Epispadias is Different from Hypospadias
About 2 months ago, I operated on a 1-year old boy with complete Epispadias. The child was referred to me by a pediatric surgeon from another city for expert surgical advice. The child had no control over his urination; he never passed urine in stream, but used to dribble urine continuously from the opening located at the base of the penis on its upper surface. The parents had also read on the internet about my extensive experience with hypospadias surgery, and thought that surgery for epispadias would be similar to hypospadias. However, I had to explain to them that epispadias is different from hypospadias, the surgery for epispadias is more complex, and epispadias has some peculiar problems which are not seen in hypospadias.
Hypospadias and epispadias are both birth defects of the external genitalia in boys. Although they can occur in girls also, they are extremely rare in girls and here we will discuss only the defects in boys.
Hypospadias is a common defect, while epispadias is much less common. While hypospadias is a result of poor development of the undersurface (ventral aspect) of the penis, epispadias is a midline defect, often associated with defect in the pubic bone (called pubic diastasis) and more severe urinary bladder defects. In hypospadias, the urethra (urinary tube) opens on the undersurface of the penis, while in epispadias, it opens on the upper surface of the penis. Another important difference is the urinary control; while almost all children with hypospadias (even severe cases) have good control of urination, most children with epispadias have urinary incontinence, meaning that they cannot control the urination but have continuous dribbling of urine. The penis in epispadias is shorter in length than the normal penis, but usually grows well at puberty.
Thus, epispadias is a more complex defect than hypospadias, and involves a more extensive surgery than hypospadias. The standard surgical technique for epispadias repair is called Cantwell-Ransley technique (CREP). In this technique, the corpora cavernosa on either side are carefully separated from the urethral plate (while preserving the nerves and blood vessels), the urethra is reconstructed, and the fully separated corpora are brought on top of the reconstructed urethra and united in the midline with sutures. This places the urethra in its natural position, creates the urethral angle (which is absent in epispadias) and provides resistance to urine flow. This gradually helps in bladder growth and gaining of urinary control by the child, a process which can take many years after the CREP surgery. While a properly performed CREP can help many children gain urinary control, some of these children may require additional procedures after many years.
After the parents of the child clearly understood about epispadias and the plan of surgery, we performed CREP on this child. The operation took about 4 hours, and the child had 2 tubes from the bladder to drain urine for 2 weeks after which the tubes were removed one after the other. The child had excellent initial results, with good cosmetic appearance of the penis and started passing urine in a good stream once every 15-20 minutes. We are keeping the child on regular follow-up and informed the parents that the surgery has been very successful, and because of the excellent initial result, the child has good chances of urinary control, although it may take many years to achieve that.
The parents of this child are very happy and gave a nice compliment in writing to express their happiness and satisfaction. The letter is given below.
“Our 1 year baby boy had severe Epispadias for which he underwent a complex operation under Dr. VVS Chandrasekharam sir. We are happy that the surgery is successful and our child is doing well. We were referred to Dr. VVS sir because he is an expert in such operations and he has explained to us very well about the operation and the post-operative care of our baby. We are thankful to the doctor and his secretary Ms. Suhasini who helped me a lot”
Again, like Hypospadias, Epispadias surgery should only be performed by experts with extensive experience with these complex reconstructive operations. The surgeon requires a lot of patience to operate on the small part for many hours. The tissue dissection and handling in genital surgeries in children is very delicate, every millimeter of tissue is important and should be handled with extreme care to achieve optimal results. There can be some complications; in expert hands, most of these are minor problems which can be managed easily. However, in less experienced hands, major complications can occur. These complications may not be life-threatening, but result in multiple re-operations and negatively affect the life of the child and the entire family. So parents have to search for the expert surgeon to perform these operations on their child.