editorial comment

1
and functional results using this technique have been satis- factory. Recently we switched to the Koyanagi procedure with en- couraging early results. The initial report in 1984 described a parameatal based preputial flap for the correction of proxi- mal hypospadias, 8 which was a modification of the previously described 1-stage technique. 9 Initial series treated with the Koyanagi repair had high complication rates. Glassberg et al reported a complication rate of 50% in 14 boys, 10 and the largest and most recent series presented by Koyanagi et al of 70 patients had a complication rate of 47%. 11 However, more recent series treated with a modification of this technique have had lower complication rates of 17% to 20%. 12, 13 The higher success rate is believed to reflect preservation of the lateral blood supply to the skin flaps and not to rely entirely on the microvasculature emanating from the region of the urethral meatus and its surrounding corpus spongiosum. 12 The timing of the repair of a penoscrotal transposition accompanied by proximal hypospadias is another area of controversy. Mobilization of the scrotal flaps was thought to potentially compromise the vasculature to the dorsal penile skin and pedicle tube graft. 10 Pinke et al suggested staging the urethroplasty and correction of the transposition due to a 70% overall complication rate. 14 Our experience indicates that combining the procedure does not lead to an unaccept- ably high complication rate. Further experience with the modified Koyanagi technique that bases the urethral blood supply on parameatal skin flaps rather than a dorsal prepu- tial tube graft may lead to a lower incidence of complications. CONCLUSIONS We believe that a single staged repair can be safely and effectively performed even in patients with the most severe proximal hypospadias accompanied by penoscrotal transpo- sition and/or bifid scrotum. The Hodgson XX and Koyanagi repairs are excellent techniques with relatively low compli- cation rates in more recent series. Pediatric urologists should continue to use these techniques in their hypospadias arma- mentarium and strive to perfect a single stage approach to severe hypospadias. REFERENCES 1. Bracka, A.: Hypospadias repair: the two-stage alternative. Br J Urol, suppl., 76: 31, 1995 2. Greenfield, S. P., Sadler, B. T. and Wan, J.: Two-stage repair for severe hypospadias. J Urol, 152: 498, 1994 3. Glenn, J. F. and Anderson, E. E.: Surgical correction of incom- plete penoscrotal transposition. J Urol, 110: 603, 1973 4. Ehrlich, R. M. and Scardino, P. T.: Surgical correction of scrotal transposition and perineal hypospadias. J Pediatr Surg, 17: 175, 1982 5. Retik, A. B., Bauer, S. B., Mandell, J., Peters, C. A., Colodny, A. and Atala, A.: Management of severe hypospadias with a 2-stage repair. J Urol, 152: 749, 1994 6. Wacksman, J.: Use of the Hodgson XX (modified Asopa) proce- dure to correct hypospadias with chordee: surgical technique and results. J Urol, 136: 1264, 1986 7. Ellsworth, P. I., Barraza, M. A. and Stevens, P. S.: Modified ASOPA procedure (Hodgson XX) achieves the goals of hypos- padias repair. J Pediatr Surg, 31: 917, 1996 8. Koyanagi, T., Nonomura, K., Gotoh, T., Nakanishi, S. and Kakizaki, H.: One-stage repair of perineal hypospadias and scrotal transposition. Eur Urol, 10: 364, 1984 9. Koyanagi, T., Matsuno, T., Nonomura, K. and Sakakibara, N.: Complete repair of severe penoscrotal hypospadias in 1 stage: experience with urethral mobilization, wing flap-flipping ure- throplasty and “glanulomeatoplasty.” J Urol, 130: 1150, 1983 10. Glassberg, K. I., Hansbrough, F. and Horowitz, M.: The Koyanagi-Nonomura 1-stage bucket repair of severe hypospa- dias with and without penoscrotal transposition. J Urol, 160: 1104, 1998 11. Koyanagi, T., Nonomura, K., Yamashita, T., Kanagawa, K. and Kakizaki, H.: One-stage repair of hypospadias: is there no simple method universally applicable to all types of hypospa- dias? J Urol, 152: 1232, 1994 12. Emir, H., Jayanthi, V. R., Nitahara, K., Danismend, N. and Koff, S. A.: Modification of the Koyanagi technique for the single stage repair of proximal hypospadias. J Urol, 164: 973, 2000 13. Sugita, Y., Tanikaze, S., Yoshino, K. and Yamamichi, F.: Severe hypospadias repair with meatal based paracoronal skin flap: the modified Koyanagi repair. J Urol, 166: 1051, 2001 14. Pinke, L. A., Rathbun, S. R., Husmann, D. A. and Kramer, S. A.: Penoscrotal transposition: review of 53 patients. J Urol, 166: 1865, 2001 EDITORIAL COMMENT This report challenges the prevalent majority opinion among ex- perienced pediatric urologists who favor a 2-stage procedure in these severe cases of hypospadias with penoscrotal transposition. The fact that these authors have switched to the Koyanagi procedure despite their claim of good success with the Hodgson XX operation is reveal- ing. Although they did achieve an excellent result in the last 3 patients using the Koyanagi procedure, Koyanagi himself in a much larger series of 70 patients had a 47% complication rate (reference 11 in article). Despite this critical commentary, I would like to take this oppor- tunity to congratulate these authors on their success and would encourage other young innovative pediatric urologists to continue their work in pursuit of a single stage procedure that would achieve predictable functional and cosmetic results in these unfortunate children. A published report such as this will encourage further research in this direction. Selwyn B. Levitt Division of Pediatric Urology Schneider Children’s Hospital Long Island Jewish and Northshore Medical Center and Westchester Medical Center New York, New York Complications of single staged repairs for proximal hypospadias References Technique No. Pts Mos Followup % Complications Wacksman 6 Hodgson XX 37 11 Koyanagi et al 11 Koyanagi 70 47 Ellsworth et al 7 Hodgson XX 12 26 25 Glassberg et al 10 Koyanagi 14 50 Emir et al 12 Modified Koyanagi 20 34 20 Sugita et al 13 Modified Koyanagi 151 72 17 Present series Hodgson/Koyanagi 20 23 20 HYPOSPADIAS WITH BIFID SCROTUM OR PENSCROTAL TRANSPOSITION 1588

