The Bracka two-stage repair for severe proximal hypospadias: A single center experience.

BACKGROUND: Surgical correction of severe proximal hypospadias represents a significant surgical challenge and single-stage corrections are often associated with complications and reoperations. Bracka two-stage repair is an attractive alternative surgical procedure with superior, reliable, and reproducible results.
PURPOSE: To study the feasibility and applicability of Bracka two-stage repair for the severe proximal hypospadias and to analyze the outcomes and complications of this surgical technique.
MATERIALS AND METHODS: This prospective study was conducted from January 2011 to December 2013. Bracka two-stage repair was performed using inner preputial skin as a free graft in subjects with proximal hypospadias in whom severe degree of chordee and/or poor urethral plate was present. Only primary cases were included in this study. All subjects received three doses of intra-muscular testosterone 3 weeks apart before first stage. Second stage was performed 6 months after the first stage. Follow-up ranged from 6 months to 24 months.
RESULTS: A total of 43 patients operated for Bracka repair, out of which 30 patients completed two-stage repair. Mean age of the patients was 4 years and 8 months. We achieved 100% graft uptake and no revision was required. Three patients developed fistula, while two had metal stenosis. Glans dehiscence, urethral stricture and the residual chordee were not found during follow-up and satisfactory cosmetic results with good urinary stream were achieved in all cases.
CONCLUSION: The Bracka two-stage repair is a safe and reliable approach in select patients in whom it is impractical to maintain the axial integrity of the urethral plate, and, therefore, a full circumference urethral reconstruction become necessary. This gives good results both in terms of restoration of normal function with minimal complication.

INTRODUCTION

Hypospadias is one of the most common congenital defect of male external genitalia, occurring in approximately 1 in 250 live male newborn of which proximal hypospadias (penoscrotal, scrotal, and perineal types) account for 20% of all cases.[12] It is a significant surgical challenge to achieve a cosmetically and functionally acceptable straight penis in such patients. Single-stage procedures are often associated with complications and reoperations, which negate the purpose of single-stage procedure. Contemporary series of -single-stage repair report complication rates of 20-50%.[345] The debate over the optimal treatment for severe cases of hypospadias is ongoing, and many surgeons believe that two-stage procedure offers superior functional and cosmetic results with fewer complications.[6]

Bracka, using his two-stage principle of repair, published his results of first 600 cases in 1995.[7] The first stage of Bracka repair consists of orthoplasty and urethral bed substitution with free preputial graft. After 6 months, the urethral plate created from free graft is tubularized to form neourethra. It can be applied to all varieties of hypospadias, and the results of Bracka procedure are considered superior and the surgery is relatively straightforward, reliable, and reproducible.[789]

We report short-term results of our initial series of Bracka two-stage repair for primary cases with proximal hypospadias performed at a single center.

MATERIALS AND METHODS

This prospective study was conducted after approval of Institute's Ethics Committee, and patients were enrolled after obtaining valid informed consent from the parents. The duration of the present study was 3 years (January 2011 to December 2013). All consecutive patients seen in outpatient department with severe proximal hypospadias with chordee and/or poor urethral plate [Figure 1] underwent Bracka two-stage procedure as primary surgery. All were included in this study and were followed-up for minimum 6 months after second stage.

Figure 1

Penoscrotal hypospadias

Surgical technique

First stage

All patients were operated under general anesthesia with caudal block. All received three doses of testosterone intramuscularly (2 mg/kg, maximum 25 mg) 3 weeks apart before the first stage. The first stage was performed after a week of the last dose of testosterone. Detailed examination on table was carried out and children were assessed for:

Position and size of abnormally located meatus,

Chordee, which was graded as I-IV,[10]

Quality and width of the urethral plate,

Configuration of glans penis and

Gonads.

