Hypospadias repair with tubularized incised plate. Is uroflowmetry necessary postoperatively?

Urinary flow rates in anterior hypospadias: Before and after repair and its clinical implication

Context

Hypospadias is a common urological anomaly which could be surgically corrected with good cosmetic results.

Aims

We aimed to detect changes in urinary flow parameters both before and after tubularised incised plate urethroplasty (TIPU) using uroflowmetry.

Settings and Design

Data collected were clinically implemented hypothesising the probability of urethrocutaneous fistula following stricture with Qmax variation.

Materials and Methods

This study is a prospective analysis done from December 2017 to October 2019. A total of 104 cases of anterior hypospadias were included in the study. A single surgical unit did TIPU. Pre-operative and post-operative uroflowmetry was done, and Qmax was recorded at 3 months, 6 months and 1 year after surgery. Mean Qmax was calculated for all intervals. A significant decrease in Qmax of a child (<2 standard deviation) was ascertained. Urethral calibration was done in those cases with a significant decrease of Qmax and analysed statistically.

Results

The mean age was 6.97 ± 2.41 years. Out of 104 children, 73 (70.2%) and 31 (29.8%) had distal and mid-shaft hypospadias, respectively. The pre-operative mean Qmax of the population was 6.20 ± 0.42 ml/s. Arithmetic mean Qmax at 3 months, 6 months and 1 year was 8.53 ± 0.42, 11.18 ± 0.47 and 13.71 ± 0.44 ml/s, respectively. On comparing the pre-operative with post-operative mean Qmax, a significant increase was found postoperatively (P < 0.0001). Twenty-four patients had significantly decreased Qmax value after 6 months. In these patients, follow-up urethral dilation was done with significant improvement.

Conclusion

The changes in maximum flow rate (Qmax) are suitable for use in routine follow-up. A significant decrease in Qmax over time indicates the onset of urethral stricture. These cases are to be intervened before venturing to redo urethroplasty.

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.

Extended TIP vs. Standard TIP for primary distal hypospadias repair: randomized study for comparing functional and cosmetic outcomes

OBJECTIVES

The aim of this study was to critically evaluate distal extension of the midline urethral plate incision, extended tubularized incised plate (e-TIP) technique, with the standard TIP and investigating predictors of functional and cosmetic success.

METHODS

In a prospective study, consecutive patients with primary distal hypospadias presented for repair were randomized to undergo either extended TIP (e-TIP) or standard TIP (s-TIP) technique. Cosmetic outcome was evaluated postoperatively using Hypospadias-Objective-Penile-Evaluation (HOPE) score and measurement of ventral-glans-closure-length (VGCL) and meatal length (ML). Functional outcome was evaluated by maximal flow rate (Qmax), average flow rate (Qave), and postvoid residual urine (PVR). The effect of preoperative parameters on the outcome was assessed with regression analysis.

RESULTS

In all 94 cases, out of 110 randomized, were available for analysis. Forty-six in e-TIP group and 48 cases in s-TIP group with comparable preoperative demographics. Median (inter-quartile range) of postoperative total HOPE-score was 57(45-60) vs. 55(44-60) for e-TIP and s-TIP (p < 0.001), respectively. The mean (SD) ratio of VGCL/ML was 87% (26) versus 46% (12) for e-TIP vs. s-TIP, respectively (p < 0.001). Both complications and functional outcomes were comparable. Urethral plate (UP) width and the use of e-TIP technique were significant predictors of successful cosmetic outcome in regression analysis (p = 0.019 and p = 0.001), respectively.

CONCLUSION

Extension of midline urethral plate can potentially create a vertical slit-like meatus located at the glans tip without compromising the functional outcome, thus providing better cosmetic outcome compared with the standard technique. The UP width was a significant predictor of superior cosmetic outcome.

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

AIM

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

METHODS

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

RESULTS

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

DISCUSSIONS

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

CONCLUSIONS

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

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.

Role of uroflowmetry before and after hypospadias repair

Aims:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Is it safe to solely use ventral penile tissues in hypospadias repair? Long-term outcomes of 578 Duplay urethroplasties performed in a single institution over a period of 14 years

OBJECTIVES

Urethral plate tubulization (Thiersch-Duplay procedure) is a widespread procedure mostly used for distal hypospadias. Concerns of long-term outcome have led to this review of the results of a series of 578 cases.

