"Simple Anatomical Closure-SAC" for distal hypospadias repair without glans wings dissection: Technical description
Ali Ekber Hakalmaz1, Ali Sezer1, Ayşe Karagöz Hakalmaz1
1Division of Pediatric Urology, Department of Pediatric Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Türkiye.
Introduction:
Glans wings dissection is an important part of hypospadias repair to ensure safe coverage of the neourethra. We here describe our technique entitled "Simple Anatomical Closure (SAC)" procedure, without extensive glans wings dissection, to preserve the distal continuity of spongious tissues and their glanular attachments.
Objective:
Our aim is to evaluate the clinical results of the SAC procedure, while questioning the absolute necessity of glans wings dissection.
Patients And Method:
Cases that underwent SAC procedure between 2018 and 2023 were retrospectively analyzed for demographic data, perioperative findings, and clinical outcomes. Anatomical inclusion criteria for performing SAC procedure were: primary distal hypospadias cases with a wide glans penis, wide ventral periurethral triangles and well-developed distal periurethral spongious tissues. Cases with more than 30 degrees of ventral curvature and/or dysplastic urethral plate were excluded. For the SAC technique: following total penile degloving and exposure of distal penile structures, the urethral plate mucosa is separated from glanular mucosa while ventral glanular periurethral triangles are deepithelialized. Urethral plate incision with or without inlay grafting is applied if indicated. A limited distal urethral spongious tissue dissection is performed towards the glans penis while preserving spongious continuity and glanular attachments. Dorsal midline plication and/or complete urethral dissection with ventral corporotomies are applied if necessary for correction of ventral curvature. Penile structures are then closed according to their anatomical order.
Results:
SAC procedure was applied in 43 (2 glanular, 18 coronal, 23 subcoronal) primary distal hypospadias cases between 2018 and 2023. The median operation age was 25 months. Urethral plate incision was done in 39 cases and preputial inlay grafting added in 18. Ventral curvature was present in 34 cases (15-30°), which was corrected with penile degloving, dorsal midline plication, urethral dissection/separation and superficial ventral corporotomies, when necessary. Mean follow-up period was 32.5 months. Late term results revealed 1 fistula, 1 glanular tilt, and 2 mild distal glans dehiscences with no ventral curvature recurrence, penile rotation, diverticula, or stenosis.
Discussion:
Glans wings dissection is a commonly used technique during hypospadias repair that possibly increases success rates. However, in selected cases, reconstruction of penile structures without extensive glans wings dissection is possible. Recently described surgical modifications also have similar principles and recommend glanuloplasty without extensive glans wings dissection.
Conclusion:
"Simple Anatomical Closure" procedure without glans wings dissection is a safe method for primary distal hypospadias repair, with satisfactory outcomes and a low complication rate.
