HYPOSPADIAS ALTERNATIVE PROCEDURE - MODIFIEDABRAMOVIC TECHNIQUE

Hyseni Nexhmi1, Abramovic V 2, Llullaku S 1

1.University Clinical Center, Department ofPediatric Surgery,

Prishtina, UNMIK- Kosova. 2. Department of Urology, Institute for Motherand Child Health in Zagreb, Croatia.

Abstract

We modified Abramovic preputial tube-plasty intwo stage repair. This technique enablesreconstruction of the urethra with a sufficientlylarge, well-vascularized, non-hair-bearingpreputial skin. The new urethra is long and largeenough, and grows along with the penis, avoidingsecundary curvature. We currently use a modifiedform of the procedure first proposed by Abramovicwith excellent results in comparisons to othermethods for correction of medial penile, proximalpenile, and penoscrotal types of hypospadias.First stage of our procedure is the formation ofa transverse preputial tube. Mobilisation andformation of even a long tube, is transposedwithout tension on the ventral surface of thepenis and sutured under the meatus. After threemonths, revascularization of the proximal pedicleis complete and, in the second stage, the distalpedicle can be severed and relocated. The entirepedicle flap is sutured with two parallel rows ofsutures as far as the apex of the glans. 57 casesin which the meatus is situated in the proximal

half of the penis, penoscrotal border or perineumhave been treated with a original (35 cases) andmodified (22 cases) Abramovic technique in thelast 14 years. Complication was postoperativefistula formation in 8 patients (14%), meatalstricture in 2 patients (3.50%), and dehiscenceof preputial pedicle flap insertion below thehypospadic meatus in 4 patients (7%). Weadvocated the two stage preputial pedicle flapprocedure as an alternative to the three stageoriginal Abramovic operative procedure.

Aims

The principal objectives are to achieve thefollowing: We have succeeded in reducing the steps of the

operative technique- from three stage in twostage repair.

The preputial flap procedure ( modification ofthe Abramovic method) is the most successfultechnique for the treatment of severe forms ofhypospadias

Introduction

The operative correction of hypospadias is acomplex problem. Reconstruction of the urethracan be done in one or more stages using one of

the three general available approaches: methodsutilizing free skin flaps, 3, 5, 9 methodsutilizing skin from the ventral surface 17 ormethods utilizing preputial pedicle flaps 1, 6, 7, 10,

13, 20, 21 and substitution urethroplasty with bladeror buccal mucosal free graft. 15, 16, 18, 19

Dorsal preputial skin is exellent material inthe vicinity of the urethral defect for thetransplantation and reconstruction of theaplastic urethra. 4,6,8 The use of dorsalpreputial skin for this procedure has thefollwing advantages:

1.The large dorsal prepuce in hypospadias,combined with lateral and ventral aplasia,gives the penis a bizarre appearance. Itsreduction is therefore indicated for aestheticreasons.

2.The skin of the prepuce is not hair-bearing. It is tender and elastic, and, especially on

its inner surface, has a very thin stratumcorneum.

3.Most important, the blood supply of the prepuceis exellent and allows the formation of arelatively long tube with a very narrowpedicle. This facilitates the transposition ofthe tube onto the ventral surface of the peniswith exact placement under the meatus.

Matherials & Methods

57 cases in the last 14 years, we have beentreated with a original three stage (35 cases)and, modified in two stage repair (22 cases)Abramovic preputial tube-plasty.

OPERATIVE TECHNIQUE

First stage

First stage of our procedure is the formationof a transverse preputial tube, wich is donesimultaneously with elongation, chordectomy,and meatotomy, if necessary.

In the same stage, the abnormal skin at thepenile base which pulls the penis toward thescrotum is corrected using multiple Z-plasty.

Since the length of the tube is determined bythe size of the defect, care must be taken toassure sufficient width at the base of thepedicle.

The width should be directly proportional tothe length.

Both lateral pedicles should have the samewidth as the pedicle flap (about 5 mm ).

The preputial skin edges are sutured. One of the pedicles is severed and is

transposed without tension on the ventralsurface of the penis and sutured three to fourmillimeters below the meatus, an ellipticalsection of skin, which corresponds to the crosssection of the pedicle flap, is excised.

To prevent empty space between the pediclespace and its insertion point, a suture ispassed through the subcutaneus tissue of the

pedicle flap and the middle of the skinincision.

The interval between the two operative stagemust be at least 3 to 6 month.

Seconde stage

In the second stage of the preputial pedicleflap procedure, the remaining distal pedicle issevered.

The incision lines are made to form theneourethra should be 5 to 6 mm apart from eachother and should converge slightly at the apexof the glans and the end of the pedicle flap.

Step - by - step closure of the urethra withinterrupted sutures of 6.0, 7.0 absorbablesurgical suture-Safil or vycril.

A thin, plastic, 8 French catheter is fixedwith a thin suture through the glans. Catheterdrainage is maintained for seven days.

The two stage preputial pedicle flap procedureas an alternative to the three stage originalAbramovic operative procedure is illustrated infigures 1 through 2.

Figure 1. First stage of the preputial pedicle flap procedure

Figure 2. Second stage of the preputial pedicle flap procedure

Results

57 cases in which the meatus is eitheroriginally, or after elongation andchordectomy, situated in the proximal half ofthe penis, penoscrotal border, scrotal sulcus,or perineum, have been treated with a Abramovictechnique (35 cases) and our modified technique(22 cases).

Table 1. summarizes our series of patients,type of operations and postoperativecomplications.

Complications was postoperative fistulaformation in 8 patients (14%), meatal stricturein 2 patients (3.50%) and, dehiscence ofpedicle flap insertion in 4 patients (7%).

Table 1. Incidence of complications related totype of operation

Type ofoperation

Number ofpatients

Postoperativefistula

N0.%

Meatalstricture

N0.%

Dehiscence ofpedicle flap

insertion

N0.%

Abramovicoperativeprocedure

Alternativeprocedure-modified

35

22

514.28

313.63

12.85

14.54

47

--

Total

57

814

23.50

47

Discussion & Conclusions

Pedicle tube procedures can be performed in one stage 2, 3, 4, 5, 6, 7, 8, 12, 20 or multistaget repair.1, 10, 11, 13, 14, 21

The author has persisted with his two-stage repair, as an alternative to the three stage original Abramovic operative procedure, for virtually all types of hypospadias, as being conistently reliable with a low complication rate. The aesthetic results is exellent. These aesthetic corrections are very important tohypospadic patients, because the altered form of the penis can have a negative psychological influence on their sexual life.

On the other hand, we currently use a modifiedform of the procedure first proposed by Abramovicwith succeeded in reducing the operativeprocedure and, in reducing the incidence ofpostoperative fistulas, which occur in about18.8% per cent in Abramovic series,1 to only 14 %in our series. The incidence of post-operativefistulas is low, and secondary closure is simpleand safe. At the latest control the meatus wasadequate in the majority of cases 52 (91.22%). However our experience is still short we have

found that the preputial pedicle flap procedure( modification of the Abramovic method) issimple to undestand, the surgery are easier toperform and, is the most successful techniquefor traetment of severe forms of hypospadias.

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