Hypospadias Surgery: An Illustrated Guide

Acknowledging the fact that hypospadiology has become a true subspecialty, this unique book highlights  and explores current philosophy and different principles and techniques of hypospadias repair. It offers an excellent practical guide to all surgeons involved in the management of this common, but troublesome disease. The aim is to help interested surgeons to develop  vision, philosophy and talent rather than just enumerate techniques. It is well illustrated with ample colour diagrams and photographs of various operations together with many technical tips. All surgeons in training will benefit by reading this book in preparing for their higher examinations and their surgical training. There is a wide diversity of opinions, and a large number of operations have been described. Here, the team of world class authors present an expert overview on the management of this condition.

• Language: English
• Publisher: Springer
• Release date: Nov 11, 2013
• ISBN: 9783662078419

Book preview

General

]>

1

Evolution of Hypospadias Surgery: Historical Perspective

Cenk Büyükünal

The term hypospadias is derived from the Greek. Hypo means under and spadon means a rent or fissure (Duckett and Baskin 1996; Zaontz and Packer 1997). Durham Smith (1997) mentioned the dictum There is nothing new in surgery not previously described, and this exactly summarises the efforts which were made in the past for the description, classification, pathology and treatment of hypospadias. Many modern surgeons mention the originality of their ideas, but an investigation of historical papers, documents and books indicates that all current techniques, theoretical and practical knowledge were described centuries ago by various surgeons.

Egyptian Civilisation and Religious Documents

Man’s interest in learning the treatment of genital abnormalities began with a simple procedure: circumcision. The first documentation on this subject was found in Egypt. The circumcision procedure as a ritual is shown in the famous relief in the tomb of Ankhmahor at Saqqara, dating from the sixth dynasty, c. 2345 BC. This relief shows two young men or adolescents being circumcised. This is probably one of the best preserved documents that we have. There is a similar relief, severely damaged, in the temple of Muten Asheru at Karnak (Filler 1995; Nunn 1996; Reeves 2001). In the Eber papyrus, discovered in 1872 near Luxor, there is a recipe for the treatment of bleeding resulting from circumcision (Rogers 1973). Bettmann and Hinch (1956) mention the application of fresh meat to stop the haemorrhage. In these documents, the anaesthetic action of carbon dioxide resulting from the acetic effect of vinegar put on Memphis limestone was used to relieve the pain of children during circumcision procedures. Analysis of these documents, however, reveals neither description nor treatment of hypospadias, with the single exception of a finding in the temple of Kom Ombo. On one of the outer walls of this temple there is a relief of surgical instruments, including metal shears, surgical knives, spatulas, small hooks and forceps (Nunn 1996; Portman 2001; Reeves 2001). Although there are no scientifically acceptable data specifying the use of these tools for penile surgery, these tiny and fine surgical instruments would seem to be efficacious for circumcision and similar surgical procedures. The ancient Jews may have learned the surgical technique of circumcision from Egyptian civilisation; and circumcision is the only surgical procedure mentioned in the Old Testament (Ellis 2001). According to Zeis, in ancient Jewish practice a deficient prepuce due to extensive circumcision or tumour may have been treated by reconstructive surgical procedures (Zeis 1963). In the texts of the Bible, the Apochrypha Pseudoepi-grapha and the Talmud, any male whose penis was cut off or any man suffering an abnormal opening could not marry (Sussman 1967). Penile amputation was an operation practised in the past. Amputation of the male organ was a fairly common form of punishment or sign of degradation into slavery, especially after wars. In 1300 BC the Egyptian pharaoh Merneptah had inscribed on the walls of the Temple of Karnak the story of the amputation of more than 13,000 phallses of his enemies (Bitschai and Brodny 1956).

Greek, Ionian and Alexandrian Civilisations

Infibulation was another interesting procedure. Infibulation means a narrowing procedure in the preputium by using a ring, pin, clamp, or a leather thong passed through two artificial holes created surgically to prevent coition or masturbation (Schwarz 1970). In ancient Greece, this surgical technique was especially performed among the professional athletes to cover the glans during the Olympic games as well as to immobilise and protect the naked organ (Barcat 1973; Dingwall 1925). In ancient Greek civilisation, the goddess Hermaphrodite was described as half man and half woman. In many antique Greek statues, genitalia resembling hypospadias may represent a kind of admiration of the goddess Hermaphrodite. Therefore nobody tried to treat this condition until the advent of two Alexandrian surgeons named Helidorus and Antyllus, who lived in the first and second centuries AD. According to the recorded data, they were the pioneers who described, classified and defined pathophysiology and the treatment of hypospadias. They mentioned the problem of proper, straightforward ejaculation in hypospadias and described the problem of acquired hypospadias due to severe inflammatory and ulcerative disease of the penis. Helidorus and Antyllus made a rough classification of hypospadias according to the location of the ectopic meatus, and declared the proximal form of the disease as incurable. They were the first to describe the partial resection of glans penis to locate the orifice more centrally. Bandaging, cauterisation and the local application of vinegar were recommended to stop the haemorrhage (Antyl 1984; Bitschai and Brodny 1956; Bussmaker and Daremberg 1851–1876). Amputation beyond the orifice was also recommended by Paul of Aegina (625–690 AD) (Aeginata 1844; Smith 1997). Galen (130–199 AD), born in Pergamon, Western Anatolia, was the first physician to use the term hypospadias. He mentioned the problems of chordee and difficulty in ejaculation towards the uterus during sexual intercourse (Galen; Rogers 1973; Smith 1997).

The Byzantine Period

Oribasius (325–403 AD) showed the same concerns, reiterated the problems mentioned by Helidorus and Antyllus and gave the details of the operation called cutting the glans a little above the coronary sulcus for those patients with the distal type of hypospadias. By means of this operation he was able to bring the neo-meatus to the tip and centre of the remnant of the glans (Lascaratos et al. 1999).

Islamic Medicine

Albucasis from Cordoba (963–1013) was a well-known Arab surgeon who made enormous contributions to the field of paediatric surgery. He used a scalpel for the treatment of an imperforate urethra during the new-born period. He used a solid non-tubulrised lead sound in order to prevent stricture formation after treatment of imperforated urinary meatus. He removed this sound intermittently to allow the child to urinate easily (Herrlinger 1970; Montagnani 1986; Spinks and Lewis 1973).

