Original Koyanagi urethroplasty versus modified Hayashi technique: outcome in 57 patients

Repair of the Bulbospongiosus Muscle to Suspend the Penis to the Pubic Bones in Proximal Hypospadias

BACKGROUND

In proximal hypospadias, ventral curvature is invariable and most have penoscrotal transposition, and we observed that the base of the penis (BOP) was located on the inferior aspect of the pubic bones in those, in contrast to the location of the BOP at the anterior end in normal penises. We also observed an unfused bulbospongiosus muscle (BSM) at surgery in those. The aim was to assess the impact of repairing the unfused BSM or transection and straightening of the urethral plate at the first operation on the low BOP.

METHOD

All consecutive proximal hypospadias operations from January 2021 to August 2023 that had a low BOP were retrospectively studied. At the first operation, some had urethral plate transection only, with no BSM repair. Some had BSM repair with or without plate transection. The BOP position was reassessed post-intervention.

RESULTS

Thirty-three cases of proximal hypospadias with low BOP were studied. At the first operation, as the key distinguishing step, 18 had BSM repair and 15 urethral plate transections. BOP shifted to the anterior end of the pubic bones in all 18 patients following BSM repair but showed no change in the 15 without BSM repair (p < 0.01). Subsequent BSM repair, during the second stage, normalized BOP in those 15. Normalising the BOP corrected penoscrotal transposition because the anterior end of the scrotum was at the anterior end of the pubic bones.

CONCLUSION

Repairing BSM is essential for normalising the BOP, which results in a normal penoscrotal relationship and normal anterior penile projection.

LEVEL OF EVIDENCE

IV.

Preoperative hormone therapy in single-stage repair of hypospadias: A comprehensive systematic review

INTRODUCTION

Preoperative hormone therapy (PHT) holds promise for obtaining better surgical conditions for patients undergoing hypospadias correction and increasing the success rate. However, the application and effects of PHT remain uncertain owing to a lack of comprehensive evaluation, thus limiting treatment strategies and development of standardized guidelines. This study aimed to review the following (ⅰ) the criteria and regimens of PHT (ⅱ) its impact on penile growth, postoperative complications, and side effects (ⅲ) and sources of inconsistent clinical outcomes.

METHODS

This systematic review was registered at PROSPERO (CRD42022346924) and conducted and reported following international recommendations, including the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We searched the databases over the last two decades to identify eligible studies. This systematic review included literature regarding the use of PHT in the treatment of children with single stage hypospadias repair. Risk of Bias (RoB) was measured using two different tools: randomized controlled trials using a modified version of the RoB Assessment Tool and non-randomized studies of interventions using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I). The R-3.6.3 software was used for the analysis.

RESULTS

In total, 25 studies involving 4094 patients were included in the systematic review. The surgeons' criteria for using PHT varied, with short penile length being the most important. The most frequently reported regimens for intramuscular (IM) testosterone were either 2 mg/kg or empiric 25 mg monthly, and the duration was 2-3 months preoperatively. Androgens were significantly effective in improving penile development, and the changes commonly peaked at 2-3 months. The effects of PHT on complications and side effects are controversial, and the potential causes include hormone sensitivity, degree of hypospadias, surgical techniques, and dosing regimens.

CONCLUSIONS

This systematic review evaluated PHT in children with hypospadias. Building on previous studies, this review provides a more specific attitude and possible aspects for resolving the controversies. Future studies should identify the applicable subgroups of patients and standardize the dose and mode of delivery for the best clinical results.

Effect of Preoperative Androgen Stimulation on Penile Size and Postoperative Complication Rate in Patients with Hypospadias: A Systematic Review and Meta-analysis

PURPOSE

To systematically review and evaluate the beneficial effects of preoperative androgen stimulation (PAS) on penile length, glans width, and postoperative complications in patients with hypospadias using meta-analysis.

MATERIALS AND METHODS

A comprehensive search of the published literature between 1980 and 2022 was done on PubMed, Embase, Google Scholar, Scopus, Web of Science, and Proquest. Studies of patients with 5-alpha reductase deficiency, differentiation sex disorder, or micro-penis without hypospadias were excluded. The full-text screening, quality assessment, and data acquisition were done independently by two reviewers. Meta-analysis was done to quantify the penile growth and postoperative complications.

