Anterior Urethral Advancement as a Single-Stage Technique for Repair of Anterior Hypospadias: Our Experience RECONSTRUCTIVE SURGERY Venkat A. Gite, Jayant V. Nikose,* Sachin M. Bote, Saurabh R. Patil Purpose: Many techniques have been described to correct anterior hypospadias with variable results. Anterior urethral advancement as one stage technique was first described by Ti Chang Shing in 1984. It was also used for the repair of strictures and urethrocutaneous fistulae involving distal urethra. We report our experience of using this technique with some modification for the repair of anterior hypospadias. Materials and Methods: In the period between 2013-2015, 20 cases with anterior hypospadias including 2 cases of glanular, 3 cases of coronal, 12 cases of subcoronal and 3 cases of distal penile hypospadias were treated with anterior urethral advancement technique. Patients’ age groups ranged from 18 months to 10 years. Postoperatively, patients were passing urine from tip of neomeatus with satisfactory stream during follow up period of 6 months to 2 years. Results: There were no major complications in any of our patients except in one patient who developed meatal stenosis which was treated by periodic dilatation. Three fold urethral mobilization was sufficient in all cases. Conclusion: Anterior urethral advancement technique is a single-stage procedure with good cosmetic results and least complications for anterior hypospadias repair in properly selected cases. Keywords: advancement; anterior urethra; hypospadias; urethral mobilization; urethrocutaneous fistula. INTRODUCTION Most (65-70%) hypospadias cases occur in anteri-or while 30% are in posterior urethra.(1) Urethral reconstruction represents a great challenge in urologic surgeries.(2) Many techniques have been demonstrated to treat anterior hypospadias. One of these is anteri- or urethral advancement, first described by Ti Chang Shing in 1984.(3) Later on various experiences have been reported for urethral advancement as a treatment of hypospadias with some drawbacks.(1) The aim of this study was to modify this technique and assess the re- sults with our modification. MATERIALS AND METHODS Study Population A total of 20 patients of anterior hypospadias were treated during the period between June 2013 to Decem- ber 2015 by anterior urethral advancement technique. Inclusion criteria: Cases who presented with varying degrees of anterior hypospadias. Exclusion criteria: Patients with hypoplastic distal ure- thra, severe chordee, mid penile and proximal penile hypospadias were excluded from this study. The preoperative meatal sites were glanular in 2 cases, coronal in 3 cases , subcoronal in 12 cases and distal penile in 3 cases. Commonest age group was 2-5 years in 10 cases (50%). Sixteen cases were non-circumcised and 4 were circumcised. All patients were subjected to history, general and local examination of genitalia and coagulation profile. Department of Urology, Grant Govt. medical college and Sir J.J. group of hospitals, Mumbai, Maharashtra, India. *Correspondence: Saikrupa, H-21, Tirupati Supreme Enclave, Jalan nagar, Aurangabad. 431005. Phone- 90116546446. Email: balajigite@yahoo.com. Received May 2016 & Accepted January 2017 Surgical technique All patients were operated under general anesthesia. A 6/0 traction suture was placed at the tip of glans pe- nis. Feeding tube was introduced into urethra (Figure 1). Distance between hypospadiatic meatus and tip of glans was measured and recorded (Figure 2).Circum- cising incision, 5mm proximal to coronal sulcus with ‘U’ shaped extension proximal to hypospadiatic meatus on ventral aspect was made. Degloving of skin down to penoscrotal junction was done to release cutaneous chordee. Dissection of urethra stared in proximal area in avascular plane and was maintained above the tunica albuginea covering each corpus cavernosum medially till reaching beneath the corpus spongiosum upto the hypospadiatic meatus (Figure 3). After 2/3rd mobili- zation of urethra inspite of deep vertical or transverse glanular slit, we excised 1-2mm rim of ventral glanular mucosa in full depth along with strip of urethral plate (Our Modification) so that there was adequate space to accommodate the urethra. Trimming of distal urethra in oblique fashion about 2mm more on ventral aspect was done. Two Glanular wings were satisfactorily mo- bilized laterally. Tension free anastamosis was accom- plished from urethra to glans with interrupted sutures. Two Glans wings were closed in two layers over the urethra (Figure 4). Intermittent fixation sutures were taken between tunica albuginea of corpus cavernosa and corpus spongiosum. Bayer’s flap and closure of skin was done. Urethral feeding tube was secured with glanular re- tention sutures (Figure 5). Dressing was applied. All Vol 14 No 04 July-August 2017 4034 Table 1. Demographic and operative data. Variables No. of Patients Distance between hypospadiatic < 0.5 cm 2 meatus to tip of glans 0.5-1 cm 15 1.1-2 cm 3 Site of hypospadiac meatus Glanular 2 Coronal 3 Subcoronal 12 Distal penile 3 Age Groups 1-1.9 Years 8 2-4.9 years 10 5-10 years 2 Complications Meatal stenosis 1 patients received broad spectrum antibiotics and an- ti-inflammatory drugs for seven days. Proximal urinary diversion was not used in any of our cases. Feeding tube was removed on 10th postoperative day . RESULTS All patients passed urine from the tip of the penis with good stream after removal of per uretehral feeding tube. Three fold urethral mobilization (the distance between hypospadiatic meatus to tip of the glans penis ) was suf- ficient to achieve tension free anastamosis in all cases (Table 1). The extent of advancement of urethra ranged from 0.5 to 2 cm. None of the patients had major com- plications like stricture, dehiscence or fistula, except one case which had meatal stenosis which occurred during our early experience (Table 1). The long term outcome was satisfactory with regards to functional and cosmetic aspect (Adequate sized meatus at tip of glans and good urinary stream). DISCUSSION For anterior hypospadias, the improvement in the cos- metic appearance of penis is the most important indi- cation for surgery.