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Alhindi S, Elrishe S, Khalaf Z. Urethral Mobilisation and Glanuloplasty Technique for Primary and Second-Stage Repair of Hypospadias: A Single Hospital Experience. Cureus 2024; 16:e63189. [PMID: 39070320 PMCID: PMC11274756 DOI: 10.7759/cureus.63189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Background Over the years, the technique used to correct hypospadias has undergone several modifications to improve outcomes and reduce complication rates. In this study, a modification has been made to the second stage of the two-stage repair of proximal hypospadias. This modification utilises urethral mobilisation and glanuloplasty, traditionally used to repair distal hypospadias, in the second stage of repair of proximal hypospadias. This study aims to assess the implications of this modification on the outcomes in addition to adding to the pre-existing literature on the outcomes of urethral mobilisation and glanuloplasty in the repair of distal hypospadias. Methodology A prospective study was conducted at Salmaniya Medical Complex in Bahrain between January 2016 and December 2021. All patients with either proximal or distal hypospadias who underwent a surgical repair using the urethral mobilisation and glanuloplasty technique were included. The following cases were excluded: patients with proximal hypospadias who did not undergo a first-stage repair, those with a hypoplastic urethra, and those aged 14 years or more. Results The mean operative time for the proximal hypospadias group was 78 minutes, while it was 62 minutes in the distal hypospadias group. Furthermore, the catheter remained in situ for a mean of three days postoperatively in the proximal hypospadias group. Overall, four of 35 patients (11.4%) experienced complications in the proximal hypospadias group. Of these, there were two (5.7%) cases of meatal stenosis, two (5.7%) cases of wound dehiscence, and no cases of diverticula or urethrocutaneous fistulas. Meanwhile, in the distal hypospadias group, one of 117 patients (0.9%) experienced a complication; the complication was meatal stenosis. there was a significant correlation between the age of patients and the complication rate (p = 0.06). The operative time was also found to be a significant factor influencing the occurrence of complications. The follow-up duration ranged between five months and 12 months. All patients had good cosmetic outcomes. Conclusions This study found that urethral mobilisation and glanuloplasty for the second-stage repair of proximal hypospadias resulted in lower complications than the traditional two-stage operation and a short duration of urinary catheterisation. There is a need to conduct studies with longer follow-up durations and objective measures of function to provide a better comparison between the different techniques used.
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Affiliation(s)
- Saeed Alhindi
- Pediatric Surgery, Salmaniya Medical Complex, Manama, BHR
| | - Sanad Elrishe
- Department of Surgery, Royal Blackburn Teaching Hospital, Blackburn, GBR
| | - Zahra Khalaf
- Department of Surgery, Royal Blackburn Teaching Hospital, Blackburn, GBR
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Scougall K, Bryce J, Baronio F, Boal RL, Castera JR, Castro S, Cheetham T, Costa EC, Darendeliler F, Davies JH, Dirlewanger M, Gazdagh G, Globa E, Guerra-Junior G, Guran T, Herrmann G, Holterhus PM, Akgül AK, Markosyan R, McElreavey K, Miranda ML, Nordenstrom A, O’Toole S, Poyrazoglu S, Russo G, Schwitzgebel V, Stancampiano M, Steigert M, Ahmed SF, Lucas-Herald AK. Predictors of surgical complications in boys with hypospadias: data from an internationa registry. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000599. [PMID: 37860275 PMCID: PMC10582860 DOI: 10.1136/wjps-2023-000599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/25/2023] [Indexed: 10/21/2023] Open
Abstract
Background Complications are frequently reported after hypospadias repair and there is a need to understand the factors that influence their occurrence. Methods Data from boys with hypospadias born between 2000 and 2020 were obtained from the International Disorders of Sex Development (I-DSD) Registry. Logistic regressions, fisher's exact tests and spearman's correlation tests were performed on the data to assess associations between clinical factors and complication rates. Results Of the 551 eligible boys, data were available on 160 (29%). Within the cohort, the median (range) External Masculinization Score (EMS) was 6 (2, 9). All presented with one or more additional genital malformation and 61 (38%) presented with additional extragenital malformations. Disorders of androgen action, androgen synthesis and gonadal development were diagnosed in 28 (18%), 22 (14%) and 9 (6%) boys, respectively. The remaining 101 (62%) patients were diagnosed as having non-specific 46,XY Disorders of Sex Development. Eighty (50%) boys had evidence of abnormal biochemistry, and gene variants were identified in 42 (26%). Median age at first hypospadias surgery was 2 years (0, 9), and median length of follow-up was 5 years (0, 17). Postsurgical complications were noted in 102 (64%) boys. There were no significant associations with postsurgical complications. Conclusions Boys with proximal hypospadias in the I-DSD Registry have high rates of additional comorbidities and a high risk of postoperative complications. No clinical factors were significantly associated with complication rates. High complication rates with no observable cause suggest the involvement of other factors which need investigation.
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Affiliation(s)
| | | | - Federico Baronio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola, Bologna, Italy
| | - Rachel L Boal
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | | | | | - Tim Cheetham
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | | | | | | | | | | | - Evgenia Globa
- Ukrainian Research Center of Endocrine Surgery Endocrine Organs and Tissue Transplantation, Kyiv, Ukraine
| | | | | | | | - Paul-Martin Holterhus
- University Hospital of Schleswig-Holstein Campus Kiel/Christian-Albrechts-University of Kiel, Kiel, Germany
| | | | - Renata Markosyan
- Yerevan State Medical University Endocrinology Clinic, Yerevan, Armenia
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Yamashiro JR, Austin JC, Braga LH, Chuang KW, Davis-Dao CA, Hecht S, Holzman SA, Khoury AE, Kurzrock EA, Lerman SE, McGrath M, Merguerian PA, Saltzman AF, Schaeffer AJ, Seideman C, Singer JS, Wang P, Wehbi EJ, Wu HY, Sturm RM. Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network. J Pediatr Urol 2023; 19:277-283. [PMID: 36775718 PMCID: PMC10686787 DOI: 10.1016/j.jpurol.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 09/12/2022] [Accepted: 12/04/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. OBJECTIVE With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. STUDY DESIGN A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. RESULTS Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. CONCLUSION Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.
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Affiliation(s)
- Justine R Yamashiro
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
| | - J Christopher Austin
- Oregon Health & Science University, 700 S.W. Campus Drive, Portland, Oregon, USA 97239, 875 Oak Street S.E., Salem, OR, 97301, USA.
| | - Luis H Braga
- McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada.
| | - Kai-Wen Chuang
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Carol A Davis-Dao
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Sarah Hecht
- Oregon Health & Science University, 700 S.W. Campus Drive, Portland, Oregon, USA 97239, 875 Oak Street S.E., Salem, OR, 97301, USA.
| | - Sarah A Holzman
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Antoine E Khoury
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Eric A Kurzrock
- University of California Davis, 4860 Y Street, Suite 2200, Sacramento, CA, 95817, USA.
| | - Steven E Lerman
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
| | - Melissa McGrath
- McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada.
| | - Paul A Merguerian
- University of Washington, 4800 Sand Point Way NE, OA.9.220, Seattle, WA, 98105, USA.
| | - Amanda F Saltzman
- University of Kentucky, 800 Rose Street, MS 237, Lexington, KY, 40536, USA.
| | - Anthony J Schaeffer
- University of Utah, 100 N Mario Capecchi Drive, Suite 3550, Salt Lake City, UT, 84113, USA.
| | - Casey Seideman
- Oregon Health & Science University, 700 S.W. Campus Drive, Portland, Oregon, USA 97239, 875 Oak Street S.E., Salem, OR, 97301, USA.
| | - Jennifer S Singer
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
| | - Peter Wang
- LHSC-Victoria Hospital, 800 Commissioners Road East, London, Ontario, N6A 5A5, Canada.
| | - Elias J Wehbi
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Hsi-Yang Wu
- Brown University, 593 Eddy Street, Suites 185 & 190, Providence, RI, 02903, USA.
| | - Renea M Sturm
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
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Faridi MS, Sharma V, Sharma AK, Yadav R. Tunica albuginea versus buccal mucosa graft urethroplasty for anterior urethral stricture: A prospective randomised pilot study. Asian J Urol 2023; 10:189-194. [PMID: 36942113 PMCID: PMC10023540 DOI: 10.1016/j.ajur.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/12/2021] [Accepted: 09/07/2021] [Indexed: 11/30/2022] Open
Abstract
Objective The objective of the study was to compare the outcome of tunica albuginea urethroplasty (TAU) and buccal mucosa graft (BMG) urethroplasty for anterior urethral stricture. Methods Thirty patients who met the inclusion criteria were randomised into two groups: TAU (Group A) and BMG urethroplasty (Group B). Surgical outcome was evaluated with pre- and post-operative work-up involving retrograde urethrogram, voiding cystourethrogram, uroflowmetry, and urethroscopy. Patients were followed up till 1 year. Results Mean duration of surgery was statistically significant between two groups (p=0.0005). Maximum urine flow rate was comparable when compared between two groups (p=0.22) but statistically significant when compared pre- and post-operatively (p<0.001). At follow-up of 1 year, the successful outcomes were 80% in Group A and 87% in Group B. A total of five patients who had unsuccessful results required redo urethroplasty. Complications were minimal in both the groups. Conclusion TAU provides outcomes equivalent to those of BMG urethroplasty. TAU has less operative time, easy to perform, and beneficial in patients with poor oral hygiene.
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Affiliation(s)
- Mohammad Shazib Faridi
- Division of Urology, Department of Surgery, Hamdard Institute of Medical Sciences & Research and HAHC Hospital, New Delhi, India
- Corresponding author.
| | - Vikas Sharma
- Department of Urology, Rajiv Gandhi Super Speciality Hospital, Tahirpur, Delhi, India
| | - Adittya K. Sharma
- Department of Urology, Apollomedics Super Speciality Hospital, Lucknow, Uttar Pradesh, India
| | - Rahul Yadav
- Department of Urology, Apollomedics Super Speciality Hospital, Lucknow, Uttar Pradesh, India
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Di H, Wen Y, Li Y. Preoperative hormone therapy in single-stage repair of hypospadias: A comprehensive systematic review. J Pediatr Urol 2023:S1477-5131(23)00021-9. [PMID: 36746717 DOI: 10.1016/j.jpurol.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/08/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Huajie Di
- Pediatrics, Xuzhou Medical University, Xuzhou 221004, China
| | - Yi Wen
- Pediatrics, Xuzhou Medical University, Xuzhou 221004, China
| | - Yuan Li
- Department of Pediatric Urology, Affiliated Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou 221002, China.
