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

A comparison of 467 uroflowmetry results in repaired hypospadias vs. normal male flows

INTRODUCTION

There are currently no clinical criteria for obstructed urinary flow after hypospadias repair surgery. Previous studies have utilized adult and pediatric nomograms and flow shapes to define obstruction, however these methods are limited by a lack of standardization and lack of interrater reliability when determining flow shapes, respectively. The idealized voider derived flow indexes offer a way to track uroflowmetry results in a volume and age agnostic manner.

OBJECTIVE

We sought to evaluate all our hypospadias patients over a 10-year period and identify patients without complications and those with complications and determine their respective flow parameters. Our secondary objective is to identify which uroflowmetry parameters are the most significant predictors of urethral stricture and meatal stenosis at the time of the uroflowmetry study.

STUDY DESIGN

Retrospective chart review was used to compile demographic information, details of hypospadias repair surgeries, and uroflowmetry results from pediatric hypospadias repair patients. Subjects were divided into distal, midshaft, and proximal groups based on the initial location of their urethral meatus. Flows from the hypospadias repair groups were compared to flows from normal age matched controls from a previous study. We compared flows from hypospadias repair patients with no complications present with those who had urethral stricture or meatal stenosis present at the time of uroflowmetry. Binary logistic regression and ROC analysis was used to assess different uroflowmetry parameters' ability to detect the presence of obstructed urine flow.

RESULTS

467 uroflowmetry studies from 200 hypospadias repair patients were included in the database. Compared to controls, the hypospadias repair groups tended to have significantly lower Qmax, Qavg, Qmax FI, Qavg FI, and longer ttQmax. Significant differences in flow parameters were observed when comparing hypospadias repair patients with and without flow obstructing complications at the time of uroflowmetry. Binary logistic regression including various uroflowmetry parameters showed Qmax FI had a significant effect on the odds of observing the absence of a stricture in proximal and distal hypospadias cases.

DISCUSSION

Of the uroflowmetry parameters analyzed, binary logistic regression and the likelihood ratio of a positive result all point to Qmax FI as the better parameter to use to detect the presence of complications in patients who have undergone distal or proximal hypospadias repair surgery.

CONCLUSION

We have established normal parameters for post-operative hypospadias repair patients which can be used to follow patients over time and allow for the identification of complications by keeping track of flow indexes which are volume and age agnostic.

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.

Outcome of Buck’s fascia repair with wingless glanuloplasty in distal penile hypospadias

Background

Hypospadias surgery is technically demanding and is often encountered with complications like fistula and glanular dehiscence. To prevent these complications we have instituted Buck’s fascia repair (BFR) with wingless glanuloplasty (WLP) in the cases of distal penile hypospadias (DPH) deemed to be suitable for TIP repair. The aim of this prospective study was to assess the outcome of Buck’s fascia repair (BFR) with minimal wingless glanuloplasty (WGP).

Methods

This prospective study included 50 patients with coronal, subcoronal and midpenile hypospadias who received a tubularization of incised plate (TIP) repair. The exclusion criteria were glanular hypospadias, Thiersch Duplay repair, proximal penile hypospadias, previous penile surgeries, uncorrectable chordee, glans size < 14 mm, flat glanular groove and preoperative testosterone therapy.

Results

Over a period of 3 years, 50 patients with mean age of 3.5 ± 0.8 years were recruited for the study. Meatal position was coronal, subcoronal and midpenile in 6, 24 and 20 patients, respectively. Fistula occurred in one patient (2%) and meatal stenosis in one. Straining on micturition was noted in two patients that needed dilatation in postoperative period. None of the patients had glanular dehiscence. Surgeon acceptability of the procedure was good. Cosmetic results were also fair.

Conclusion

Buck’s fascia repair with Wingless glanuloplasty is a good repair for the distal penile hypospadias. It is effective and is associated with low fistula rates and glanular dehiscence. It is technically simple procedure involving minimal dissection. However, caution should be observed in midpenile hypospadias to avoid tight repair in subcoronal region.

Bladder and voiding dysfunction in adolescents with anorexia nervosa: a novel finding and potential causes

PURPOSE

This study aimed to investigate the bladder capacity (BC) and bladder dynamics of adolescents with anorexia nervosa (AN).

