Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience

Surgical and functional outcomes of Dorsal Inlay Graft urethroplasty in revision vs primary hypospadias repair in the pediatric age

INTRODUCTION

Over the years, Dorsal Inlay Graft (DIG) urethroplasty has gained worldwide acceptance for primary hypospadias repair. However, its safety and effectiveness for revision surgery are yet to be proven.

OBJECTIVE

The aim of the study is to assess and compare complication rates and functional outcomes of DIG surgery in revision versus primary hypospadias repair.

MATERIAL AND METHODS

We carried out a retrospective analysis of data collected from 53 consecutive DIG urethroplasties performed by a single surgeon at our institution. Patients were stratified in two groups - primary repair and redo-urethroplasty. For each group, we recorded standard pre-operative characteristics, surgical technicalities, complication rates and uroflowmetry parameters.

RESULTS

Out of 53 DIG urethroplasties, 21 (39.6 %) where primary and 32 (60.4 %) were re-do. As expected, the two groups differed for median age at surgery: 20 months for primary and 68.5 months for revision surgery (p < 0.001). Additionally, all 21 (100 %) primary interventions were performed with a preputial graft, whereas among revision DIG urethroplasties only 2 (6.3 %) where preputial and 30 (93.8 %) were buccal (p < 0.001). Catheterization time (7 vs 8 days, p = 0.155) and postoperative complication rates (14.3 % vs 9.4 %, p = 0.581) were comparable between the primary and revision surgery group, respectively (all p > .05). Forty-two of the 53 patients underwent uroflowmetry during follow-up. Of these, 19 (63 %) patients presented with abnormal uroflowmetry and 11 (37 %) had equivocal parameters with no difference between the two groups.

DISCUSSION

Dorsal Inlay Graft urethroplasty has long been known to be safe and effective for primary hypospadias repair. On the other hand, data on dorsal inlay graft urethroplasty as a salvage surgery after primary hypospadias repair failure is scarce. Surprisingly, according to our findings, surgical outcomes and complication rates are comparable between primary and revision hypospadias cases. Additionally, our results in the redo group are absolutely encouraging if compared to those reported in the literature for the same subset of patients.

CONCLUSIONS

According to our findings, DIG urethroplasty is a safe and effective option to treat revision hypospadias repair.

Efficacy comparison between Mathieu combined urethral plate incision and onlay island flap urethroplasty for distal hypospadias in patients with urethral plate stenosis

The aim of the study was to compare the efficacy of Mathieu combined urethral plate incision (Mathieu-IP) versus onlay island flap urethroplasty in patients with distal hypospadias complicated by urethral stenosis. The clinical data of 70 patients with distal hypospadias complicated by urethral plate stenosis treated in the Department of Urology, Anhui Provincial Children's Hospital (Hefei, China), from May 2019 to May 2022, were retrospectively analyzed. Thirty-eight patients underwent Mathieu-IP (Mathieu-IP group) and 32 underwent onlay island flap urethroplasty (Onlay group). Follow-ups at 1 month, 6 months, and 12 months postoperatively assessed operative time, complications, urethral meatus morphology, and family satisfaction. The Mathieu-IP group had significantly shorter operative time (mean ± standard deviation [s.d.]: 81.58 ± 5.18 min) versus the Onlay group (mean ± s.d.: 110.75 ± 6.05 min; P < 0.05). Surgical success rates were 78.9% (Mathieu-IP group) and 75.0% (Onlay group), with no significant difference ( P > 0.05). Complications were comparable between the groups. The Mathieu-IP group resulted in a vertical slit-shaped urethral meatus in 89.5% versus 13.8% in the Onlay group ( P < 0.05). Family satisfaction with general penile appearance and skin shape showed no significant differences, but the Mathieu-IP group had higher satisfaction with meatal position ( P < 0.05). Mathieu-IP offers simplicity, safety, and shorter operative time compared to Onlay. Both the techniques effectively treat urethral plate stenosis in distal hypospadias, with reduced postoperative complications compared to tubularized incised plate urethroplasty. Mathieu-IP results in a vertical slit-shaped urethral meatus which enhances urinary stream, indicating its potential for broader adoption.

Comparative outcomes among inlay grafted incised plate, onlay preputial flap and tubularized incised plate urethroplasty for the repair of distal penile hypospadias with a narrow urethral plate

PURPOSE

We conducted this study, comparing the outcomes among Transverse Onlay Island Flap, inlay grafted incised plate and our previous records of tubularized incised plate urethroplasty (TIPU) in patients with narrow urethral plates, aiming to determine which method of repair provides a good outcome.

METHODS

This hybrid study included two datasets. The first from a prospective randomized study evaluating outcomes of two treatment modalities; Inlay graft and only flap for distal hypospadias with shallow urethral plate with 80 patients (40 patients in each group) included, the second based on our previous records of TIPU in 40 patients with distal primary hypospadias with narrow urethral plate.

RESULTS

The success rate in inlay graft urethroplasty group (n = 40) was 87.5%; glandular dehiscence occurred in one case (2.5%), fistulas occurred in 2 cases (5%), and narrow meatus occurred in two cases (5%). Success rate in onlay flap urethroplasty group (n = 40) was 82.5%; glandular dehiscence occurred in two cases (5%), fistulas occurred in two cases (5%), and narrow meatus occurred in three cases (7.5%). TIPU group (n = 40) had success rate of 62.5%; glandular dehiscence occurred in eight cases (20%), fistulas occurred in five cases (12.5%), and narrow meatus occurred in seven cases (17.5%), with five cases exhibiting both narrow meatus with fistula.

CONCLUSION

Inlay graft and onlay flap urethroplasty for repair of distal penile hypospadias with narrow urethral plate had higher success rate and fewer complications than traditional TIPU. Moreover, operative time was shorter in TIPU.

