Fistula after single-stage primary hypospadias repair – A systematic review of the literature

Lateral incision 1-stage urethroplasty with oral mucosal graft for patients with penile urethral stricture after hypospadias repair-a preliminary report

PURPOSE

To report our early experience of a novel surgical approach for penile urethral strictures after hypospadias repair, using a lateral incision to keep the ventral tissue and vasculature of the penis intact and to avoid the need for tissue interposition.

PATIENTS AND METHODS

A total of 21 patients underwent lateral incision 1-stage urethroplasty with oral mucosal graft. The median age of the patients was 21 years old (range, 13-47). The median number of prior procedures for hypospadias repair was 3 (range, 1-9) with 18 of 21 patients (85.7%) undergoing greater than 1 prior reconstructive procedure. The mean length of the penile urethral strictures was 4.5 ± 1.7 cm, with a range of 1.0 to 8.0 cm. Selection criteria for lateral incision 1-stage urethroplasty include: non-obliterative stricture, no or mild penile curvature and no urethrocutaneous fistula.

RESULTS

Median follow-up was 30 months (range, 6-73). Success was achieved in 17 of 21 patients (80.9%). The 4 (19.0%) patients with treatment failure developed recurrent urethral strictures. Of the 4 men with recurrent strictures, 3 were ultimately treated successfully by DVIU (2) or two-stage urethroplasty (1), and one patient chose repeated dilation.

CONCLUSIONS

For patients with penile urethral stricture after hypospadias repair with non-obliterative stricture, no significant penile curvature and no urethrocutaneous fistula, a lateral approach with oral mucosal graft is a simple technique that avoids the need for tissue interposition and keeps the penile ventral tissue and vasculature intact, resulting in a low risk of complications.

Tubularized incised plate repair in 473 primary distal hypospadias cases: An evaluation of outcomes according to coverages and stent types

AIM

We have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair.

MATERIALS AND METHODS

Only distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent).

RESULTS

A total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference.

CONCLUSIONS

Spongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training.

Ultrasound-guided dorsal penile nerve block is a safe block in hypospadias surgery: A retrospective clinical study

Caudal and dorsal penile nerve blocks are commonly used regional anesthesia methods in hypospadias surgery. Some studies have reported that regional anesthesia methods are risk factor for the development of postoperative complications following hypospadias surgery. The aim of the current study is to evaluate the relationship between postoperative complications and regional anesthesia methods used in distal hypospadias surgery. Forty-nine distal hypospadias patients were included. Patients had either received caudal or ultrasound (US)-guided dorsal penile nerve block. The age, type of hypospadias, regional anesthesia method, operation time, and postoperative complications were recorded. Fisher exact test and Mann-Whitney U tests were used to compare the data. Caudal epidural block was used in 25 (51%) patients and US-guided dorsal penile nerve block in 24 (49%) patients. There was no statistically significant difference between the groups regarding the types of hypospadias, operation time, and age. Fistula developed in 4 (16%) patients in the caudal block group and in none of the patients in the dorsal penile nerve block group. Fistula rates were statistically significantly different between the groups (P = .030). Conflicting data are found in the literature on the long-term postoperative complications of the regional anesthesia techniques used in hypospadias surgery. In our study, all patients with urethrocutaneous fistula were in the caudal block group. We believe that our study will contribute to the literature as it is the only study comparing caudal block with US-guided dorsal penile nerve block using in-plane technique in terms of postoperative complications in hypospadias surgery.

Management of urethral fistula after hypospadias repair with particular reference to purse-string sutures: a 24-year review

PURPOSE

To review our management of urethral fistulae following hypospadias repair over a 24-year period. To showcase our innovations, particularly the purse-string closure technique.

METHODS

We reviewed our prospectively maintained database from 1997 to 2020 to identify patients with fistula. Two main surgical techniques were used: traditional linear closure and purse-string suture. Other innovations included anchoring skin to corpora and intersectional skin closure.

RESULTS

Sixty two patients presented with 73 urethral fistulae after hypospadias repair. 55/62 were operated: 28-purse-string technique, 23-linear closure, 4-redo urethroplasty. Cure after the first attempt was achieved in 26/28 (93%) in the purse-string group and 16/23 (70%) in the linear group (p = 0.015). Spontaneous resolution occurred in 6/62 patients (9.6%), in 3 spontaneously and in 3 after a single dilation. 1 patient awaits surgery. Closure after first fistula repair was 22/24 (92%) in distal hypospadias and 20/27 (74%) in proximal hypospadias (p = 0.051).

CONCLUSION

Remarkably, conservative management was succesful in almost 10% of urethral fistulae, either spontaneously or after a single dilation. Purse-string closure, rarely described in the literature, coupled with our other innovations, helped bring down our recurrence rates significantly with no patient needing more than two surgeries for cure.

Long-term outcome of non-stented tubularized incised plate urethroplasty for distal hypospadias repair: a complication analysis

Introduction

Although it is apparently simpler to perform unstented tubularized incised plate (TIP) repair for distal hypospadias repair, consensus on feasibility of the use of unstented repair is still a matter of debate. Evidence reporting that unstented repair outcome is comparable to stented repair, especially in the long-term, is still weak due to reporting outcome inconsistencies, different study designs, inclusion of more than one technique, and inherent variability in meatal locations. Thus, we need a continuous and evolving assessment of the outcome of unstented repair to compile adequate evidence on the advantage of unstented TIP repair in distal hypospadias entity. The aim of this article was to review our long-term results with tubularized incised plate urethroplasty for distal hypospadias repair without a postoperative stent to determine its outcome which might justify its use.

