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Appendicular Mucosal Tube Implant with Dartos Wrap Operation for Hypospadias

Aims and Objective: To develop a better operation for hypospadias patients with poor and bad quality urethral plate and damaged urethral plate as in hypospadias cripples. Materials and Methods: I operated 21 cases of hypospadias with Appendicular mucosal tube implant with Dartos wrap operation from 17/04/2017 to 03/03/2019, in Jawale Institute of pediatric Surgery, and that group was labeled as group A. 27 cases of hypospadias were operated in same time span with conventional techniques such as extended Snodgrass operation and Byar’s two-stage operation (group B), kept as control. 7 patients (33.33%) were cases of hypospadias cripples with multiple surgeries done in the past. 4 patients (9.52%) patients had congenital short urethra. Remaining 10 patients (50%) were fresh cases with no operation done in past but with bad and fibrotic urethral plate. The longest follow up was 3 years and the shortest of 1 year. Technique of Operation: Appendicectomy performed by open technique and the serosa of Appendix cut longitudinally and stripped off the mucosal tube. The proximal hypospadias opening sutured with the appendicular mucosal tube with 6 sutures of 5-0 Vicryl. Dartos fascia is raised from the scrotum wrapped over the tube and 8 - 10 interrupted stitches taken with 5-0 Vicryl. Glanuloplasty performed over it. Suprapubic diversion did and kept for 3 weeks postoperatively. Results: In group A, 3 patients developed fistula and only


Introduction
The incidence of hypospadias [1] is generally 1 in 200 live births. There are a variety of operations described for hypospadias. Results of hypospadias surgery largely depend on quality of urethral plate. Generally, the variety of operations available for hypospadias has bad results when the quality of urethral plate is poor. There are a good number of cases done by less qualified doctors with multiples surgeries done which destroy the urethral plate, known as hypospadias cripples. Such patients also have poor results with the conventional operations. The conventional operations described in medical literature for above type of patients are Byar's two staged urethroplasty, extended Snodgrass operation, Buccal mucosa urethroplasty, bladder mucosa urethroplasty and Duckett's transverse island operation. All these operations are technically demanding and have a very high complication rate. I am describing an operation here which is technically less demanding and has much lower complication rates than the above options.
Aims and objectives: To develop a better operation for hypospadias with poor and bad quality urethral plate and damaged urethral plate as in hypospadias cripples

Materials and Methods
I operated 21 cases of hypospadias with Appendicular mucosal tube implant with Dartos wrap operation from 17/04/2017 to 03/03/2019, in Jawale Institute of pediatric Surgery, and that group was labeled as group A (Table 1). Age range for group A was 1 year to 13 years. 7 patients (33.33%) were cases of hypospadias cripples (Table 1) with multiple surgeries done in the past. 4 patients (9.52%) patients had congenital short urethra. Remaining 10 patients (50%) were fresh cases with no operation done in past but with bad and fibrotic urethral plate (  Babcock's forceps to avoid damage. Appendicular artery is divided between ligatures without damaging the appendix. The appendix is ligated at the base with 3-0 vicryl and distal appendix excised. The appendicular stump is cauterized with cautery and buried by 3-0 vicryl. The muscles closed by interrupted 3-0 vicryl. Skin closed by 3-0 vicryl subcuticular sutures. The appendicectomy can also be performed by laparoscopy, but my choice was open surgery.
A small cut is made in the terminal part of appendix. No.10 infant feeding tube coated with KY jelly passed through the appendix through and through.
The serosa of appendix cut longitudinally and stripped off the mucosal tube ( Figure 2) without creating a breach in it. Blunt and sharp dissection are needed to accomplish this step. Now the serosa is completely excised and only mucosal tube is left. The mucosal tube scrapped with a blunt scalpel to strip of any remaining part of submucosa and muscularis to keep only the mucosal tube ( Figure 3). The tube is kept in Metronidazole solution (500 mg in 100 ml) for 10 minutes to disinfect it.
A glans stitch is taken by 4-0 vicryl on round body needle. The penile skin is degloved till the base of the penis. The urethral plate or its remnants are fully excised. Any chordee tissue around and below urethral plate is completely excised.
Chordee test is performed by applying tourniquet at the base of penis and by injecting saline in corporal bodies through glans penis. Thus, it is confirmed that there is no residual chordee. The proximal hypospadias opening mobilized for 1 cm and any fibrous tissue around it excised. The 5 mm distal part of the opening is excised to have healthy tissue for anastomosis.
A midline incision is taken on median raphe of scrotum. Dartos fascia which is medial and inferior to the testis dissected off from the skin and testis on both sides ( Figure 4). Dissection is performed and Dartos fascia separated from perineal

