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Duarsa GWK, Tirtayasa PMW, Daryanto B, Nurhadi P, Renaldo J, Tarmono T, Utomo T, Yuri P, Siregar S, Wahyudi I, Situmorang GR, Palinrungi MAA, Hutasoit YI, Hutahaean AYA, Zulfiqar Y, Sigumonrong YH, Mirza H, Rodjani A. Common Practice of Hypospadias Management by Pediatric Urologists in Indonesia: A Multi-center Descriptive Study from Referral Hospitals. Open Access Maced J Med Sci 2019; 7:2242-2245. [PMID: 31592011 PMCID: PMC6765069 DOI: 10.3889/oamjms.2019.628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Hypospadias is the second most common congenital anomalies among human congenital disabilities. There are over 300 surgery techniques being introduced to treat hypospadias. The successful of hypospadias repair is assessed by several outcomes as well as complications following surgery. AIM: This study aims to show the multicenter hypospadias data in Indonesia descriptively. METHODS: All the data were compiled based on questionnaires, which were distributed to Indonesian pediatric urologists. The questionnaire includes several questions containing demographic aspect, preferred techniques being used, and complications being found regarding hypospadias repair. RESULTS: Eighteen Indonesian pediatric urologists from 12 centres involved in this study. The data were collected from June – September 2018 based on the surgeon’s experience throughout 2017. From 591 cases based on the returned questionnaire, penile-type hypospadias was the most common type of hypospadias being treated (35.7%) followed by penoscrotal (28.9%) and scrotal-type (12.9%). Moderate severity of chordee was mostly seen among all cases (40.6%). Tubularised incised plate (TIP), + Thiersch Duplay, was the most common technique being used to treat hypospadias (44.3%), followed by onlay island preputial flap (14.9%) and two-stage technique (14%). The incidence of urethrocutaneous fistulae in this study was 13.9%. CONCLUSION: This study showed how Indonesian pediatric urologists dealt with hypospadias cases. TIP + Thiersch Duplay procedure being the preferred technique used by most participants and the rate of urethrocutaneous fistulae as one of the complications was comparable with previous studies.
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Affiliation(s)
- Gede Wirya Kusuma Duarsa
- Divison of Urology, Department of Surgery, Faculty of Medicine Universitas Udayana, Sanglah Hospital, Denpasar, Indonesia
| | - Pande Made Wisnu Tirtayasa
- Divison of Urology, Department of Surgery, Faculty of Medicine Universitas Udayana, Sanglah Hospital, Denpasar, Indonesia
| | - Besut Daryanto
- Department of Urology, Faculty of Medicine Universitas Brawijaya, Saiful Anwar Hospital, Malang, Indonesia
| | - Pradana Nurhadi
- Department of Urology, Faculty of Medicine Universitas Brawijaya, Saiful Anwar Hospital, Malang, Indonesia
| | - Johan Renaldo
- Department of Urology, Faculty of Medicine Universitas Airlangga, Soetomo Hospital, Surabaya, Indonesia
| | - Tarmono Tarmono
- Department of Urology, Faculty of Medicine Universitas Airlangga, Soetomo Hospital, Surabaya, Indonesia
| | - Trisulo Utomo
- Department of Urology, Faculty of Medicine Universitas Gadjah Mada, Sardjito Hospital, Yogyakarta, Indonesia
| | - Prahara Yuri
- Department of Urology, Faculty of Medicine Universitas Gadjah Mada, Sardjito Hospital, Yogyakarta, Indonesia
| | - Safendra Siregar
- Department of Urology, Faculty of Medicine Universitas Padjajaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Irfan Wahyudi
- Department of Urology, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Gerhard Reinaldi Situmorang
- Department of Urology, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Muhammad Asykar A Palinrungi
- Division of Urology, Department of Surgery, Faculty of Medicine Universitas Hasannudin, Wahidin Sudirohusodo Hospital, Makassar, Indonesia
| | | | | | - Yevri Zulfiqar
- Division of Urology, Department of Surgery, Faculty of Medicine, Universitas Andalas, M. Djamil Hospital, Padang, Indonesia
| | - Yacobda H Sigumonrong
- Department of Urology, Faculty of Medicine, Universitas Sumatera Utara, Adam Malik Hospital, Medan, Indonesia
| | - Hendy Mirza
- Department of Surgery, Persahabatan Hospital, Jakarta, Indonesia
| | - Arry Rodjani
- Department of Urology, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Staged transverse preputial island flap urethroplasty for proximal hypospadias: a single-center experience. Pediatr Surg Int 2019; 35:823-827. [PMID: 31049665 DOI: 10.1007/s00383-019-04480-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the intermediate outcomes of our institution's experience with staged TPIF urethroplasty for proximal hypospadias repair. METHODS We retrospectively evaluated the medical records of patients who underwent repair of proximal hypospadias using staged TPIF urethroplasty at our hospital from 2011 to 2017. RESULTS One hundred and two patients were included in the present study. The mean follow-up was 52.4 months (range 13-74 months). The mean age at the time of the first surgery was 13.5 months (range 11-65 months). There were two main types of initial complications including meatal stenosis in four (3.9%) and urethrocutaneous fistula in three (2.9%) patients after the first stage. Surgical complications were seen in 15 patients after second stage, including urethrocutaneous fistulas in 8 (7.8%), urethral strictures in 5 (4.9%), urethral diverticula in 2 (1.9%). Overall complication rates after second stage were 14.7%. The incidence of fistulas was lower in patients who underwent repair with a tunica vaginalis flap (1/29, 3.4%) than with the dartos fascia (7/73, 9.6%; p = 0.435). CONCLUSIONS Our results show that staged TPIF urethroplasty is a viable and durable technique for primary severe proximal hypospadias. This procedure was associated with a 14.7% complication rate in the present study. Staged TPIF urethroplasty can reduce the incidence of urethral strictures and diverticula associated with the second stage.
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Distal Urethroplasty and Glanuloplasty Procedure Can be Suitable for All Types of Glanular/Subcoronal Hypospadias. Urology 2019; 124:248-253. [DOI: 10.1016/j.urology.2018.06.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/08/2018] [Accepted: 06/18/2018] [Indexed: 11/18/2022]
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Hemesath TP, de Paula LCP, Carvalho CG, Leite JCL, Guaragna-Filho G, Costa EC. Controversies on Timing of Sex Assignment and Surgery in Individuals With Disorders of Sex Development: A Perspective. Front Pediatr 2019; 6:419. [PMID: 30687685 PMCID: PMC6335325 DOI: 10.3389/fped.2018.00419] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/18/2018] [Indexed: 12/23/2022] Open
Abstract
Appropriate management of disorders of sex development (DSD) has been a matter of discussion since the first guidelines were published in the 1950s. In the last decade, with the advent of the 2006 consensus, the classical methods, especially regarding timing of surgery and sex of rearing, are being questioned. In our culture, parents of DSD newborns usually want their children to undergo genital surgery as soon as possible after sexual assignment, as surgery helps them to confirm the assigned sex. Developmental psychology theories back this hypothesis. They state that anatomic differences between sexes initiate the very important process of identification with the parent of the same sex. Sex-related endocrinological issues also demand early care. For example, using dihydrotestosterone cream to increase penile length or growth hormone treatment to improve final height require intervention at young ages to obtain better results. Although the timing of surgery remains controversial, recent evidence suggests that male reconstruction should be performed between 6 and 18 months of age. Feminizing surgery is still somewhat controversial. Most guidelines agree that severe virilization requires surgical intervention, while no consensus exists regarding mild cases. Our perspective is that precocious binary sex assignment and early surgery is a better management method. There is no strong evidence for delays and the consequences can be catastrophic in adulthood.
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Affiliation(s)
- Tatiana Prade Hemesath
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Psycology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Leila Cristina Pedroso de Paula
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Endocrinology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Clarissa Gutierrez Carvalho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Julio Cesar Loguercio Leite
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Medical Genetics Service, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Guilherme Guaragna-Filho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Eduardo Corrêa Costa
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
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Mammo TN, Negash SA, Negussie T, Getachew H, Dejene B, Tadesse A, Derbew M. Hypospadias Repair in Ethiopia: A Five Year Review. Ethiop J Health Sci 2019; 28:735-740. [PMID: 30607090 PMCID: PMC6308759 DOI: 10.4314/ejhs.v28i6.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Hypospadias repair is one of the problematic issues in pediatric surgery. As a result of the multiple complications following the procedure, a variety of techniques have been used and newer methods continue to emerge. There is still controversy regarding the best method of repair. We aimed to determine the outcome of surgery and factors contributing to unfavorable outcomes in children with hypospadias. Materials and Methods This is a retrospective review undertaken from September 2009 to August 2014. The research was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. All children who underwent hypospadias repair and had regular follow-up were included in the study. Results A total of 202 boys aged less than 13 years were assessed. Most surgeries (80.3%) were performed in children older than 18 months. Transverse incised plate urethroplasty (TIP) was frequently performed for distal hypospadias (71.2 %), while transverse ventral preputal flap (TVPF) was the most common procedure done for proximal hypospadias (62.8 %). Overall success rate for first surgery was 55.9 %. There was a high rate of major post-operative complications (44.1%) of which urethrocutaneous fistula (UCF) was the most common (31.2%) followed by meatal stenosis and glans breakdown (7.4 % each). These complications were found to be higher in those who were operated at a later age and those with proximal hypospadias (p=0.03 and p=0.01 respectively). There was also a significant difference among the type of procedures with TIP and TVPF having the least complications (p<0.01). Conclusion From our experience, we found TIP a relatively safe and reliable method of repair for distal hypospadias while TVPF single stage repair was superior in the proximal ones. The high rate of complications in our institution was associated with higher burden of severe hypospadias and older age at surgery.
