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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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Abstract
This review summarizes data regarding commonly used surgical techniques to repair distal and proximal hypospadias. We review evidence concerning indications for various procedures used in primary hypospadias repair, and their complications, urinary function and esthetic results. Available evidence suggests TIP is preferable to Mathieu for distal hypospadias correction. Current data do not identify a clear preference between TIP and onlay flap for proximal repair when there is ventral curvature <30°, or between various flap and graft options when curvature is >31°. A review of objective data helps clarify decision-making for distal hypospadias repair. Additional objective evidence is needed to identify preferred options for proximal hypospadias repair. Measuring glansplasty dimensions (meatal size and distance from meatus to corona) may improve urinary function assessments, and provide additional objective data for decision-making between various surgical techniques.
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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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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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Kadian YS, Singh M, Rattan KN. The role of tunica vaginalis flap in staged repair of hypospadias. Asian J Urol 2016; 4:107-110. [PMID: 29264214 PMCID: PMC5717980 DOI: 10.1016/j.ajur.2016.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/07/2016] [Accepted: 10/10/2016] [Indexed: 11/16/2022] Open
Abstract
Objective The surgical repair of hypospadias is done in two stages in a select group of patients with severe anomaly. The first stage (I) procedure consists of correction of penile shaft curvature and second stage (II) repair involves the creation of a neourethra. This neourethra needs a cover of an intermediate layer in order to have good functional and cosmetic results. Among the various local flaps, tunica vaginalis flap is a good option for the use as an intermediate layer. Methods We have managed 22 patients of chordee with hypospadias by staged repair. In Stage I, chordee correction was done by dividing the urethral plate and covering the penile shaft with dorsal prepucial flaps. In Stage II, a neourethra was created and covered with tunica vaginalis flap either through the same incision (14/22) or via a subcutaneous tunnel (8/22). An indwelling catheter was kept for 10 to 12 days. Results Eighteen (81.8%) patients had successful functional and cosmetic repair. Two patients (9.1%) had urethrocutaneous fistula of which one healed on subsequent dilatation while the other one (4.5%) needed repair. Overall fistula formation rate was 4.5%. In two patients, the external urinary meatus could be made upto subglanular or coronal level. Conclusion Staged repair of chordee with hypospadias is valuable in selected group of patients and tunica vaginalis flap is an excellent intermediate layer to cover the neourethra. However preoperative counseling is particularly essential in patients where the external urinary meatus can be created at coronal or subglanular level.
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Affiliation(s)
- Yogender S Kadian
- Department of Paediatric Surgery, Pt B D Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Mahavir Singh
- Department of Surgery, Pt B D Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Kamal N Rattan
- Department of Paediatric Surgery, Pt B D Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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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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Snodgrass W, Bush N. Primary hypospadias repair techniques: A review of the evidence. Urol Ann 2016; 8:403-408. [PMID: 28057982 PMCID: PMC5100143 DOI: 10.4103/0974-7796.192097] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 02/28/2016] [Indexed: 11/23/2022] Open
Abstract
This review summarizes data regarding commonly used surgical techniques to repair distal and proximal hypospadias. We review evidence concerning indications for various procedures used in primary hypospadias repair, and their complications, urinary function and esthetic results. Available evidence suggests TIP is preferable to Mathieu for distal hypospadias correction. Current data do not identify a clear preference between TIP and onlay flap for proximal repair when there is ventral curvature <30°, or between various flap and graft options when curvature is >31°. A review of objective data helps clarify decision-making for distal hypospadias repair. Additional objective evidence is needed to identify preferred options for proximal hypospadias repair. Measuring glansplasty dimensions (meatal size and distance from meatus to corona) may improve urinary function assessments, and provide additional objective data for decision-making between various surgical techniques.
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Harper L, Michel JL, Sauvat F. Preliminary experience using a tunica vaginalis flap as the dorsal component of Bracka's urethroplasty. BJU Int 2016; 119:470-473. [PMID: 27458903 DOI: 10.1111/bju.13604] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate clinical use of a tunica vaginalis flap as the dorsal component of a two-stage urethroplasty in boys with cripple hypospadias. PATIENTS AND METHODS We performed the first stage of a Bracka two-stage urethroplasty, using a tunica vaginalis flap as the dorsal component in six boys with cripple hypospadias. We analysed their clinical characteristics and the results of this technique. RESULTS The mean (range) age of the boys was 57 (34-120) months. The mean (range) number of previous procedures the boys had undergone was 4 (3-5). At the 6-month follow-up, all the boys presented significant fibrosis of the dorsal graft rendering it unusable for tubularisation. CONCLUSIONS Exposure to the external environment seems to induce retraction and fibrosis of the tunica vaginalis. We believe one should be very cautious about using tunica vaginalis as the dorsal component of a two-stage urethroplasty, as significant fibrosis might well render the flap unusable.
