Comparison of Barcat-Redman Technique with Duckett Technique in the Management of Distal Hypospadias.
Present Address: Department of Urology, Chandka Medical College1, 3, Larkana, Civil Hospital2, Dadu, Department of Pediatric Surgery services Hospital4, Lahore, Department of Urology, Mayo Hospital5, Lahore.
Aims: To compare the efficacy, safety and complication of Barcat-Redman technique with conventional duckett technique in the management of distal hypospadias.
Study type, settings and duration: Prospective study carried out at urology department, services hospital, Lahore from 15th April 1998 to 14th April 2000.
Patients and Methods All Patients with distal hypospadias presenting to the Urology Department Services Hospital, Pediatric Surgery, Services Hospital and Mayo Hospital Lahore were included in the study. !These patients were divided into two groups on alternate basis where Group-A patients underwent Barcat-Redman technique and Group-B Patients underwent Duckett technique for the management of hypospadiasis. Success of both procedures as good, fair and failure were assessed at 3 months follow up.
Results: A total of 60 patients were enrolled, 30 patients underwent Barcat-Redman technique (Group-A) and 30 patients were underwent Duckett technique (Group-B). Ages of the patients ranged from 5 to 25 years with a mean of 11+-5.8 Years. All the patients presented with dystopia of external urethral meatus and chordee (ventral curvature). The subcoronal type of hypospadias was seen in 43(71.7%) patients and distal penile urethral opening 17(28.3%). All patients had distal type of hypospadias associated with chordee. Of the 30 patients in Group-A who underwent Barcat-Redman technique, 21(70%) had good results, 5(16.6%) had fair results and 4(13.6%) were failure. In 30 patients of Group-B that underwent Duckett technique, 19(63.4%) patients had good result, 6(20%) had fair results while, 5(16.6%) were failure. The overall morbidity rate was 36.6% while, hospital stay was 3 days and the difference was statistically insignificant (P=0.860).
Conclusions: It is concluded that probably there will never be an operation for hypospadias that will be uniformly and totally successful, but Barcat-Redman technique is superior to Duckett technique.
Key words: Distal Hypospadias, Barcat-Redman technique, Duckett technique.
Hypospadias was first described by Galen who reported that chordee does not produce infertility but causes difficulty in propelling sperm forward1. Later Pare detailed the nuances of hypospadias and chordee2. Hypospadias surgery was first documented by Heliodorous and Antyllus (100!-200AD) and later by Duckett, when they did the amputation of penile shaft distal to hypospadias meatus3,4. Hypospadias is a congenital malformation of the urethra in which external urethral meatus opens on the ventral surface of the penis and it is associated with absence of distal urethra and corpus spongiosum. This results in incomplete fusion of urethral folds5,6. More than 200 methods of corrective surgery for hypospadias have been described with its complication rate varying between 10-15%4,5. The repair of hypospadias may be either multistaged or single staged7.
In multistaged repair, the tube urethroplasty of Denis Brown is commonly used4,8 where, the chordee is released first (orthroplasty) and urethral reconstruction is one on a second stage after an interval of 6 to 12 weeks. The main disadvantages of multistaged repair are high morbidity, longer exposure to anaesthesia, inconvenience to the patient and improper blood supply of scared skin from previous surgical procedure7,9.
Single stage was popularized nearly 2 decades ago where chordee correction and urethral reconstruction are carried out in the same sitting8. Single stage repair is preferred to multistaged repair because of the advantage of less morbidity, short exposure to anesthesia, good cosmetic results and unscared skin. Chordee can be perfectly released after introduction of an artificial erection technique. The effect of chordee can be mild to severe according to deficiency of structure on ventral aspect of penis on subcoronal and distal penile. Chordee may be categorized as severe at 800, moderate at 400 and mild at 200 angulations with penile shaft. Degree of chordee was assessed by Horton test pre operatively and measured with protector10. Urethroplasty can be performed using penile or preputial skin or a free skin graft, buccal or bladder mucosa. The main object of the hypospadias repair is to provide straight penis with meatus at the tip of the glans and good cosmetic results in single stage11,12.
Redman technique is a modification of Mathieu's procedure in which glans flap is mobilized in addition to parameatal base flap. This technique is applied to a wide range of hypospadias deformity with decreased incidence of fistula formation. Cosmetic and functional results are excellent with only 3.5% patients requiring reoperation6. Another single staged (Duckett technique) requires transverse preputial island flap, tube urethroplasty. It is a modification of the Hodgson III and Asopa procedure and this procedure is limited by the size of inner dorsal hood and can not be used for more severe defects4,8.