METHODS

The participants consisted of 15 adolescents newly diagnosed with AN according to the DSM 5 criteria and in the acute weight loss period who were questioned about the symptoms of lower urinary tract (LUT) dysfunction. Functional bladder capacity (FBC) and voided volume with uroflowmetry were measured for each subject; the larger volume of the two was chosen for the bladder capacity. Uroflowmetry was used to obtain uroflow curves for the participants whose patterns were labeled as pathologic if they were outside the bell-shape.

RESULTS

Fourteen (93.3%) of the patients exhibited at least one of the LUT dysfunction symptoms (pathologic voiding symptom/urinary incontinence/pathologic uroflow pattern). BC was observed to increase in 86.6% (n = 13) of the patients. Eighty% of the patients (n = 12) showed pathological uroflow patterns. In patients with pathological uroflow patterns, which showed insufficiency of bladder contraction, assistance of abdominal muscles was needed during voiding.

CONCLUSION

The novel findings presented in this study are the increase of BC in adolescents with AN, the presence of at least one type of voiding or bladder dysfunction, and the pathology of uroflow patterns of most patients show that the bladder dynamics is affected in AN. The most important contribution of this study to the literature is that impaired bladder dynamics was determined to be a medical complication of AN.

LEVEL OF EVIDENCE

Case-control analytic study, Level III.

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.

"Fossa navicularis" and "septum glandis": A "flow-control chamber" for the male urethra?

A clear understanding of the normal anatomy of the glanular urethra is essential for anatomical reconstruction of the male urethra. In hypospadias surgery, tubularization of the neourethra over a catheter or stent has been the standard method for decades. However, the male urethra is not a tubular structure with uniform configuration and diameter by forming a fossa (navicularis) in the glans penis. We recently investigated the structural anatomy of the glanular urethra using magnetic resonance imaging (MRI). We have shown that the male urethra does not have a uniform tubular structure and not covered by the corpus spongiosum to the end. The glanular urethra that forms the "fossa navicularis" has a wider caliber than the proximal urethra. Its vertical elliptical shape resembles a laterally compressed slit-like passage. The fossa navicularis is covered by a thin layer of fibrous tissue ("septum glandis") which is an extension of tunica albuginea of the corpus cavernosum and the corpus spongiosum. Our hypothesis is based on the results of MRI of the glanular urethra and the basic principles of fluid dynamics. We analyzed the flow dynamics of urine on this particular component of the urethra in terms of shape and structural properties. Because of its wider caliber than the proximal urethra, the glanular urethra (fossa navicularis) should cause an increase in pressure and a decrease in velocity of the urine flow. The navicular shape of the fossa and its elliptical external opening (the meatus) should allow urine to be expelled at higher flow rates and at opposite angles at the upper and lower corners which make the wave-like shape of the urine. It can be said that the changes in the volumetric form, pressure and velocity, as well as the wave-like shape of the urine flow are caused by the "fossa navicularis" covered by the "septum glandis". We propose that the "fossa navicularis" and "septum glandis" play a role as 'flow control chamber" in controlling the flow of the urine exiting the urethra, which must be taken into account for successful functional reconstruction of hypospadias.

Chronological Changes In Uroflowmetry After Hypospadias Repair: An Observational Study

Aim

Urinary flow after urethroplasty is of paramount importance. The aim of this study is to evaluate the progression of uroflowmetry (UF) parameters after different distal and proximal hypospadias repair techniques.

Methods

In this cohort study, cases that underwent primary hypospadias repair at our institution between March 2010 and December 2018 were included when uncomplicated, asymptomatic and toilet-trained. UF findings and post void residual were described after each specific technique.

Results

In all, 88 patients were eligible. Time to last UF ranged from 35 to 138 months postoperatively. Significant increase started 36 months after distal tubularized incised plate urethroplasty (TIP) and afterwards than Mathieu technique. While was noticed 24 and 36 months after Onlay technique and proximal TIP, respectively; however, TIP showed steady significant increase atall time intervals. Duckett repair exhibited insignificant change in maximum flow rate (Qmax) values, buccal mucosal graft (BMG) and inner preputial graft (IPG), significant increase in the Qmax values after 6 and 24 months, respectively, then remained steady high. Transposed preputial flap (TPF) showed significant increase at 6-12 months only, then remained steady lower than the other two techniques. Obstructed flow was 37% after distal TIP, 30% after Mathieu, 25% after proximal TIP, 66.7% after Duckett repair, and 33.3% after TPF. There were no obstructed cases after BMG and IPG.

