlier correction of penoscrotal transposition was done transposing the penis to a neo hole created in the skin of mons pubis or creating scrotal rotational aps and bringing them caudal to penis. Modied Glenn Anderson's method is commonly used. This method is known to cause major penile lymphoedema following surgery due to circular incision around the root of the penis that delay correction of the frequently associated hypospadias and increase the incidence of complications. We used novel method to correct 22 cases of penoscrotal transposition i.e.HAMBARDE`s Technique of O-T-O PLASTY. This method has given excellent cosmetic and functional outcome,allowed early surgical correction of hypospadias after 6 months with almost nil complications. MATERIAL AND METHODS We retrospectively reviewed 22 patients ,age ranging from 2 to 23 years that underwent two-stage repair for penoscrotal transposition with hypospadias. The operative principle was based on achieving a normal anatomical position of the penis and scrotum using a novel method i.e. HAMBARDE`s technique of O-T-O PLASTY. All cases were associated with midpenile or penoscrotal hypospadias. Hypospadias correction was performed after a period of 6 months with Onlay tube urethroplasty. 7 patients were having unilateral undescended testis and 1 patient was having unilateral inguinal hernia. RESULTS Cosmetic and functional results of HAMBARDE`s Technique of O-T-O PLASTY were excellent. No major complications were observed. Of 22 patients, only 2[9%] had stula after hypospadias repair. CONCLUSION HAMBARDE`s Technique of O-T-O PLASTY for reconstruction of penoscrotal transposition is a simple technique, free of major complications. The purpose of this innovative method is to improve functional outcome and cosmetic appearance of the penis. A minimum period of 6 months between consecutive urethroplasties is important. Preserving the prepuce and making its use for subsequent urethroplasty after 6 months gives excellent short term and long term outcome. ABSTRACT KEYWORDS : Penoscrotal transposition,hypospadias,HAMBARDE`s Technique , O-T-O PLASTY Dr. ashwini S. hambarde Gynaecologist, Ramkrishna Hospital,N 5,Cidco,Aurangabad, India Dr. thavendra Dihare Paediatric Surgeon,Wardha Sawangi, India VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra 124 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Figure 3 Figure 4 DISCUSSION Penoscrotal transposition results from abnormal genital tubercle development with delay in the midline fusion of the urethral folds. 90% patients had associated anomalies like hypospadias, chordee,undescended testis and renal agenesis . Imperforate anus may present in some cases.1,2,3 Differential diagnosis must include pseudohermaphroditism, penoscrotal hypospadias, micropenis, intrauterine penile amputation and penile agenesis with a midline skin tag anterior to the anus. Surgery of more complex cases of Penoscrotal transposition is technically challenging.4,5,6,7,8 Various surgeries have been advocated by many surgeons. Mcllvoy and Harris rst performed surgery to move the penis into a more cranial position through a subcutaneous tunnel beneath the prepenile scrotum. Forshall and Rickham used a 9 different technique in two patients in whom the cranially located scrotal aps were elevated, rotated medially and caudally and sutured beneath the penis. This method was 10 also used by Glenn and Anderson. The technique was later 11 modied by Dresner in 1982. Mark and his colleagues in 12 2000 presented a radically divergent view of Penoscrotal 13 transposition stating that the penis and not the scrotum was malpositioned. They transferred the penis after straightening into a button hole designed in the skin of the mons-pubis. Complications of penoscrotal transposition include urethral and testicular injury, urinary stula, ap necrosis and penile edema. Circular incision at the root of the penis partially compromises lymphatic drainage, which may interfere with healing of the neourethra. Majority of the studies showed 14 signicant number of complications like Arena . study in et al 2005 showed 38% complications in their work, Glassberg 15 et 16al et al. in 1998 reported 50% complications and Koyanagi . in 1994 found 48% complications in their work. All of them used 17 same technique with hypospadias correction in the same stage. Hence, to reduce the complications, we planned hypospadias correction at later date. Glenn-Anderson technique left gross penile edema with dark pigmentation later on. Saleh et al. demonstrated a 10% 18 complication rate by just preserving the dorsal strip of penile skin. We have modied it with O shaped circular incisions on 18 both scrotal halves and T shaped incision at intervening skin just proximal to hypospadiac urethral meatus. Penile base was left intact.hence completely avoided complications like penile lymphoedema,ap necrosis or infection None of our patients had signicant edema and all were discharged on 7th post-op day. Penoscrotal transposition is a rare congenital anomaly often with severe hypospadias and other genital anomalies. Surgical correction of these anomalies is technically demanding and should be done in stages. With our experience of 22 cases of Penoscrotal transposition by O-T-O PLASTY,this method is completely free of complications like penile edema,ap necrosis and infection.This supple and untouched prepuce can be more useful in future chordee correction and Onlay tube repair.We can authenticate that this is the best repair technique cosmetically and functionally. REFERENCES 1. Pinke LA, Rathbun SR, Husmann DA, Kramer SA. Penoscrotal transposition: Review of 53 patients. J Urol . 2001;166:1865–8 2. Glenn J, Anderson E. Surgical correction of incomplete penoscrotal transposition. J Urol. 1973;110:603–5 3. Ehrlich R, Scardino P. Surgical correction of scrotal transposition and perineal hypospadias. J Pediatr Surg. 1982;17:175–7 4. Glassberg K, Hansbrough F, Horowitz M. The Koyangi-Nonomura1-stage bucket repair of severe hypospadias with and without penoscrotal transposition. JUrol. 1998;60:1104–7 5. Mori Y, Ikoma F. 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Germiyanoglu C, Ozkardes H, Altug U et al.Reconstruction of penoscrotal transposition. Br J Url.73:202-3,1994. 15. Arena F, Romeo C, Manganaro A, Arena S, Zuccarello B, Romeo G. Surgical correction of penoscrotal transposition associated with hypospadias and bid scrotum: Our experience of two-stage repair. J Pediatr Urol. 2005;1:289–4. 16. Glassberg KI, Hansbrough F, Horowitz M. The Koyanagi-Nonomura 1-stage bucket repair of severe hypospadias with and without penoscrotal transposition. J Urol. 1998;160:114–7. 17. Koyanagi T, Nonomura K, Yamashita T, Kanagawa K, Kakizaki H. One-stage repair of hypospadias: Is there no simple method universally applicable to all types of hypospadias? J Urol. 1994;152:1232–7. 18. Saleh A. Correction of incomplete penoscrotal transposition by a modied Glenn-Anderson technique. Afr J Paediatr Surg . 2010;7:181–4. VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra