Management of failed hypospadias: choosing the right method and achieving optimal results

An insight of pathological anatomy of urethral stricture and surgical manipulations for children suffered from hypospadias

BACKGROUND

Manipulation of urethral stricture is difficult and challenging. Accurate analysis and evaluation of the pathological circumstances of narrowed urethra and surrounding tissues were important for cure. The detailed descriptions of anatomic pathology of urethral stricture are rare. An insight of the pathological anatomy of the strictured urethra and the corresponding corrections is essential for an ultimate cure. The aim of the study is to interpret the pathological anatomies of the strictured urethra and the corresponding surgical manipulations.

METHODS

From April 2007 to April 2020, eight boys who suffered from postoperative urethral stricture for hypospadias correction were studied retrospectively. The pathological anatomies of the strictured urethra were described and the corresponding surgical manipulations were analyzed.

RESULTS

All eight patients were eventually cured through surgery. The patient age was 2.58-11 years old (mean value of 4.73). The therapeutic duration was 12-130 months (mean value of 47.75). The surgical manipulation was 1-9 times (mean value of 4.5). Curative follow-up was 8-138 months (mean value of 77.75). They were all applied with flap tubularization for their primary urethroplasty.

CONCLUSIONS

Based on the principal contradiction of the pathological anatomies of the urethral stricture, one-stage or staged surgical manipulations can be applied. After stricture was resolved, refining techniques of Mathieu, TIP, modified Duckett, glanular reconstruction and et al. can be used. Although it was tiring, utilizing the ventral or dorsal penile flap with relatively good blood supply and flexibility to reconstruct the urethra is possible and successful. To reconstruct an anatomically normal urethral tract should be pursued in the primary and consequential procedures for hypospadias and urethral stricture.

Adults with previous hypospadias surgery during childhood: Beware of bulbar strictures

BACKGROUND

Urethral strictures represent the most frequent long-term complication in men after history of hypospadias surgery.

OBJECTIVES

To better define the spectrum of men previously treated for hypospadias during childhood, presenting at an adult urology clinic with persistent urethral complications.

STUDY DESIGN

Retrospective review of the records of 42 consecutive adult patients with a personal history of hypospadias repair during childhood referred at one adult tertiary urology center between 2004 and 2017. Those with persistent urethral strictures were included: 28 patients (median age 28yr [17-81]). Residual chordee, aesthetic concerns, isolated fistulas, and motives of consultation unrelated to hypospadias were excluded. Early initial success rate and location of urethral stricture were studied. Statistical Analysis was done by non-parametric tests.

RESULTS

On the 42 consecutive adults eligible, a total of 28 patients had a persistent urethral stricture. During childhood, 13/28 boys had required multiple surgical revision procedures, including six of them for postoperative urethral strictures. During adulthood, initial urethral assessment revealed 29 urethral strictures in 28 patients (penile urethra 23/29, bulbar urethra 8/29). The early initial success rate of stricture treatment was 50% (median follow-up: 4 years [1-7]). Additional surgical procedures were needed and performed in 11 patients. Eight patients were eventually diagnosed with a bulbar stricture, either isolated (n = 5) or combined with a distal stricture (n = 3), without significant relationship with initial position of meatus.

DISCUSSION

Predictive factors for bulbar strictures locations could not be identified. It was however observed that symptomatic bulbar strictures do exist in adults, in the long term after penile hypospadias repair during childhood, independently of the initial site of hypospadias, initial success of primary repair, and the type of surgical reconstructions performed during childhood.

CONCLUSION

Bulbar strictures represent more than 25% of the overall strictures diagnosed in adult patients treated for hypospadias during childhood, independently of the original site of urethral reconstruction.

Utility and safety of hyperbaric oxygen therapy as a rescue treatment in complicated cases of hypospadias: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to define the current evidence and systematically summarize the relevant data regarding the utility and safety of hyperbaric oxygen therapy (HBOT) as an adjunctive treatment in complicated re-operative cases of hypospadias.

METHOD

The authors systematically searched the PubMed, EMBASE, Web of Science, and Scopus databases on August 5, 2021. Patients were divided into two groups, i.e. HBOT and non-HBOT. The main outcomes were graft failure rate and the incidence of complications following urethroplasty. The proportion of patients developing adverse events due to HBOT was the secondary outcome. The pooled risk ratio and heterogeneity were calculated using the Mantel-Haenszel method and the I² statistics respectively. The quality assessment of the included studies was performed using the Downs and Black scale.