RESULTS

The initial literature search yielded 2,389 records, wherein 32 studies were eligible for the systematic review and meta-analysis. Preoperative testosterone stimulation increased the penile length and glans width by 9.34 mm (95% CI: 6.71-11.97) and 3.26 mm (95% CI: 2.50-4.02), respectively. A longer penis at the baseline led to greater length gain following treatment (1 mm longer at the baseline was likely to gain 0.5 mm more). However, the increase in penile length was not associated with the severity of hypospadias. While the treatment did not affect the overall complication rate, the postoperative fistula risk was lower in those receiving PAS (RR=0.52, 95% CI: 0.30-0.91, p=0.02).

CONCLUSIONS

The beneficial effects of PAS on increasing the penile length and glans width were again confirmed. More gain of penile length was expected in the larger penis at baseline. There are no reported increased postoperative complications in association with PAS.

Complication rates of proximal hypospadias: meta-analyses of four surgical repairs

INTRODUCTION

Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques.

METHODS

The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included.

RESULTS

Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin.

DISCUSSION

The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short.

CONCLUSION

This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.

Results of the one-stage proximal hypospadias repair with modified Koyanagi technique: A prospective cohort study in a single Vietnam centre

Introduction

Proximal hypospadias is the most severe type of hypospadias. Our approach to Koyanagi technique for proximal hypospadias aims to improve the blood supply to the neourethral flaps and reduce meatal complications.

Methods

Our prospective study included 75 patients who were operated for proximal hypospadias by our Koyanagi technique at Viet Duc hospital between January 2019 and December 2020. The clinical information obtained included a detailed medical history; preoperative, intraoperative, and postoperative data; short-term outcomes by the HOSE score were evaluated by a different physician.

Results

The mean (range) age was 3.59 ± 2.41 years (1.5–14), 86.7% under 5 years old. There are 31 penoscrotal, 31 scrotal, and 13 perineal hypospadias. The length of the neourethra ranged from 3.5 to 8 cm, mean 5.02 ± 0.88 cm. Evaluation of the surgeon at 6 months after surgery: primary success 81.3%. Complications occurred in 14 cases (18.7%), included 10 urethrocutaneous fistula and 4 dehiscence of the urethra. No cases of meatal stenosis or recession, urethral stricture, urethral diverticula. The mean HOSE score was found to be 14.47 ± 1.35, ranged 11 to 16. 57 patients (76%) had a total HOSE 14 and above and 18 patients had score below 14 (24%)

Conclusion

Our modified Koyanagi technique give us a good result for one-stage reconstruction of proximal hypospadias. Applying the HOSE score makes postoperative evaluation of hypospadias more objective and reliable.

•

Proximal hypospadias is one of the most challenging conditions.

•

Modified Koyanagi techniques improve the blood supply to the neourethral flaps.

•

The HOSE score is an objective appraisal of the outcome of hypospadias repair.

Koyanagi urethroplasty for proximal hypospadias: A stage procedure?

OBJECTIVE

To report experience and technical refinements with the Koyanagi urethroplasty for proximal hypospadias.

METHODS

A retrospective study was conducted between 2004 and 2017. Medical records of patients treated by the Koyanagi technique were investigated. The penile ventral skin was closed either with a Byars flap or using an "Ombredanne's chasuble" (OC). The cohort was divided chronologically into two groups of the same number of patients (early -E- and late experience group-LEG-). Demographics, anatomical findings and surgical outcomes were compared between groups using univariate analysis. A logistic regression was performed to assess factors associated with the occurrence of a postoperative urethrocutaneous fistula or urethroplasty dehiscence (UD).

RESULTS

The Koyanagi urethroplasty was performed in 67 patients, 33 in the EEG and 34 in the LEG. The overall surgical complication rate was 64.2% (n=43), including 42 fistula or UD, higher in the EEG (81.8%) than in the LEG (44.1%, P<0.01). However, in the LEG, patients underwent the surgery older and the use of OC more frequent. After multivariate analyses, factors associated with a postoperative fistula or UD were the year of surgery (OR=0.71 [0.53-0.96] P=0.02), the age at surgery (OR=1.11 [1.01-1.22], P=0.03); contrary to the skin coverage method or the stenting duration (P>0.05). An urethral stenosis occurred in 1 patient (1.5%). At last follow-up, 64.2% of patients required a further procedure and 80.6% of urethral meatus were glandular.

