Staged segmental urethroplasty for scrotal/perineal hypospadias: a new concept

Advantages of Urethroplasty Terminating at the Corona for Severe Hypospadias: Complications, Uroflowmetry, and Esthetics

PURPOSE

Mid-shaft/proximal (msp) and penoscrotal/scrotal/perineal (pssp) hypospadias treated by urethroplasty (UP) terminating at the corona (UPC) or UP terminating at the tip of the glans (UPG) were compared.

METHODS

UP performed at a single institute (n = 234) between 2003 and 2020 were grouped as: msp-UPC (n = 23), msp-UPG (n = 75), pssp-UPC (n = 81), and pssp-UPG (n = 55) to compare data obtained from medical records for post-UP complications (PUC; urethral stenosis, urethrocutaneous fistula, diverticulum formation, and bleeding; n = 234), post-UP uroflowmetry (PUF; average flow rate (Qave), maximum flow rate (Qmax), voiding time (VT), voided volume (VV) and urine flow curves) in 57 UP patients [msp-UPC (n = 5), msp-UPG (n = 12), pssp-UPC (n = 32), pssp-UPG (n = 8)] and 9 controls, and post-UPC esthetics (EST; n = 104). P < 0.05 was considered significant.

RESULTS

Mean ages at UP (years) were: msp-UPC (3.1 ± 3.0), msp-UPG (3.3 ± 1.4), pssp-UPC (4.6 ± 2.4), and pssp-UPG (3.4 ± 1.4); p < 0.0001 by ANOVA test. Overall, there were significantly more PUC in pssp-UPG compared with pssp-UPC except for bleeding. Ages at PUF assessment were similar. Mean Qave (mL/s) for pssp-UPG (4.0 ± 1.0) was significantly less than pssp-UPC (5.9 ± 2.5; p < 0.05) and both were significantly less than controls (6.9 ± 1.8; p < 0.05, p < 0.01, respectively). Mean Qmax (mL/s) for pssp-UPC (11.4 ± 4.8) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.05) and for controls (14.9 ± 4.4) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.01). All VT (seconds) were similar to controls; all urine flow curves were normal. For EST in UPC (n = 104), 3 cases requested meatal advancement.

CONCLUSIONS

UPC may be a valid option for treating pssp hypospadias because of significant differences in PUC/PUF and minimal EST issues compared with UPG.

LEVEL OF EVIDENCE

Prognosis Study Level-Ⅱ.

A useful tip for preventing surgical site infections after hypospadias repair. A single surgeon's experience of 376 cases

PURPOSE

We report the efficacy of pre- and post-operative showering for preventing surgical site infections (SSIs) and urethrocutaneous fistula after hypospadias surgery.

MATERIALS AND METHODS

In 2006, standardised pre- and postoperative showering was introduced for hypospadias patients. Showering involves washing the genitals and groin 2 h preoperatively as well as immediately after the removal of a stent postoperatively. Data from 520 procedures performed on 376 hypospadias patients by a single surgeon from 1996 to 2015 were collected prospectively. The shower (S) group comprised 258 patients (372 procedures) and the nonshower group comprised 118 patients (148 procedures). Management protocols were identical for two groups.

RESULTS

Patient demographics were similar. SSIs were significantly less in the S group (0% vs. 2.0%; P < 0.05). The incidence of fistulas was lower in the S group (2.0% vs. 6.3%). The mean duration of follow-up was significantly shorter in the S group (3.6 vs. 12.8 years; P < 0.05) but longer than the mean time taken for complications to develop (0.4 years).

CONCLUSIONS

Our results suggest that pre- and post-operative showering may contribute to preventing SSIs and fistulas in hypospadias patients.

Undermining the epidermis around the U-shaped skin incision preserves thick, well-vascularized tissue that effectively prevents posturethroplasty complications

PURPOSE

We modified the U-shaped skin incision technique (UIT) during urethroplasty (UP) to prevent post-UP complications (post-UPC).

PATIENTS AND METHODS

Our modified UIT (mUIT) involves undermining the epidermis for 5-7 mm around the U-shaped incision to create a thicker, better vascularized tissue layer for suturing the neourethra compared with UIT. To prevent injury to underlying connective tissue and avoid compromising blood perfusion, the scalpel should be held at a more slanted angle than is conventional. After the urethral plate is incised in the midline, stay sutures are placed to the middle of the penile shaft as a landmark, and three to five sutures are placed through the thick layer created by undermining. To facilitate mobilizing connective tissue during neourethroplasty, relaxing incisions may be used on the edges of the connective tissue. We compared 207 hypospadias patients who had primary or staged UP using either mUIT (n = 110) or UIT (n = 97) between 2003 and 2017 for incidence of post-UPC.

RESULTS

mUIT had significantly less post-UPC than UIT after a mean follow-up of 6.44 ± 0.26 years after final UP, 1/110 (0.9%) versus 15/97 (15.5%) (p < .0001).

CONCLUSIONS

Undermining the edges of the U-shaped incision during mUIT would appear to prevent post-UPC.

LEVEL OF EVIDENCE

Level III.

Surgical management of hypospadias in cases with concomitant disorders of sex development

INTRODUCTION

To review the surgical treatment of hypospadias (HP) associated with disorders of sex development (DSD).

PATIENTS AND METHODS

HP cases were assessed for DSD by gross examination for atypical external genitalia, and assessment of hormone levels and karyotype. There were 58 HP cases with concomitant DSD treated between 1999 and 2017. DSD classification, type of HP, sex assignment, hormonal abnormality, surgical strategy, and post-urethroplasty complications (post-UPC) were reviewed.

RESULTS

DSD were sex chromosome abnormalities (n = 4), 46,XY (n = 51), 46,XX (n = 1), and 47,XY + 21 (n = 2). HP was perineal: (n = 26), scrotal: (n = 16), penoscrotal: (n = 15), and midshaft: (n = 1); repair was primary (n = 6) or staged (n = 52). Mean age at final urethroplasty (UP) was 4.12 ± 0.21 years; all cases had soft tissue interposition at UP. At mean follow-up 5.16 ± 0.56 years after final UP, observed post-UPC (n = 8; 13.8%) were urethral stenosis (n = 3), urethral diverticulum (n = 2), urethrocutaneous fistula (n = 2), and curvature (n = 1). Mean onset of post-UPC was 1.24 ± 0.77 years (range 0.1-6.3). The second half of our cases (n = 29; treated 2015 ~) had significantly less post-UPC (0/29; 0%) than the first half (8/29; 27.6%) (p = 0.0075).

CONCLUSIONS

Although UP for HP + DSD was formidably challenging, we achieved a significant decrease in post-UPC through a combination of surgical techniques and experience.