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Affiliation(s)
- Luke Harper
- Department of Pediatric Surgery, CHU F Guyon, Bellepierre, Saint-Denis de La Réunion, Réunion Island, France
| | - Jean-Luc Michel
- Department of Pediatric Surgery, CHU F Guyon, Bellepierre, Saint-Denis de La Réunion, Réunion Island, France
| | - Frederique Sauvat
- Department of Pediatric Surgery, CHU F Guyon, Bellepierre, Saint-Denis de La Réunion, Réunion Island, France
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Hueber PA, Salgado Diaz M, Chaussy Y, Franc-Guimond J, Barrieras D, Houle AM. Long-term functional outcomes after penoscrotal hypospadias repair: A retrospective comparative study of proximal TIP, Onlay, and Duckett. J Pediatr Urol 2016; 12:198.e1-6. [PMID: 27318548 DOI: 10.1016/j.jpurol.2016.04.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/30/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION A variety of techniques are available for proximal hypospadias repair. Onlay, proximal tubularized incised plate (TIP), and Duckett are among the popular choices because they can be performed as a one-step procedure. However, the decision to select a procedure often comes down to the surgeon's preference rather than that supported by evidence-based data. In particular, there is a paucity of literature on the long-term urinary outcomes after proximal hypospadias repair. OBJECTIVE The aim of this study was to evaluate the evolution of long-term uroflowmetry parameters after proximal hypospadias surgery over a long-term follow-up including the adolescent period. STUDY DESIGN Files from patients who underwent primary proximal hypospadias repair at our institution between 1997 and 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (pTIP vs. Onlay vs. Duckett) was performed according to the following postoperative time interval endpoints: 0-1 years, 1-2, >2-4, >4-6, >6-10, >10-12, and >12 years. Maximal urinary flow rate (Qmax) in relation to voiding volume (VV) adjusted for age or body surface area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques. RESULTS Fifty-two patients met the inclusion criteria with a median follow-up of 10 years: 25 (59.6%) TIP, 18 (34/6%) Onlay, and nine (17.3%) Duckett. Overall, Qmax increased progressively according to time and age in particular during the period covering adolescence. At follow-up 12 years postoperatively, median Qmax values were 18.5 mL/second, 13.8 mL/second and 16.6 mL/second for TIP, Onlay, and Duckett, respectively, with no significant differenced detected between groups (p = 0.5) see figure). Compared with normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax<25th percentile of nomograms was more prevalent in patients aged 3-7 years old at 83.8% but decreased to less than 21.2% in patients aged >13 years for all procedures (see figure). DISCUSSION These results are consistent with previous work showing frequently reduced Qmax after hypospadias surgery with great potential for improvement at puberty. CONCLUSION These results suggest that the obstructive urinary flow pattern observed in patients early on is a frequent finding after proximal hypospadias surgery. However, because of the remarkable improvement observed at puberty a watchful waiting approach is proposed in order to avoid unnecessary intervention.
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Affiliation(s)
- Pierre-Alain Hueber
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Monica Salgado Diaz
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Yann Chaussy
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Julie Franc-Guimond
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Diego Barrieras
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Anne-Marie Houle
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada.
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El-Ghoneimi A. Commentary to "Hypospadias: Are we as good as we think when we correct proximal hypospadias?". J Pediatr Urol 2016; 12:197. [PMID: 27461378 DOI: 10.1016/j.jpurol.2016.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, University of Paris-Diderot, University Hospital Robert Debre, APHP, Paris, France.
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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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Abstract
This review discusses means for straightening ventral curvature >30°, and then subsequent urethroplasty using either one-stage flaps or two-stage flaps or grafts. The wide variation in reported results from these various techniques makes determination of best management difficult; however, it is clear that complications for repairs done in major centers can range to ≥50%. Given the rarity of proximal hypospadias with ventral curvature >30°, which occurs in approximately 400 newborns annually in the USA, centers should refer these cases to subspecialists within the group who can then develop and maintain expertise.
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Arnaud A, Ferdynus C, Harper L. Can separation of the scrotal sac in proximal hypospadias reliably predict the need for urethral plate transection? J Pediatr Urol 2016; 12:121.e1-5. [PMID: 26747011 DOI: 10.1016/j.jpurol.2015.10.011] [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: 06/23/2015] [Accepted: 10/31/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION One of the main challenges in proximal hypospadias repair is correcting curvature. The best technique to achieve this remains the object of debate. Indeed, some authors believe the urethral plate should be kept and used as often as possible. In some cases, however, even after extensive mobilization and dorsal plication, significant curvature remains and it is necessary to transect the urethral plate. Having a reliable pre-dissection marker of the need for urethral transection would be useful in choosing a technique.We wanted to determine if presence of marked separation of the scrotal sac (SSS), also referred to as bifid scrotum, could reliably predict the need for urethral plate transection. STUDY DESIGN We prospectively enrolled a series of boys with proximal hypospadias. We noted age, degree of hypospadias, meatal position, presence of cryptorchidism, and presence or absence of SSS. During surgery we fully degloved the penile shaft, freeing all ventral tissues, and radically dissected the more proximal bulbar urethra. We then performed an erection test. If there was residual curvature <30° we performed a dorsal plication, if it was >30° we transected the urethral plate. RESULTS Twenty-nine patients were included, of whom 18 presented SSS. The average age was comparable in both groups, as was type of hypospadias and meatal position. We estimated transection of the urethral plate to be necessary in 15 out of the 18 children with SSS, and 2 out of the 11 children without SSS. The relative risk for requiring urethral plate transection in case of SSS in this series was 4.58. CONCLUSION Techniques that commit to urethral plate transection are criticized because they preclude using the urethral plate. In our study presence of SSS was predictive for the need to transect the plate. Obviously one can decide to keep the urethral plate at all cost, and mobilize it more than we did, or accept more residual curvature, but in reality our aim was to determine a preoperative marker allowing us to define a patient category. We believe presence of SSS is a marker of severity, and that this "severity" translates into "a less usable urethra". As recent studies caution us about the evolution of the reconstructed native urethra and the possibility that it may not grow as well as the other penile tissues, we believe this extra information could influence the surgeon's decision as to the most appropriate technique for each patient.