PATIENTS AND METHODS

A retrospective review was conducted of 578 patients treated in a single institution following the same procedure and with the same follow-up. Most patients had distal hypospadias (517/578) and were operated on between 12 and 24 months of age (343 patients). The mean follow-up was 25.6 months (6 months-17 years). Evaluation was focused on urethral complications related to inadequate healing of the reconstructed urethra (fistula, urethral dehiscence, urethral stenosis and clinical dysuria). Complications were arbitrarily categorized into early (when occurring less than one year after surgery) and late (after one year). All data were submitted to statistical analysis.

RESULTS

Of the 578 patients, 153 (26.5%) had unsatisfactory outcomes, of which 118 (20.4%) had inadequate urethral healing. Of these, 97 appeared early (57%) and 73 appeared late (43%). Fistula and dehiscence were significantly more frequent in the first post-operative year (p<0.0001), whereas stenosis of the reconstructed urethra was more frequent after one year. Follow-up and age at last consultation were significantly higher in patients with complications. Limits and flaws of this study focused on the absence of consensus on evaluation of hypospadias surgery. The paucity of literature on long-term outcomes of urethral plate tubulization was highlighted. A possible explanation of late stenosis of the reconstructed urethra was the poor growth capacity of the dysplastic tissues located beyond the division of the corpus spongiosum. Urethroplasties solely using ventral tissues may represent an additional risk of late failure, as they may not grow with the rest of the genital tubercle.

CONCLUSION

Significant short and late complications occur with techniques tubularizing the urethral plate, mostly fistulae in the first post-operative year and urethral stenosis after 1 year following surgery. Urethroplasties using ventral tissues may not grow at the same pace as the rest of the genital tubercle and may explain late urethral dysfunction. This series confirms the necessity of long-term follow-up of hypospadias reconstructions.

Recent advances in understanding/management of hypospadias

Hypospadias is the second most common birth anomaly, affecting 1 of every 300 males. The abnormal position of the urinary opening, and associated downward curvature of the penis in some cases, potentially impact both urinary and sexual function. Modern surgical correction most often involves tubularization of the urethral plate, those tissues which normally should have completed urethral development. This article discusses recent progress in hypospadias repair. Prospective data collection in consecutive patients promotes better understanding of both patient and technical factors that influence surgical complications. Patients with a proximal urinary opening near or within the scrotum, those failing prior to repairs, and/or those with a small glans diameter have increased likelihood for urethroplasty complications. Quality review of reliable data led to two layer urethroplasty covered with tunica vaginalis in proximal repairs, significantly reducing postoperative fistulas. Neither preoperative androgens used to grow a small diameter glans, nor a change in sutures used to approximate the glans wings reduced wound dehiscence, but a recent technical modification of the glansplasty with more extensive dissection before suturing has. The observation that reoperation increases risk for further complications three-fold suggests the less common proximal repairs and reoperations should be subspecialized so that designated surgeons can gain greater expertise. In addition, surgeons performing hypospadias repair must better define the complications that occur so that scientific reporting of outcomes becomes more standardized. Standardized objective means to assess results are also needed so that surgeons performing different repairs can compare outcomes.

Comparison of transverse island flap onlay and tubularized incised-plate urethroplasties for primary proximal hypospadias: a systematic review and meta-analysis

Purpose

This meta-analysis was conducted to compare postoperative outcomes between transverse island flap (TVIF) onlay and tubularized incised-plate (TIP) urethroplasties for primary proximal hypospadias.

Materials and Methods

A comprehensive literature search updated to 21^st May 2014 was carried out for relevant studies. After literature identification and data extraction, odds ratio (OR) with 95% confidential interval (CI) was calculated to compare postoperative complication rate between TVIF onlay and TIP. Meta-regression and subgroup analyses were applied to find potential affective factors.

