This document describes techniques for the single stage repair of male and female epispadias. For male epispadias, the technique involves partial penile disassembly, mobilization of the urethral plate, penile lengthening, and urethroplasty. This provides excellent cosmetic and functional results while avoiding complications of other techniques. For incontinent female epispadias, the technique uses tubularization of the urethral strip and double breasting of the bladder neck to create a new continence zone, achieving dry intervals in previously incontinent patients.

1. DR. AMILAL BHAT
S. N. MEDICAL COLLEGE
JODHPUR
SINGLE STAGE REPAIR OF
MALE & FEMALE EPISPADIAS

2. INTRODUCTION

3. Isolated male epispadias rare anomaly,
Incidence of 1 : 117,000 males.
Dorsal urethral defect
INTRODUCTION

4. 1) Balanic/Glanular
2) Penile
3) Penopubic ( MC type – 70%)
TYPES OF EPISPADIAS

5. Varying degrees of dorsal chordee/ torque
with/without the potential incompetence of
the sphincter mechanism.
DORSAL CURVATURE AND TORQUE

6. ASSOCIATED ANOMALIES
Ureterovesical junction is inherently deficient
in complete epispadias .
Incidence of reflux is between 30% - 40% .
Very rarely agenesis of the left kidney.

7. WHO SHOULD OPERATE ???
PAEDIATRIC UROLOGIST
GENERAL UROLOGIST
PAEDIATRIC SURGEON
PLASTIC SURGEON
GENERAL SURGEON
EPISPADIAS STILL REMAINS A CHALLENGE TO THE UROLOGIST !

8. 6 MONTHS
12 MONTHS
18 MONTHS
2 YEARS
5 YEARS

9. Straight penis
Adequate length
Cosmesis
Continence
Creation of normal meatus
Preservation of upper tract
GOALS

10. TECHNIQUES FOR EPISPADIAS REPAIR
Young’s urethroplasty - Two stage
- Urethra position
-Cosmesis
- fistula

11. CANTWELL RANSLEY
High fistula rate
Chances of neurovascular
damage
Continence
Residual curvature

12. MITCHELL’ S PENILE DISASSEMBLY
Extensive procedure
Requires good experience
Meatus becomes hypospadiac
Difficult to manage hypospadias in
want of skin & urethral plate ventrally

13. PARTIAL PENILE
DISASSEMBLY
Mobilization of urethral plate from
Corporal bodies and division of dorsal ligament
Penile lengthening
Raising glanular flaps, keeping the urethra
attached in the distal part
Urethroplasty
Corporoplasty keeping the urethra ventrally
Skin closure with/without z-plasty

14. SKIN INCISION

15. PENILE DEGLOVING

16. PENILE LENGTHENING

17. PENILE LENGTHENING

18. MOBILIZATION OF URETHRAL PLATE

19. MOBILIZATION OF URETHRAL PLATE FROM
CORPORAL BODIES

20. MOBILIZATION OF URETHRAL PLATE

21. GLANULAR WINGS & URETHROPLASTY

22. GLANULOPLASTY

23. GLANULOPLASTY

24. CORPOROPLASTY KEEPING URETHRA VENTRALLY

25. CORPOROPLASTY

26. VENTRAL URETHRAL FIXATION

27. SKIN CLOSURE

28. Patients and methods
• Retrospective study Primary Isolated Epispadias --
43 cases
• July 2000 to July 2012.
• Patients age 6 -26 years (mean 8.9)
• Peno-pubic (24- 55.6% ), Penile (17) & Glanular
(2 ).
• Dorsal Curvature: Mild- 6 ,Moderate-23 & Severe-
14
• Torque: Mild -9, Moderate -1
• Incontinent: -7

29. RESULTS OF PENOPUBIC EPISPADIAS (24)
• Excellent Cosmesis & Function 87.5 %
• Satisfactory 22.5 %
• Mild Residual Chordee 08.3 %
• Mild Torque 04.2 %
• Second Surgery None

30. RESULTS OF PENILE & GLANULAR EPISPADIAS
Excellent Cosmesis & Function
Penile (17) --- 100%
Glanular (2) --- 100%
 Fistula / Stricture / Chordee / Torque --- None
 Follow up period --- 2-10 years

31. POSTOPERATIVE RESULTS

32. ADVANTAGES
All advantages of Mitchell’s disassembly
In addition - better blood supply
- Lesser chances of
meatal stenosis
- Can be done with less
experience

33. • Bladder neck –Wide
• Pubic Symphysis -- Diastasis
• External sphincter -- Deficient.
• Dorsal chordee & short penis
PENO-PUBIC EPISPADIAS - INCONTINENT

34. DOUBLE BREASTING OF BLADDER NECK
AND POSTERIOR URETHRA

35. MOBILIZATION OF URETHRAL PLATE

36. MOBILIZATION OF BLADDER NECK
AND POSTERIOR URETHRA

37. EXCISION OF MUCOSAL STRIP FROM POSTERIOR
URETHRA AND BLADDER NECK

38. DOUBLE BREASTING OF BLADDER NECK
AND POSTERIOR URETHRA

39. DOUBLE BREASTING OF BLADDER NECK
AND POSTERIOR URETHRA

40. TUBULARIZATION OF URETHRAL PLATE
AND SPONGIOPLASTY

41. CORPOROPLASTY AND GLANULOPLASTY

42. VENTRAL FIXATION OF URETHRA

43. Z-PLASTY AND SKIN CLOSURE

44. POSTOPERATIVE RESULTS

45. Patients and methods
• Incontinent peno-pubic -- 7cases
• July 2008 to July 2012.
• Age 10m -26 years (mean 12.7)
• Curvature : Moderate - 5 & Mild 2
• Torque: Mild -3, Moderate- 1
•