(4) Many techniques have been de- scribed to correct anterior hypospadias.(5) The goal of hypospadias repair is to have functionally and cosmeti- cally normal penis.(1) The preoperative meatal sites were glanular in 2 cases, coronal in 3 cases, subcoronal in 12 cases and distal penile in 3 cases (Table 1). Common age group was 2-5 years in 10 cases (Table 1). Sixteen cases were non-circumcised and 4 were circumcised. Various techniques used to treat anterior hypospadias have their own drawbacks like breakdown of repair due Figure 1. (a): Pre Op image with feeding tube; (b): Measurement of urethral plate. Figure 2. (a): Dissection of urethra in proximal area; (b): Excision of ventral glanular mucosa with urethral plate; (c): Intermittent fixa- tion sutures between tunica and corpus cavernosa and spongiosa; (d): Glans wings closed in layers. Anterior Urethral Advancement Technique for Anterior Hypospadias Repair-Gite et al. Reconstructive Surgery 4035 to precarious blood supply in Mathieu, meatal regres- sion and stenosis in meatal advancement and glanu- loplasty (MAGPI). Results of tubularised incised plate urethroplasty (TIPS) repair depend on various factors like characters of urethral plate, together with an inci- dence of disruption, fistula and meatal stenosis.(1) Urethral advancement is considered as a good sin- gle-stage technique for distal hypospadias repair,(2) but the main drawback for this technique was meatal ste- nosis and need for high degree of expertise of the sur- geon to dissect the urethra without causing any injury. (3) Various methods used to decrease meatal stenosis are vertical and horizontal slitting of the glans, tunneling of the glans using hair transplant apparatus, and trimming of urethra in an oblique fashion about 1 to 2 mm more on vertical aspect.(3) In all our cases, the entire urethral plate was made free from corpora in glanular area by cutting 1 to 2 mm rim of ventral glanular mucosa in full depth with satisfac- tory lateral mobilization of glanular wings which is not described in other series, along with oblique spatulation of urethra. By this technique, in our series only one pa- tient developed meatal stenosis which happened during early phase of our experience. This was resolved by twice weekly dilatation with feeding tube under local anesthesia for two weeks. Urethral mobilization should be started proximally where urethra is surrounded by spongiosa all around and not distally where spongiosa tissue splayed later- ally.(1) Threefold urethral mobilization can provide ten- sion free urethral anastomosis in patients with anterior hypospadiasis as observed in our series,(5) however At- ala et al. described 4 to 5 fold urethral mobilization to provide tension free urethral anastomosis. This differ- ence may be due to inclusion of mid shaft hypospadias cases in their series.(6) The extent of urethral advancement in our series ranged from 0.5 to 2 cm, matching with other series where maximum urethral advancement was 1.5 cm,(7) 2.1 cm,(1) and 2.5 cm.(8) Average operative time to dissect urethra in our series was 40 minutes matching with 30 to 60 minutes described by Awad et al.(3) We did not employ proximal diversion except per urethral feeding tube which was kept for 10 days. Stenting or urinary diversion is unnecessary after distal hypospadias sur- gery.(6) Urethral advancement for distal hypospadias repair has variable incidence of fistula ranging from less than 1% to 16.7%.(2) In our series postoperative fistula was not recorded as we had fixed the healthy distal end of ure- thra to the tip of glans penis after excision of unhealthy distal 2 mm of urethra, with meticulous dissection of urethra without injuring it. Absence anastomosis be- tween urethra and the neo-urethra may also be the rea- son for absence of fistula. In our series patients were followed up from 6 months to 2 years with respect to site and size of the meatus, ca- liber of urinary stream, presence of fistula and chordee. All patients had cosmetically and functionally normal penis with 100 % success rate in our series by this tech- nique with our modification except one case who de- veloped meatal stenosis which was resolved by meatal dilatation. In a series of Aawad et al., 3.9 % patients developed meatal stenosis which was resolved by dil- atation.(3) Anterior urethtral advancement with our modification is easy to learn, rapid procedure and gives excellent re- sults. However, limitation of our study is small number of cases and technique applied to a selected group of patients. CONCLUSIONS Anterior urethral Advancement technique is a sin- gle-stage procedure with best cosmetic results with least complications for anterior hypospadias in properly selected cases. CONFLICT OF INTREST None of the contributing authors have any conflict of intrest, including specific financial interests or relation- ships and affiliations relevant to the subject matter or Figure 3. Postoperative image. Figure 4. Voiding photo with satisfactory stream at 6 months fol- low up. Anterior Urethral Advancement Technique for Anterior Hypospadias Repair-Gite et al. Vol 14 No 04 July-August 2017 4036 materials discussed in the manuscript. REFERENCES 1. 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