Results

A total of 6 studies including 309 patients receiving TVIF onlay and 262 individuals subjected to TIP met inclusion criteria. The synthetic data suggested that TVIF onlay and TIP were comparable in terms of total complication rate (OR 0.85, 95% CI 0.56–1.30, p = 0.461), fistula (OR 0.68, 95% CI 0.38–1.21, p = 0.194), recurrent curvature (OR 1.16, 95% CI 0.43–3.12, p = 0.766), dehiscence (OR 0.95, 95% CI 0.33–2.74, p = 0.920), diverticulum (OR 1.90, 95% CI 0.53–6.78, p = 0.321), meatal stenosis (OR 0.74, 95% CI 0.20–2.77, p = 0.651) and urethral stricture (OR 1.49, 95% CI 0.41–5.50, p = 0.545), without significant heterogeneity for each comparison group. Meta-regression and subgroup analyses revealed no significant findings. One-way sensitivity analysis indicated that the results were stable. No publication bias was detected using both funnel plot and Egger’s test. Also, there were no obvious differences observed in cosmetic and functional outcomes.

Conclusions

This meta-analysis suggests that TVIF onlay and TIP urethroplasties are clinically equivalent. Given the inherent limitations of included studies, this conclusion should be interpreted with caution and wait to be confirmed by more well-designed randomized controlled trials with high quality in the future.

Foreskin retractility following hypospadias repair with preputioplasty--medium term outcomes

AIM

To assess the medium term outcome of hypospadias repair and preputioplasty with regard to foreskin retractility, and whether this could be predicted by assessing retractility at the end of the operation.

MATERIALS AND METHODS

The data were obtained from a prospectively maintained database regarding patients who had hypospadias repair with preputioplasty between January 2003 and June 2010. The foreskin retractility at the end of the operation was documented in the operation notes, and the latest foreskin status was obtained from clinical notes or by contacting parents.

RESULTS

The total number was 207, and 170 (82.1%) had distal hypospadias. At the latest follow up at a median of 2 years and 3 months after the date of operation (range 13 months to 4 years 7 months), 159 boys (76.8%) had a retractile foreskin, 27 (13%) were under observation for a tight foreskin, and 8 (3.9%) had undergone circumcision due to tightness. The foreskin was retractile at the end of the operation in 154 (73.3%) patients. Of these, 130 (84%) had a retractile foreskin at the later follow-up clinic. Of the 49 patients who had a non-retractile foreskin at the end of the operation, 29 went on to have a retractile foreskin, while 20 had a tight foreskin. Fisher's exact test showed that foreskin retractility at the end of the operation has a significant relation to foreskin retractility in the medium term, and that patients with distal hypospadias have a greater probability of achieving a retractile foreskin.

CONCLUSION

A primarily retractile foreskin can be achieved in over 75% with less than 4% requiring a circumcision due to tightness. Distal location of hypospadias and retractility at the end of operation predicted success.

Foreskin reconstruction does not increase urethroplasty or skin complications after distal TIP hypospadias repair

AIM

To compare urethral and skin complications between consecutive patients undergoing distal TIP (tubularized incised plate) hypospadias repair with prepucioplasty versus circumcision.

METHODS

Prospective case-cohort study comparing urethroplasty and skin complications between consecutive patients undergoing distal TIP with prepucioplasty versus circumcision. Those with <1 month follow-up or prior circumcision were excluded. Decision for prepucioplasty or circumcision was made exclusively by caregivers. Operative technique was the same except skin closure. Postoperative foreskin retraction was deferred ≥6 weeks after prepucioplasty.

RESULTS

Of 343 circumcision and 85 prepucioplasty cases, median age and follow-up were 8 (3-420) and 7 (1.5-97.5) months, respectively. Urethroplasty complications occurred in 30 (8.7%) circumcision patients [16 fistulas, 13 glans dehiscences, 1 meatal stenosis due to balanitis xerotic obliterans (BXO) 5 years postoperatively], versus 7 (8.0%) after prepucioplasty [4 fistulas, 2 glans dehiscences, 1 urethral stricture], p = 1.0. Skin complications resulting in reoperation occurred in 7 (2.0%) circumcision patients and 2 (2.3%) prepucioplasty patients, including an unsightly dorsal whorl in 1 and BXO 66 months postoperatively in another, p = 1.0.

CONCLUSION

Prepucioplasty does not increase urethroplasty or skin complications after distal TIP hypospadias repair. We found no contraindication for prepucioplasty among consecutive patients, indicating hypospadiologists can manage the foreskin in distal repairs according to caregiver preference.

