Redo Epispadias Repair

Redo epispadias repair

Redo epispadias repair is an additional or revision repair operation conducted to either repair a failed previous epispadias repair operation or because of complications or lack of desired functional or cosmetic appearance. It is more complicated than the primary repair due to scar tissue, distorted anatomy and previous surgical interventions.

Redo Epispadias Repair Indications

The redo surgery can be suggested when a patient has:

• Persistent or persistent epispadias malformation.
• Continuous urinary incontinence as a result of poor reconstruction of bladder neck.

Urethral complications, including:

• Urethral stricture
• Urethral fistula
• Meatal stenosis
• Aesthetic issues (penile curvature, dorsal chordee)
• Abortive primary repair of the neck of the bladder.
• Dehisced or ill-healing repair.

Revision epispadias surgery

Revision epispadias surgery is carried out to fix the problems or failures of the epispadias repair. Due to the possibility of scarring or alteration of tissues, one should plan the procedure carefully and select the technique.

Anaesthesia & Positioning

• Surgical intervention is done via general anaesthesia.
• The patient is positioned in his supine position with his legs slightly separated to expose his genitals.
• Antibiotics are used prophylactically.

Marking and Incision

• The surgeon also crows past scars and outlines cuts to avoid tissue with low vascularity.
• Depending on the defect and any prior repair a circumferential dorsal incision or a midline dorsal incision are fashioned.

Release of Scar Tissue

• The scar tissue that was left after the first surgery is densely removed.
• The surgeon releases the urethral plate, corporal cavernosa, and skin overlying it.
• Additional measures are employed to ensure blood supply and neurovascular bundles integrity. 

Correction of Penile Curvature (Chordee) 

• The backs of the corporal bodies are checked.

In case the penis is curved upwards, the surgeons do:

• Fibrosis release
• Corporal dorsal grafting or plication.
• This is to obtain a straight penile axis.

Urethral Reconstruction

Based on the presence of healthy tissue, surgeons use one of the following ones:

Re-tubularization of Existing Urethral Plate

• Applicable in case the urethral plate is retainable.
• The plate is rolled and sewn in order to restore urethra.
• Graft Augmentation (in case plate is scarred or deficient)
• Buccal mucosa graft (cheek inner)
• Preputial skin graft (unless done previously)
• Full-thickness skin graft
• Grafts increase or reconstruct the urethral tube.

Two-Stage Urethroplasty

• Applied in cases where tissues are scarred and require one repair.

Stage 1: Stage of placing graft and letting it heal.

Stage 2: Months later Tubularization is performed.

Bladder Neck Reconstruction (In case of continence problem)

In the case of patients with chronic incontinence:

• Young-Dees-Leadbetter procedure

or

• Adjusted tightening of the bladder neck.

This step:

• Repairs the bladder neck.
• Narrows the outlet
• Enhances functioning of the sphincter.
• Depending on the approach, May need abdominal incision or endoscopic.

Meatal Reconstruction

• The urinary aperture is reconfigured to form a beak like front-facing slit that is slit like.
• Suture of the edges is done without tension in order to minimize stenosis.

Penile Skin Closure and Glans

• The new urethra is approximated against the glans wings.
• The rearrangement of penile skin is performed to ensure that the skin does not become tight around the shaft.
• In order to enhance cosmetic appearance, Z-plasty or rotational flaps can be employed.

Catheter Placement

• Urethral catheter (retained between 2 and 3 weeks)
• Suprapubic catheter can be included with the complicated cases or bladder neck repairs.
• Drains are not needed very often unless a lot of tissue dissection was performed.

Dressing & Recovery

• 48 to 72 hours of pressure dressing.
• Analgesia and administered antibiotics.
• Length of stay 3-7 days, sometimes complex.

Post-redo recovery of Epispadias Repair

Hospital stay

• 3 to 7 days with reconstruction complexity and bladder neck repair.

At home

• Catheter care until removal
• Antibiotics and analgesics
• Limited exercise during 4-6 weeks.
• Frequent dressing and wound check-ups.

Follow-up Tests

• Ultrasound
• Uroflowmetry (in children over 6 years old)
• Continence assessment
• Cystoscopy where complications occur.

Redo epispadias urethroplasty

When the initial urethral reconstruction has not been successful, or has caused stenosis, fistula or left the urethra inadequately distanced or shaped, redo epispadias urethroplasty is undertaken. Redo urethroplasty is also more complicated than primary repair because of the scarring and prior surgery.

