The term complex hypospadias is used as the equivalent of the English word crippled (crippled) hypospadias. In general, complex hypospadias is used to describe non-standard hypospadias cases with unacceptable dysfunction and appearance after one or more unsuccessful operations due to hypospadias, which are much more difficult to repair than the initial state, and who do not have enough tissue for repair because they have been depleted beforehand. These cases are usually seen after severe (proximal) hypospadias repairs. However, repeated unsuccessful attempts of complications after distal hypospadias repairs may lead to similar situations.
Evaluation of the result obtained after hypospadias repair differently by different people, unfortunately, also causes differences of opinion on complex hypospadias cases. The sole purpose of hypospadias repair is to carry the meat to the glans end, which may condemn the patient to live with a scarred, asymmetrical, recessed-protruding penis with suture tunnels in the skin, scattering and urination, and residual cord in erection. However, many surgeons will consider this penis a complex hypospadias.
Parents often do not understand the situation adequately. Problems usually occur during puberty and after having a sexual life. Psychological and physiological functions may be adversely affected. Unfortunately, at that time, the patient was no longer a child, and most of the physicians to whom he would consult for a remedy did not have sufficient experience in treating such complications at this age. In recent years, special centers have been established in some countries that deal with complications in adult patients who have undergone hypospadias repair in childhood. The reports of these centers are remarkable and serve as a warning to physicians dealing with pediatric surgery.
Problems seen in complex hypospadias cases
Asymmetrical glans and penile body skin
Irregular, bad scars, suture marks, suture tunnels on glans and penile body
Variegated , non-uniform skin color and elasticity
Contraction, stretching and dimples due to subcutaneous adhesions
Mea not in its normal location and not in the form of a cleft
Excess skin in different parts of the penis
Hair growth on the skin of the penis body
Urethral strictures
Urethra diverticulum (megalourethra, urethrocele)
Urethra openings
Fistulas in the urethra
Hair growth in the urethra, stone formation
Prolapse of the urethra
Balanitis xerotica obliterans (BXO)
Residual cordia (more than 30 degrees)
Penis trunk Torsion (rotation) in the hip (more than 30 degrees)
Lateral curvature (curvature to the right or left) of the penis body
Inadequacy of the penile body skin (prevents the penis from reaching sufficient length during erection, causes painful erection) )
Shortening of the penis due to dense ventral scar tissue
Loss of sensation in the penis
Intensive scarring as a result of secondary healing due to skin necrosis
Partial loss of one or both cavernous bodies
Glans loss, atrophy, reduction in size
REASONS FOR COMPLEX HYPOSPADIA
Surgical errors come first. Surgeon’s inexperience, lack of knowledge, carelessness and underestimation of the phenomenon are the causes of errors. One of the biggest mistakes that a surgeon who has failed the first repair will make is to try to lighten the situation to the patient’s family. The family easily believes this and their reactions are suppressed. However, if the surgeon convinces himself of this, he may refrain from doing some of the procedures that he should do in the second surgery in order not to escalate the situation. Many of the recurring complications arise for this reason. For example, a common mistake is 1-2 mm at the coronal level. It is to suture a large urethral fistula with a small circumferential incision without bringing healthy tissue over it, without examining the cause of its formation. Sometimes, the diameter of a small-looking fistula may increase several times that of the original when the tract is excised at the same level and dissected until it reaches the normal urethral wall. The healing of the wound lips, which are approached with sutures, depends on the adequate nutrition. With thin-walled, scarred, over-tightened sutures, wound lips with impaired circulation cannot heal, and recurrence of the fistula is inevitable. Trying to support a repair made without paying attention to these basic principles with surrounding tissues reduces the risk of recurrence, but it does not eliminate it. If the subsequent attempts of this failed fistula repair are done in a similar way, the diameter of the urethra will gradually become thinner and urethral stenosis will occur in addition to the fistula. Now, the urethra needs to be brought to normal diameter with additional tissue for repair. If the entire foreskin was removed in the first operation, the dimensions of the procedure may progress to the removal of an oral mucosal graft, and in such a case, a complex hypospadias will need to be mentioned.
TREATMENT PRINCIPLES IN COMPLEX HYPOSPADIAS CASE
The aim is to obtain a normal penis as much as possible. Since these patients are non-standard, the standard maneuvers and techniques used in hypospadias surgery may be insufficient. Because the tissues are scarred, have lost their elasticity and are mostly insufficient. Unexpected situations may always occur during the surgery of these cases and the surgeon may have difficulty in making a decision. In a patient presenting with only a fistula complaint, serious problems such as urethral stricture, residual chordee, and hair growth in the urethra due to the use of a scrotal flap may be noticed by the surgeon. Closing the fistula without touching these will cause the patient to come back with other complaints in the future. In these patients, only fistula closure is usually unsuccessful. In such a case, the family should be informed that the repair required for the patient is larger than their expectation.
In complex hypospadias cases, chordee may be inadequately corrected in the first operation, or it may be due to extensive fibrosis developed later. If there is a ventral cord that needs correction (greater than 30 degrees) in the initial erection test, the skin must first be degloving up to the scrotum. During this procedure, excessive thinning of the skin covering the penis should be avoided. If chordee does not improve with excision of the scars around the newly opened urethra as a result of the complication, the condition of the urethral plate should be re-evaluated and a decision should be made between preservation or excision. Because if there is a chance to improve the cord by performing dorsal plication, the urethral plate may be preserved. A TIP incision can also be made to increase the diameter if necessary prior to this tubularization, but this should not be attempted more than twice (redo TIP).
In some patients, the ventral skin is not suitable for re-urethra. In addition, due to the chordee, the body of the penis may need to be released. In this case, the ventral useless tissues are cleaned up to the corpuscles. If the chordate is still not healed when the corpus is reached, transverse incisions (1-3 corporotomy ventrally between 3 and 9 o’clock in length) can be made. In this method, which we have applied more frequently in recent years, the incisions are superficial and corporal grafts are not required in the cut areas. After this, complete correction of the cord is usually achieved with dorsal midline plication. In this way, after the chordee is corrected, a graft is placed over the corpuscles and a new urethra is created 6 months later. Foreskin, if any, or oral mucosa is the most suitable option for this graft. It is not recommended to immediately tubularize the graft in the first attempt to complete the surgery in a single session. This practice reduces the chance of graft retention. Covering the urethra with cancellous tissue, if any, may reduce the complications of fistula and opening the urethra. It has been suggested that if a good spongioplasty is performed in the repair of distal hypospadias, there is no need for additional dartos-like support flaps.
Surgical interventions that can be used in complex hypospadias cases are maneuvers and techniques that are generally used in primary repairs, applied similarly or sometimes slightly differently.
