Cantwell-Ransley technique in complete epispadias repair

Cantwell-Ransley technique in complete epispadias repair

KhaledA. Ismail, MD; Mohamed  H. Mazhar Ashour, MD;

Akram El Batarny, MD; Mohamed  Hashish, MD

Pediatric  Surgery Unit-Department of General  Surgery-Tanta  University.

Background/Purpose: Epispadias  is a rare congenital  anomaly of the external genitalia occurring in approximately one in 118 000 males and one in 400 000 females. The purpose of this study is to evaluate the results ofCantwell-Ransley operation in the repair of complete epispadias.

Patients   &  methods:  Between  June  2006  and  June  2012,   11  patients  with  complete epispadias  were treated with the Cantwell-Ransley  technique  at the Pediatric  Surgery Unit­ Tanta University Hospital. Patients were followed up for 3 months to report any complication.

Results:  11 male cases with epispadias were admitted to the Pediatric Surgery Unit-Tanta University Hospital in the period from June 2006 to June 2012 with history of bladder exstrophy repair 1-2 years earlier. All cases were peno-pubic. Their age ranged from 1 7112 years to 3 years, with a mean of 2 3/12 years. Cantwell-Ransley  operation was performed to all patients with satisfactory results. Only one case showed mild wound infection that was conservatively managed. Another case developed urethra cutaneous fistula, which was surgically treated by simple excision & closure after 6 months of epispadias repair.

Conclusion: The cosmetic and functional outcomes ofCantwell-Ransley epispadias repair appear to be excellent.

Key words: Epispadias, Cantwell-Ransley operation.

Introduction:

Epispadias is  a  rare  congenital   anomaly of the  external  genitalia occurring in approximately one in 118 000 males and one in  400  000  females.l  The  defect   however is   also   seen   in   association  with    classic bladder  exstrophy (the exstrophy-epispadias complex) with an incidence of approximately one in 40 000.2 The first documented report of epispadias dates  back  to AD 610-641 and Byzantine  Emperor  Heraclius.l According to meatal   position   certain  degrees   of  severity have  been described, including balanic epispadias (the less  severe  and  less common grade),  penile  or continent  epispadias (some degree  of incontinence is often  present)  and peno-pubic   or   incontinent  epispadias.  In the  latter  category the  whole  urethral  plate is widely  open  as  well  as the  bladder  neck, the  external  sphincter  is deficient,  the  pubic

bones  are  separated to  various  degrees,  and

the penis is short and connected to the pubis.3

In 1895, Cantwell  introduced the true urethroplasty for reconstruction of male epispadias. He created a tube from the urethral plate, freed it completely to its proximal  base and then transplanted it below the corpora cavernosa.   The  technique  was  modified   in

1903 by Bullitt  who, after losing  most of the urethral  plate,  inadvertently discovered that the preputial skin could be usedfortheterminal segment. For most of the last 50 years the most popular  technique used for epispadias repair has been the Young modification of Cantwell technique.3  Gross   and   Cresson   mobilized the urethral  plate from  both corpora  but with a  narrow   attachment to  the  ventral   penile skin for blood supply. Mclndow converted epispadias  to   hypospadias  by  tabularizing the urethral  plate and transposing it ventrally beneath  the  corpora.   In  1963,  Michalowski

and  Modelski  recommended  a  multi-stage

Am-ShamsJSurg2014;7(2):393-400

epispadias repair. Since then, urethral  repairs using   preputial    graft   or   bladder   mucosa graft   have    been   described.4-9    The   wide variety  of techniques reflects the generally unsatisfactory    cosmetic      and     functional results from penile reconstruction.  In 1989, Ransley  et aP reported a modification of the earlier   Cantwell repair.  Since  then,   due  to the  excellent cosmetic  and functional results achieved with  this technique, the  Cantwell­ Ransley  epispadias repair has been widely adopted.3

Patients and  methods:

Between   June  2006  and  June  2012,  11 patients    with    complete   epispadias   were treated with the  Cantwell-Ransley technique at the Pediatric Surgery Unit-Tanta University Hospital.

All cases were subjected to:

•       Complete  history taking.

•       Thorough  clinical  examination.

•   Complete   urine   analysis   before operation, to  detect  and manage  any urinary tract infection before  surgery.

