Urinary function after Snodgrass repair of distal hypospadias: comparison with the Mathieu repair

Modified versus Classical Tubularised Incised Plate Urethroplasty in Hypospadias: A Comparative Study

BACKGROUND

Hypospadias is a wide-world congenital malformation that accounts for 1 of 300 live male births. Many procedures were considered for its management. As the tubularised incised plate (TIP) urethroplasty, the most prevalent technique, caused many complications, several modifications were applied to the original operation to improve the outcomes and alleviate complications. The aim of this study was to compare the outcome of the ordinary TIP urethroplasty with the technique modified without dissection of the glans penis.

MATERIALS AND METHODS

A total of 82 patients with a mean age of 18.8 (±14.8) months, were randomly assigned to undergo TIP with either complete glans wings mobilisation (Group A, n = 42 patients) or without glans dissection (Group B, n = 40 patients). To evaluate the effect of modified TIP urethroplasty without glanular dissection for treatment of distal hypospadias in contrast to classical TIP repair.

RESULTS

Both techniques showed similar outcomes regarding functional repair, with good to excellent results between 88% and 90% after 6 months of follow-up. Most confronted post-operative complications were wound infection, oedema, urethrocutaneous fistulas and meatal stenosis. Less frequently haematoma, post-operative bleeding and glans dehiscence were encountered. The differences in complication rates between the two studied groups were statistically insignificant except for oedema (P = 0.04), and need for urethral dilatation (P = 0.002) that were more prevalent among patients who were treated with classic TIP repair with complete glans wings mobilisation.

CONCLUSION

From our point of view, it seems that TIP without glanular dissection technique does not outweigh TIP with complete glans wings mobilisation regarding functional outcomes and post-operative complications.

Urethral Plate Characteristics in Cases of Non-proximal Hypospadias May Not Be Associated With a Higher Risk of Complications When a Two-Stage Repair Is Applied

PURPOSE

To investigate whether a two-stage repair of distal- and mid-shaft hypospadias (non-proximal hypospadias) could eliminate the risk factors resulting from adverse urethral plate characteristics and eventually reduce complication rates.

METHODS

We retrospectively reviewed all cases of primary surgical repair of non-proximal hypospadias performed in our center between 2009 and 2018. In all cases where adverse urethral plate characteristics were found, such as meatal stenosis, a shallow urethral groove, a thick web of tissue between the native meatus and the urethral groove or in the presence of a very "thin," skin-like distal urethra, a two-stage repair was routinely undertaken. In cases of native meatal stenosis, a meatotomy, and meatoplasty were performed. In cases of a very "thin" distal urethra we incised the skin proximally up to the point of a normal urethral fold and a meatoplasty was performed at that point. Hypospadias repair was then performed in a second operation, 3-6 months following the first procedure. Urethroplasty, both in cases of a single-stage repair and in cases of a two-stage repair, was always performed using the Thiersch-Duplay technique. Patients with a follow-up of less than 12 months were excluded from this study.

RESULTS

Over a period of 10 years, 208 boys underwent primary surgical repair of non-proximal hypospadias. Eighty-nine of the 208 patients (42.8%) underwent single-stage hypospadias repair. Two-stage repair of the hypospadias was required in 119 (57.2%) of the patients. The overall complication rate was 3.4% in the group operated in a single stage and 7.6% in the group that required a two-stage repair (p = 0.09). The most frequent complication reported was urethrocutaneous fistula (p = 0.31), followed by meatal stenosis (p = 0.37), urethral stricture (p = 0.08) and wound dehiscence (p = 0.16). There was no significant difference between the complication rates of the two groups.

CONCLUSION

Patients with distal hypospadias and poor urethral plate characteristics repaired in a two-stage approach have comparable low-complications to those with favorable urethral plate characteristics repaired in a single-stage.

Repair of distal hypospadias by construction of neourethra from augmented urethral plate with two lateral strips of glans skin and coverage with dartos flap followed by skin closure with preputial flap: single center series

Introduction

Hypospadias is one of the most common anomalies in boys. Many surgical techniques for reconstruction of distal hypospadias have been described, each method having a different success rate. Our objective in this study is the assessment of the surgical technique for repair of distal hypospadias by construction of a neourethra from the augmented urethral plate with two lateral strips of glanular skin, coverage with a dartos flap, and followed by skin closure with preputial skin flap.

Material and methods

From March 2016 to November 2018, repair of distal hypospadias was performed in 56 children with a mean age of 3.2 years (range 2 to 8 years old). Minimum follow-up was 12 months, maximum up to 24 months. Success was defined by cosmetic appearance of the penis, parent perception of penile appearance, and urinary function. Uroflowmetry was done in 22 children at the 12 months follow-up. Parents evaluation of procedure was done by questionnaire using the pediatric penile perception score (PPPS).

Results

The results were successful with straight penile shaft, conical glans, slit-like meatus located at the tip of the glans, with no rotation, and normal micturition. Five children had urethrocutaneous fistula (8.9%) that were treated with simple closure. Parents reported 'very satisfactory' (98.2%) and 'satisfactory' (1.8%).

Conclusions

The described technique of repair of distal hypospadias in children with different variants of urethral plate width and glans size showed good results, both operator's and parent's perception of the results being very satisfactory. This technique is categorised stage 2a in the IDEAL (Idea, Development, Evaluation, Assessment, and Long-term study) staging system for surgical innovations.

Urinary flow measurement in hypospadias correlated to surgical procedure and risk of development of urethra-cutaneous fistula

AIM

To explore the correlation between fistula development and urinary flow measurements after hypospadias repair with emphasis on patients with urethrocutaneous fistula complications and to identify risk factors for fistula development.

METHODS

Urinary flow was examined in boys operated on for hypospadias. Outcome of maximum urinary flow (ml/s) (Q_max), voided volume for age (ml) (Volume), and pathological flow pattern (n) (Curve) was compared between the Byars, Mathieu, and Tubularized Incised Plate (TIP) surgical repair methods and between the groups of those who had and had not developed a fistula. Logistic regression analysis was performed for age at operation, genetics, comorbidity, or urinary flow measurements regarding the development of urethrocutaneous fistula.

RESULTS

Seventy-three boys underwent hypospadias repair. Overall, the urinary flow measurements differed significantly between the three reconstructive methods, being favorable for the Mathieu procedure regarding Q_max (p < 0.01), volume (p = 0.04), and frequency of pathological voiding curve (p < 0.01; Table). The frequency of urethrocutaneous fistula was 18% (13/73) and did not differ significantly between the three different reconstructive surgery methods (Byar 33%, Mathieu 32%, and TIP 12%; p = 0.22). Urinary flow measurements did not differ between patients with and without fistula complications regarding Q_max 10 ml/s (4-16) vs. 8 ml/s (2-18), voided volume 74 ml (35-171) vs. 71 ml (9-270), or abnormal urinary flow pattern (23% vs. 30%). On logistic regression analysis, age at operation, genetics, comorbidity, and urinary flow measurement parameters did not turn out to be independent risk factors for development of urethrocutaneous fistula after hypospadias repair.

DISCUSSIONS

The study demonstrated significant differences between the urinary flow measurement results between the three different repair methods, favoring the Mathieu procedure. A low Q_max was a common postoperative finding. Urinary flow measurements did not differ between boys developing fistula and those who did not. No risk factors for fistula development were identified. The study did not support that it would be possible, at an early postoperative stage, to identify those with an upcoming postoperative fistula neither with urinary flow measurements nor through risk factors. No similar reports have studied the possibility of using postoperative urinary flow measurements to determine patients at risk of fistula development after hypospadias repair.

CONCLUSIONS

Urinary flow measurements were favorable after hypospadias reconstruction with Mathieu compared with Byars and TIP. Furthermore, urinary flow measurements did not differ between reconstructed with and without a fistula complication. No risk factor for fistula development was identified.

Chronological Changes In Uroflowmetry After Hypospadias Repair: An Observational Study

Aim

Urinary flow after urethroplasty is of paramount importance. The aim of this study is to evaluate the progression of uroflowmetry (UF) parameters after different distal and proximal hypospadias repair techniques.

Methods

In this cohort study, cases that underwent primary hypospadias repair at our institution between March 2010 and December 2018 were included when uncomplicated, asymptomatic and toilet-trained. UF findings and post void residual were described after each specific technique.

Results

In all, 88 patients were eligible. Time to last UF ranged from 35 to 138 months postoperatively. Significant increase started 36 months after distal tubularized incised plate urethroplasty (TIP) and afterwards than Mathieu technique. While was noticed 24 and 36 months after Onlay technique and proximal TIP, respectively; however, TIP showed steady significant increase atall time intervals. Duckett repair exhibited insignificant change in maximum flow rate (Qmax) values, buccal mucosal graft (BMG) and inner preputial graft (IPG), significant increase in the Qmax values after 6 and 24 months, respectively, then remained steady high. Transposed preputial flap (TPF) showed significant increase at 6-12 months only, then remained steady lower than the other two techniques. Obstructed flow was 37% after distal TIP, 30% after Mathieu, 25% after proximal TIP, 66.7% after Duckett repair, and 33.3% after TPF. There were no obstructed cases after BMG and IPG.

Discussion

Improvement by time varied between techniques. After repair most cases are below the 50th percentile, implying that the reconstructed urethra is not functioning as a normal urethra. Staged repair for proximal hypospadias is preferable to a heroic one-stage procedure.

Conclusion

Choice of the surgical technique for hypospadias repair had impact on the improvement of Qmax values. TIP improved 36 months postoperatively. However, for proximal cases staged graft repair had earlier improvement and higher Qmax values than proximal TIP and Onlay techniques.

Role of uroflowmetry before and after hypospadias repair

Aims:

To study the role of uroflowmetry in the preoperative and early postoperative period in children undergoing hypospadias repair.

Materials and Methods:

Twenty-six cases undergoing hypospadias repair over 1 year (tubularized incised plate [TIP] Snodgrass [17 patients], TIP with Snodgraft [5 patients], Duckett's onlay flap [2 patients], and Duckett's tube [2 patients] urethroplasty) were prospectively evaluated with preoperative ultrasound and uroflowmetry and postoperative uroflowmetry at 3 months after the surgery and at 6 and 9 months interval if these dates fell within the study period on follow-up. The parameters studied were maximum flow rate (Q_max), average flow rate (Q_av), total voided volume, voiding time, and type of curve. Preoperative and postoperative uroflow data were compared.

Results:

Twenty-six cases comprised of anterior hypospadias (n = 8), mid penile (n = 11), and posterior hypospadias (n = 7). Fourteen patients had obstructed flow rates preoperatively. While 69% patients (18/26) had obstructed flow rates at 3 months postoperatively, it dropped to 43% at 9 months. Following TIP (Snodgrass) repair, 88% (15/17) had obstructed flow rates postoperatively. Best results were seen in patients undergoing circumferentially epithelialized urethral reconstruction (TIP with Snodgraft, Duckett's onlay flap, and Duckett's tube).

Conclusions:

Abnormal uroflow is an inherent aspect of hypospadias in 50% of the cases. Both preoperative and postoperative uroflow evaluation is necessary for meaningful conclusion. Patients with preoperative normal flow rates but obstructed postoperative flow rates need clinical evaluation. Obstructive flow rates are more common after TIP (Snodgrass) repair. The urinary flow rates improve with time.

Primary hypospadias repair techniques: A review of the evidence

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.

Primary hypospadias repair techniques: A review of the evidence

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.

Parental Decisional Regret after Primary Distal Hypospadias Repair: Family and Surgery Variables, and Repair Outcomes

PURPOSE

Decisional regret is defined as distress after making a health care choice and can be an issue for parents electing distal hypospadias repair for their sons. We assessed the influence on decisional regret of variables related to the family, surgery and outcomes.

MATERIALS AND METHODS

Charts for 372 patients undergoing primary distal hypospadias repair between 2005 and 2012 were reviewed, and validated questionnaires, including the Decisional Regret Scale, Pediatric Penile Perception Score and Dysfunctional Voiding and Incontinence Scoring System, were administered to parents.

RESULTS

Data were available for 172 of 372 families (response rate 46.2%). Of 323 parents 128 (39.6%) presented with moderately strong decisional regret, with good agreement within couples. Predictors of decisional regret included intermediate parental educational level (OR 3.19, 95% CI 1.52-6.69), patient not being the first born (OR 2.01, 95% CI 1.07-3.78), family history of hypospadias (OR 4.42, 95% CI 1.96-9.97), initial desire to avoid surgery (OR 2.07, 95% CI 1.04-4.12), younger age at followup (OR 0.81, 95% CI 0.72-0.91), presence of lower urinary tract symptoms (OR 4.92, 95% CI 1.53-15.81) and lower Pediatric Penile Perception Score (OR 0.86, 95% CI 0.75-0.99). Decisional regret was unrelated to parental desire to avoid circumcision, surgical variables, development of complications and duration of followup.

CONCLUSIONS

Decisional regret is a problem in a significant proportion of parents electing distal hypospadias repair for their sons. In our experience family variables seemed to be predictors of decisional regret, while surgical variables did not. Predictors of decisional regret included worse parental perception of penile appearance and the presence of lower urinary tract symptoms. However, the latter could be unrelated to surgery. Irrespective of the duration of followup, decisional regret seems decreased in parents of older patients.

Normalized Urinary Flow at Puberty after Tubularized Incised Plate Urethroplasty for Hypospadias in Childhood

PURPOSE

An obstructive urinary flow pattern is frequently seen after tubularized incised plate urethroplasty for hypospadias. However, the significance of this finding has not been determined and long-term results are few. We describe postoperative long-term uroflowmetry results after puberty in males who underwent tubularized incised plate urethroplasty in childhood.

MATERIALS AND METHODS

A total of 126 boys underwent tubularized incised plate urethroplasty for distal penile to mid shaft hypospadias at Queen Silvia Children's Hospital in Gothenburg between 1999 and 2003. Of the patients 48 were toilet trained at surgery. We report on 40 patients who had data available at 2 and 12 months postoperatively, 7 years postoperatively and at puberty (median age 15.0 years, range 13.7 to 17.1). Of the patients 31 had distal and 9 had mid penile hypospadias. Clinical examination, urinary medical history, uroflowmetry and ultrasound measuring residual urine were performed. Maximum urinary flow was correlated to age and voided volume, using Miskolc nomograms for comparison of percentiles.

RESULTS

At 1 year postoperatively 15 boys (37.5%) had normal urinary flow (above 25th percentile), compared to 16 (40%) at 7 years and 38 (95%) at puberty (p <0.0001). Improvement was significant in patients with distal (p <0.0001) and mid penile hypospadias (p = 0.008), as well as in patients who did (p = 0.0078) and did not undergo intervention (p <0.0001). During followup 5 patients underwent meatotomy due to obstructive symptoms and 4 underwent dilation. Three of these 9 patients had lichen sclerosus.

CONCLUSIONS

There is great potential for normalization of urinary flow at puberty for boys with hypospadias treated with tubularized incised plate urethroplasty. Unless symptoms occur, a conservative approach seems preferable.

Long-term functional outcomes of distal hypospadias repair: a single center retrospective comparative study of TIPs, Mathieu and MAGPI

INTRODUCTION

Tubularized Incised-Plate (TIP) urethroplasty is currently the preferred technique for distal hypospadias repair. Nevertheless, concerns have been raised on the long-term functionality of the reconstructed neourethra.

OBJECTIVE

The aim of this study is to evaluate long-term uroflowmetry parameters' evolution after TIP surgery over a long-term follow-up including the adolescent period. TIP patients were compared to normal children using established Miskolc nomograms, as well as to patients who underwent Mathieu and Meatal Advancement and Glanuloplasty (MAGPI) surgery repairs for distal hypospadias.

STUDY DESIGN

Files from patients who underwent primary distal hypospadias repair at our institution between January 1, 1997 and January 31, 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (TIP vs. Mathieu vs. MAGPI) was performed according to the following postoperative time interval endpoints: 0-6 months, 6-12 months, 12-24 months, 24-48 months, 4-6 years, 6-10 years and >10 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

153 patients met the inclusion criteria: 70 (43%) TIP, 24 (17%) Mathieu and 59 (35%) MAGPI. Overall, Qmax increases progressively according to time and age and in particular during the period covering adolescence with a similar trend regardless of the type of surgery. Uroflowmetry profiles in terms of Qmax, VV and PVR were equivalent between surgeries at each examined time point. At 10 years of follow-up postopertively, mean Qmax were 17.2 ml/s, 18.8 ml/s and 21.6 ml/s respectively with no significant difference detected between groups (p = 0.344). Compared to normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax< 5th percentile of nomograms was more prevalent in patients aged 2-7 years old at 60% but decreased to less than 10%in patients aged >13 years for all procedures combined (see abstract figure) but without detected differences between surgery types (p = 0.276).

DISCUSSION

After sub-optimal obstructive maximal urinary flows in the early postoperative period, hypospadias patients treated with TIP exhibit favourable long-term evolution with age and during adolescence in particular compared to normal children. In addition, a similar trend was found for patients treated with Mathieu and MAGPI with no significant differences detected between procedures. Nevertheless, because of the relatively small sample size we cannot exclude that a statistical difference between surgeries would have been detected if the study was adequately powered on every endpoint. Nevertheless and also as suggested by the values obtained, this potential difference may be quite small and not clinically relevant.

CONCLUSION

These results suggest that the obstructive urinary flow pattern observed in patients early on is possibly an intrinsic feature associated to the malformation itself and may be less of a consequence of the surgical technique.

Do adult men with untreated hypospadias have adverse outcomes? A pilot study using a social media advertised survey

OBJECTIVE

Hypospadias is usually treated in childhood. Therefore, the natural history of untreated mild hypospadias is unknown. We hypothesized that men with untreated hypospadias, especially mild, do not have adverse outcomes.

MATERIALS

Facebook was used to advertise an electronic survey to men older than 18 years. Men with untreated hypospadias identified themselves and indicated the severity of hypospadias with a series of questions. Outcomes included: Sexual Health Inventory for Men (SHIM), penile curvature and difficulty with intercourse, International Prostate Symptom Score (IPSS), Penile Perception Score (PPS), psychosexual milestones, paternity, infertility, sitting to urinate, and the CDC HRQOL-4 module.

RESULTS

736 men completed self-anatomy questions and 52 (7.1%) self-identified with untreated hypospadias. Untreated hypospadias participants reported worse SHIM (p < 0.001) and IPSS scores (p = 0.05), more ventral penile curvature (p = 0.003) and resulting difficulty with intercourse (p < 0.001), worse satisfaction with meatus (p = 0.011) and penile curvature (p = 0.048), and more sitting to urinate (p = 0.07). When stratified by mild and severe hypospadias, severe hypospadias was associated with more adverse outcomes than mild hypospadias.

CONCLUSION

Men with untreated hypospadias reported worse outcomes compared with non-hypospadiac men. Mild untreated hypospadias had fewer adverse outcomes than severe hypospadias. Research is needed to determine if treatment of childhood hypospadias improves outcomes in adults, especially for mild hypospadias.

Systematic review and meta-analysis of studies comparing the perimeatal-based flap and tubularized incised-plate techniques for primary hypospadias repair

PURPOSE

To conduct a systematic review and meta-analysis of studies comparing the perimeatal-based flap (PBF) and tubularized incised-plate (TIP) techniques for primary hypospadias repair and determine whether the two techniques had similar reported outcomes.