Material and methods

After a review of 154 patients with distal penile hypospadias, who underwent repair in Minia Urology & Nephrology University Hospital in the period between June 2015 and February 2018, we excluded cases who underwent MAGPI repair, redo cases and patients who failed to complete follow-up. We chose 72 patients who had only 1^st time TIP repair and whom we could contact. A total of 44 out of 72 cases with stented repair were assigned to Group A, while 28 cases with unstented repair were assigned to Group B. Success was assessed based on Hypospadias Objective Penile Evaluation (HOPE) score by three separate senior pediatric urology consultants, independent of the surgeon and in the absence of high post-void residual urine (PVR). Average rate was calculated to be compared between both study groups.

Results

There was no statistically significant difference regarding preoperative meatal location and age at repair and short-term complications. In the long-term; there was no statistically significant difference between the occurrence of urethrocutanous fistula (UCF, 4 vs 2 cases in Group A & B, respectively) and complete disruption (2 cases in each group) with need for redo repair. Results of total mean of HOPE score calculated showed no statistically significant differences between study groups and also failed to showed statistical significance on individual domains of HOPE score.

Conclusions

Unstented TIP repair showed a similar outcome to stented TIP repair of distal hypospadias especially in the long-term despite a more troublesome early postoperative period.

Concomitant repair of meatal stenosis and urethral fistula does not increase the risk of fistula recurrence post-hypospadias surgery

OBJECTIVES

To evaluate whether meatal stenosis treated concomitantly with urethral fistula repair alters the results of fistula closure.

METHODS

A retrospective cohort study, included were all children who underwent local fistula closure following hypospadias repair between 2006-2017. Patients who underwent reoperative urethroplasty were excluded. Data were extracted from electronic records, and missing data were supplied by telephone interviews. Characteristics of patients and fistulas were compared between children who underwent fistula closure only and those who underwent meatoplasty for meatal stenosis during the same surgery. The primary endpoint was fistula recurrence.

RESULTS

In total, 106 local repairs of urethrocutaneous fistulas were performed during the study period, and 25 of them included concomitant meatoplasty for meatal stenosis. There was no difference in terms of location, size, and number of fistulas or the number of recurrent fistulas between the 81 patients who underwent fistula closure only and the 25 who underwent concomitant meatoplasty. The fistula recurrence rate was 17/81 (21%) for the fistula only group and 5/25 (20%) for the fistula and meatoplasty group after a median follow-up of 7 and 8 years, respectively. Meatoplasty was required in a subsequent procedure in 5/81 in the former group vs. 3/25 patients in the latter group.

CONCLUSIONS

The presence and repair of meatal stenosis does not alter the recurrence rate of urethrocutaneous fistulas repaired concomitantly following hypospadias repair.

Urethral Tissue Reconstruction Using the Acellular Dermal Matrix Patch Modified with Collagen-Binding VEGF in Beagle Urethral Injury Models

Objectives

Urethral tissue reconstruction for hypospadias is challenging for urologists. In this study, bovine acellular dermal matrix (ADM) patch loading with collagen-binding vascular endothelial growth factor (CBD-VEGF) was used to repair the urethral injury in beagles.

Methods

The safety and effectiveness of the scaffold implantation were carefully evaluated by comparing among the urethral injury control group, ADM implantation group, and ADM modified with CBD-VEGF implantation group during 6 months. Urodynamic examination, urethral angiography, and pathological examination were performed to evaluate the recovery of urethral tissue.

Results

Stricture, urethral diverticulum, and increased urethral closure pressure were observed in the control group. Fistula was observed in one animal in the ADM group. By contrast, no related complications or other adverse situations were observed in animals treated with ADM patch modified with CBD-VEGF. The average urethra diameter was significantly smaller in the control animals than in scaffold implantation groups. Pathological examination revealed more distribution of proliferative blood vessels in the animals treated with ADM modified with CBD-VEGF.

Conclusions

Overall, ADM patches modified with CBD-VEGF demonstrated an optimized tissue repair performance in a way to increase tissue angiogenesis and maintain urethral function without inducing severe inflammation and scar formation.

An atypical complication after hypospadias repair: A combined dorsal and lateral subcoronal urethrocutaneous fistulas

Urethrocutaneous fistula (UCF) is one of the most common complications of hypospadias repair (HR). We present an unusual combined lateral and dorsal subcoronal (CLDSC) UCFs. Dorsal UCF has not been reported in children yet. A 10-year-old patient was admitted with the complaint of CLDSC UCFs following HR. A long fistula tract from the urethral meatus to the dorsal fistula orifice was excised together with urethroplasty. The patient did well postoperatively. Dorsal penile UCF is an unusual complication; but if it occurs, total excision of the fistula tract together with urethroplasty could be considered to prevent further complications.

Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade

BACKGROUND

Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade.

METHODS

A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes.

RESULTS

The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load.

CONCLUSIONS

Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.

Promising results for hypospadias repair using alloderm® (Regen): A randomized controlled trial

INTRODUCTION;: Hypospadias is a congenital disorder of urethra in which meatus is not at its correct place and occurs in 1 of 250 live male birth. Many techniques have been used for the repair of hypospadias and to decrease the incidence of fistula. Alloderm has been recently used for the repair of urologic congenital defects, and reconstructive surgeries, but not used in hypospadias in a randomized controlled trial. Therefore, the aim of this study was to assess the efficacy of Alloderm® (Regen) to reduce fistula rate in hypospadias repair.

