An 11-year boy presented to us with complaints of passing very narrow stream of urine with straining and difficulty. On clinical examination, he had coronal hypospadias with severe meatal stenosis, mild chordee and narrow glans groove. We planned a single stage hypospadias repair urethroplasty in this child.
Fig 1: Clinical examination showing narrow meatus at the coronal region
Fig 2: Artificial erection test shows no chordee.
Surgery was started by artificial erection test. Artificial erection test showed no chordee. Meatus was pinpoint for which dorsal meatotomy was done. The next important step during the surgery was to create the urinary passage from the level of the meatus to the tip of the glans. We found shallow glans groove and making a neourethra in a shallow groove without incising the urethral plate was difficult. Hence in this boy we proceeded by incising the urethral plate and placing a small buccal inlay graft.
Oral mucosa graft harvest
Graft was harvested from the lower lip. Stay suture was taken over the vermilion border using 4-0 prolene and lower lip was retracted. Incision was marked and local anesthesia was infiltrated at the marked site. 2x2cm oral mucosal was graft harvested and graft defatted. Hemostasis at the lip was achieved by bipolar cautery.
Fig 3: Graft harvested from the lower lip.
The harvested lower lip graft was sutured in the diamond shaped defect in the dorsal urethral plate and sutured all around using 6-0 PDS. Quilting of the graft was done in the centre in the neourethral groove. Following this tubularization of the urethral plate was done over a 7 Fr IFT using 6-0 PDS in a continuous subcuticular fashion. Local tissues were used as a second layer. Glansplasty was done using 6-0 PDS. Dorsal prepuce was divided in the midline and rotated to the underside of the penis to cover the ventral side. Skin closed on the ventral side in 2 layers using 6-0 PDS and 7-0 PDS.
Fig 4: Oral mucosa graft sutured in the dorsal urethral bed. Urethroplasty and Glansplasty done using 6-0 PDS.
Fig 5: First picture shows completion of repair. Second picture was taken during the first dressing change which was done on post operative day 7
Dressing was changed 7 days after surgery. Catheter was removed on post-operative day 12. After catheter removal he was passing urine in single straight stream with no leak.
Fig 4: Passing urine in single straight stream after catheter removal.
Primary distal oral mucosa inlay graft urethroplasty
Oral mucosa inlay graft is used in hypospadias wherein the urethral plate is too narrow to be tubularized on its own and a deep incision is required in the urethral plate. The raw area created by incising the urethral plate must be covered by a graft before urethroplasty. The materials which are commonly used are inner prepuce or oral mucosa graft. The healing of oral mucosa is very superior compared to the inner prepuce because of the good vascularity and less risk of graft shrinkage. Using a graft to augment the urethral plate makes the urethral plate wide which in turn leads to a wide urethral passage with minimal risk of stricture or stenosis. This type of repair can be used in primary as well as redo cases. This method was used in the above-mentioned case because he was a prepubertal boy with a shallow glans groove.
Oral mucosa is a suitable tissue for use as a graft because it is very vascular, non-hair bearing and has excellent healing property. The graft is taken from the inner cheek or the lip. Harvesting the graft is an easy procedure with minimal complications. The graft must be quilted thoroughly in the urethral bed for it to be taken up. This graft heals well in majority of the patients. Some patients may develop meatal stenosis which can be dealt with by dilating the meatus daily at home using a meatal dilator.
Oral mucosa inlay graft has very high success rate at our centre. Oral mucosa graft inlay urethroplasty is a preferred single stage urethroplasty technique in distal hypospadias mainly in adults and pre-pubertal boys.
About Hypospadias Foundation
Hypospadias Foundation located in Kharghar, Navi mumbai, Maharashtra is the topmost centre in india and one of the leading centres in the world for hypospadias treatment. Children and adults not only from India but from all over the world visit and get treated successfully at hypospadias foundation. Over the last 15 years we have been performing more than 200 surgeries per year with complication rate of less than 5%. Our expertise in this area has helped us achieve the success in this field.
Dr A K Singal is a top and expert surgeon who has dedicated his life in treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias.
Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.
Contact us:
For appointment kindly contact us at the contact details given below.
MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India – Tue/Saturday: 4:00pm-6:00pm, Call for appointments: +91-9324180553. Or email us at hypospadiasfoundationindia@gmail.com
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