Department of Urology, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-8555, Japan.
J Pediatr Urol. 2022 Jun;18(3):365.e1-365.e8. doi: 10.1016/j.jpurol.2022.03.013. Epub 2022 Mar 22.
Proximal hypospadias repair is a challenge in the pediatric urology field. Although the previous reports showed that the Belt-Fuqua staged procedure is reliable with a low complication rate for midshaft hypospadias, this procedure has not been generally applied to more proximal hypospadias with severe ventral curvature due to technical limitations. To solve these technical limitations, we developed a modified Belt-Fuqua procedure using an asymmetric long skin sleeve looking like a Japanese long-sleeved Kimono called a "furisode". The aim of this study was to evaluate the outcomes of this new modification of the Belt-Fuqua procedure for the repair of proximal hypospadias with severe curvature in children.
The study retrospectively reviewed consecutive patients with proximal hypospadias with severe curvature underwent this new technique. The major modifications included are proximal degloving beyond the urethral meatus, asymmetrical ventral transposition of dorsal preputial skin like a furisode sleeve, and circumferential proximal anastomosis of preputial skin to native meatus in the first stage. Hypospadias severity was evaluated objectively in two ways: preoperatively by the Glans-Urethral Meatus-Shaft score and intraoperative direct measurement of ventral curvature. The primary outcome was urethroplasty complications.
A total of 66 patients completed both stages of the furisode technique. The median Glans-Urethral Meatus-Shaft score was 11. Overall, 60 (91%) patients showed ventral curvature greater than 60 degrees after degloving, and 35 (53%) underwent ventral grafting with a dermal graft in the first stage. Median urethral length constructed at the second stage was 41.5 mm. The median follow-up period was 25 months. Complications occurred in 9 patients (14%); 7 had urethral diverticula, 1 showed a fistula and 1 had a urethral stricture. Neither glans dehiscence nor meatal stenosis occurred.
There are a couple of advantages of this furisode technique to other tunneled flap techniques like the Ulaanbaatar procedure. The first is the ease of glans reshaping with a Firlit collar at the first stage because of no urethra in the glans. The second is that a long neourethra could be made by the same skin flap with one anastomosis to the native urethra.The weakness of this procedure was that urethral diverticula were prone to occur less than one year after urethroplasty.
The furisode technique, a new modification of the Belt-Fuqua procedure, provides an alternative staged repair of proximal hypospadias. This technique was easily applied for hypospadias with severe curvature requiring ventral grafting.
近端尿道下裂修复是小儿泌尿外科领域的一项挑战。尽管之前的报告显示，Belt-Fuqua 分期手术对于中轴型尿道下裂具有可靠的低并发症率，但由于技术限制，该手术尚未广泛应用于更靠近近端且伴有严重腹侧弯曲的尿道下裂。为了解决这些技术限制，我们开发了一种改良的 Belt-Fuqua 手术，使用类似于日本长袖和服的不对称长皮套，称为“浴衣”。本研究的目的是评估这种新的改良 Belt-Fuqua 手术在修复伴有严重弯曲的近端尿道下裂患儿中的效果。
本研究回顾性分析了 66 例近端尿道下裂伴严重弯曲的连续患者，这些患者接受了这种新技术。主要改良包括：在尿道外口近端进行脱套，不对称地将背侧包皮向腹侧移位，类似于浴衣袖套；在第一阶段，将包皮的近端进行环形吻合至原尿道外口。通过术前的尿道下裂严重程度评分（Glans-Urethral Meatus-Shaft 评分）和术中直接测量腹侧弯曲程度，对尿道下裂严重程度进行客观评估。主要结局为尿道成形术并发症。
66 例患者均完成了浴衣技术的两期手术。术前平均 Glans-Urethral Meatus-Shaft 评分为 11 分。总体而言，60 例（91%）患者在脱套后出现大于 60 度的腹侧弯曲，35 例（53%）患者在第一阶段行腹侧皮片移植。二期手术中构建的尿道长度中位数为 41.5mm。中位随访时间为 25 个月。9 例（14%）患者出现并发症，其中 7 例出现尿道憩室，1 例出现瘘管，1 例出现尿道狭窄。均未出现龟头裂开或尿道外口狭窄。
与 Ulaanbaatar 手术等隧道皮瓣技术相比，这种浴衣技术有几个优点。首先，由于龟头没有尿道，因此在第一阶段使用 Firlit 领可以更容易地重塑龟头形状。其次，通过相同的皮瓣进行吻合，可以形成一个较长的新尿道，与原尿道吻合。该手术的缺点是尿道下裂术后不到一年，尿道憩室容易发生。
改良的 Belt-Fuqua 手术，即浴衣技术，为近端尿道下裂提供了一种替代的分期修复方法。对于需要腹侧皮瓣移植的严重弯曲的尿道下裂，该技术易于应用。