METHODS & MATERIALS

This was a randomized controlled trial. Sixty patients were divided into two groups, 30 children underwent surgery using Alloderm® (Regen) as the Alloderm group and 30 without using it as controls. In the Alloderm group, 21 underwent primary surgery (12 mid-shaft hypospadias who underwent concurrent chordee correction and urethroplasty, and 9 penoscrotal who underwent 2 stage surgery, chordee was first corrected and then 6 months later TIP was performed), and 9 underwent fistula repair due to previous surgeries. In the control group, 24 patients underwent primary surgery (15 mid-shaft, and 9 penoscrotal) and 6 fistula repair the same as the Alloderm group but without using Alloderm.

RESULTS

There was no meaningful difference between the two groups regarding age (P = 0.634). There was no meaningful difference regarding the operation type between the two groups (P = 0.371). There was no meaningful difference regarding the meatal location between the two groups (P = 0.781). There were no significant post-operative complications in the both groups. No bleeding or diverticulum occurred. Recurrence of fistula occurred in one patient in the Alloderm group after fistula repair and in 2 in the control group. Overall, In the Alloderm group, 3 (2 after TIP and 1 after fistula repair) patients and in the control group 8 (6 after TIP, 2 after fistula repair) patients developed fistulas after surgery (10% vs 26.7%). There was a statistically meaningful difference regarding fistula formation between the two groups using Chi-square test (P = 0.014).

CONCLUSION

Alloderm® (Regen) can be used for hypospadias and fistula repair with very few complications and good results. Fistula was less probably occurred in the Alloderm group compared to the standard repair of hypospadias.

Tubularized incised plate urethroplasty for megameatus intact prepuce hypospadias variant: First reported case in Indonesia

INTRODUCTION AND IMPORTANCE

Megameatus intact Prepuce (MIP) is a rare variant of hypospadias characterized by a wide meatus with a normally conformed prepuce, no chordee, and usually no effects in micturition or sexual physiology. However, quality of life and psychosexuality may be affected.

CASE PRESENTATION

A 6-year-old-boy was referred by a general practitioner to the hospital due to an abnormality of the urethral meatus. The patient did not have any complaints. A large external urethral orifice at the ventral area of the coronal glans was discovered. The prepuce was normally-conformed, and there weren't any signs of chordee. The patient was diagnosed with an MIP hypospadias variant and underwent a tubularized incised plate (TIP) urethroplasty. During the follow-up, one week after the procedure, the patient did not have any complaints. Physical examination showed excellent anatomical and functional outcome based on the cosmetic appearance resembling a normal penis and urinary stream.

CLINICAL DISCUSSION

Awareness regarding this abnormality is necessary as MIP is often not diagnosed until circumcision. Even though MIP patients are usually asymptomatic, surgery should still be considered based on aesthetic and psychosexual reasons. TIP urethroplasty was chosen for this patient based on the clinical findings of this patient. TIP procedure for MIP patients could result in an excellent penile performance and function with a very low complication rate.

CONCLUSION

TIP urethroplasty is able to fulfil satisfactory cosmetic and functional outcomes for the MIP hypospadias variant. Awareness of the disorder should be increased to prevent potential psychosexual disturbances.

The Application of Multilayer Direct Closure With a Longitudinal Relaxing Incision in Urethrocutaneous Fistula Repair

The simple closure of a urethrocutaneous fistula is technically easy, but direct suture tension is associated with a higher urethral fistula recurrence rate. We describe a multilayer direct closure with a longitudinal relaxing incision in urethrocutaneous fistula repair, avoiding the tension associated with the direct suturing of the surgical skin wound. From March 2015 to January 2018, 46 urethrocutaneous fistulas in 34 patients were repaired at the Hypospadias Center of our hospital. During the operations, after the urethral fistula closure, a longitudinal penile skin incision was created 0.5 to 1.5 cm from the edge of the surgical wound. The penile skin wound was closed, and the longitudinal penile skin incision made during the operation was used as a relaxing incision to reduce the skin tension of the closed fistula area. The urethral fistula repairs were successful, and no signs of infection or poor healing were present at the closure sites of the penile skin wounds. The relaxing incisions gradually healed within 7 to 21 days after operation, and the residual scars were soft and did not significantly differ in color from normal skin. The key to increasing the success rate of urethrocutaneous fistula repair is creating a longitudinal relaxing penile skin incision. The technique aims to avoid the direct suture tension of the penile skin wound, thereby providing a favorable environment for the normal healing of the urethral fistula suture site.

Predictive Value of C-Reactive Protein for Early Postoperative Complications in Children After Hypospadias Surgery

Background: This study explored the predictive value of postoperative C-reactive protein in children with hypospadias for postoperative complications and the risk factors. Methods: The clinical and follow-up data of 106 children with hypospadias who were treated with operations at Kunming Children's Hospital in 2020 were, respectively, analyzed. According to the occurrence of postoperative complications, the patients were divided into two groups: 25 patients with postoperative complications were the complications group, and 81 without postoperative complications were the control group. The baseline data, clinical characteristics, laboratory test indexes, and outcome of the two groups were collected. Receiver operating characteristic (ROC) was used to calculate the optimal cutoff value of C-reaction protein (CRP). Logistic regression was used to analyze the risk factors of hypospadias after surgery. A probability value (P) < 0.05 was considered statistically significant. Results: According to the result of the ROC curve, the optimal cutoff value of CRP was 11.7 mg/L. Logistic regression showed that the length of urethral defect, the urethral material, the operative produce, and the postoperative CRP level were related to the occurrence of postoperative complications of patients with DCC. The length of the urethral defect and the CRP level were the independent risk factors of the prognosis of hypospadias patients. The CRP level was related to the occurrence of postoperative complications and fistula. Conclusions: Postoperative CRP level can be used as a reliable marker for predicting the prognosis of hypospadias patients.