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Affiliation(s)
| | - Samuel A Negash
- Unit of pediatric of surgery, Department of surgery, Addis Ababa University, Ethiopia
| | - Teamir Negussie
- Unit of pediatric of surgery, Department of surgery, Addis Ababa University, Ethiopia
| | - Hanna Getachew
- Unit of pediatric of surgery, Department of surgery, Addis Ababa University, Ethiopia
| | - Belachew Dejene
- Unit of pediatric of surgery, Department of surgery, Addis Ababa University, Ethiopia
| | - Amezene Tadesse
- Unit of pediatric of surgery, Department of surgery, Addis Ababa University, Ethiopia
| | - Miliard Derbew
- Unit of pediatric of surgery, Department of surgery, Addis Ababa University, Ethiopia
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Tonnhofer U, Hiess M, Metzelder M, Hebenstreit D, Springer A. Midline Incision of a Graft in Staged Hypospadias Repair-Feasible and Durable? Front Pediatr 2019; 7:60. [PMID: 30931285 PMCID: PMC6423900 DOI: 10.3389/fped.2019.00060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/14/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose: In severe hypospadias staged repair is commonly used and it is regarded as feasible, safe, and durable. In this article we want to describe the results of a modification of the staged repair: a midline incision of the graft during the second stage. Materials and Methods: This is a consecutive single team (2 surgeons) retrospective series. Between 2014 and 2017, 250 patients underwent hypospadias repair, among them 35 patients that had primary staged hypospadias surgery with completed first and second stage repair. 24 (68.6%) cases received a preputial skin graft and 11 (31.4%) buccal mucosa graft. Median age at first stage was 1.5 (0.5-22.1) years, mean time between first and second stage operation was 0.72 (0.4-1.76) years. Follow up rate was 100%, mean follow up period was 1.50 (0.4-3.8) years. Results: The total complication rate was 22.9%. In buccal mucosa repair the complication rate was 36.4% and in preputial graft repair the complication rate was 16.7%, respectively. In 23 patients (65.7%) during second stage urethroplasty a midline incision was performed (8 glandular graft, 15 penile graft, 6 at level of urethral opening). Complication rate in non-incised urethroplasty was 8.3%, in incision at glandular level 37.5%, in incision at penile level 13.3% and in incision at urethral opening 16.7%, respectively. Conclusions: Two stage repair is the method of choice in the correction of severe hypospadias. In selected cases a midline incision of the graft is feasible and can be applied if needed. Randomized studies will be needed to evaluate the true benefit of incising the graft.
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Affiliation(s)
- Ursula Tonnhofer
- Department of Pediatric Surgery, Medical University Vienna, Vienna, Austria
| | - Manuela Hiess
- Department of Urology, Medical University Vienna, Vienna, Austria
| | - Martin Metzelder
- Department of Pediatric Surgery, Medical University Vienna, Vienna, Austria
| | - Doris Hebenstreit
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria
| | - Alexander Springer
- Department of Pediatric Surgery, Medical University Vienna, Vienna, Austria
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Qin D, Tang Y, Wang X, Mao Y, Chen S, Chen Y. [Application of cavernosum reduction technology in glanuloplasty during repair of moderate-severe hypospadias]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1454-1457. [PMID: 30417624 DOI: 10.7507/1002-1892.201801135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the application of cavernosum reduction technology in glanuloplasty during the repair of moderate-severe hypospadias and evaluate the effectiveness. Methods The clinical data of 192 patients with moderate-severe hypospadias between November 2015 and May 2017 were retrospectively analyzed. Among them, 103 patients were treated with the cavernosum reduction technology in glanuloplasty during the repair (observation group), 88 patients were treated with repair and glanuloplasty without the cavernosum reduction technology (control group). There was no significant difference in maximum transverse diameter of glans and the height of glans between 2 groups ( t=1.652, P=0.152; t=1.653, P=0.077). The length of reconstructed urethra, complications (e.g. glans dehiscence and fistula), and the maximum flow rate at 3 months after operation in 2 groups were recorded. Results The length of reconstructed urethra were (35.51±7.79) mm in observation group and (32.17±6.37) mm in control group. In observation group, the meatus location after the correction of chordee was proximal in 24 cases and scrotum-perineum in 79 cases. In control group, the meatus location after the correction of chordee was proximal in 21 cases and scrotum-perineum in 67 cases. There was no significant difference in the meatus location between 2 groups ( χ 2=0.008, P=0.920). All patients were followed up 6-12 months after operation (mean, 9 months). There were 3 cases of urethral fistula, 2 cases of glans dehiscence, and 3 cases of urethral orifice stricture in observation group, with the incidence of complications of 7.8%. There were 7 cases of urethral fistula, 3 cases of glans dehiscence, and 4 cases of urethral orifice stricture in control group, with the incidence of complications of 15.9%. There was a significant difference in the incidence of complications between 2 groups ( χ 2=4.027, P=0.040). The appearance of the penis was satisfactory, and the urethral orifice was fissured, which was close to the appearance of the normal urethral orifice. At 3 months after operation, the maximal flow rates were (6.23 ± 0.54) mL/s in observation group and (5.44±0.92) mL/s in control group. There was significant difference in the maximum flow rate between 2 groups ( t=1.653, P=0.000). Conclusion Cavernosum reduction technology being applied in the repair of moderate-severe hypospadias can reduce the probability of glans dehiscence, urethral fistula, urethrostenosis, and other postoperative complications, and improve the success and satisfaction of surgery.
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Affiliation(s)
- Daorui Qin
- Department of Pediatric Surgery of Children's Medical Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu Sichuan, 610072, P.R.China
| | - Yunman Tang
- Department of Pediatric Surgery of Children's Medical Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu Sichuan, 610072,
| | - Xuejun Wang
- Department of Pediatric Surgery of Children's Medical Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu Sichuan, 610072, P.R.China
| | - Yu Mao
- Department of Pediatric Surgery of Children's Medical Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu Sichuan, 610072, P.R.China
| | - Shaoji Chen
- Department of Pediatric Surgery of Children's Medical Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu Sichuan, 610072, P.R.China
| | - Yuejiao Chen
- Department of Pediatric Surgery of Children's Medical Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu Sichuan, 610072, P.R.China
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Alsowayan OS. Management of hypospadias in Saudi Arabia: A national survey. Urol Ann 2018; 10:391-394. [PMID: 30386092 PMCID: PMC6194794 DOI: 10.4103/ua.ua_88_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Hypospadias is one of the most common congenital anomalies of the penis. Different methods of hypospadias management are described in the literature. We try in this study to evaluate the national trends and to compare them with international practices. Materials and Methods: A multiple choice survey was distributed among a sample of national practitioners using a weblink between September and December 2017. It included questions about participants demographics, number of cases operated on per year, perioperative care and preferences, long-term follow-up, and complications. Data were analyzed and compared with international practices. Results: Results of 47 practitioners were evaluated and analyzed in this study. The majority of the participants were pediatric urologists (48.9%) and from the central province (44.7%). Most of the participants prefer to operate on patients between the ages of 1 and 2 years (48.9%) and operate at ≥20 cases per year (76.6%). Tubularized incised plate (TIP) is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for proximal cases. All participants use a form of a second layer and a stent for their repairs. The majority reported an overall complication rate of ≤10% for distal penile hypospadias (76.1%) and >10% for proximal penile cases (59.6%). Conclusion: This study helped us identify national trends in hypospadias management, which were comparable to the international trends. TIP repair is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for more complex proximal variants. Although data in this study come from reports of personal experience, it can serve as a backbone for the future prospective studies on this topic.
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Affiliation(s)
- Ossamah Saleh Alsowayan
- Department of Urology, King Fahd Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Genetic Polymorphism in the RYR1 C6487T Is Associated with Severity of Hypospadias in Chinese Han Children. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7397839. [PMID: 30027098 PMCID: PMC6031201 DOI: 10.1155/2018/7397839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/01/2018] [Indexed: 11/28/2022]
Abstract
Objective Hypospadias is a common congenital malformation of the male external genitalia. Most cases have an unknown etiology, which is probably a mix of monogenic and multifactorial forms, implicating both genetic and environmental factors. Ryanodine receptor 1 (RYR1) mutations are a common cause of congenital diseases associated with both dominant and recessive inheritance in humans. Herein, we evaluated the correlations of RYR1 C6487T polymorphism with the risk and severity of hypospadias. Methods 263 congenital hypospadias children and 312 healthy children were recruited. The polymorphism of RYR1 C6487T in the peripheral blood was detected by polymerase chain reaction-restriction fragment length polymorphism, and different genotypes and allelic genes were analyzed to explore their associations with the risk of congenital hypospadias. Results The distribution frequencies of CC/CT/TT genotypes and two alleles (C and T) at RYR1 C6487T showed significant differences between the case and control groups (P < 0.05). The frequency of C allele in the case and control groups was 46.95% and 54.94%, respectively, and of T allele was 53.05% and 45.06% (P < 0.05). In addition, the distribution frequency of CC/CT/TT genotypes exhibited significant difference between patients with mild hypospadias and those with moderate or severe hypospadias (all P > 0.05), suggesting that RYR1 C6487T polymorphism is correlated with the severity of congenital hypospadias (X2 = 13.722, P = 0.001). Conclusion Our study demonstrated that RYR1 C6487T polymorphism might be associated with an increased risk of congenital hypospadias in Chinese Han children. Our findings highlight the heterogeneous nature of hypospadias genetic susceptibility.