Indications

Redo urethroplasty is done in case of:

• Chronic or recurrent epispadias malformation.
• Urethral fistula
• Urethral stricture
• Meatal stenosis
• Having bad cosmetic or functional outcomes induced by the previous urethroplasty.
• Proximal urethral deformities-related urinary incontinence.

Redo Epispadias Urethroplasty- Step-by-Step Procedure

Anaesthesia & Preparation

• General anaesthesia
• Supine position
• Prophylactic antibiotics
• Light insertion of catheter (where possible) to define lumen.

Incision & Exposure

• Incisions will be made on the existing scars to prevent damaged tissue.
• A dorsal penile incision is usually applied.

Scar tissue is deftly removed in order to reveal:

• Urethral plate
• Corporal bodies
• Glans wings

Examination of Urethral Plate

The surgeon dictates the possibility of preserving the urethral plate:

Salvageable Urethral Plate

In the event that they are reasonably healthy and broad enough:

• Plate augmentation or
• Re-tubularization (when the width 1.2-1.5 cm)
• Unsuitable Urethral Plate

In case scarred, narrow, or unhealthy:

• Surgery of scarred areas.
• Graft reconstruction or staged reconstruction.

Techniques of Urethral Reconstruction

Redo urethroplasty can be done with one or all of the following options based on the quality of tissues available:

Technique 1:Re-tubularization of Existing Urethral Plate

• Should only be done in case the plate is healthy.
• The plate is rolled and sutured on a catheter.
• Interrupted or continuous absorbable sutures are utilised.
• Suggested: mild relapse or slight scarring in the past.

Technique 2: Onlay Graft Urethroplasty 

• Applied to plate that is narrow but can be saved.

Graft options:

• Buccal mucosa graft (most reliable)
• Preputial skin graft (preserved)
• Full-thickness skin graft

Steps:

• Graft on one side of urethral plate.
• Edges suture to dilate the tube.
• Re-tubularization done on catheter.

Technique 3: Tubular Graft Urethroplasty 

• Misused in case the whole segment of the urethra requires reconstruction.

Steps:

• Graft harvested (typically buccal mucosa)
• Rolled into a tube
• Anastomosed both at the proximal and distal.
• Neovascularization was facilitated by dartos or tunica flaps.

Method 4 -Two-Stage Urethroplasty 

• Evidenced by gross scarring or unsuccessful suture.

Stage 1:

• Scarred tissue excised
• Corporal bodies with buccal or skin graft.
• Left to heal and grow (3-6 months)

Stage 2:

• Growth of graft into final urethra.
• Indicated: the high complexity redo cases.

Approach 5: Unified Strategy 

Surgeons may combine:

• Plate augmentation
• Graft insertion
• Tunica or dartos flap cover.
• In particular, when treating fistula and stricture both.

Glansplasty

• Glans wings are mobilized
• Clogs over reconstructed urethra.
• Secures a slit-like, anterior meatus.

Tissue Coverage

Surgeons should add to minimize the risk of fistulas:

• Dartos flap
• Tunica albuginea flap
• Preputial flap with vascularity.
• These form a protective intermediary layer.

Catheterization

• Urethral catheter: 2–3 weeks
• Suprapubic catheter: when complex or proximal reconstruction is needed.

Closure & Dressing

• Sutures are fined absorbable.
• Pressure dressing applied
• Administered antibiotics, analgesics.

Recovery

• Hospital stay: 3–7 days
• Catheter care at home
• Avoid pressure, sitting astride, or vigorous activity during 46 weeks.
• Flow test and evaluation follow-up.

Epispadias repair recurrence treatment

The original defect or complications associated with it have been re-emerged or not completely addressed, including an open urethral defect, persistent dorsal opening, urinary incontinence, or continued chordee.

The treatment is determined by the section of the previous repair that failed, urethra, bladder neck, penile alignment, or meatus.

Causes of Recurrence

Epispadias may recur as a result of:

• Scar tissue formation
• Poor blood circulation to the reconstructions tissues.
• Partially dehisced wounds (opening wounds).
• Obstruction of the urethra in the dorsal position.
• Bladder neck reconstruction giving rise to incontinence.
• Poor quality of tissues due to previous surgeries.

Recurrence Treatment

• It is normally surgical, and the treatment depends on the recurrence type and the severity.

Redo Epispadias Repair

• Applied to recurrence of the dorsal urethral opening or cosmetic deformity.