RESULT

Four studies constituting 176 patients (101 in the HBOT group) were included (Figure). Variations were observed among these studies in terms of the age of participants, the number and types of previous operations performed, and the protocol of administration of HBOT. The graft failure rate (RR 0.19; 95% CI 0.05-0.73, p = 0.02) and the incidence of complications (RR 0.40, 95% CI 0.20-0.77, p = 0.007) were significantly low in the HBOT versus the non-HBOT group. Apart from myringotomy insertion (n = 10; 9.9%) and claustrophobia (n = 1), no other adverse events were associated with HBOT. All studies had a moderate risk of bias. An almost perfect agreement (kappa = 0.956, p < 0.0001) was observed between the two investigators assessing the risk of bias.

CONCLUSION

The present systematic review and meta-analysis significantly favor the administration of HBOT versus no HBOT in terms of graft failure rate and incidence of complications following urethroplasty. The available data also highlights the safety of HBOT in complicated cases of hypospadias. However, well-designed randomized controlled trials need to be conducted for an optimal comparison between the two treatment groups.

Application and efficacy of reconstructing forked corpus spongiosum in distal/midshaft hypospadias repair

We reviewed our experience in reconstructing forked corpus spongiosum (FCS) in distal/midshaft hypospadias repair and analyzed the efficacy of this surgical technique. From August 2013 to December 2018, 137 consecutive cases of distal/midshaft hypospadias operated by the same surgeon in Urology Department, Children's Hospital of Fudan University (Shanghai, China), were retrospectively analyzed. Sixty-four patients who underwent routine tubularized incised plate (TIP) or onlay island flap (ONLAY) surgery were included in the nonreconstructing group, and 73 patients who underwent reconstructing FCS during TIP or ONLAY surgery were included as the reconstructing group. Thirty-eight cases underwent TIP, and 26 underwent ONLAY in the nonreconstructing group, with a median follow-up of 44 (range: 30–70) months. Twenty-seven cases underwent TIP, and 46 underwent ONLAY in the reconstructing group, with a median follow-up of 15 (range: 6–27) months. In the nonreconstructing/reconstructing groups, the mean age at the time of surgery was 37.55 (standard deviation [s.d.]: 29.65)/35.23 (s.d.: 31.27) months, the mean operation duration was 91.95 (s.d.: 12.17)/93.84 (s.d.: 14.91) min, the mean neourethral length was 1.88 (s.d.: 0.53)/1.94 (s.d.: 0.53) cm, and the mean glans width was 11.83 (s.d.: 1.32)/11.56 (s.d.: 1.83) mm. Twelve (18.8%)/5 (6.8%) postoperative complications occurred in the nonreconstructing/reconstructing groups. These included fistula (5/2), glans dehiscence (3/0), diverticulum (1/2), residual chordee (3/0), and meatus stenosis (0/1) in each group. There was a significant difference in the overall rate of complications (P = 0.035). These results indicate that the technique of reconstructing FCS provides excellent outcomes with fewer complications in distal/midshaft hypospadias repair.

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.

Use of dCELL (Decellularized Human Dermis) in Repair of Urethrocutaneous Fistulas or Glans Dehiscence

Background

In hypospadias repairs, there is some evidence to suggest that a "waterproofing" layer can be helpful in reducing the risk of urethrocutaneous fistula formation. The most likely role of this layer is to prevent the creation of overlapping suture lines. Many hypospadias surgeons use a dartos fascia interposition flap for this purpose. However, raising a dartos fascia flap adds time to the procedure, can result in devascularization of the overlying skin, and can create unsightly torsion of the penis, which may be hard to correct. To avoid these problems, the senior author has started to use dCELL (decellularized human dermis) as an alternative to dartos fascia to separate the suture lines.

Methods

Between March and July 2018, a pilot study was performed in 8 patients undergoing closure of a urethrocutaneous fistula or glans dehiscence combined with dCELL. Data on infections, wound breakdown, length of stay and catheterization, surgical time, and hospital stay were collected.

Results

All patients had a successful reconstruction. One patient developed a urinary tract infection, possibly related to prolonged catheterization following his repair.

Conclusion

Our results suggest that dCELL may be useful in the repair of urethrocutaneous fistulas and glans dehiscence after hypospadias surgery.