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ISSN: Print -2349-0977, Online - 2349-4387


 
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CASE IN POINT: RECONSTRUCTIVE SURGERY
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 49-51

Modified Cantwell-Ransley repair in penopubic epispadias with continent bladder


Department of Urology, Lourdes Hospital, Kochi, Kerala, India

Date of Web Publication26-Oct-2015

Correspondence Address:
Dr. H Krishnamoorthy
Department of Urology, Lourdes Hospital, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-0977.168243

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How to cite this article:
Bansal D, Rathore RS, Pillai B, Krishnamoorthy H. Modified Cantwell-Ransley repair in penopubic epispadias with continent bladder. Astrocyte 2015;2:49-51

How to cite this URL:
Bansal D, Rathore RS, Pillai B, Krishnamoorthy H. Modified Cantwell-Ransley repair in penopubic epispadias with continent bladder. Astrocyte [serial online] 2015 [cited 2022 Jul 3];2:49-51. Available from: http://www.astrocyte.in/text.asp?2015/2/1/49/168243

Epispadias is a rare entity, with a reported incidence of in 117,000 males.[1] It is characterized by failure of the urethral plate to tubularize on the dorsum of the penis with defect ranging from glandular to penopubic location. In addition, male patients demonstrate a dorsal chordee, whereas female patients exhibit a bifid clitoris.[2] Isolated epispadias with continence is a very rare entity comprising <10% of all epispadias cases. Many surgical techniques have been described for the repair of male epispadias, of which modified Cantwell–Ransley repair has become the procedure of choice.[3] Here, we are presenting our experience in performing modified Cantwell–Ransley repair in two patients of epispadias without incontinence.

Two boys, aged 5 and 9 years underwent surgical repair for correction of isolated epispadias in our centre for the past 1 year. Preoperatively, both children had penopubic type of epispadias with continence. Examination of the genitalia revealed epispadias of penopubic type, the scrotum was normal in size, containing normal descended testes [Figure 1]. Plain pelvic radiographs showed no separation of the pubic rami and a normal spine in both cases [Figure 2]. Abdominal ultrasonography did not demonstrate any associated renal or other anomalies. Cystourethrography also did not show vesicoureteral reflux and both children were able to hold the contrast in their bladder with no incontinence [Figure 3].
Figure 1: Preoperative picture of penopubic epispadias.

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Figure 2: X-ray pelvis showing no evidence of pelvic diastasis.

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Figure 3: Preoperative cystogram showing urinary continence.

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Both children were operated under general anesthesia. The operative technique used was modified Cantwell–Ransley technique. The procedure involved initial placement of traction stitches on the glans penis. The urethral strip was incised on the lateral edges of the urethral plate and around the epispadiac meatus. The skin was dissected off and glans wings were created. The urethral plate was dissected as thick as possible to preserve vasculature. The urethral plate vascularity was based on proximal blood supply and vascularized contralateral edge [Figure 4]. The corpora cavernosa were separated, preserving the neurovascular bundle.
Figure 4: Dissection of urethral plate

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The urethra was tubularized using a continuous running suture (5-0 vicryl) in a single layer over eight French Foley's catheter [Figure 5]. The corpora were then rotated medially over the urethra and reapproximated using absorbable 5-0 sutures on the dorsal surface in an interrupted fashion. Glans wings and the skin were reapproximated with interrupted 5-0 vicryl suture [Figure 6].
Figure 5: Tubularization of urethra over Foley's catheter.

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Figure 6: Approximation of glans wings and prepuce.

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The dressing was changed on the 4th postoperative day and the catheter was removed on the 14th postoperative day. Both children underwent regular follow-up examinations at 1, 3, and 6 months and were evaluated for outcomes. Oxybutynin (0.1–0.15 mg/kg per dose) was started in the postoperative period to decrease the incidence of bladder spasms and to relieve patient's discomfort.