Results
Patients were followed up weekly for 6 weeks and monthly thereafter.

Discussion
The use of whole appendix with pedicle graft [2] as a replacement of urethra is reported in the medical literature. But it is a complex and time-consuming operation. The appendicular vascular pedicle is short and such operation generally can only replace posterior urethra. Operation with appendix as a free graft [3] with anastomosing its vessels to the local vessels by microvascular technique is also reported. The vascular anastomosis is extremely challenging and prone to complications. Buccal mucosal urethroplasty [4] and bladder mucosa urethroplasty [5] operations are also described in the literature of hypospadias surgery for hypospadias with bad quality of urethral plate. The results of these operations are generally poor and are as follows. In a series of 50 cases of proximal hypospadias, treated with bladder mucosal urethroplasty [5] the long-term complications observed were, urethra-cutaneous fistula in nine patients (18%), urethral stricture in 15 patients (30%), meatal stricture in four patients (8%), and prolapse of meatus in seven patients (14%).
Early oral complications of buccal mucosal urethroplasty [6] in a series of 21 patients were as follows. Eighteen (85.7%) patients had mild pain, 13 (61.9%) had mild intraoral swelling, none of the patients had oral bleeding that needed extra procedure. Twelve (57.1%) of the 21 patients needed analgesic agents after the operation while 14 (66.7%) of them have remarked that perineal incision was more painful. Twenty (95.3%) of 21 patients stated that they could go under the same procedure again. None of our patients had speech disorders or intraoral numbness.
The results of my group B patients with 27 cases done by extended Snodgrass operation and Byar's two-stage operation were as follows. 11 patients developed fistula and 9 (33.33%) required repaired. 9 (33.33%) patients developed strictures and all of them required multiple urethral dilatation under GA. 7 (25.92%) patients developed meatal stenosis.UFR at the end of 12 weeks was badly reduced with average of 5.78 ML/Sec.
The results of my Appendicular mucosal tube implant with Dartos wrap operation (group A) were as follows. 3 patients developed fistula and only 1 (4.76%) required repair at the end of 6 weeks. 2 (9.52%) patients developed grade 3 infection and settled with conservative treatment. 2 (9.52%) patients developed hematoma in postoperative period. It was drained successfully by taking a small skin incision and settled with conservative management. No patient developed stricture or stenosis. UFR was normal at the end of 12 weeks with average of 12.85 Ml/sec. The cosmetic result was measured on the scale of excellent, good average and poor. 5 patients (23.8%) had excellent cosmetic result, 10 patients (47.61%) had good result, 4 patients (19.04%) had average result and only 2 patients (9.52%) had poor result. It is obvious that the results of this operation are far superior to group B patients and patients with bladder and buccal mucosa urethroplasty. 4 patients in my series (Group A) had congenital short urethra [8]. It is a rare congenital anomaly of urethra where skin forms the ventral wall of the urethra. The treatment of these cases is very challenging as generally entire urethra is to be sacrificed [8]. The treatment is generally done in a staged manner where first stage is done as Byar's stage one urethroplasty.  neovascularizes the tube rapidly. The tube has healthy mucosa, hence does not contract and leads to a stricture. The Dartos which is a tough fibro muscular tissue acts as Corpus Spongiosum which is absent in these patients.

Conclusion
The operation is an important addition to the armament of a hypospadiologist.
The operation proves to be a much better option compared to the conventional for the said category of patients. We need an operative series with longer follow up and larger patient numbers.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.