Comparison of effect between dartos fascia and tunica vaginalis fascia in TIP urethroplasty: a meta-analysis of comparative studies

Background

Tubularized incised plate (TIP) urethroplasty is the most commonly performed procedure for hypospadias. Several flap procedures have been recommended to decrease the postoperative complication rate in TIP repair, but no single flap procedure is ideal. This study aimed to compare the outcomes of dartos fascia (DF) and tunica vaginalis fascia (TVF) as intermediate layers in TIP urethroplasty.

Methods

We searched PubMed, EMBASE, the Cochrane Library, Web of Science, clinicaltrials.gov, and other sources for comparative studies up to April 16, 2020. Studies were selected by the predesigned inclusion criteria. The primary outcomes were postoperative complications. The secondary outcomes were functional and cosmetic outcomes.

Results

The pooled RR with 95% CI were calculated. We extracted the relevant information from the included studies. Only 6 comparative studies were included. No secondary outcomes were reported. The RR of the total complications rate for DF was 2.41 (95% CI 1.42–4.07, P = 0.0001) compared with TVF in TIP repair. For each postoperative complication, the RRs were 6.48 (2.20–19.12, P = 0.0007), 5.95 (1.13–31.30, P = 0.04), 0.62 (0.25–1.52, P = 0.29), and 0.75 (0.23–2.46, P = 0.64) for urethrocutaneous fistula, prepuce-related complications, meatal/urethral stenosis, and wound-related complications, respectively.

Conclusions

This meta-analysis reveals that compared to DF, TVF is a better option in TIP repair in terms of decreasing the incidence of the total postoperative complications, urethrocutaneous fistula, and prepuce-related complications. However there is limited evidence for functional and cosmetic outcomes. Overall, larger prospective studies and long-term follow-up data are required to further demonstrate the superiority of TVF over DF.

Trial registration

PROSPERO CRD42019148554.

Single-stage urethroplasty: An eight-year single-centre experience and its associated factors for urethrocutaneous fistula

Introduction:

This study aimed to describe single-stage urethroplasty and to determine factors associated with urethrocutaneous fistula after the procedure at our institution.

Methods:

All hypospadias patients without any prior surgery who underwent single-stage urethroplasty from July 2010 to January 2018 were included. In total, 179 patients were followed for at least one year postoperatively. Information on types of hypospadias, operation techniques, chordee degree, preoperative pyuria (urine white blood cell count >5/HPF), urethral defect length and urethrocutaneous fistula formation was collected.

Results:

We obtained 103 cases of posterior (57.5%), middle (57 cases) and anterior (19 cases) hypospadias on whom onlay preputial island flap (71 cases), tubularized incised plate (46 cases) and Duckett’s transverse preputial island flap (35 cases) were conducted. After 47.1±25.8 months of follow-up, urethrocutaneous fistula were found in 23 (12.8%) patients associated with posterior hypospadias occurrence ( p=0.025), longer urethral defect ( p=0.007) and preoperative pyuria ( p<0.001). Chordee degree ( p=0.886) and age ( p=0.187) were not significant factors associated with urethrocutaneous fistula formation.

Conclusion:

Single-stage urethroplasty is a versatile procedure for various hypospadias cases, with a urethrocutaneous fistula rate of 12.8%. Posterior hypospadias, preoperative pyuria and longer urethral defect were associated with urethrocutaneous fistula formation.

Level of evidence

Level 2B.

In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair

OBJECTIVE

To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair.

STUDY DESIGN

We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair.

RESULTS

Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs.

CONCLUSION

Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children.

Tunica vaginalis graft for recurrent urethrocutaneous fistula repair after hypospadias surgery

OBJECTIVES

To evaluate the outcomes of recurrent urethrocutaneous fistula repair using tunica vaginalis graft as an intermediate protective layer.

METHODS

We retrospectively reviewed the data of 45 children with recurrent urethrocutaneous fistula who underwent tunica vaginalis graft repair between February 2011 and January 2019. The repair was carried out at least 6 months after a previous fistula repair. Follow up at an outpatient clinic was scheduled on a weekly basis for 1 month, then monthly for 6 months and then annually. During follow up, every patient was evaluated by history taking. The site of repair and the act of micturition were inspected. Urine analyses together with culture and sensitivity tests were carried out if required. Successful repair was defined as the absence of recurrence, with good force and caliber of the urinary stream.

RESULTS

This study included 45 patients with recurrent urethrocutaneous fistula who were managed with a tunica vaginalis graft as a second layer. The mean age of patients was 6.7 ± 2.8 years. The mean postoperative hospital stay was 5.5 ± 0.7 days. The repair was successful for 43 (95.6%) patients, and urethrocutaneous fistula recurrence was reported for two (4.4%) patients, which were repaired after 6 months. In all patients, the cosmetic appearance of the penis was satisfactory without torsion or ventral chordee.

CONCLUSION

Tunica vaginalis graft is a simple and fast procedure that is highly effective as a protective second layer for recurrent urethrocutaneous fistula repair.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in Indonesia

INTRODUCTION

Hypospadias is one of the most common congenital malformations with a worldwide increasing trend over the years. Despite advancements in hypospadias repair, complications still occur. One of the most common complications of hypospadias repair surgery is Urethrocutaneous fistula. Studies attempting to analyze the association between the complication and risk factors are always beneficial, especially for studies performed in different areas of the world. We hypothesize that several evaluated risk factors among Indonesian hypospadias patients could be associated with the occurrence of urethrocutaneous fistula after the repair procedure.

OBJECTIVE

To determine the risk factors associated with urethrocutaneous fistula after hypospadias repair surgery by collecting and analyzing data obtained from multiple centers in Indonesia.