CONCLUSION

In this study the complication rate, particularly the urethrocutaneous fistula, remained high. Urethral stenosis, were rare but the follow-up was too short to clearly identified them. Considering as a 2 stage procedure koyanagi uretroplasty allows to obtain finally good results.

LEVEL OF EVIDENCE

III.

Single-stage versus staged interposition urethroplasty for glandular hypospadias with severe penile curvature: 15-year experience

Purpose

Our study examined the benefit of an alternative interposition urethroplasty (IU) procedure for glandular hypospadias (GH) with severe penile curvature (SPC). The technique involved transecting and reconstructing the urethra to preserve the distal glandular and coronal urethra and correct the curvature. We compared procedural characteristics, outcomes, and surgical complications for the single-stage and staged IU techniques.

Methods

We retrospectively studied 44 patients with GH with SPC who underwent single-stage or staged IU between March 2005 and June 2020. Demographics, operative details, complications, and uroflometry findings were analyzed.

Results

The median age at initial surgery was 37.5 months. Ten patients underwent single-stage IU repair, and 34 patients underwent staged IU repair. The median length of the interposition neourethra was 3.2 cm (2.2–4.3). The median follow-up duration was 58 months, and the overall complication rate was 13.6%. Complications were noted in 30% (3/10) and 8.8% (3/34) of patients in the single-stage and staged IU groups, respectively (p > 0.05). Fistula formation was noted in one and three patients in the single-stage and staged groups, respectively (8.8% vs. 10%, p > 0.05). Two cases of urethral stricture were documented in the single-stage group only. No chordee recurrence or urethral diverticula was noted in any of the patients.

Conclusion

IU is a reliable and durable technique for GH with SPC. It avoided penile shortening, preserved the distal urethra, and reduced the risk of chordee recurrence. The staged IU technique had more superior outcomes compared to the single-stage IU technique.

Koyanagi- Snow-Hayashi Urethroplasty in Severe Hypospadias Repair: Between Hope and Reality

OBJECTIVE

To present the results of Koyanagi-Snow-Hayashi urethroplasty in severe hypospadias repair.

METHODS

From June 2015 to December 2019, 43 patients with severe hypospadias associated with curvature underwent Koyanagi- Snow-Hayashi urethroplasty. All patients were treated for the first time and by a single surgeon. Thirty-five patients included in this study presented a form of disorders of sex development. The age of the patients at surgery varied from 12 to 120 months (mean age 21 months ± 6 months). The median follow-up was 28 months (range, 5-65 months).

RESULTS

Functional and esthetic results were satisfactory with a straight and excellent appearance of the penis, without any complications in only ten patients (23%). While 30 of 43 patients (70 %) required additional procedures. Postoperative complications encountered in our patients were dominated by fistulas which were found in 17 of 43 patients (39.5%). Among them, 3 fistulas appeared in the penile shaft between 11 and 28 days and disappeared spontaneously. While proximal fistulas have been required surgical repair. Diverticulum seemed to be a significant complication of this technique, it was found in 4 of 43 (9%). This study also revealed the presence of a peculiar complication for this procedure, urethral meatus in the shape of fish lips.

CONCLUSION

The use of Koyanagi-Snow-Hayashi urethroplasty in severe hypospadias repair gives a complete penile straightening in all cases. However, Despite the modifications added by Snow and Hayashi to Koyanagi urethroplasty to improve the vascular supply of the flap, the rate of complications encountered with this technique remains high.

Two simple modifications can potentially change the future of proximal hypospadias surgery. Our series and a review of the literature

Background/Objective

To draw a hint towards two simple modifications that could potentially decrease the complication rate.

Patients and Methods

It was a single center, single operator and retrospective study. All patients with severe hypospadias operated according to koyanagi with or without modifications were presented. The surgical technique was described. Complications like fistula, stenosis, dehiscence and urethral diverticulum were studied.

Results and Limitations

Nineteen patients were included and presented in a chronological manner. The first four patients were operated according to the original koyanagi technique. The next 15 patients were operated according to koyanagi and the urethroplasty was covered by a tunica vaginalis flap. In 10 of them, glanduloplasty was done primarily and in the last 5 patients, glanduloplasty was done as a secondary procedure. The complication rates were 100% in the original koyanagi group, and 0% in the subset were glanduoplasty was deferred.