Sabuncuoglu şerafeddin (fifteenth century) was a surgeon from Central Anatolia, one of the master surgeons of the Ottoman Period in all aspects of surgery. The miniature in Fig. 1.1 shows him and one of his trainees (a female physician, not a midwife!). In his book Cerrahiye-i Ilhaniye, chapter 55, he describes the fine scalpel mibza used for the treatment of meatal stenosis in hypospadias (or imperforate urinary meatus). This scalpel was more straight than the scalpel used by Albucasis. şerafeddin’s most important contribution was to use a sound with a patent canal. This was very practical for children, enabling them to urinate through it instead of removing it for every urination. In his famous manuscript, he describes the importance of the location of the urinary meatus and gives a detailed classification of hypospadias. He also mentions different repair methods for the correction of erroneous circumcision performed by unqualified people (chapter 57). This book also contains many miniature drawings concerning the operative procedures, surgical instruments and technical details. The paediatric surgical part of this book can be accepted as the first paediatric surgical atlas, with its various colourful, informative pictures (Büyükünal and Sary 1991; Numanoglu 1973; Sabuncuoğlu 1465; Uzel 1992; Unver 1939).

Fig. 1.1.

Serafeddin using an instrument to dilate meatal stenosis

The Renaissance Period

Since the Renaissance period, several historical anecdotes and scientific data related with the social problems created by hypospadias have been recorded. In 1556, Amatus Lusitanus from Portugal (Rogers 1973) treated a 2-year-old boy with penoscrotal hypospadias. He created a canal by using a silver cannula that he directed from the proximal ectopic urinary meatus up to the penile shaft as far as a surgically created meatus in the imperforate glans. This was the first real scientific development since the primitive techniques of Antyllus, Helidorus, Oribasius and Paul of Aegina. In the mid-sixteenth century, Henry II became king of France. Despite his active sexual life and his robust and athletic appearance, he had severe chordee. This was the reason why he had no children during the first 10 years of his marriage. Jean Fernel, the private surgeon of the king, corrected his problem and the king went on to father ten children by his queen, Catherine de Medici (Duckett and Baskin 1996; Smith 1997).

According to the records of the University of Rome (Cassar 1974; Duckett and Baskin 1996), the case of Maltese woman called Mathia seems very interesting. She applied for the annulment of her marriage due to her husband’s problem: severe hypospadias with chordee. This case was discussed in the Bishop’s Court; two medical witnesses examined her husband and his penis was reported as inept, incapable and useless for perforation. As a result, the Court annulled the marriage. This was the normal procedure in sixteenth-century Europe, and the Common Law established by religious authorities conferred the right for a patient to be examined in the presence of Court officials and medical authorities without any respect to individual privacy. Ambrois Paré, the famous French surgeon of the sixteenth century, was one of the first in medical history to describe the details of chordee malformation and its surgical treatment. He advised cutting off all fibrotic tissue to make the penis more straight (Johnson 1968; Paré 1575). This was a very scientific and reliable contribution.

The Seventeenth to Eighteenth Centuries

Fabricius of Aquapendente (1533–1619) mentioned the importance of carving glans tissue until the normal meatus appears (Fabricii ab Aquapendente 1619, 1641). This technique was recommended for the distal forms and is not considered relevant to modern surgery. Pierre Dionis, the author of the famous book Cours d’opérations, published in 1707, advised the technique of Albucasis for the treatment of an imperforated glans in the neonate, but he refused to use a lead sound. He thought that frequent urination in a neonate would suffice to prevent the reunion of the edges of the wound or adhesions. He used a lead catheter only for older patients, in the postoperative period after urethroplasty. His technique for the excision of chordee was similar to Paré’s technique. He simply incised the fibrous bands to make the shaft more straight (Dionis 1710, 1718). Lorenz Heister (1683–1758), a German surgeon, developed a technique for the treatment of the chordee problem which, albeit logical, was practically inapplicable. To make the penile shaft more straight, he advised the application of emollients to the contracted side and astringents to the opposite side of the penis. He also advised small skin incisions in the ventral side of the shaft. In addition, he recommended a special bandage technique after chordee correction. He found a positive correlation between paternity rates and the location of the ectopic hypospadiac meatus (Heister 1743).

The Nineteenth Century

Significant improvements in the understanding of the precise pathology of hypospadias were achieved and the fundamental characteristics of modern surgical techniques were created in the nineteenth century.

Creation of a Neourethra

Efforts to Create an Urethra by Using Local Flaps

In 1838, Dieffenbach perforated the glans down to the urethral meatus and inserted a cannula in between, until the neourethra was covered by normal urothelium (Dieffenbach 1837, 1847) ( Fig. 1.2). Although it was a clever idea, the operation was not successful. In 1861, Bouisson suggested a ventral transverse incision to straighten the penile shaft and thus alleviate the chordee problem (Bouisson 1869, 1861). This was not a radical way to treat chordee. In addition, Bouisson was the first surgeon to use a rotated local pedicled scrotal flap in order to cover the ventral defect. The inner surface of this scrotal flap was used to create the anterior part of the neourethra with a technique resembling the Mathieu operation ( Fig. 1.3).

Fig. 1.2.

Dieffenbach pierced the glans and left a catheter in place until the channel became epithelialised. The operation was not successful

Fig. 1.3.

Bouisson (1861) used scrotal tissue to reconstruct the urethra

In 1869, Karl Thiersch started for the first time to use local tubularised skin flaps to repair epispadias (Horton et al. 1973; Thiersch 1869). Théophile Anger adopted this technique to repair hypospadias. He used longitudinal flaps on either side of the urethral groove and permitted them to overlap without denuding. Although the result was unsuccessful (Anger 1874a, b, 1875), Anger was the real initiator of the modern urethroplasty technique in hypospadias surgery. He performed two parallel but asymmetrical incisions in the skin of the ventral shaft. This manoeuvre theoretically prevented the overlapping between the urethral and skin closures and thus reduced the rate of fistula formation ( Fig. 1.4).