MATERIALS AND METHODS

A nationwide, retrospective study with 12 hospitals in Indonesia of children with a diagnosis of hypospadias was conducted. The collected data, taken from patients admitted in 2018, from each center's medical records consisted of patient identity, repair technique used, neourethra length, percutaneous cystostomy, and splint size as independent variables speculated to be possible risk factors correlated to the presence of urethrocutaneous fistulae. Binomial logistic regression analysis was performed using SPSS 21.0 to determine the relationship between urethrocutaneous fistulae as a post-repair complication and possible risk factors.

RESULTS

We collected 591 hypospadias cases from 12 centers in 9 cities in Indonesia. Most patients came when they were already at the age of more than four years old (60.4%). The chordee-only and failed urethroplasty groups are excluded from the analysis as they are not classified as true hypospadias. Most repairs were performed by using the Tubular Incised Plate (TIP) with Thiersch-Duplay technique (44.16%). Most of the reconstructed neourethra are 2-3 cm in length (32.13%). The 8 Fr urethral splint (46.41%) was mostly used during the operation. Most surgeons decided not to perform cystostomy throughout the procedure (61.03%) based on personal preferences. Urethrocutaneous fistula was found in 80 patients (15.27%) out of the total patients who underwent the surgery. The binomial logistic regression analysis shows that age (OR = 1.398, p = 0.015), the decision to not perform cystostomy (OR = 2.963, p = 0.014), and splint size (OR = 1.243, p = 0.023) are significantly associated (p < 0.05) with the development of urethrocutaneous fistula.

CONCLUSION

Age and splint size are significant risk factors for urethrocutaneous fistula after hypospadias repair in Indonesia, whereas performing percutaneous cystostomy during the repair decreases the risk for urethrocutaneous fistula occurrence.

Two-stage repair of proximal hypospadias with moderate to severe chordee using inner preputial skin graft: prospective evaluation of functional and cosmetic outcomes

OBJECTIVE

To critically evaluate inner preputial graft (IPG) used in staged proximal hypospadias with severe chordee regarding cosmetic and functional outcomes.

PATIENTS AND METHODS

In this prospective study, patients with primary proximal hypospadias with moderate to severe chordee (> 30°) after penile degloving were considered candidates for staged repair between June 2011 to July 2017. After transection of the urethral plate (UP) and penile straightening, the bare shaft was covered with IPG. Tubularization of the graft was done as a second stage. Cosmetic and functional outcomes were assessed using HOSE score and uroflowmetry (UF). Additionally, factors influencing success were analyzed.

RESULTS

In all, 38 consecutive cases were included. Native meatus was at proximal penile in 17, penoscrotal in 11, scrotal in 7, and perineal in 3 cases. Median age was 26 and 32 months at the first stage and the second stage, respectively. Preoperative testosterone was given for ten patients with a small penis and/or severe curvature. The mean follow-up was 18 ± 8.2, median 15 months. Grafts took well in all cases after the first stage except one. Cosmetic success achieved in 33 (86.8%). A total of ten complications occurred in six cases. Unplanned intervention was needed in 5/38 cases. Functionally, UF study revealed normal flow in 7/23 (30.4%), equivocal in 11/23(47.8%), and obstructed flow in 5/23(21.7%).

CONCLUSION

Inner preputial graft use in proximal hypospadias with moderate to severe chordee seems to have a good technical outcome and functionally mimic the normal urethral function and could be considered an ideal option for substitution urethroplasty.

Diagnosis and Treatment of Hypospadias With Megameatus Intact Prepuce

Purpose: To evaluate the diagnosis and treatment methods of hypospadias with megameatus intact prepuce (MIP). Materials and Methods: A retrospective analysis was performed in 27 MIP children, 13 of whom underwent tubularized incised plate urethroplasty (TIP procedure), 7 underwent the Duplay procedure, 5 underwent the Mathieu procedure, 1 underwent meatal advancement and glanuloplasty (MAGPI procedure), and 1 underwent the glans approximation procedure (GAP). The patients were followed for 6-36 months to evaluate the surgical outcomes by the Pediatric Penile Perception Score (PPPS). Results: A total of 27 patients with a mean age of 8.12 ± 3.0 years were enrolled in this study, and 25 cases (25/27, 92.6%) were accidentally discovered during the first visit for phimosis. The patients had a formed urethra of 0.5 to 1.5 cm. Complications occurred in 4 of the 27 patients (14.81%): 2 patients with urethral fistula and 2 patients with meatal stenosis. One patient had a case of self-healed urethral fistula, and the remaining 3 patients underwent reoperation. The post-operative effect was satisfactory in all patients, and the urinary flow and stream during urination were normal. The overall average PPPS score of non-operative surgeons and parents was satisfactory. There were no significant differences in meatus appearance, glans appearance, skin appearance, and general appearance PPPS score among the Mathieu, TIP, and Duplay surgical procedures. Conclusions: MIP clinical manifestations are concealed and usually noted when circumcision is attempted. The suitable procedure for each patient should be tailored according to the anatomic features, and several techniques can be used with good functional and cosmetic results.

Dermal regeneration sheet Integra® in management of recurrent Urethrocutaneous fistula after hypospadias surgery

BACKGROUND

Urethrocutaneous fistula UCF is the most common complication following surgical repair of hypospadias. Currently, the surgical technique mostly used to prevent recurrence employs preputial dartos or testicular tunica vaginalis flaps as a urethral covering. However, autologous tissues are limited in patients with multiple surgeries, and the use of biomaterials as a urethral coverage may represent a good alternative.