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and functional results using this technique have been satis-factory.

Recently we switched to the Koyanagi procedure with en-couraging early results. The initial report in 1984 described aparameatal based preputial flap for the correction of proxi-mal hypospadias,8 which was a modification of the previouslydescribed 1-stage technique.9 Initial series treated with theKoyanagi repair had high complication rates. Glassberg et alreported a complication rate of 50% in 14 boys,10 and thelargest and most recent series presented by Koyanagi et al of70 patients had a complication rate of 47%.11 However, morerecent series treated with a modification of this techniquehave had lower complication rates of 17% to 20%.12, 13 Thehigher success rate is believed to reflect preservation of thelateral blood supply to the skin flaps and not to rely entirelyon the microvasculature emanating from the region of theurethral meatus and its surrounding corpus spongiosum.12

The timing of the repair of a penoscrotal transpositionaccompanied by proximal hypospadias is another area ofcontroversy. Mobilization of the scrotal flaps was thought topotentially compromise the vasculature to the dorsal penileskin and pedicle tube graft.10 Pinke et al suggested stagingthe urethroplasty and correction of the transposition due to a70% overall complication rate.14 Our experience indicatesthat combining the procedure does not lead to an unaccept-ably high complication rate. Further experience with themodified Koyanagi technique that bases the urethral bloodsupply on parameatal skin flaps rather than a dorsal prepu-tial tube graft may lead to a lower incidence of complications.

CONCLUSIONS

We believe that a single staged repair can be safely andeffectively performed even in patients with the most severeproximal hypospadias accompanied by penoscrotal transpo-sition and/or bifid scrotum. The Hodgson XX and Koyanagirepairs are excellent techniques with relatively low compli-cation rates in more recent series. Pediatric urologists shouldcontinue to use these techniques in their hypospadias arma-mentarium and strive to perfect a single stage approach tosevere hypospadias.