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6
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Do MT, Kim L, Im YJ, Hahn S, Park K. Effect of Preoperative Androgen Stimulation on Penile Size and Postoperative Complication Rate in Patients with Hypospadias: A Systematic Review and Meta-analysis. World J Mens Health 2023:41.e19. [PMID: 36649924 DOI: 10.5534/wjmh.220173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
- Minh-Tung Do
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Louis Kim
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
| | - Young Jae Im
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
| | - Seokyung Hahn
- Department of Human Systems Medicine, Medical Statistics Laboratory, Seoul National University College of Medicine, Seoul, Korea
| | - Kwanjin Park
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea.
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Kern NG, Tuong MN, Villanueva C, Gargollo P, Herndon CDA. Pediatric urologists' confidence and accuracy in estimating penile curvature. J Pediatr Urol 2022; 19:180.e1-180.e6. [PMID: 36446690 DOI: 10.1016/j.jpurol.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/28/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Assessment and management of congenital penile curvature (PC) can be variable. Methods for correction of PC usually are dependent on degree of PC which is reliant on how degree is assessed. We sought to assess the confidence and accuracy of measuring PC and hence management using case-based examples. METHODS A survey was emailed to members of the Societies for Pediatric Urology. Demographic information, management strategies for PC, and self-reported confidence in measuring PC were assessed. A Likert scale measured self-confidence. Case scenarios were used to assess ability to measure PC and methods of correction. The cases consisted of three computer-generated penis model images with arc-type ventral curvature and one image of lateral curvature in an infant. RESULTS The response rate was 30% (108/355). The mean confidence score was 3.6 ± 0.8 (3-fairly confident; 4-very confident). In clinic, 89% of urologists used eyeball estimates to assess PC; 5% used both eyeball and goniometer. In the operating room, 71% used eyeball estimates, 8% used goniometer, and 16% used both. If sole decision-maker, urologists recommend surgical correction of PC over observation at median 30° (IQR 21-30°). At a median of 45°, there was a shift in corrective surgical preference from dorsal plication (DP) (IQR 30-54°) to ventral lengthening (IQR 34-60°). Urologists underestimated PC degree for all cases (summary table). For all cases, there was no association between years in practice or confidence level on estimated PC degree. In case 1, only 24% of urologists would correct a mean estimate of 23° PC; those who would correct had a higher mean PC estimate vs those who would not (28° vs 21°, p < 0.001). Case 2 and 4 had similar estimations and correction methods. In case 2, those who chose VL had a higher mean PC estimate vs those who did not (43° vs 37°, p < 0.01), but no estimate difference was seen for DP (p = 0.52). In case 4 with lateral PC, those who chose DP had a higher mean PC estimate vs those who did not (41° vs 33°, p = 0.049). Yet in case 3, there was no difference in PC estimate in urologists who chose VL vs not (57° vs 53°, p = 0.16). CONCLUSIONS A uniform underestimation of PC existed despite self-reported confidence in the ability to measure PC. An increasing willingness to perform surgical correction was demonstrated with a shift towards VL for ventral curvature and less so for lateral curvature as PC worsens.
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Affiliation(s)
- Nora G Kern
- Department of Urology, University of Virginia, Charlottesville VA USA.
| | - Mei N Tuong
- Department of Urology, University of Virginia, Charlottesville VA USA.
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Li J, Li S, Yang Z, Ke Z, Zhang T, Yin J. A simple technique to repair distal and mid-shaft hypospadias using a de-epithelialized Byars' flap. J Int Med Res 2022; 50:3000605221115150. [PMID: 35999815 PMCID: PMC9421228 DOI: 10.1177/03000605221115150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe standard and modified de-epithelialized Byars' flap techniques in tubularized incised plate urethroplasty and evaluate postoperative outcomes. METHODS We retrospectively evaluated data for 404 primary hypospadias repair patients who underwent standard (Group A) or modified (Group B) urethroplasty between January 2016 and 2021. Group B's data were analyzed to evaluate whether our modified technique was effective for all hypospadias types. RESULTS There was no difference in the ratio of different hypospadias types between Groups A (n = 145) and B (n = 259). Median follow-up duration was 35 months. Fistula occurred in 19 patients in Group A and 12 in Group B (statistically significant difference). The total complication rate was statistically significantly different between the groups. In Group B, 3/142 patients with distal hypospadias developed urethrocutaneous fistula vs 4/95 with mid-shaft hypospadias and 5/22 with proximal hypospadias. No difference was noted between the distal and mid-shaft groups. Significant differences were observed when comparing distal and mid-shaft groups with the proximal group; total complication rates were similar. Glans dehiscence and meatal stenosis rates were similar between Groups A and B, and among the hypospadias phenotypes. CONCLUSION Our modified procedure is simple to perform and yields excellent results in distal and mid-shaft hypospadias repair.
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Affiliation(s)
- Jiaqiang Li
- Department of Pediatric Urology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Shoulin Li
- Department of Pediatric Urology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Zhilin Yang
- Department of Pediatric Urology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Zhicong Ke
- Department of Pediatric Urology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Tiejun Zhang
- Department of Pediatric Urology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Jianchun Yin
- Department of Pediatric Urology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
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¿Cuáles son los factores que afectan la dehiscencia del glande tras la cirugía de hipospadias? Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2020.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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10
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Ghidini F, Castagnetti M. Pediatric urology research in 2020: A bibliometric analysis of the top 100 most cited articles. Urologia 2021; 89:474-480. [PMID: 34965806 DOI: 10.1177/03915603211025239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pediatric Urology deals with genitourinary diseases. Present study aimed to collect the top-cited article in Pediatric Urology in order to define the most debated and studied topics. METHODS The journals reported in "Urology & Nephrology" category of the 2019 edition of Journal Citation Reports, together with the most relevant journals of "Transplantation," "Pediatrics," and "Surgery" categories, were browsed. The articles of interest in Pediatric Urology with more than 50 citations were collected. A bibliometric analysis was performed to collect the top 100 cited articles. RESULTS The top-cited articles were published in 27 journals (23%), with a median impact factor of 2.676 (IQR 1.981-5.642). Seventeen of them (63%) belonged to "Urology and Nephrology" category. The median number of citations was 82 (IQR 64-113). The most productive journal, with 23 articles, was "The Journal of Urology." Forty-eight top-cited articles were Guidelines or Reviews of the literature and only four papers were randomized controlled trials. The most relevant topic was "congenital anomalies" with 18 articles. As to minimally invasive surgery, eight studies were identified. All of them dealt with robotic-assisted laparoscopic surgery. Two articles reported the current evidence about transitional care. CONCLUSIONS The top-cited articles were dispersed among journals of different areas. Current scientific literature deal with congenital anomalies, more specifically with obstructive uropathies and hypospadias. In the last decade, one of the most relevant innovation in pediatric urology was the introduction of robotic surgery. Transitional care has become a timely topic.
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Affiliation(s)
- Filippo Ghidini
- Paediatric Urology Unit, Department of Mother and Chile Health, University Hospital of Padova, Padua, Italy
| | - Marco Castagnetti
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.,Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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11
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Karabulut R, Turkyilmaz Z, Atan A, Kaya C, Sonmez K. What are the factors affecting glanular dehiscence after hypospadias surgery? Actas Urol Esp 2021; 46:4-15. [PMID: 34838491 DOI: 10.1016/j.acuroe.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/29/2020] [Indexed: 10/19/2022]
Abstract
BACKGROUND Glanular dehiscence (GD) is one of the main complications after hypospadias surgery. There is a limited number of publications regarding GD in the literature. OBJECTIVE The aim of this work is to reveal the factors that affect GD after a literature review. EVIDENCE ACQUISITION A literature search for relevant articles was performed in database using the search term glans dehiscence without setting date range limit or any other limits. All articles related to GD after hypospadias surgery were included in this study. After collecting the information from full text articles, 71 articles were included in this systematic review. In these studies, localization of hypospadic meatus, type of surgery, and other clinical data which were thought to behave as risk factors for GD were obtained. Chi-Square test was used to evaluate the differences between the parameters, where p < 0.05 was taken as statistically significant. RESULTS After evaluating the 71 articles that met the inclusion criteria, 309 cases (3.48%) of GD after 8858 hypospadias repairs were obtained in this review. GD rates were found significantly high for proximal hypospadias (5%), two-stage hypospadia repairs (5%) and re-do hypospadias repair (8.75%) (p = 0.002, 0.022, and 0.004, respectively). Glans width <14 mm, urethral plate (UP) width <7 mm, hypospadias surgeries performed before 6 months of age and after puberty, and caudal block anesthesia increased the rate of GD. CONCLUSIONS The rate of GD increases after proximal, cripple and staged hypospadias surgeries, a glans width <15 mm and UP width <8 mm, postpubertal surgeries, and caudal anesthesia use during surgery.
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Affiliation(s)
- Ramazan Karabulut
- Gazi University, Faculty of Medicine, Department of Pediatric Surgery, Ankara, Turkey.
| | - Z Turkyilmaz
- Gazi University, Faculty of Medicine, Department of Pediatric Surgery, Ankara, Turkey
| | - A Atan
- Gazi University, Faculty of Medicine, Department of Urology, Ankara, Turkey
| | - C Kaya
- Gazi University, Faculty of Medicine, Department of Pediatric Surgery, Ankara, Turkey
| | - K Sonmez
- Gazi University, Faculty of Medicine, Department of Pediatric Surgery, Ankara, Turkey
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Snodgrass W, Bush N. Recurrent ventral curvature after proximal TIP hypospadias repair. J Pediatr Urol 2021; 17:222.e1-222.e5. [PMID: 33339735 DOI: 10.1016/j.jpurol.2020.11.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/19/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
EXTENDED SUMMARY Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened while preserving the urethral plate to use TIP repair. That is usually done by dorsal plication (DP). However, we reported recurrent VC was commonly found after DP in boys with proximal urethroplasty complications, and have diagnosed VC in patients similarly straightened by WS. We reviewed our proximal TIP patients and now report their recurrent VC. METHODS We used a prospectively-maintained database to identify all patients with proximal TIP by WS and document recurrent VC. Penile straightening was primarily done by midline DP using 5-0 or 6-0 polypropylene, and/or other maneuvers including combinations of urethral plate elevation off the corpora, mobilization of the urethra to the external sphincter, and ventral corporotomies. Recurrent VC was suspected by a characteristic 'hunched-over' appearance and resistance to lifting the glans cephalad (Figure), and confirmed in all cases by artificial erection intraoperatively. RESULTS 58 of the 77 patients with follow up had VC straightened. Recurrent VC was diagnosed in 26%. It was suspected during this review in another 10% who had recurrent urethroplasty complications which we now know often indicate VC, or urethral plate elevation with no treatment for corporal disproportion. This recurrent VC was objectively measured in nearly half those diagnosed, averaging 52 (30-75). It was diagnosed before puberty in all cases. There was no difference in recurrent VC in those managed with DP alone versus those straightened by DP and/or other maneuvers. DISCUSSION The finding that 1 of every 4 patients had recurrent VC after proximal TIP, and that as many as 1 of every 3 might have had that complication, is concerning. During most the study the extent of VC was visually estimated, and most patients were thought to have <45° with no tension on the UP after straightening. We reported 70% of patients operated elsewhere for proximal hypospadias and presenting with urethroplasty complications had recurrent VC ≥ 30° following earlier DP. In that series, in the current patients, and in an earlier report by Braga et al., an intact urethral plate correlated with increased risk for recurrent VC. Despite our improved ability to diagnose recurrent VC, we have not found it in boys who underwent STAG repair with urethral plate transection. CONCLUSIONS Recurrent VC after proximal TIP repair occurred in at least 1 of every 4 patients despite DP and/or additional maneuvers to straighten the penis while preserving the urethral plate. Accordingly, we now only perform proximal TIP when there is little (<30°) or no VC.