Conclusions

Systematically covering the urethroplasty with a tunica vaginalis flap and deferring the glanuloplasty might ameliorate the results of the koyanagi technique.

Perineal hypospadias: back to the future Chordee Excision & Distal Urethroplasty

PURPOSE

Perineal hypospadias correction has swung from two-stage repair in the 1960s to one-stage repair in the 1980s and back to two-stage repair in the 2000s. The author's experience with a technique in which Chordee Excision and Distal Urethroplasty (CEDU) was performed at the first operation leaving a 1-cm segment as perineal urethrotomy to be reconstructed at the second operation is presented.

PATIENTS AND METHODS

Between January 2013 and December 2016, the CEDU technique was performed in 63 patients with perineal hypospadias. The records of 59 patients who maintained regular follow-up were reviewed. The principle is to excise the hypoplastic urethral plate, atretic corpus spongiosum, and longitudinal layer of tunica albuginea; split the glans in the midline; and reconstruct a healthy urethral plate using preputial and lateral skin flaps to the tip of the glans. Distal urethroplasty was performed leaving 1 cm at the proximal end to be reconstructed 3-6 months later. This principle was used by Duplay in the 1880s. Patient age ranged between 6 months and 2 years (mean 8 months). All the patients had perineal hypospadias and bifid scrotum with severe deep chordee. Follow-up period ranged from 17 to 53 months (mean 36). A transurethral Silastic catheter was inserted for 4 days. Three months later, the remaining 1 cm of the new urethra was reconstructed, and final adjustment of the glans and foreskin was performed.

RESULTS

Satisfactory results were obtained in 54 patients (90%). Three children experienced glans dehiscence that was corrected in the second stage, one child developed fistula after the second operation, and one developed diverticulum. The fistula and diverticulum were corrected at the third operation successfully.

DISCUSSION

It was necessary in this series to divide the urethral plate and excise the hypoplastic corpus spongiosum and the outer longitudinal layer of tunica albuginea to correct the associated deep chordee. The lateral skin flaps receive double blood supply from the base of the penis and the preputial vessels. This natural urinary diversion allows early removal of the catheter, reduces the discomfort of the patient, and allows the new urethra to heal without urine irritation for 3 months. Long-term follow-up for 15 years is necessary to assess the technique objectively.

CONCLUSIONS

The CEDU technique diverts urine away from the site of urethroplasty for 3 months without a catheter. It reduces the hospital stay and patient discomfort. It produces satisfactory results and has become a the standard technique in perineal hypospadias.

Preoperative hormonal stimulation effect on hypospadias repair complications: Meta-analysis of observational versus randomized controlled studies

INTRODUCTION

Preoperative hormonal stimulation (PHS) is commonly administered to improve hypospadias outcomes. However, current literature provides no clear evidence to support its use, and controversies exist regarding its effect on postoperative complications. Herein we systematically evaluate the effect of PHS on postoperative complications rates following hypospadias repair.

MATERIALS AND METHODS

Comprehensive literature search performed on April 2016 including OVID MEDLINE, EMBASE, Web of Science, Cochrane Library, Clinicaltrials.gov, World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and ProQuest. Study quality assessment followed the Cochrane collaboration recommendation using risk of bias assessment, ROBINS-I and NOQAS. Effect estimates were extracted as relative risk (RR) with 95% confidence interval (CI) and pooled using Mantel-Haenzel method. Evidence quality was assessed using GRADE approach. Protocol Registration: PROSPERO CRD42016037881.

RESULTS

Twenty-one publications from 16 trials examining the effect of androgenic PHS on postoperative outcome were included. Subgroup analysis based on study design (including nine cohort studies with moderate to high risk of bias for patient selection) showed no significant difference on postoperative outcomes (RR 1.31, 95% CI 0.95-1.81) (table). Pooled effect estimates with moderate quality of evidence from three randomized controlled trials suggest that significant lesser postoperative complications occur among patients exposed to PHS (RR 0.36, 95% CI 0.20-0.65). Uniformly, the reported adverse effects related to PHS were mild and transient, with good overall tolerance.

CONCLUSIONS

Effect estimates generated from the better quality of evidence showed that PHS may decrease postoperative complications following hypospadias repair. Future studies should aim at identifying indicated subgroup of patients that will benefit from it and standardizing the dose and mode of delivery for best clinical result.

