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HYPOSPADIASBy DENIS BROWNE, M.B., F.R.C.S.

Surgeon to the Hospital for Sick Children, Great Ormond Street

In order to explain the reasoning which leadsto the technique described, it is necessary first tostate the requirements of a satisfactory operation.With these in mind one can then set out the manyunfavourable factors facing the surgeon in hiscorrection of this deformity, and against themplace the few but important favourable ones.From this statement of the elements of the problema solution is then deduced.

Requirements for a SatisfactoryOperation

i. It must be applicable to all degrees of thedeformity. The misplaced opening of the urethramay be anywhere from just in front of the anusranging forwards through a cleft scrotum to thebase of the penis, and thence to just short of thenormal position. Without discussing in detailthe vast number of procedures described in theliterature, it is undeniable that none of them tacklethe really difficult types. The operations ofEdmunds, Bucknill, Ombredanne and the variousfree-graft techniques all lose their usefulness as theroot of the penis is passed.

2. It must construct a urethra free from hairs onthe inside. If this obvious requirement is notobserved, phosphatic calculi will form upon thehairs with extremely inconvenient results. Thisplaces out of consideration the procedure ofBucknill in all cases, and that of Ombredanne in allbut the mildest.

3. The new urethra must be of a size and elasticityapproximately normal. A urethra wide enough toallow free micturition but too narrow to permit theinsertion of a cystoscope may not cause trouble toits owner. But it is hardly necessary to labour thepoint that there may be trouble and it may be veryserious. I think there are very few, if any,urethrae constructed by free skin grafts that willpass this test.i 4. It must be capable of completion by the timethe child first goes to school, that is to say about fiveyears of age. The importance of this to theaffected boy is immense, for obvious reasons. Ido not say that the published procedures are nevercompleted by this time, but it must be a mostuncommon event if they are.

5. It should be capable of consistent performance

by any reasonably skilful surgeon and not dependupon either great technical accomplishment orgreat good fortune.

Unfavourable Factors in the Operationi. The passage of urine through the operation

area. If this is allowed to go on it has both amechanical and a physiological action in hinderingtealing. A flood of urine let loose at high pressureinto the newly-joined tissues is very apt to find away out other than that intended by the surgeon,and this new opening will become skin-lined andtherefore permanent with amazing rapidity. Thephysiological action of urine is not so important,but in its presence true primary union does notoccur.

2. The presence of erectile tissue. In my ex-perience erections are not one of the majorhindrances to the success of the operation, but ifthey could throw a sudden increase of tension upona line of sutures this would be disastrous.

3. The tendency of the subcutaneous tissues of theregion to excessive oedema upon trauma. This isone of the really great difficulties, as oedema bothputs tension upon sutures and impedes circulation,with consequent defective healing.

4. The extreme thinness and fragility of thepenile skin. A degree of tension upon sutures thatwould be perfectly safe on the face or the abdomenwill cut through the skin of the penis with rapidityand completeness.

5. The difficulty of getting sufficient skin atcertain points. At the distal end of the penis thereis in the prepuce a superfluity of skin; at its basethere is none at all to spare for surgical manoeuvres.To get the epidermal resources equally distributedis a problem to which many answers have beenattempted.

Favourable Factors in the Operationi. The character of the penile skin. This is

quite different from that of any other skin in thebody, and in many ways resembles the mucousmembrane which is the normal lining of theurethra. The curious and easy change of thesurface of the glans and the inside of the prepucefrom a sheltered and mucous-secreting state to anexposed and dry one is extremely interesting and

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suggestive. For the purpose of the operation thepenile skin, including the large reservoir of surfacein the prepuce, has many important properties. Itis hairless ; it is extremely mobile ; it is extremelyextensible and (most important of all) it neverforms keloid.

There are many puzzling points about thebehaviour of this surface. No one has ever seencontraction or keloid along the line of a circum-cision scar, provided that scar remains in its properplace. But if, during healing, the line of incisionis allowed to slip forward over the tip of the glans,it contracts into a tight ring that will hardly allowthe passage of urine. Similarly, the completeabsence of thickening or contraction in the sub-cutaneous tissues after the procedure described isin curious contrast to the persistent accumulations§of tough fibrous scar tissue after a gonococcalulceration or a traumatic division of the urethra.However, there is no doubt about the fact that if achannel is constructed lined with penile skin it willremain indefinitely, with no tendency to contract.This is well shown in the persistent post-operativefistula which is the well-known bugbear of thesurgeon in this condition. This has all the qualitiesof the ideal artificial urethra; it has a hairlesselastic lining and no tendency to contract.