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Rynja SP, de Jong TPVM, Bosch JLHR, de Kort LMO. Proximal hypospadias treated with a transverse preputial island tube: long-term functional, sexual, and cosmetic outcomes. BJU Int 2018; 122:463-471. [PMID: 29624839 DOI: 10.1111/bju.14234] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study long-term urinary and sexual function, and cosmetic outcomes in adult patients who underwent single-stage transverse preputial island tube (TPIT) for proximal hypospadias repair in childhood. Long-term data on outcomes of patients with proximal hypospadias with severe coexisting curvature and insufficient urethral plate are scarce, but are necessary to decide which repair technique is most beneficial. PATIENTS, SUBJECTS AND METHODS Patients with proximal hypospadias operated with TPIT (TPIT Group) were compared to patients with distal hypospadias repair (Distal Group) and to a control group of male medical students (Control Group). Participants completed the International Prostate Symptom Score, the International Index of Erectile Function (IIEF-15), additional non-validated questions, and performed uroflowmetry. Cosmesis was assessed in the patients with hypospadias using the Pediatric Penile Perception Score (PPPS); stretched penile length was also measured. RESULTS Of the 121 eligible patients with hypospadias, 54 with either TPIT or distal hypospadias repairs participated. The TPIT Group comprised 12 patients (median age of 20.0 years) and the Distal Group comprised 42 patients (median age of 19.6 years). The complication rates were similar, at 8 of the 12 patients in the TPIT Group vs 26/42 (62%) in the Distal Group (P = 0.76). Urinary outcomes were similar in the TPIT, Distal, and the Control (comprised of 148 medical students with a median age of 21.0 years) groups. The TPIT Group had a lower maximum urinary flow rate compared to the Control Group, at 24.1 vs 28.6 mL/s (P < 0.05). IIEF-15 scores were similar in the TPIT, Distal and Control groups, except for 'Orgasmic Function' (7.5 vs 10.0 vs 10.0, respectively; P < 0.01). Although the TPIT Group had a smaller penile length compared to the Distal Group (10.1 vs 12.9 cm, P < 0.01), PPPS outcomes were similar. CONCLUSION In these TPIT patients, long-term urinary, sexual and cosmetic outcomes were similar to those in patients with distal hypospadias repairs and controls.
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Affiliation(s)
- Sybren P Rynja
- University Medical Center (UMC), Utrecht, The Netherlands
| | - Tom P V M de Jong
- University Children's Hospital UMC Utrecht, Utrecht, The Netherlands
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Ru W, Shen J, Tang D, Xu S, Wu D, Tao C, Chen G, Gao L, Wang X, Shen Y. Width proportion of the urethral plate to the glans can serve as an appraisal index of the urethral plate in hypospadias repair. Int J Urol 2018; 25:649-653. [PMID: 29717506 DOI: 10.1111/iju.13585] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To find a new appropriate evaluation for urethral plate quality in hypospadias repair, with particular interest in the width proportion of the urethral plate to the glans, serving as an appraisal index. METHODS Data were prospectively collected from prepubertal boys who underwent primary tubularized incised plate hypospadias repair between January 2014 and April 2016 in one center. Intrinsic parameters of the penis (meatal location, glans width, urethral plate width and curvature degree) were measured during the operation. Urethroplasty complications were recorded during follow up. The correlation between width proportion of the urethral plate to the glans and urethroplasty complications was analyzed. RESULTS Primary tubularized incised plate repair was carried out in 442 patients (mean age 2.8 years, range 0.5-12 years). At mean follow up of 26 months (range 12-38 months), urethroplasty complications occurred in 59 (13.3%) patients. The width proportion of the urethral plate to the glans was weakly correlated to both the glans width and meatal location. The width proportion of the urethral plate to the glans ranged from 0.18 to 0.73, with a mean of 0.39. The cut-off value of width proportion of the urethral plate to the glans was determined to be 0.36 by the receiver operating characteristic curve. Urethroplasty complications occurred in 17 out of 254 patients (6.7%) with width proportion of the urethral plate to the glans >0.36, and 42 out of 188 patients (22.3%) with width proportion of the urethral plate to the glans ≤0.36. The width proportion of the urethral plate to the glans ≤0.36 showed an increased odds of 4.819-fold (95% confidence interval 2.548-9.112, P < 0.001) risk of urethroplasty complications compared with width proportion of the urethral plate to the glans >0.36. Midshaft and proximal meatal location also increased the risk of urethroplasty complications. CONCLUSIONS The present study highlights the value of the width proportion of the urethral plate to the glans for objectivity and accuracy in urethral plate evaluation, which in turn serves as an independent factor influencing outcomes in tubularized incised plate repair.
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Affiliation(s)
- Wei Ru
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Jing Shen
- Amcare Women's and Children's Hospital, Hangzhou, China
| | - Daxing Tang
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Shan Xu
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Dehua Wu
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Chang Tao
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Guangjie Chen
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Lei Gao
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Xiaohao Wang
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Yiding Shen
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
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Koyanagi T. ACU lecture: One-stage hypospadias repair - Future is Asia the East. Int J Urol 2018; 25:314-317. [PMID: 29577435 DOI: 10.1111/iju.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/13/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Tomohiko Koyanagi
- Hokkaido University, Sapporo, Hokkaido, Japan.,Jinyukai Hospital, Sapporo, Hokkaido, Japan
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González R, Lingnau A, Ludwikowski BM. Results of Onlay Preputial Flap Urethroplasty for the Single-Stage Repair of Mid- and Proximal Hypospadias. Front Pediatr 2018; 6:19. [PMID: 29473028 PMCID: PMC5809423 DOI: 10.3389/fped.2018.00019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/22/2018] [Indexed: 11/25/2022] Open
Abstract
AIMS To report current results of preputial flap onlay urethroplasty using the principle of the total preputial flap (TPF) for the one-stage repair of mid- and proximal hypospadias. METHODS This study was a retrospective chart review of patients in a prospectively kept database of all hypospadias operations performed at two institutions from January 1 2011 to August 2017. Inclusion criteria: all patients who underwent hypospadias repair using a preputial only flap urethroplasty based on the principle of the TPF. Demographic data, duration of follow-up, complications, and reoperations were recorded. A successful result was considered to be a straight penis, a glanular meatus, and absence of voiding symptoms. Whenever possible an uroflow was obtained during the follow-up visits. RESULTS Forty-nine children met the inclusion criteria. All patients had marked penile curvature. Three patients had chromosomal abnormalities. The mean age at the time of surgery was 22 months (11-110) and the mean duration of follow-up 23.4 months (1-79). In 48 cases, the urethral plate could be preserved without dividing it. The penile curvature was corrected with chordectomy alone in 10 patients, 38 required a dorsal plication of the tunica albuginea, and 1 required an additional ventral dermal graft. In 38 patients (77.5%), the initial operation was successful, and no further operations were needed. There were eight urethrocutaneous fistulas, three dehiscences of the glans approximation. One patient suffered a wound infection and partial loss of the flap. CONCLUSION One-stage repair of mid- and proximal hypospadias preserving the urethral plate and using a TPF for the urethroplasty and coverage of the ventral penis is successful in 77.5% of cases. Complications in the remaining patients were easily managed or did not require treatment. Compared to a planned two-stage approach, the technique described in this report resulted in significantly fewer procedures till complete resolution of the problem.
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Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Kinder- und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - Anja Lingnau
- Department of Urology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Risk factors for failed urethrocutaneous fistula repair after transverse preputial island flap urethroplasty in pediatric hypospadias. Int Urol Nephrol 2017; 50:191-195. [PMID: 29282594 DOI: 10.1007/s11255-017-1773-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We review our experience in urethrocutaneous fistula (UCF) repair after transverse preputial island flap urethroplasty (Duckett) in pediatric hypospadias to investigate the risk factors for unsuccessful outcome. METHODS Two hundred and nineteen UCFs repairs conducted in our center from January 2015 to December 2016 after Duckett technique were retrospectively reviewed and 182 had a follow-up for more than 6 months. The age of patients, size, localization and numbers of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCFs, hospital of primary surgery and postoperative infection were analyzed as potential risk factors. Stratified analysis and assessment of additive interaction were performed to have a better understanding of the relation between the risk factors. Logistic regression analysis was used for multivariate analysis. RESULTS UCF repairs were succeeded in 121 (66.5%) and failed in 61 (33.5%) at first operation. In the univariate analysis, size and numbers of UCFs (P = 0.01 and P = 0.035, respectively), interval time of two operations (P = 0.042) and hospital of primary surgery (P = 0.02) were statistically related with the outcome. In the multivariate analysis, UCF ≥ 2 (OR 2.71, 95%, CI 1.095-6.692, P = 0.031), size ≥ 2 mm (OR 2.45, 95% CI 1.267-4.757, P = 0.08) and primary surgery not at our hospital (OR 2.21, 95% CI 1.094-4.126, P = 0.026) were identified as independent risk factors for unsuccessful outcome. In the stratified analysis, multiplicative interaction between the 3 risk factors was not found. CONCLUSIONS Our study suggested that UCF repairs after transverse preputial island flap urethroplasty were easier to fail if the UCF was ≥ 2 mm, the numbers of UCFs was ≥ 2, or the surgeon had less experience. The age of patients, site of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCF and postoperative infection were not significantly related to the success rate of UCF repair.
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Zheng D, Fu S, Li W, Xie M, Guo J, Yao H, Wang Z. The hypospadias classification affected the surgical outcomes of staged oral mucosa graft urethroplasty in hypospadias reoperation: An observational study. Medicine (Baltimore) 2017; 96:e8238. [PMID: 29381913 PMCID: PMC5708912 DOI: 10.1097/md.0000000000008238] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The staged graft urethroplasty is a recommended technique for repairing complex hypospadias. This retrospective study aimed to investigate the outcomes of this technique in hypospadias patients undergoing reoperation and to analyze the underlying contributing factors including age, meatus location, and graft and suture type.We retrospectively analyzed 40 hypospadias patients undergoing reoperation who received a staged oral graft urethroplasty, including 15 buccal mucosal grafts and 25 lingual mucosal grafts. Median age at presentation was 18.5 years, and median follow-up was 17.5 months (range 8-30 months). The patients were classified according to their original meatus location.Twenty-five complications developed in 12 of 40 (30%) cases, including 6 fistulas (15%), 7 infections (17.5%), 9 cases of glans dehiscence (22.5%), and 3 cases of stenosis (7.5%). There was no significant difference in the overall complication rates between prepuberty and postpuberty groups. In addition, no significant difference in complications was found between the 2 graft techniques. The complications were significantly higher in the original perineal type compared with the original penoscrotal type (7/10 vs 5/30, P = .0031). Seven patients who originally had perineal hypospadias developed multiple complications.Based on this study, the staged graft urethroplasty is an effective technique in reoperative hypospadias repairs with reasonable complication risk. The hypospadias classification affects the surgical outcomes.