OBJECTIVE

The goal of the present study is to assess the results and complications of recurrent UCF correction using a dermal bovine regeneration sheet as a urethral covering.

MATERIALS AND METHOD

From May 2016 to January 2019, all patients with recurrent UCF of the authors center were repaired using this technique. The inclusion criteria were patients who had undergone one or more unsuccessful UCF repair surgeries and the absence of preputial tissue. The informed consent has been signed by all the patients. Patients were examined in outpatient consultations where their urinary stream was evaluated and a physical examination of the penis was conducted.

RESULTS

A total of 12 patients and 13 UCFs were included in the study. The median follow-up was 18 months, (range: 4-26), and only two patients (15%) developed a recurrence of UCF. No complications were observed in the remaining patients (85%) during their evolution. No patient developed a fibrosis increase or loss of elasticity of the tissues in contact with the dermal matrix.

CONCLUSION

The use of an Integra® sheet as a urethral covering during urethral fistula surgery appears to be a safe, effective, and easily reproducible option. However, prospective studies with larger numbers of patients should be performed to corroborate these results.

Megameatus intact prepuce treated with urethral plate-preserving surgery: a retrospective study of an unusual hypospadias variant

BACKGROUND

Megameatus intact prepuce (MIP) is a unique variant of hypospadias and is a clinically rare condition. Due to the anatomical characteristics of the MIP hypospadias variant presenting a unique challenge to surgeons, no single urethroplasty method provides a universal solution for all patients. The purpose of this study was to evaluate the outcomes of hypospadias after MIP repair by urethral plate-preserving urethroplasty.

METHODS

A retrospective study was performed on 25 coronal or distal MIP patients, with a median age of 8, with most deficiencies being discovered during their first hospital visit for phimosis. Correction with urethroplasty was performed for all patients; 5 underwent the Mathieu procedure, 13 underwent the tubularized incised plate (TIP) procedure, and 7 underwent the Duplay procedure. The 25 patients were followed up for 6 to 36 months to evaluate the surgical outcomes.

RESULTS

There were no significant differences in intraoperative bleeding, hospital stays, postoperative analgesia rate, and cure rate among the three surgical procedures. The operative time for the Mathieu procedure was longer than that for the TIP and Duplay procedures, which did not differ. Complications occurred in 4 of the 25 patients (16.0%), and the overall complication-free survival rate at 1 year after surgery was 80.5%. The age at the time of surgery, urethral plate width, urethroplasty length, surgical procedures, or meatal location (coronal or distal penis) were not independently predictive of complications.

CONCLUSIONS

The clinical manifestations of MIP are often concealed and then accidentally discovered during hospital visits for phimosis; thus, the actual incidence of MIP might be higher. The urethral plate should be preserved during MIP-correcting treatment, especially for coronal or distal MIP. The same satisfactory outcomes can be obtained with Mathieu, TIP, or Duplay urethroplasty.

Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience

INTRODUCTION

Fistulas are a common complication of hypospadias surgery; they are more frequent after mid-shaft and posterior hypospadias repair. Surgical treatment of fistula still remains challenging with a significant failure rate. The basic principle is to add layers between skin and neourethra in order to decrease the incidence of recurrent urethrocutaneous fistula (UCF). We report our experience of UCF repair using a vascularized tunica vaginalis flap (TVF) after posterior and mid-shaft hypospadias surgery.

MATERIAL AND METHODS

A retrospective review of all patients operated on using TVF for UCF in our institution between December 2005 and July 2017 was performed.

RESULTS

Among 36 cases, TVF was used at a first attempt in 22 patients; 14 children had a prior attempt to close the fistula, and four of them had two surgeries before TVF repair. UCF was respectively penoscrotal (n = 3, 8%), posterior (n = 19, 53%), midshaft (n = 9, 25%) and anterior (n = 5, 14%). The size of the fistula was more than 5 mm in 26 patients. The UCF was treated successfully in every case after one single procedure. In the three children with two fistulas, both fistulas were successfully treated by the same TVF. After an average follow-up time of 45 months there was no recurrence of the initial UCF. In four cases of undescended testis, it was possible to dissect the flap through an inguinal incision and perform an orchydopexy in the same time. One patient presented a testicular atrophy after undescended testis surgery.

DISCUSSION

Area review of published series shows excellent results in UCF repair including recurrent fistula (Table). TVF can aspire to some advantages with regard to a dartos flap (DF). First of all, a nearly 2.5-fold lower incidence of fistula after fistula repair with TVF than with DF (5.1% vs. 12.2%) has been shown. Secondly, TVF allows treating multiple fistulas, and can also be brought to the anterior part of the penis until the balano preputial furrow, allowing curing anterior fistula. Furthermore, it doesn't lead to aesthetic complications such as penile rotation or distal skin necrosis, which can occur during DF procedures.

CONCLUSION

TVF is a simple and reproductive technique for UCF repair, with a high success rate. The risk of testicular atrophy has to be considered in case of associated undescended testis surgery, and careful attention must be given to the TVF dissection. This technique should be considered as first choice treatment for any UCF.

Risk factors for failed urethrocutaneous fistula repair after transverse preputial island flap urethroplasty in pediatric hypospadias

OBJECTIVES

We review our experience in urethrocutaneous fistula (UCF) repair after transverse preputial island flap urethroplasty (Duckett) in pediatric hypospadias to investigate the risk factors for unsuccessful outcome.

METHODS

Two hundred and nineteen UCFs repairs conducted in our center from January 2015 to December 2016 after Duckett technique were retrospectively reviewed and 182 had a follow-up for more than 6 months. The age of patients, size, localization and numbers of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCFs, hospital of primary surgery and postoperative infection were analyzed as potential risk factors. Stratified analysis and assessment of additive interaction were performed to have a better understanding of the relation between the risk factors. Logistic regression analysis was used for multivariate analysis.