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Affiliation(s)
- Alexis Arnaud
- Department of Pediatric Surgery, CHU F Guyon, Bellepierre, Réunion Island, France
| | - Cyril Ferdynus
- Methodology Unit (USM), CHU F Guyon, Bellepierre, Réunion Island, France
| | - Luke Harper
- Department of Pediatric Surgery, CHU F Guyon, Bellepierre, Réunion Island, France.
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A New Modification of the Koyanagi Technique for the One-stage Repair of Severe Hypospadias. Urology 2016; 93:175-9. [PMID: 27041473 DOI: 10.1016/j.urology.2016.03.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/09/2016] [Accepted: 03/17/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To describe a new modification of the Koyanagi technique for the one-stage repair of severe hypospadias and its short-term outcomes. PATIENTS AND METHODS Our modified Koyanagi technique was performed in 24 patients with severe hypospadias between February 2012 and January 2015. The age of the patients ranged from 1.9 to 11.9 years (mean = 3.5 years). The flap design was similar to the Koyanagi technique, but our modified technique highlighted the following points: after the chordee was completely corrected, the urethral plate was recreated using foreskin, and then a U-shaped incision was made on the original and recreated urethral plate (as in the Duplay technique); a pedicled flap of the tunica vaginalis or scrotal dartos was used for additional coverage of the neourethra. RESULTS The operation time lasted from 120 to 150 minutes (mean = 140 minutes). There were 5 patients (20.8%) who developed complications: 4 patients (16.7%) developed a fistula and 1 patient (4.2%) developed dehiscence of the urethra. There were no reported urethral strictures, meatal stenosis, or urethral diverticula. The complications in the 5 patients were successfully addressed with secondary repair, and all patients achieved satisfactory cosmetic and urethral functional results. CONCLUSION The modified Koyanagi technique simplified the operation and better preserved the blood supply to the flap. The additional coverage of the neourethra using a pedicled flap of the tunica vaginalis or scrotal dartos significantly decreased the rate of fistula formation. This technique is highly suitable for the one-stage repair of severe hypospadias with penoscrotal transposition.
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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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Benign penile skin anomalies in children: a primer for pediatricians. World J Pediatr 2015; 11:316-23. [PMID: 25754752 DOI: 10.1007/s12519-015-0015-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 09/20/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern. DATA SOURCES The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions. RESULTS Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age. CONCLUSION This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.
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Schneuer FJ, Holland AJA, Pereira G, Bower C, Nassar N. Prevalence, repairs and complications of hypospadias: an Australian population-based study. Arch Dis Child 2015; 100:1038-43. [PMID: 26310454 DOI: 10.1136/archdischild-2015-308809] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 07/31/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To investigate hypospadias' prevalence and trends, rate of surgical repairs and post-repair complications in an Australian population. METHODS Hypospadias cases were identified from all live-born infants in New South Wales, Australia, during the period 2001-2010, using routinely collected birth and hospital data. Prevalence, trends, surgical procedures or repairs, hospital admissions and complications following surgery were evaluated. Risk factors for reoperation and complications were assessed using multivariate logistic regression. RESULTS There were 3186 boys with hypospadias in 2001-2010. Overall prevalence was 35.1 per 10,000 live births and remained constant during the study period. Proportions of anterior, middle, proximal and unspecified hypospadias were 41.3%, 26.2%, 5.8% and 26.6%, respectively. Surgical procedures were performed in 1945 boys (61%), with 1718 primary repairs. The overall post-surgery complication rate involving fistulas or strictures was 13%, but higher (33%) for proximal cases. Complications occurred after 1 year post-repair in 52.3% of cases and up to 5 years. Boys with proximal or middle hypospadias were at increased risk of reoperation or complications, but age at primary repair did not affect the outcome. CONCLUSION One in 285 infants were affected with hypospadias, 60% required surgical repair or correction and one in eight experienced complications. The frequency of late complications would suggest that clinical review should be maintained for >1 year post-repair.