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Affiliation(s)
- Warren Snodgrass
- Hypospadias Specialty Center, 3716, Standridge Drive, Suite 200, Colony, TX, 75056, USA.
| | - Nicol Bush
- Hypospadias Specialty Center, 3716, Standridge Drive, Suite 200, Colony, TX, 75056, USA.
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Misra D, Amin AM, Vareli A, Lee L, McIntosh M, Friedmacher F. Urethral fistulae following surgery for scrotal or perineal hypospadias: A 20-year review. J Pediatr Urol 2020; 16:447.e1-447.e6. [PMID: 32654895 DOI: 10.1016/j.jpurol.2020.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/04/2020] [Accepted: 06/12/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Urethral fistulae (UF) following hypospadias surgery can be a frustrating complication with reports of even 15 attempts to close a difficult fistula (Richter 2003). UF occurring in scrotal or perineal hypospadias (SPH) pose a further challenge because of the under-virilised penis. OBJECTIVE To review the outcomes of a single surgeon's experience over 20 years of managing UF in SPH. To analyse the traditional approach of fistula closure and three alternative techniques. MATERIALS AND METHODS A prospectively maintained database of patients who underwent hypospadias surgery for SPH from January 1997 to September 2018 was reviewed. Patients with UF were identified and their data recorded. The techniques of fistula closure were: a-Traditional approach. b Purse-string closure. c. Right angle intersection technique where the skin and urethra are closed at right angles to each other. d Anchoring skin to corpora away from the fistula closure. RESULTS 32 patients with 41 fistulae were identified. Follow-up ranged from 1 to 18 years. 10/32 (31%) had concomitant meatal stenosis or urethral strictures. The sites of UF were: penoscrotal 19/41 (46%), midpenile 14/41 (34%), coronal or subcoronal in 8/41 (20%). One fistula resolved spontaneously after a single urethral dilatation. 4 patients with a coronal fistula were laid open to the glandular meatus creating a coronal hypospadias, with redo-urethroplasty later (in 2 a buccal graft was used). Of the rest, 29 fistulae were cured after one surgery, while 7 needed two attempts. No patient needed more than two surgeries to close the fistula. The recurrence rates were as follows- Purse-string suture: 10%, Right angle intersection technique: 14.3%, Anchoring skin to corpora: 16.7%, Traditional approach: 21.7%. Although the purse-string suture technique had the lowest recurrence rate, the figures did not reach statistical significance (P-0.95). CONCLUSION Urethral fistulae occurring in SPH pose challenges because of the under-virilised penis. A third of patients may have meatal stenosis or urethral strictures which must be identified and dealt with. The three novel techniques we employed helped drive down our recurrence rate. Purse string sutures reduce the weak area to a dot and are an excellent way to deal with small fistulae (<5 mm). Other innovations include offsetting the skin suture line by anchoring it to the penile shaft well away from the fistula repair or closing the fistula and skin at right angle to each other. The fact that no patient needed more than two operations to lose the UF, was gratifying.
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Affiliation(s)
- Devesh Misra
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK.
| | - Amir Mohd Amin
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Anastasia Vareli
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Leonie Lee
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Mikhailia McIntosh
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Florian Friedmacher
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
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Han JH, Song SH, Lee JS, Park S, Kim SJ, Kim KS. Efficacy of additional tunica vaginalis flap coverage for protecting against urethrocutaneous fistulas in tubularized incised plate urethroplasty: A prospective, randomized controlled trial. Investig Clin Urol 2020; 61:514-520. [PMID: 32734722 PMCID: PMC7458875 DOI: 10.4111/icu.20200024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We compared the protective effect of additional tunica vaginalis flap coverage combined with a dartos flap against urethrocutaneous fistulas in tubularized incised plate (TIP) urethroplasty in a randomized controlled trial. MATERIALS AND METHODS This prospective, randomized controlled trial in a single tertiary center enrolled 50 patients in whom it was feasible to perform single TIP urethroplasty between 2016 and 2017. Consecutive children were randomly allocated to study group A (additional tunica vaginalis flap coverage, n=25) or control group B (dartos-only coverage, n=25). All patients were examined in the outpatient clinic at 1, 3, 12, and 24 months. Postoperative cosmetic outcomes were evaluated by surgeons and parents using the Pediatric Penile Perception Scale questionnaire. RESULTS In group B, 1 of 25 patients (4.0%) developed an urethrocutaneous fistula within 12 months. An additional two cases of fistula were found in all proximal-type hypospadias patients at 24 months in the same group without statistical significance (p=0.07). The penile cosmetic satisfaction rate was not significantly different between the groups according to scores on the Pediatric Penile Perception Scale. CONCLUSIONS Our randomized controlled trial did not show a significant decrease in the incidence of or a significant slowing of the progression of postoperative fistulas after TIP urethroplasty by the use of additional tunica vaginalis coverage. A tunica vaginalis flap is not routinely recommended but could have a selective role in proximal-type TIP urethroplasty with deficient dartos and subcutaneous tissue to cover the neourethra.
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Affiliation(s)
- Jae Hyeon Han
- Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang Hoon Song
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Seong Lee
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Sungchan Park
- Department of Urology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sung Jin Kim
- Department of Urology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Kun Suk Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Two-stage repair of proximal hypospadias with moderate to severe chordee using inner preputial skin graft: prospective evaluation of functional and cosmetic outcomes. World J Urol 2020; 38:2873-2879. [PMID: 31938842 DOI: 10.1007/s00345-020-03075-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 01/02/2020] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To critically evaluate inner preputial graft (IPG) used in staged proximal hypospadias with severe chordee regarding cosmetic and functional outcomes. PATIENTS AND METHODS In this prospective study, patients with primary proximal hypospadias with moderate to severe chordee (> 30°) after penile degloving were considered candidates for staged repair between June 2011 to July 2017. After transection of the urethral plate (UP) and penile straightening, the bare shaft was covered with IPG. Tubularization of the graft was done as a second stage. Cosmetic and functional outcomes were assessed using HOSE score and uroflowmetry (UF). Additionally, factors influencing success were analyzed. RESULTS In all, 38 consecutive cases were included. Native meatus was at proximal penile in 17, penoscrotal in 11, scrotal in 7, and perineal in 3 cases. Median age was 26 and 32 months at the first stage and the second stage, respectively. Preoperative testosterone was given for ten patients with a small penis and/or severe curvature. The mean follow-up was 18 ± 8.2, median 15 months. Grafts took well in all cases after the first stage except one. Cosmetic success achieved in 33 (86.8%). A total of ten complications occurred in six cases. Unplanned intervention was needed in 5/38 cases. Functionally, UF study revealed normal flow in 7/23 (30.4%), equivocal in 11/23(47.8%), and obstructed flow in 5/23(21.7%). CONCLUSION Inner preputial graft use in proximal hypospadias with moderate to severe chordee seems to have a good technical outcome and functionally mimic the normal urethral function and could be considered an ideal option for substitution urethroplasty.
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Manasherova D, Kozyrev G, Nikolaev V, Abdullaev F, Abdulkarimov G, Kushnir B, Gazimiev M. Bracka's Method of Proximal Hypospadias Repair: Preputial Skin or Buccal Mucosa? Urology 2019; 138:138-143. [PMID: 31901472 DOI: 10.1016/j.urology.2019.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/16/2019] [Accepted: 12/23/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze treatment results of staged surgical repair of proximal forms of hypospadias according to Bracka's technique using preputial vs buccal grafts. MATERIAL AND METHODS We retrospectively reviewed 220 patients with proximal forms of hypospadias treated with Bracka's urethroplasty technique. They were divided into 2 groups: Group I-108 patients treated with preputial skin grafts in 2001-2013; Group II-112 patients who underwent urethroplasty with buccal mucosa grafts in 2013-2016. RESULTS AND DISCUSSION Of the Group I patients with preputial skin grafts, complications were obtained in 33 (31%) cases; in Group II-23 (20%) cases. Complications include fistulas, defects of urethra, and scar contraction of grafts. The cosmetic results according to Hypospadias Objective Penile Evaluation scale were more satisfactory when buccal mucosa grafts were used. Further studies are needed to analyze the long-term changes posturethroplasty with both preputial skin and buccal mucosa grafts. CONCLUSION This is one of the only studies to compare complications and histology of the 2 free grafts: preputial skin and buccal mucosa. This study affirms that a staged surgical method with the use of free grafts according to Bracka's technique is a successful method of treatment of proximal forms of hypospadias in children achieving good functional and cosmetic results with a relatively low rate of complications.