Discussion

Improvement by time varied between techniques. After repair most cases are below the 50th percentile, implying that the reconstructed urethra is not functioning as a normal urethra. Staged repair for proximal hypospadias is preferable to a heroic one-stage procedure.

Conclusion

Choice of the surgical technique for hypospadias repair had impact on the improvement of Qmax values. TIP improved 36 months postoperatively. However, for proximal cases staged graft repair had earlier improvement and higher Qmax values than proximal TIP and Onlay techniques.

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.

Management of Urethral Strictures After Hypospadias Repair

Strictures of the neourethra after hypospadias surgery are more common after skin flap repairs than urethral plate or neo-plate tubularizations. The diagnosis of stricture after hypospadias repair is suspected based on symptoms of stranguria, urinary retention, and/or urinary tract infection. It is confirmed by urethroscopy during anticipated repair, without preoperative urethrography. The most common repairs for neourethra stricture after hypospadias surgery are single-stage dorsal inlay graft and 2-stage labial mucosa replacement urethroplasty.

Tubularised incised-plate versus tubularisation of an intact and laterally augmented plate for hypospadias repair: A prospective randomised study

OBJECTIVES

To compare the outcome of hypospadias repair using tubularised incised-plate (TIP) urethroplasty and tubularisation of an intact and laterally augmented urethral plate.

PATIENTS AND METHODS

This prospective randomised study included 370 patients with primary distal hypospadias. All had urethral plate widths of 8-10 mm and a glans of ⩾15 mm. Exclusion criteria were previous repair, circumcision, a wide urethral plate of >10 mm or a narrow plate of <8 mm in diameter, a small glans of <15 mm in diameter, chordee of >30°, and hormonal stimulation. Patients were randomised into two groups: Group 1 (185 patients) underwent TIP urethroplasty and Group 2 (185 patients) underwent tubularisation of the intact plate with lateral augmentation of the urethral plate using penile skin. The follow-up period was 12-28 months.

RESULTS

There were 172 evaluable patients in Group 1 and 177 in Group 2. The urethroplasty was successful in 83.2% and 94.4% in Groups 1 and 2, respectively. Complications occurred in 16.8% in Group 1 and 5.6% in Group 2 (P = 0.001). Meatal stenosis occurred in 7% and 3.4% in Groups 1 and 2, respectively (P = 0.130). There were statistically significant differences in the wound dehiscence, fistula, and re-operation rates of Group 1 versus Group 2, at 6% versus 0%, 9.8% versus 2.8%, and 13.4% versus 5.6%, respectively. The presence of mild chordee did not affect the complication rate (P = 0.242). The mean (SD) operative time was 56.7 (8.9) min in Group 1 and 93.7 (8.3) min in Group 2 (P < 0.001).

CONCLUSION

The outcome of tubularised intact and laterally augmented plate is better than classical TIP urethroplasty of hypospadias. Further trials are mandatory to extend the indications of the technique.

Assessment of postoperative outcomes of hypospadias repair with validated questionnaires

PURPOSE

A standardized assessment for the optimal repair of hypospadias remains elusive. This study utilized validated questionnaires to assess the postoperative functional, cosmetic, and psychosocial outcomes of hypospadias repair.

MATERIALS AND METHODS

172 patients who underwent hypospadias repair under the care of a single surgeon were identified. 25 agreed for follow-up using the validated questionnaires of Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Scale (PPPS), and Pediatric Quality of Life Inventory (PedsQL™4.0).

RESULTS

Mean follow-up was 59months postoperatively (range 7-113months). Techniques used included tubularized incised plate urethroplasty, meatal advancement and glanuloplasty, and a 2-stage repair. 23 of 25 patients achieved a HOSE score of 14 or more (maximum of 16). The PPPS scores correlated with severity of the hypospadias. Those with glanular hypospadias (mean score=10) scored higher than those with coronal (mean score=9) and penile/penoscrotal hypospadias (mean score=7). There was no correlation between PedsQL™4.0 scores and the severity of hypospadias or procedure used.

