Double breasting of bladder neck and posterior urethra for continence in isolated peno-pubic epispadias.

OBJECTIVE

The objectives of surgical repair of epispadias include the achievement of urinary continence, cosmetically acceptable genitalia with correction of curvature and normal genital function. To achieve all the aforementioned objectives, patients usually undergo two- or multiple-stage surgeries. Traditionally, the patients undergo epispadias repair in the first stage through modified Cantwell-Ransley or Mitchell-Bagli procedure. Subsequently, in the second stage, bladder neck repair is performed to achieve continence, the most common procedure being modified Young-Dees-Leadbetter. There is no reported single-stage technique of epispadias repair achieving both cosmesis and continence in isolated incontinent epispadias. The objectives of the study were to assess continence and cosmesis with partial penile disassemble and double breasting of bladder neck and posterior urethra in isolated peno-pubic epispadias.

MATERIALS AND METHODS

A retrospective analysis of surgical outcome of seven cases of primary isolated incontinent peno-pubic epispadias repair from July 2008 to July 2012 was carried out. Patients' age varied from 10 months to 16 years. Penile de-gloving is done with mobilization of urethral plate from ventrum to dorsum, distally till mid-glans and proximally up to pubic symphysis with preservation of blood supply at both ends. Partial mobilization of corporal bodies from its attachment and division of peno-pubic ligament are done to lengthen the penis. A mucosal strip of 5-7 mm is excised to denude the mucosa for double breasting. Tubularization of urethral plate with double breasting from the region of bladder neck to posterior urethra is done to increase the outlet resistance and then tubularization of distal urethral plate. Approximation of mobilized pelvic floor muscles is done to complete sphincteroplasty. Spongioplasty along the entire length and corporoplasty with medial rotation of corporeal bodies is done. Glanuloplasty with meatoplasty is done to bring the meatus ventrally and then skin cover to penis is done with rotation of ventral flaps or z plasty.

RESULTS

Preoperatively, three patients (42.8%) had moderate and four (58.2%) had severe chordee. Three (42.8%) of the seven patients had mild torque toward right. Six patients became fully continent and had excellent cosmesis postoperatively, while one was partially continent with a dry interval of 2 h and required anticholinergics. None of the patients developed fistula, stricture, wound dehiscence or necrosis in a follow-up period of 1-5 years; however, one patient had mild residual chordee but did not require any additional surgery.

CONCLUSION

Double breasting of bladder neck and posterior urethra with sphincteroplasty and partial penile disassembly produces a reliable tubularized neourethra with complete chordee correction with emphasis on achievement of continence and near-normal-appearing penile morphology through a single-stage surgery. Mobilization of urethral plate and proximal urethra up to bladder neck helps correction of chordee as well as torsion. Partial penile disassembly keeping the urethra attached to glans maintains the dual blood supply, thus preventing stricture and fistula. This small series is a preliminary study, and more studies at different centers may authenticate it by reproducing the results.