Use of the processus vaginalis: A new technique for reinforcing the neourethra in hypospadias associated with undescended testis.

Incidence of the undescended testis (UDT) along with hypospadias varies from 6 to 31%. The repair of UDT and hypospadias is rarely done simultaneously. Here we present a novel technique that uses processus vaginalis as vascular cover for neourethra in hyposapdias patients with UDT. We have done urethroplasty and orchiopexy simultaneously. This is the first report of processus vaginalis being used to reinforce the urethra.

INTRODUCTION

Repair of undescended testis (UDT) with hypospadias is rarely done simultaneously and there are more chances of fistula formation due to lack of adequate vascular cover for the neourethra.Objective of this technique was to use processus vaginalis as vascular cover to reinforce the urethra.

CASE REPORT

A 12-year-boy was presented with proximal penile hypospadias and bilateral palpable undescended testis. Patient had a mild chordee and the length of penis was adequate. Patient was evaluated for intersex and karyotype was 46 XY. Genitoscopy revealed evidence of large prostatic utricle. After release of chordee, tube pedicle urethroplasty (Duckett's) was done.The required 5 cm long tube was constructed on number 10 feeding tube.We routinely do proximal anastomosis first before making the tube.

To prevent complications like fistula, the urethral repair needs vascular cover. At this juncture, we planned to do orchidopexy along with the repair of hypospadias. Inguinal crease incision was taken on right side and herniotomy done close to the internal ring. After mobilizing the cord structure proximally, testis was brought down into scrotum along with its processus vaginalis [Figure 1]. Testis was fixed into extra dartos pouch and processus vaginalis was cut open to form the flap [Figure 2]. This processus vaginalis was used to cover the neourethral repair as a blanket wrap [Figure 3]. The postoperative course was uneventful and patient voided single good stream on day 10th of operation. Patient is on regular follow-up with no complications.

Figure 1

Testis separated from prossess vaginalis

Figure 2

Testis brought in scrotum with processes vaginalis

Figure 3

Processess vaginalis wrap over neourethra

DISCUSSION

Incidence of the undescended testis along with hypospadias varies from 6 to 31%.[1] Urethrocutaneous fistula is the most common complication associated with the proximal hypospadias repair. There are various techniques to prevent formation of fistula.

There are various methods for protective intermediate vascular cover to the neourethra that would prevent fistula formation, for e.g., Snow (1986) described the use of Tunica vaginalis wrap;[2] Retik was the first to use dorsal subcutaneous flap from the prepuce;[3] Motiwala described the use of Dartos flap from the scrotum;[4] Tunica vaginalis wrap is the most common method used with good results and long-term follow-up.[5]

In patients of hypospadias associated with the undescended testis, tunica vaginalis is not available to be used as protective layer for hypospadias repair. As scrotum is not well developed because of undescended testis, one cannot get easily the dartos fascia for cover of urethral repair.

Yamataka et al., described method of using gubernaculum as vascular cover after dissecting it from testis and leaving its anomalous distal attachment to the pubic tubercle intact, but the limitation of gubernaculum is that it is not long enough to cover whole urethra.[6]

We present a case where we could develop processus vaginalis flap and do orchidopexy to reinforce neourethra with processus vaginalis giving good results. Our technique is useful to cover the anastomosis and suture line and simultaneously allow repair of UDT. Processes vaginalis is long and can be easily brought down with testis possessing good vascular supply. In order to achieve adequate mobilization of processus vaginalis, herniotomy should be done at internal ring level.

There are no reports in literature regarding use of processus vaginalis as vascular cover and this simple technique would reduce the complication rate of hypospadias repair with UDT.