REFERENCES

1. Bracka, A.: Hypospadias repair: the two-stage alternative. Br JUrol, suppl., 76: 31, 1995

2. Greenfield, S. P., Sadler, B. T. and Wan, J.: Two-stage repair forsevere hypospadias. J Urol, 152: 498, 1994

3. Glenn, J. F. and Anderson, E. E.: Surgical correction of incom-plete penoscrotal transposition. J Urol, 110: 603, 1973

4. Ehrlich, R. M. and Scardino, P. T.: Surgical correction of scrotaltransposition and perineal hypospadias. J Pediatr Surg, 17:175, 1982

5. Retik, A. B., Bauer, S. B., Mandell, J., Peters, C. A., Colodny, A.and Atala, A.: Management of severe hypospadias with a2-stage repair. J Urol, 152: 749, 1994

6. Wacksman, J.: Use of the Hodgson XX (modified Asopa) proce-dure to correct hypospadias with chordee: surgical techniqueand results. J Urol, 136: 1264, 1986

7. Ellsworth, P. I., Barraza, M. A. and Stevens, P. S.: ModifiedASOPA procedure (Hodgson XX) achieves the goals of hypos-padias repair. J Pediatr Surg, 31: 917, 1996

8. Koyanagi, T., Nonomura, K., Gotoh, T., Nakanishi, S. andKakizaki, H.: One-stage repair of perineal hypospadias andscrotal transposition. Eur Urol, 10: 364, 1984

9. Koyanagi, T., Matsuno, T., Nonomura, K. and Sakakibara, N.:Complete repair of severe penoscrotal hypospadias in 1 stage:experience with urethral mobilization, wing flap-flipping ure-throplasty and “glanulomeatoplasty.” J Urol, 130: 1150, 1983

10. Glassberg, K. I., Hansbrough, F. and Horowitz, M.: TheKoyanagi-Nonomura 1-stage bucket repair of severe hypospa-dias with and without penoscrotal transposition. J Urol, 160:1104, 1998

11. Koyanagi, T., Nonomura, K., Yamashita, T., Kanagawa, K. andKakizaki, H.: One-stage repair of hypospadias: is there nosimple method universally applicable to all types of hypospa-dias? J Urol, 152: 1232, 1994

12. Emir, H., Jayanthi, V. R., Nitahara, K., Danismend, N. and Koff,S. A.: Modification of the Koyanagi technique for the singlestage repair of proximal hypospadias. J Urol, 164: 973, 2000

13. Sugita, Y., Tanikaze, S., Yoshino, K. and Yamamichi, F.: Severehypospadias repair with meatal based paracoronal skin flap:the modified Koyanagi repair. J Urol, 166: 1051, 2001

14. Pinke, L. A., Rathbun, S. R., Husmann, D. A. and Kramer, S. A.:Penoscrotal transposition: review of 53 patients. J Urol, 166:1865, 2001

EDITORIAL COMMENT

This report challenges the prevalent majority opinion among ex-perienced pediatric urologists who favor a 2-stage procedure in thesesevere cases of hypospadias with penoscrotal transposition. The factthat these authors have switched to the Koyanagi procedure despitetheir claim of good success with the Hodgson XX operation is reveal-ing. Although they did achieve an excellent result in the last 3patients using the Koyanagi procedure, Koyanagi himself in a muchlarger series of 70 patients had a 47% complication rate (reference 11in article).

Despite this critical commentary, I would like to take this oppor-tunity to congratulate these authors on their success and wouldencourage other young innovative pediatric urologists to continuetheir work in pursuit of a single stage procedure that would achievepredictable functional and cosmetic results in these unfortunatechildren. A published report such as this will encourage furtherresearch in this direction.

Selwyn B. LevittDivision of Pediatric UrologySchneider Children’s HospitalLong Island Jewish and Northshore Medical Center and

Westchester Medical CenterNew York, New York

Complications of single staged repairs for proximal hypospadias

References Technique No.Pts

MosFollowup

%Complications

Wacksman6 Hodgson XX 37 — 11Koyanagi et al11 Koyanagi 70 — 47Ellsworth et al7 Hodgson XX 12 26 25Glassberg et al10 Koyanagi 14 — 50Emir et al12 Modified Koyanagi 20 34 20Sugita et al13 Modified Koyanagi 151 72 17Present series Hodgson/Koyanagi 20 23 20

HYPOSPADIAS WITH BIFID SCROTUM OR PENSCROTAL TRANSPOSITION1588