•       Operative     repair     by     usmg     the

Cantwell-Ransley technique.

Pre operative  preparation often included treatment   with    testosterone   to    improve the  vascularity  of  the  preputial   and  penile skin  and  to  increase  the  size  of  the  penis. Patients  received  3 intra  muscular  injections of 2 mg/kg  testosterone at monthly intervals preoperatively.  Also  topical   testosterone cream  5% was applied to the urethral  plate.

With the patient lying supine, artificial erection   was  performed by  saline  injection at both corpora cavemosa to  detect presence of  chordee  and  mark  its  site  and  extent.  A traction suture was placed through the ventral aspect of the glans penis, and then a wide strip ofurethral mucosa extending for the prostatic urethral meatus to the tip of the glans was outlined  and incised on the dorsum. Thick glandular flaps were constructed bilaterally. The ventral  skin was taken down to the level of the scrotum. Care was taken to preserve the vascularity ofthe urethral  plate, which arised proximally  and   extended   upward   between

the  corpora as a blood  supply to the urethral

plate.  The  corpora  were  dissected ventrally on the surface of Buck fascia. The plane was followed closely  bilaterally to the  dorsum  of the penis between the corpus spongiosum and the  corporal  body.  The  suspensory ligament was divided  in some  cases  with  small  sized penis.  The  urethral  plate  was  dissected  just on  the  corporal   bodies  to  the  level  of  the prostate and the glans, respectively. Care was taken to leave the most distal one centimeter attachment of the mucosal  plate  to the  glans intact. The urethral strip was tabularized over an 8 French silicon  stent, and a tube was fashioned by continuous 5/0 PDS sutures.

Afterward, the corporal bodies were closed

over   the   neo   urethra.   The   now   ventrally placed  urethra  was secured  in place between the  corpora.  The glanular  wings  were  closed and  the  ventral  skin  sutured   to  the  ventral edge of the corona, while the flaps provided coverage ofthe dorsum.

A silicon  stent  was  secured  and  a plastic

occlusive dressing  applied.

Patients  were followed up for 3 months to report any complication.

Results:

Our  study   included   11  cases  with epispadias, admitted  to the Pediatric  Surgery Unit-Tanta  University Hospital  in the  period from June 2006 to June 2012.  All cases were males,   with   history   of   bladder   exstrophy repair 1-2 years earlier. All cases were peno­ pubic  type.  Their  age  ranged   from  1  7112 years to 3 years, with a mean of 2 3/12  years.

2 cases had a history of associated bilateral congenital inguinal  hernias,  which  were repaired in the same session after bladder closure.

Testosterone was given in a dose of 2 mg/

Kg,  in 3 monthly doses  before  operation, in addition  to topical 5% ointment applied to the urethral  plate.

Cantwell-Ransley          operation         was

performed to all patients  as previously mentioned.  Artificial  erection   by  saline injection  in   both   corpora   was   performed in the beginning of the procedure to detect presence  or absence of dorsal chordee,  which

was seen  in 3 cases. The site and extent  was

m-     ams      ur;g_      4;    _:        -4

Figure  (1): Peno-pubic  epispadias  after repair of bladder exstrophy.

Figure (3): Traction sutures applied to Glans.

Figure (5): Degloving ofPenile Skin.

determined. Fibrous tissue in the corpora responsible for chordee was excised, and artificial erection  was  perfonned  again  to deal with any residual chordee present.

Complete    disassembly     of     suspensmy

Figure (2): Ventral prepuce.

Figure (4): jVfarking the urethral flap.

Figure (6): Dissection of corpora cavernosa.

ligament of the penis was resorted to only 5 cases, while the remaining cases undetwent disassembly of both corpora without the suspensmy ligament.

The  urethral plate was dissected till its

Figure  (7):  Both  corpora   dissected  and disassembled.

Figure (8): Disassembled 3 components.

Figure  (9):  Neo  urethra  completed  using continuous 5/0 P DS sutures.

Figure (10): Suturing both corpora over neo urethra.

Figure (11): At the end of the operation.

distal end at the glans, and a tube was created over an 8 French silicon catheter using 5/0 continuous PDS sutures. The corpora were sutured  together   using  interrupted   sutures over the ventrally placed neo urethra with internal  rotation  to  prevent  occurrence   of dorsal chordee.