Fig. 1.4.

Anger (1874) used two parallel asymmetrical incisions to avoid overlapping urethral and skin sutures

In 1870 Moutet used scrotal tissue to reconstruct the urethra (Moutet 1870). The ventral penile skin defect over the raw surface of the neourethra was covered by bipedicled suprapubic abdominal skin flaps.

In 1874 Duplay used the Bouisson technique to release the chordee (Duplay 1874; Smith 1981) ( Fig. 1.5a–c). In the second stage he incised the ventral skin on either side of the urethral groove. This flap, namely the urethral groove, was tubularised. The edges of the outer skin were sutured over the tube ( Fig. 1.5d, e). In 1880 Duplay described a second procedure (Duplay 1880) where a narrower strip was used. This was a real buried strip which would be popularised by Browne 69 years later. Duplay did not consider suturing the outer skin edge-to-edge to the sides of the urethral strip.

Fig. 1.5.

a–c Duplay (1874) used a transverse incision closed longitudinally to correct chordee. d, e A U-shaped incision to tubularise the skin distal to the meatus

Wood, in 1875 (quoted by Mayo 1901), presented a meatal-based flap technique to create a neourethra ( Fig. 1.6). Basically, his proposal was similar to the technique of Mathieu. He also introduced the idea of the buttonhole flap to cover the ventral surface of the penis and the raw surface of the newly created urethra. The buttonhole technique had originally been mentioned by Thiersch for the coverage of a dorsal shaft defect in epispadias surgery (Thiersch 1869).

Fig. 1.6.

Wood (1875) described the meatal-based flap. He also buttonholed the prepuce to cover the neourethra

Rosenberg (1891), Landerer (1891) and Bidder (1892) used basically similar principles of treatment for proximal types of hypospadias. Their modification was to bury the ventral part of the penis into the scrotum by using penoscrotal sutures to create a neourethra from the inner part of the scrotal tissue. In the second stage they divided this surgically created penoscrotal fusion and covered the raw surface in the ventral part of the neourethra using lateral skin flaps from the penile shaft.

Rochet (1899) used a distally created meatal-based scrotal flap to create a complete scrotal-urethral channel. This tube was buried in a subcutaneous tunnel which was created in the ventralpart of the penile shaft.

Techniques for Reconstructing the Urethra by Using Vascularised Island Flaps

In 1896 Van Hook described for the first time the creation of vascularised dorsal preputial flaps to reconstruct the urethra. In addition, he suggested using lateral oblique vascularised flaps from the lateral part of the preputium and penile skin. This was a proximally based pedicled tube derived from the preputium. These techniques were performed in two stages. To our knowledge, he is the first surgeon to describe and use vascularised island flaps in hypospadias surgery.

Urethral Construction with Free Grafts

In 1897 Nové-Josserand described the application of split-thickness free skin grafts for the reconstruction of the urethra ( Fig. 1.7). This was a two-stage procedure. He reported his results again in 1914 (Nové-Josserand 1914). He was the first to successfully use a free graft to create urethra.

Fig. 1.7.

Nové-Josserand (1897) used split-thickness skin graft to reconstruct the neourethra

Urethral Elongation

Beck (1898) and Hacker (1898) presented a special technique for the distal type of hypospadias without chordee. They undermined and mobilised the urethra and advanced it into the glans. Tunnelisation of the glans was performed with the help of a trochar-like instrument ( Fig. 1.8). For deeper grooves they advised cutting the glans medially and reapproximating it over the advanced urethra.

Fig. 1.8.

Beck and Hacker (1897) undermined and advanced the urethral meatus into the glans

The Concept of Chordee Correction

In 1842, Mettauer advocated making many subcutaneous incisions to treat skin tethering. Although this was a very modern and scientific concept for the mid-nineteenth century it was ignored and instead a misconception pointed out by Bouisson in 1860 continued for more than a century. Duplay (1874a,b; 1880) mentioned the importance of chordee release even before urethroplasty. Lauenstein in 1892 used pubic skin flaps to treat skin deficiency in the ventral surface of the hypospadiac penile shaft. In 1844 Pancoast resected a small part from the dorsal corpora to correct a bending problem, almost a century before the so-called Nesbit’s procedure (Pancoast 1844,1972).

The Twentieth Century

Creation of Neourethra

Efforts to Create Urethra by Local Flaps

Ombrédanne, a real scientific pioneer, reached one of the milestones of hypospadiology. In his reports and his famous book (Ombrédanne 1911, 1925, 1932) he advised performing a large round flap to create an urethra ( Fig. 1.9a, b, p. 12). After the creation of the urethra, the defect in the ventral penile shaft was covered by a dorsal preputial flap which was brought down by the philosophy of the buttonhole technique ( Figs. 1.9c, d, 1.10, p. 13). This was a single-stage repair with a reasonable rate of complication. In 1913 credit was given to Edmunds (DeSy and Oesterlinck 1980) as the first surgeon to transfer the dorsal preputial flap to cover the ventral penile skin after an extensive chordee release. This extensive chordee release was performed in the first stage, followed by the second stage where healthy and abundant skin was easily manipulated into a Duplay-type urethroplasty.

Fig. 1.9a–d.

Ombredanne (1911) designed a large round flap and used a purse-string suture to reconstruct the neourethra

Fig. 1.10.

The Ombredanne method of fixation of the penis after hypospadias repair

Bevan in 1917 created a rectangular-shaped meatal based flap and carried it through the surgically created glanular channel aiming to treat distal types of hypospadias. According to the author, this technique is considered the initial version of flip-flap techniques. In 1917 Beck presented his two-stage technique for proximal hypospadias plus severe chordee. In the first stage he released the chordee and brought a bipediculated preputial flap to cover the ventral skin defect. In the second stage, a Duplay-type urethroplasty was performed and was covered by a pediculated lateral penoscrotal rotation flap.

In 1932, Mathieu used a meatal-based penile skin flap technique for the treatment of distal hypospadias. The flap was rotated superiorly and sutured to the internal lips of the two paramedian glanular and shaft incisions. The ventral skin defect was closed by suturing external edges of the glans and skin.