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Affiliation(s)
- Francisco Javier Schneuer
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, The University of Sydney, St. Leonards, New South Wales, Australia
| | - Andrew J A Holland
- Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Westmead, New South Wales, Australia
| | - Gavin Pereira
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Carol Bower
- Telethon Kids Institute, The University of Western Australia, Crawley, Western Australia, Australia
| | - Natasha Nassar
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, The University of Sydney, St. Leonards, New South Wales, Australia
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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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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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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: 75] [Impact Index Per Article: 8.3] [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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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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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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75
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Ekenze SO, Nwangwu EI, Amah CC, Agugua-Obianyo NE, Onuh AC, Ajuzieogu OV. Disorders of sex development in a developing country: perspectives and outcome of surgical management of 39 cases. Pediatr Surg Int 2015; 31:93-9. [PMID: 25326123 DOI: 10.1007/s00383-014-3628-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Improvements in diagnostic testing and genital repair have significantly advanced the management of disorders of sex development (DSD). Challenges however, still exist in the management of DSD. This study evaluated the types, challenges of surgical management, and outcome of DSD in south-east Nigeria. METHODS Retrospective analysis of 39 children with DSD managed from January 2005 to December 2013 at the University of Nigeria Teaching Hospital, Enugu, Nigeria. RESULTS Types of DSD were: 46, XX DSD in 17 (43.6 %) cases; 46, XY DSD 16 (41 %); Ovotesticular DSD 5 (12.8 %); and one (2.6 %) 46, XY Ovotesticular DSD. Median age at definitive gender assignment was 3 years (range 2 months-14 years). Gender assignment was female for 20 (51.3 %; all 46, XX DSD, one each of 46, XY DSD, Ovotesticular DSD and 46, XY Ovotesticular DSD), and male for 19 (48.7 %; 15 of 46, XY DSD, 4 of Ovotesticular DSD). Eight cases reared as male before presentation required gender reassignment after evaluation and counselling. Genital repair was undertaken at mean age of 4.1 years (range 6 months-14 years). After average follow-up of 22.5 months (range 1 month-7 years), a total of eleven (28.2 %) developed procedure-related complications. Challenges were delayed diagnosis, inadequate diagnostic facilities, and need for gender reassignment. CONCLUSION There is a wide spectrum of DSD in our setting. Time to diagnosis, evaluation, and outcome may be improved by public enlightenment initiative, focused education of healthcare personnel and provision of relevant diagnostic facilities through enhanced funding and collaboration.
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Affiliation(s)
- S O Ekenze
- Sub-Department of Paediatric surgery, University of Nigeria Teaching Hospital Enugu, Enugu, 400001, Nigeria,
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76
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Yang T, Zou Y, Zhang L, Su C, Li Z, Wen Y. Byars two-stage procedure for hypospadias after urethral plate transection. J Pediatr Urol 2014; 10:1133-7. [PMID: 24931759 DOI: 10.1016/j.jpurol.2014.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 05/15/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report on the outcomes of primary hypospadias repaired with the Byars two-stage procedure. MATERIALS AND METHODS Primary hypospadias repairs with the Byars two-stage procedure, between 2009 and 2012, were retrospectively reviewed. Medical charts were reviewed and analyzed. Follow up was at two weeks, three months, six months and one year after surgery. Complications, which included fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum, recurrent penile curvature and others, were documented and analyzed. RESULTS One hundred and twenty-eight cases were included in the present study. The median follow up was 30 months (range 13-44 months). All flaps took successfully after the first stage. Overall complication rates were 11.8%. Complications included: seven cases of fistula; five glans dehiscence; two urethral strictures, which developed after fistula repair; and one concealed penis. No recurrent penile curvature was recorded. CONCLUSIONS The Byars two-stage procedure is an option for primary hypospadias when the urethral plate is transected. It had an 11.8% complication rate in this present study.
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Affiliation(s)
- T Yang
- Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China.
| | - Y Zou
- Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - L Zhang
- Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - C Su
- First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Z Li
- Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - Y Wen
- Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
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77
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Long-term followup of men born with hypospadias: urological and cosmetic results. J Urol 2014; 193:975-81. [PMID: 25268894 DOI: 10.1016/j.juro.2014.09.103] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE We present data on long-term functional and cosmetic results after hypospadias surgery. MATERIALS AND METHODS Males older than 18 years with hypospadias treated in Sweden were asked to participate in the study, as well as age matched controls and circumcised men. All participants answered questionnaires, and a subgroup was examined during an outpatient visit. Relationships with outcome were analyzed using analysis of variance and regression analysis. RESULTS A total of 167 patients with a mean age of 34 years and 169 controls with a mean age of 33 years answered the questionnaire. Of the patients 63% had distal, 24% mid and 13% proximal hypospadias. A total of 46 patients and 49 controls presented for physical examination. Patients were significantly less satisfied with the penile cosmetic outcome regarding all parameters of the Penile Perception Score. There was a difference in penile length between patients and controls (mean 9.7 vs 11.6 cm, p <0.001). More patients than controls reported voiding dysfunction symptoms (p = 0.003). Patients had a lower maximum urinary flow rate than controls (p = 0.001). These differences were most prominent between patients with proximal hypospadias and controls. CONCLUSIONS Men operated on for hypospadias were less satisfied with the cosmetic result than controls, and had a shorter penile length. Patients presented with more symptoms of voiding dysfunction and displayed a lower maximum urinary flow rate. Patients with proximal hypospadias were more affected than those with milder hypospadias. Our results indicate that patients with hypospadias can be subgrouped and that those with severe phenotypes should be followed more closely during childhood as well as later in adulthood.
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78
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Ságodi L, Kiss Á, Kiss-Tóth E, Barkai L. [Questions and dilemmas in the management of hypospadias]. Orv Hetil 2014; 155:1097-101. [PMID: 25002312 DOI: 10.1556/oh.2014.29907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hypospadias is the second most common congenital malformation in males. Etiology remains unknown in about 70% of the cases. Distal hypospadias is considered not only developmental abnormality of the urethra in males, but it may also constitute a mild form of sexual development disorder in 46,XY males. Most urologists and endocrinologists consider that it is necessary to perform a detailed investigation of children presenting with proximal hypospadias associated with a small phallus or poorly developed scrotum and undescended testes. Currently, there is no generally accepted recommendation for the preoperative evaluation of hypospadias and, therefore, masculinizing surgery without preoperative evaluation is performed in these children. The authors summarize the international literature data and their own experience for the assessment and management of hypospadias concerning questions and problems related to preoperative investigation, masculinizing surgery and additional surgery. A detailed algorithm is presented for preoperative evaluation of both proximal and distal hypospadias.