46. RESULTS
 All continent except one
 One had partial continence dry interval 2 hours
-- Put on– immipramine
 Follow up period – 6 to 36 Months

47. CONCLUSIONMobilization of urethral plate and corporal bodies &
division of dorsal ligament corrects dorsal curvature
and torque.
Partial Penile Disassembly with double breasting of
bladder neck and posterior urethra produces a
continent zone .
As good as Young_Dees Lead Better with addition of
urethral factors
 Our initial results are encouraging but more
multicentre studies are required to validate the
technique.
Less extensive, reliable, reproducible & simple .

48. Female epispadias - very rare
[1 in 484000 ]
Male : Female – 3 to 4 : 1
TYPES
Vestibular
Subsymphysial/penopubic
Retrosymphysial

49. FACTORS FOR CONTINENCE
1) Bladder – Capacity, Contractability
2) Bladder Neck – Competence
3) Urethral Factors
- Length of posterior urethra
- Pliability
- Healthy spongiosal tissue
4) External sphincter

50. BLADDER FLAP REPAIRS
1) Bladder flap for urethral reconstruction &
tubularization of the trigone
2) Young-Dees-Leadbetter procedure with bladder
neck suspension
3) Young Dees procedure and simultaneous
perineal reconstruction
PROCEDURES FOR CONTINENCE

51.  URERHRAL PLATE TUBULARIZATION
Urethral plate tubularization and bladder neck
suspension (De Jong)
PROCEDURES FOR CONTINENCE

52. DISADVANTAGES OF DESCRIBED TECHNIQUES
Two stage
Genitoplasty in second stage
Extensive procedure
Urethral factors not utilised
Continence ?

53.  Incompetent bladder neck
 No urethral resistance
 Small capacity bladder
CAUSES OF INCONTINENCE IN FEMALE EPISPADIAS

54. A new continence zone :
a) Tubularization of the urethral strip
b) Double breasting of the urethral wall from the
bladder neck to the neomeatus
c) Approximation of bulbocavernous and
ischicavernous muscles
d) Coaptation of the lax pelvic floor muscles
around the reconstructed urethra.
OUR TECHNIQUE

55. 1. Mobilization of urethral plate.
2. Denudation of urethral strip.
3. Tubularization of urethra.
4. Double breasting of spongiosal tissue & trigonal flap.
5. Corporoplasty, Sphincteroplasty, & Genitoplasty.

56. MOBILIZATION OF URETHRAL PLATE

59. DENUDATION OF URETHRAL STRIP

60. TUBULARIZATION OF URETHRAL PLATE

61. TUBULARIZATION OF URETHRAL PLATE

62. DOUBLE BREASTING OF BLADDER NECK & SPONGIOSAL TISSUE

63. DOUBLE BREASTING OF BLADDER NECK &
SPONGIOSAL TISSUE

64. MOBILIZATION OF CAVERNOSUM,
ISCHIOCAVERNOSUS & BULBOCAVERNOSUS

65. MOBILIZATION OF CAVERNOSUM,
ISCHIOCAVERNOSUS & BULBOCAVERNOSUS

66. CORPOROPLASTY AND SPHINCTEROPLASTY

67. CORPOROPLASTY AND SPHINCTEROPLASTY

68. GENITOPLASTY AND MONSPLASTY

69. GENITOPLASTY AND MONSPLASTY

70. POST OPERATIVELY– FULLY CONTINENT

71. 6 cases managed since 1991
4 cases – results published [ Sept. 2008 ]
2 cases – penopubic epispadias with total
incontinence [ 5 yrs & 7 yrs ]

72. Both patients - fully continent
- dry interval of 4 to 5 hrs/day
Follow up - 2-5 years
RESULTS

73. PRE – OP CYSTOGRAM POST– OP CYSTOGRAM
RESULTS

74. Bladder neck reconstruction -- double breasting
Urethral factor utilisation -- using urethral tissue with the urethral
plate
Approximation of bulbocavernous and ischiocavernous muscles
Pelvic factors -- approximation of the pelvic floor muscles.
Simple, effective, reproducile , less extensive
The bladder capacity will increase
-- important factor in achieving continence
-- helpful in cases in which bladder neck reconstruction and
ureteral reimplantation is required later
CONCLUSIONS

76. Perineal one stage
repair is the
procedure of
choice in female
epispadias

77. Campbell-Walsh Urology (10th
Edition)
Chapter 124, Page 3374

78. Campbell-Walsh Urology (10th
Edition)
Chapter 124, Page 3374

79. This technique utilizes both bladder & urethral factors
for continence.
Simple, effective and reproducible technique for
continence and cosmesis.
CONCLUSIONSTHANKS

80.
CONCLUSIONS
• Complete chordee correction
• Increase in penile length
• Neourethra with spongiosum
 Restore the penile anatomy nearest to normal.
• Acceptable complication rate.