Neo-yoke repair for severe hypospadias: A simple modification for better outcome

BACKGROUND

Although staged repair for reconstructing severe hypospadias is more popular, various one-stage repairs have been attempted. Koyanagi repair (parameatal-based and fully extended circumferential foreskin flap urethroplasty) has enabled correction of severe hypospadias in one stage. However, its un-acceptably high incidence of complications has initiated a series of technical modifications, including the "yoke" repair.

OBJECTIVES

To retrospectively analyze the outcome of a proposed modification of the originally described yoke repair, for patients with severe hypospadias. This modification was developed to reduce complications.

STUDY DESIGN

Over 4 years (between Jan 2011 and Jan 2015), all cases of severe hypospadias were included in this study; except those with prior attempts at repair, circumcised cases, and cases with severe hypogonadism - because of partial androgen insensitivity - not responding to hormonal manipulations. The make-up of the neo-urethra in this modification is the urethral plate with its spongiosal tissue proximally, a circum-coronal preputial pedicled flap in the middle, and an incorporated part of the augmented preputial flap and the preserved V-shaped glanular urethra, distally. Close postoperative follow-up was conducted to investigate the outcome.

RESULTS

Thirty-one children with a median age of 32.48 months had repair of severe hypospadias using the neo-yoke technique. After a median follow-up of 26.7 months, the overall complication rate was 16.1%. Four children developed urethrocutaneous fistula (12.9%). Meatal drop-back occurred in one case (3.2%). No meatal stenosis or urethral sacculation was detected during follow-up of the studied group. Almost all cases had cosmetically appealing outlook. Single-staged repair of severe hypospadias using parameatal foreskin-based urethroplasty has passed through different modifications, all aimed at optimizing the outcome (Table).

CONCLUSION

Neo-yoke repair for severe hypospadias is a natural development of established one-stage techniques, which resulted in better mid-term outcomes. However, an extended study is needed to declare the long-term results.

Can separation of the scrotal sac in proximal hypospadias reliably predict the need for urethral plate transection?

INTRODUCTION

One of the main challenges in proximal hypospadias repair is correcting curvature. The best technique to achieve this remains the object of debate. Indeed, some authors believe the urethral plate should be kept and used as often as possible. In some cases, however, even after extensive mobilization and dorsal plication, significant curvature remains and it is necessary to transect the urethral plate. Having a reliable pre-dissection marker of the need for urethral transection would be useful in choosing a technique.We wanted to determine if presence of marked separation of the scrotal sac (SSS), also referred to as bifid scrotum, could reliably predict the need for urethral plate transection.

STUDY DESIGN

We prospectively enrolled a series of boys with proximal hypospadias. We noted age, degree of hypospadias, meatal position, presence of cryptorchidism, and presence or absence of SSS. During surgery we fully degloved the penile shaft, freeing all ventral tissues, and radically dissected the more proximal bulbar urethra. We then performed an erection test. If there was residual curvature <30° we performed a dorsal plication, if it was >30° we transected the urethral plate.

RESULTS

Twenty-nine patients were included, of whom 18 presented SSS. The average age was comparable in both groups, as was type of hypospadias and meatal position. We estimated transection of the urethral plate to be necessary in 15 out of the 18 children with SSS, and 2 out of the 11 children without SSS. The relative risk for requiring urethral plate transection in case of SSS in this series was 4.58.

CONCLUSION

Techniques that commit to urethral plate transection are criticized because they preclude using the urethral plate. In our study presence of SSS was predictive for the need to transect the plate. Obviously one can decide to keep the urethral plate at all cost, and mobilize it more than we did, or accept more residual curvature, but in reality our aim was to determine a preoperative marker allowing us to define a patient category. We believe presence of SSS is a marker of severity, and that this "severity" translates into "a less usable urethra". As recent studies caution us about the evolution of the reconstructed native urethra and the possibility that it may not grow as well as the other penile tissues, we believe this extra information could influence the surgeon's decision as to the most appropriate technique for each patient.

A New Modification of the Koyanagi Technique for the One-stage Repair of Severe Hypospadias

OBJECTIVE

To describe a new modification of the Koyanagi technique for the one-stage repair of severe hypospadias and its short-term outcomes.