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Affiliation(s)
- László Ságodi
- Miskolci Egyetem, Egészségügyi Kar Preventív Egészségtudományi Tanszék Miskolc Egyetemváros u. 1. 3515
| | - Ákos Kiss
- Borsod-Abaúj-Zemplén Megyei Kórház és Egyetemi Oktató Kórház Gyermeksebészeti Osztály Miskolc
| | - Emőke Kiss-Tóth
- Miskolci Egyetem, Egészségügyi Kar Preventív Egészségtudományi Tanszék Miskolc Egyetemváros u. 1. 3515
| | - László Barkai
- Miskolci Egyetem, Egészségügyi Kar Elméleti Egészségtudományi Tanszék Miskolc Borsod-Abaúj-Zemplén Megyei Kórház és Egyetemi Oktató Kórház Csecsemő- és Gyermekosztály Miskolc Debreceni Egyetem Klinikai Központ Gyermekegészségügyi Továbbképző Intézet Miskolc
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79
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Soave A, Riechardt S, Engel O, Rink M, Fisch M. Komplikationen bei Hypospadiekorrekturen. Urologe A 2014; 53:1001-5. [DOI: 10.1007/s00120-014-3498-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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80
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Thiry S, Gorduza D, Mouriquand P. Urethral advancement in hypospadias with a distal division of the corpus spongiosum: outcome in 158 cases. J Pediatr Urol 2014; 10:451-4. [PMID: 24291250 DOI: 10.1016/j.jpurol.2013.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 10/29/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Outcome of urethral mobilization and advancement (Koff procedure) in hypospadias with a distal division of the corpus spongiosum and redo cases with distal urethral failure. MATERIALS AND METHODS From January 1999 to November 2012, 158 children with a distal hypospadias (115 primary cases and 43 redo cases) underwent surgical repair using the Koff technique with a median age at surgery of 21 months (range, 12-217 months). RESULTS Mean follow-up was 19 months (median, 14 months). Thirty patients (19%) presented with a complication (13.9% in primary cases and 32.5% in redo surgery) mostly at the beginning of our experience. Meatal stenosis was the most common one (3.5% in primary case, 6% overall). Ventral curvature (>10°), which is considered as a possible long-term iatrogenic complication of the Koff procedure, was not found in patients with fully grown penis except in one redo patient who had, retrospectively, an inadequate indication for this type of repair. Of 158 patients, 33 reached the age of puberty (>14 years old) with a mean follow-up of 34 months, only one presented with a significant ventral curvature. CONCLUSION Urethral mobilization and advancement is a reasonable alternative for anterior hypospadias and distal fistula repair in selected cases. It has two major advantages compared to other techniques: it avoids any urethroplasty with non-urethral tissue and eliminates dysplastic tissues located beyond the division of the corpus spongiosum, which may not grow at the same pace as the rest of the penis. Significant iatrogenic curvature in fully grown penis is not supported by this series.
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Affiliation(s)
- S Thiry
- Department of Pediatric Urology, Hôpital Femme, Mère, Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Urology and Pediatric Urology, Cliniques universitaires Saint Luc, 10 Avenue Hippocrate, 1200 Woluwé, Belgium.
| | - D Gorduza
- Department of Pediatric Urology, Hôpital Femme, Mère, Enfant, 59 Boulevard Pinel, 69677 Bron, France
| | - P Mouriquand
- Department of Pediatric Urology, Hôpital Femme, Mère, Enfant, 59 Boulevard Pinel, 69677 Bron, France
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81
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Hadidi AT. Perineal hypospadias: the Bilateral Based (BILAB) skin flap technique. J Pediatr Surg 2014; 49:218-23. [PMID: 24439613 DOI: 10.1016/j.jpedsurg.2013.09.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 09/29/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to present the "bilateral based skin flap (BILAB) technique" for patients with perineal hypospadias associated with severe deep chordee and report the follow up. OPERATIVE PRINCIPLE The short urethral plate is incised, the hypoplastic corpus spongiosum excised, the glans split in the midline, and a healthy urethral plate is reconstructed from the lateral penile skin and foreskin to the tip of the glans. PATIENTS AND METHODS Between January 2005 and December 2011, the BILAB technique was performed in 68 patients with perineal hypospadias associated with severe chordee as a one or two stage repair. The records of 63 patients who maintained regular follow up were reviewed. The new urethra was reconstructed from the new urethral plate during the same setting in 26 patients. The remaining 37 patients had the urethroplasty performed 3-6 months later as a two stage repair. Patient age ranged from 8 months and 2 years (mean 10 months). Follow-up period ranged from 18 months to 8 years (mean 43 months). RESULTS Satisfactory results were obtained in 54 patients (85%). Two children developed diverticula, two patients developed glans dehiscence, one child developed fistula, and one child had complete wound dehiscence, and urethroplasty was successfully reconstructed 6 months later. Three patients developed scar contraction 6-12 months after surgery. This was corrected by excision of the scarred intermediate layer. CONCLUSIONS The BILAB technique is a reliable technique for patients with perineal hypospadias. It produces slit like meatus at the tip of the glans. The surgeon may decide intra-operatively whether to complete the urethroplasty in one or two stages. Long term follow up until puberty is being carried out.
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Affiliation(s)
- Ahmed T Hadidi
- Hypospadias Clinic, Department of Pediatric Surgery, Emma and Sana Offenbach Hospitals, Germany.
