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.