Patients and Methods
This Study was conducted from April 1998 to April 2000 in the Departments of Urology and Paediatric Surgery, Services Hospital, Lahore and Mayo Hospital, Lahore. Patients with previous history of surgery for hypospadia, those with proximal penile and posterior hypospadias, micropenis and ambiguous genitalia and those without chordee were excluded. Patients with distal hypospadias were selected and divided into 2 groups on alternate basis. Group-A underwent Barcat-Redman technique and Group-B underwent Duckett technique for the repair. All patients under went complete blood picture along with erytherocyte sedimentation rate, urinalysis & culture, blood urea, serum creatinine, intravenous urogram (if required) and ultrasound of the urinary tract. All procedures were performed under general anesthesia, in supine position. Preoperative antibiotic was given an hour before operation. The procedures were carried out in single stage where orthoplasty and urethroplasty were carried out simultaneously.
In Barcat-Redman technique, stay suture was applied to the glans and tourniquet at the root of penis. Proximal and distal full skin flaps were created in equal length including urethral groove. (Group-A, Barchat-Redman technique (Figure-1)). Fibrous plaque distal to urethral opening responsible for chordee was completely excised, chordee was checked by infiltrating normal saline in carpora. Urethra proximal to hypospadiac opening was extensively mobilized to gain length. Glandular wings were developed by creating a deep cleft in the glans. Ventral and dorsal flaps were sutured using 4/0 vicryl (polyglactin), the urethral extension was laid into the split glans and the meatus was brought to the tip. After that tourniquet was removed and haemostasis was secured. At the end glans wings were closed with skin closure over the tube with 4/0 vicryl which was not removed, urethral stent was left in situ and dressing was changed 48 hours after surgery.
A- Proximal and distal flaps were created that include the urethral groove.
B- Full thickness flaps were taken with a meatal base.
C- Proximal urethra was dissected for several centimeters.
D- Created a deep cleft in the glans.
E- Ventral and dorsal flaps with lateral suture lines.
F- The urethral extension was laid into the glans split and the meatus was brought to the tip. Glans wings were closed with skin closure6.
In Duckett transverse prenuptial island technique, after application of stay suture and tourniquet, a circumferential incision was made around the corona (Figure-2). The inner prenuptial island flap was mobilized away from the prenuptial and penile skin to make a rectangle of shiny skin. Fibrous chordee was completely excised. The pedicle was mobilized down to the base of penis, the pedicle flap was made to make a tube over the stent using 4/0 vicryl suture. An oblique anastomosis was made proximally over a tube with the urethral opening. Bayer's flap was made to resurface the penis using 4/0 vicryl (polyglactin). Glans channel was made through the glans. After that tourniquet was removed, haemostasis was secured and urethral stent was left in situ and dressing was changed 48 hours after surgery.
In both techniques, a feeding tube of 8-12 FR was used as a urethral stent just proximal to the urethral suture line. Another feeding tube of 4-8 FR as drainage tube was passed through the stenting tube into the bladder for the drainage of urine. The drainage tube was removed after 48 hours and stenting tube was retained for 10 days.
A- A circumferential incision was made around corona.
B- The fibrous chordee tissue was excised.
C- The inner preputial island flap was mobilized away from the dorsal preputial and penile skin.
D- The pedicle was mobilized down to the base of the penis.
E- A glans channel was made underneath the skins cap out to the tip of the penis. An oblique anastomosis was made proximally over a tube.
F- Bayers flap was made to resurface the penis and urethral stent was left in13.
All the patients were given pre and postoperative antibiotics for a week and they were examined and discharged from the hospital on third postoperative day if there was no contraindication. They were called on 10th postoperative day for removal of stent and advised to visit out-patient department at the 3rd month after surgery. At each visit, history was taken and systemic and local examinations done for any urethral fistula, rotational deformity, disruption or stricture formation. Success of both procedures was marked as Good = Tube patent with no fistula, Fair = Tube patent with fistula and Failure = Tube disruption.
Comparison between the two techniques was made regarding the management of distal hypospadias in terms of the efficacy, success and occurrence of complication.
A total of 60 patients were included in the study with 30 in each group. Ages of the patients ranged from 5 to 25 years with a mean age of 11+-5.8 years. Forty seven (78.4%) patients belonged to urban areas while, 13(21.6%) were of rural areas. All the patients presented with dystopia of external urethral meatus and chordee (ventral curvature). Thirty (50%) presented with misdirected stream and 3(5%) each with spraying of urine and narrow stream. The subcoronal type of distal hypospadias was present in 43(71.7%) patients while, 17(28.3%) had distal penile urethral opening. Glandular type of hypospadias was not seen. The common anomalies associated with distal hypospadias were not seen. All patients with distal hypospadias had associated chordee, while mild chordee was found in subcoronal type and was noted in 17(28.3%) patients. Moderate chordee was found in distal penile type and was noted in 43(71.7%) patients.
