Leveuf: A Rescue Technique after the Failure of Other Hypospadias Techniques
Nabil Jakhlal*, Youness Khdach, Harrison Sumba, Tariq Karmouni, Khalid El Khader, Abdellatif Koutani and Ahmed Iben Andaloussi
Department of Urology, Mohammed V University, Morocco
Submission: May 18, 2018;Published: July 06, 2018
*Corresponding author: Nabil Jakhlal, Department of Urology B, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco, Tel: 212615327218; Email: email@example.com
How to cite this article: Nabil J, Youness K, Harrison S, Tariq K, Khalid El K, et.al. Leveuf: A Rescue Technique after the Failure of Other Hypospadias Techniques. Glob J Reprod Med. 2018; 5(2): 555657. DOI:10.19080/GJORM.2018.05.555657.
The patient care of adults who have had complications of primary surgery of hypospadias remains atherapeutic challenge. These patients can be divided into three categories. We report a case of ypospadias that we classify in the second group and for which we opted for a Leveuf urethroplasty with a satisfactory result.
The patient care of adults who have had complications of primary surgery of hypospadias remains a therapeutic challenge. They are undoubtedly a difficult population to treat because these usually include the presence healed and poorly vascularized tissues, aesthetic deformation, lower urinary tract symptoms resulting into psychosexual consequences.These patients can be divided into three categories: the first group are the primary cases, the second group includes patients who had previous surgery during childhood and have a late complication (for example, a urethrocutaneous fistula, a persistent bend, urethral stricture,urethral diverticulum and poor aesthetic result), and the third group are patients who have undergone several failed surgeries called “crippled hypospadias” . We report a case of hypospadias that we classify in the second group and for which we opted for a Leveuf urethroplasty.
A 27-year-old patient with a history of failure of primary surgery for hypospadias at the age of 5, who consults for management of this malformation. Physical examination revealed a proximal hypospadias (penoscrotal orifice) with an estimated curvature of 60 °C.Our treatment consisted firstly of straightening of the penis with dorsal plication of corpora cavernosa according to Nesbit. Subsequently, the patient was
operated for Leveuf urethroplasty in two stages, a first burial
time, and a second release time of the penis from the scrotum (Figure 1&2). An interval of 7 months took place between the two Leveuf periods. The post-operative evolution was favorable with a decline of 6 months.
Hypospadias surgery complications include fistulas of
the urethra, strictures of the meatus and urethra, glandular
dehiscence, curvature persistence, mucosal ectropion,
urethrocele, xerotica obliterans balanitis (sclero-atrophic lichen),
hairs and urethral lithiasis, multi-operated hypospadias . The
complication rate of primary surgery is between 6 and 30% .
It is variable depending on the anomaly and the technique used.
Operative failures may result from wound infection, urinary
extravasation, hematoma, ischemia and flap and graft necrosis
or errors in the technique and postoperative care during primary
repair surgery [4,5].
A patient with a defective hypospadias repair would have a
more densely scarred penis in adulthood with less vascularized
and less malleable tissue . Therefore, repeated attempts
for surgical repair in these complicated cases are less likely to
succeed. This is evident in a study by Hensle et al.  in a group
of adult patients with hypospadias repair, complications were
noted in 37.5% of patients without previous surgery, 41.67%
of patients having had one or more interventions in childhood,
but in which the local tissue was relatively intact, and 63.6%
of patients who underwent several unsuccessful hypospadias
repairs with varying degrees of deformation of the penis and loss
of local tissue.Whatever the cause of the reconstruction failure,
the principles of the surgical revision remain identical to those
of the first surgery.
The three essential stages of this surgery are :
I. Assessment and correction of a residual curvature:
Excision of fibrosis to release any curvature and excision of
scar tissue, which may include some, or even entire length
of previous urethroplasty with any surrounding fibrous
tissue. This often leads to a proximal migration of the
urethral meatus. If the curvature persists after dissection
of the ventral radius, then a dorsal plication of the corpora
cavernosa is indicated [8,9].
II. Resumption of urethroplasty: An adequate glans cleft
is created with the insertion of a graft or flap. The creation
of a neo-urethra and reconstruction of the glans can be done
in one or more operating times. If proximal hypospadias and
requiring extensive reconstruction with defect of the penile
skin, it is best to proceed in two stages with subsequent
closure usually within an average of 4-6 months.
III. The reconstruction of the ventral side of the penis:
this step should include a tight closure of the neo-urethra
with good coverage by a vascularized overlying tissue. In
particular, care is taken not to overlap the suture planes to
reduce the risk of fistula.
There is no standard urethroplasty technique in this type
of surgery. In a sequence of surgical resumption of hypospadias
in children, a surgical decision algorithm was based on the
presence or absence of an elastic urethral plate (UP): When
the UP did not have a visible scar, a TIP procedure (tubularized
incised plate) was performed. If the UP was previously excised
but a skin band without a visible scar remained at its location, a
single-step inlay graft was used. When UP, residual skin or neourethra
were visibly healed or there was a persistent ventral
curvature greater than 30 °C, hair in the neo-urethra or suspicion
of xerotica obliterans balanitis, all largely abnormal tissues were
excised up to the healthy urethra, and secondly, urethroplasty by
oral mucosal graft (OM) was performed .
In majority of resumption cases, the foreskin is no
longer available and the penile skin is poorly vascularized,
consequently urethroplasty by a local scrotal flap or an oral
mucosal graft would be preferable. Unlike flaps, grafts are easier
to harvest and sufficiently available but depend on the subject
to hold. This emphasizes the importance of vascularization of
the bed of the graft. Bürger et al.  described the use of OM
in recovery operations after failure of hypospadias surgery in
6 patients and reported good functional results in all patients.
Since then, several articles have been published on the use of
OM grafts in one or more times , including Fichtner et al.
 and Metro et al.  who reported complication rates of 20
and 57% respectively. The scrotal skin can be used in different
ways, usually in several stages: as the roof of the urethroplasty
according to Leveuf technique , or as a cover of the neourethra
according to Cecil-Culp [16,17]. These techniques could
be useful tools in case of deficient of the penile skin and in
reducing the formation of fistula [18,19].
The first step in the care of patients who have had
complications of primary hypospadias surgery is the vigilant
evaluation of each patient, the anatomical features and the
material available to initiate the reconstruction. Leveuf is a
technique that could be useful in case of deficient penile skin
and to reduce the formation of fistula. However, it is important for the surgeon to know about the pros and cons of all routine
procedures and that this type of reconstruction should only be
performed in highly specialized centers.