Patient Perspectives and Outcomes in Adult Hypospadias Repair

Background Hypospadias is a common congenital anomaly that needs repair at an early age (six months to one year). Ironically, many cases in India present late due to a lack of healthcare facilities, poverty, and illiteracy. Adult patients are different from children as they are aware of their genitalia. They are concerned with the aesthetics and, predominantly, the potency. In this study, we present the perspectives and outcomes of 111 adult cases of hypospadias. Methodology In this retrospective study conducted between January 2010 and December 2020, 111 patients aged more than 14 years who were diagnosed with hypospadias of any level with or without mild-to-moderate chordee were included. Hypospadias repair using a tubularized incised plate (TIP) urethroplasty technique was performed, and patients after surgery were followed up at three months, six months, and 12 months for any complications with physical examination, uroflowmetry, and patient-related outcomes (PROs). Results Age varied from 14 years to 32 years (mean = 19.88 years, SD = 5.93). The most frequent meatus positions after chordee adjustment were distal (n = 64, 57.65%), middle (n = 25, 22.52%), and proximal (n = 22, 19.82%). Among these, four patients had penoscrotal transposition. Chordee was present in 65.7% (n = 73) of the cases. (<30° in 38.7%, n = 43; 30°-60° in 23.4%, n = 26, and >60° in 3.6%, n = 4). Chordee was corrected using many techniques, including ventral corporotomies. Urethroplasty was done using TIP and spongioplasty in 89% (n = 99), and one patient underwent inner preputial onlay flap urethroplasty. Snodgraft was used to augment the urethral plate in 10 cases. The success rate of one-stage surgery was 74.77% in our series, which significantly correlated with PROs. Uroflow varied from 12 mL/second to 18 mL/second, and in the majority of the cases, the flow rate improved over time. The most common complication was urethrocutaneous fistula in 11 (11.8%) patients, followed by glanular dehiscence in nine (8.1%) patients. Conclusions Adult patients undergoing primary hypospadias repair generally show good outcomes. Patients can have an acceptable mild degree of residual chordee and torsion, which correlate well with PROs. In our series, hypospadias fistula was the most common complication of hypospadias surgery, followed by glanular dehiscence.

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.

Predictors of successful outcome of tubularized incised plate for primary distal hypospadias repair

Background

Several preoperative factors affect the outcome of Tabularized Incised Plate (TIP) repair. Our aim was to collect and analyze all these factors to define what the most important predictive factors are.

Methods

Hundred patients (1–5 years old) with primary distal hypospadias were included. Exclusion criteria included previous penile operations and hormonal treatment or associated congenital anomalies. Anogenital distance (AGD), stretched penile length (SPL), meatal site, glanular shape, chordee and torsion degree, plate width and glans meatus shaft (GMS) score were assessed. TIP repair was done to all patients and followed up for one year. The outcome was correlated with the above parameters.

Results

Mean ± SD of age of patients was 3.5 ± 1.5 years, while weight was 14.1 ± 3.0 kg. Complication rate was 18% including urethrocutaneous fistula (UCF) and meatal stenosis 14%, repair breakdown 1% and urethral stricture 3%. Patients with chordee degree < 30° and distal penile meatal location were associated with increased risk for complications by 11.6 and 8.2 times; 95% CI was (1.46–91.75) and (1.02–66.52), respectively (p < 0.05 for each). Plate width ≥ 9 mm, AGD > 5 cm, GMS score ≤ 7 (p < 0.001 for each), age of patient ≤ 2 years old, and SPL > 3.5 cm (p < 0.01 for each) were associated with successful outcome of repair.

Conclusion

The proposed successful criteria of TIP repair were absent chordee, coronal/subcoronal penile meatal location, plate width ≥ 9 mm, AGD > 5 cm, age of patient ≤ 2 years old, GMS score ≤ 7, SPL > 3.5 cm and grooved glanular shape.

Are there any benefits of using an inlay graft in the treatment of primary hypospadias in children? A systematic review and metanalysis

INTRODUCTION

Dorsal inlay graft urethroplasty (DIGU) has been described as an effective method for hypospadias repair with the proposed advantage of reducing the risk of complications. We aimed to systematically assess whether DIGU has any additional advantages over standard tubularized incised plate urethroplasty (TIPU) repair in children with primary hypospadias.

MATERIALS AND METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The a priori protocol is available at the PROSPERO database (CRD42020168305). A literature search was conducted for relevant publications from 1946 until January 10, 2020 in seven different databases. Randomized controlled trials (RCTs), comparative studies (TIPU vs DIGU) and single arm case series (>20 cases) of DIGU were eligible for inclusion. Secondary hypospadias, two-stage repairs, disorders of sex development, significant curvature of >30°, and a mean or median follow-up of less than 12 months were excluded.

DISCUSSION

A total of 499 articles were screened and 14 studies (3 RCTs, 5 non-randomized studies (NRSs), and 6 case series) with a total of 1753 children (distal: 1334 (76%) and proximal: 419 (24%)) were found eligible. Mean follow-up of the studies was between 16 and 77 months. DIGU was found superior to TIPU in decreasing meatal/neourethral stenosis (p = 0.02, 95% CI 0.02-0.78). All other parameters were found comparable including overall complications, fistula and glans dehiscence rates. Success rates were similar among the groups ranging between 48% and 96% for DIGU and 43-96% in the TIPU group. The lack of standardization in the definition of complications and success was the major limitation of this study.

CONCLUSIONS

Using an inlay graft during primary hypospadias repair decreases the risk of meatal/neourethral stenosis. However, current evidence does not demonstrate superiority of DIGU over TIPU in terms of treatment success and overall complication rates.

Narrow urethral plate augmentation in anterior and middle hypospadias repair: Onlay flap VS. Inlay graft. A prospective randomized comparative study

INTRODUCTION

The measurement of the urethral plate width (as an objective parameter) and its effect of this width on the results of tubularized incised plate urethroplasty (TIPU) have been reported in two series and both authors reported that a urethral plate width < 8 mm is associated with higher complication rates. The augmentation of the urethral plate either by dorsal inlay graft urethroplasty (DIGU) or Onlay flap has been compared with the original TIPU in different degrees of hypospadias with better surgical results in augmented cases.