In 1950, Denis Browne popularised his buried strip of skin method (Browne 1936, 1949, 1953). Until recent times this technique was favoured by most paediatric surgeons and paediatric urologists.

Davis (1940, 1950) developed a tube from the dorsal penile skin. The pedicle of the tube was situated in the proximal part of the dorsal penile shaft. The penis was bent in the dorsal direction to bring the tip of the glans to the base of the pedicle of the tubularised flap, whose tip was anastomosed to the edges of the hypospadiac meatus. The base of the flap was divided as a second-stage operation.

For treatment of distal hypospadias, Horton and Devine (1959) created a flip flap from the ventral surface of the shaft adjacent to the urethral meatus, and a triangular midline glanular flap to form the distal urethra (Devine 1961; Dieffenbach 1837). The ventral surface could easily be covered by lateral glanular flaps. In 1965, Mustardé combined the Bevan rectangular flap technique and midline glanular triangular flap techniques. Instead of incising the glans, he passed the tube through a surgically created glanular tunnel. He also benefited from the preputial buttonhole technique to cover the ventral skin defect.

Techniques for Reconstruction of the Urethra by Using Vascularised Island Flaps

In 1961, Des Prez et al. and Broadbent et al. presented a single-stage technique for severe proximal forms (Broadbent et al. 1961; Des Prez et al. 1961). They used a lateral vascularised preputial island flap for urethral reconstruction. The new urethral meatus was anastomosed to the tip of the glans by either splitting or tunnelling the glans tissue.

Toksu (1970) and Hodgson (1970) created a technique based on a vertical preputial vascularised flap from the inner preputial surface in 1970. This single-stage procedure was indicated only for distal cases.

In 1971, Asopa presented a similar technique which is applicable to severe proximal hypospadias (Asopa et al. 1971). In this technique, a horizontal preputial flap is prepared from the inner surface and tubularised to form a neourethra. This urethra was brought down to the ventral surface by means of a Byars flap.

In 1968 Hinderer presented a technique which is applicable for all types of hypospadias (Hinderer 1971, 1975). A vascularised flap beginning from the hypospadiac meatus extending beyond the midline to the inner surface of the preputium was prepared to form the urethral canal. Instead of splitting, the glans is tunnelled by a special type of trochar in order to bring the pediculated flap through it.

Standoli (1979, 1982) created a neourethra by using a vascularised island flap which is horizontally prepared from the outer surface of the preputium. This was a real island flap with its intact vascular pedicle and this pedicle was rotated around the penis to bring the neourethra to the ventral side of the shaft.

In 1980 Duckett popularised his preputial island flap which is created from the inner surface of the preputium in horizontal direction (Duckett 1980, 1981a). A ventral skin defect was covered by the outer preputial skin using the Byars technique.

Asopa popularised his double-face prepuce flap in order to create a neourethra and to cover the ventral skin defect (Asopa and Asopa 1984). This approach, presented in 1984, is still used by many hypospadiologists.

Urethral Construction with Free Grafts

Free Skin Grafts► McIndoe (1937) used Nové-Josserand’s split-thickness graft method by using a special type of trochar to introduce the graft under the penile skin and through the glans. This was a two-stage technique.

In 1961 Horton and Devine created a single-stage procedure which can be used for all types of proximal cases (Devine and Horton 1961; Horton and Devine 1959). They used a full-thickness inner preputial free skin graft to create an urethra. A triangular glanular flap was used for the anastomosis between the graft and glanular meatus. A notable initiator of this technique was Humby (1941), who used a full-thickness preputial flap years before Horton and Devine in 1941.

Other Free Grafts► Free grafts prepared from tissues such as the appendix, the urethra and other vessels were used by various authors yet without significant clinical success (Smith 1997). On the other hand, bladder mucosa and buccal mucosa are associated with higher consistency and are still used by various surgeons with reasonable complication rates. Bladder mucosa was used by Memmelaar in 1947 and by Marshall and Spellman in 1955. This method was popularised by Hendren and Reda (1986) and Ransley et al. (1987). Buccal mucosa for the creation of a neourethra was used by Humby in 1941 and Mirabet in 1964, but popularised by Duckett (1986), Dessanti et al. (1992) and Ransley from the UK.

Urethral Elongation

In 1981, Duckett presented a meatal advancement and glanuloplasty (MAGPI) technique for subcoronai and glanular cases without chordee (Duckett 1981b). In 1982, Baran used a modification of the Beck and Hacker technique by elongating the distal urethra to the tip of the penis through a surgically created tunnel (Baran and Çenetoğlu 1993). A glanular triangular flap was used in the meatal anastomosis in order to prevent stricture formation. This was an operation especially advised for circumcised hypospadiac patients.

The Concept of Chordee Correction

In 1913, Edmunds transferred preputial skin to the ventrum of the penis in order to stabilise the deficient skin. In 1917 Beck had used the buttonhole technique by passing the glans through the preputium in order to transfer the dorsal skin easily to the ventral part. This was popularised by Nesbit (1941, 1965, 1966). Blair and Byars in 1938 and Byars in 1955 used the relevant model of dorsal preputial flaps to treat the deficient skin problem in the ventral surface of the shaft. Byars in 1955 drew attention to the extensive removal of the fibrous tissues from the entire ventral half of the penile circumference down to the corpus cavernosum.

The modern concept of chordee correction, mentioned in 1842 by Mettauer, was rediscovered by Smith of the USA in 1967. Smith’s work contributed in a major way to the realisation of the importance of tethering and shortening of the skin and subcutaneous tissues.

In 1968 Allen and Spence and in 1970 King used the same concept in the operative treatment of chordee problems. In 1965 Nesbit reported the successful results of his dorsal plication technique in three consecutive cases of chordee without hypospadias (Nesbit 1965, 1966). During the past 15 years J.W. Duckett’s philosophy of corporal disproportion has enlarged the horizons of our knowledge and surgical philosophy of chordee problems (Baskin et al. 1994; Duckett 1987; Duckett and Baskin 1996).

