Back to the Future: The Cecil-Culp Technique for Salvage Penile Reconstructive Procedures
Dana A. Weiss, MD1, Christopher J. Long, MD1, Jennifer R. Frazier, MPH1, Aseem R. Shukla, MD1, Arun K. Srinivasan, MD1, Thomas F. Kolon, MD1, John P. Gearhart, MD2, Douglas A. Canning, MD1.
1Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
BACKGROUND:
Re-operative penile reconstruction is challenging. In particular, tension-free skin closure is necessary to avoid skin necrosis and flap loss. The repair popularized by Cecil and Culp in the 1940's using the scrotum to provide a vascularized bed for complex hypospadias repairs fell out of favor due to temporal trends towards single stage repairs and the concern for utilizing hair bearing skin on the penile shaft. We hypothesize that a modified Cecil-Culp (CC) concept of penile scrotalization in which we leave the penis attached to the scrotum for 1 year rather than 6 weeks as originally described, provides vascular support to optimize skin mobilization in cases of complex penile reconstruction.
METHODS:
We reviewed our IRB approved registries to identify patients who underwent a CC repair from 1987 to 2016. CC was utilized in multi-stage hypospadias complication repairs or in the setting of insufficient ventral penile shaft skin coverage. We reviewed the anatomic abnormality, the number and type of prior surgeries, and complications before and after CC.
RESULTS:
39 patients underwent CC: 23 with a history of a failed hypospadias repair, and 16 with isolated penile curvature, bladder exstrophy, or skin loss due to trauma. The average age at time of CC repair was 66.9 months in hypospadias patients, and 52.7 months in non-hypospadias patients. Patients with a history of hypospadias underwent an average of 3.6 surgeries prior to CC repair, ranging from 1 to 9. There were 5/39 patients (13%) who had a total of 9 complications after CC repair, including a scrotal abscess requiring drainage, wound infection requiring admission and IV antibiotics, hypospadias fistulae in 5, dehiscence of urethroplasty, and difficulty removing the urethral stent requiring cystoscopy in OR. The time from CC placement to take down was on average 421 days for non-hypospadias cases, and 339 days for patients with a history of hypospadias. In no patient was the scrotal skin used for penile shaft coverage after takedown. Only 2 patients required surgery after CC takedown, one for stent removal, and one for scrotoplasty. 32 patients have completed all stages of surgical reconstruction, while 7 patients have yet to undergo takedown. The mean follow up after last surgery has been 2.1 years.
CONCLUSION:
Modification of CC repair by delaying 9-12 months before CC takedown maintains the benefits of a robust vascular bed for wound healing while avoiding transfer of hair bearing scrotal skin to the penile shaft. We believe CC repair is an important tool for penile reconstructive surgery of complex hypospadias repairs with inadequate skin as well as for traumatic injuries. Further studies are needed to understand the patient reported perspectives of this multi-stage procedure which better ensures optimal outcomes at the expense of additional planned surgeries.
| Non-Hypospadias n = 16 | Hypospadias n = 23 | |||||
| Original Anatomy | Circumcision n=8 | Other n=8 | Distal n=4 | Midshaft n=3 | Penoscrotal n= 15 | Perineal n=1 |
| Age at Cecil in mos (mean, median) | 52.7, 24.3 | 66.9, 53.9 | ||||
| 43.1, 19.5 | 62.4, 33.9 | 80.7, 49.7 | 45.2, 25.9 | 71.1, 59.4 | 15.9 | |
| Time from first Cecil to Cecil takedown in days (mean, median) | 420.9, 340 (n=13) | 339.5, 364 (n=19) | ||||
| 484.4, 369.5 | 319.4, 252 (n=5) | 395.5, 380 | 277, 277 (n=2) | 299.1, 294.5 (n=12) | 725 | |
| Duration of Follow Up since take down in days (mean, median, range) | 884.4, 653, 4-11497 (n=13) | 666.6, 287, 0-3004 (n=19) | ||||
| 392.3, 290.5, 4-938 | 1671.6, 1674, 97-3060 (n=5) | 118, 127, 70-148 | 307.5, 307.5, 287-328 (n=2) | 714.6, 393.5, 0-2120 (n=12) | 3004 | |
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