OBJECTIVE

To evaluate the surgical results of longitudinal Onlay preputial flap (LOF) vs (DIGU) techniques in augmentation of the narrow urethral plate.

STUDY DESIGN

Primary anterior and middle hypospadias cases with narrow urethral plates were randomly allocated into two groups; group one operated by DIGU and group two operated by (LOF). The Success rate, individual complication rate, and operative times were compared.

RESULTS

39 cases completed the study. No significant differences in patients' characteristics were detected. In the DIGU group, one case (5.3%) complicated with fistula and glandular dehiscence wherein in the LOF group, 7 cases (35%) Complicated with 5 fistulae, 2 glanular dehiscences, one flap loss, one diverticulum (p= .02). No significant differences in the rates of individual complications.

DISCUSSION

Variables affecting the success of hypospadias repairs are many. Urethral plate quality is an important variable among these variables. The definition of urethral plate quality is usually subjective. In the DIGU group, only 1/19 (5.3%) case had two complications, fistula and glandular dehiscence. Mouravas et al., in their comparative study between TIPU and G-TIP without mention of urethral plate width reported a significant reduction of the overall complications and urethral stenosis without significant reduction in fistula rate. In their G-TIP group, only 2 cases out of 24 (8.3%) were complicated with one fistula and one glandular dehiscence where in the TIPU group, 7 cases (30.4%) were complicated with one glandular dehiscence and 6 cases with urethral stenosis. In the LOF group, fistula in 5/20 cases (25%) was the commonest complication followed by glandular dehiscence in 2 cases (10%). Diverticulum and flap loss occurred in one case for each (5%). In the multivariate analysis of 474 patients' cohort by Spinoit et al., there were no significant differences between the risk of re-intervention after TIP and Onlay flap in anterior and middle hypospadias (25.8% vs. 18.8%), and (22.2% vs. 20%) respectively.

CONCLUSION

Our data suggest that augmentation of the narrow urethral plate with DIGU has a better surgical outcome than with LOF. No significant difference in cosmetic outcomes detected.

Reconstructing forked corpus spongiosum to correct glans droop in distal/midshaft hypospadias repair

Purpose

We reviewed our experience and efficacy of reconstruction of a forked corpus spongiosum (FCS) to correct glans droop in distal/midshaft hypospadias repair.

Methods

Eighty-five consecutive patients who underwent distal/midshaft hypospadias repair by the same surgeon in our center from October 2015 to June 2018 were retrospectively analyzed. All cases were accompanied by different degrees of glans droop, which we corrected by cutting off and reconstructing the FCS along the plate. We recorded the degrees of glans droop, development of the FCS, and postoperative complications including residual chordee, fistula, diverticulum, glans dehiscence, meatus stenosis, and urethral stricture.

Results

The follow-up period ranged from 5 to 37 months (mean, 19.7 months). Two patients (2.3%) developed a coronal fistula and underwent a second repair. Two patients (2.3%) developed a mild urethral diverticulum and underwent continued observation. One patient (1.2%) developed a meatus stenosis that resolved after 1 month of meatus expansion combined with external mometasone furoate. No patients developed postoperative residual chordee or urethral stricture.

Conclusions

The degree of glans droop is closely associated with the development of an FCS. Reconstructing the FCS to correct the glans droop can yield satisfactory outcomes and should be popularized in distal/midshaft hypospadias repair.

Urethral plate in tubularized incised plate urethroplasty: how wide is enough?

Background

Previous reports found that a preincision urethral plate (UP) width <8 mm increased the occurrence of urethroplasty complications (UCs) in tubularized incised plate (TIP) hypospadias repair. However, is the classification of the UP width based on an 8 mm cut-off value to predict the outcome of TIP urethroplasty objective enough or universally applicable? The purpose of our study was to assess the effect of the UP width on the outcomes of TIP hypospadias repair in the Eastern population we served.

Methods

We retrospectively reviewed the records of patients who underwent TIP hypospadias repair by the same surgeon between August 2013 and December 2019 in our hospital. Data were collected, including demographics, intrinsic parameters of the penis, surgical parameters and subsequent surgical outcomes. The data were analyzed and the cut-off value of the UP width was calculated using a receiving-operator curve.

Results

Primary TIP urethroplasty was carried out in 116 patients with a mean age of 35.89±29.40 months. The meatal location was distal in 49 patients, midshaft in 56 patients and proximal in 11 patients. The mean glans width was 12.28±1.36 mm, the mean UP width was 5.74±1.37 mm, the mean neourethral length was 1.96±1.32 cm, and the mean operation duration was 87.52±11.47 min. During a median follow-up of 42 (range: 6 to 80) months, UCs developed in 12 patients, and the UP width was significantly related to the occurrence of UCs (P=0.014). According to the 6 mm cut-off value of the UP width by the receiver operating characteristic curve, patients were divided into two groups. Group A (UP width ≥6 mm) included 69 patients, and Group B (UP width <6 mm), 47 patients. UCs occurred in 3 patients in Group A vs. 9 patients in Group B, P=0.010.

Conclusions

UP width is a potential risk factor for UCs after TIP hypospadias repair. Using this technique with an UP width ≥6 mm is sufficient to result in a good outcome of hypospadias repair.

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.

Ingrafts in hypospadias surgery: Longer-term outcomes

BACKGROUND

The technique of hypospadias repair with a dorsal inlay graft (ingraft) was initially reserved for boys with an unfavorable glans configuration or in previously failed repairs. Although the ingraft technique has been used for some time, there is scarce literature describing its longer term outcomes. Additionally, there is minimal data comparing inner preputial skin and buccal mucosal graft outcomes in primary and reoperative surgery.

OBJECTIVE

To describe longer-term outcomes in the use of buccal mucosa and inner preputial skin ingrafts for primary and revisional hypospadias repairs.

STUDY DESIGN

We conducted a single-center retrospective review of our hypospadias repairs employing ingrafts along with a review of the literature.