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Han XR, Wen X, Wang S, Hong XW, Fan SH, Zhuang J, Wang YJ, Zhang ZF, Li MQ, Hu B, Shan Q, Sun CH, Bao YX, Lin M, He T, Wu DM, Lu J, Zheng YL. Associations of TGFBR1 and TGFBR2 gene polymorphisms with the risk of hypospadias: a case-control study in a Chinese population. Biosci Rep 2017; 37:BSR20170713. [PMID: 28894026 PMCID: PMC5629700 DOI: 10.1042/bsr20170713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/04/2017] [Accepted: 09/06/2017] [Indexed: 02/06/2023] Open
Abstract
This case-control study investigated the association of transforming growth factor-β (TGF-β) receptor type I and II (TGFBR1 and TGFBR2) gene polymorphisms with the risk of hypospadias in a Chinese population. One hundred and sixty two patients suffering from hypospadias were enrolled as case group and 165 children who underwent circumcision were recruited as control group. Single nucleotide polymorphisms (SNPs) in TGFBR1 and TGFBR2 genes were selected on the basis of genetic data obtained from HapMap. PCR-restriction fragment length polymorphism (PCR-RFLP) was performed to identify TGFBR1 and TGFBR2 gene polymorphisms and analyze genotype distribution and allele frequency. Logistic regression analysis was conducted to estimate the risk factors for hypospadias. No significant difference was found concerning the genotype and allele frequencies of TGFBR1 rs4743325 polymorphism between the case and control groups. However, genotype and allele frequencies of TGFBR2 rs6785358 in the case group were significantly different in contrast with those in the control group. Patients carrying the G allele of TGFBR2 rs6785358 polymorphism exhibited a higher risk of hypospadias compared with the patients carrying the A allele (P<0.05). The TGFBR2 rs6785358 genotype was found to be significantly related to abnormal pregnancy and preterm birth (both P<0.05). The frequency of TGFBR2 rs6785358 GG genotype exhibited significant differences amongst patients suffering from four different pathological types of hypospadias. Logistic regression analysis revealed that preterm birth, abnormal pregnancy, and TGFBR2 rs6785358 were the independent risk factors for hypospadias. Our study provides evidence that TGFBR2 rs6785358 polymorphism might be associated with the risk of hypospadias.
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Affiliation(s)
- Xin-Rui Han
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Xin Wen
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Shan Wang
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Xiao-Wu Hong
- Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai 200032, P.R. China
| | - Shao-Hua Fan
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Juan Zhuang
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
- Jiangsu Key Laboratory for Eco-Agricultural Biotechnology around Hongze Lake, School of Life Sciences, Huaiyin Normal University, Huaian 223300, P.R. China
| | - Yong-Jian Wang
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Zi-Feng Zhang
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Meng-Qiu Li
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Bin Hu
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Qun Shan
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Chun-Hui Sun
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Ya-Xing Bao
- Department of Orthopedics, The Affiliated Municipal Hospital of Xuzhou Medical University, Xuzhou 221009, P.R. China
| | - Meng Lin
- Department of Urology Surgery, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Tan He
- Department of Urology Surgery, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Dong-Mei Wu
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Jun Lu
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
| | - Yuan-Lin Zheng
- Key Laboratory for Biotechnology on Medicinal Plants of Jiangsu Province, School of Life Science, Jiangsu Normal University, Xuzhou 221116, P.R. China
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Arshadi H, Sabetkish S, Kajbafzadeh AM. Modified tubularized incised plate urethroplasty reduces the risk of fistula and meatal stenosis for proximal hypospadias: a report of 63 cases. Int Urol Nephrol 2017; 49:2099-2104. [PMID: 29039059 DOI: 10.1007/s11255-017-1725-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To report the feasibility of modified tubularized incised plate (TIP) urethroplasty technique for proximal hypospadias in 63 cases. METHODS From January 2004 to March 2010, 63 patients underwent one-stage TIP urethroplasty (modified Snodgrass technique repair) using 2-3 of three covering layers (corpus spongiosum, dartos, and tunica vaginalis). The primary meatus was proximal penile, penoscrotal, scrotal, and perineal in 38, 13, 10, and 2 patients, respectively. All patients had chordee that was corrected with dorsal plication. Glanuloplasty was performed in all cases. Complications and cosmetic results were documented after 6-72 months of follow-up. RESULTS A total of 63 boys with proximal hypospadias underwent Snodgrass hypospadias repair at a mean age of 8.5 months (range 6-54). Mean operative time was 210 ± 35 min. Patients were followed up with 6-month intervals for up to 6 years postoperatively. After 6 years of follow-up, nine urethrocutaneous fistulae, four bleeding, four meatal stenoses, and one urethral stricture were reported. Cosmetic result was satisfactory according to parent's opinion and another surgeon. No residual chordee was observed in any cases (without artificial correction). CONCLUSION In conclusion, this preliminary report can be estimated as an alternative technique with acceptable complication and cosmetic results for proximal hypospadias correction.
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Affiliation(s)
- Hamid Arshadi
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran
| | - Shabnam Sabetkish
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran.
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Current challenges with proximal hypospadias: We have a long way to go. J Pediatr Urol 2017; 13:457-467. [PMID: 28549608 DOI: 10.1016/j.jpurol.2017.03.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/17/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Proximal hypospadias repair has continued to challenge the pediatric urologist despite great efforts to develop better techniques for repair. METHODS In this article, we review the literature regarding modern proximal hypospadias repair approaches and outcomes. We also present our current approach to proximal hypospadias repair surgery and outcome tracking. Finally, we review the literature on surgical outcome tools that may help us standardize research. RESULTS Proximal hypospadias repair has significant variability in technique. Overall modern data would suggest that we require great improvement in our surgical management of this challenging problem. Though tools exist to begin to standardize the reporting of hypospadias outcomes, collaborative efforts are still required for future research. CONCLUSION Future research in proximal hypospadias repair needs to utilize new reporting tools as well as engage in collaborative efforts between institutions.
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Mattos RMD, Araújo SRRD, Quitzan JG, Leslie B, Bacelar H, Parizi JLG, Martins GMC, Cruz MLD, Macedo A. Can a graft be placed over a flap in complex hypospadias surgery? An experimental study in rabbits. Int Braz J Urol 2017; 42:1228-1236. [PMID: 27649106 PMCID: PMC5117981 DOI: 10.1590/s1677-5538.ibju.2016.0168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/05/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose: To develop a rabbit experimental study to test the hypothesis that surgical repair of hypospadias with severe ventral curvatures might be completed in one stage, if a graft, such as buccal mucosa, could be placed over the tunica vaginalis flap used in corporoplasty for ventral lengthening, with the addition of an onlay preputial island flap to complete the urethroplasty. Materials and methods: The experimental procedure with rabbits included a tunica vaginalis flap for reconstruction of the corpora after corporotomy, simulating a ventral lengthening operation. A buccal mucosa graft was placed directly on top of the flap, and the urethroplasty was completed with an onlay preputial island flap. Eight rabbits were divided into 4 groups, sacrificed at 2, 4, 8 and 12 weeks postoperatively, and submitted to histological evaluation. Results: We observed a large number of complications, such as fistula (75%), urinary retention (50%) and stenosis (50%). There were two deaths related to the procedure. Histological evaluation demonstrated a severe and persistent inflammatory reaction. No viable tunica vaginalis or buccal mucosa was identified. Conclusions: In this animal model, the association of a buccal mucosa graft over the tunica vaginalis flap was not successful, and resulted in complete loss of both tissues.
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Affiliation(s)
| | | | | | - Bruno Leslie
- Universidade Federal de São Paulo, São Paulo, Brasil
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Abstract
The majority of patients with DSD will be found to carry an XY karyotype and be assigned male gender. From a phenotypical standpoint, most will present with proximal hypospadias ± cryptorchidism. In this review article, the authors present the current status of reconstruction of the male genitalia in this setting. The report addresses the following topics: surgical input in the evaluation of the newborn with an undervirilized external genitalia, including gender assignment considerations; controversies surrounding timing and indication for hypospadias surgery in proximal cases as well as use of testosterone; surgical techniques and decision-making process for one- vs. two-stage repairs; complications of hypospadias surgery based on technique used for repair; and long-term follow-up. The high complication rates observed in the treatment of proximal hypospadias attest to its challenging nature. Concentration of experience, tracking carefully identified patient-centered outcomes and long-term follow-up of this patient population are recommended.
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Affiliation(s)
- Rodrigo L P Romao
- IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joao L Pippi Salle
- Division of Urology, Department of Surgery, Sidra Medical and Research Center, PO Box 26999, Doha, Qatar.
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Schlomer BJ. Correction of Residual Ventral Penile Curvature After Division of the Urethral Plate in the First Stage of a 2-Stage Proximal Hypospadias Repair. Curr Urol Rep 2017; 18:13. [PMID: 28213855 DOI: 10.1007/s11934-017-0659-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW The first stage of a 2-stage proximal hypospadias repair involves division of the urethral plate and correction of any residual ventral penile curvature (VPC). Options to correct residual VPC include dorsal corporal shortening or ventral corporal lengthening techniques. This review discusses these options and suggests an approach to management. RECENT FINDINGS Recent reports of 2-stage proximal hypospadias repairs indicate low rates of recurrent VPC with either dorsal corporal shortening or ventral corporal lengthening. Dorsal corporal shortening with dorsal plication may be preferentially used for mild to moderate residual VPC after division of urethral plate and ventral corporal lengthening reserved for severe residual VPC. Ventral corporal lengthening with grafts has been associated with urethroplasty complications after the second stage hypospadias surgery. Ventral corporal lengthening with relaxing incisions of corpora has been reported, but concerns about adverse effects require longer term studies. Little guidance exists to choose the best technique for VPC correction during first stage hypospadias repair after division of urethral plate. Reported literature suggests good results with dorsal plication techniques and ventral corporal lengthening. A practical approach is to use dorsal plication techniques for mild to moderate residual VPC after division of urethral plate (<45°) and reserve ventral corporal lengthening for severe residual VPC (>45°).