Medium to long term results following single stage Snodgrass hypospadias repair

INTRODUCTION

The Snodgrass technique for primary hypospadias repair was described in 1994 and involves dorsal incision and tubularisation of the urethral plate distal to the meatus. While the advantages of good short-term outcome and good cosmesis have been reported, there is little data on long-term results in patients who have undergone a Snodgrass repair as a primary procedure for hypospadias. Our aim is to retrospectively review our medium to long-term results of primary tubularised incised-plate urethroplasty for hypospadias repair over a two-year period with up to eight-year follow-up.

PATIENTS AND METHODS

We conducted a case note review of 74 patients who had undergone single-stage Snodgrass hypospadias repair, performed by a single surgeon (AB), from April 2000 to January 2003.

RESULTS

The mean documented follow up was 56 months (3-103 months). The mean age of patients at time of surgery was three and a half years. 95% (70) of patients had a distal (glanular, coronal, sub-coronal, distal shaft) meatus and 5% (4) had a proximal (mid-shaft) meatus. The overall complication rate was 7% (5). Two patients developed fistulae, which was noted and repaired at six months post-op with no further surgical intervention required. One patient underwent an EUA and meatal advancement glansplasty at 6 months for mild glanular dehiscence. Two further patients required EUA and dilatation procedures at two and three years respectively, both for mild meatal stenosis. Again, no further intervention was required. From a cosmetic perspective, two patients were noted to have some residual bulkiness of the skin around the corona and a further two patients were noted to have a small meatus, but with no functional symptoms.

CONCLUSION

Our study has shown a low long-term complication rate in patients undergoing Snodgrass repair as a primary procedure for distal and midshaft hypospadias repair. This supports the results of earlier studies that have shown good functional and cosmetic outcome in the short-term for this procedure which persists into the medium/long term.

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

Purpose:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

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

PURPOSE

We compared complication rates, urinary symptoms and cosmetic outcomes as perceived by parents of patients undergoing 1 of 4 repairs for proximal hypospadias associated with ventral curvature.

MATERIALS AND METHODS

A total of 93 patients underwent hypospadias repair between 2004 and 2010. In patients requiring no urethral plate transection the repair consisted of tubularized incised plate urethroplasty (26 patients) or onlay island flap urethroplasty (31). In patients requiring urethral plate transection the repair consisted of onlay island flap on albuginea (18 patients) or 2-stage repair (18). Complications were assessed by chart review. A customized questionnaire and the Pediatric Penile Perception Score were administered to parents to evaluate their perception of urinary symptoms and cosmetic outcomes, respectively.

RESULTS

After a median followup of 4.5 years (range 2.2 to 8.4) complications developed in 21 patients (23%) without any difference among procedures or between patients who did and did not require urethral plate transection. Parents of 75 patients (80%) participated in the survey without differences among repairs (p = 0.35). Reported urinary symptoms were not different among repairs. For Pediatric Penile Perception Score the only difference concerned the question about penile length (p = 0.03), with the score being significantly better for the techniques requiring urethral plate transection (p = 0.05). The 2-stage repair had a significantly better score for the question about penile length and overall Pediatric Penile Perception Score than all other techniques.

CONCLUSIONS

Overall complication rates were comparable among repairs and did not increase after urethral plate transection. Urinary symptoms as reported by parents were comparable among the procedures. Perceived penile length was significantly better after urethral plate transection. The 2-stage repair yielded the best cosmetic results.

How do asymptomatic toilet-trained children void following tubularized incised-plate hypospadias repair?

PURPOSE

: To evaluate the functional outcome in the form of urinary flow rates in asymptomatic children following uncomplicated tubularized incised plate urethroplasty (TIPU) hypospadias repair.

METHODS

: We reviewed the records of children who underwent TIPU at our institution between April 1997 and September 2007 and included only asymptomatic toilet-trained children who had an uncomplicated postoperative course and had undergone uroflometry not less than 1 year postoperatively. Unfavourable voiding parameters were either a plateau curve, a peak flow below the 5th percentile range in nomogram or a post-void residual (PVR) more than 20% of the total functional capacity of the bladder. Uroflowmetry findings were analyzed against variables, including the surgeon, the severity of hypospadias, the presence of a hypoplastic urethra, the use of double layer closure, the performance of a spongioplasty and the use of a stent. Serial uroflowmetries, when available, were compared with respect to the initial flow study.