In Group-A, following Barcat-Redman technique, 21(70%) patients had good results and 5(16.6%) fair results while, 4(13.6%) were failures. Four (13.4%) patients developed tube disruption and 5(16.6%) urethral fistula. The overall morbidity rate was 30% while hospital stay was 3 days. In Group-B, following Duckett technique 19(63.4%) patients had good results and 6(20%) had fair results while 5(16.6%) were failures. Five (16.6%) patients developed tube disruption and 6(20%) had urethral fistulae. The overall morbidity rate was 36.6% while hospital stay was 3 days.
Comparing the two techniques, the success rate were 70% in Group-A and 63.4% in Group-B. Similarly the morbidity in Group-A was 30% and in Group-B 36.6% respectively. No significant difference was found between the two techniques.
Hypospadias is one of the commonest congenital anomaly of male urethra whose incidence is 1 in 300 live male births. About 6000 boys are born each year in USA and when one child is affected, the next newborn will have 10-15% more chance of this anomaly3. With a family history of hypospadias there is a 21% chance that a second family member would be affected3.
Above 200 reconstructive procedures for hypospadias have been described4 but despite large number of operative techniques its complication rate is high4,7. The approaches to hypospadias surgery has changed over the decade since the identification of the urethral plate as an anatomical entity and this has simplified this surgery. A few procedures using the same principles allow a single stage repair in all cases. In 1980s where modern principles of surgery were standardized; better, functional and cosmetic results of hypospadias surgery have been observed2,4,9. Though there are many techniques of hypospadias repair but not all are practiced. The main steps for successful hypospadias surgery are correction of penile chordee, reconstruction of missing urethra (urethroplasty), covering of penis and fashioning of the slit shaped urethral meatus5,8.
In the present study all patients had a single stage procedure along with chordee correction. Besides the desirability of completing the reconstruction in one operation, the single stage procedure has the additional advantage of using skin that is unscared from previous surgical procedures and the normal blood supply of which has not been disrupted4.
The hypospadias repair is recommended to be performed between 6-9 months or in older children at the time of referral7,14. The ages of the patients in the present study were between 5-25 years, where as Elder et al had age range from 7-27 years and Hendren et al of 9 months to 22 years. In the present study many patients came in adult age for infertility due to hypospadias. The delay in the treatment is usually because of fear of surgery, embarrassment and ignorance. Referral due to painful erection, penile pain during intercourse or inability to penetrate the vagina have also been reported15,16.
In our study subcoronal type of distal hypospadias was commonly seen (71.6%). Welch reported 62% openings as subcoronal or penile while 20% were at the penoscrotal angle and 16% were in the scrotum or perineum13,15. In the present study all patients had distal type of hypospadias associated with chordee.; mild chordee was noted in 28.3% and moderate in 71.7% patients. The recurrence of chordee was not seen at follow up on 3rd month after surgery. Flynn17 and Belman3 reported that delayed recurrent penile chordee was associated with growth of phallus at adult age. In addition to the delay in the onset of chordee, a lag time existed between the age at which chordee developed and the age at which patient presented for evaluation. During follow up after an evaluation of patients from 1986-1997, chordee reoccurred 10 years after successful hypospadias and chordee repair, and this may be secondary to the redevelopment of corporal disproportion and extensive urethral fibrosis6,16.
The Barcat-Redman technique is a modification of Mathieu procedure in which glans flap is mobilized in addition to parameatal base flap. This technique has been applied to a wide range of hypospadias deformities with decreased incidence of fistula formation. Cosmetic and functional results are excellent with only 3.5% of the patients requiring reoperation because surgical technique does not depend on the configuration of glans, depth of the urethral grooves, caliber of the urethral meatus and circumcision6,11. The technique allows anatomical superior glans reconstruction in distal hypospadias repair. The fistula rate can be reduced by tissue coverage of the neourethra1,18. The Duckett technique requires transverse preputial island flap tube urethroplasty described by Duckett as a modification of Hodgson-III and Asopa procedure.
It has a justifiable popularity in the management of distal hypospadias, but this procedure is limited by the size of the inner dorsal hood and can not be used for more severe defects,19.
The single stage surgery got popularity nearly 2 decades ago with simultaneous introduction of the techniques of devine and Horton8. In this single stage repair, the chordee correction and urethral reconstruction is carried out in same sitting. Single stage is preferred to multi staged repair because of the advantage of less morbidity, short exposure to anaesthesia, good cosmetic results and unscared skin8,20. In the present study the overall success rate in Group-A and Group-B was 70% and 63.4% respectively and the difference was statistically insignificant but other studies showed 96.5% and 85% success rate respectively21 which are much better than ours.