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Affiliation(s)
- Bruce J Schlomer
- Department of Urology, University of Texas Southwestern, 2350 Stemmons Freeway, Suite D-4300, MC F4.04, Dallas, TX, 75207, USA.
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Keays MA, Dave S. Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes. Can Urol Assoc J 2017; 11:S48-S53. [PMID: 28265319 DOI: 10.5489/cuaj.4386] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In this article, we present the current approach to hypospadias, a review of the classification, preoperative evaluation, and factors that enable decision-making during surgery. We will then discuss patient-reported outcomes, evaluating the patients' and parents' perspectives regarding hypospadias repair.
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Affiliation(s)
- Melise A Keays
- Division of Urology, Department of Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Sumit Dave
- Division of Urology, Department of Surgery and Pediatrics, London Health Sciences Centre, London, ON, Canada
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Sullivan KJ, Hunter Z, Andrioli V, Guerra L, Leonard M, Klassen A, Keays MA. Assessing quality of life of patients with hypospadias: A systematic review of validated patient-reported outcome instruments. J Pediatr Urol 2017; 13:19-27. [PMID: 28089292 DOI: 10.1016/j.jpurol.2016.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/08/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential. OBJECTIVE To identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population. METHODS A systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains. RESULTS A total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae. CONCLUSIONS While many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.
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Affiliation(s)
- K J Sullivan
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada
| | - Z Hunter
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada
| | - V Andrioli
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada
| | - L Guerra
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada
| | - M Leonard
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada
| | - A Klassen
- Department of Pediatrics, McMaster University, 3N27, 1280 Main Street West, Hamilton, ON, Canada; Department of Clinical Epidemiology & Biostatistics, McMaster University, 3N27, 1280 Main Street West, Hamilton, ON, Canada
| | - M A Keays
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada.
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Pfistermüller KLM, Manoharan S, Desai D, Cuckow PM. Two-stage hypospadias repair with a free graft for severe primary and revision hypospadias: A single surgeon's experience with long-term follow-up. J Pediatr Urol 2017; 13:35.e1-35.e7. [PMID: 27746246 DOI: 10.1016/j.jpurol.2016.08.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 08/17/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation. OBJECTIVE To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up. MATERIALS AND METHODS Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n = 208): indications for a two-stage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n = 93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months. RESULTS For the primary repairs (n = 208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n = 93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8). DISCUSSION In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the two-stage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%. CONCLUSION The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity.
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Affiliation(s)
- K L M Pfistermüller
- Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom.
| | - S Manoharan
- Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom
| | - D Desai
- Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom
| | - P M Cuckow
- Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JN, United Kingdom
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Springer A, Tekgul S, Subramaniam R. An Update of Current Practice in Hypospadias Surgery. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.eursup.2016.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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76
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Moscardi PRM, Gosalbez R, Castellan MA. Management of High-Grade Penile Curvature Associated With Hypospadias in Children. Front Pediatr 2017; 5:189. [PMID: 28929092 PMCID: PMC5591333 DOI: 10.3389/fped.2017.00189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/16/2017] [Indexed: 11/16/2022] Open
Abstract
Penile curvature is a frequent feature associated with hypospadias with also a great variability of severity among each patient. While the low-grade curvature (<30°) can be relatively easily corrected by simple techniques like penile degloving and dorsal plication, severe cases often demand more complex maneuvers to manage it. A great number of surgical techniques have been developed to adequately correct curvatures greater than 30°; however, each one of them should be individualized to different patients and local conditions encountered. In this article, we will review the evaluation of the pediatric patient with penile curvature associated with hypospadias with a special attention to high-grade cases, their management, indications for surgical treatment, and several surgical options for their definitive treatment.
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Affiliation(s)
- Paulo R M Moscardi
- Pediatric Urology, Children's Urology Associates, Miami, FL, United States
| | - Rafael Gosalbez
- Pediatric Urology, Children's Urology Associates, Miami, FL, United States
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Kang L, Huang L, Zhang J. Re: Omar Fahmy, Mohd Ghani Khairul-Asri, Christian Schwentner, et al. Algorithm for Optimal Urethral Coverage in Hypospadias and Fistula Repair: A Systematic Review. Eur Urol 2016;70:293-8. Eur Urol 2016; 71:e154. [PMID: 27890384 DOI: 10.1016/j.eururo.2016.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/16/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Lei Kang
- Department of Urology, Xi'an Children's Hospital, Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Lugang Huang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jingti Zhang
- Department of Urology, Xi'an Children's Hospital, Xi'an Jiaotong University, Xi'an, People's Republic of China.
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Tam YH, Pang KKY, Wong YS, Tsui SY, Wong HY, Mou JWC, Chan KW, Lee KH. Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias. Pediatr Surg Int 2016; 32:1087-1092. [PMID: 27473011 DOI: 10.1007/s00383-016-3954-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique. METHODS We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra. RESULTS There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture. CONCLUSIONS Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.
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Affiliation(s)
- Yuk Him Tam
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China.
| | - Kristine Kit Yi Pang
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Yuen Shan Wong
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Siu Yan Tsui
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Hei Yi Wong
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Jennifer Wai Cheung Mou
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Kin Wai Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Kim Hung Lee
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
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Two-stage graft urethroplasty for proximal and complicated hypospadias in children: A retrospective study. J Pediatr Urol 2016; 12:286.e1-286.e7. [PMID: 27020542 DOI: 10.1016/j.jpurol.2016.02.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/18/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Although two-stage graft urethroplasty is widely used, the literature regarding the complication rates and functional characteristics of reconstructed neourethra is relatively modest. OBJECTIVES The aim was to analyze the complication rates and uroflow data of boys who have previously undergone a two-stage graft urethroplasty procedure for proximal and complicated hypospadias. PATIENTS AND METHODS We retrospectively reviewed the clinical outcomes of 52 boys with proximal (n = 44) and complicated (n = 8) hypospadias who underwent two-stage graft urethroplasty repair (median age of 15 months and 3 years respectively) between 2004 and 2015. Fifteen toilet-trained boys without fistulas underwent uroflowmetry. The uroflow data were plotted on age-volume-dependent normograms with normal controls. The median follow-up was 34 months (8 months-8 years). RESULTS AND COMPLICATIONS Complications were identified in three patients (6%) after the first stage (i.e. contracture of the graft) and in 20 patients (38.4%) after the second stage, including meatal stenosis (n = 8, 15.3%), urethral stricture (n = 4, 7.6%), urethrocutaneous fistula (n = 8, 15.3%), glandular dehiscence (n = 1, 1.9%), and diverticulum (n = 1, 1.9%). The patients with failed hypospadias experienced fewer complications than those who underwent the two-stage procedure for primary repair (25% and 45%, respectively). The reoperation rate was 36.8%. Eleven of the 15 toilet-trained boys were asymptomatic but exhibited flow rates below the normal range (median Qmax = 7 mL/s, range 3.5-16.7). Only one of the boys with a low flow rate was confirmed to have urethral stenosis under general anesthesia. DISCUSSION In our study, primary hypospadias repair requiring urethral plate transection elicited worse outcomes than those observed in the prior failed hypospadias cases. However, because of our study's retrospective design, we were unable to accurately assess the initial position of the meatus in the redo hypospadias cases. Our data also demonstrated that the majority of cases without any voiding symptoms exhibited flow rates that were below the normal range despite no urethral stricture under general anesthesia. These findings indicate that urethras reconstructed via two-stage graft urethroplasty repair are not functionally equivalent to normal urethras, at least prior to puberty. CONCLUSION Two-stage graft urethroplasty repair was successful in 62% of cases after the second-stage procedure, but one-third of the boys required a reoperation after the two-stage planned repair. We demonstrated that although we used a urethral tissue substitute, the urine flow patterns of the patients without strictures were abnormal.
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Ansari MS, Agarwal S, Sureka SK, Mandhani A, Kapoor R, Srivastava A. Impact of changing trends in technique and learning curve on outcome of hypospadias repair: An experience from tertiary care center. Indian J Urol 2016; 32:216-20. [PMID: 27555680 PMCID: PMC4970393 DOI: 10.4103/0970-1591.185089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Apart from numerous clinical factors, surgical experience and technique are important determinants of hypospadias repair outcome. This study was aimed to evaluate the learning curve of hypospadias repair and the impact of changing trends in surgical techniques on the success of primary hypospadias repair. Materials and Methods: We retrospectively analyzed of data of 324 patients who underwent primary repair of hypospadias between January 1997 and December 2013 at our center. During the initial 8 years, repairs were performed by multiple 5 different urologists. From 2005 onwards, all procedures were performed by a single urologist. The study cohorts was categorized into three groups; Group I, surgeries performed between 1997–2004 by multiple surgeons, Group II, between 2005–2006 during the initial learning curve of a single surgeon, and Group III, from 2007 onwards after completion of the learning curve of the single surgeon. The groups were compared in respect to surgical techniques, overall success and complications. Results: Overall 296 patients fulfilled the inclusion criterion, 93 (31.4%), 50 (16.9%), and 153 (51.7%) in Group I, II, and III, respectively. Overall success was achieved in 60 (64.5%), 32 (64%), and 128 (83.7%) patients among the three groups respectively (P < 0.01). Nineteen (20.4%), 20 (40%), and 96 (62.7%) patients underwent tubularized incised plate repair in Group I, II, and III, with successful outcome in 12 (63.2%), 15 (75%), and 91 (94.8%) patients, respectively (P < 0.01). The most common complication among all groups was urethrocutaneous fistula, 20 (21.5%) in Group I, 11 (22%) in Group II, and 17 (11.1%) in Group III. Conclusion: There is a learning curve for attaining surgical skills in hypospadias surgery. Surgeons dedicated for this surgery provide better results. Tubularized incised plate urethroplasty appear promising in both distal and proximal type hypospadias.