RESULTS

: In total, 59 patients were eligible for the study. The mean age at surgery was 2.4 years. Hypospadias was distal penile in 50 (85%) and mid and proximal penile in 9 (15%). Mean follow-up was 3.3±2 (1-9.5) years. The uroflow curve was bell-shaped in 18 (30%), interrupted in 8 (14%), slightly flattened in 27 (46%) and plateau in 6 (10%). Flow rate nomograms revealed that 40 (68%) were above the 20th percentile, 10 (17%) were below the 5th percentile and 9 (15%) were between these ranges. PVR was >20% of the pre-void volume in 9 children (15%). No patient demonstrated all three unfavourable parameters together. The groups of children with unfavourable functional voiding parameters were compared to the children with favourable parameters specifically with respect to the possible predictors of outcome. Follow-up uroflometry in 17 patients showed improvement in the flow curve, flow rate and PVR with significant improvement of maximum urinary flow rate (Qmax) and PVR values.

CONCLUSIONS

: Asymptomatic, urodynamic abnormalities were observed in our study following uncomplicated TIPU repair. These abnormalities were not related to the variation of the technique among surgeons. Spontaneous improvement has been noted on serial flow studies.

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

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

Hypospadias repair with tubularized incised plate: Does the obstructive flow pattern resolve spontaneously?

OBJECTIVE

The aim of this prospective study was to evaluate whether urinary flow improves with time after tubularized incised plate (TIP) repair.

PATIENTS AND METHOD

Between 1999 and 2003, primary TIP was performed in 126 boys. In patients old enough (48 boys, mean age at surgery 46 months, range 18-103), uroflowmetry was performed 1 year and 7 (median, range 3-10) years post surgery. Miskolc nomograms were used to compare results from the two follow ups (Q(max) in relation to voided volume and age).

RESULTS

Eleven boys had symptoms of obstruction resulting in intervention. For the other 37 boys, the mean Q(max) was 13.6 ± 5.6 ml/s 1 year postoperatively (mean voided volume 107 ± 43 ml) and 49% had flows below the 5th percentile. Seven years postoperatively the mean Q(max) was 19.0 ± 8.1 ml/s (mean voided volume 235 ± 112 ml) and 32% had flows below the 5th percentile. In the group with flows below the 5th percentile at 1 year, all improved and 28% improved to above the 25th percentile. Proximal hypospadias was more often associated with obstructive flow than distal (75%/75% compared to 43%/21% 1/7 years postoperatively).

CONCLUSION

We found spontaneous improvement (P = 0.00022) 7 years after TIP repair, although many boys still had a Q(max) in the low normal or obstructive range.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

To evaluate urinary function in patients with distal hypospadias undergoing repair by the tubularized incised-plate urethroplasty (TIP or Snodgrass), compare the results with those in patients treated by the Mathieu technique, and show the potential issues inherent to the evaluation of such results.

PATIENTS AND METHODS

A cross-sectional assessment was performed of uncomplicated distal hypospadias operated on during a 3-year period, already toilet trained, and able to void volitionally. Evaluation included clinical assessment urinary symptoms and urinary stream, and uroflowmetry.

RESULTS

Out of 83 patients operated on during the study period, 10 (12%) developed complication and 32 were not toilet trained or refused to participate in the study. Median follow-up in the remaining 41 patients included in the study was 20 (3-36) months. None of these patients presented voiding symptoms or urinary stream abnormalities. Uroflowmetry was normal in 30 cases and obstructive in 11 (27%). An obstructive flow pattern was more common in patients undergoing TIP versus Mathieu repair, 8 of 19 (42%) versus 3 of 22 (14%), respectively (P = 0.07). Four TIP cases with an obstructive uroflow pattern were managed conservatively.

CONCLUSIONS

Although both the TIP and the Mathieu repair allow good results in terms of urinary function after distal hypospadias repairs, the TIP technique seems more likely to be associated with urine flow pattern abnormalities. The actual clinical relevance of this finding remains ill defined.

Outcome of pediatric hypospadias repair in adulthood

PURPOSE

To review the evolution of the technique of hypospadias repair.

METHODS

A search of Pubmed, Medline and the Journal of Pediatric Urology was performed, and papers dealing with surgical techniques for hypospadias repair were critally reviewed. Special emphasis was given to papers on the effects in the long term of hypospadias repair on voiding and sexual dysfunction.

RESULTS

The techniques for hypospadias repair have evolved over the years. The most popular technique now is tubularized incised plate urethroplasty. Long-term results with the use of the new techniques of the hypospadias repair in terms of voiding and sexual problems should be addressed.