RESULTS

UCF repairs were succeeded in 121 (66.5%) and failed in 61 (33.5%) at first operation. In the univariate analysis, size and numbers of UCFs (P = 0.01 and P = 0.035, respectively), interval time of two operations (P = 0.042) and hospital of primary surgery (P = 0.02) were statistically related with the outcome. In the multivariate analysis, UCF ≥ 2 (OR 2.71, 95%, CI 1.095-6.692, P = 0.031), size ≥ 2 mm (OR 2.45, 95% CI 1.267-4.757, P = 0.08) and primary surgery not at our hospital (OR 2.21, 95% CI 1.094-4.126, P = 0.026) were identified as independent risk factors for unsuccessful outcome. In the stratified analysis, multiplicative interaction between the 3 risk factors was not found.

CONCLUSIONS

Our study suggested that UCF repairs after transverse preputial island flap urethroplasty were easier to fail if the UCF was ≥ 2 mm, the numbers of UCFs was ≥ 2, or the surgeon had less experience. The age of patients, site of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCF and postoperative infection were not significantly related to the success rate of UCF repair.

Ointment Fistulography: Introducing a Novel Technique for Single or Multiple Urethrocutaneous Fistula Diagnosis After Hypospadias Surgery

INTRODUCTION AND OBJECTIVE

Hypospadias is a common congenital malformation of the male genital tract. The most frequent complication after hypospadias repair is urethrocutaneous fistula.¹ Its incidence has been reported up to 35% worldwide.² The diagnosis of these fistulas is sometimes challenging particularly with tiny and multiple fistulas. Usually, parents complain of urinary spraying, sprinkling, or passing a single stream of urine from the undersurface of the penis after the surgery. Urethrocutaneous fistulas are not always visible on physical examination. Locating the fistula and status of the surrounding skin is very important in order to choose the surgical repair technique.³ The patency and anatomy of the distal urethra should also be determined before the repair surgery.⁴ That is why urologists usually use retrograde urethrography or cystoscopy to find the location of fistula. However, these modalities have their own risk for children and are not always helpful. Sometimes the contrast media inserted can clog some fistulas especially near the glans and preclude the diagnosis. We present an easy technique to screen for urethrocutaneous fistulas after hypospadias surgery.

TECHNIQUE

In this technique (Video 1), an antibiotic ointment is inserted through the meatus while the base of the penis is held; the ointment is then gently pushed through the meatus. As shown in the video, the ointment will protrude through the fistulas anywhere along the shaft. This technique can also be performed reversely as the ointment inserted from the fistulas will protrude from the meatus. For younger children under the age of 3, we exclusively perform this technique under anesthesia on the repair surgery day, whereas in toddlers we perform this technique in the office and once again under anesthesia right before the repair surgery.

RESULT

This technique shows even tiny and multiple fistulas not detectable on physical examinations. We have used this technique in our clinic and have not missed any fistulas. The diameter of the protruded ointment in reverse fistulography is an indicator of the distal urethral diameter. Therefore, in case of narrow ointment diameter, distal urethral strictures should be suspected as correction of distal obstruction is an important determinant in the success rate of fistula repair surgery.⁵ CONCLUSION: We suggest this diagnostic technique as a safe, inexpensive, easy, office-based, feasible, and reproducible method. Negative urine culture is not required for this examination. Also, there is no need to insert contrast media as in retrograde urethrography or induce anesthesia as in cystoscopy. We believe this simple technique help urologists around the world to diagnose this common complication of hypospadias surgery without the need for special equipment.

Complications following completion lymphadenectomy versus therapeutic lymphadenectomy for melanoma - A systematic review of the literature

PURPOSE

Completion lymph node dissection (CLND) following a positive sentinel lymph node biopsy (SLNB) has been reported to be less morbid than lymphadenectomy for palpable disease (therapeutic lymph node dissection; TLND). The reporting of morbidity data can be heterogeneous, and hence no 'average' surgical complication rates of these procedures has been reported. This review aims to determine complications rates to inform patients undergoing surgery for metastatic melanoma.

METHODS

A systematic review of English-language literature from 2000 to 2017, reporting morbidity information about CLND and TLND for melanoma, was performed. The methodological quality of the included studies was performed using the methodological index for non-randomised studies (MINORS) instrument and Detsky score. Pooled proportions of post-operative complications were constructed using a random effects statistical model.

RESULTS

After application of inclusion and exclusion criteria, 18 articles progressed to the final analysis. In relation to TLND (1627 patients), the overall incidence of surgical complications was 39.3% (95% CI 32.6-46.2); including wound infection/breakdown 25.4% (95% CI: 20.9-30.3); lymphoedema 20.9% (95% CI: 13.8-29.1); and seroma 20.4% (95% CI: 15.9-25.2). For CLND (1929 patients), the overall incidence of surgical complications was 37.2% (95% CI 27.6-47.4); including wound infection/breakdown 21.6% (95% CI: 13.8-30.6); lymphoedema 18% (95% CI: 12.5-24.2); and seroma 17.9% (95% CI: 10.3-27). The complication rate was marginally lower for CLND but not to statistical significance.

DISCUSSION

This study provides information about the incidence of complications after CLND and TLND. It can be used to counsel patients about the procedures and it sets a benchmark against which surgeons can audit their practice.

Complications after prominent ear correction: A systematic review of the literature

BACKGROUND

There is great diversity in reported post-operative outcomes for otoplasty, with the incidence of haematoma or infection ranging from 0% to 15.6% and 0%-10%, respectively. With such variability, it is difficult to determine an overall 'average' incidence of common post-operative complications.