RESULTS

A total of 47 patients met inclusion criteria. Primary repair was performed in 38 patients, all with unfavorable glans characteristics at a mean age of 16 months and redo repairs in 9 boys at a mean age of 110 months. We used a buccal mucosal graft (BMG) in 19 boys and the remaining 28 were grafted with inner preputial skin. The complication rate was 32% in primary repairs and amongst those, 6 of 28 patients (21%) with skin grafts and 6 of 10 patients (60%) with BMGs suffered a complication. Only BMGs were used in reoperative situations and complications occurred in 2 of 9 cases (22%) of those cases. Overall, 8 patients (42%) with BMG and 6 patients (21%) with preputial skin ingrafts experienced a complication, at an average time of 17 months (range: 0.4-66 months) and 24 months (range: 1.1-113 months), respectively. Surgical correction of the complications resulted in resolution of symptoms in a majority of patients.

DISCUSSION

In our experience, BMGs used as salvage therapy in revisional hypospadias surgery, had lower observed complication rates when compared to its use in primary repair. Inner preputial skin ingrafts for primary repair yielded an acceptable complication rate. Our study describes some of the longest follow-up times in the literature with complications observed even up to 10 years postoperatively. This reinforces the need for active long-term follow-up in reporting outcomes in hypospadias surgery.

Snodgrass vs Snodgraft operation to repair the distal hypospadias in the narrow urethral plate

BACKGROUND

Using the Snodgraft technique in patients with urethral plate less than 8 mm to repair distal hypospadias is still debatable. Some authors assume that augmentation may be beneficial. We aimed to compare the outcomes of the Snodgrass vs Snodgraft procedure in patients with a narrow urethral plate less than 8 mm.

METHODOLOGY

This prospective randomized study included 60 children who had been treated by the Snodgrass or Snodgraft procedure for repair of distal penile hypospadias with narrow urethral plate from March 2017 to September 2018. They were randomized into two subgroups. Group 1 (30 patients) underwent tubularized incised plate urethroplasty, whereas the second group (30 patients) underwent the Snodgraft procedure by using the inner prepuce. Operative details, postoperative period, and complications were reported and statistically analyzed using IBM SPSS software package version 20.0.

RESULTS

The operative time was longer for patients who underwent the Snodgraft procedure: 78 (55-95) and 110 (80-140) minutes in groups 1 and 2, respectively. In group 1, there was one case of meatal stenosis which was resolved by urethral dilation using the local anesthetic cream in the outpatient clinic. In addition, there was another case of distal penile fistula. In group 2, there was a case of complete wound disruption and another of distal penile fistula. There was no significant difference in the complication rate in any group.

CONCLUSION

The operative time was longer in group 2 than in group 1 but with comparable outcomes. The Snodgraft procedure is not superior to the Snodgrass operation in the narrow healthy urethral plate.

Can Grafted Tubularized Incised Plate Urethroplasty be Used to Repair Narrow Urethral Plate Hypospadias? Its Functional Evaluation Using Uroflowmetry

Aim:

Using uroflowmetry, the aim of this study is to determine the functional results of the grafted tubularized incised plate (GTIP) urethroplasty used to repair poor urethral plate hypospadias.

Settings and Design:

Seventy-one patients (mean age: 5.7 years, follow-up: 1–5.5 years) were selected from those who underwent surgery using the GTIP technique from 2013 to 2015 at our institution.

Methods:

Patients included were able to void voluntarily and had no fistula. The flow pattern, maximum urinary flow rate (Q_max), voided volume (vv), average flow rate, and voiding time were measured. The results were expressed as percentiles and interpreted according to Siroky nomogram. The Q_max was considered normal if >25^th percentile, as equivocally obstructed when in the 5^th–25^th percentile, and obstructed if <5^th percentile.

Results:

Hypospadias was distal in 45, mid penile in 17 and proximal penile in 9. The uroflow curve was bell-shaped in 24 (30%), interrupted in 9 (14%), slightly flattened in 31 (46%), and a plateau in 7 (10%). Flow rate nomograms revealed that 49 (68%) were above the 25^th percentile, 9 (17%) were below the 5^th percentile, and 13 (15%) were between these ranges. Eleven patients showed improvement in the flow curve and maximum urinary flow rate (Q_max) in follow-up uroflowmetry.

Conclusion:

GTIP repair provides satisfactory functional results. A long-term follow-up is needed to confirm these results.

Comprehensive evaluation of grafting the preservable narrow plates with consideration of native plate width at primary hypospadias surgery

INTRODUCTION

Dorsal inlay graft urethroplasty using inner-face preputial graft was described as an adjunct method to the classic tubularized incised plate (TIP) urethroplasty, aiming at reducing the risk of neourethral stenosis.

OBJECTIVES

To evaluate the impact of dorsal inlay grafting of preservable narrow plates, in relation to native plate width.

METHODS

Consecutive children with penile hypospadias with narrow plate (width < 8 mm) were evaluated prospectively between Jan 2014 and Jun 2018. Included cases were stratified into two groups: group A (plate width: 4 to <8 mm) and group B (plate width: < 4 mm). All cases were approached by TIP urethroplasty, with dorsal inlay grafting (inner-face prepuce). Cases with significant chordee (non-preservable plates), circumcised cases, and redo cases were excluded.

RESULTS

A total of 104 hypospadias cases with narrow plates were included in this study. Among group A (n = 81), the need for postrepair urethral dilations was reported in two cases (2.5%) vs seven cases (30%) in group B (n = 23) (P-value < 0.001). Another two cases (2.5%) in group A developed urethrocutaneous fistulae vs three cases (13%) in group B (P-value = 0.0624). Surgical repair of the reported five cases with fistulae, revealed an ample neourethral wall; disclosing well-taken grafts in both groups.

DISCUSSION

Few published studies evaluated grafting the incised plate in penile hypospadias. To the authors knowledge, this is the first study that selectively evaluated the impact of grafting narrow plates in relation to its native pre-incision width.