METHODS

The PubMed, Embase and Cochrane databases were searched using the terms: hypospadias, Snodgrass, TIP*, tubularized incised plate, tubularized incised-plate, Mathieu*, perimeatal-based flap, perimeatal flap, meatal-based flap and meatal based flap. No other limits were used. Inclusion criteria included: primary hypospadias repair only; both including the PBF and TIP techniques; at least one of the quantitative outcomes obtainable from study; comparative studies.

RESULTS

Twelve studies fulfilled the inclusion criteria and were included in the final analysis. Meta-analysis showed that there were no significant differences between the two techniques when comparing fistula (OR = 1.47; 95 % CI: 0.82-2.63; P = 0.20), meatal stenosis (OR = 0.53; 95 % CI: 0.24-1.16; P = 0.11), and wound dehiscence (OR = 0.82; 95 % CI: 0.24-2.84; P = 0.76). Both the studies which assessed cosmesis objectively showed a consistent better cosmetic result of the TIP technique (P < 0.05).

CONCLUSION

There were no significant differences of complication rates between the two techniques, and the TIP technique was usually of better cosmesis. Given the large clinical heterogeneity among studies, future more well-designed studies with full data and uniform criterion were awaited.

Single-stage repair of hypospadias using longitudinal dorsal island flap: Single-surgeon experience with 102 cases

Purpose:

There are many techniques of harvesting vascularized skin flaps from penile skin for hypospadias repairs. Here, we review our experience with the use of longitudinal dorsal island flap (LDIF) for mid- and proximal hypospadias repairs and to assess the results and complications of onlay and tubularized repairs.

Materials and Methods:

We retrospectively reviewed the data of all children with hypospadias operated by a single surgeon using the LDIF technique. The severity of hypospadias, technique, complications, and follow-up were assessed.

Results:

Over a 9.4-year period, 102 children (mean age 4.2 years, range 6 months to 11 years) were operated for primary hypospadias using the LDIF technique. All children had poorly formed urethral plates and hence were considered unsuitable for tubularized incised plate repair. The hypospadias was classified as midpenile, proximal penile/penoscrotal or perineal in 29, 64, and 9 children respectively. Onlay LDIF repair was done in 85 children, while in 17 children, tubularized LDIF repair was performed. At a mean follow-up of 1.8 years, complications occurred in 12 (12%) children. Complications were more common after tubularized repairs than onlay repairs (24% vs. 9.5%). All glans dehiscences occurred after onlay repairs, while meatal stenosis and diverticulum occurred after tubularized repairs. No child had urethral stenosis after onlay repair, and uroflow studies in 16 children demonstrated normal curves and flow rates.

Conclusions:

We report the use of LDIF for single-stage mid and proximal hypospadias repair with good success and an acceptable complication rate. Onlay repairs had fewer complications than tubularized repairs. Our results indicate that the specific advantages and versatility of LDIF make it a good option to consider in cases of hypospadias with poorly developed urethral plates where onlay or substitution urethroplasty is indicated.

Applications of triangular glanular flap in hypospadias repairs for different purposes

Hypospadias is a congenital anomaly of the penis with an ectopic, ventrally-placed meatus due to insufficient development of the anterior urethra. Tubularisation of glanular flaps without plate incision is performed with addition of a triangular flap in order to move the meatus more distally and avoid meatal stenosis. Subcoronally, mid-shaft, and coronally placed 41 hypospadias cases were treated with the tubularisation of the glanular flaps without incision of the urethral plate, a technique similar to TIP technique. Triangular flaps were added at the most distal end of one of the glanular flaps in all cases for different purposes. A medially-based triangular flap was elevated at the distal end of the right-sided longitudinal flap to carry the last suture more distally. The flap increased meatal diameter and carried the last suture more distally. No meatal stenosis was observed for an average of 18.02 (12-30) months. The final localisation of the meatus was satisfactory in all patients. Meatal stenosis, demonstrated after hypospadias repair, is a challenge for both the surgeon and the patient. A distal triangular glanular flap is planned to avoid this challenge. Besides, it helps to carry the meatus more distally. Promising results support the use of the glanular flap while longer follow-up is required for better evaluation.