During the last quarter of the 20th century, there were a couple of innovative techniques and important discoveries regarding the pathologic anatomy and treatment modalities in hypospadiology. According to the anatomical studies of Baskin et al. (1998), since there are no neural elements in the dorsal midline (12 o’clock position) of the penile shaft, a mid-dorsal single plication suture could be recommended for the treatment of corporal disproportion. In 1973 Barcat made a modification in the Mathieu procedure by mobilising the glans flap in addition to the parameatal flap and splitting the glans dorsally to bury the urethral tube. In 1984 Koyanagi et al. created an ingenious technique (Koyanagi et al. 1984,1995). This is a meatal-based flap which can be easily and circumferentially extended to the glans to form a foreskin flap to be converted to an urethral plate. In their experience, this technique could be used universally for the treatment of all types of hypospadias.

In 1994 Snodgrass from the USA presented his tubularised incised plate technique for the treatment of distal hypospadias. Recently it has been shown that this technique could be applicable to proximal hypospadias (Snodgrass et al. 1998, 2002). In 1998 Perovic from Yugoslavia presented his penile disassembly technique for the treatment of severe penile curvatures and especially for glans tilt and curvatures that are located distally (Perovic et al. 1998).

Milestones in Modern Hypospadiology

Browne (1936), Smith (1938), and Schaffer and Erbes (1950) made an anatomical classification of hypospadias according to the localisation of the ectopic meatus. Barcat in 1973 presented a new concept related to the new localisation of the meatus after the chordee release procedure.

In 1974, Gittes and McLaughlin popularised the artificial erection test by injecting saline solution after placing a tourniquet at the base of the penis. This was a real advance in the diagnosis and treatment of chordee.

In 1980 DeSy and Oosterlinck introduced silicone foam dressing, which was considered a significant improvement for paediatric patients and solved the issue of various postoperative care problems. Jensen, in 1981, presented the idea of "supplemental local block for postoperative pain relief by using 0.5 % bupivacaine solution. This was a revolution in the anaesthesia of hypospadias and postoperative pain problems.

Surgical correction became more effective and less complicated after improved optic magnification techniques andnew suture materials (Manley and Epstein 1981).

After the declaration of the Section of Urology of the AAP in 1975 and the paper of Schultz et al., the operation age for hypospadias decreased to between 6 and 18 months (Schultz et al. 1983; Shokeir and Hussein 1999).

Monfort and Lucas (1982) recommended testosterone stimulation in the preoperative period to increase the size and the vascularity of the penile shaft and skin. This was found to be extremely useful for the patient as well as the surgeon.

Among modern diversion techniques, a simple method, Silastic tubing placed through the repair into the bladder allowing a constant dripping from the catheter into the diaper, which was popularised by Duckett and Snyder (1985; Duckett 1992), was another revolution. Oral intake of oxybutinin made this application even more tolerable by the young patients (Duckett 1987; Duckett and Baskin 1996).

In 1994, Snow used tunica vaginalis as an additional protective tissue to cover the urethra to prevent fistula formation. Since the 1990s, subcutaneous tissues prepared from the dorsal preputial skin or dartos has been used for the same purpose.

From the historical perspective, it can be concluded that, in the twenty-first century, no paediatric surgeon or paediatric urologist can claim originality for any of the techniques and principles for the treatment of hypospadias. Most of the modern techniques of reconstructive procedures were developed through the work of innovative and pioneer surgeons of previous centuries. Recent improvements are due not only to developments in paediatric anaesthesia, antibiotics, suture materials and catheters, but to the incredible efforts of the old masters.

References

Aeginata P: Seven books of Paulus Aeginata. Sydenham Society, London, 1844.

Allen TD, Spence HM: The surgical treatment of coronal hypospadias and related problems. J Urol. 1968; 100:504–508.

Anger MT: Hypospadias. Bull Soc Chir Paris. 1874a; p 32.

Anger MT: In: Murphy LJT (ed): (1972) The history of urology. Thomas, Springfield, Illinois. 1874b; p 454.

Anger MT: Hypospadias péno-scrotal, compliqué de coudure de la verge: redressment du pénis et uréthro-plastie par inclusion cutanée:guérison. Bull Soc Chir Paris. 1875; p 179.

Antyl (1st century AD) In: Hauben DJ (ed): The history of hypospadias. Acta Chir Plast. 1984; 26:196–199.

Asopa R, Asopa HS: One stage repair of hypospadias using double island preputial skin tube. Int J Urol. 1984; 1:41–43.

Asopa HS, Elhence EP, Atria SP, et al: One stage correction of penile hypospadias using a foreskin tube: a preliminary report. Int Surg. 1971; 55:435–448.

Baran NK, Çenetoğlu S: Pictorial history of hypospadias repair techniques. Gazi Medical Faculty, Plast Reconstr Surg. 1993; pp 1–50.

Barcat J: Current concepts of treatment of hypospadias. In: Horton CE (ed): Plastic and reconstructive surgery of the genital area. Little Brown, Boston, 1973; pp 249–263.

Baskin LS, Duckett JW, Ueoka K, et al: Changing concepts of hypospadias curvature lead to more onlay island flap procedures. J Urol. 1994; 151:191–196.

Baskin LS, Erol A, Li YW, et al: Anatomic studies of hypospadias. J Urol. 1998; 160:1108–1115.

Beck C: A new operation for balanic hypospadias. NY Med J. 1898; 67:147.

Beck C: Hypospadias and its treatment. Surg Gynecol Obstet. 1917; 24:511.

Bettmann OL, Hinch PS: A pictorial history of medicine, 2nd edn. Thomas, Springfield, Illinois. 1956; pp 4–5.

Bevan AD: A new operation for hypospadias. JAMA. 1917; 68:1032.

Bidder A: Eine Operation der Hypospadie mit Lappenbildung aus dem Scrotum. Dtsch Med Wochenschr. 1892; 10:208.

Bitschai J, Brodny ML: A history of urology in Egypt. Riverside, New York, 1956.

Blair VP, Byars LT: Hypospadias and epispadias. J Urol. 1938; 40:814.

Bouisson MF: Remarques sur quelques variétés de l’hypospadias et sur le traitment qui leur convient. Bull Ther. 1860; 59:349–362.

