Master V.W., 14 years boy, was referred to us from Jalgaon, with history of multiple failed surgeries. At presentation, he had a penscrotal hypospadias for which he underwent a two stage urethroplasty at one year of age at one of the medical colleges in Mumbai. Due to complications, he needed three further surgeries including bladder mucosa grafting, buccal mucosa grafting and then urethroplasty which all failed. Finally at the age of 5 years, a perineal urethrostomy was performed and all hope of surgical corrections was abandoned.
His family and relatives did not lose hope and asked their local doctor to search for any possibility of repair after a few years and they found out about Hypospadias Foundation on internet. They finally reached us and at examination he still had severe hypospadias with penoscrotal transposition. There were multiple scars on the belly due to previous surgeries (pic1). He was passing urine through a perineal urethrostomy (artificial opening made in front of anus)- see pic 2. His penis still had chordee (bend).
Notice the uncorrected severe penoscrotal transposition and scars in abdomen due to previous surgery. It still looks like an uncorrected Hypospadias inspite of multiple procedures.
On the underside, the urinary opening is near the anus and there is unsightly skin in between then a patch of pink mucosa near the tip of penis.
We planned to do the major corrective surgery in two stages. We took up VW for first stage surgery which included the following
- Cystoscopy and ascertaining usable urethral passage
- Excision of all scar tissue on underside of penis
- Straightening the penis – chordee correction
- Closing the perineal urethrostomy and establishing a penoscrotal meatus (pic3)
- Correcting the penoscrotal transposition (pic4)
- Left orchiopexy was needed as the left testis was caught in the fibrosis
- Buccal mucosa graft (pic 5)
During first redo hypospadias surgery the opening was advanced to in between testis and unsightly scarred skin was excised.
Scrotal flaps made and urethral tube matured for correction of penoscrotal transposition
Buccal mucosa placed from hypospadias scrotal mucosa to the mucosa on the underside of penis- see the buccal mucosa has been properly fixed to underlying tissues
After full healing of the buccal mucosa graft (pic6), after 4 months, we did the second stage surgery – tubularisation of the buccal graft into a nice wide bore urethra (7).
3 months after surgery, buccal mucosa has healed well and the boy is ready for buccal mucosa urethroplasty
Mucosal tube is made after deep dissection on either side, buccal mucosa second stage urethroplasty in progress
For proper healing, we did a second stage neourethral coverage with a Tunica Vaginalis flap from right testis (pic8). Tunica Vaginalis is a thin membrane which surrounds the testis and has excellent blood supply and healing properties. It is often used as a second layer insurance cover in difficult or complex hypospadias repairs as in the present case (pic9).
Tunica vaginalis flap being placed over new urethra for additional security against failures
Skin flaps on either side compete the urethroplasty, notice the good final outcome as there is no penoscrotal transposition now.
Finally, we did a glansplasty to bring the urinary opening to almost the tip of penis (10). The final outcome was very good as the child had a straight penis, testis in normal location below the penis and a normal urinary opening with normal urine passage.