Reconstructive surgery of the anterior urethra.

RECONSTRUCTIVE surgery of the anterior urethra for hypospadias, fistulas or strictures, presents the surgeon with many problems. While the usual methods of repair may give good results, complications and failures still occur and a more reliably effective procedure would be welcome. A study of the post-operative course in a series of cases, the results of which were published in 1964, revealed four major technical inadequacies in treatment which were responsible for the majority of the complications experienced with operations of the buried skin strip type : defective rearrangement of the skin, inadequate urinary drainage, insufficient vascularity of the skin and inadequate wound closure. Defective Rearrangement of the Skin.-In the treatment of urethral fistulas or urethral strictures, the elasticity and mobility of the skin is generally adequate for the wound to be closed without tension. In hypospadias, however, there is a congenital insufficiency of skin on the urethral side of the penis which, together with the surplus of skin on the dorsal side and the oblique lateral raphes, is probably caused by a formation of folds in the ectoderm-covered borders of the urethral groove (van der Meulen, 1964, 1967). Correction of this insufficiency of skin is essential and may be accomplished by redistributing the skin by the methods developed by the author (Figs. 3 and 5). Inadequate Drainage.-Healing of the wound can easily be disturbed if adhesion between the skin and the underlying raw surface is prevented bytheaccumulation ofblood or urine. This may be avoided in one of two ways :