Bouisson MF: De l’hypospadias et de son traitment chirurgical. Trib Chir. 1861; 2:484.

Broadbent TR, Woolf RM, Toksu E: Hypospadias — one stage repair. Plast Reconstr Surg. 1961; 27:154–159.

Browne D: A comparison of the Duplay and Denis Browne techniques for hypospadias operation. Surgery. 1953; 34:787.

Browne D: An operation for hypospadias. Lancet. 1936; 1:141.

Browne D: An operation for hypospadias. Proc R Soc Med. 1949;41:466–468.

Bussemaker UC, Daremberg CV: Ouvres d’Oribase, texte Grec en Grande Partie Inédit. Imprimerie Nationale, Paris, 1851–1876 (6 vols).

Büyükünal SNC, Sary N: Şarafeddin Sabuncuoğlu, the author of the earliest pediatric surgical atlas: Cerrahiye-i Ilhaniye, J Pediatr Surg. 1991; 26:1148–1151.

Byars LT: A technique for consistently satisfactory repair of hypospadias. Surg Gynecol Obstet. 1955; 100:184–190.

Cassar P: A medico-legal report of the 16th century from Malta. Med Hist. 1974; 18:354–359.

Davis DM: The pedicle tube graft in the surgical treatment of hypospadias in the male. Surg Gynecol Obstet. 1940; 71:790.

Davis DM: The surgical treatment of hypospadias,especially scrotal and perineal. Plast Reconstr Surg. 1950; 5:373.

Des Prez JD, Persky L, Kiehn CL: One stage repair of hypospadias by island flap technique. Plast Reconstr Surg. 1961; 28:405–411.

Dessanti A, Rigamonti W, Merulla V et al: Autologous buccal mucosa graft for hypospadias repair: an initial report. J Urol. 1992; 147:1081–1084.

De Sy WA, Oosterlinck W: Silicone foam elastomer: A significant improvement in postoperative penile dressing. J Urol. 1982; 128:39–41.

Devine CJ, Horton CE: A one stage hypospadias repair. J Urol. 1961; 85:166–172.

Dieffenbach JF: Die operative Chirurgie. Brockhaus, Leipzig, 1845.

Dieffenbach JF: Guérison des fentes congénitales de la verge, de l’hypospadias. Gaz Hebd Med. 1837; 5:156.

Dingwall EJ: Male infibulation. Bale and Danielson, London, 1925.

Dionis P: In: Haeger K (ed) The illustrated history of surgery. Harold Strake, London, 1718; pp 132–134.

Dionis PA: Course of chirurgical operations demonstrated in Royal Garden at Paris, 2nd edn. J Tonson, London. 1710; pp 137–155.

Duckett JW: Transverse preputial island flap technique for repair of severe hypospadias. Urol Clin North Am. 1980; 7:423–431.

Duckett JW: The island flap technique for hypospadias repair. Urol Clin North Am. 1981a; 8:503–511.

Duckett JW: MAGPI (meatal advancement and glanuloplasty): a procedure for subcoronal hypospadias. Urol Clin North Am. 1981b; 8:513–520.

Duckett JW: Use of buccal mucosa urethroplasty in epispadias. Meeting of Society of Pediatric Urology, Southampton, England. 1986.

Duckett JW: Hypospadias. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds): Adult and pediatric urology, vol II, 2nd edn. Year Book Medical Publishers, Chicago. 1987; pp 1880–1915.

Duckett JW: Successful hypospadias repair. Contemp Urol. 1992; 4:42–55.

Duckett JW, Snyder HM: Hypospadias pearls. Soc Pediatr Urol Newslett. 1985; 7:4.

Duckett JW, Baskin LS: Hypospadias. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds) Adult and pediatric urology, vol 3, 3rd edn. Mosby, St Louis. 1996; pp 2549–2589.

Duplay S: De l’hypospadias périneo-scrotal et de son traitement chirurgical. Arch Gen Med. 1874a; 1:613,657.

Duplay S: De l’hypospadias périnéo-scrotal et de son traitment chirurgical. Asselin, Paris, 1874b.

Duplay S: Sur le traitement chiurgical de l’hypospadias et de l’epispadias. Arch Gen Med. 1880; 5:257.

Edmunds A: An operation for hypospadias. Lancet. 1913; 1:447.

Elder JS, Duckett JW, Snyder HM: Onlay island flap in the repair of mid and distal hypospadias without chordee. J Urol. 1987; 138:376.

Ellis H: A history of surgery. Greenwich Medical Media, London. 2001; pp 4–5.

Fabricii ab Aquapendente H: Opera Chirurgica Patavii: Franciscum Bolzettam, 1641.

Fabricii ab Aquapendente H: Opera Chirurgica Venetiis: Apud Robertum Megliettum, 1619.

Filler J: Disease. British Museum Press, London. 1995; p:90.

Galen (c. 130–201 AD). In: Opera Omnia vol 10. Kühn, Leipzig, Cnobloch, p 1001

Gittes RF, McLaughlin AP III: Injection technique to induce penile erection. Urology. 1974; 4:473–474.

Hacker V: Zur operativen Behandlung der Hypospadia Glandis. Beitr Z Klin Chir. 1898; 22:271–276.

Heister L: General system of surgery in three parts. Winnys, London. 1743; pp 129–138; 243–250.

Hendren WH, Reda EF: Bladder mucosa graft for reconstruction of male urethra. J Pediatr Surg. 1986; 21:189.

Herrlinger R: History of medical illustration: from antiquity to 1600. Medicina Rara, New York, 1970.

Hinderer U: Behandlung der Hypospadie und der inkompletten Hypospadieformen nach eigenen Methoden von 1966 bis 1975. In: Schmied E, Widmaier W, Reichert H (eds) Wiederstellung von Form und Funktion organischer Einheiten der verschiedenen Körperregionen: Jahrestagung der Deutschen Gesellschaft für Plastische und Wiederherstellungschirurgie. Thieme, Stuttgart. 1975; pp 263–290.

Hinderer U: New one-stage repair of hypospadias (technique of penis tunnelization). In: Hueston JT (ed) Transactions of the 5th International Congress of Plastic and Reconstructive Surgery. Butterworth, Stoneham. 1971; pp 283–305.