The glandular resection and central embedding modification (GRACE) in Duckett and Barcat hypospadias repair

INTRODUCTION

We recently reported a novel modification of the Barcat technique termed glandular resection and central embedding (GRACE). Here, we report results from a large patient population and apply this modification also to Duckett hypospadias repair.

PATIENTS AND METHODS

We retrospectively evaluated 488 patients who had undergone primary or secondary hypospadias repair by Barcat or Duckett using the GRACE modification.

RESULTS

For all GRACE repairs, cosmetic appearance was favorable regarding meatal position, shape and overall appearance. Maximum and average flow were above the 5th percentile in at least 95%. In Barcat and Duckett repairs, urethrocutaneous fistulas occurred in 5 and 30.7%, urethral strictures in 3 and 20.8%, and meatal strictures in 5 and 25.3%, respectively.

CONCLUSIONS

The initially reported favorable cosmetic and functional results were confirmed both for Duckett and Barcat repair using the GRACE modification. Complication rates were favorably low for Barcat and higher, but consistent with published results, for Duckett repair.

Primary severe hypospadias: comparison of reoperation rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs

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.

Glandular resection and central embedding in hypospadias repair--a novel modification of the Barcat technique

PURPOSE

Urethrocutaneous fistula and urethral or meatal stricture, to date, remain the commonest complications of hypospadias repair, with increased tissue tension being a major cause of failure. We developed a novel technique comprising glandular resection and central embedding of the neourethra to specifically address this critical issue. We report the results of the first 112 procedures, of which 7 cases were a secondary hypospadias repair.

MATERIALS AND METHODS

All patients who underwent hypospadias repair using the glandular resection and central embedding technique over a period of 10 years were included into this retrospective single-surgeon case series. An independent third-party observer carried out follow-up examinations including urometric evaluation.

RESULTS

The median follow-up was 37 months (range, 7-147 months). In the group of primary hypospadias repair, urethrocutaneous fistulas were observed in 4%, all requiring surgical revision, and meatal or urethral stricture were observed in 4% of the patients, treated either surgically or by dilatation. In 98% of the patients, the neomeatus was located at the tip of the glans. A cosmetically impeccable slitlike appearance of the meatus was achieved in 84%, and a cosmetically acceptable oval shape was achieved in 10% of the patients. Both maximum and average urinary flow rates were within the standard ranges for the respective age groups in 93.7% and 96%, respectively. There was no significant residual urine in 92% of the patients. In the group of secondary hypospadias repairs, both cosmetic and functional results were similar, and no complications were noted.

CONCLUSIONS

Glandular resection and central embedding is a promising expansion of the repertoire of Barcat modifications. It allows safe embedding of the neourethra and glandular closure without detrimental tension. The cosmetic and functional results are encouraging.

Outcome of hypospadias repair in toilet-trained children and adolescents

PURPOSE

To review a leading causes and surgical outcome of hypospadias repair in toilet-trained children and adolescents in our department.

MATERIALS AND METHODS

Over the period from 1987 to 2010, 84 toilet-trained children and adolescents with a median age of 13 years (range 4-18) underwent hypospadias repair. Voiding symptoms were a cause for referral in 31(36%) patients, difficulties in self-appraisal or patient desire in 49(55.7%) and 4(4.8%) patients with DSD underwent male genitoplasty as a part of sex reassignment. Of those 43(51.2%) had glanular hypospadias, 36(42.9%) distal and 5(5.9%) had proximal type of hypospadias. Meatoplasty was performed in 18(21.4%) patients, MAGPI in 24(28.6%), Mathieu flip-flap in 20(23.8%), preputial pedicled flap as onlay in 2(2.4%) and as tubularized in 2(2.4%) patients, and TIP procedure was done in 16(19%). Two (2.4%) patients required two stage repair.

