Clinical challenge

Prof. Oliver Hakenberg Section editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem.

Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org

Case study No. 71

A 28-year-old man has undergone several hypospadias repairs since childhood. Nevertheless, he is still complaining of dysuria and physical examination shows a meatal stenosis which only admits a guidewire (Fig. 1). His voiding urethrogram is also shown (Fig. 2).

Discussion point • What surgical procedure is advisable?

Figure 1 Figure 2

Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunisia. E-mail: aminbouker@gmail.com

Evaluation of curvature and length of stenosis prior to planning surgery

Comments by Prof. Tony Mundy London (GB)

You can tell a lot from a clinical photograph and from an x-ray image but there are some things that can’t be judged. Most notably, before any operation for hypospadias but particularly revision surgery, I would want to know whether he has a straight erection. He has an apparently straight penis in the photograph with no evidence of curvature in any direction but a formal evaluation before and after an injection of Caverject would be necessary before any surgery.

There is obvious scarring and some swelling towards the right-hand side of the base of the penis and no clear distinct coronal sulcus at the base of the glans. Obviously I cannot comment on the appearance of the dorsum of the penis. The question here is not just about the state of the skin but also about the state of the dartos layer.

Your “clinical comment” says that he has meatal stenosis but it doesn’t say how long that stenosis is and it is impossible to tell from the x-ray image. That is very important in planning revisional surgery.

The imaging shows a bulbar penile urethra that is ballooned, presumably by the meatal stenosis, but there is no evidence of stenosis anywhere else although the proximal bulbar urethra is not clearly shown. It is however striking that the proximal bulbar urethra is of considerably more narrow calibre than the more distal bulbar urethra and has not been “ballooned” in the same way. It may be that this is because it is normal urethra with a normal corpus spongiosum around it whereas more distally the urethra is “man-made” but I would be concerned about this disparity and would insist on a cystoscopy prior to any intervention as well as seeing the rest of the x-ray series.

In theory, at least, it may well be that meatal stenosis is responsible for all of his symptoms of dysuria in which case it would be interesting, if it is indeed a very short stenosis, just to open up the meatus and see whether that resolves his symptoms. Knowing that that is the case would help decide whether to do any further surgery and, if so, how. Given that he is 28 he presumably would like to have a normal looking penis and be able to pass urine and ejaculate normally as well, but you never know unless you ask.

As always with revisional surgery the patient needs to be counselled that this may be best done in stages, particularly having had several operations, as this man clearly has. I would expect to do a staged procedure, if he was my patient.

If the proximal bulbar urethra is normal then it may be best in the first instance to deal with the meatal stenosis and the absent distal penile urethra. I would make a dorsal incision at the meatus to open up the meatus, with or without ventral spatulation as well, and extend that incision distally along the ventral aspect of the shaft of the penis, through the glans to the tip of the penis. This incision would be through the skin and the dartos down on to the tunica of the corpora cavernosa up to the tips of the corpora then through the substance of the glans to the tip of the penis where the meatus is to be sited. The dissection in the substance of the glans will be to create a space in the glans which, with buccal mucosal grafting, can be closed up as a glanular urethra at a second-stage. This would require a little bit of manoeuvring of the skin in the region of the coronal sulcus to get a more normal appearance but it doesn’t look as though that would be too difficult. The full length of this ventral incision from the site of the present meatus to the tip of the “new meatus” could then be undermined on each side so that a 2 cm wide buccal mucosal graft can be harvested and then quilted onto the tunica, between the skin margins to form the basis of the new urethra.

If it is decided that the bulbar penile urethra needs to be reconstructed and that this is the time to do it then at the same stage a ventral stricturotomy and marsupialisation of the proximal penile and bulbar urethra could be performed. Then, at the second-stage, the entire urethra could be closed up to give a more even urethral calibre. Alternatively, this could be done as part of the second-stage. This would be about six months after the first stage.

If the proximal bulbar urethra has been shown to be normal then no further action would be necessary. If, however, the proximal bulbar urethra had been shown to be abnormal then it may well be that a staged or single-stage buccal mucosal graft inlay urethroplasty may be necessary to restore that area to normal. Again, that would be part of the staged urethroplasty of the rest of the bulbar urethroplasty. This 40-year-old man was an emergency referral for acute anuria, severe dyspnea and abdominal swelling. In addition, a large testicular tumour (10x20 cm) was seen. The history was vague as to the duration of the testicular swelling.

Test results:

• α-fetoprotein was 13.149 IU/ml • β-HCG 220 mU/ml • LDH 650 U/l • serum creatinine 119 µmol/l • serum potassium 6.0 mmol/l

The patient was tested positive for COVID-19. The CT scan, performed without contrast media because of acute renal failure, is shown in fig. 1-3.

Fig. 1 Fig. 2

Fig. 3

Discussion point • What immediate and further management is necessary?

Case provided by Prof. Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. E-mail: oliver.hakenberg@med.uni-rostock.de

Case study No. 71 continued

The required surgery was performed in two stages 6 months apart.

First stage: A guidewire was inserted into the urethra. Ventral incision showed that the patient had undergone previous skin urethroplasty (Fig. 1). A stone was removed (Fig. 2). Hairy areas were excised and inner skin to skin anastomoses were done (Fig. 3). Excess skin was trimmed and the urethra was tubularised over a 24Ch Foley catheter and covered with dartos flaps (Fig. 4). Buccal mucosa graft (BMG) was harvested and quilted onto the distal aspect of the urethra (Fig. 5).

Second stage, 6 months later: Skin incision was made on the lateral edges of the BMG (Fig. 6) and due to localized skin contracture, the urethral plate was incised in the midline (Fig. 7) and a small BMG was added in an Asopa fashion. The distal urethra was tubularised and waterproofed with dartos fascia (Fig. 8) before skin closure. 1 2 3 4