CONCLUSION

Validated questionnaires revealed generally good functional, cosmetic, and early psychosocial outcomes after hypospadias repair. The use of validated questionnaires in routine follow-up sessions may facilitate objective assessment of both functional outcomes and patient satisfaction.

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.

Long-term functional outcomes of distal hypospadias repair: a single center retrospective comparative study of TIPs, Mathieu and MAGPI

INTRODUCTION

Tubularized Incised-Plate (TIP) urethroplasty is currently the preferred technique for distal hypospadias repair. Nevertheless, concerns have been raised on the long-term functionality of the reconstructed neourethra.

OBJECTIVE

The aim of this study is to evaluate long-term uroflowmetry parameters' evolution after TIP surgery over a long-term follow-up including the adolescent period. TIP patients were compared to normal children using established Miskolc nomograms, as well as to patients who underwent Mathieu and Meatal Advancement and Glanuloplasty (MAGPI) surgery repairs for distal hypospadias.

STUDY DESIGN

Files from patients who underwent primary distal hypospadias repair at our institution between January 1, 1997 and January 31, 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (TIP vs. Mathieu vs. MAGPI) was performed according to the following postoperative time interval endpoints: 0-6 months, 6-12 months, 12-24 months, 24-48 months, 4-6 years, 6-10 years and >10 years. Maximal urinary flow rate (Qmax) in relation to Voiding Volume (VV) adjusted for Age or Body Surface Area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques.

RESULTS

153 patients met the inclusion criteria: 70 (43%) TIP, 24 (17%) Mathieu and 59 (35%) MAGPI. Overall, Qmax increases progressively according to time and age and in particular during the period covering adolescence with a similar trend regardless of the type of surgery. Uroflowmetry profiles in terms of Qmax, VV and PVR were equivalent between surgeries at each examined time point. At 10 years of follow-up postopertively, mean Qmax were 17.2 ml/s, 18.8 ml/s and 21.6 ml/s respectively with no significant difference detected between groups (p = 0.344). Compared to normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax< 5th percentile of nomograms was more prevalent in patients aged 2-7 years old at 60% but decreased to less than 10%in patients aged >13 years for all procedures combined (see abstract figure) but without detected differences between surgery types (p = 0.276).

DISCUSSION

After sub-optimal obstructive maximal urinary flows in the early postoperative period, hypospadias patients treated with TIP exhibit favourable long-term evolution with age and during adolescence in particular compared to normal children. In addition, a similar trend was found for patients treated with Mathieu and MAGPI with no significant differences detected between procedures. Nevertheless, because of the relatively small sample size we cannot exclude that a statistical difference between surgeries would have been detected if the study was adequately powered on every endpoint. Nevertheless and also as suggested by the values obtained, this potential difference may be quite small and not clinically relevant.

CONCLUSION

These results suggest that the obstructive urinary flow pattern observed in patients early on is possibly an intrinsic feature associated to the malformation itself and may be less of a consequence of the surgical technique.

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.

Failed hypospadias in paediatric patients

Failed hypospadias refers to any hypospadias repair that leads to complications or causes patient dissatisfaction. The complication rate after hypospadias repairs ranges from 5-70%, but the actual incidence of failed hypospadias is unknown as complications can become apparent many years after surgery and series with lifelong follow-up data do not exist. Moreover, little is known about uncomplicated repairs that fail in terms of patient satisfaction. Risk factors for complications include factors related to the hypospadias (severity of the condition and characteristics of the urethral plate), the patient (age at surgery, endocrine environment, and wound healing impairment), the surgeon (technique selection and surgeon expertise), and the procedure (technical details and postoperative management). The most important factors for preventing complications are surgeon expertise (number of cases treated per year), interposition of a barrier layer between the urethroplasty and the skin, and postoperative urinary drainage. Major complications associated with failed hypospadias include residual curvature, healing complications (preputial dehiscence, glans dehiscence, fistula formation, and urethral breakdown), urethral obstruction (meatal stenosis, urethral stricture, and functional obstruction), urethral diverticula, hairy urethra, and penile skin deficiency.

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.

Coverage of urethroplasty in pediatric hypospadias: randomized comparison between different flaps

OBJECTIVES

The use of covering urethroplasty with flaps in hypospadias surgery has been well recommended. Various techniques have been described for flap harvesting. The aim of the present study was to compare the outcome and complication rate of dorsal preputial flaps and ventral dartos flaps.

