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| LETTER TO THE EDITOR |
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| Ahead of print publication |
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Commentary on “Spongiosum-combined glanuloplasty reduces glans complications after proximal hypospadias repair”
Sachit Anand1, Hüseyin Özbey2
1 Department of Pediatric Surgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra 400053, India
2 Department of Pediatric Surgery, Division of Pediatric Urology and Andrology, I.M. Sechenov First Moscow State Medical University, Moscow 119435, Russia
| Date of Submission | 05-Dec-2021 |
| Date of Acceptance | 17-Jan-2022 |
| Date of Web Publication | 11-Mar-2022 |
Correspondence Address:
Hüseyin Özbey,
Department of Pediatric Surgery, Division of Pediatric Urology and Andrology, I.M. Sechenov First Moscow State Medical University, Moscow 119435
Russia
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/aja20222 PMID: 35295002
Article in PDF
Dear Editor,
We read the recent article by Lyu et al.[1] with great interest and appreciate their efforts in describing a new technique for glansplasty in children with proximal hypospadias. In this article, the images that locate the diverted corpus spongiosum are almost the same as those described using the glanular-frenular collar (GFC) technique.[2] We would therefore like to thank the authors for adopting the GFC technique as a model for their reconstructive technique. As per the magnetic resonance imaging (MRI) findings of the normal human penis, it is evident that the glans wings do not fuse in the midline.[3] Rather, they are separated by the septum glandis with the frenulum connected to it. Furthermore, the ventral wall of the glanular urethra is formed by an extension of the fibrous tissue forming the septum glandis. It not only makes glanular urethra-septum glandis-frenulum as a unit that has a common origin but also provides a notion that glans dehiscence can be prevented by adopting the techniques which create a neoseptum (and a neofrenulum) supporting the glans wings.[2]
In patients with hypospadias, MRI has also shown that the extensions of the diverted corpus spongiosum are located under the mucosalized inner foreskin around the ventral surfaces of the glans penis.[4] This ectopic attachment results in tilted glans and/or ventral curvature. The authors also confirm that the correction of the glans tilt is obtained by using this inner foreskin localized around the ventral surface of the glans. The most important step in the GFC technique is limited spongioplasty up to the subcoronal level.[2] Another important step is rotating the mucosal collar over the glans, which provides a three-dimensional representation and facilitates the use of its inner layer as a septum.[2] It is believed that these steps are crucial in providing favorable functional and cosmetic outcomes and can be an alternative to fusion of glans wings, as demonstrated in the index study.
It must also be highlighted that the two groups compared here are heterogeneous and appear as “apples” versus “oranges”. In one group (new-maneuver group), the excess tissue volume due to spongiosum mobilization led to two-layered closure. On the other hand, no intervening coverage layer between the skin and neourethra in the control group might have been a major factor responsible for a significantly high incidence of coronal fistula. The authors could have eliminated this confounding bias by utilizing an intervening coverage layer in the control group. In addition, statistically speaking, comparing two procedures that were performed at different time points can be a major source of bias. Moreover, in the index study, we are very skeptical that the actual incidence of glans dehiscence has been reported. Due to the dysplastic glans in proximal hypospadias, some glans dehiscence may have been hidden (also quoted by the authors) and may have been reported as coronal fistulae.
We would also like to bring to your attention that creating a frenular triangle during glansplasty not only yields better surgical outcomes in terms of postoperative complications but also has long-term advantages. The genital end bulbs, a type of sensory corpuscles, are abundant in the region of the frenulum.[5] This makes the frenulum the most sensitive and erogenous part of the penis during sexual intercourse. Therefore, to achieve optimal long-term functional outcomes (in terms of sexual satisfaction), we must adopt the techniques that recreate these regions.[2] Thus, it is high time to start scrutinizing the newer procedures and techniques such that they do not impair the protopathic sensibility of the glans penis.
| Author Contributions | |  |
Both authors drafted the manuscript, read and approved the final version of the manuscript. HÖ will act as the guarantor of the manuscript.
| Competing Interests | | |
Both authors declare no competing interests.
| References | | |
| 1. | Lyu YQ, Yu L, Xie H, Huang YC, Li XX, et al. Spongiosum-combined glanuloplasty reduces glans complications after proximal hypospadias repair. Asian J Androl 2021; 23: 532–36.  |
| 2. | Özbey H, Etker Ş. Hypospadias repair with the Glanular-Frenular Collar (GFC) technique. J Pediatr Urol 2017; 13: 34.e1–6. |
| 3. | Özbey H, Kumbasar A. Glans wings are separated ventrally by the septum glandis and frenulum penis: MRI documentation and surgical implications. Turk J Urol 2017; 43: 525–9. |
| 4. | Kureel SN, Gupta A, Sunil K, Dheer Y, Kumar M, et al. Surgical anatomy of the penis in hypospadias: magnetic resonance imaging study of the tissue planes, vessels, and collaterals. Urology 2015; 85: 1173–78. |
| 5. | Halata Z, Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res 1986; 371: 205–30. |
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