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Affiliation(s)
- M S Ansari
- Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shikhar Agarwal
- Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjoy Kumar Sureka
- Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anil Mandhani
- Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rakesh Kapoor
- Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Aneesh Srivastava
- Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Chen C, Yang TQ, Chen JB, Sun N, Zhang WP. The Effect of Staged Transverse Preputial Island Flap Urethroplasty for Proximal Hypospadias with Severe Chordee. J Urol 2016; 196:1536-1540. [PMID: 27259652 DOI: 10.1016/j.juro.2016.05.098] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE We compare the effects of staged tranverse preputial island flap urethroplasty and the Byars 2-stage procedure in patients with proximal hypospadias and severe chordee. MATERIALS AND METHODS We studied 87 consecutive children referred for proximal hypospadias with severe chordee between March 2011 and March 2014. Of the cases 42 were repaired with staged tranverse preputial island flap (group 1) and 45 were managed by 2-stage Byars urethroplasty (group 2). Mean ± SD age at first stage surgery was 26.6 ± 13.3 months in group 1 and 24.8 ± 14.7 months in group 2. Postoperative complications in both groups were assessed regarding fistulas, urethral strictures, diverticula, meatal stenosis and glanular dehiscence. RESULTS After the second stage 2 patients (4.8%) in group 1 and 10 (23.2%) in group 2 had urethrocutaneous fistulas (p <0.05). One patient (2.4%) in group 1 and 2 patients (4.4%) in group 2 had urethral strictures (p >0.05). All patients with stricture were cured by repeated dilation and no patient required reoperation. One patient (2.4%) in group 1 and no patient in group 2 had diverticulum (p >0.05). No patient in either group had signs or symptoms of meatal stenosis or residual chordee. Three patients (7.1%) in group 1 and 12 (26.7%) in group 2 needed reoperation (p <0.05). CONCLUSIONS Two-stage urethroplasty, particularly tranverse preputial island flap partial urethroplasty, is appropriate for treating patients with proximal hypospadias and severe chordee. Use of the tranverse preputial island flap can decrease complications associated with the second stage and significantly improve the success rate.
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Affiliation(s)
- Chao Chen
- Department of Pediatric Surgery, First Affiliated Hospital of Guangxi Medical University, NanNing, China
| | - Ti-Quan Yang
- Department of Pediatric Surgery, First Affiliated Hospital of Guangxi Medical University, NanNing, China
| | - Jia-Bo Chen
- Department of Pediatric Surgery, First Affiliated Hospital of Guangxi Medical University, NanNing, China
| | - Ning Sun
- Department of Pediatric Urology, Beijing Children's Hospital, Affiliated to Capital Medical University, Beijing, China
| | - Wei-Ping Zhang
- Department of Pediatric Urology, Beijing Children's Hospital, Affiliated to Capital Medical University, Beijing, China.
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Pippi Salle JL, Sayed S, Salle A, Bagli D, Farhat W, Koyle M, Lorenzo AJ. Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period. J Pediatr Urol 2016; 12:28.e1-7. [PMID: 26279102 DOI: 10.1016/j.jpurol.2015.06.011] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 06/25/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled. OBJECTIVE To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias. METHODS Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later. RESULTS A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR. CONCLUSIONS Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes.
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Affiliation(s)
- J L Pippi Salle
- Division of Urology, Sidra Medical and Research Center, Doha, Qatar.
| | - S Sayed
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - A Salle
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - D Bagli
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - W Farhat
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - M Koyle
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - A J Lorenzo
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
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Dason S, Wong N, Braga LH. The contemporary role of 1 vs. 2-stage repair for proximal hypospadias. Transl Androl Urol 2016; 3:347-58. [PMID: 26813851 PMCID: PMC4708137 DOI: 10.3978/j.issn.2223-4683.2014.11.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved-a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and-depending on technique-have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.
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Affiliation(s)
- Shawn Dason
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Nathan Wong
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Luis H Braga
- Division of Urology, McMaster University, Hamilton, ON, Canada
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Pérez-Brayfield MR, Jorge JC, Avilés LA, Díaz J, Ortiz V, Morales-Cosme W. Concordance of Expert and Parental Opinion about Hypospadias Surgical Outcome Is Severity Dependent. Front Pediatr 2016; 4:2. [PMID: 26835440 PMCID: PMC4725097 DOI: 10.3389/fped.2016.00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/11/2016] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Hypospadias is a male congenital condition where the opening of the urethral meatus is not located in the typical anatomical position. It has been a challenge for empirical studies to ascertain the level of concordance of opinion among parents and urologists with regard to surgical outcomes according to hypospadias severity. MATERIALS AND METHODS Parents of children who had undergone hypospadias repair were recruited for this study (n = 104). A set of questionnaires that included some items with Likert scale were created to evaluate postsurgical satisfaction by parents and urologists. SAHLSA-50, a validated instrument for adult Spanish-speaking adults, was used to assess health literacy. Cohen's kappa (κ) coefficient was used to assess interobserver agreement and Chi Square "Goodness of Fit" Test was used to determine probability of satisfaction. FINDINGS Concordance on the level of satisfaction with surgical outcomes for Type cases I was slight (κ = 0.20; CI 95% 0-0.60), for Type II cases was moderate (κ = 0.54; CI 95% 0.13-0.94), and for Type III cases was substantial (κ = 0.62; CI 95% 0-0.56). However, the probability of satisfaction did not change according to severity (Chi Square "Goodness of Fit" Test; parents, p = 0.84; pediatric urologists, p = 0.92). These results cannot be explained by parental health literacy according to SAHLSA-50 test scores. CONCLUSION The level of concordance of opinion among parents and urologists with regard to their level of satisfaction with surgical outcomes is related to hypospadias severity, whereby the greatest level of concordance of opinion was achieved among most severe cases. This study underscores the need for longer follow-up to properly assess satisfaction with hypospadias repair, especially for the less severe forms of the condition.
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Affiliation(s)
| | - Juan Carlos Jorge
- Department of Anatomy and Neurobiology, School of Medicine, University of Puerto Rico , San Juan, PR , USA
| | - Luis A Avilés
- Department of Social Sciences, School of Public Health, University of Puerto Rico , San Juan, PR , USA
| | - Joanne Díaz
- MD Program, School of Medicine, University of Puerto Rico , San Juan, PR , USA
| | - Vanessa Ortiz
- Division of Urology, School of Medicine, University of Puerto Rico , San Juan, PR , USA
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GÖLLÜ BAHADIR G, ERGÜN E, TELLİ O, KHANMAMMADOV F, ÇAKMAK AM. Hormone therapy in hypospadias surgery: a survey on the current practice in Turkey. Turk J Med Sci 2016; 46:1624-1628. [DOI: 10.3906/sag-1507-72] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 01/30/2016] [Indexed: 11/03/2022] Open
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Hardwicke J, Bechar J, Hodson J, Osmani O, Park A. Fistula after single-stage primary hypospadias repair – A systematic review of the literature. J Plast Reconstr Aesthet Surg 2015; 68:1647-55. [DOI: 10.1016/j.bjps.2015.07.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/09/2015] [Accepted: 07/21/2015] [Indexed: 01/17/2023]
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Bacelar H, Rondon AV, Mattos R, Quitzan JG, Leslie B, Delcelo R, de Araújo SR, Ortiz V, Macedo A. Onlay foreskin flap anastomosed directly to the tunica albuginea: a short-term experimental study in rabbits. J Pediatr Urol 2015; 11:274.e1-6. [PMID: 26148440 DOI: 10.1016/j.jpurol.2015.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/27/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In severe hypospadias, urethral plate division is necessary for curvature correction. To configure the new urethra, an approach has been described using a foreskin flap directly anastomosed in an 'onlay' fashion to the tunica albuginea of the corpora cavernosa. Results suggest that it is possible to use the corpus cavernosum albuginea as the posterior wall of the neourethra without the need of a dorsal graft. OBJECTIVE The present experimental study aimed to evaluate the histological characteristics and healing pattern of this procedure. STUDY DESIGN Sixteen New Zealand male rabbits were divided into two groups of eight animals. Eight animals underwent 1-cm longitudinal dorsal incision of the penile urethra and the edges were anastomosed to the tunica albuginea (Group 1). Eight other animals underwent complete excision of 1.0 cm of penile urethra. Urethroplasty was performed using a foreskin flap directly anastomosed as an onlay to the albuginea, as shown in the figure (Group 2). Sacrifice and histological assessment was performed 2, 4, 8 and 12 weeks postoperatively. RESULTS In Group 1, a mild inflammatory process was noted that became almost imperceptible at 12 weeks. Fibrosis was mild at all stages in this group. Over time, a regenerative epithelium covered the corpus cavernosum. Immunohistochemistry using specific CK-7 and CK-20 confirmed the presence of urothelium. No complications were microscopically detected in this group. Group 2 presented with a more intense inflammatory infiltrate, which also resolved over time. Fibrosis was slightly more intense in this group, especially in animals that had urethral strictures. Group 2 presented with three fistulas, two were associated with urethral stricture. Histological evaluation showed the presence of epithelization over the albuginea, which turned out to be similar to the normal urothelium over time and was confirmed by immunohistochemistry. Non-keratinized stratified squamous epithelium of the foreskin flap showed good integration to the urethra. DISCUSSION Microscopic analysis showed that inflammation, fibrosis and complications were similar to previous studies. At 12 weeks there was a well-developed epithelium similar to normal urethra, which was confirmed by immunohistochemistry; this was similar to what occurs in the TIP technique, as previously demonstrated. It was hypothesized that the epithelium regeneration developed from the urethral edges, as demonstrated in other experimental studies. CONCLUSION The albuginea was covered by mature urothelium after 12 weeks, which presumably grew from the urethral edges. The foreskin flap onlay that was directly anastomosed to the albuginea completely integrated and constituted the roof of the neourethra.
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Affiliation(s)
- H Bacelar
- Department of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - A V Rondon
- Department of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - R Mattos
- Department of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - J G Quitzan
- Small Animals Surgery Department, Pontifícia Universidade Católica do Paraná, São José dos Pinhais, Brazil.
| | - B Leslie
- Department of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - R Delcelo
- Department of Pathology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - S R de Araújo
- Department of Pathology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - V Ortiz
- Department of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - A Macedo
- Department of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.
