Discussion
The patient’s repaired of proximal hypospadias surgery was extremely challenging, because of having many surgical complications. At present, the more popular stage I surgery is: the urethral plate is cut off to straighten the penis to correct the curvature of the penis, and the urethra is formed by the cross-cutting island-shaped foreskin flap[7]. Other modern techniques include: Thierch-Duplay , Onlay , and stage II surgery[8; 9]. In 1975, Reddy first described the urethral plate incision and tube urethroplasty[10]. In 1994, Snodgrass et al. Popularization, but recent long-term follow-up studies have shown that: for proximal hypospadias, most children have functional urinary flow obstruction and decreased urinary flow rate after the operation[11]. Since most children with proximal hypospadias have severe penile curvature, the fibrous tissue of the urethral plate needs to be removed for correction. Therefore, the urethral plate preservation surgery (Thierch-Duplay, Onlay, urethral plate incision and roll tube urethroplasty) It is not an ideal surgical method. Stage I urethroplasty with continuous sealed Y skin flap of penis and scrotum can sharply peel off the urethral plate, remove the fiber cord, completely straighten the penis, and enable stage I urethroplasty.
Since 2000, more in-depth research has been conducted on both sides of the base of the urethral orifice and the inner foreskin flap on the back for repairing proximal hypospadias. Stage I urethroplasty with continuous sealed Y skin flap of penis and scrotum is a simple technique. It has six advantages. Firstly, the material of the new urethral flap is sufficient. The new urethroplasty flap used in this operation is continuous from the urethral opening to the dorsal foreskin inner plate. The length of the flap is exactly the distance from the ectopic urethral orifice to the tip of the penis. Do not measure the length of the flap. Secondly, preserve the original natural anatomical structure. It is currently believed that the urethral plate is a natural urethroplasty structure of hypospadias , and the inner plate of the foreskin and the urethra come from the same germ layer during embryonic development . Utilizing the inner foreskin and urethral plates on both sides of the urethra orifice as the new urethroplasty material, it is most in line with the natural physiological anatomy of hypospadias; at the same time, the original axial blood supply of the entire skin flap of the new urethra is almost unchanged, which is conducive to wound healing and surgery. After the complications are repaired again, the success rate of the reoperation in this group is higher; Thirdly , make the bilateral scrotum suture to eliminate the scrotal division and translocation. Fourthly, There is no anastomosis in the new urethra. The joint of the original urethral orifice of the operation is formed by a rolled tube urethral plate. There is no need for circular anastomosis, which can significantly reduce complications such as anastomotic stenosis; Fifthly, the success rate is high. Preserve the blood supply of the distal foreskin, so that the flaps will not be too long and poor blood supply, especially with the scrotum or testicular tunica on both sides of the scrotum to cover the ventral side of the formed urethra to increase the level of tissue and avoid sutures Overlap, significantly reduce the occurrence of complications such as urinary fistula. Sixth, the surgical technique is not demanding, easy to master, good postoperative appearance, smooth urine. In this group, 93.3% of the external genitalia were satisfied with the appearance, and the obstructive urinary flow curve was only 12.5%. It has two disadvantages. Firstly,There is a suture opening on the dorsal and ventral sides of the urethra, which need to be sutured carefully, and the thread knot in the urethra when sutured on the dorsal side, the thread should not be too long. The author generally keeps 1-1.5mm, and the absorption time of the absorbable thread should be within With in one month, otherwise the thread knot is too long and urinary is not smooth, some of the thread knot urinary scale will condense and urethral stones will appear. Secondly, The operation is not complicated, but requires skilled operation skills
The indications for surgery are: applicable to any severe proximal hypospadias, especially hypospadias accompanied by scrotal division and penile-scrotal translocation.
Intraoperative precautions: (1) The urethroplasty flap is a fascial flap pedicled at the urethral opening, and the blood supply of the flap must be protected; (2) When the new urethral flap is formed in a tubular shape, the thread knots outside, no tension, and the shape is formed Do not leak urine afterwards. (3) The anastomosis between the new urethral skin tube and the head of the penis is close to the ventral side, the new urethral opening will no longer be on the same side, and there will be no urethral stenosis. In short, the I-stage urethroplasty with continuous Y skin flap of penis and scrotum makes full use of and rarely destroys the natural anatomical and physiological structure of the original hypospadias. It is an ideal surgical method for proximal hypospadias.