CONCLUSIONS

According to the presented authors' experience, 4 mm width is the border line of clinical relevance that defines poor urethral plate. Grafting that plate failed to compensate for its native poor characteristics; however, it offered a valuable neourethral wall that proved indispensable when redo surgery deemed necessary, without adding grafting-related problems. Nevertheless, further extended comparative studies came across as a necessity to verify the long-term outcomes of grafting the incised poor plates.

Does grafted tubularized incided plate improve the outcome after repair of primary distal hypospadias: A prospective randomized study?

OBJECTIVE

To detect whether grafting the incised plate during Snodgrass repair would improve outcome.

MATERIALS AND METHODS

Sixty patients with primary distal hypospadias were included. Patients were equally randomized using closed envelop method to either Snodgrass or grafted tubularized incised plate repair (GTIP). All operations were performed by a single surgeon. All intaroperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meatus at the tip of the glans with no stenosis, fistula or diverticulum.

RESULTS

All 60 patients were evaluated at 1 year of follow-up. Mean age at surgery was 40±15months. Both groups were comparable as regard to patients' age, meatus location, length and width and depth of urethral plate and glans width. Success was documented in 29/30 patients (96.7%) in the Snodgrass group. The only complication was meatal stenosis in one patient, whereas success was documented in 28/30 patients (93.3%) in the GTIP group. The two failures were secondary to partial glans dehiscence. Success rate was not statistically different. Flow rate data at 1 year showed insignificant difference between both groups as regards Q-max and voiding time. The only statistically significant difference between both groups was a longer operative time 106±12min in the GTIP group compared to only 77±9 for the Snodgrass group (p = 0.005).

CONCLUSIONS

Snodgrass and GTIP techniques for primary distal hypospadias repair have similar outcome. With a significantly shorter operative time, Snodgrass repair remains the first choice for primary distal hypospadias repair.

TYPE OF THE STUDY

Prospective randomized study.

LEVEL OF EVIDENCE

Level I.

Age-related changes in urinary flow following dorsal inlay graft urethroplasty for hypospadias in early childhood: Potential improvement over 11 years of age

INTRODUCTION

One of the goals of hypospadias repair is to create a neourethra with normal urinary stream and normal growth. Several studies have reported that dorsal inlay graft urethroplasty (DIG) has wide indications for various clinical phenotypes of hypospadias, with good short-term outcomes and few complications. However, there have been no reports that evaluated both short-term and long-term functional outcomes using uroflowmetry in patients with DIG.

OBJECTIVE

The aim was to investigate whether uroflowmetry parameters change with time following DIG for hypospadias in early childhood.

MATERIALS AND METHODS

Uroflowmetry parameters after DIG for hypospadias in childhood were retrospectively evaluated and compared between two defined ages at follow-up: 4-6 years and 11-13 years. Maximum urinary flow (Q_max) under the 25th percentile on the Miskolc nomogram was defined as obstruction. To evaluate the shapes of uroflow quantitatively, the flow index (FI) was used. The FI cut-offs for the flow shapes were defined as tower >1.253, plateaus <0.659; bells were between these two values.

RESULTS

Thirty-four patients met the inclusion criteria. The median operative age was 1.8 years (range 1.0-4.9 years). The median follow-up time was 10.3 years (range 7.2-12.3 years). The mean ± SD Q_max at the two follow-up times increased with time, from 9.2 ± 3.7 to 18.8 ± 7.8. The mean ± SD FI changed from 0.53 ± 0.19 to 0.85 ± 0.31. Both Q_max and the FI were significantly improved (p < 0.001, p < 0.001, respectively). There were significantly fewer patients with obstruction evaluated by the Miskolc nomogram at 11-13 years of age (n = 11, 32.4%) than at 4-6 years (n = 31, 91.2%) (p < 0.001). Plateau shapes assessed by the FI were seen in 24 (70.6%) patients at 4-6 years and 10 (29.4%) patients at 11-13 years (Table). The number of patients with plateau shapes was significantly decreased (p = 0.001).

DISCUSSION

Only one report noted long-term outcomes and spontaneous uroflowmetry resolution after tubularized incised plate urethroplasty. The current report is the first to present the short-term and long-term uroflowmetry outcomes after DIG. In addition, the FI was used for the first time to evaluate uroflowmetry after hypospadias repair. It was found that the uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood.

CONCLUSION

Uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood.

Width proportion of the urethral plate to the glans can serve as an appraisal index of the urethral plate in hypospadias repair

OBJECTIVES

To find a new appropriate evaluation for urethral plate quality in hypospadias repair, with particular interest in the width proportion of the urethral plate to the glans, serving as an appraisal index.

METHODS

Data were prospectively collected from prepubertal boys who underwent primary tubularized incised plate hypospadias repair between January 2014 and April 2016 in one center. Intrinsic parameters of the penis (meatal location, glans width, urethral plate width and curvature degree) were measured during the operation. Urethroplasty complications were recorded during follow up. The correlation between width proportion of the urethral plate to the glans and urethroplasty complications was analyzed.

RESULTS

Primary tubularized incised plate repair was carried out in 442 patients (mean age 2.8 years, range 0.5-12 years). At mean follow up of 26 months (range 12-38 months), urethroplasty complications occurred in 59 (13.3%) patients. The width proportion of the urethral plate to the glans was weakly correlated to both the glans width and meatal location. The width proportion of the urethral plate to the glans ranged from 0.18 to 0.73, with a mean of 0.39. The cut-off value of width proportion of the urethral plate to the glans was determined to be 0.36 by the receiver operating characteristic curve. Urethroplasty complications occurred in 17 out of 254 patients (6.7%) with width proportion of the urethral plate to the glans >0.36, and 42 out of 188 patients (22.3%) with width proportion of the urethral plate to the glans ≤0.36. The width proportion of the urethral plate to the glans ≤0.36 showed an increased odds of 4.819-fold (95% confidence interval 2.548-9.112, P < 0.001) risk of urethroplasty complications compared with width proportion of the urethral plate to the glans >0.36. Midshaft and proximal meatal location also increased the risk of urethroplasty complications.