2. The presence of a reservoir of suitable surfacefor a newv urethra in the prepuce. In this curiousstructure there is, as a mere matter of geometry,enough area of no functional use to supply a newunder surface to the penis when that is needed,and in addition to form a buried tube of thenecessary length and diameter. I have found thatby taking advantage of the properties of this skinin the way of mobility, extensibility and power ofepithelialization it is possible, by very simplemeasures, to effect the necessary changes ofposition.

First Stages of the OperationIn the severer degrees of the deformity there is a

curious element, something more than the simplefailure of fusion, that is seen in such apparentlysimilar conditions as a hare-lip or cleft palate.This is a failure of development of the parts con-cerned, the under surface of the penis and thecorpus spongiosum, so that they are only re-presented by a short fibrous band that ties downthe penis into a permanent chordee. Irn additionthere may be two other elements needing treat-ment, a narrowing of the urinary meatus and afailure of development of its floor, which mayconsist of two extremely thin fused sheets of skinand mucosa. The urethral meatus must be en-larged to a proper size and if the floor is undulythin it must be slit up and skin sewn to mucosa by

minute catgut sutures so as to preserve the size ofthe opening.The chordee is treated very simply by incising

transversely across the penis just below the glansand continuing the cut out into the prepuce oneither side. Then the penis is pulled out straightwith one hand while, with a blunt scissors in theother, everything that prevents straightening ofthe penis is divided and freed, so that it can slipdown towards the base. When the penis willstraighten easily and completely, the transversecut is sewn into a longitudinal line by fine catgutsutures. This will produce a tightening of theskin round the proximal part of the penis, whichis relieved by a simple incision down the dorsum.The mobility of the penile skin in this region oftenshows by the way in which the turning of a trans-verse incision into a longitudinal one on the ventralsurface is countered automatically by the longi-tudinal relieving incision on the dorsum stretchingout transversely. This incision is left unsutured toheal as it will.When the penis is straightened and the ventral

surface covered, it is wrapped in ribbon gauzesoaked with paraffin and flavine. This dressing isleft on for a week and then removed after softeningin a hot bath. If the freeing has been properlydone there is no tendency for the chordee to recur,and the penis will usually grow in a surprising wayonce normal erections are possible.The best time for this preliminary operation is

about i8 months of age, when the child and theparts are large enough to make the operation fairlysafe and easy, but on the other hand there are stillsome years left for the penis to grow before thenew urethra is constructed.

Second Stage of the Operationi. Diversion of the urine. This is essential for

the reasons given. It is sometimes objected toupon the grounds that it increases the severity ofthe operation. It certainly adds an extra pro-cedure, but apart from the great increase in theprobability of primary healing which it gives, thereis an equally great diminution in the pain sufferedby the patient. Anyone who has watched thefirst passage of urine through a newly-constructedurethra must be struck with the way in which theanticipation of pain makes the child restrain theact, until forced to yield by the distension of thebladder, and with the agony caused by the lettingloose of a flood of high pressure fluid into the rawtissues. The granulation tissue which forms after afew days is far less sensitive. Suprapubic drain-age, which I have used in many cases, is far lesssatisfactory than perineal. Its main fault is thatit does not fulfil the purpose of keeping urine outof the urethra. The reason for this is that the child

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FIG. i .-Technique of perineal drainage. The Malecotcatheter has been inserted into the bladder on asound, which is now shown half withdrawn andwith its curve reversed, so that the point makes thecatheter project in the perineum. A cut is beingmade down upon this point with a diathermyneedle. The catheter will be thrust out through thiscut as soon as a piece of it is exposed.

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FIG. 2.-Outlining the ventral incisions and raising thelateral flaps of penile skin. The small figure on theright shows the outlines of the strip of skin that willbe buried to form the new urethra. The maindrawing shows the lateral flaps raised and dissectedfree, and the puncturing of the scrotum on eitherside to allow free egress of blood and serum.