The surgical technique for first stage procedure is essentially the same as reported by Bracka[7] using inner preputial skin as a free graft. However, unlike Bracka we meshed the graft with 18 G needle before quilting it to the prepared bed with 5-0 chromic catgut suture [Figure 2]. Dressing was changed on the 5th postoperative day to assess graft take and fresh dressing was applied, which was kept for five more days. On the 10th postoperative day, dressing and indwelling Foley catheter were removed and patients were discharged. All patients were called up in the outpatient clinic to assess graft take and to plan the second stage, which was usually performed 6 months following first stage. Application of mild steroid based cream was advised when uneven scarring of graft was found on follow-up.

Figure 2

(a) Quilted free graft from inner preputial skin; (b) well taken graft at the time of second stage

Second stage

Second stage surgery was performed under general anesthesia with caudal block and the technique was similar to Bracka.[7] Urethroplasty was done over feeding tube size 7 Fr to 10 Fr depending on the age of the patients. Urethroplasty was done with subcuticular, interrupted or continuous sutures taken around 2-3 mm apart, inverting the edge with either 6-0 polydioxanone (PDS II) or Vicryl as per operating surgeon's preference [Figure 3]. The waterproofing second layer was given by:

Figure 3

Second stage: (a) Completed urethroplasty; (b) final appearance

Vascularized dartos flap or

Tunica vaginalis flap or

Local dartos tissue.

Glansplasty was done in a single layer with 5-0 PDS II or Vicryl with subcuticular interrupted suturing technique and skin cover was given. Paraffin gauze applied around the shaft and absorbent gauze dressing was given. Dressing was changed on 5th postoperative day and catheter was removed on 10-14th postoperative day depending on length and complexity of urethroplasty. Intravenous antibiotic was given for 5 days and was switched over to oral antibiotic for five more days.

All patients were called for follow-up on an outpatient basis with 4 hour of fasting on 21st postoperative day for urethral (meatal) calibration under anesthesia. It was done to ensure timely follow-up and to assess the result of a complex reconstruction objectively. If the meatus was found adequate and child was voiding with good quality urinary stream, follow-up was advised at 2 months and 6 months. If child had poor stream or metal stenosis, child was again called for metal dilatation 3 weeks later.

Over a period of 3 years, 43 patients underwent Bracka procedure out of which 30 patients had completed two-stages, while 13 patients are awaiting second stage [Table 1]. The mean age in our study was 4 years and 8 months (range; 2-10 years). The location of meatus was penoscrotal in 77%, scrotal in 23%. Chordee was present in all patients mainly of grade III and IV. Most of them were corrected by doing penile degloving with excision of the urethral plate and all fibrosis, but 3 of them required dorsal plication. There was no case of graft loss in our study. However, graft contraction occurred in 10 patients. Out of these 10 cases, 5 patients had approximately 20% contraction, and 5 had approximately 10% graft contraction. Uneven scarring of graft was noted in 3 patients who were treated by mild steroid based ointment. After application of ointment for 4-12 weeks graft become smooth and supple and did not require revision of first stage.

Table 1

Results

Urethroplasty was done by continuous interlocking subcuticular suturing in 10 patients, while in 20 patients it was done by interrupted suturing. We used Vicryl as a suture material in 10 patients during PDS II in 20 patients. Second layer was given by tunica vaginalis flap in 6 patients, vascularized dorsal dartos flap in 20 patients and surrounding subcutaneous tissue in 4 patients. Eight patients developed urethrocutaneous fistula, out of which six were junctional (at the site of hypospadiac meatus). Further analysis of fistula revealed 6 out of first 10 cases developed fistula and all four in whom surrounding subcutaneous tissue were used as second layer developed fistula. Out of 8 patients who developed fistula 5 tiny fistulae got spontaneously closed with regular meatal dilatation under anesthesia at interval of 3 weeks for 3-5 sessions. Only 3 patients required formal fistula closure amounting to 10% fistula rate in our series. We did not find any urethral stricture formation or glans dehiscence in our study. Two patients had meatal stenosis which was treated by self-meatal dilatation.