CONCLUSIONS

The present study highlights the value of the width proportion of the urethral plate to the glans for objectivity and accuracy in urethral plate evaluation, which in turn serves as an independent factor influencing outcomes in tubularized incised plate repair.

Reinforcing the ventral penile shaft with pedicled fat/connective tissues before urethroplasty lowers the risk for post-urethroplasty complications in hypospadias

PURPOSE

CHARGE is our technique for reinforcing the ventral penile shaft with pedicled pericordal/scrotal fat, pedicled perimeatal connective tissue, or a combination of these at the time of initial hypospadias surgery. Such pedicled grafts "charge" poorly developed urethral plates and thin ventral foreskin prior to urethroplasty to improve compromised vascular perfusion that could prevent post-urethroplasty complications (post-UPC).

METHODS

We reviewed post-UPC in 179 staged hypospadias repair patients (1997-2015). CHARGE, adopted routinely in 2010 was used in 39 patients (C-group), not indicated in 7 because ventral connective tissue was thick, and not used in 133 (NC-group). Initial hypospadias surgery included foreskin degloving with or without chordectomy, dorsal plication, tunica albuginea incision, or a combination of these.

RESULTS

Subject demographics were similar. NC had significantly more post-UPC than C (25 versus 0; p<.01) comprising stenosis (n=14), fistula (n=7), diverticulum (n=2), and wound infection (n=2) that developed after a mean of 0.7±0.2years (range: 1day-2.8years). Extra time taken for CHARGE was less than 15minutes in all cases. Mean follow-up after urethroplasty (years) was significantly shorter in C (1.5±1.0 versus 5.7±3.8) (p<.01), but almost double the time taken to develop post-UPC.

CONCLUSION

CHARGE would appear to prevent post-UPC.

LEVEL OF EVIDENCE

Retrospective Comparative Study - Level III.

Grafted tubularised incised-plate urethroplasty: An objective assessment of outcome with lessons learnt from surgical experience with 263 cases

Objective

Snodgrass urethroplasty remains the preferred technique in primary distal hypospadias but development of meatal stenosis often limits distal extension of the midline incision of the urethral plate (MIUP), which remains a limiting factor in reconstructing an apical neomeatus (NM). We here-in assess the cosmetic and functional outcome with distal extension of the MIUP in grafted tubularised incised-plate urethroplasty (G-TIP) repair.

Patients and methods

This prospective study included the surgical experience of 263 cases of primary hypospadias operated upon between 2012 and 2015. The G-TIP technique included standard steps of Snodgrass urethroplasty, including degloving and harvesting of glans wings, followed by MIUP that was extended distally beyond the margins of the urethral plate (UP) into the glans. The incised bed was grafted with a free preputial skin graft and fixed to the bed with polydioxanone 7-0 suture. The UP was tubularised and the suture line reinforced with a Dartos flap. The urethral catheter was removed at 7–10 days after the repair and the outcome was assessed at follow-up using the Hypospadias Objective Scoring Evaluation (HOSE) system.

Results

An apical NM was achieved in 96% of the patients with a 3.7% incidence of urethrocutaneous fistula. The presence of suture tracks and graft at the margins of the NM were seen in the initial 4% and 5% of cases, respectively. Acceptable cosmetic results, with objective HOSE scores of >14, were achieved in 96% of cases.

Conclusion

The G-TIP repair is a straightforward and feasible technique facilitating reconstruction of an apical NM, with an optimum outcome based on HOSE scoring. However, multicentre data are needed for undertaking comparative analysis and to assess the universal applicability of this technique in primary hypospadias.

Correction of penile ventral curvature in patients with minor or no hypospadias: a single surgeon's experience of 43 cases

PURPOSE

To report our experience of correcting penile ventral curvature associated with minor or no hypospadias.

METHODS

We reviewed 43 penile ventral curvature patients treated by a single surgeon from 1997 to 2015. Of these, 23 had minor hypospadias. Curvature was corrected using degloving, chordectomy, dorsal plication (DP), tunica albuginea incision (TAI), or a combination of these. Outcome was confirmed by induced artificial erection and post-operative appearance.

RESULTS

Mean age at curvature correction was 3.2 ± 2.6 years. 17/43 had degloving and chordectomy (DC), 16/43 had DP after DC, and 10/43 had TAI after DC, because of ventral shortening and severe curvature caused by a short hypoplastic urethra. Other procedures required were primary meatoplasty (n = 4) and urethroplasty (UP; n = 1) at the time of curvature correction, and UP after correction of curvature (n = 11). Complications included recurrence of curvature after DP (n = 3/16; 18.8 %) and urethral stenosis after UP with tubed peritoneum (n = 1/10; 10 %). There were no recurrences of curvature in TAI cases. Parents reported penile cosmesis as good (n = 38; 88.4 %), acceptable (n = 4; 9.3 %), or poor (n = 1; 2.3 %).

CONCLUSION

We recommend TAI followed by UP for correcting penile ventral curvature with short hypoplastic urethra. Tubed peritoneum is not recommended for UP.

Selecting the right method for hypospadias repair to achieve optimal results for the primary situation

BACKGROUND

Over the past two decades, Snodgrass tubularized incised plate (TIP) urethroplasty has become one of the dominant surgical techniques with wide applications and excellent cosmetic results. However, TIP has many limitations. We performed a retrospective study at our department and assessed the outcome of the inlay internal preputial graft for extending the applications of TIP.

METHODS

Between January 2009 and December 2013, we performed a retrospective study consisting of approximately 508 primary distal and moderate cases. Patients with primary distal hypospadias who had mild or no chordee and good penile development were divided into the following 3 groups based on their procedures: (1) classic TIP hypospadias repair group (n = 198); (2) inlay buccal mucosa graft group (n = 150); and (3) inlay internal preputial graft group (n = 160). The median age was 1.6 years (range 1-4 years). Our data were analyzed statistically by the Chi square test with P < 0.05 indicating significant differences.