PATIENTS AND METHODS

Our modified Koyanagi technique was performed in 24 patients with severe hypospadias between February 2012 and January 2015. The age of the patients ranged from 1.9 to 11.9 years (mean = 3.5 years). The flap design was similar to the Koyanagi technique, but our modified technique highlighted the following points: after the chordee was completely corrected, the urethral plate was recreated using foreskin, and then a U-shaped incision was made on the original and recreated urethral plate (as in the Duplay technique); a pedicled flap of the tunica vaginalis or scrotal dartos was used for additional coverage of the neourethra.

RESULTS

The operation time lasted from 120 to 150 minutes (mean = 140 minutes). There were 5 patients (20.8%) who developed complications: 4 patients (16.7%) developed a fistula and 1 patient (4.2%) developed dehiscence of the urethra. There were no reported urethral strictures, meatal stenosis, or urethral diverticula. The complications in the 5 patients were successfully addressed with secondary repair, and all patients achieved satisfactory cosmetic and urethral functional results.

CONCLUSION

The modified Koyanagi technique simplified the operation and better preserved the blood supply to the flap. The additional coverage of the neourethra using a pedicled flap of the tunica vaginalis or scrotal dartos significantly decreased the rate of fistula formation. This technique is highly suitable for the one-stage repair of severe hypospadias with penoscrotal transposition.

The contemporary role of 1 vs. 2-stage repair for proximal hypospadias

This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved-a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and-depending on technique-have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.

The influence of pre-operative hormonal stimulation on hypospadias repair

Androgen stimulation to temporarily promote penile growth has been commonly used to facilitate hypospadias repair. Although some series suggest improvement in both functional and cosmetic outcomes, a recent systematic review and meta-analysis showed a possible relationship between pre-operative hormonal stimulation and higher complications. As a result, indications and treatment regimens remain controversial. Here, we review the available literature and present our clinical practice.

Perineal hypospadias: the Bilateral Based (BILAB) skin flap technique

PURPOSE

The purpose of this study was to present the "bilateral based skin flap (BILAB) technique" for patients with perineal hypospadias associated with severe deep chordee and report the follow up.

OPERATIVE PRINCIPLE

The short urethral plate is incised, the hypoplastic corpus spongiosum excised, the glans split in the midline, and a healthy urethral plate is reconstructed from the lateral penile skin and foreskin to the tip of the glans.

PATIENTS AND METHODS

Between January 2005 and December 2011, the BILAB technique was performed in 68 patients with perineal hypospadias associated with severe chordee as a one or two stage repair. The records of 63 patients who maintained regular follow up were reviewed. The new urethra was reconstructed from the new urethral plate during the same setting in 26 patients. The remaining 37 patients had the urethroplasty performed 3-6 months later as a two stage repair. Patient age ranged from 8 months and 2 years (mean 10 months). Follow-up period ranged from 18 months to 8 years (mean 43 months).

RESULTS

Satisfactory results were obtained in 54 patients (85%). Two children developed diverticula, two patients developed glans dehiscence, one child developed fistula, and one child had complete wound dehiscence, and urethroplasty was successfully reconstructed 6 months later. Three patients developed scar contraction 6-12 months after surgery. This was corrected by excision of the scarred intermediate layer.

CONCLUSIONS

The BILAB technique is a reliable technique for patients with perineal hypospadias. It produces slit like meatus at the tip of the glans. The surgeon may decide intra-operatively whether to complete the urethroplasty in one or two stages. Long term follow up until puberty is being carried out.

Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review

PURPOSE

We conducted a systematic review and meta-analysis to summarize the effect of preoperative hormonal stimulation on complication rates following proximal hypospadias repair.

MATERIALS AND METHODS

We comprehensively searched the published and unpublished literature between 1990 and 2010. Eligibility criteria were applied. Title, abstract and full text screening was carried out by 2 independent authors, and discrepancies were resolved by consensus. Heterogeneity between studies was tested using Cochran chi-square Q test and quantified by calculating I(2). Quality appraisal of included studies was performed. Meta-analysis was conducted when appropriate using a random effects model.

RESULTS

Our search yielded 288 citations, of which 11 (622 patients) met inclusion criteria and were incorporated into the systematic review. Most series were retrospective observational studies of moderate or low methodological quality. Of the patients 45% underwent administration of preoperative hormonal stimulation, with intramuscular testosterone being the most commonly prescribed formulation. Four studies addressed postoperative complication rate stratified by preoperative hormonal stimulation use and were included in a meta-analysis. The odds ratio for a complication occurring with preoperative hormonal stimulation use was 1.67 (CI 0.96-2.91, p = 0.07, I(2) = 0%). No persistent side effects due to preoperative hormonal stimulation were reported.