DISCUSSION

Notwithstanding the dispute on single-stage versus two-stage repairs is ardent, agreement exists that procedure assignment in hypospadias repair is highly based on the patient's individual anomaly status and on the surgeon's individual experience and preferences. But the ultimate surgical goal is common and that is; to reconstruct a normal or near normal appearance of penis mimicking that of postcircumcision one, to have adequate caliber water-proof neourethra extending to the apex of glans for upright voiding with normal urine stream, to create a straight penis adequate for sexual intercourse and to control the risk of complications.[11]

Management of severe proximal hypospadias is challenging and several surgical techniques are suggested. Single-stage procedures are often associated with complications like fistulae, stricture, metal stenosis etc., and require re operations.[345] No single surgical procedure is ideal and the quest for such procedure continues.[9] There has been a resurgence of the two-stage procedure for such severe proximal hypospadias cases in recent years.[12]

Once the graft is quilted onto the corpora, the first issue is graft take. Unlike Bracka, we meshed the free graft with 18 G needle before quilting it on corpora. Meshing of free graft precludes any fluid or hematoma collection between the graft and its bed, and thus minimizes the chances of graft loss. Meshing of graft widens the graft, which can cover a larger surface. Mokhless et al.[13] conducted histological studies on the grafted mucosa and found that the free graft showed excellent uptake within 5 days. At 6 months, the mucosa was well-vascularized and pliable displaying epithelial hyperplasia with mild focal keratinization. A retraction of 20% of grafted area usually occurs between stages; therefore harvesting a graft slightly larger than required is recommended.[14] We harvested and quilted a larger graft than required and thereby we could avoid the adverse effects of graft contraction. We achieved 100% graft take as were the results of others.[915]

The second stage was done 6 months after the first stage because by this time the graft would be pliable, soft, and mature. At that time it is unlikely to undergo any further contraction.[7] As for all other techniques, major complications of the staged repair include fistula formation, metal stenosis, suture line dehiscence, stricture and diverticulum formation. Most of the urethroplasty complications tend to occur in the first 6-12 months after the second stage.[16] It has been a norm to provide vascularized second layer and the options are tunica vaginalis flap or dartos vascularized flap. The adjunct of waterproofing layer seems to be crucial to reduce the fistula rate. Accordingly, Telfer et al.[17] reported a 63% fistula rate in cases operated without and a 4.5% rate in those operated with such an additional layer. The initial higher fistula rate might be due to learning curve of a new technique[714] and we attribute our initial higher fistula rate to the phenomenon of learning curve. Out of 8 patients who developed fistula 5 were spontaneously closed with regular meatal dilatation under anesthesia at interval of 3 weeks for 3-5 sessions and similarly 2 fistulae spontaneously closed in study by Ferro et al.[15] Stricture formation following tube urethroplasty is uncommon but when it occurs, it is a devastating complication. Stricture formation is less likely after the two-stage procedure because the linear suture line of the urethroplasty is given time to contract fully before the second stage is performed.[15] Fortunately we did not find any stricture formation. Meatal stenosis is another common complication of urethroplasty. Two patients in our small series had meatal stenosis, which were treated by regular meatal dilatation.

According to Bracka, one of the major advantages of staged repair is the possibility to achieve a good cosmetic result with placement of the urethra deep in the glans and creation of a natural slit-like meatus. Accordingly, most series report an excellent cosmetic results and patient satisfaction.[79111815] In our series, all patients had meatus at the tip, passing urine in good single stream and complication rates comparable to contemporary series as shown in Table 2.

Table 2

Comparison with contemporary series

Though our study period was limited to 3 years and a shorter follow-up, we are committed for long-term follow-up of our patients and to address any of the delayed complication that may arise.

CONCLUSION

Two-stage Bracka repair for severe proximal hypospadias with chordee and/or poor urethral plate is a good option with satisfactory results. Second layer in form of vascularized dartos or tunica vaginalis flap is perhaps mandatory to prevent fistula formation. A trial of metal dilatation should be given before proceeding to fistula closure. Mild steroid based ointment improved quality of graft in patients in whom graft was uneven. The two-stage Bracka repair reconstructs the new urethra from a free preputial skin graft and it is reliable and easily reproducible technique with very good cosmetic results.