RESULTS

The mean follow-up period was 18 months (range 6‒24 months). In the classic TIP group, the incidence of urinary fistula and meatal stenosis were both 3.0 % (6/198); in the inlay buccal mucosal graft group, the incidence of urinary fistula was 3.3 % (5/150), and the incidence of stenosis was 2.7 % (4/150); and in the inlay internal preputial graft group, the incidence of urinary fistula was 3.1 % (5/160), and the incidence of meatal stenosis was 4.4 % (7/160). The success rates of each group were as follows: the classic TIP group has a success rate of 93.9 % (186/198); the inlay buccal mucosa graft group had a success rate of 94.0 % (141/150); and the inlay internal preputial graft group had a success rate of 92.5 % (148/160). There were no statistically significant differences between the 3 groups with respect to complication rates.

CONCLUSIONS

As the inner foreskin Snodgraft does not appear to be worse than the buccal mucosa graft, it is a good method for hypospadias repair, and this method is not inferior to TIP.

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

PURPOSE

We report the efficacy of staged segmental urethroplasty (SSUP) versus non-staged urethroplasty (NSUP) for treating scrotal/perineal hypospadias (SPH).

METHODS

Between 1997 and 2015, 29 SPH patients underwent UP (SSUP: n = 15; NSUP: n = 14). Incidences of urethrocutaneous fistula (UF), stenosis of the neourethra (SNU), diverticula formation, and residual chordee (RC) were compared. Differences were statistically significant if p < 0.05.

RESULTS

The difference in mean age at NSUP (3.2 ± 1.3 years) and at the final stage of SSUP (5.5 ± 2.4 years) was significant (p < 0.05). Mean operative times for NSUP and SSUP (total for all stages) were not significantly different (231.5 ± 117.5 versus 272.5 ± 99.4 min); however, the incidence of postoperative complications was significantly less in SSUP (n = 1; UF) compared with NSUP (n = 6; 2 cases of UF, 3 cases of SNU, and 1 case of RC; (p < 0.05). Mean follow-up was significantly shorter in SSUP; 1.4 ± 1.2 years versus 7.0 ± 4.5 years in NSUP (p < 0.05).

CONCLUSION

SSUP would appear to be effective for treating SPH because of a significantly lower incidence of UF, SNU and RC during the first postoperative year, the period when complications have been reported to arise most frequently.

Evaluation of Onlay Island Flap Technique in Shallow Urethral Plate Hypospadiasis

Background:

Hypospadias is one of the most common congenital genital anomalies in males that necessitates to be operated early in infancy (when 6 to 9 months old). On the other hand, hypospadias is a challenging field of pediatric urology with multiple reconstruction techniques. A perfect hypospadias repair is supposed to return urethral continuity with sufficient caliber, eradicate phallus curvature, and supply an acceptable appearance with low complications.

Objectives:

This study aimed to evaluate the outcomes of using onlay island flap technique in the repair of hypospadias with shallow urethral plate.

Patients and Methods:

In this prospective study within June 2012 to December 2013, we performed onlay island flap procedure to repair hypospadias with shallow urethral plate measuring less than 6 millimeter. This technique was selected for all types of hypospadiasis except subcoronal type. Nesbit’s dorsal plication procedure was established for chordee. In cases with very small glans, urethroplasty was performed without glansplasty.

Results:

Twenty three patients with mean age of 30 (range 10 - 60) months underwent onlay island flap repair; all had a shallow urethral plate < 6 mm, 3 had a very small glans, and 18 had chordee. Meatus was located in distal shaft in 5 cases, mid shaft in 8, proximal in 6 and penoscrotal type in 4 patients. Chordee was corrected with Nesbit’s dorsal plication in 16 cases. Complications were: meatal stenosis in 2 cases and urethrocutaneous fistula in 2 patients, all of which were repaired surgically. Mean follow up time was 13 (3 - 20) months. All cases that had glansplasty have excellent esthetic appearance.

Conclusions:

This technique offers acceptable results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.

Is combined inner preputial inlay graft with tubularized incised plate in hypospadias repair worth doing?

BACKGROUND

It has been noted that after tubularized incised plate urethroplasty (TIP) repair, the final meatal position is glanular but not at the optimum position. Inner preputial inlay graft combined with tubularized incised plate (G-TIP) has been proposed for redo urethroplasty. We extended this indication to be the standard technique for primary hypospadias repair. We conduct this prospective study to obtain a wide, slit-like appearance neomeatus at the optimum position in the glans proper and to judge if hypospadias repair complications differ from TIP repair in the published data in the literature.

PATIENTS AND METHODS

This prospective study included 230 consecutive patients who underwent this technique. The study was conducted from November 2011 to August 2014 for all hypospadias cases to be repaired in a single stage regardless of the width and depth of urethral plate or the glans size and shape. Localization of the meatus was glanular in 13 patients, coronal in 75, distal penile in 112, mid penile in 25 and proximal in five. The urethral plate was incised deeply and extended distally beyond the end of the plate by 3 mm in glans proper. The mucosal graft was harvested from the inner prepuce, inlayed and quilted in the incised urethral plate. The neourethra was created over a urethral catheter in two layers. The vascular dartos flap was mobilized dorsally and moved ventrally to cover the neourethral suture line as a barrier.

RESULTS

The follow-up period ranged from 5 to 36 months. Excellent cosmetic and functional results were achieved in 221 of 230 patients (96.09%). Neither meatal stenosis nor urethral diverticulum were encountered. An excellent glanular position of a wide slit-like neomeatus was achieved using this technique. Nine patients (3.91%) developed urethrocutaneous fistula. Excellent urinary stream was reported by parents.

CONCLUSIONS

Combined inner preputial graft with TIP urethroplasty secures the optimal glanular position of a wide slit-like neomeatus because of extension of the incision beyond the end of the plate, thus optimizing functional and cosmetic outcome with no meatal stenosis.

Soft tissue interposition is effective for protecting the neourethra during hypospadias surgery and preventing postoperative urethrocutaneous fistula: a single surgeon's experience of 243 cases

PURPOSE

Soft tissue interposition (STI) during hypospadias repair (HR) purportedly prevents postoperative urethrocutaneous fistula (PUF) by supporting the neourethra. We report our experience.

