A strategy for management of ischemic tissues and skin flaps in re-operative and complex hypospadias repair
Moneer K. Hanna, MD,FRCS1, Christine White, MD2.
1New York Presbyterian-Cornell, New York, NY, USA, 2Rutgers RJWSt. Barnabas Medical Center, New Jersey, NJ, USA.
Background: Repeated and multiple surgeries for hypospadias results in a varying degree of scarring and hypovascularity of the tissues and the penile skin. During repeat surgery skin flap ischemia may exhibit pale appearance without capillary refill due to arterial insufficiency, or more frequently rigid blue color with rapid refill due to venous insufficiency. This tissue ischemia may result in poor healing and vasodilator agents can be helpful. Herein we review the results of our strategy for management these compromised hypovascular tissues using 2% nitroglycerine ointment (NTG) and hyperbaric oxygen therapy (HBOT) for redo surgery of hypospadias during the past 3 years with emphasis on the tissues and skin flaps healing.
Material & Methods: Between May 2014 and June 2017, 56 patients (2-19 years old) underwent re-operative repair of proximal hypospadias complications following failed surgeries (3-6 attempts). Group I included 24 patients were noted to exhibit significant tissue ischemia of the skin flaps post-operatively. The re-operative procedures included: surgical repair following multiple glans dehiscence (9pts), urethroplasty and urethral mobilization after partial or total breakdown of prior repairs (6), repair of urethral fistulas following multiple attempted closures (5), and correction of recurrent chordee with revision of scarred skin flaps (4). NTG was applied at the conclusion of surgery and following approval by their insurance (within 36 hours) daily HBOT for 90 minutes was instituted (6-10 sessions). Local steroids (Betamethasone cream 0.05% for young or 0.1% for older children) was applied to the skin starting 4-6 weeks postoperatively and continued daily for 3 months in order to reduce/avoid scar or keloid formation. The median follow up was 14 months. This protocol was not used in Group II (32 pts.).
Results: In Group I: 22/24 ((90.6%) the repairs were successful with notable remarkable decrease of postoperative edema. One patient developed wound infection and the distal repair broke down. Another patient who had had 5 prior surgeries elsewhere and a staged buccal mucosal graft for glans dehiscence by us developed breakdown of the very distal repair resulting in a low glandular subterminal meatus. In Group II a successful outcome was noted in 23/32 (75%) at 3 weeks post-operatively. Subsequently 4/9 pts. were lost to follow up, 5 pts. underwent additional surgery and 4/5 achieved good outcome. The fifth pt. declined further surgery. The Follow up group II varied between 6 months and 3 years
Conclusions: Generally, flap nonviability is believed to be related to derangement of its microcirculation. Nitroglyerin is a potent vasodilator and is currently applied to all post mastectomy skin flaps in various centers. HBOT has demonstrated well established utility in the salvage of compromised grafts/flaps in plastic surgery. It enhances tissue circulation, improves vascularization, and promotes angiogenesis. The proposed treatment modality appears to result in reversal of tissue hypoxia and improved wound healing. This preliminary report show Improved outcome with less morbidity at short term follow up in a group of patients who endured multiple hypospadias surgical failures and It warrants further application in a larger number of patients
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