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Abstract
Hypospadias is a challenging field of urogenital reconstructive surgery with different techniques being currently used. Modern surgery claims that it is possible to create a functionally and cosmetically normal penis. Continuous re-evaluation and assessment of outcome may have a major impact on future clinical practice. Assessment of outcome includes: complication rate, cosmetic appearance of the penis, functional outcome (micturition, sexuality), and psychological factors such as quality of life and psychosexual life. This article briefly reviews current strategies of outcome assessment. Somehow in the future, we will be able to give an accurate estimation of the long-term consequences of being born with hypospadias.
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Affiliation(s)
- Alexander Springer
- Department of Pediatric Surgery, Medical University of Vienna , Vienna , Austria
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83
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Merriman LS, Arlen AM, Broecker BH, Smith EA, Kirsch AJ, Elmore JM. The GMS hypospadias score: assessment of inter-observer reliability and correlation with post-operative complications. J Pediatr Urol 2013; 9:707-12. [PMID: 23683961 DOI: 10.1016/j.jpurol.2013.04.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/08/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE An agreed upon method for describing the severity of hypospadias has not been established. Herein we assess the inter-observer reliability of the GMS hypospadias score and correlate it with the risk of a post-operative complication. METHODS A 3-component method for grading the severity of hypospadias was developed (GMS). Eighty-five consecutive patients presenting for hypospadias repair were graded independently by at least 2 surgeons using the GMS criteria. Scores were compared statistically to determine agreement between the observers. The outcomes of these patients were then reviewed to determine how the GMS score correlates to the risk of a surgical complication. RESULTS The G, M, and S scores had excellent agreement between observers. The GMS total score was exactly the same or differed by one point in 79/85 (93%) of patients. The complication rate was 5.6% for patients with a GMS score of 6 or less, but was 25.0% for patients with a GMS score greater than 6. CONCLUSIONS The GMS score provides a concise method for describing the severity of hypospadias and appears to have high inter-observer reliability. The GMS score also appears to correlate with the risk of a surgical complication.
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Affiliation(s)
- Laura S Merriman
- Department of Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Georgia Pediatric Urology, Atlanta, GA, USA
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Steven L, Cherian A, Yankovic F, Mathur A, Kulkarni M, Cuckow P. Current practice in paediatric hypospadias surgery; a specialist survey. J Pediatr Urol 2013; 9:1126-30. [PMID: 23683539 DOI: 10.1016/j.jpurol.2013.04.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 04/05/2013] [Indexed: 11/15/2022]
Abstract
AIM To undertake an online survey of current hypospadias surgery practice among those specialists attending the IVth World Congress of the International Society for Hypospadias and Disorders of Sex Development (ISHID), 2011. MATERIALS AND METHODS An online survey covering 22 separate questions relating to proximal and distal hypospadias surgery was set up, and all delegates registered for the conference were invited to complete this questionnaire anonymously. The data was analysed by three of the authors. RESULTS A total of 162 delegates registered for the conference of whom 74% were paediatric surgeons, paediatric urologists, plastic surgeons and adult/adolescent urologists. 93 delegates completed the online survey, and most of them (57%) were from Europe. The majority of surgeons see over 20 new patients/year (90%) and perform primary hypospadias surgery in over 20 patients/year (76%). The tubularized incised plate (TIP) repair is the most frequent technique used for the management of distal hypospadias (59%); other techniques used included Mathieu, onlay and TIP with graft. A variety of techniques are used for proximal hypospadias, but nearly half of the respondents (49%) preferred a staged approach. Self reported complication rates for distal hypospadias surgery are favourable (less than 10%) for 78% of the respondents. However, proximal hypospadias complication rates are higher. CONCLUSIONS With a majority of paediatric urologists and European delegates responding to our survey, the results suggest that there are differences in the management of proximal and distal hypospadias between surgeons, yet no differences were observed according to the region of their practice. Variations in long-term outcomes appear to be in keeping with the current literature.
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Affiliation(s)
- Lisa Steven
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
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85
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Herbst KW, Ferrer FA, Makari JH. The Need for Additional Procedures in Patients Undergoing Proximal Hypospadias Repairs as Reported in the Pediatric Health Information System Database. J Urol 2013; 190:1550-5. [DOI: 10.1016/j.juro.2013.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 10/27/2022]
Affiliation(s)
| | | | - John H. Makari
- Connecticut Children's Medical Center, Hartford, Connecticut
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Cimador M, Vallasciani S, Manzoni G, Rigamonti W, De Grazia E, Castagnetti M. Failed hypospadias in paediatric patients. Nat Rev Urol 2013; 10:657-66. [PMID: 23917119 DOI: 10.1038/nrurol.2013.164] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Failed hypospadias refers to any hypospadias repair that leads to complications or causes patient dissatisfaction. The complication rate after hypospadias repairs ranges from 5-70%, but the actual incidence of failed hypospadias is unknown as complications can become apparent many years after surgery and series with lifelong follow-up data do not exist. Moreover, little is known about uncomplicated repairs that fail in terms of patient satisfaction. Risk factors for complications include factors related to the hypospadias (severity of the condition and characteristics of the urethral plate), the patient (age at surgery, endocrine environment, and wound healing impairment), the surgeon (technique selection and surgeon expertise), and the procedure (technical details and postoperative management). The most important factors for preventing complications are surgeon expertise (number of cases treated per year), interposition of a barrier layer between the urethroplasty and the skin, and postoperative urinary drainage. Major complications associated with failed hypospadias include residual curvature, healing complications (preputial dehiscence, glans dehiscence, fistula formation, and urethral breakdown), urethral obstruction (meatal stenosis, urethral stricture, and functional obstruction), urethral diverticula, hairy urethra, and penile skin deficiency.