METHODS

Data from 243 hypospadias patients treated by a single surgeon from 1997 to 2014 by urethroplasty (UP) with STI (n = 229; UP + STI) and UP without STI (n = 14; UP-STI) were collated prospectively and compared for incidence of PUF. Re-operative UP were excluded.

RESULTS

Hypospadias was distal (n = 55), mid-shaft (n = 59), proximal/penoscrotal (n = 109), scrotal (n = 15), and perineal (n = 5). UP was single-staged in 86, multi-staged in 157; mean age at UP was 3.1 ± 2.4 years. Soft tissue used for STI was prepucial inner dartos fascia (inner dartos: n = 88), ventral dartos fascia (ventral dartos: n = 15), pedicled external spermatic fascia (ESF: n = 84), adipose tissue surrounding the spermatic cord (pericordal: n = 9), scrotal adipose tissue (n = 8), or a combination of tissues (combined: n = 25). Mean follow-up was 6.4 ± 4.6 (range 0.6-16.8) years. Overall incidence of PUF was 10/243 (4.1 %); 7/229 (3.1 %) for UP + STI and 3/14 (21.4 %) in UP-STI (p < 0.05); incidence versus type of hypospadias was 1/55 for distal (1.8 %), 3/59 for mid-shaft (5.1 %), 5/109 for proximal/penoscrotal (4.6 %), 0/15 for scrotal (0 %), and 1/5 for perineal (20 %); incidence versus type of STI was 7/88 for inner dartos, 0/15 for ventral dartos, 0/84 for ESF, 0/9 for pericordal adipose tissue, 0/8 for scrotal adipose tissue, and 0/25 for combined. All PUF were repaired successfully. Satisfaction with penile cosmesis was acceptable (10.3 %) or good (89.7 %) without any testicular complications or scrotal deformity.

CONCLUSION

STI, especially ESF, would appear to effectively prevent PUF in HR.

Urethral plate grafting improves the results of tubularized incised plate urethroplasty in primary hypospadias

OBJECTIVE

We conducted a competitive efficacy trial in order to examine whether grafting the raw area of the urethral plate (UP) with inner preputial skin in children with primary hypospadias (PH) during tubularized incised plate urethroplasty (TIP) improves the results of the operation.

MATERIAL AND METHODS

Fifty consecutive patients with pathology ranging from glanular to proximal penile PH were randomized into two groups, comparable for age and pathology, to be operated on either with TIP or a grafted TIP (G-TIP) procedure. Three patients failed the re-examination protocol, so the TIP group comprised 23 children aged 9.0 months-9.6 years (mean age 3.4 years) and the G-TIP group comprised 24 children, aged 10.0 months-9.4 years (mean 3.5 years). The patients were followed up for a period of 2-5 years (mean 3.2 years).

RESULTS

Within the TIP group, we observed the development of fistula with concomitant neourethral stenosis in two cases (8.7%), stenosis without fistula in four (17.4%), and glans dehiscence in one case (4.35%). Within the G-TIP group there was one case of fistula without stenosis (4.16%), no case of neourethral stenosis, and one case of glans dehiscence (4.16%). Two cases of non-slit-like meatus were observed in the TIP group. The results show that the complications of neourethral stenosis are significantly reduced (p < 0.05) in the G-TIP group, as is the total number of complications and unsatisfactory results. The duration of the TIP operation was 72-110 (mean 92) min, and for the G-TIP 100-136 (mean 115) min. No postoperative symptoms were observed that could be attributed to prolonged anesthesia time.

CONCLUSION

UP grafting with inner preputial skin, when added to the TIP procedure in the treatment of PH, results in a significantly smaller number of unsatisfactory results, and particularly fewer cases of neourethral stenosis. G-TIP can be used as the procedure of choice in PH patients.

Modified Snodgrass tubularized incised plate urethroplasty prevents fistula formation in hypospadias

Urethrocutaneous fistula is a common complication after redo urethroplasty for hypospadias, or urethroplasty for patients with thin urethral plate. We modified Snodgrass' tubularized incised plate urethroplasty (STIPU) by stripping the most superficial skin from both sides of the U-shaped incision to expose more subcutaneous tissue along the suture line. Our modified STIPU would appear to be effective in preventing postoperative urethrocutaneous fistula formation in redo urethroplasty for hypospadias, and urethroplasty for patients with thin urethral plate.

"Snodgraft" technique for the treatment of primary distal hypospadias: pushing the envelope

PURPOSE

"Snodgraft" modification has been proposed to reduce the risk of meatal/neourethral stenosis in distal hypospadias. We applied the Snodgraft technique by using inner preputial graft in primary distal hypospadias repair.

MATERIALS AND METHODS

A total of 102 consecutive patients undergoing the Snodgraft procedure were prospectively studied between 2006 and 2011. Mean patient age was 7.2 years. Localization of the meatus was glanular in 5 patients, coronal in 49, subcoronal in 45 and mid penile in 3. In all patients the posterior urethral plate was incised, and the graft harvested from the inner prepuce was sutured from the old meatus to the tip of the glans. A neourethra was created over a urethral catheter using 6-zero polyglactin suture. An interpositional flap was laid over the urethra as a second barrier. All patients were followed at 3 to 6-month intervals for cosmetic and functional results.

RESULTS

At a mean of 2.4 years of followup no patient had meatal stenosis or diverticulum at the inlay graft site. However, urethrocutaneous fistula was observed in 10 patients (9.8%). A slit-like appearance of neomeatus was achieved in all patients. During followup no obstructive urinary flow pattern was detected, and early and long-term maximum urine flow rates were comparable.

CONCLUSIONS

No meatal/neourethral stenosis was observed in any patient undergoing a Snodgraft procedure. A randomized trial will be needed to prove that the incidence of meatal/neourethral stenosis is lower after Snodgraft repair compared to routine tubularized incised plate repair.