As Stephen Koff already mentioned in his publication, rather than being a specific type of hypospadias repair, mobilization of the anterior urethra is an adjunctive surgical technique for improving the position of the meatus and is adaptable to a variety of hypospadiac conditions [1].
The pyramid exposure provides a safe and simple dissection of the urethral plate and allows subsequent caliber with excellent functional and cosmetic results [2].
Mark Zaonts described a glandular approximation procedure for glanular and coronal hypospadias with a wide, deep glanular groove [3].
The corpus spongiosum and urethra are supplied by bulbourethral arteries, one on either side, which are the branches of the internal pudendal arteries. Hence, the urethra with corpus spongiosum can be safely mobilised to the level of the penoscrotal junction without fear of de-vascularisation [5]. The postoperative healing process involves an inflammation response with vascular endothelial growth factors so one must consider an anastomosis of the corpus spongiosum to the glans in addition to the urethral mobilisation.
The technique we propose combines elements from all these procedures. The main rationale for this approach is to correct the defect using the child's native urethra and avoid a suture urethroplasty with its potential complications.
What the history of hypospadias repair has thought us is that no procedure fits all. The surgical technique should be decided intraoperatively and customised accordingly after degloving the penis and observing the true extent of the defect. Furthermore, the selected method may not be sufficiently appropriate, potentially leading to the patient requiring a repeat procedure. Therefore, it is our strong opinion that careful patient selection is the most important step when considering urethral advancement.
Patients with curvature more than 60 degrees are not candidates for this technique because even with good dissection of the native urethra you cannot achieve a tension-free suture to the tip of the glans. The length of the advancement after urethral mobilisation is smaller than the length of the degloved penis.
Another important feature is the size of the glans, but should not be considered as an element of exclusion for this technique. If the lateral wings of the glans are extensively prepared, as per Snodgrass TIP procedure, the subsequent glansplasty should not compress the advanced urethra.
Redo cases represent a special category of hypospadias patients. This procedure can successfully be applied in these situations if specific criteria are met, but most importantly, the scar tissue must be excised entirely before starting the urethral dissection.
In our studied population only four cases presented with medium-term complications. We found that the reason was retraction of the advanced neourethra. We also observed that this happened in older boys, possibly because the advanced stage of virilisation and in redo cases.
Advancement of the native urethra in hypospadias patients is not a new technique, variations of the procedure have been published through the years [6], [7]. The main amendment in the procedure we performed is the longitudinal, median incision made in the avascular plane between the two corpus cavernosum from the inferior limit of the disassembled native urethra to the tip of the glans obtaining a sulcus in which the urethra-spongiosum complex is placed and advanced distally. When correctly performed this longitudinal incision doesn't injure the corpora and contributes to both the tension free suture of the urethra-spongiosum complex to the glans and a smooth healing process with no retraction.