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Affiliation(s)
- Dina Manasherova
- Moscow State University, Faculty of Fundamental Medicine, Moscow, Russia.
| | - German Kozyrev
- Uroandrology Department of the Russian Children's Clinical Hospital of the Russian Ministry of Health, Moscow, Russia.
| | - Vasily Nikolaev
- Uroandrology Department of the Russian Children's Clinical Hospital of the Russian Ministry of Health, Moscow, Russia
| | - Fuad Abdullaev
- Uroandrology Department of the Russian Children's Clinical Hospital of the Russian Ministry of Health, Moscow, Russia
| | - Gamzat Abdulkarimov
- Uroandrology Department of the Russian Children's Clinical Hospital of the Russian Ministry of Health, Moscow, Russia
| | - Berta Kushnir
- Department of Anatomical Pathology of the Russian Children's Clinical Hospital of the Russian Ministry of Health, Moscow, Russia
| | - Magomed Gazimiev
- Urology Department of Sechenov First Moscow State Medical University, Moscow, Russia
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Bandini M, Sekulovic S, Stanojevic N, Spiridonescu B, Pesic V, Sansalone S, Slavkovic M, Briganti A, Salonia A, Montorsi F, Djinovic R. Prevalence and surgical management of pubic hypertrophy in hypospadias patients: results from a high-volume surgeon. Int Braz J Urol 2019; 45:1238-1248. [PMID: 31808413 PMCID: PMC6909876 DOI: 10.1590/s1677-5538.ibju.2019.0267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/19/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction: Pubic hypertrophy, defined as an abnormal and abundant round mass of fatty tissue located over the pubic symphysis, is frequently underestimated in patients with hypospadias. We examined the prevalence of this condition, as well as the outcomes associated with its surgical treatment. Material and methods: Within 266 hypospadias patients treated at our clinic, we assessed the prevalence of pubic hypertrophy, and we schematically described the surgical steps of pubic lipectomy. Multivariable logistic regression (MLR) tested for predictors of pubic hypertrophy. Finally, separate MLRs tested for predictors of fistula and any complications after pubic lipectomy. Results: Of 266 hypospadias patients, 100 (37.6%) presented pubic hypertrophy and underwent pubic lipectomy. Patients with pubic hypertrophy more frequently had proximal hypospadias (44 vs. 7.8%), disorders of sex development (DSD) (10 vs. 0.6%), cryptorchidism (12 vs. 2.4%), and moderate (30°-60°) or severe (>60°) penile curvature (33 vs. 4.2%). In MLR, the location of urethral meatus (proximal, Odds ratio [OR]: 10.1, p<0.001) was the only significant predictor of pubic hypertrophy. Finally, pubic lipectomy was not associated with increased risk of fistula (OR: 1.12, p=0.7) or any complications (OR: 1.37, 95% CI: 0.64-2.88, p=0.4) after multivariable adjustment. Conclusions: One out of three hypospadias patients, referred to our center, presented pubic hypertrophy and received pubic lipectomy. This rate was higher in patients with proximal hypospadias suggesting a correlation between pubic hypertrophy and severity of hypospadias. Noteworthy, pubic lipectomy was not associated with increased risk of fistula or any complications.
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Affiliation(s)
- Marco Bandini
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, BelMedic General Hospital, Belgrade, Serbia.,Division of Oncology and Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Sasha Sekulovic
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, BelMedic General Hospital, Belgrade, Serbia
| | - Nikola Stanojevic
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, BelMedic General Hospital, Belgrade, Serbia
| | - Bogdan Spiridonescu
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, BelMedic General Hospital, Belgrade, Serbia.,Clinical Institute Fundeni, Center for Uronephrology and Renal Transplantation, Bucharest, Romania
| | - Vladislav Pesic
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, BelMedic General Hospital, Belgrade, Serbia
| | - Salvatore Sansalone
- Department of Experimental Medicine and Surgery, University of Tor Vergata, Rome, Italy
| | - Milan Slavkovic
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, BelMedic General Hospital, Belgrade, Serbia
| | - Alberto Briganti
- Division of Oncology and Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Division of Oncology and Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology and Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Rados Djinovic
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, BelMedic General Hospital, Belgrade, Serbia
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Prevalence, assessment and surgical correction of penile curvature in hypospadias patients treated at one European Referral Center: description of the technique and surgical outcomes. World J Urol 2019; 38:2041-2048. [PMID: 31654219 DOI: 10.1007/s00345-019-02961-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/13/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Penile curvature (PC) is a common component of hypospadias, but its presence is inconstantly assessed. We aim to report prevalence of PC in hypospadias patients, as well as to report our method to assess and correct PC, with the associated postoperative outcomes. METHODS We scrutinized 303 pediatric hypospadias patients operated (2013-2018) at our referral center. PC was routinely assessed and eventually corrected with dorsal plications (DP) as one-stage procedure, or ventral tunica attenuations ± DP as two-stage repair. PC severity and surgical treatment of PC were compared between primary and failed hypospadias. Finally, PC severity, failed repair and PC treatment were tested as predictors of perioperative complications. RESULTS PC (> 10°) was identified in 274/303 (90.4%) patients, 86.1% with distal, 91.8% with midshaft, and 100% with proximal hypospadias, respectively. PC was found in 51/64 (79.7%) of failed hypospadias. One-stage and two-stage procedures were adopted in 211/274 (77%) and 63/274 (23%) children, respectively. PC severity (p = 0.1) and PC treatment (p = 0.4) did not differ between primary and failed hypospadias. PC severity (all p > 0.2), failed repair (p = 0.8), and PC treatment (all p > 0.09) were not predictors of perioperative complications. 95.6% of patients achieved a straight penis. CONCLUSION Less than 1/10 patients did not require PC correction. High rate of residual PC in failed hypospadias and similar severity between failed and primary suggest that PC was usually under-corrected. It is possible to correct PC completely and the resulting complication would not be associated with PC severity, failed repair or treatment adopted.
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Persistent or recurrent ventral curvature after failed proximal hypospadias repair. J Pediatr Urol 2019; 15:344.e1-344.e6. [PMID: 31068257 DOI: 10.1016/j.jpurol.2019.03.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/17/2019] [Accepted: 03/29/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Persistent or recurrent ventral curvature (VC) in patients with complications after proximal hypospadias repair is reported. METHODS Records of patients undergoing re-operation for complications after proximal repair performed elsewhere were reviewed, including earlier operative reports when available. Original extent of VC, means used for straightening, and presenting complaints and findings at re-operation were tabulated. Ventral curvature at re-operation was objectively measured by goniometry and classified as due to short ventral skin and/or scarring of skin/dartos, short neourethra, or short ventral corpora (corporal disproportion). The finding of corporal disproportion at re-operation was considered to be failure of initial straightening. RESULTS There were 73 patients with an average of 2.7 [1-5] prior operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50° (30-90). This was due to short skin/scarring in 7% patients, a short neourethra in 23%, and corporal disproportion in 70%. Initial straightening was performed by chordee excision in 18 patients, dorsal plication in 23, and ventral lengthening in 15. Persistent or recurrent corporal disproportion was significantly more likely after chordee excision or dorsal plication than after ventral lengthening (p = 0.005). Of patients with VC, 93% also had urethroplasty complications, including recurrent fistulas and wound dehiscences that appeared related to the curvature. DISCUSSION The VC that was encountered during proximal hypospadias re-operations was important for several reasons. First, all patients with VC who had completed urethroplasty had complications that included recurrent fistulas and wound dehiscences (Figure). Even if they had healed without complications, this VC exceeded 30° in all cases, which is associated with sexual dysfunction in adults. This VC was not reported by 37% of caregivers and sometimes not apparent on pre-operative physical examination. It is possible there is selection bias in this series, although nearly all patients were self-referred for complications, and nearly 40% of them were not aware their son had VC. Furthermore, the finding that most initially had dorsal plication agrees with an earlier survey of pediatric urologists' preferences for straightening penile curvature. CONCLUSIONS The most common complication in this series was persistent or recurrent VC, and nearly all these patients also had urethroplasty complications. This VC was more likely when the urethral plate was preserved during straightening and when chordee excision or dorsal plication rather than ventral lengthening was performed. These data suggest that surgeons should objectively measure VC and consider ventral lengthening rather than chordee excision or dorsal plication when it is ≥ 30°. Re-operations for urethroplasty complications should include artificial erection.
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Staged transverse preputial island flap urethroplasty for proximal hypospadias: a single-center experience. Pediatr Surg Int 2019; 35:823-827. [PMID: 31049665 DOI: 10.1007/s00383-019-04480-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the intermediate outcomes of our institution's experience with staged TPIF urethroplasty for proximal hypospadias repair. METHODS We retrospectively evaluated the medical records of patients who underwent repair of proximal hypospadias using staged TPIF urethroplasty at our hospital from 2011 to 2017. RESULTS One hundred and two patients were included in the present study. The mean follow-up was 52.4 months (range 13-74 months). The mean age at the time of the first surgery was 13.5 months (range 11-65 months). There were two main types of initial complications including meatal stenosis in four (3.9%) and urethrocutaneous fistula in three (2.9%) patients after the first stage. Surgical complications were seen in 15 patients after second stage, including urethrocutaneous fistulas in 8 (7.8%), urethral strictures in 5 (4.9%), urethral diverticula in 2 (1.9%). Overall complication rates after second stage were 14.7%. The incidence of fistulas was lower in patients who underwent repair with a tunica vaginalis flap (1/29, 3.4%) than with the dartos fascia (7/73, 9.6%; p = 0.435). CONCLUSIONS Our results show that staged TPIF urethroplasty is a viable and durable technique for primary severe proximal hypospadias. This procedure was associated with a 14.7% complication rate in the present study. Staged TPIF urethroplasty can reduce the incidence of urethral strictures and diverticula associated with the second stage.
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21
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Pescheloche P, Parmentier B, Hor T, Chamond O, Chabaud M, Irtan S, Audry G. Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience. J Pediatr Urol 2018; 14:421.e1-421.e6. [PMID: 29859768 DOI: 10.1016/j.jpurol.2018.03.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/31/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Fistulas are a common complication of hypospadias surgery; they are more frequent after mid-shaft and posterior hypospadias repair. Surgical treatment of fistula still remains challenging with a significant failure rate. The basic principle is to add layers between skin and neourethra in order to decrease the incidence of recurrent urethrocutaneous fistula (UCF). We report our experience of UCF repair using a vascularized tunica vaginalis flap (TVF) after posterior and mid-shaft hypospadias surgery. MATERIAL AND METHODS A retrospective review of all patients operated on using TVF for UCF in our institution between December 2005 and July 2017 was performed. RESULTS Among 36 cases, TVF was used at a first attempt in 22 patients; 14 children had a prior attempt to close the fistula, and four of them had two surgeries before TVF repair. UCF was respectively penoscrotal (n = 3, 8%), posterior (n = 19, 53%), midshaft (n = 9, 25%) and anterior (n = 5, 14%). The size of the fistula was more than 5 mm in 26 patients. The UCF was treated successfully in every case after one single procedure. In the three children with two fistulas, both fistulas were successfully treated by the same TVF. After an average follow-up time of 45 months there was no recurrence of the initial UCF. In four cases of undescended testis, it was possible to dissect the flap through an inguinal incision and perform an orchydopexy in the same time. One patient presented a testicular atrophy after undescended testis surgery. DISCUSSION Area review of published series shows excellent results in UCF repair including recurrent fistula (Table). TVF can aspire to some advantages with regard to a dartos flap (DF). First of all, a nearly 2.5-fold lower incidence of fistula after fistula repair with TVF than with DF (5.1% vs. 12.2%) has been shown. Secondly, TVF allows treating multiple fistulas, and can also be brought to the anterior part of the penis until the balano preputial furrow, allowing curing anterior fistula. Furthermore, it doesn't lead to aesthetic complications such as penile rotation or distal skin necrosis, which can occur during DF procedures. CONCLUSION TVF is a simple and reproductive technique for UCF repair, with a high success rate. The risk of testicular atrophy has to be considered in case of associated undescended testis surgery, and careful attention must be given to the TVF dissection. This technique should be considered as first choice treatment for any UCF.