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Çayan F, Çayan S. Prenatal diagnosis of penoscrotal hypospadias and review of the literature. Turk J Urol 2015; 39:116-8. [PMID: 26328092 DOI: 10.5152/tud.2013.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 12/20/2012] [Indexed: 11/22/2022]
Abstract
Urinary tract abnormalities are frequently detected during obstetrical ultrasonography (US). However, hypospadia is often missed on prenatal US, despite it being the most common congenital defect of the male external genitalia. The prenatal recognition of hypospadias is important because it will alert the physician to order karyotyping and to look for any possible associated dysmorphic syndromes. Here, we present a case of a penoscrotal hypospadia mimicking female genitalia and describe our experience of applying two-dimensional and three-dimensional US in the prenatal diagnosis of hypospadia. Prenatal ultrasound scans should include a study of the genitals and should not only be used for sex determination.
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Affiliation(s)
- Filiz Çayan
- Department of Gynecology and Obstetrics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Selahittin Çayan
- Department of Urology, Faculty of Medicine, Mersin University, Mersin, Turkey
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Hussein NS, Samat SBA, Abdullah MAK, Gohar MN. Cosmetic and functional outcomes of two-stage hypospadias repair: an objective scoring evaluation and uroflowmetry. Turk J Urol 2015; 39:90-5. [PMID: 26328087 DOI: 10.5152/tud.2013.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 01/25/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The functional outcome following hypospadias repair is as important as the cosmetic outcome. Currently, structured scoring systems, patient questionnaires and evaluations of photographs and uroflowmetry are used to assess the results of hypospadias repair. In the present study, we assessed the outcomes of two-stage hypospadias repair using Hypospadias Objective Scoring Evaluation-HOSE and measures of uroflowmetry. MATERIAL AND METHODS Over a period of eight years, from January 1997 to December 2004, 126 hypospadias patients were treated, 90 of these patients received two-stage repairs and 36 patients received single-stage repairs. HOSE questionnaire and uroflowmetry data were obtained to evaluate the long-term outcome of the two-stage hypospadias repairs. RESULTS The age at the time of assessment ranged from 8 to 23 years-old, with a mean follow-up time of 39.78 months. Thirty-five patients had proximal hypospadias, and 20 had distal hypospadias. Of the 55 patients who received complete two-stage hypospadias repair and agreed to participate in the study, nineteen patients had acceptable HOSE scores and 36 patients had non-acceptable scores. The uroflow rates of 43 of the subjects were below the fifth percentile in three patients, equivocal (between the 5(th) and 25(th) percentile) in four patients and above the 25(th) percentile in 36 patients. CONCLUSION Two-stage repair is a suitable technique for all types of hypospadias with varying outcomes. HOSE and uroflowmetry are simple, easy, non-invasive and non-expensive tools for objectively assessing the long-term outcomes of hypospadias repair.
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Affiliation(s)
- Naser S Hussein
- Department of Urology, Al-Karam Teaching Hospital, Baghdad, Iraq
| | | | | | - Mohd Nor Gohar
- Department of Surgical, School of Medical Sciences, Kelantan, Malaysia
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Stanasel I, Le HK, Bilgutay A, Roth DR, Gonzales ET, Janzen N, Koh CJ, Gargollo P, Seth A. Complications following Staged Hypospadias Repair Using Transposed Preputial Skin Flaps. J Urol 2015; 194:512-6. [PMID: 25701546 PMCID: PMC4509837 DOI: 10.1016/j.juro.2015.02.044] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Proximal hypospadias repair using a staged approach is a complex reconstructive operation with the potential for significant complications requiring repeat surgery. We report outcomes of staged hypospadias repair using transposed preputial skin flaps and factors predictive of postoperative complications. MATERIALS AND METHODS We retrospectively analyzed patients who underwent staged proximal hypospadias repair using transposed preputial skin flaps between 2002 and 2013. Patient demographics, operative details, complications, reoperations and factors predictive of complications were reviewed. RESULTS A total of 56 patients were identified with a mean age of 14.1 months (median 14.3) at first stage. Mean followup was 38.6 months (median 34.1). Complications requiring additional unplanned operation(s) were observed in 38 patients (68%), including fistulas in 32 (57%), diverticula in 8 (14%), meatal stenosis in 5 (9%), urethral stricture in 8 (14%) and glans dehiscence in 3 (5%). In addition, redo first stage repair was performed in 4 patients (7%). Since some patients had more than 1 complication, the total number of complications is greater than the number of patients undergoing a redo operation. On univariate analyses the use of small intestinal submucosa was significantly associated with an increased risk of fistula (91% vs 49%, p = 0.02) and urethral diverticulum (64% vs 24%, p = 0.04). Incision of the tunica albuginea of the corpora was associated with an increased likelihood of fistula (77% vs 44%, p = 0.03). Finally, patients with glans dehiscence were significantly younger at first stage (5.8 vs 14.8 months, p = 0.01). CONCLUSIONS The reoperation rate for complications in children undergoing staged hypospadias repair using transposed preputial skin flaps is higher than previously reported.
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Affiliation(s)
- Irina Stanasel
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - Hoang-Kim Le
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - Aylin Bilgutay
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - David R Roth
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - Edmond T Gonzales
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - Nicolette Janzen
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - Chester J Koh
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - Patricio Gargollo
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas
| | - Abhishek Seth
- Scott Department of Urology, Baylor College of Medicine and Texas Children's Hospital, Houston, and Scott and White Healthcare, Temple, Texas.
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McNamara ER, Schaeffer AJ, Logvinenko T, Seager C, Rosoklija I, Nelson CP, Retik AB, Diamond DA, Cendron M. Management of Proximal Hypospadias with 2-Stage Repair: 20-Year Experience. J Urol 2015; 194:1080-5. [PMID: 25963188 DOI: 10.1016/j.juro.2015.04.105] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE We describe our experience with 2-stage proximal hypospadias repair. We report outcomes, and patient and procedure characteristics associated with surgical complications. MATERIALS AND METHODS We retrospectively studied patients with proximal hypospadias who underwent staged repair between January 1993 and December 2012. Demographics, preoperative management and operative technique were reviewed. Complications included glans dehiscence, fistula, meatal stenosis, nonmeatal stricture, urethrocele/diverticula and residual chordee. Cox proportional hazards model was used to evaluate the associations between time to surgery for complications and patient and procedure level factors. RESULTS A total of 134 patients were included. Median patient age was 8.8 months at first stage surgery and 17.1 months at second stage surgery, and median time between surgeries was 8 months. Median followup was 3.8 years. Complications were seen in 71 patients (53%), with the most common being fistula (39 patients, 29.1%). Reoperation was performed in 66 patients (49%). Median time from urethroplasty to surgery for complication was 14.9 months. Use of preoperative testosterone decreased risk of undergoing surgery for complication by 27% (HR 0.73, 95% CI 0.55-0.98, p = 0.04). In addition, patients identified as Hispanic were at increased risk for undergoing surgery for complications (HR 2.40, 95% CI 1.28-4.53, p = 0.01). CONCLUSIONS We review the largest cohort of patients undergoing 2-stage hypospadias repair at a single institution. Complications and reoperation rates were approximately 50% in the setting of complex genital reconstruction.
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Affiliation(s)
- Erin R McNamara
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Harvard-Wide Pediatric Health Services Research Fellowship, Boston, Massachusetts.
| | - Anthony J Schaeffer
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tanya Logvinenko
- Clinical Research Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ilina Rosoklija
- Divison of Urology, Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alan B Retik
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Diamond
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc Cendron
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Effects of oral testosterone undecanoate treatment for severe hypospadias. Int Urol Nephrol 2015; 47:875-80. [DOI: 10.1007/s11255-015-0972-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/31/2015] [Indexed: 11/26/2022]
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Pfistermuller KLM, McArdle AJ, Cuckow PM. Meta-analysis of complication rates of the tubularized incised plate (TIP) repair. J Pediatr Urol 2015; 11:54-9. [PMID: 25819601 DOI: 10.1016/j.jpurol.2014.12.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 12/22/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine overall complication rates of the tubularized incised plate (TIP) repair and assess the effects of technical modifications, length of follow-up and geographical location of reported results. MATERIALS AND METHODS A systematic literature search was undertaken, using Medline and Pubmed, in order to identify relevant articles. Random effects models were used to estimate pooled complication rates. Meta-regression was performed for each outcome by using mixed effects models with type of hypospadias (primary distal, primary proximal and secondary) as predictors. RESULTS Of the 189 articles that were identified, 49 studies (4675 patients) were included in the analysis. Fistula and re-operation rates were significantly higher in secondary repairs (15.5% and 23.3%) compared to primary proximal (10.3% and 12.2%) and primary distal (5.7% and 4.5%) (P = 0.045 and P < 0.001, respectively). Technical modifications reduced fistula rates from 10.3% to 3.3% (P = 0.003) and re-operation rates from 13.6% to 2.8% (P = 0.001). The rate of meatal stenosis was highest in the secondary repairs, with follow-up >1 year (12.7%). Comparison of geographical location showed that complication rates for all but one variable were significantly lower in North America when compared to Europe and the rest of the world. Mean meatal stenosis rates were 1.8% in North America, 3.4% in Europe and 8.2% in the rest of the world (P = 0.002). This remained significant in a multivariable model incorporating repair technique and length of follow-up (P = 0.046). Mean rates of urethral stricture, fistula and re-operation followed a similar pattern (P = 0.045, P = 0.009 and P < 0.001, respectively). Mean follow-up was shortest in the North American group, at 11.9 months, compared to Europe, at 17.8 months, and the rest of the world, at 18.9 months. DISCUSSION The present meta-analysis has shown that the lowest complication rates for the TIP repair are when it is applied to primary distal hypospadias. Complication rates are higher for all variables when the TIP repair is used for primary proximal hypospadias. Lower complication rates than those reported in this TIP review have been documented in some studies using a staged repair for correction of primary proximal or secondary hypospadias [11,12,68], implying that a staged approach may be superior to the TIP repair in these settings. Documentation of follow-up duration was limited, making assessment of the impact of length of follow-up difficult. Geographical location had a noticeable effect on outcome, with all but one complication being lower in the North American than the other groups. Mean follow-up was shortest in North America and it is suggested that the short follow-up in the North American studies may have led to under-reporting of late complications. CONCLUSION The TIP repair has evolved to incorporate modifications that have significantly lowered complications. Higher complication rates are seen with secondary and proximal repairs; however, limited, published long-term data impair a true assessment of outcome.