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Affiliation(s)
- Marcello Cimador
- Section of Paediatric Urology and Paediatric Surgery Unit, Department for Mother and Child Care and Urology, University of Palermo, Via A. Giordano 3, 90127 Palermo, Italy
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Key discussions from the Working Party on Disorders of Sex Development (DSD) evaluation, Foundation Merieux, Annecy, France, March 14-17, 2012. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2013; 2013:12. [PMID: 23829860 PMCID: PMC3708759 DOI: 10.1186/1687-9856-2013-12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 06/18/2013] [Indexed: 11/13/2022]
Abstract
Four topics from the DSD Working Party, a meeting to provide information regarding future studies, reported here are the complexities of hypospadias, surgical treatment of virilized genitalia of 46,XX DSD individuals, advances in phalloplasty and psychological, social and sexual outcomes.
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88
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Primary severe hypospadias: comparison of reoperation rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs. J Urol 2012; 189:1508-13. [PMID: 23154207 DOI: 10.1016/j.juro.2012.11.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2012] [Indexed: 11/21/2022]
Abstract
PURPOSE We compared complication rates, urinary symptoms and cosmetic outcomes as perceived by parents of patients undergoing 1 of 4 repairs for proximal hypospadias associated with ventral curvature. MATERIALS AND METHODS A total of 93 patients underwent hypospadias repair between 2004 and 2010. In patients requiring no urethral plate transection the repair consisted of tubularized incised plate urethroplasty (26 patients) or onlay island flap urethroplasty (31). In patients requiring urethral plate transection the repair consisted of onlay island flap on albuginea (18 patients) or 2-stage repair (18). Complications were assessed by chart review. A customized questionnaire and the Pediatric Penile Perception Score were administered to parents to evaluate their perception of urinary symptoms and cosmetic outcomes, respectively. RESULTS After a median followup of 4.5 years (range 2.2 to 8.4) complications developed in 21 patients (23%) without any difference among procedures or between patients who did and did not require urethral plate transection. Parents of 75 patients (80%) participated in the survey without differences among repairs (p = 0.35). Reported urinary symptoms were not different among repairs. For Pediatric Penile Perception Score the only difference concerned the question about penile length (p = 0.03), with the score being significantly better for the techniques requiring urethral plate transection (p = 0.05). The 2-stage repair had a significantly better score for the question about penile length and overall Pediatric Penile Perception Score than all other techniques. CONCLUSIONS Overall complication rates were comparable among repairs and did not increase after urethral plate transection. Urinary symptoms as reported by parents were comparable among the procedures. Perceived penile length was significantly better after urethral plate transection. The 2-stage repair yielded the best cosmetic results.
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Proximal hypospadias repair outcomes in patients with a specific disorder of sexual development diagnosis. Adv Urol 2012; 2012:708301. [PMID: 22778726 PMCID: PMC3388319 DOI: 10.1155/2012/708301] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 05/07/2012] [Accepted: 05/07/2012] [Indexed: 12/03/2022] Open
Abstract
Boys with undermasculinized external genital and/or 46,XY disorders of sex development (DSD) often receive masculinizing genitoplasty. Such procedures are done to correct ventral curvature of the phallus, reposition a proximally located urethral meatus, and cosmetically correct the appearance of labioscrotal folds. No studies to date have assessed if patients with a specific DSD diagnosis have worse outcomes for severe proximal hypospadias procedures or whether or not these patients require more extensive surgical maneuvers than severe proximal hypospadias patients without a specific DSD diagnosis. We retrospectively reviewed consecutive proximal hypospadias repairs performed at our institution from 1998 to 2010 and compared the anatomy, surgical technique required for repair, and outcomes in patients with and without a definitive DSD diagnosis. Boys with a specific DSD diagnosis do have significantly more atypical anatomy when undergoing proximal hypospadias masculinizing genitoplasties. They are more likely to require associated gonad procedures but do not have an increased risk of complications or number of surgeries when compared to other proximal hypospadias patients without a specific DSD diagnosis. The risk of complications is consistent with reports in the literature, and the mean number of procedures in this contemporary study is fewer than in historic reports.
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Castagnetti M, El-Ghoneimi A. The influence of perioperative factors on primary severe hypospadias repair. Nat Rev Urol 2012; 8:198-206. [PMID: 21475332 DOI: 10.1038/nrurol.2011.24] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hypospadias is one of the most common congenital malformations of the male genitalia. Severe cases present with associated curvature greater than 30° and the meatus opening proximally to the penoscrotal junction. The perioperative management of patients with primary severe hypospadias is variable. Systematic evaluation of the upper urinary tract and the search for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias, and should be limited to severe cases with associated extraurinary malformations. Detection of a disorder of sex development is key for gender assignment and prognosis, but the identification of cases warranting a full work-up and the influence of such a diagnosis on the success of hypospadias repair is controversial. Preoperative hormonal stimulation allows for penile growth irrespective of the administration route. Associated morbidity is minimal, but its influence on the success of surgery is still unknown. An age of 6-18 months is generally recommended for surgery, but no trial data support this policy. Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery, whereas postoperative antibiotic prophylaxis and type of dressing have minimal impact on surgical success. Overall, most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined. Clinicians should be made aware of the evidence supporting any single intervention in order to standardize their management policies. We hope the issues outlined here will prompt researchers to design new studies to address the clinically relevant questions.