Hodgson NB: A one-stage hypospadias repair. J Urol. 1970; 104:281–284.

Horton CE, Devine CJ, Baran NK: Pictorial history of hypospadias repair techniques.In: Horton CE (ed) Plastic and reconstructive surgery of the genital area. Little Brown, Boston. 1973; pp 237–248.

Horton CE, Devine CJ: Film: a one-stage hypospadias repair. Eaton Laboratories, 1959.

Humby G: A one stage operation for hypospadias. Br J Surg. 1941; 29:84–92.

Jensen BH: Caudal block for postoperative pain relief after genital operations. A comparison between morphine and bupivacaine. Acta Anesthesiol Scand. 1981; 25:373–375.

Johnson T: The works of that famous chirurgion Ambrose Paré, translated out of Latine and compared with the French by T Johnson. Cotes TH, Young R, London, 1634. Reprinted by Milord, Boston, 1968.

King LR: Hypospadias — a one-stage repair without skin graft based on a new principle: chordee is sometimes produced by skin alone. J Urol. 1970; 103:660–662.

Koyanagi T, Nonomura H, Kakizaki H, et al: Hypospadias repair. In: Thüroff JW, Hohenfellner M (eds): Reconstructive surgery of the lower urinary tract in children. Isis Medical Media, Oxford. 1995; pp 1–21.

Koyanagi T, Nonomura K, Gotoh T et al: One stage repair of perineal hypospadias and scrotal transposition. Eur J Urol. 1984; 10:364–367.

Landerer: Dtsch Z Chir. 1891; p 32.

Lascaratos J, Kostakopoulos A, Louras G: Penile surgical techniques described by Oribasius (4th century CE). BJU Int. 1999; 84:16–19.

Lauenstein C: Zur Plastik der Hypospadie. Arch Klin Chir. 1892; 43:203.

Manley CB, Epstein ES: Improved optical magnification have made surgical correction at an earlier age more successful. J Urol. 1981; 125:698–700.

Marshall VF, Spellman RM: Construction of urethra in hypospadias using vesical musocal grafts. J Urol. 1955; 73:335–342.

Mathieu P: Traitement en un temps de Phypospadias balanique et juxta-balanique. J Chir. 1932; 39:481.

Mayo CH: JAMA. 1901; 36:1157.

McIndoe AH: An operation for cure of adult hypospadias. Br Med J. 1937; 1:385.

Memmelaar J: Use of bladder mucosa in a one stage repair of hypospadias. J Urol. 1947; 58:68–73.

Mettauer JP: Practical observations on those malformations of the male urethra and penis, termed hypospadias and epispadias, with an anomalous case. Am J Med Sci. 1842; 4:43.

Mirabet Ippolito V: Modification de la técnica de McIndoe para el tratamiento de los hipospadias. Doctoral thesis, Valencia, 1964.

Monfort G, Lucas C: Dihydrotestosterone penile Stimulation in hypospadias surgery. Eur Urol. 1982; 8:201–203.

Montagnani CA: Pediatric surgery in Islamic medicine from the middle ages to renaissance. In: Rickam PP (ed) Historical aspects of pediatric surgery. Prog Pediatr Surg, vol 20. Springer, Berlin Heidelberg New York. 1986; pp 39–51.

Moutet: De l’uréthroplastie dans hypospadias scrotal. Montpellier Méd, May, 1870.

Mustardé JC: One stage correction of distal hypospadias and other people’s fistulae. Br J Plast Surg. 1965; 18:413–420.

Nesbit RM: Congenital curvature of the phallus: report of three cases with description of correction operation. J Urol. 1965; 93:230–232.

Nesbit RM: Operation for correction of distal penile ventral curvature with and without hypospadias. Trans Am Assoc Genitourin Surg. 1966; 58:12–14.

Nesbit RM: Plastic procedure for reconstruction of hypospadias. 1941; 45:699–707.

Nové-Josserand G: Traitment de l’hypospadias; nouvelle méthode. Lyon Méd. 1897; 85:198.

Nové-Josserand G: Résultates éloignés de l’uréthroplastie par la tunnelisation et la greffe dermo-épidermique dans les formes graves de l’hypospadias et de l’épispadias. J Urol Med Chir. 1914; 5:393.

Numanoğlu Y: Cerrahiye-i Ilhaniye: The earliest known book containing pediatric surgical procedures. J Pediatr Surg. 1973; 8:547–548.

Nunn JF: Ancient Egyptian medicine. Chapter 8: Surgery, trauma and dangerous animals. British Museum Press, London. 1996; pp 163–190.

Ombrédanne L: Hypospadias pénien chez Tenfant. Bull Mem Soc Chir Paris. 1911; 37:1076.

Ombrédanne L: Précis clinique et opératoire de chirurgie infantile. Masson, Paris. 1925; pp 654–689.

Ombrédanne L: Précis clinique et opératoire de chirurgie infantile. Masson, Paris. 1932; p 851.

Pancoast J: Hypospadias. In: Treatise on operative surgery. Carey and Hart, Philadelphia. 1844; p 317.

Pancoast J: In: Murphy LJT (ed): The history of urology. Thomas, Springfield, Illinois. 1972; p 456.

Paré A: Les oeuvres de M. Ambroise Paré. Chez Gabriel Buon, Paris, 1575.

Perovic SV, Vukadinovic V, Djordjevic MLJ, et al: The penile disassembly technique in hypospadias repair. Br J Urol. 1998; 81:479–487.

Portman I: A guide to the Temple of Kom Ombo. Palm Press, Cairo. 2001; p 19.

Ransley PG, Duffy PG, Oesh IL et al: The use of bladder mucosa and combined bladder mucosa/preputial skin grafts for urethral reconstruction. J Urol. 1987; 138:1096.

Reeves C: Egyptian medicine. Shire Publications, Buckinghamshire, UK. 2001; pp 26–27, 29–31.

Rochet V: Nouveau procédé pour réfaire le canal pénien dans l’hypospadias. Gaz Hebd Med Chir. 1899; 4:673.