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Affiliation(s)
- Pierre Pescheloche
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France.
| | - Benoit Parmentier
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Thevy Hor
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Olivier Chamond
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Maud Chabaud
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Sabine Irtan
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Georges Audry
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
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Acimi S. What is the pathogenesis of proximal hypospadias? Turk J Urol 2018; 44:357-361. [PMID: 29799398 DOI: 10.5152/tud.2018.85530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 12/23/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To report the information concerning the pathogenesis of proximal hypospadias and causes of curvature associated with it. MATERIAL AND METHODS From January 2009 to December 2015, 74 patients underwent repair of proximal hypospadias. In 70 patients we performed a systematic biopsies in the lateral areas of the urethral plate, as well as under this plate. The study of the histological structure of these areas was performed using routine staining with hematoxylin and eosin, and the Masson's trichrome which color the collagen fibers in blue and monoclonal antibody against alpha-smooth muscle actin. RESULTS This prospective study shows that the fibrotic tissue abnormally present on the ventral side of the penis consists of a mixture of fibrous connective tissue, nerve nets, short vessels, and smooth muscle fibers. In contrast to the scrotal dartos, penile dartos fascia does not contain smooth muscle fibers. Therefore, these fibers may come from a blood vessel or spongy tissue which existed during neonatal period in the distal part of the penis before disappearing. In addition, in 13 cases, the presence downstream of the urethral meatus, of a bifurcation of corpus spongiosum into two branches supposes that the corpus spongiosum is form by fusion around the urethra of two mesenchymal bodies. The arterial supply of this purely masculine formation originates from a new vascularization and it is probably, developed under secretion of androgens (angiogenic substances in target tissues). CONCLUSION These findings allow us to suggest that the proximal hypospadias is due to avascular necrosis of the distal part ie. poorly vascularized part of the corpus spongiosum.
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Affiliation(s)
- Smail Acimi
- Department of Visceral Surgery, Children hospital Canastel, Faculty of Medicine, University of Oran, Oran, Algeria
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Ru W, Shen J, Tang D, Xu S, Wu D, Tao C, Chen G, Gao L, Wang X, Shen Y. Width proportion of the urethral plate to the glans can serve as an appraisal index of the urethral plate in hypospadias repair. Int J Urol 2018; 25:649-653. [PMID: 29717506 DOI: 10.1111/iju.13585] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To find a new appropriate evaluation for urethral plate quality in hypospadias repair, with particular interest in the width proportion of the urethral plate to the glans, serving as an appraisal index. METHODS Data were prospectively collected from prepubertal boys who underwent primary tubularized incised plate hypospadias repair between January 2014 and April 2016 in one center. Intrinsic parameters of the penis (meatal location, glans width, urethral plate width and curvature degree) were measured during the operation. Urethroplasty complications were recorded during follow up. The correlation between width proportion of the urethral plate to the glans and urethroplasty complications was analyzed. RESULTS Primary tubularized incised plate repair was carried out in 442 patients (mean age 2.8 years, range 0.5-12 years). At mean follow up of 26 months (range 12-38 months), urethroplasty complications occurred in 59 (13.3%) patients. The width proportion of the urethral plate to the glans was weakly correlated to both the glans width and meatal location. The width proportion of the urethral plate to the glans ranged from 0.18 to 0.73, with a mean of 0.39. The cut-off value of width proportion of the urethral plate to the glans was determined to be 0.36 by the receiver operating characteristic curve. Urethroplasty complications occurred in 17 out of 254 patients (6.7%) with width proportion of the urethral plate to the glans >0.36, and 42 out of 188 patients (22.3%) with width proportion of the urethral plate to the glans ≤0.36. The width proportion of the urethral plate to the glans ≤0.36 showed an increased odds of 4.819-fold (95% confidence interval 2.548-9.112, P < 0.001) risk of urethroplasty complications compared with width proportion of the urethral plate to the glans >0.36. Midshaft and proximal meatal location also increased the risk of urethroplasty complications. CONCLUSIONS The present study highlights the value of the width proportion of the urethral plate to the glans for objectivity and accuracy in urethral plate evaluation, which in turn serves as an independent factor influencing outcomes in tubularized incised plate repair.
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Affiliation(s)
- Wei Ru
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Jing Shen
- Amcare Women's and Children's Hospital, Hangzhou, China
| | - Daxing Tang
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Shan Xu
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Dehua Wu
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Chang Tao
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Guangjie Chen
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Lei Gao
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Xiaohao Wang
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Yiding Shen
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
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Abstract
PURPOSE To know the limits of the preservation of the urethral plate in the correction of the curvature associated with proximal hypospadias. METHODS From January 2002 to January 2015, we treated 224 patients of proximal hypospadias. In 182 cases, we used of the lateral pictures taken during the successive saline erection tests to measure the correction obtained after each stage. RESULTS The analysis of the lateral pictures taken at the successive saline erection tests clearly demonstrated that release of the skin and dartos fascia provides an important correction of the chordee. This correction is complete of all curvature lower than 45 degrees and in 3 fourths of cases for curvatures between 45 and 90 degrees. However, for angles 90 degree and more, the release of the skin and dartos fascia was insufficient in more than 73.7% of cases. And the mobilization of the urethral plate with resection of the underlying fibrous tissue realized gives a very low correction of the chordee (0-20 degrees). CONCLUSIONS The essential factor responsible of curvature associated with proximal hypopsadias is the fibrosis tissue present on the ventral side of the penis. However, in the severe forms, a short urethral plate must be transected to obtain a complete correction of the chordee.
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Bush NC, Snodgrass W. Pre-incision urethral plate width does not impact short-term Tubularized Incised Plate urethroplasty outcomes. J Pediatr Urol 2017; 13:625.e1-625.e6. [PMID: 29133164 DOI: 10.1016/j.jpurol.2017.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/20/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Two reports have found that urethral plate (UP) widths <8 mm before tubularized incised plate (TIP) incision increased urethroplasty complications. The present study measured pre-incision UP width in consecutive boys undergoing TIP to determine if it affected outcomes. METHODS The present study followed the method previously used by Holland and Smith, and Sarhan et al. to measure UP width before creating glans wings or performing midline plate incision in consecutive patients with primary hypospadias and ventral curvature <30°, who all underwent TIP repair (Summary Fig.). Glans width at its widest point was also measured. Multiple logistic regression assessed urethroplasty complications (fistula, glans dehiscence, meatal stenosis/urethral stricture, diverticulum) based on pre-incision UP width, glans width, patient age, and meatal location. RESULTS The UP widths were determined in 224 consecutive primary TIP repairs during 2012-2015: 200 distal, 11 midshaft, and 13 proximal. The UP width was <8 mm in 192/224 (86%) patients. Mean pre-incision width was 6.1 mm (SD 1.5, range 2-11), without difference in UP widths according to meatal location (P = 0.06). Mean post-incision UP width was 12 mm (SD 2.2, range 10-16). Mean change in width after incision (delta/original UP width) was 116% (SD 63, range 20-250). There was follow-up in 186 patients for a mean of 6 months. Urethroplasty complications (five fistulas, six glans dehiscence) were diagnosed in 11 (6%): 9/165 distal, 1/9 midshaft, and 1/12 proximal repairs. There was no difference in those <8 vs ≥8 mm (11/160 vs 0/26, P = 0.17). Similarly, UP width was not different between patients with and without urethroplasty complications. Multiple logistic regression in these 186 patients - including meatal location, UP width, glans width, and age - found only glans width <14 mm was associated with increased odds of urethroplasty complications (OR 19.2, 95% CI 3.5-106, AUC = 0.799). DISCUSSION The data show that pre-incision UP width is not an independent risk factor for urethroplasty complications. However, it is possible that technical factors, such as how deeply the dorsal incision is made or size of the urethral stent, might contribute to this finding by other authors. After watching the TIP repair, Smith stated that the plate incision was deeper than he made. Sarhan et al. reported a mean change of 57% in UP width after incision, whereas the present one was double at 116% (i.e. from 6 mm pre-incision to 12 mm post incision), and they used an 8-Fr catheter. While they stated that they incised the plate deeply, the lower percentage increase in width suggests that it was not as deep as was recommended. CONCLUSIONS The UP width before incision did not increase urethroplasty complications. Surgeons do not need to measure or categorize the UP to determine suitability for TIP repair, as long as the plate incision is made deeply to the corpora.
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Affiliation(s)
- N C Bush
- PARC Urology, 5680 Frisco Square Blvd., Suite 2300, Frisco, 75033, TX, USA.
| | - W Snodgrass
- PARC Urology, 5680 Frisco Square Blvd., Suite 2300, Frisco, 75033, TX, USA
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Oottamasathien S, Hotaling JM, Craig JR, Myers JB, Brant WO. Amniotic therapeutic biomaterials in urology: current and future applications. Transl Androl Urol 2017; 6:943-950. [PMID: 29184795 PMCID: PMC5673810 DOI: 10.21037/tau.2017.09.01] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
To examine the rationale and applications of amniotic tissue augmentation in urological surgery. Published literature in English-language was reviewed for basic science and clinical use of amniotic or amnion-chorionic tissue in genitourinary tissues. Basic science and animal studies support the likely benefit of clinical applications of amnion-derived tissues in a variety of urologic interventions. The broad number of properties found in amniotic membrane, coupled with its immunologically privileged status presents a number of future applications in the urological surgical realm. These applications are in their clinical infancy and suggest that further studies are warranted to investigate the use of these products in a systematic fashion.
