Challenging cases in hypospadias surgery require expertise
Saturday, 29 March 2008 - MILAN - Challenging cases and trouble-shooting procedures in hypospadias were presented in a supplemental symposium in the last day of the 23rd European Association of Urology (EAU) Annual Congress held in Milan, Italy. Dr. Emilio Merlini stressed a specialist surgeon’s ‘dedicated interest’ in hypospadias surgery as occupying a vital role in the success of a difficult procedure.
“Ideally the specialist surgeon should have an annual volume of at least 40-50 cases,” said Merlini (Torino, Italy) in his state-of-the-art lecture on ‘Hypospadiology in 2008.’ He also pointed out that the recommended time for primary repair is at 6 to 15 months when the anesthetic complication risk goes down. He, however, said that when this ideal timing is not possible nor practical, there is another opportunity between 3 to 4 years old.
Merlini also urged specialist surgeons to stick to one procedure and avoid using a variety of procedures in order to prevent surgical disasters. “These procedures have to be done by experts since the learning curve is long and difficult,” he added. Among the commonly encountered complications are fistulas, tissue breakdown, persistent curvature and diverticulum.
He also said that some specialists employ a one-stage repair when the urethral plate does not require transection and when its axial integrity “can be maintained.”
“When the plate is of adequate width and depth, it can be tubularised directly using the second stage of the two-stage repair. When, as it often happens, the urethral plate is not adequately developed and requires augmentation before it can be tubularised, then that second-stage procedure is modified by adding a dorsal releasing incision graft (also called Snodgrass and ‘Snodgraft’ procedures),” Merlini pointed out.
Furthermore, Merlini said that most experts consider the two-stage repair as offering the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. “This procedure combines excellent function and cosmesis with optimum reliability,” he said.
Merlini also cautioned urologists not to be complacent and assume that surgically pleasing results will be maintained into adult life. “It is recommended that active follow-up be maintained through to genital maturity,” he said.
