Modified complete penile disassembly for epispadias repair: a case report
Aldilla Wahyu Rahmadian, Paksi Satygraha
Received: 29 Mar 2018 - Accepted: 21 Jul 2018 - Published: 07 Nov 2018
Keywords: Diphallia, dorsal chordee, epispadias, modified complete penile disassembly
This article is published as part of the supplement Malang Continuing Urology Education: Reconstruction and Functional Urology, commissioned by Committee for the 1st InaGURS International Workshop & Symposium of Reconstruction &.
©Aldilla Wahyu Rahmadian et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Aldilla Wahyu Rahmadian et al. Modified complete penile disassembly for epispadias repair: a case report. Pan African Medical Journal. 2018;31(1):7. [doi: 10.11604/pamj.supp.2018.31.1.15613]
Available online at: https://www.panafrican-med-journal.com/content/series/31/1/7/full
Modified complete penile disassembly for epispadias repair: a case report
Aldilla Wahyu Rahmadian1,&, Paksi Satygraha1
1Department of Urology, Brawijaya University, Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia
Aldilla Wahyu Rahmadian, Department of Urology, Brawijaya University, Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia
The incidence of complete epispadias is approximately 1 in 120,000 males and 1 in 450,000 females. This was the second case we have experienced in Saiful Anwar General Hospital Malang in the last 10 years. Current methods of epispadias repair in bladder exstrophy are the Cantwell-Ransley repair (1989), modified Cantwell-Ransley repair (1992, 1995), and the penile disassembly technique described by Mitchell and Bagli (1996). This report aimed to review the experience of repairing epispadias with a modified complete penile disassembly technique. A 13-year old boy came with epispadias, diphallia, and dorsal chordee. The surgery was done by a urologist specializing in urethral reconstruction, using a modified complete penile disassembly technique. Postoperative results were observed, including cosmetic appearance, uroflowmetry study, and erectile function. Operation duration was approximately two and half hours, with no complications intraoperatively. Compared to the original complete penile disassembly technique, the ventral foreskin was left intact and not dissected to completely separate the two corpora cavernosa. The urethral catheter was withdrawn from the patient 1 month after surgery, on complaining of dysuria and being satisfied with the appearance. Two months after surgery, the patient was able to control micturition, with satisfactory Qmax (15cc/s), voided volume (50cc), and post-voiding residual volume (50cc), and preserved cystotomy catheter. The erection was maintained at the preoperative condition (EHS level 2). Routine uroflowmetry study is planned for the 24th month. This epispadias repair technique is an individual preference of the operator without disobeying common guidelines. The first experience of using modified complete penile disassembly for epispadias shows promising results.
The incidence of complete epispadias is approximately 1 in 120,000 males and 1 in 450,000 females [1-3]. The urethra is displaced dorsally, and epispadias is classified based on urethral position in males . Females with epispadias have a bifid clitoris and separation of the labia [5-7]. Urinary incontinence is a common problem. The dorsal curvature of the penis (dorsal chordee) is also present . This was the second case we have experienced in Saiful Anwar General Hospital Malang in the last 10 years.
A 13-year-old boy came to our hospital with a congenital urogenital anomaly with common signs of complete epispadias: penopubic epispadias, diphallia, dorsal chordee, and incontinence. The penis was 5 cm in total length, with a 4.6 cm groove from penile tip to the penopubic junction. The glans penis was clefted, and the corpora cavernosa were separated. The external urethral meatus was located at the penopubic junction. Scrotum and testes were normal. No sign of symphysiolysis or bladder abnormality. Prostate was normal for digital rectal examination (Figure 1). Current methods of epispadias repair in bladder exstrophy are the Cantwell-Ransley repair (1989), modified Cantwell-Ransley repair (1992, 1995), and the penile disassembly technique described by Mitchell and Bagli (1996) . The procedure decided upon by three urologists was a modified complete penile disassembly. This technique was adapted from the epispadias repair technique developed by Mitchell and Bagli . This approach better recapitulates the anatomy of the penis and allows better placement of the bladder or urethra into the pelvis . Operation duration was approximately two and half hours, with no complications intraoperatively. In the complete penile disassembly technique, the penis is dissected into three components, the right and left corpora with their associated hemiglans, and the urethral wedge (urethral plate with its associated spongiosa). Dissection begins on the ventral aspect of the penis then moves medially just above the Buck fascia but is taken down to the tunica albuginea of the corpora. The penis is then separated into the three previously mentioned components. Compared to the original complete penile disassembly technique, the modified penile disassembly technique leaves the ventral penile foreskin intact and not dissected to completely separate the two corpora cavernosa. The urethra is tubularized using a continuous running suture. The corpus cavernosum was approximated above the urethra to provide an anatomically ventral location of the urethra. The glans was reconstructed in two layers. A silicone stent was left indwelling in the neourethra  (Figure 2).
Epispadias is a mild form of bladder exstrophy, and in severe cases, exstrophy and epispadias coexist . Complete epispadias is the least severe form of EEC (epispadias exstrophy complex) and presents with a dorsally open urethral meatus with mild pubic diastasis and a closed anterior abdominal wall and bladder [5-8]. The diagnosis of epispadias alone should be ensured with the support of radiological imaging besides detailed physical examination. A plain pelvic X-ray can easily detect the existence of any pelvic bone deformities. If suspicious, an abdominal CT scan with contrast can be performed to detect any intrabdominal anatomical abnormality, especially in the bladder or pelvic bone [9, 10] (Figure 3). Surgery is required to correct incontinence, remove the chordee to straighten the penis and extend the urethra out onto the glans penis [3, 11]. The decision on technique is very operator-dependent. Modified complete penile disassembly was chosen based on its advantages during surgery and postoperatively. During surgery, we could completely examine each part of the penis and rearrange them into the best-expected position. Postoperatively, cosmetic appearance and function close to normal are the results of the intraoperative arrangement  (Figure 4). The urethral catheter was withdrawn from the patient 1 month after surgery, on the complaint of dysuria and being satisfied with the appearance. Two months after surgery, the patient showed satisfactory results; total flaccid and erect penile length was 4.0 and 6.8cm, respectively. The patient achieved a level 2 erectile hardness score (EHS). Uroflowmetry study results were Qmax 15cc/s, voided volume 50cc, and post-voiding residual volume 50cc, with total continence. The cosmetic appearance is satisfactory according to the patient's perspective [11, 13]. The suprapubic cystotomy catheter was preserved until this publication.
Epispadias repair technique is an operator choice without disobeying common guidelines. The first experience using a modified complete penile disassembly for epispadias shows promising results. Further considerations include a radiological study as part of the preoperative examination.
The authors declare no competing interests.
Aldilla Wahyu Rahmadian contributed to the drafting the article and developed the study design and Paksi Satygraha contributed to the data analysis and final approval the manuscript.
Figure 1: (A) diphallia; (B) penopubic epispadias; (C) chordee
Figure 2: steps of modified complete penile disassembly surgery
Figure 3: postoperative result
Figure 4: (A) postoperative flaccid penile length 4.0cm; (B) postoperative erect penile length 6.8cm; (C) postoperative scar
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