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Affiliation(s)
- Siam Oottamasathien
- Department of Surgery and Section of Pediatric Urology, University of Utah, Salt Lake City, Utah, USA.,Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - James M Hotaling
- Department of Surgery and Section of Pediatric Urology, University of Utah, Salt Lake City, Utah, USA.,Department of Surgery and Division of Urology Section of Men's Health, University of Utah, Salt Lake City, Utah, USA
| | - James R Craig
- Department of Surgery and Section of Pediatric Urology, University of Utah, Salt Lake City, Utah, USA.,Department of Surgery and Division of Urology Section of Men's Health, University of Utah, Salt Lake City, Utah, USA
| | - Jeremy B Myers
- Department of Surgery and Section of Pediatric Urology, University of Utah, Salt Lake City, Utah, USA.,Department of Surgery and Division of Urology Section of Men's Health, University of Utah, Salt Lake City, Utah, USA
| | - William O Brant
- Department of Surgery and Section of Pediatric Urology, University of Utah, Salt Lake City, Utah, USA.,Department of Surgery and Division of Urology Section of Men's Health, University of Utah, Salt Lake City, Utah, USA
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Chua ME, Gnech M, Ming JM, Silangcruz JM, Sanger S, Lopes RI, Lorenzo AJ, Braga LH. Preoperative hormonal stimulation effect on hypospadias repair complications: Meta-analysis of observational versus randomized controlled studies. J Pediatr Urol 2017; 13:470-480. [PMID: 28939350 DOI: 10.1016/j.jpurol.2017.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Michael E Chua
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michele Gnech
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Section of Pediatric Urology, Urology Unit, University Hospital of Padova, Padua, Italy
| | - Jessica M Ming
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Stephanie Sanger
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | | | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Luis H Braga
- Department of Urology, McMaster Children's Hospital and University, Hamilton, ON, Canada; Department of Surgery/Urology, McMaster University, Hamilton, ON, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
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Current challenges with proximal hypospadias: We have a long way to go. J Pediatr Urol 2017; 13:457-467. [PMID: 28549608 DOI: 10.1016/j.jpurol.2017.03.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/17/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Proximal hypospadias repair has continued to challenge the pediatric urologist despite great efforts to develop better techniques for repair. METHODS In this article, we review the literature regarding modern proximal hypospadias repair approaches and outcomes. We also present our current approach to proximal hypospadias repair surgery and outcome tracking. Finally, we review the literature on surgical outcome tools that may help us standardize research. RESULTS Proximal hypospadias repair has significant variability in technique. Overall modern data would suggest that we require great improvement in our surgical management of this challenging problem. Though tools exist to begin to standardize the reporting of hypospadias outcomes, collaborative efforts are still required for future research. CONCLUSION Future research in proximal hypospadias repair needs to utilize new reporting tools as well as engage in collaborative efforts between institutions.
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Snodgrass W, Bush NC. Re-operative urethroplasty after failed hypospadias repair: how prior surgery impacts risk for additional complications. J Pediatr Urol 2017; 13:289.e1-289.e6. [PMID: 28043766 DOI: 10.1016/j.jpurol.2016.11.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 11/14/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE The primary aim of this report was to compare urethroplasty complications for primary distal and proximal repairs with those after 1, 2, 3, and 4 or more re-operations. METHODS Prospectively collected data on consecutive hypospadias repairs (tubularized incised plate (TIP), inlay, two-stage graft) from 2000 to 2015 were reviewed. Isolated fistula closures were excluded. Extracted information included patient age, meatal location, repair type, primary vs. re-operative surgery, number of prior operations, any testosterone use, glans width, and urethroplasty complications. Pre-operative testosterone stimulation was used during the study period until 2012. Initially, it was given for a subjectively small-appearing glans, but from 2008 to 2012 use was determined by glans width <14 mm. Patients initially managed elsewhere were queried for any testosterone treatment. The number of prior operations was determined by patient history and confirmed by review of records. Calibrations, dilations, cystoscopies, and/or isolated skin revisions were not considered as prior urethroplasty operations. Multiple logistic regression was performed for all patients, and for the subset of patients undergoing re-operation, using stepwise regression for the following potential risk factors: meatal location (distal vs. midshaft/proximal), number of prior surgeries (0, 1, 2, 3, ≥4), pre-operative testosterone use (yes/no), small glans (<14 vs. ≥14), surgery type (TIP, inlay and two-stage graft), and age (continuous in months), with P-values <0.05 considered statistically significant. RESULTS In contrast to the 135/1085 (12%) complication rate in patients undergoing primary distal and proximal TIP repair, re-operative urethroplasty complications occurred in 61/191 (32%) TIP, 16/46 (35%) inlay, and 49/124 (40%) two-stage repairs, P<0.0001. Data regarding testosterone use was available for 1490 (96%) patients. A total of 139 received therapy, of which 65 (46%) had urethroplasty complications vs. 229 of 1351 (16%) without treatment, P = 0.0001. Logistic regression in 1536 patients demonstrated that each prior surgery increased the odds of subsequent urethroplasty complications 1.5-fold (OR 1.51, 95% CI 1.25-1.83), along with small glans <14 mm (OR 2.40, 95% CI 1.48-3.87), mid/proximal meatal location (OR 2.54, 95% CI 1.65-3.92), and use of pre-operative testosterone (OR 2.57, 95% CI 1.53-4.31); age and surgery type did not increase odds (AUC = 0.739). DISCUSSION Urethroplasty complications doubled in people undergoing a second hypospadias urethroplasty compared with those undergoing primary repair. This risk increased to 40% with three or more re-operations. Logistic regression demonstrates that each surgery increases the odds for additional complications 1.5-fold. Mid/proximal meatal location, small glans <14 mm, and use of pre-operative testosterone also significantly increase odds for complications. These observations support the theory that previously operated tissues have less robust vascularity than assumed in a primary repair, and suggest additional adjunctive therapies are needed to improve wound healing in re-operations. The finding that even a single re-operative urethroplasty has twice the risk for additional complications vs. a primary repair emphasizes the need for hypospadias surgeons to 'get it right the first time'. The fact that 40% of the re-operative urethroplasties in this series followed distal repairs emphasizes that there is no 'minor' hypospadias. CONCLUSIONS A single re-operative hypospadias urethroplasty has twice the risk for additional complications vs. the primary repair, which increases to 40% with three or more re-operations. These results support a theory that vascularity of penile tissues decreases with successive operations, and suggest the need for treatments to improve vascularity. The higher risk for complications during re-operative urethroplasties also emphasizes the need to get the initial repair correct.
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Affiliation(s)
- W Snodgrass
- PARC Urology, 5680 Frisco Square Blvd, Suite 2300, Frisco, TX 75034, USA.
| | - N C Bush
- PARC Urology, 5680 Frisco Square Blvd, Suite 2300, Frisco, TX 75034, USA
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Outcome of urethroplasty after parenteral testosterone in children with distal hypospadias. J Pediatr Urol 2017; 13:292.e1-292.e7. [PMID: 28111208 DOI: 10.1016/j.jpurol.2017.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/04/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pre-operative testosterone use in hypospadias surgery is known to increase penile dimensions and vascularity, which should facilitate tension-less formation of the urethral tube and tissue healing. However, androgens can have a negative effect on wound healing. There are very few randomized studies on postoperative results after androgen use, and this study attempted to understand the utility of pre-operative testosterone in distal hypospadias. OBJECTIVE To study the effect of parenteral testosterone in children undergoing single stage urethroplasty for distal hypospadias, especially the occurrence of urethrocutaneous fistula and wound dehiscence. DESIGN Patients were prospectively enrolled and randomized into two groups: Group 1 (control group) and Group 2 (receiving three injections of pre-operative intramuscular testosterone enanthate (2 mg/kg) at 1 monthly intervals; they were further subdivided into those operated 1 month (Group 2A) or 3 months (Group 2B) later. Patients with micropenis, previous testosterone use or any surgical intervention were excluded. Preputial skin was studied with hematoxylin and eosin (H&E) staining and CD31 immunohistochemistry. Patients were followed up for at least 18 months. RESULTS Ninety four patients underwent urethroplasty over a 3.5-year period. Penile dimensions increased significantly after testosterone use (Summary table). On H&E staining, proliferating blood vessels and increased lymphocytic infiltrates were significantly increased in Group 2B. Group 2 patients tended to have more postoperative edema and inflammation. Although urethrocutaneous fistula rates were similar in Group 1 (n = 7) and Group 2 (n = 5) (P = 0.438), wound dehiscence occurred only in Group 2 (P = 0.01). DISCUSSION The total number of patients in this study was small and this was a drawback. Although, several factors played a role in wound healing, the overall higher complication rate, especially wound dehiscence in Group 2, pointed to a higher incidence of inflammatory reaction and healing complication rates with testosterone use. CONCLUSION Testosterone should be used judiciously in distal hypospadias. While tissue availability significantly increased, there was an increase in inflammatory reaction and edema, which increased the risk of wound dehiscence in cases of precocious surgery.
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El Darawany HM, Al Damhogy ME. Urethral Mobilization as an Alternative Procedure for Distal Hypospadias Repair. Urology 2017; 104:183-186. [DOI: 10.1016/j.urology.2017.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 11/16/2022]
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Intermediate-Term Followup of Proximal Hypospadias Repair Reveals High Complication Rate. J Urol 2017; 197:852-858. [DOI: 10.1016/j.juro.2016.11.054] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 11/20/2022]
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Abstract
This review summarizes data regarding commonly used surgical techniques to repair distal and proximal hypospadias. We review evidence concerning indications for various procedures used in primary hypospadias repair, and their complications, urinary function and esthetic results. Available evidence suggests TIP is preferable to Mathieu for distal hypospadias correction. Current data do not identify a clear preference between TIP and onlay flap for proximal repair when there is ventral curvature <30°, or between various flap and graft options when curvature is >31°. A review of objective data helps clarify decision-making for distal hypospadias repair. Additional objective evidence is needed to identify preferred options for proximal hypospadias repair. Measuring glansplasty dimensions (meatal size and distance from meatus to corona) may improve urinary function assessments, and provide additional objective data for decision-making between various surgical techniques.
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Springer A, Tekgul S, Subramaniam R. An Update of Current Practice in Hypospadias Surgery. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.eursup.2016.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Moscardi PRM, Gosalbez R, Castellan MA. Management of High-Grade Penile Curvature Associated With Hypospadias in Children. Front Pediatr 2017; 5:189. [PMID: 28929092 PMCID: PMC5591333 DOI: 10.3389/fped.2017.00189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/16/2017] [Indexed: 11/16/2022] Open
Abstract
Penile curvature is a frequent feature associated with hypospadias with also a great variability of severity among each patient. While the low-grade curvature (<30°) can be relatively easily corrected by simple techniques like penile degloving and dorsal plication, severe cases often demand more complex maneuvers to manage it. A great number of surgical techniques have been developed to adequately correct curvatures greater than 30°; however, each one of them should be individualized to different patients and local conditions encountered. In this article, we will review the evaluation of the pediatric patient with penile curvature associated with hypospadias with a special attention to high-grade cases, their management, indications for surgical treatment, and several surgical options for their definitive treatment.