RESULTS

Twenty-three (27.4%) developed surgery-related complications such as meatal stenosis in 3(15.5%), breakdown of primary repair in 7(8.3%), and urethral fistula in 13(15.5%) patients, respectively.

CONCLUSIONS

There are clear differences in terms of complications rate and overall success compared with the repair in the earlier ages.

Importance of urinary flow studies after hypospadias repair: a systematic review

A systematic review was performed of publications relating to the results of urinary flow studies after hypospadias repair dating back to 1978, when what appears to be the first publication on this topic was found. The literature search was performed using the key words "hypospadias" combined with "urinary flow", "urine flow", "uroflow", "uroflowmetry", and "long-term". We also reviewed the abstracts and full-length articles cited in the reference list of selected articles. Criteria for inclusion in the present systematic review included descriptions of patient selection, surgical technique, the severity of disease (proximal vs distal), and the method used to determine uroflow, as well as a definition of urethral obstruction. In all, 339 article titles were found. Of these, 25 abstracts appeared relevant and the full text of these articles were reviewed, with 22 of the papers included in this review. Sixteen reports had appeared in the literature since 2001, compared with six between 1978 and 2000, suggesting an increasing interest in this topic. On the basis of the results of the present systematic review, we recommend that asymptomatic children operated on for hypospadias in infancy should have one flow study after toilet training, with that study repeated if the results are abnormal. It appears that early abnormal flows improve spontaneously, so that children operated on after toilet training who are asymptomatic should undergo their first uroflow measurement 1 year after surgery. Children with obstructed flow parameters or borderline flows should be followed until adulthood, until long-term follow up studies clarify the significance of abnormal flow parameters. Given the present findings, we anticipate that in the next two decades urologists will need to treat a number of men with strictures resulting from hypospadias repairs performed in childhood.

Foreskin reconstruction and preservation of a thin distal urethra: a challenge in tubularized incised plate urethroplasty

PURPOSE

The aim of this retrospective study was to evaluate the functional and cosmetic outcome of tubularized incised plate urethroplasty (TIPU) with preputial reconstruction and preservation of a thin distal urethra when applicable.

METHODS

The records of 64 boys with hypospadias, who underwent TIPU between 2000 and 2007 were analyzed. 33 (52%) underwent foreskin reconstruction and a thin distal urethra was preserved and incorporated in 19 (30%) patients. The Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), and uroflowmetry were evaluated in 55 boys (86%) after a mean of 4.8 years.

RESULTS

All patients had a vertically oriented meatus. The overall rate of fistula occurrence was 9% and of wound dehiscence, 5%. Among 33 preputial reconstructions, two (6%) patients had dehiscence and three (9%) had a fistula. No cases of stricture or stenosis occurred. There were significantly more complications with reconstruction of the foreskin (p = 0.012) and preservation of a thin distal urethra (p = 0.021). Uroflowmetry was normal in 76% of patients. PPPS and HOSE revealed excellent results.

CONCLUSION

TIPU produces excellent cosmetic and functional results with few complications; complications are more common after foreskin reconstruction and use of a thin distal urethra.

Hypospadias surgery past, present and future

PURPOSE OF REVIEW

Hypospadias surgery has been in continuous evolution for many years with steadily improving reported results. Despite this many unanswered questions on its cause, management and outcomes remain. Recent research has done little to clarify most matters.

RECENT FINDINGS

There is increasing evidence of a balance of genetic and developmental factors in the development of hypospadias, but there is doubt whether the incidence of hypospadias is increasing or not. Many technical aspects of hypospadias repair and variations of perioperative management seem to have little effect on outcome, whereas the age at which surgery is performed may. Although efforts are being made to relate anatomical findings to outcome, a lack of objective assessment and standardization is a handicap. Severe hypospadias, particularly that associated with significant chordee, remains challenging although strategies for management are being developed. The future may lie in development of autologous tissue culture for these severe cases.

SUMMARY

Further development of hypospadias surgery would benefit from objective, standardized methods of describing anatomy and outcome measures to facilitate effective comparison of techniques and procedures.