METHODS

A total of 130 patients were prospectively evaluated from January 2008 to December 2011. Using the tubularized incised plate urethroplasty procedure, urethroplasty was carried out by a single surgeon. Patients were randomly divided in two groups: group A (57 patients), in which a preputial flap was carried out using three different techniques; and group B (73 patients), in which a single or a double ventral dartos flap was used.

RESULTS

A total of 41 complications occurred in 24 patients. Urethrocutaneous fistulas were observed in 14.9%, quite equally distributed between groups A and B. There was only one urethrocutaneous fistula in a patient treated with the double ventral dartos flaps. Five cases (3.8%) of glans dehiscence were observed: four after single ventral dartos flap and one after dorsal preputial flap. Six patients in group A and seven in group B experienced meatal stenosis. In three cases of iatrogenic torsion of the penis, a dorsal preputial flap was laterally transposed. Finally, a lower complication rate was observed for double ventral dartos flap versus the other techniques.

CONCLUSIONS

The use of a double ventral dartos flap should represent the first-line technique for coverage of distal urethroplasty.

Hypospadias repair at a tertiary care center: long-term followup is mandatory to determine the real complication rate

PURPOSE

The field of reconstructive surgery for hypospadias is lacking standard techniques and followup. Most published series include complication rates after a short followup. We report and analyze the long-term outcome of primary hypospadias repair at a single tertiary care center.

MATERIALS AND METHODS

We reviewed 1,061 operations performed at our institution between 1997 and 2010 and registered as hypospadias repair. The operations were performed in 543 patients born between June 1997 and June 2005. A retrospective database was created with information about hypospadias characteristics, surgery and followup.

RESULTS

A total of 474 primary repairs were selected, excluding incomplete/incorrect files. Distal penile hypospadias was reported in 366 patients (77.2%), mid penile hypospadias in 54 (11.4%) and proximal hypospadias in 54 (11.4%). Initial repair technique was based on incised plate in 189 patients (39.9%), meatal advancement in 171 (36%), onlay flap in 82 (17.3%) and other or combined techniques in 25 (5.3%). Insufficient information was reported for 7 patients (1.5%). Mean age at first operation was 22.6 months (range 4 to 134) and mean followup after first operation was 34.0 months (0 to 145). Of the children 360 (75.9%) had a good long-term outcome and required only 1 procedure. Reoperation was needed in 114 patients (24.1%), of whom 54 (47.4%) underwent reoperation in the first year of followup.

CONCLUSIONS

Overall a good long-term outcome without further complication was achieved in 75.9% of our cases. Of the 24.1% of patients who needed reoperation only 47.4% presented within the first year postoperatively, indicating the need for long-term followup when reporting outcomes of hypospadias repair.

Preliminary experience with the use of acellular collagen matrix in redo surgery for urethrocutaneous fistula

OBJECTIVE

To show that splinting of the urethral repair with acellular collagen matrix is a safe and useful adjunct in the procedure to manage complex urethrocutaneous fistula. Urethrocutaneous fistula is one of the most common complications of hypospadias surgery. Management of persistent urethrocutaneous fistula is challenging because it is complicated by a lack of or poor quality of tissues at the site of repair.

METHODS

Between 2006 and 2011, 12 boys underwent urethrocutaneous fistula repair (10) or redo urethroplasty (2) using acellular collagen matrix by a single surgeon. Mean age was 6.8 years (range 3.1-14.8); median follow-up was 2.5 years (range 0.4-3.8). Urethrocutaneous fistula was closed and acellular collagen matrix was used as a splint. All the patients were assessed by an independent observer; all boys were successfully treated with no further recurrence of fistula.

RESULTS

On palpation, the previous site of the acellular collagen matrix implant was soft and subtle, revealing healthy underlying tissues. Cosmetic outcome was excellent in all patients, with no signs of scarring or tethering. All patients had a single good urinary stream. Uroflows were within normal range of age-matched standardized nomograms with nonobstructive bell-shaped curves. One boy had late wound infection, which healed with debridement, but had no recurrence of fistula.

CONCLUSION

Splinting of the urethral repair with acellular collagen matrix in redo surgery is safe and is a useful adjunct that effectively prevents further recurrence of complications such as urethrocutaneous fistula.

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.