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Affiliation(s)
- Paulo R M Moscardi
- Pediatric Urology, Children's Urology Associates, Miami, FL, United States
| | - Rafael Gosalbez
- Pediatric Urology, Children's Urology Associates, Miami, FL, United States
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Tam YH, Pang KKY, Wong YS, Tsui SY, Wong HY, Mou JWC, Chan KW, Lee KH. Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias. Pediatr Surg Int 2016; 32:1087-1092. [PMID: 27473011 DOI: 10.1007/s00383-016-3954-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique. METHODS We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra. RESULTS There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture. CONCLUSIONS Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.
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Affiliation(s)
- Yuk Him Tam
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China.
| | - Kristine Kit Yi Pang
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Yuen Shan Wong
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Siu Yan Tsui
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Hei Yi Wong
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Jennifer Wai Cheung Mou
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Kin Wai Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Kim Hung Lee
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
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Snodgrass W, Bush N. Primary hypospadias repair techniques: A review of the evidence. Urol Ann 2016; 8:403-408. [PMID: 28057982 PMCID: PMC5100143 DOI: 10.4103/0974-7796.192097] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 02/28/2016] [Indexed: 11/23/2022] Open
Abstract
This review summarizes data regarding commonly used surgical techniques to repair distal and proximal hypospadias. We review evidence concerning indications for various procedures used in primary hypospadias repair, and their complications, urinary function and esthetic results. Available evidence suggests TIP is preferable to Mathieu for distal hypospadias correction. Current data do not identify a clear preference between TIP and onlay flap for proximal repair when there is ventral curvature <30°, or between various flap and graft options when curvature is >31°. A review of objective data helps clarify decision-making for distal hypospadias repair. Additional objective evidence is needed to identify preferred options for proximal hypospadias repair. Measuring glansplasty dimensions (meatal size and distance from meatus to corona) may improve urinary function assessments, and provide additional objective data for decision-making between various surgical techniques.
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Abstract
Hypospadias surgery is a humbling art form. The evolution of surgical techniques has made distal hypospadias outcomes favorable, but recent publications suggest that our complication rates for proximal hypospadias are much higher than previously reported. To explain these shortcomings, we examine the literature and focus on the lack of standardized documentation, the subsequent inability to objectify the severity of the phenotype, and the underestimation of complications due to lack of long-term follow up. The variability in surgical technique and the fact that the literature abounds with small case series from single institutions also limits our ability to compare outcomes. We believe that the use of standardized and scored phenotype assessments from diagnosis through the extended postoperative period will allow for improved scientific assessment of outcomes. This will facilitate multi-institution collaboration and tabulation of outcomes, allowing rapid data accumulation and assessment for this rare disorder. As surgeons, we must follow boys through puberty into adulthood and must honestly report our results in order to advance our surgical approach to this complicated problem.
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Affiliation(s)
- Christopher J Long
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas A Canning
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Long CJ, Canning DA. Hypospadias: Are we as good as we think when we correct proximal hypospadias? J Pediatr Urol 2016; 12:196.e1-5. [PMID: 27296789 DOI: 10.1016/j.jpurol.2016.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Hypospadias surgery is a humbling art form. Although outcomes with distal hypospadias are favorable, recent publications have suggested that the complication rates are much higher than previously anticipated for proximal hypospadias. The present review examined the literature concerning proximal hypospadias, to explore some of the inadequacies and identify some of the reasons behind these shortfalls in the reported data. METHODS A systematic review of the published literature was conducted using keywords relevant to proximal hypospadias and long-term outcomes. RESULTS The literature for hypospadias was reviewed, and outcomes for distal vs proximal variants were compared. The quality of the literature for proximal hypospadias was examined, and the shortcomings that led to underreporting of the surgical outcomes were identified. Special focus was on the lack of standardized documentation, the subsequent inability to objectify the severity of the phenotype, and the underestimation of complications due to lack of long-term follow-up. There was also a great deal of variability in the utilized techniques, and the literature was filled with small case series from single institutions. To enable scientific assessment of outcomes, it is proposed that the following be implemented: acceptance and incorporation of standardized phenotype assessment scores in the pre-operative period, objective intraoperative hypospadias characterization, and postoperative score assessment. CONCLUSIONS Treatment of proximal hypospadias is much less successful than the distal variant. A specialty wide commitment to standardize the hypospadias language is required to make advancement in surgical outcomes. Boys need to be followed through puberty into adulthood, and honest reporting of outcomes must be discussed so that surgical techniques for this complicated disease process can be advanced.
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Affiliation(s)
- C J Long
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Wood Center, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - D A Canning
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Wood Center, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Fahmy O, Khairul-Asri MG, Schwentner C, Schubert T, Stenzl A, Zahran MH, Gakis G. Algorithm for Optimal Urethral Coverage in Hypospadias and Fistula Repair: A Systematic Review. Eur Urol 2016; 70:293-8. [DOI: 10.1016/j.eururo.2015.12.047] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 12/29/2015] [Indexed: 11/30/2022]
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Results of distal hypospadias repair after pediatric urology fellowship training: A comparison of junior surgeons with their mentor. J Pediatr Urol 2016; 12:162.e1-4. [PMID: 27317623 DOI: 10.1016/j.jpurol.2015.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 12/14/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Teaching and learning hypospadias repair is a major component of pediatric urology fellowship training. Educators must transfer skills to fellows, without increasing patient complications. Nevertheless, few studies report results of surgeons during their first years of independent practice. PURPOSE To review outcomes of distal hypospadias repairs performed during the same 2-year period by consecutive, recently matriculated, surgeons in independent practice, and to compare them to results by their mentor (with >20 years of experience). MATERIALS Exposure to hypospadias surgery during fellowship was determined from case logs of five consecutive fellows completing training from 2007-2011. TIP was the only technique used to repair distal hypospadias. No fellow operated independently or performed complete repairs under supervision. Instead, the first 3 months were spent assisting their mentor, observing surgical methodology and decision-making. Then, each performed selected portions under direct supervision, including: degloving, penile straightening, developing glans wings, incising and tubularizing the urethral plate, creating a barrier layer, sewing the glansplasty, and skin closure. Overall fellow participation in each case was <50%. In 2011-2012, urethroplasty complications (fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum) were recorded for consecutive patients undergoing primary distal repair by these recent graduates in their independent practices. The fellow graduating in 2011 provided 1 year of data. All patients undergoing repair during the study period were included in the analysis, except those lost to follow-up after catheter removal. Composite urethroplasty complications were compared between junior surgeons, and between junior surgeons and their mentor, with Fisher's exact contingency test. RESULTS Training logs indicated fellow participation ranged from 76-134 hypospadias repairs, including distal, proximal and reoperative surgeries. Post-graduation case volumes ranged from 25-68 by junior surgeons versus 136 by the mentor. With similar mean follow-up, urethroplasty complication rates were statistically the same between the former fellows, and between them versus the mentor, ranging from 5-13%. Nearly all were fistulas or glans dehiscence. Junior surgeons reported they performed TIP as learned during fellowship, with one exception who used 7-0 polydioxanone rather than polyglactin for urethroplasty. DISCUSSION This is the first study directly comparing hypospadias surgical outcomes by recently graduated fellows in independent practice with those of their mentor. We found junior surgeons achieved similar results for distal TIP hypospadias repair. Although their participation during training largely comprised observation and surgical assistance, with discrete performance of key steps, skills sufficient to duplicate the mentor's results were transferred. These data suggest there should be no learning curve for distal hypospadias after training. This report raises several considerations for surgical educators. First, mentors should review their own results, to be certain that they are correctly performing and teaching procedures. Second, programs need to determine key steps for procedures they teach, and then emphasize their optimal performance. Finally, mentors should expect former fellows to report back their initial results of hypospadias repair to be certain lessons taught were learned. Otherwise, preventable complications resulting from technical errors will be multiplied in the children operated by their trainees as they enter independent practice.
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Abstract
This review discusses means for straightening ventral curvature >30°, and then subsequent urethroplasty using either one-stage flaps or two-stage flaps or grafts. The wide variation in reported results from these various techniques makes determination of best management difficult; however, it is clear that complications for repairs done in major centers can range to ≥50%. Given the rarity of proximal hypospadias with ventral curvature >30°, which occurs in approximately 400 newborns annually in the USA, centers should refer these cases to subspecialists within the group who can then develop and maintain expertise.
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Arnaud A, Ferdynus C, Harper L. Can separation of the scrotal sac in proximal hypospadias reliably predict the need for urethral plate transection? J Pediatr Urol 2016; 12:121.e1-5. [PMID: 26747011 DOI: 10.1016/j.jpurol.2015.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/31/2015] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Alexis Arnaud
- Department of Pediatric Surgery, CHU F Guyon, Bellepierre, Réunion Island, France
| | - Cyril Ferdynus
- Methodology Unit (USM), CHU F Guyon, Bellepierre, Réunion Island, France
| | - Luke Harper
- Department of Pediatric Surgery, CHU F Guyon, Bellepierre, Réunion Island, France.
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Ekinci S, Çiftçi AÖ, Karnak İ, Şenocak ME. Eccentric circummeatal based flap with limited urethral mobilization: An easy technique for distal hypospadias repair. J Pediatr Urol 2016; 12:116.e1-6. [PMID: 26738636 DOI: 10.1016/j.jpurol.2015.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 09/28/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hypospadias is a common congenital anomaly. Over 300 techniques have been described for repairing hypospadias. OBJECTIVE Eccentric circummeatal based flap with combined limited urethral mobilization technique (ECMB-LUM) is a simple procedure to repair distal hypospadias with minimal complication rate. This study presents results of this technique, highlighting surgical pitfalls to achieve the best result. STUDY DESIGN Medical records of patients with distal hypospadias operated on using the same technique between 1998 and 2011 were reviewed retrospectively. Age at surgery, position of meatus preoperatively and postoperatively, duration of urethral catheterization and hospitalization, early and late complications, previous hypospadias repairs, and secondary surgical interventions were evaluated. In the surgical technique an eccentric circummeatal based flap is outlined. The proximal part of the flap is dissected from the underlying urethra and Buck's fascia. If the flap is not long enough, the distal urethra is mobilized a few millimeters (Figure). The eccentric flap is sutured to the tip of the glans. The glans wings are approximated in the midline. A urethral catheter of 6 Fr or 8 Fr is passed and left in the bulbous urethra or the urinary bladder. Diverged limbs of corpus spongiosum are approximated on the urethra, then, the glans and skin of the penile shaft are sutured. RESULTS Of the 171 consecutive patients operated on using the ECMB-LUM technique; 115 had coronal, 47 had subcoronal, and nine had glanular meatus. The mean age at surgery was 4.5 (1-17) years. Patients were hospitalized for 2.2 ± 0.7 days. Mean duration of urethral catheterization was 2.3 ± 0.5 days. All but eight patients had ECBF-LUM as primary repair. There were no early complications such as bleeding, hematoma, and wound infection. All patients voided spontaneously after catheter removal. Late complications were meatal stenosis, urethrocutaneous fistula, meatal regression, and glandular dehiscence (Table). These patients were treated using dilatation, fistula repair, meatoplasty, and secondary repair with the same technique, respectively. Eventually all patients had a vertical slit-like meatus on the tip of a natural looking glans. DISCUSSION The most commonly used distal hypospadias repair techniques are glanular approximation, meatal advancement and glanuloplasty, Koff, Mathieu, Thiersch-Duplay procedure, tubularized incised plate repairs, and modifications of these techniques. Cosmetic and functional results and complication rates of ECMB-LUM technique are comparable with those of the commonly used techniques.