The failure rate in the present study in Group-A was 30% out of which 13.4% had complete disruption of tube while, 16.6% developed urinary fistulae. Another study showed 3.5% re-operation while, 5.0% developed urinary fistula6,20. The high failure in our study was probably due to postoperative infection and the learning curve of experience. Failure rate in Group-B was 36.6% out of which 16.6% had complete disruption of tube while 20% developed urinary fistulae. Another study showed 10-15% secondary surgery rate while 20% developed urinary fistulae again showing high failure in our study. Other cause of failure could be a glans channel which compresses the pedicle, hence Duckett transverse preputial island flap technique now a days is less practiced than it was done in the past4,19.
The important factors which are responsible for success are use of vascularized tissue, careful tissue handling, non overlaping suture lines, meticulous haemostasis, tension free anastomosis and fine suturing materials and instruments14,21.
In the present study failure rate was high in both the techniques but success rate was high in Barcat-Redman technique as compared to Duckett technique.
1. Barthold JS, Teer TL, Redman JF. Modified Barcat balanic groove technique for hypspadias repair: Experience with 295 cases.J Urol 1996; 155: 1735-7.
2. Glazier DB, Zaontz MR. the history of hypospadias. J Urol 1990; 159: 133.
3. Belman AB. Hypospadias update. J Urology 1997; 49: 166-72.
4. Duckett JW. Hypospadias. In: Petric.. Campbells urology. 7th ed. Philadelphia: W.B Saunders; 1998. 2093-2116.
5. Goepel M, Otto T, Gropft D, Rubben H. Recent considerations for hypospadias repair, results of 252 operations from 1985 to 1990. J Urol 1996; 29: 63-6.
6. Koff SA, Brinkman J, Ulrich J, Deigtton D. Extensive Mobilization of the urethral plate and urethra for repair of hypospadias. The modified Barcat technique. J Urol 1994; 151: 466-9.
7. Hurwitz RS, Ozersky D, Kaplan HJ. Chordee without hypospadias: complication and management of the hypoplastic urethra. B J Urol 1987; 138: 372-5.
8. Hendren WH, Horton CE. Experience with I-stage repair of hypospadias and chordee using free graft of prepuce. J Urol 1988; 140: 1259-64.
9. Elder JS, Dukett JW, Synder HN. Onlay Island flap in the repair of mid and distal penile hypospadias without chordee. J Urol 1987; 138:376-9.
10. Perovic SV, Djordjevic ML, Djakovic NG. A new approach to the treatment of penile curvature. J Urol. 1998 Sep;160(3 Pt 2):1123-7.
11. Rees MJW, Sinclair SW, Hiles RW, Smith PJB. A 10 Year prospective study of hypospadias repair at Frenchay Hospital. Br J Urol 1981; 53: 637-40.
12. Kaplan GW. Repair of proximal hypospadias using a perputial free graft for neourthral construction and a preputial pedicle flap fro ventral skin converage. J Urology 1988; 140: 1270-72.
13. Kodama R, Wisslow BH. Hypospadias. In: Marshall FF editor. Operative urology. WB Saunders Company Philadelphia, 1991; 519.
14. Kay R. Hypospadias. In: Resnic MI, Novic AC. Urology secret, 1st ed. Jaypee Brothers, New Delhi India. J Urology, 1995; 48: 158-60.
15. Jurkiewicz MJ, Krizec TJ, Ariyan S. Reconstruction of genitalia. In change KN and Mathes S. Plastic Surgery principles and practice. Landon: Churchill Livingstone Publishers; 1990: 2: 1255-80.
16. Vandersteen DR, Husmann DA. Late onset recurrent penile chordee after successful correction at hypospadias repair. J Urology 1998; 160: 1131-3.
17. Flynn JT, Johnston SR, Blandy JP. Late sequelae of hypospadias repair. Br J Urol 1980; 52: 555-9.
18. Hayashi Y, Kojima Y. Current concepts in hypospadias surgery. Int J Urol 2008;15:651-64.
19. Ratan SK, Ratan J, Rattan KN. Is tubularization of the mobilized urethral plate a better alternative to tubularization of an incised urethral plate for hypospadias repair? Pediatric Surgery Int 2009;25:185-90.
20. Djakovic N, Nyarangi-Dix J, Ozturk A, Hohenfellner M. Hypospadias. Adv Urol. 2008: 650(135).
21. Mouriquand PDE, Persad R, Sahrma S. Hypospadias repair: Current Principles and Procedure. Br J Uro11995; 76: 9-22.
Department of Urology, Service Hospital1, 2 ,4,5, Lahore, Department of Urology, Mayo Hospital3, Lahore.
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|Publication:||Pakistan Journal of Medical Research|
|Article Type:||Clinical report|
|Date:||Mar 31, 2011|
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