At the end of operation, a plastic occlusive

dressing was applied with urethral catheter kept in place for 7-10 days.

All cases were given IV intra and post operative broad spectrum antibiotics.

As regards post operative complications, only one case showed mild wound  infection that  was  conservatively   managed.  Another case   developed   urethro  cutaneous   fistula, which  was surgically treated  by  simple excision & closure 6 months later.

Satisfactory  reconstruction  was  obtained

in  all cases  where  the  penis  was  achieved with  a  conical  glans,  apicoventral  meatus, with downward direction on standing.

The  mothers  of  young  patients  reported

straight erections post operatively.

The results of continence could not be evaluated  as  all  cases  were  too  young  for such evaluation.

Discussion:

Epispadias is a rare condition and most commonly described as a part of the bladder exstrophy complex.lO This study included 11 cases with epispadias associated with bladder exstrophy   in   6   years   period.   Lottmann et aP reported 40 cases in 8 years, while Kajbafzadeh   et  al4  reported  180  cases  in

15  years,  of  them,  75  cases  underwent  the

Cantwell-Ransley   operation.   Ashraf  Hafez et alll  performed 14 post pubertal epispadias cases in 7 years. Their ages ranged from 14 to 34 years.

All  our  cases  had   previous  first  stage bladder exstrophy closure, followed by epispadias repair 1-2 years later. The age incidence  of our cases  ranged  from  1 7/12 years to 3 years, with a mean of2 3/12 years. All were males.

Two  cases  had  a  history  of  associated

bilateral   congenital   inguinal   hernias   that

were repaired in the first stage with closure of

bladder exstrophy.

All  cases  were  peno  pubic  type,  with evident dorsal chordee in 3 cases (27.2%). Hammoudal2 reported 42 male cases with epispadias in 4 years period. Of them, 29 cases had complete epispadias as a component of bladder exstrophy.

As  a  rule,  all  our  cases  received  3  IM

injections of testosterone at monthly intervals before operation, in addition to topical application of testosterone 5% ointment. This was performed to facilitate penile growth and improving  vascularity.  Jacob  Ben-Cham  et ai13 & Gearhart & Jeffsl4 recommended  pre operative  administration  of testosterone  for the same reason.

Lottmann et aP recommended pre operative testosterone administration to increase penile size and blood supply, and hence facilitates its reconstruction.  Gearhart15 suggested that testosterone   application   helps   to  enhance the penile skin, increase vascularity of the urethral plate and soften any area of scarring, which may decrease the incidence of post operative skin and urethral necrosis.l5

As previously described, all our cases were

subjected to the Cantwell-Ransley  procedure. Baird et  all  performed  the same  technique to 129 boys, of which 97 had classic bladder exstrophy and 32 had primary complete epispadias.

Artificial erection was performed to all our

cases before proceeding to penile disassembly. Saline injection into both corpora separately was performed to detect chordee and assess its direction  and  extent.  We found  3  cases with dorsal chordee that was corrected by excising  all fibrous tissue  over the  corpora that was responsible for angulations.

The neo urethra reached the  glans' tip in

a normal position without shortening as the distal part of the urethral plate was kept intact. The end result was an apicoventral meatus in a conical glans.

The catheter was kept for 7-10 days then removed. The end result was satisfactory.

Mild  post  operative  edema  & inflammation  of  the  skin  was  seen  in  one case, which  was conservatively  treated  and

completely resolved. Another case developed

Am-ShamsJSurg2014;7(2):393-400

urethra-cutaneous fistula  that  was surgically treated    by   simple    excision    and                                                              closure

6  months   later.     No  urethral    stenosis   or

recurrence was seen among our cases.

Baird  et al 1 in their  large  series using the Cantwell-Ransley technique stated  that any chosen surgical  technique to reconstruct peno pubic epispadias must address  four factors: Correction of dorsal chordee, Urethral reconstruction, Glanular  reconstruction and Closure   of  penile  skin.  They  had  25  cases having   post   operative   fistula   representing

19.3%, reduced  to 15.5% after 3 months.