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<.ii::FiG. 3.-Showing the dorsal relaxation incision on the penis. On the left is the line of the incision,

and on the right the appearance of the penis after it has been made and spread widely open.

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370 POSrI GRADUATE MEDICAL JOURNAL August I949

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FIG. 4.-Showing the drawing of the lateral skin flapsover the isolated strip of skin which is buried toform the new urethra. The ' double-stop ' suturesare shown being inserted to keep all tension off thetiny catgut sutures which join the skin edges. Theglass bead is threaded on the nvlon suture with thealuminium cvlinder behind it. The aluminiumcylinder of the upper nylon suture has not yet beencrushed.

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FIG. 5.-The completed suturing. The new ventralsurface of the penis is drawn up on to the glans, sothat its raw under surface is in contact with theraw patches on either side of the new meatus, andheld there by several catgut mattress sutures. Thesutures holding the draining catheter in positionare shown.

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BROWNE: Hypospadias

tries to micturate at intervals, the sphincter of thebladder relaxes to allow the proximal urethra tofill and then its contents are driven forward bythe ejaculator urinae. Though this small amountor urine is not so deadly to healing as the fullcontents of the bladder, it can be very in-convenient.

I have found a Malecot catheter very satis-factory; some self-retaining device is necessaryas otherwise the catheter will be inevitably ex-truded by bladder contractions. It is passed on asound into the bladder and then the sound iswithdrawn partially and reversed so that its pointis made to protrude in the perineum. A cut aboutan inch long is then made down upon this point bya Zliathermy knife, and as soon as a tiny piece ofrubber shows at the bottom of the cut the catheteris thrust out through the soft floor of the urethra(Fig. i). In this way a very small hole is madewhich closes within a day or two after withdrawalof the tube. I think that persistent sinuses in thisregion, whichi are occasionally reported, must bedue to a far too large and wide opening of theurethra.A linen suture is then inserted to close the skin

and this is then tied tightly round the catheter.Another stitch of the same material is insertedloosely into the skin an inch away from the in-cision and this again is tied round the catheter.These stitches are to guard against the catheterbeing dragged out by the child, the danger of thisbeing particularly great when he is half asleep.It is curious how little the catheter is resented,which may be partly because the child cannot seeit and does not realize it is there. From thecatheter a narrow plastic tube leads into a bottleunder the bed, thus providing a negative pressurewhich keeps the bladder empty.

2. Formation of the urethra. Taking advantageof the peculiar local reactions which have beenset out, this passage is formed deliberately as afistula. A strip of skin is buried, with no atteSmpt tosew its edges together, leaving the spread ofepithelium from it and the closing of the healingtissues round it to form it inevitably into a tube.I find that surgeons who have heard of this devicebut have not the time to come and see the casesupon which it has been used nearly always objectthat it must result in a stricture. There are threeanswers to this. The first and most important isthat it doesn't. The second is that accidentalfistulae have no tendency to obliteration bystricture formation, and deliberately produced onesbehave in the same way. The third is thaturethras produced by Edmunds, perhaps the firstman to gain a large number of successes in thiscondition, were perfectly satisfactory. Yet it isobvious that his technique of raising and suturing

the edges of the buried strip to form a tubemust surround far more of its circumference withscar tissue than leaving it as a flat ribbon. Inaddition, the omission to suture the'edges meansthat a certain amount of new surface is formed bythe spread of epithelium from them before theyunite, with a consequent widening of the bore. Itis interesting to compare this method withHamilton Russell's operation for the excision ofgonococcal strictures, in which he merely sewed aflat strap of urethral mucosa together where thestricture had been and left this to form a tubespontaneously.

Fig. 2 shows the lines of incision to outline theurethral strip.

I have found much the best instrument for thispurpose to be very sharp-pointed small scissors,one blade of which is thrust under the skin. Thesescissors are also used for the small, but far fromeasy, detail of stripping the very adherent skinfrom the glans on either side of the site of the newmeatus.The skin flaps are raised up widely on either

side by divulsion with blunt scissors, so that theycan fall together quite loosely with about an inchto spare; there must not be the slightest suspicionof tension on the joining flaps. A considerableamount of haemorrhage occurs during this pro-cess, but I think it is inadvisable to ligature any butlarge and obvious bleeding points. Attempts togain a perfectly dry field waste time and are apt tofill the wound with catgut and damaged tissue. Ihave never known the bleeding to cause anxiety.