CONCLUSIONS

To our knowledge this is the only systematic review and meta-analysis thus far that has critically assessed the effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair. The published literature is of low quality and lacks standardized reporting of important patient and surgical details. The effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair remains unclear and requires further investigation.

[Abnormalities of the penis in boys]

Abnormalities of the male genitalia have increased in the last 2 decades in numerous developed countries and remain a frequent reason of consultation in pediatric surgery. The diagnostic spectrum is wide, and surgeons should pay particular attention to these abnormalities because of their potential psychological effect. Anatomically, these abnormalities can affect one of three parts of the penis. First, the foreskin may not be fully retracted. This is normal at birth and can be caused by prepuce adherents that can continue until adolescence. Today, true phimosis is treated with topical corticoids from the age of 3 years. If medical treatment fails, a surgical procedure is required. Second, the urethra can be affected by hypospadia, which is the most frequent abnormality of the urethra. It is associated with ectopic urethral meatus, hypoplastic foreskin, and penis curvature. Its pathogenic background is not clearly understood. Surgery options differ according to the type of hypospadia and according to the surgeon's experience. It is sometimes hard to deal with, especially in a perineal form, where genetic and hormonal studies are recommended. These interventions can lead to complications ranging from stenosis to fistula. Therefore, parents have to be informed of the benefits and risks of the surgical procedures. Epispadias is rare but more serious because of the increasing risk of urinary incontinence. Finally, abnormalities of the corpora cavernosa - often associated with hypospadias - can include penis curvature and micropenis, for which an endocrinological analysis is essential.

The influence of perioperative factors on primary severe hypospadias repair

Hypospadias is one of the most common congenital malformations of the male genitalia. Severe cases present with associated curvature greater than 30° and the meatus opening proximally to the penoscrotal junction. The perioperative management of patients with primary severe hypospadias is variable. Systematic evaluation of the upper urinary tract and the search for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias, and should be limited to severe cases with associated extraurinary malformations. Detection of a disorder of sex development is key for gender assignment and prognosis, but the identification of cases warranting a full work-up and the influence of such a diagnosis on the success of hypospadias repair is controversial. Preoperative hormonal stimulation allows for penile growth irrespective of the administration route. Associated morbidity is minimal, but its influence on the success of surgery is still unknown. An age of 6-18 months is generally recommended for surgery, but no trial data support this policy. Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery, whereas postoperative antibiotic prophylaxis and type of dressing have minimal impact on surgical success. Overall, most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined. Clinicians should be made aware of the evidence supporting any single intervention in order to standardize their management policies. We hope the issues outlined here will prompt researchers to design new studies to address the clinically relevant questions.

Hypospadias surgery past, present and future

PURPOSE OF REVIEW

Hypospadias surgery has been in continuous evolution for many years with steadily improving reported results. Despite this many unanswered questions on its cause, management and outcomes remain. Recent research has done little to clarify most matters.

RECENT FINDINGS

There is increasing evidence of a balance of genetic and developmental factors in the development of hypospadias, but there is doubt whether the incidence of hypospadias is increasing or not. Many technical aspects of hypospadias repair and variations of perioperative management seem to have little effect on outcome, whereas the age at which surgery is performed may. Although efforts are being made to relate anatomical findings to outcome, a lack of objective assessment and standardization is a handicap. Severe hypospadias, particularly that associated with significant chordee, remains challenging although strategies for management are being developed. The future may lie in development of autologous tissue culture for these severe cases.

SUMMARY

Further development of hypospadias surgery would benefit from objective, standardized methods of describing anatomy and outcome measures to facilitate effective comparison of techniques and procedures.

Modified Koyanagi's procedure for proximal hypospadias: our experience

Koyanagi described an elegant technique for one-stage proximal hypospadias repair. It is particularly suited for the most severe forms of hypospadias. A modified Koyanagi technique was used to repair the hypospadias in 14 children, aged 3-9 years. One child developed breakdown of the suture line, three other children developed small urethrocutaneous fistula needing closure and one child had post-operative meatal stenosis. Despite the high rate of complications, modified Koyanagi's procedure is a good procedure of choice for severe/proximal hypospadias.