Kajbafzadeh et  al4  who  worked  on  180 boys with epispadias performed their new technique  in   75   cases.   The   results   were much  better  than  in  any  of  the  remaining cases  who  underwent other techniques. 84% were   regarded   as  very   satisfactory,  and  a poor outcome requiring minor skin revision, fistula excision or urethral dilatation occurred in  only  16%.  Fistula  occurred   in  only  4% and urethral stricture occurred in 5.3%.  They had no case of urethral ballooning or skin dehiscence.

Baird  et  all  found  that  this  technique  is

reliable,   and  a review   of  published  studies has not demonstrated loss of glans or corporal tissue  as reported in other repairs. Surer et all6 showed an initial postoperative fistula rate of

23% reducing  to 19% at 3 months.

Ransley  et all7, Surer  et all6 and Mollard et ai18 stated that the cosmetic and functional outcomes of Cantwell-Ransley epispadias repair  appear to be excellent.

Conclusion

Any  chosen  surgical   technique to reconstruct peno  pubic  epispadias must address four factors:  Correction of dorsal chordee, urethral reconstruction, glanular reconstruction and closure  of penile skin.

The  cosmetic  and functional outcomes of Cantwell-Ransley epispadias repair appear to be excellent.

Reference

1-   Baird   AD,   Gearhart   JP,   Mathews   RI: Applications of the modified Cantwell­ Ransley epispadias repair in the exstrophy­ epispadias  complex. Journal   of  Pediatric

Urology 2005; 1: 331-336.

2-  Lancaster PAL: Epidemiology of bladder exstrophy: A communication from the international clearinghouse for birth defects monitoring  systems. Teratology  1987; 36:

221.

3-   Lottmann HB, Yaqouti M,  Melin Y:  Male Epispadias Repair: Surgical and functional results with the Cantwell-Ransley procedure in 40 patients. The Journal ofUralogy 1999;

162: 1176-1180.

4-   Kajbafzadeh  AM,  Duffy PG, Ransley PG: The revolution of penile reconstruction in epispadias repair: A report of 180 cases. The Journal ofUralogy 1995; 154: 858-861.

5-    Jr Duckett JW: Epispadias. Ural Clin N Amer 1978; 5: 107. 

6-   De   Sy  WA,  Oosterlinck  W:   One-stage hypospadias  repair  by  free  full-thickness skin graft and island flap techniques. Ural Clin N Amer 1981; 8: 491.

7-   Vyas  PR,    Roth    DR,     Perlmutter   AD: Experience   with   free   grafts  in   urethral reconstruction. J Ural1987; 137: 471.

8-   Ransley PG, Duffy PG, Oesch IL, Hoover D: Autologous bladder mucosa graft for urethral substitution. Brit J Ural1987; 58: 331.

9-   Hendren WH, Crooks KK: Tubed free skin graft for construction of male urethra. JUral

1980; 123: 858.

10- Dominic    Frimberger:    Diagnosis    and management of epispadias. Seminars in Pediatric Surgery, 2011; 20: 85-90.

11- Hafez  AT, Helmy  T:  Complete  penile disassembly for epispadias repair in post pubertal  patients.  Urology,  2011; 78  (6):

1407-1410.

12- Hammouda HM: Results of complete penile disassembly for epispadias repair in 42 patients. The Journal ofUralogy, 2003; 170:

1963-1965.

13- Ben-Chaim J, Peppas DS, Jeffs RD, Gearhart JP: Complete male epispadias: Genital reconstruction and achieving continence. The Journal ofUralogy, 1995; 153: 1665-1667.

14- Gearhart JP, Jeffs RD: The use of parenteral testosterone therapy in genital reconstructive surgery. J Urol1987; 138(2): 1077.

15- Gearhart JP: Evolution of epispadias repair. Timing, techniques and results. J Urol1998;160: 177.

16- Surer I, Baker LA,  Jeffs RD, Gearhart JP: The    modified    Cantwell-Ransley    repair for         exstrophy   and   epispadias:    10-year experience. J Ural2000; 164: 1040-1042.

17- Ransley PG, Duffy PG, Wollin M: Bladder exstrophy and epispadias. In: Spitz L, Nixon lll-I, editors. Pediatric Surgery. London: Butterworths; 1988: 620-632. 

18- Mollard  P,  Bassett   T,  Mure   PY:  Male epispadias: Experience with 45 cases. JUral 1998; 160: 55-59.