3. The relaxation incision. To get the completerelaxation that has been mentioned it is necessaryto take full advantage of the mobility and ex-tensibility of the penile skin by means of a longi-tudinal dorsal slit, similar to that made in thefirst stage. This is spread widely open (Fig. 3)and allowed to epithelialize spontaneously, a pro-cess which, as has been pointed out, occurs rapidlyand easily in the penis in a way that suggests thehealing qualities of mucosa rather than skin.

In addition to doing away with tension, thisincision has another function in preventing the ex-cessive oedema, which is one of the difficulties ofthe region, by allowing free outflow of serum. Toguard against oedema in the scrotum small in-cisions should be made with the sharp-pointedscissors, running from the inner raw surfaces outthrough the skin (Fig. 2). No drains are used inthese small holes and they heal rapidly andautomatically.

4. Tension sutures for the lateral flaps. All thatis necessary for the success of the operation is toget a junction of the skin edges along the ventralline of suture. This will occur rapidly and'soundlyinside a week, provided that all tension is kept off

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372 POST GRADUATE MEDICAL JOURNAL August 1949

the edges, that no urine is allowed to burst themapart and that they are adjusted with extremeaccuracy.

After many experiments I have worked out adevice which I have found very satisfactory forthis and other operations in which tension has tobe kept off joining skin edges. I call it the'double stop ' suture. It is a variant of the ancienttrick of crushing a split shot or lead bead on thesuture, which has the obvious advantage of notgrasping any tissues and so interfering with theblood supply to the healing edges as do ordinarydeep sutures. I think the reason why split shot ofthis kind have fallen out of use is that lead is anunsuitable metal, because of its extreme softness,which allows the suture to pull through whenquite a small force is applied. In addition thecrushing of the shot deforms it.The double stop suture consists of one bead or

button which goes against the skin, and analuminium cylindrical bead which is threaded onthe suture to the outer side of it and locks thesuture when crushed upon it. To crush it a veryefficient instrument can be made by cutting downthe jaws of an old pair of artery forceps to abouta I in. and removing the catches (Fig. 4). Thesestop sutures are placed about i in. away from theedges of the skin flaps, and adjusted so that whenlocked there is an I in. of slack in them. If theyare drawn tight they may cause sloughing wheretheir pressure comes.To remove them one cuts between the two

beads, which has the advantage that the skin is nottouched and consequently very little objection is

made by the child when they are taken out. Evenlightly applied stops may sink into the tissues in away that makes it difficult to cut between them andthe skin, particularly in a very sensitive region andwith a young patient.

5. Jfoining the skin edges. This is done by thesmallest possible catgut sutures applied with theutmost care, to avoid inversion or maladjustment.When the whole ventral surface of the flaps hasbeen joined, it is then lifted upwards and sewn tothe tip of the glans so that the raw undersurfaces of the penile skin are in contact with theraw surfaces produced on either side of the newmeatus.

6. After treatment. If there is any oozing afteroperation, this may be controlled bv a pad and firmpressure for a few hours, but after this the woundsare left open to the air with no dressing butsulphonamide and penicillin powder blown uponthem. The stop sutures are removed after sevendays and the urethral catheter after a week; thechild is then allowed to get up. It is perhapsnecessary to give a warning to those unfamiliarwith operations of the kind that the oedema andthe large bare area on the dorsum of the penismake the immediate post-operative appearance inmany cases rather alarming. They may be con-soled with the assurance that the healing processeswill restore the normal outline in the mostastonishing way in the course of. a few weeks.Along the line of the new urethra there is for abouta year a steadily diminishing thickening in thesubcutaneous tissues; this finally disappears andthe tissues become supple and elastic.

* Footnote to Editorial (p. 356).

Mr. Morson points out that this example of a patient making use of his relationshipto a surgeon for commercial purposes is not unique. Many years ago when a patient ofMr. Morson's arrived at a nursing home in order to undergo a serious operation, hebrought with him two bags, one containing his clothes, the other rolls of toilet paper.He asked the Sister-in-charge to distribute these latter among the inmates of the home.It subsequently transpired he was the proprietor of a well-known brand of toilet paper,of which these rolls were samples.

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