CONCLUSION

There is a need for valid studies on the outcomes of hypospadias repair in adults that were performed in childhood in terms of cosmetic appearance, voiding and sexual performance.

Comparative Analysis of Tubularized Incised Plate Versus Onlay Island Flap Urethroplasty for Penoscrotal Hypospadias

PURPOSE

Despite being the dominant technique for repair of distal hypospadias, application of the tubularized incised plate approach for penoscrotal hypospadias remains controversial. We report our experience with severe hypospadias, comparing tubularized incised plate to transverse island flap onlay urethroplasty.

MATERIALS AND METHODS

We retrospectively reviewed consecutive patients with penoscrotal hypospadias presenting between 1998 and 2006. Based on surgeon preference 35 children underwent tubularized incised plate and 40 underwent onlay urethroplasty. Penoscrotal transposition and degree of ventral curvature, type of ventral curvature repair, complication rate, postoperative uroflowmetry pattern in toilet trained patients and number of reoperations were compared between the 2 groups.

RESULTS

Mean patient age at surgery was 17 months (range 9 to 91) for tubularized incised plate urethroplasty and 17.8 months (10 to 58) for the onlay procedure. Urethroplasty was performed over an 8Fr catheter in all patients. With mean followups of 30 months (range 6 to 74) and 38.8 months (16 to 80) the overall complication rates were 60% and 45% for the tubularized incised plate and onlay procedures, respectively. Fistula occurred in 15 patients and repair breakdown in 3 patients (total 51.4%) treated with tubularized incised plate repair, compared to 8 and 2 patients, respectively (25%), treated with onlay repair (p = 0.01). Fistula location also differed significantly between the 2 groups, with proximal fistulas occurring in 11 of 15 tubularized incised plate repairs (73.3%) vs 2 of 8 onlay repairs (25%, p = 0.02). Recurrent ventral curvature was more frequent after onlay urethroplasty (5.7% vs 12.5%, not significant). At a mean age of 5.1 years a plateau uroflow curve (vs normal bell curve) was observed in 16 of 24 children (66.7%) who underwent tubularized incised plate repair and in 7 of 21 (33.3%) who underwent onlay repair (p <0.01).

CONCLUSIONS

In this series the overall complication rate was similar for tubularized incised plate and onlay urethroplasty. Despite similar urethroplasty calibers, the uroflow curves and fistula positions in patients undergoing tubularized incised plate repair suggest that the neourethra distal to the fistula may be relatively narrow, creating flow resistance and leading to proximal fistula. Longer followup and close monitoring are needed before embracing one approach over the other.

Split prepuce in situ onlay hypospadias repair: 17 years of experience

PURPOSE

We report our 17-year experience using split prepuce in situ onlay hypospadias repair, including long-term followup of the first 100 patients initially reported on in 1998.

MATERIALS AND METHODS

We identified 421 patients who underwent in situ onlay repair. Charts were retrospectively reviewed to determine preoperative management, intraoperative details and complications.

RESULTS

In situ onlay repair was used to repair glanular hypospadias in 22 cases (5.2%), coronal hypospadias in 184 (43.7%), distal shaft hypospadias in 152 (36.1%), mid shaft hypospadias in 51 (12.1%), proximal shaft hypospadias in 7 (1.6%) and hypospadias in the penoscrotal region in 5 (1.2%). Repair was successful with 1 procedure in 376 patients (89.4%), which increased to 99.8% after a second procedure. Complications were defined as any problem that gave the surgeon or family reason for concern. Functional complications requiring reoperation occurred in 45 patients (10.6%). Minor complications requiring simple procedures or early postoperative evaluation occurred in 17 patients (4%). Concerns not requiring intervention occurred in 27 patients (6.4%). There were no urethral strictures. Three patients (0.7%) were lost to followup. Repair is pending in 1 patient.

CONCLUSIONS

In situ onlay repair preserves the urethral plate and allows the formation of a well vascularized flap with adequate tissue to completely cover the neourethra, resulting in a low rate of major complications. With longer followup, inclusion of more mid shaft repairs and expansion to more proximal degrees of hypospadias our complication rates are higher than previously reported but there have been no urethral strictures in 17 years of experience. Since complications present at a median of 158 days (mean 570) after the procedure, long-term followup is indicated.