This includes:

• Re-opening incision
• Releasing scar tissue
• Reproduction of the urethral plate.
• The penile curvature (when existing) is to be corrected.
• Re-tubularization or urethra augmentation.
• Recreating a normal meatus
• This resembles primary epispadias repair except that there is scarring.

Redo Urethroplasty (In Urethral Failure)

• In case of the recurrence of the condition in the urethral tube: fistula, stenosis, or breakdown:

Options:

• Re-tubularization of plate (in case tissue is still healthy)

Onlay graft repair using:

• Buccal mucosa
• Preputial skin (if preserved)
• Tubularized graft urethroplasty (in case of significant flaws)
• Severe scarring Two-stage urethroplasty.

Bladder Neck Reconstruction (Incontinence Continues)

• Recurrence in most cases occurs in form of persistence of urinary leakage.

Treatment includes:

• Young-Dees-Leadbetter repair (gold standard)
• Adjustments on bladder neck tightening surgeries.
• Urethral lengthening
• Repositioning the urethra due to continence.
• In complicated situations, adulthood artificial sphincter implantation can be discussed.

Treatment of Residual Penile Curvature

In the event of recurrence; dorsal chordee:

• Release of fibrotic bands
• Dorsal corporoplasty
• Grafting (when there is deficiency of tissue)
• This fills the penile straightness back.

Meatal Reconstruction

In case of recurrence, a broadened, elevated or deformed meatus:

• Meatal advancement
• Meatoplasty
• Glans wing reapproximation
• This enhances urinary flow and urinary looks.

Treatment of Fistula (Recurring Problem)

In case the repaired urethra leaks:

Treatment:

• Fistula excision
• Layered closure
• Protective flap (dartos or tunica).
• Catheter-based healing care.
• Minor fistulas (less than 3 mm) hardly resolve; they are often repaired by surgery.

Stricture or Narrowing Management

In case there is poor urine flow due to recurrence:

Treatment:

• Dilation (temporary solution)
• Internal urethrotomy (only mild cases)
• Redo urethroplasty (definitive)

Multi-stage Reconstruction (In the case of severe recurrence)

In case of overgrown scarring of tissues due to previous surgery:

• Stage 1: Graft applied
• Stage 2: Reconstructed urethra after 3-6 months.
• Complex re-repairs are normally so.

Limited Role Non-surgical Management

Only mild problems to be used:

• Catheterization to assist in healing of minor breakdowns.
• Antibiotics for infection
• Topicals on superficial wound problems.
• Pelvic floor therapy (in older children and adults with mild incontinence) 

Nevertheless, the recurrence that is really true practically always demands surgery.

Best hospital for redo epispadias repair India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Redo epispadias repair and redo urethroplasty are more complicated due to scar tissue, distorted anatomy and poor availability of healthy tissues. The treatment is tailored and can include re-tubularization of the urethral plate, graft-based urethroplasty, staged reconstruction, tightening of the bladder neck, or re-correction of the remaining curvature. In spite of all these, modern reconstructive methods, particularly layered flaps coverage and buccal mucosal grafts, provide great functional and cosmetic results. Follow-up timeliness, timely identification of complications, and surgical expertise experience are key factors in preventing recurrence and guaranteeing success in the long term. The majority of patients may have better urinary control, straight penis, and forward-directed urinary stream with proper management which significantly improves the quality of life.

Redo epispadias repair India GetWellGo

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FAQ

1. Does redo epispadias surgery present more challenges than the initial surgery?

• Yes. The complications of redo surgery include scar tissue, deformed anatomy, and poor access to normal tissue.

2. Does redo surgery increase urinary continence?

• Yes. Redo surgery particularly in association with bladder neck reconstruction can have a significant effect of enhancing continence in most children and adults.

3. How successful is redo epispadias repair?

• Success rates are high when done by the experienced reconstructive surgeons. A number of patients attain proper urinary control and normal forward urinary stream. The effects of cosmetic are also usually good.

4. Will my child require more than one redo operation?

• There are cases that are complex- some with severe scarring or problems at the neck of the bladder- which may need to be done in stages. Nevertheless, a large number of patients correct completely after a single successful redo surgery.

5. Is it possible to perform redo epispadias or continence surgery in adults?

• Yes. Adults having epispadias complications not properly treated may have revision urethroplasty done, bladder neck repair or continence.

6. Is relapse possible following redo surgery?

• This can occur although it is more likely in cases of severe cases but the risk is minimized in cases where surgery is performed by well-trained pediatric urology practitioners or hypospadias/epispadias experts.