METHODS

A systematic review of the most relevant medical databases was conducted for studies available in English published between January 1, 2000, and December 31, 2015. Using the dataset, pooled estimates for the incidence of the primary and secondary outcomes were calculated for all included studies. The primary outcome was haematoma and/or bleeding incidence, and the secondary outcomes included infection, skin/wound healing problems, suture-related problems, scarring, pain and itching, and revision surgeries/recurrence. Comparable sub-group analysis of studies was also performed using calculated pooled proportions.

RESULTS

After screening, 28 articles involving 3493 patients were included in the study. Pooled proportions revealed that haematoma and/or bleeding incidence was 2.5% (95% CI: 1.4-3.8%), infection 0.8% (95% CI: 0.4-1.3%), skin/wound healing problems 3% (95% CI: 1.4-5.1%), suture-related problems 1.8% (95% CI: 0.8-3.2%), scarring 1.6% (95% CI: 0.8-2.6%), pain and itching 13% (95% CI: 5.4-23.1%) and revision surgeries/recurrence 5% (95% CI: 2.9-7.7%).

CONCLUSIONS

By pooling proportions of reported complications, the results of this study could be useful in the personal audit of practice and will be a point of reference for comparing novel surgical techniques in the future.

Risk Factors for Urethrocutaneous Fistula Repair After Hypospadias Surgery: A Retrospective Study

OBJECTIVES

We review our experience in urethrocutaneous fistula (UCF) repair after hypospadias surgery to investigate the risk factors for unsuccessful outcome.

METHODS

Two hundred eleven patients had undergone UCF repair in our department from January 2005 to December 2015. This study included 185 patients who were followed up for more than 6 months. The age of patients, size, site and number of UCFs, number of UCF repairs, urethral complications other than UCF, and postoperative infection were included as potential risk factors. Binary logistic regression analysis was used for multivariate analysis. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Stratified analysis and assessment of additive interaction were performed to have a better understanding of the relation between the risk factors.

RESULTS

Urethrocutaneous fistula repairs failed in 38 patients (20.5%) at first attempt. In the univariate analysis, size of UCFs (P = 0.012), times of UCF repair (P = 0.008), and postoperative infection (P = 0.044) were statistically related with the outcome of surgery. In the multivariate analysis, only the size of UCFs (P = 0.030; adjusted OR, 2.42; 95% CI, 1.09-5.36) and times of repair (P = 0.008; adjusted OR, 3.09; 95% CI, 1.35-7.07) were identified as risk factors for unsuccessful outcome. We had consistent results in the stratified analysis. No additive or multiplicative interaction between the 2 risk factors was found.

CONCLUSIONS

Our study suggested that UCF repairs after hypospadias surgery were easier to fail if one of the UCFs was larger than 2 mm or it had been repaired repeatedly. But when both factors existed, the increase of the risk was not statistically significant. The age of patients, site and number of UCFs, complications other than UCF, and postoperative infection were not significantly related to the success rate of UCF repair.

Psychosocial outcomes in adult men born with hypospadias: A register-based study

In this nationwide matched cohort study, we have investigated whether being born with hypospadias affect subsequent psychosocial outcomes in adulthood. We analyzed prospectively collected data from national Swedish registers. Data on the diagnoses were collected from the National Patient Register and the Medical Birth Register. Data on psychosocial outcomes such as educational and income level, marital status and disability pension were collected from Statistics Sweden. The effects of covariates, such as age, county of birth, presence of other malformations and psychiatric illness, were taken into account. The associations between hypospadias and psychosocial outcomes were calculated using conditional logistic regression and expressed as odds ratios (OR) and 95% confidence intervals (CI). We included 4378 men diagnosed with hypospadias, born between 1969 and 1993 in Sweden. Patients with hypospadias were matched with unaffected men by year of birth and birth county. We did not detect any differences in educational or income level. The probability of entering marriage (OR 1.02, 95% CI 0.90-1.14) did not differ, regardless of phenotype. We did, however, detect a 40% increased probability of receiving a disability pension, (OR 1.39, 95% CI 1.20-1.61). In conclusion, men born with hypospadias in Sweden do not differ from unaffected men with respect to the majority of psychosocial outcomes studied. They are, however, at increased risk of receiving a disability pension, which motivates further investigations.

Hypospadias

Hypospadias is a hypoplasia of the tissues forming the ventral side of the penis responsible of an ectopic meatus of the urethra. This congenital anomaly results in a fusion defect of the two epithelial surfaces of the urethral groove between the 11th and the 18th weeks of development. The earlier this process arrests, the more the form is proximal and severe. This is the second genital malformation in boys with 1 case per 250 male births. Its origin is often multifactorial (genetic, endocrine, placental and environmental). Three anatomical forms exist: proximal, middle and distal (the most common). Additional exams (endocrine, genetic and morphological) are realized early, before surgery, in case of severe hypospadias, familial, associated with cryptorchidism, bifid scrotum, micropenis and/or skeletal, kidney, and/or heart abnormalities. It clarifies pubertal prognosis. The surgical management is made between 6months and 12months: it limits the functional and aesthetic impact of this malformation. Many surgical techniques are described. They all have in common the three operating time: penile straightening, urethroplasty, reconstruction of the ventral side of penis. They are based on direct sutures, local flaps pedicled, and grafts (skin or mucosa). The rate of postoperative complications is between 6 and 30 %. The two main complications are fistulae and stenoses. The psychological follow-up of these children is necessary to adulthood. Surgery of hypospadias remains a delicate surgery and must be performed by experienced surgeons.