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Affiliation(s)
- Marco Castagnetti
- Section of Pediatric Urology, Urology Unit, Department of Oncological and Surgical Sciences, University Hospital of Padova, Monoblocco Ospedaliero, Via Giustiniani 2, 35128 Padua, Italy. marcocastagnetti@ hotmail.com
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Springer A, Subramaniam R. Split dorsal dartos flap transposed ventrally as a bed for preputial skin graft in primary staged hypospadias repair. Urology 2012; 79:939-42. [PMID: 22381252 DOI: 10.1016/j.urology.2012.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 12/29/2011] [Accepted: 01/06/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe a modification of the 2-stage repair using a dorsal split dartos fascia flap, as a well vascularized bed for the graft in the first stage.The 2-stage repair is a commonly used technique in proximal hypospadias or in hypospadias with severe chordee, or in cases with urethral plate of poor or dubious quality. METHODS Between 2006 and 2009, 32 patients underwent a staged hypospadias repair: 8 (25.0%) midshaft with chordee and/or poor urethral plate, 14 (43.8%) proximal penile, 7 (21.9%) peno-scrotal, and 3 (9.4%) perineal hypospadias. Plication was necessary in 27 (84.4%). All cases received a preputial skin graft. Median age at the first stage was 21 months (range 15-26); median follow-up was 35 months (range 20-55) and the median time between the 2 stages was 8 months (range 6-12). RESULTS Graft take was 100% after the first stage. Follow-up after second-stage repair showed 31 of 32 (96.8%) had a successful functional outcome (straight erection; good, single urine stream; voiding in a standing position) and cosmetic outcome (slitlike meatus positioned at the tip of the glans, "normal looking circumcised penis"); one fistula occurred. One patient has mild residual ventral curvature. CONCLUSION Using a vascularized dorsal split dartos flap ventrally underneath and laterally of the skin graft in the first stage offers the advantages of an excellent graft take and the provision of versatile dartos tissue for a waterproofed and secured urethroplasty.
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Giannantoni A. Hypospadias Classification and Repair: The Riddle of the Sphinx. Eur Urol 2011; 60:1190-1; discussion 1191-2. [DOI: 10.1016/j.eururo.2011.08.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 08/21/2011] [Indexed: 10/17/2022]
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Current world literature. Curr Opin Urol 2011; 21:535-40. [PMID: 21975510 DOI: 10.1097/mou.0b013e32834c87d0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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El-Ghoneimi A. Editorial comment. J Urol 2011; 186:1637. [PMID: 21862051 DOI: 10.1016/j.juro.2011.04.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Trends in hypospadias surgery: results of a worldwide survey. Eur Urol 2011; 60:1184-9. [PMID: 21871708 DOI: 10.1016/j.eururo.2011.08.031] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 08/11/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hypospadias is a challenging field of urogenital reconstructive surgery, with different techniques currently being used. OBJECTIVE Evaluate international trends in hypospadias surgery. DESIGN, SETTING, AND PARTICIPANTS Paediatric urologists, paediatric surgeons, urologists, and plastic surgeons worldwide were invited to participate an anonymous online questionnaire (http://www.hypospadias-center.info). MEASUREMENTS General epidemiologic data, preferred technique in the correction of hypospadias, and preferred technique in the correction of penile curvature were gathered. RESULTS AND LIMITATIONS Three hundred seventy-seven participants from 68 countries returned completed questionnaires. In distal hypospadias (subcoronal to midshaft), the tubularised incised plate (TIP) repair is preferred by 52.9-71.0% of the participants. Meatal advancement and glanuloplasty (MAGPI) is still a preferred method in glandular hypospadias. In the repair of proximal hypospadias, the two-stage repair is preferred by 43.3-76.6%. TIP repair in proximal hypospadias is used by 0.9-16.7%. Onlay flaps and tubes are used by 11.3-29.5% of the study group. Simple plication and Nesbit's procedure are the techniques of choice in curvature up to 30°; urethral division and ventral incision of the tunica albuginea with grafting is performed by about 20% of the participants in severe chordee. The frequency of hypospadias repairs does not influence the choice of technique. CONCLUSIONS In this study, we identified current international trends in the management of hypospadias. In distal hypospadias, the TIP repair is the preferred technique. In proximal hypospadias, the two-stage repair is most commonly used. A variety of techniques are used for chordee correction. This study contains data on the basis of personal experience. However, future research must focus on prospective controlled trials.
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Rigamonti W, Castagnetti M. Onlay on Albuginea: Modified Onlay Preputial Island Flap Urethroplasty for Single-stage Repair of Primary Severe Hypospadias Requiring Urethral Plate Division. Urology 2011; 77:1498-502. [DOI: 10.1016/j.urology.2010.09.048] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 09/27/2010] [Accepted: 09/27/2010] [Indexed: 11/26/2022]
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Pediatrics: 20 years of hypospadias repair—yet still no consensus. Nat Rev Urol 2010; 7:647. [PMID: 21188776 DOI: 10.1038/nrurol.2010.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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