Rogers BO: History of external genital surgery. In: Horton CE (ed): Plastic and reconstructive surgery of the genital area. Little Brown, Boston. 1973; pp 3–47.

Rosenberger: Dtsch Med Wochenschr. 1891; 9:1250.

Sabuncuoğlu Ş: Cerrahiye-i Ilhaniye, Istanbul Fatih National library, 1465; no 79 (1st manuscript).

Schaeffer DD, Erbes J: Hypospadias. Am J Surg. 1950; 80:183.

Schultz JR, Klykylo WM, Wacksman J: Timing of elective hypospadias repair in children. Pediatrics. 1983; 71:342–351.

Schwartz GS: Infìbulation, population control and the medical profession. Bull NY Acad Med. 1970; 46:964.

Section of Urology, American Academy of Pediatrics: The timing of elective surgery on genitalia of male children with particular reference to undescended testis and hypospadias. Pediatrics. 1975; 56:479.

Shokeir AA, Hussein MI: The urology of Pharaonic Egypt. BJU Int. 1999; 84:755–761.

Smith CK: Surgical procedures for correction of hypospadias. J Urol. 1938; 40:239.

Smith DR: Repair of hypospadias in pre-school child. A report of 150 cases. J Urol. 1967; 97:723–730.

Smith ED: Durham Smith repair of hypospadias. Urol Clin North Am. 1981; 8:451–455.

Smith ED: The history of hypospadias. Pediatr Surg Int. 1997; 12:81–85.

Snodgrass W: Tubularized incised plate urethroplasty for distal hypospadias. J Urol. 1994; 151:464–465.

Snodgrass W, Baskin LS, Mitchell ME: Hypospadias. In: Gillenwater JY, Grayhack JT, Howards SS, Mitchell ME (eds): Adult and pediatric urology, vol III, 4th edn. Lippincott, Williams and Wilkins, Philadelphia. 2002; pp 2509–2532.

Snodgrass W, Koyle M, Manzoni G, et al: Tubularized incised plate hypospadias repair for proximal hypospadias. J Urol. 1998; 159:2129–2131.

Snow BW: Use of tunica vaginalis to prevent fistula in hypospadias surgery. J Urol. 1986; 136:861.

Spinks MS, Lewis GL: Albucasis: On surgery and instruments. A definitive edition of the Arabic text with English translation and commentary. The Wellcome Institute of the History of Medicine, London. 1973; pp:170:827.

Standoli L: Correzione dell’ipospadia in tempo unico: technica dell’uretroplastica con lembo ad isola prepuziale. Rass IT Chir Ped. 1979; 21:82–91.

Standoli L: One-stage repair of hypospadias: Preputial island flap technique. Ann Plast Surg. 1982; 9:81–88.

Sussman M: Diseases in the bible and the Talmud. In: Brothwell D, Sandison AT (eds): Diseases in antiquity: a survey of the diseases. Injuries and surgery of early population. Thomas, Springfield, Illinois. 1967; p 209.

Thiersch C: Über die Entstehungsweise und operative Behandlung der Epispadie. Arch Heilkunde. 1869; 10:20.

Toksu E: Hypospadias: one-stage repair. Plast Reconstr Surg. 1970; 45:365.

Ünver AS: Şerafeddin Sabuncuoğlu: Kitabül Cerrahiye-i Ilhaniye (Cerrahname), Istanbul, Y.Ü Typ Tarihi Enstitüsü, Adet. 1939; 12:870–1465.

Uzel I: Şarafeddin Sabuncuoğlu: Cerrâhiyyetü’l-hâniyye, vol-I, Atatürk Kültür Dil ve Tarih Yüksek Kurumu Yayynlary, III. Dizi. 1992; pp 280–281.

Van Hook W: A new operation for hypospadias. Ann Surg. 1896; 23:378.

Wood J: cited by Mayo CH: JAMA. 1901; 36:1157

Zaontz MR, Packer MG: Abnormalities of the external genitalia. Pediatr Clin North Am. 1997; 44:1267–1297.

Zeis E: Die Literatur und Geschichte der plastischen Chirurgie. Wilhelm Englemann, Leipzig. 1963; pp 145–173.

]>

2

Men Behind Principles and Principles Behind Techniques

Ahmed T. Hadidi

The philosopher Santayana (1863–1952) said: Those who cannot remember the past are condemned to repeat it. In an address to the Royal College of Surgeons, Winston Churchill remarked: The longer you look back, the further you can look forward (McCarthy 1990).

As Durham Smith mentioned in his forward to this book, Although the penile repairs can be grouped into five or six major principles, depending on the tissues used, each has been subject to countless variations as one surgeon after another adds yet another modification to an already thrice-modified variation of a procedure adapted from a principle derived from the original!

From Alexandria, Egypt came the first hypospadias pioneers, Helidorus and Antyllus. Living in the first century, they were the first to describe and define the pathophysiology and treatment of hypospadias (Bussemaker and Daremberg 1851).

The aim of this chapter is to reduce the enormous variety of techniques in hypospadias to a few basic principles and to give credit to the great pioneers who first described these concepts (Table 2.1). The following account is by no means exhaustive, nor does it include all the techniques described for hypospadias repair.

Table 2.1.

Short list of men behind principles

In dealing with a boy with hypospadias, the surgeon has to correct the following major abnormalities:

1.

Abnormal ventral curvature or chordee, by orthoplasty

2.

Abnormal proximal meatal insertion, by urethroplasty

3.

abnormal looking glans penis, by glanuloplasty and meatoplasty

4.

abnormal looking prepuce, either by circumcision or prepuce reconstruction

Abnormal Ventral Curvature of the Penis and Orthoplasty

Gittes and McLaughlin, writing in 1974, described intraoperative saline inflation of the corpora cavernosa. This guided and ensured successful orthoplasty. This artificial erection test has been refined with Normosol and transglanular needle placement ( Fig. 2.1).

Fig. 2.1.

Artificial erection test described by Gittes and Maclaughlin (1974)

There are two types of chordee associated with hypospadias. The first is the chordee that is occasionally present in patients with distal hypospadias (skin chordee). This superficial chordee is subcutaneous, proximal to the