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Affiliation(s)
- K L M Pfistermuller
- Department of Urology, Hillingdon Hospital, Hillingdon Hospital NHS Trust, Pield Heath Road, Uxbridge UB8 3NN, United Kingdom.
| | - A J McArdle
- Department of Paediatrics, Northwick Park Hospital, Watford Road, Harrow HA1 3UJ, United Kingdom.
| | - P M Cuckow
- Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, United Kingdom.
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Spinoit AF, Poelaert F, Van Praet C, Groen LA, Van Laecke E, Hoebeke P. Grade of hypospadias is the only factor predicting for re-intervention after primary hypospadias repair: a multivariate analysis from a cohort of 474 patients. J Pediatr Urol 2015; 11:70.e1-6. [PMID: 25797860 DOI: 10.1016/j.jpurol.2014.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 11/11/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is an ongoing quest on how to minimize complications in hypospadias surgery. There is however a lack of high-quality data on the following parameters that might influence the outcome of primary hypospadias repair: age at initial surgery, the type of suture material, the initial technique, and the type of hypospadias. OBJECTIVES The objective of this study was to identify independent predictors for re-intervention in primary hypospadias repair. STUDY DESIGN We retrospectively analyzed our database of 474 children undergoing primary hypospadias surgery. Univariate and multivariate logistic regression was performed to identify variables associated with re-intervention. A p-value <0.05 was considered statistically significant and therefore considered as a prognostic factor for re-intervention. RESULTS Distal penile hypospadias was reported in 77.2% (n = 366), midpenile in 11.4% (n = 54) and proximal in 11.4% (n = 54) of children. Initial repair was based on an incised plate technique in 39.9% (n = 189), meatal advancement in 36.0% (n = 171), an onlay flap in 17.3% (n = 82) and other or combined techniques in 5.3% (n = 25). In 114 patients (24.1%) re-intervention was required (n = 114) of which 54 re-interventions (47.4%) were performed within the first year post-surgery, 17 (14.9%) in the second year and 43 (37.7%) later than 2 years after initial surgery. The reason for the first re-intervention was fistula in 52 patients (46.4%), meatal stenosis in 32 (28.6%), cosmesis in 35 (31.3%) and other in 14 (12.5%). The median time for re-intervention was 14 months after surgery [range 0-114]. Significant predictors for re-intervention on univariate logistic regression (polyglactin suture material versus poliglecaprone, proximal hypospadias, lower age at operation and other than meatal advancement repair) were put in a multivariate logistic regression model. Of all significant variables, only proximal hypospadias remained an independent predictor for re-intervention (OR 3.27; p = 0.012). DISCUSSION The grade of hypospadias remains according to our retrospective analysis the only objective independent predicting factor for re-intervention in hypospadias surgery. This finding is rather obvious for everyone operating hypospadias. Curiously midpenile hypospadias cases were doing slightly better than distal hypospadias in terms of re-intervention rates. Our study however has also some shortcomings. First of all, data was gathered retrospectively and follow-up time was ill-balanced for several variables. We tried to correct this by applying sensitivity analysis, but possible associations between some variables and re-intervention might still be obscured by this. Standard questionnaires to analyze surgical outcome were not available. Therefore, we focused our analysis on re-intervention rate as this is a hard and clinically relevant end point. CONCLUSIONS This retrospective analysis of a large hypospadias database with long-term follow-up indicates that the long-lasting debate about factors influencing the reoperation rate in hypospadias surgery might be futile: in experienced hands, the only variable that independently predicts for re-intervention is the severity of hypospadias, the only factor we cannot modify. This retrospective multivariate analysis of a large hypospadias database with long-term follow-up suggests that the only significant independent predictive factor for re-intervention is proximal hypospadias. In our series, technique did not influence the re-intervention rate.
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Affiliation(s)
| | - Filip Poelaert
- Department of Urology, Ghent University Hospital, Gent, Belgium
| | | | | | - Erik Van Laecke
- Department of Urology, Ghent University Hospital, Gent, Belgium
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium.
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Arlen AM, Kirsch AJ, Leong T, Broecker BH, Smith EA, Elmore JM. Further analysis of the Glans-Urethral Meatus-Shaft (GMS) hypospadias score: correlation with postoperative complications. J Pediatr Urol 2015; 11:71.e1-5. [PMID: 25797855 DOI: 10.1016/j.jpurol.2014.11.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/17/2014] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVE The Glans-Urethral Meatus-Shaft (GMS) score is a concise and reproducible way to describe hypospadias severity. We classified boys undergoing primary hypospadias repair to determine the correlation between GMS score and postoperative complications. STUDY DESIGN Between February 2011 and August 2013, patients undergoing primary hypospadias repair were prospectively scored using the GMS classification. GMS scoring included a 1-4 scale for each component: G - glans size/urethral plate quality, M - meatal location, and S - degree of shaft curvature, with more unfavorable characteristics assigned higher scores [Figure]. Demographics, repair type, and complications (urethrocutaneous fistula, meatal stenosis, glans dehiscence, phimosis, recurrent chordee and stricture) were assessed. Total and individual component scores were tested in uni- and multivariate analysis. RESULTS Two-hundred and sixty-two boys (mean age 12.3 ± 13.7 months) undergoing primary hypospadias repair had a GMS score assigned. Mean GMS score was 7 ± 2.5 (G 2.1 ± 0.9, M 2.4 ± 1, S 2.4 ± 1). Mean clinical follow-up was 17.7 ± 9.3 months. Thirty-seven children (14.1%) had 45 complications. A significant relationship between the total GMS score and presence of any complication (p < 0.001) was observed; for every unit increase in GMS score the odds of any postoperative complication increased 1.44 times (95% CI, 1.24-1.68). Urethrocutaneuous fistula was the most common complication, occurring in 21 of 239 (8.8%) of single-stage repairs. Patients with mild hypospadias (GMS 3-6) had a 2.4% fistula rate vs. 11.1% for moderate (GMS 7-9) and 22.6% for severe (GMS 10-12) hypospadias (p < 0.001). Degree of chordee was an independent predictor of fistula on multivariate analysis; S4 (>60° ventral curvature) patients were 27 times more likely to develop a fistula than S1 (no curvature) boys (95% CI, 3.2-229). DISCUSSION The GMS score is based on anatomic features (i.e. glans size/urethral plate quality, location of meatus, and degree of chordee) felt to most likely impact functional and cosmetic outcomes following hypospadias repair. We demonstrated a statistically significant increase in the likelihood of any postoperative complication with every unit increase in total GMS score. The concept that factors aside from meatal location affect hypospadias repair and outcomes is not novel, and degree of ventral curvature and urethral plate quality are often cited as important factors. In our series, boys with greater than 60° of ventral curvature undergoing a single-stage repair were 27 times more likely to develop a fistula than those without chordee on multivariate analysis, making severe curvature an independent predictor of urethrocutaneous fistula formation. That meatal location did not retain significance on multivariate analysis highlights the importance of considering the entire hypospadias complex when determining severity, rather than just evaluating the position of the meatus. Our study has several limitations that warrant consideration. While GMS scores were assigned prospectively, the data was collected retrospectively, subjecting it to flaws inherent with such study design. Furthermore, type of repair is influenced by surgeon preference and subjective assessment of hypospadias characteristics not incorporated in our scoring system (i.e. tissue quality, urethral hypoplasia, penoscrotal transposition). Despite these limitations, our study demonstrates a strong correlation between the GMS classification and surgical complications, furthering supporting its potential as a tool to standardize hypospadias severity and gauge postoperative complications. CONCLUSION The Glans-Urethral Meatus-Shaft (GMS) classification provides a means by which hypospadias severity and reporting can be standardized, which may improve inter-study comparison of reconstructive outcomes. There is a strong correlation between complication risk and total GMS score. Degree of chordee (S score) is independently predictive of fistula rate.
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Affiliation(s)
- Angela M Arlen
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University of Medicine, Atlanta, GA, USA.
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University of Medicine, Atlanta, GA, USA.
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA.
| | - Bruce H Broecker
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University of Medicine, Atlanta, GA, USA.
| | - Edwin A Smith
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University of Medicine, Atlanta, GA, USA.
| | - James M Elmore
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University of Medicine, Atlanta, GA, USA.
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Hofer MD, Cheng EY, Bury MI, Xu W, Hong SJ, Kaplan WE, Sharma AK. Androgen Supplementation in Rats Increases the Inflammatory Response and Prolongs Urethral Healing. Urology 2015; 85:691-7. [DOI: 10.1016/j.urology.2014.11.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 10/27/2014] [Accepted: 11/25/2014] [Indexed: 11/29/2022]
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Zheng DC, Yao HJ, Cai ZK, Da J, Chen Q, Chen YB, Zhang K, Xu MX, Lu MJ, Wang Z. Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience. Asian J Androl 2015; 17:94-7. [PMID: 25248656 PMCID: PMC4291885 DOI: 10.4103/1008-682x.137688] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/27/2014] [Accepted: 07/07/2014] [Indexed: 11/04/2022] Open
Abstract
It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20-60 months) and 35 months (18-60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.
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Affiliation(s)
- Da-Chao Zheng
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Hai-Jun Yao
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Zhi-Kang Cai
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Jun Da
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Qi Chen
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Yan-Bo Chen
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Ke Zhang
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Ming-Xi Xu
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Mu-Jun Lu
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Zhong Wang
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
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