Double-face preputial island flap revisited: is it a reliable one-stage repair for severe hypospadias?

The double-face onlay-tube-onlay transverse preputial flap: An advantageous alternative to the two-stage hypospadias repair?

OBJECTIVE

To compare the surgical outcomes and complications of boys who underwent double-face onlay-tube-onlay transverse preputial island flap (DFOTO) one-stage repair vs. two-stage repair for proximal hypospadias.

STUDY DESIGN

Males with proximal hypospadias who underwent DFOTO or two-stage repair at a single institution from 2008 to 2021 were identified. Patients who had prior hypospadias surgery were excluded. Outcomes were surgical complications, number of surgical procedures, operative time, and post-operative uroflowmetry results.

RESULTS

Fifty-three males who underwent DFOTO and 39 who underwent two-stage repair were included. Median age at surgery was 1.1 years (IQR 0.83-1.6) and median follow-up was 3.0 years (IQR 1.2-6.8). Although not statistically significant, the DFOTO group had higher rates of urethrocutaneous fistula (30% vs. 15%, p = 0.10), urethral stricture (15% vs. 3%, p = 0.07) and urethral diverticulum (8% vs. 3%, p = 0.39). Although the unplanned re-operation rate was higher in DFOTO (58% vs. 33%, p = 0.02), the mean number of procedures and median total surgical time were lower in DFOTO (1.8 ± 0.9 vs. 2.4 ± 0.8, p = 0.0004; 337 min [IQR 278-460] vs. 468 min [IQR 400-563], p = 0.008). There were no significant differences between groups for mean peak flow rates and post void residuals.

CONCLUSIONS

In males who underwent DFOTO, 42% achieved completion of their proximal hypospadias repair with one operation, while the remainder had largely minor complications. Accounting for reoperation rates, the mean number of procedures per patient was lower in the DFOTO group. Comparable results can be achieved with both techniques; the risks of higher unplanned operation rates in the DFOTO group should be considered with the benefit of fewer total procedures.

Current perspectives in hypospadias research: A scoping review of articles published in 2021 (Review)

Hundreds of papers are written about hypospadias every year referring to all aspects of the pathology, being one of the most common congenital malformations. The present study conducted a scoping review of articles published in 2021 to present the main issues and summarize current perspectives and achievements in the field. It searched for the keyword 'hypospadias' in the three most popular databases (PubMed, Scopus and Web of Science). After the analysis of the publications, they were categorized into different domains. The present review was performed respecting the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA ScR) guidelines. A total of 284 articles were included. These were published in 142 different journals. The most accessed was the Journal of Paediatric Urology with 54 articles. The main identified domains were related to surgical techniques, postoperative care, complications, anesthesia, anatomical factors, genetics, environmental factors, endocrinology, associated malformations, questionnaires and recommendations, management, biological materials, animal models, retrospective studies of centers, social media, bibliometrics, small gestational age, neoplasm, or fertility. Promising modifications of existing surgical techniques were presented with improved outcomes for both the proximal and distal types of hypospadias. Relevant anatomical and etiological, and also genetic factors were clarified. Aspects of the peri- and postoperative management referring to the antibiotherapy, analgesia, dressing techniques, and the future use of novel bioengineering agents to prevent, reduce or treat the occurring complications were discussed.

Complication rates of proximal hypospadias: meta-analyses of four surgical repairs

INTRODUCTION

Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques.

METHODS

The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included.

RESULTS

Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin.

DISCUSSION

The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short.

CONCLUSION

This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.

Surgical management of primary severe hypospadias in children: an update focusing on penile curvature

Over the past two decades, assessment and treatment of associated curvature has emerged as a major issue in treating patients with proximal hypospadias. However, the cut-off for defining a curvature as clinically significant is still unclear, as not all patients are bothered by the same degree of curvature and, although the need for a method to assess the curvature objectively has been emphasized, no standard method yet exists. Curvature is multifactorial. The same degree of curvature can be due to any possible combination of skin and/or subcutaneous dartos tethering, a short urethral plate and an intrinsic corpora disproportion. Different strategies can be used to treat curvature, depending on the underlying cause, surgeon preferences, and the goals of the repair. In the past 10 years, use of urethral plate transection and ventral lengthening procedures has increased, although the lack of long-term follow-up data on ventral lengthening procedures suggests that the use of such procedures should be selective. Furthermore, straightening manoeuvres are influenced by the technique used for subsequent urethroplasty and, in turn, may influence the success rate of the urethroplasty. This Review provides a comprehensive overview of the major developments from the past 10 years in the management of severe proximal hypospadias in children.

Comparison of Penile Appearance and Outcomes Between Prefabricated Urethra and Pre-implanted Urethral Plate for Treatment of Children With Severe Hypospadias: A Retrospective Study

Objective: To compare the effect of prefabricated urethra and pre-implanted urethral plate in the treatment of severe hypospadias in children. Methods: We retrospectively analyzed the clinical data of 53 patients who diagnosed as severe hypospadias underwent staging urethroplasty from January 2015 to January 2018 in the Department of Pediatric Surgery, First People's Hospital, Zunyi City. The patients were divided into two groups: group A (n = 25) were treated with prefabricated urethra and group B (n = 28) were treated with pre-implanted urethral plate. After the second stage surgery, the ratios of complications such as urethral fistula, urethral stenosis, urethrocele, and recurrence chordee were compared. The penis was scored from meatus, glans, shaft skin, general appearance by the parents, blinded urologists according to The Pediatric Penile Perception Score, and the scores were compared too. Results: All patients were followed up after two stage operations for an average of 28 months. Glans dehiscence occurred in two patients (8%), urethral orifice stenosis occurred in one (4%) and urethral fistula occurred in three (12%) in group A. No urethral stenosis, urethrocele and recurrence chordee was observed. One patient presented urethral plate inactivation (3.6%), two patients presented urethral fistula (7.1%) and one patient presented urethral stenosis (3.6%) in group B. No urethrocele, glans dehiscence and recurrence chordee was observed. The total complication rate in group A was 24 and 14.3% in group B, respectively, and the difference was not statistically significant (P = 0.582). The differences between two groups scored by parents in glans (P = 0.030) was statistically significant. The differences between two groups scored by operators in meatus (P = 0.041), shaft skin (P = 0.000), glans (P = 0.001), and general appearance (P = 0.007) were statistically significant. The differences between two groups scored by counterparts in meatus (P = 0.006), shaft skin (P = 0.003), glans (P = 0.010), and general appearance (P = 0.014) were statistically significant. Conclusion: Both prefabricated urethra and pre-implanted urethral plate methods are suitable for correction of severe hypospadias as staging surgery in children. In general, pre-implanted urethral plate is more worthy of spread because it is much more applied in patients with small glans and achieve good appearance of penis.