The cosmetic appearance of the penis was excellent in one child and reasonably good in another one due to mild wound dehiscence, which healed by secondary intention [Figure 7]. There was no dorsal cordee in these two children. The appearance of the penis with conical-shaped glans was acceptable to the parents at 1 year after surgery. None of the two children developed fistula or urethral narrowing requiring urethral dilatation. Both children voided well after catheter removal and also on subsequent follow up. Continence was maintained in both cases after surgery. Since both cases were prepubertal children, results of their adequate sexual activity could not be assessed.
Figure 7: Follow-up picture after 1 month of surgery.

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Epispadias represents one end of the spectrum of the exstrophy–epispadias complex (EEC). The combined incidence of the EEC spectrum is approximately 1 in 10,000 births and isolated male epispadiasis defect is present in 10% of cases of EEC. Most male epispadias patients (about 70%) have complete epispadias with urinary incontinence.[4]

Several surgical procedures have been described in the literature, for the repair of either complete epispadias or classical bladder exstrophy. The Cantwell–Ransley technique is the most popular and widely used approach for epispadias repair.[5] Since epispadias is rare and the operative techniques are technically challenging, it is important to involve a surgeon who is experienced in this.

Ransley and colleagues reported a fistula rate of 4% and urethral stricture rate of 5.3%.[6] In our series, no patient developed urethrocutaneous fistula similar to the findings of Pippi Salle et al.[7] Both children were continent in our study and hence bladder neck reconstruction was not required.

Penile cosmesis following repair is a subjective measurement. It can differ for surgeon and patients. Lottmann et al. in a series of 40 patients reported a 90% successful anatomic and functional results following repair at a mean follow-up period of 3 years.[8] In our series, for both parents, appearance of penis was cosmetically acceptable at 1 year follow-up and it was similar to the finding of Geahart et al.[9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gearhart JP, Mathews RI. Exstrophy-epispadias complex. In: Wein AJ, editor. Campbell-Walsh Urology. 10th ed. Philadelphia: Saunders Elsevier; 2007. p. 3544.  Back to cited text no. 1
    
2.
Frimberger D. Diagnosis and management of epispadias. Semin Pediatr Surg 2011;20:85-90.  Back to cited text no. 2
    
3.
Lodh B, Khumukcham S, Amer B, Kaku AS. Modified Cantwell-Ransley repair of male penopubicepispadias: Report of two cases and review of the literature. J Case Rep 2013;3:344-8.  Back to cited text no. 3
    
4.
Ebert AK, Reutter H, Ludwig M, Rösch WH. The exstrophy-epispadias complex. Orphanet J Rare Dis 2009;4:23.  Back to cited text no. 4
    
5.
Baird AD, Gearhart JP, Mathews RI. Applications of the modified Cantwell-Ransleyepispadias repair in the exstrophy-epispadias complex. J Pediatr Urol 2005;1:331-6.  Back to cited text no. 5
    
6.
Ransley PG, Duffy PG. Bladder exstrophy closure and epispadias repair. In: Spitz L, Coran AG, editors. Rob and Smith Operative Surgery. London: Chapman and Hall Medical; 1995. p. 745-9.  Back to cited text no. 6
    
7.
Pippi Salle JL, Jednak R, Capolicchio JP, França IM, Labbie A, Gosalbez R. A ventral rotational skin flap to improve cosmesis and avoid chordee recurrence in epispadias repair. BJU Int 2002;90:918-23.  Back to cited text no. 7
    
8.
Lottmann HB, Yaqouti M, Melin Y. Male epispadias repair: Surgical and functional results with the Cantwell-Ransley procedure in 40 patients. J Urol 1999;162:1176-80.  Back to cited text no. 8
    
9.
Gearhart JP, Leonard MP, Burgers JK, Jeffs RD. The Cantwell-Ransley technique for repair of epispadias. J Urol 1992;148:851-4.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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