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Affiliation(s)
- Saniye Ekinci
- Hacettepe University Medical Faculty, Department of Pediatric Surgery, Ankara, Turkey.
| | - Arbay Özden Çiftçi
- Hacettepe University Medical Faculty, Department of Pediatric Surgery, Ankara, Turkey
| | - İbrahim Karnak
- Hacettepe University Medical Faculty, Department of Pediatric Surgery, Ankara, Turkey
| | - Mehmet Emin Şenocak
- Hacettepe University Medical Faculty, Department of Pediatric Surgery, Ankara, Turkey
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Snodgrass W, Bush N. TIP hypospadias repair: A pediatric urology indicator operation. J Pediatr Urol 2016; 12:11-8. [PMID: 26515776 DOI: 10.1016/j.jpurol.2015.08.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 08/28/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We review development and evolution of TIP hypospadias repair, including technical changes made to improve its results. We also discuss general risk factors for hypospadias surgical complications. METHODS We describe use of a database with prospective data entry to first identify our most common complications and their frequency, and then to monitor results of technical modifications made to reduce their occurrence. Multiple logistic regression of various factors recorded in the database was done to identify those predicting increased risk for urethroplasty complications. RESULTS Fistula and glans dehiscence are the two most common complications we encountered after TIP repair. Changes in urethral plate tubularization and barrier layers covering the neourethra resulted in a significant reduction in fistulas after proximal TIP. Changes in glansplasty sutures and use of preoperative testosterone to increase glans size did not reduce likelihood for dehiscence, whereas increasing the extent of glans wings dissection did. Logistic regression analysis confirmed proximal meatal location and reoperation predicted increased complications, but also identified glans width ≤ 14 mm as an independent risk factor for hypospadias urethroplasty complications. CONCLUSIONS Systematic, prospective data collection facilitated identification of complications and their risk factors, and provided a means to assess results of modifications made to address them. Limiting the algorithm used for hypospadias repair increases expertise in those techniques used. Reported low surgical volumes for proximal hypospadias repair suggest subspecialization of these cases be carried out so that designated surgeons can achieve sufficient volume to analyze their results and make improvements.
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Dason S, Wong N, Braga LH. The contemporary role of 1 vs. 2-stage repair for proximal hypospadias. Transl Androl Urol 2016; 3:347-58. [PMID: 26813851 PMCID: PMC4708137 DOI: 10.3978/j.issn.2223-4683.2014.11.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Shawn Dason
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Nathan Wong
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Luis H Braga
- Division of Urology, McMaster University, Hamilton, ON, Canada
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Management of Long-Segment and Panurethral Stricture Disease. Adv Urol 2015; 2015:853914. [PMID: 26779259 PMCID: PMC4686630 DOI: 10.1155/2015/853914] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 11/05/2015] [Indexed: 01/18/2023] Open
Abstract
Long-segment urethral stricture or panurethral stricture disease, involving the different anatomic segments of anterior urethra, is a relatively less common lesion of the anterior urethra compared to bulbar stricture. However, it is a particularly difficult surgical challenge for the reconstructive urologist. The etiology varies according to age and geographic location, lichen sclerosus being the most prevalent in some regions of the globe. Other common and significant causes are previous endoscopic urethral manipulations (urethral catheterization, cystourethroscopy, and transurethral resection), previous urethral surgery, trauma, inflammation, and idiopathic. The iatrogenic causes are the most predominant in the Western or industrialized countries, and lichen sclerosus is the most common in India. Several surgical procedures and their modifications, including those performed in one or more stages and with the use of adjunct tissue transfer maneuvers, have been developed and used worldwide, with varying long-term success. A one-stage, minimally invasive technique approached through a single perineal incision has gained widespread popularity for its effectiveness and reproducibility. Nonetheless, for a successful result, the reconstructive urologist should be experienced and familiar with the different treatment modalities currently available and select the best procedure for the individual patient.
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Pfistermuller KLM, McArdle AJ, Cuckow PM. Meta-analysis of complication rates of the tubularized incised plate (TIP) repair. J Pediatr Urol 2015; 11:54-9. [PMID: 25819601 DOI: 10.1016/j.jpurol.2014.12.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 12/22/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine overall complication rates of the tubularized incised plate (TIP) repair and assess the effects of technical modifications, length of follow-up and geographical location of reported results. MATERIALS AND METHODS A systematic literature search was undertaken, using Medline and Pubmed, in order to identify relevant articles. Random effects models were used to estimate pooled complication rates. Meta-regression was performed for each outcome by using mixed effects models with type of hypospadias (primary distal, primary proximal and secondary) as predictors. RESULTS Of the 189 articles that were identified, 49 studies (4675 patients) were included in the analysis. Fistula and re-operation rates were significantly higher in secondary repairs (15.5% and 23.3%) compared to primary proximal (10.3% and 12.2%) and primary distal (5.7% and 4.5%) (P = 0.045 and P < 0.001, respectively). Technical modifications reduced fistula rates from 10.3% to 3.3% (P = 0.003) and re-operation rates from 13.6% to 2.8% (P = 0.001). The rate of meatal stenosis was highest in the secondary repairs, with follow-up >1 year (12.7%). Comparison of geographical location showed that complication rates for all but one variable were significantly lower in North America when compared to Europe and the rest of the world. Mean meatal stenosis rates were 1.8% in North America, 3.4% in Europe and 8.2% in the rest of the world (P = 0.002). This remained significant in a multivariable model incorporating repair technique and length of follow-up (P = 0.046). Mean rates of urethral stricture, fistula and re-operation followed a similar pattern (P = 0.045, P = 0.009 and P < 0.001, respectively). Mean follow-up was shortest in the North American group, at 11.9 months, compared to Europe, at 17.8 months, and the rest of the world, at 18.9 months. DISCUSSION The present meta-analysis has shown that the lowest complication rates for the TIP repair are when it is applied to primary distal hypospadias. Complication rates are higher for all variables when the TIP repair is used for primary proximal hypospadias. Lower complication rates than those reported in this TIP review have been documented in some studies using a staged repair for correction of primary proximal or secondary hypospadias [11,12,68], implying that a staged approach may be superior to the TIP repair in these settings. Documentation of follow-up duration was limited, making assessment of the impact of length of follow-up difficult. Geographical location had a noticeable effect on outcome, with all but one complication being lower in the North American than the other groups. Mean follow-up was shortest in North America and it is suggested that the short follow-up in the North American studies may have led to under-reporting of late complications. CONCLUSION The TIP repair has evolved to incorporate modifications that have significantly lowered complications. Higher complication rates are seen with secondary and proximal repairs; however, limited, published long-term data impair a true assessment of outcome.
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Affiliation(s)
- K L M Pfistermuller
- Department of Urology, Hillingdon Hospital, Hillingdon Hospital NHS Trust, Pield Heath Road, Uxbridge UB8 3NN, United Kingdom.
| | - A J McArdle
- Department of Paediatrics, Northwick Park Hospital, Watford Road, Harrow HA1 3UJ, United Kingdom.
| | - P M Cuckow
- Department of Paediatric Urology, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, United Kingdom.
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Necrosis of the ventral penile skin flap: a complication of hypospadias surgery in children. Adv Urol 2015; 2015:452870. [PMID: 25922604 PMCID: PMC4397417 DOI: 10.1155/2015/452870] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/20/2015] [Accepted: 03/22/2015] [Indexed: 12/02/2022] Open
Abstract
Objectives. To review cases of hypospadias that were repaired with TIPU method and consequently resulted in the necrosis of ventral penile skin flaps. Methods. Eighty-three patients with hypospadias underwent TIPU procedure by two surgeons. Neourethra in all patients was covered with dartos flap prepared from the preputium or penile shaft. In cases where ventral skin could not be covered primarily, closure was ensured by using preputial Ombredanne or Byars' flaps to repair ventral defects. Results. The median age of patients was 4 years. Twenty-five (30.12%) patients that underwent hypospadias repair had urethral opening at the coronal level, 33 (39.75%) at the distal penis, 10 (12.04%) at the midpenis, and 15 (18.07%) at the proximal penis. The ventral skin defect could not be primarily covered in 10 patients with penile shaft hypospadias. Consequently, Byars' method was used in 8 of these patients to cover the defect and the Ombredanne method was used in the remaining 2. Ventral skin flap necrosis developed in 5 patients (4 Byars and 1 Ombredanne). It was medically treated in 4 patients. Urethral fistula developed in the other patient whose necrosis was deeper. The mean hospital stay was 7 days for patients without necrosis, and 14 for those with necrosis. Conclusion. We are of the opinion that dartos flaps used in the TIPU method in order to cover neourethra and decrease the incidence of fistula development lead to necrosis in the Ombredanne or Byars' flaps by causing low blood supply to the preputium and thus extend hospital stay.
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Spinoit AF, Poelaert F, Van Praet C, Groen LA, Van Laecke E, Hoebeke P. Grade of hypospadias is the only factor predicting for re-intervention after primary hypospadias repair: a multivariate analysis from a cohort of 474 patients. J Pediatr Urol 2015; 11:70.e1-6. [PMID: 25797860 DOI: 10.1016/j.jpurol.2014.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 11/11/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is an ongoing quest on how to minimize complications in hypospadias surgery. There is however a lack of high-quality data on the following parameters that might influence the outcome of primary hypospadias repair: age at initial surgery, the type of suture material, the initial technique, and the type of hypospadias. OBJECTIVES The objective of this study was to identify independent predictors for re-intervention in primary hypospadias repair. STUDY DESIGN We retrospectively analyzed our database of 474 children undergoing primary hypospadias surgery. Univariate and multivariate logistic regression was performed to identify variables associated with re-intervention. A p-value <0.05 was considered statistically significant and therefore considered as a prognostic factor for re-intervention. RESULTS Distal penile hypospadias was reported in 77.2% (n = 366), midpenile in 11.4% (n = 54) and proximal in 11.4% (n = 54) of children. Initial repair was based on an incised plate technique in 39.9% (n = 189), meatal advancement in 36.0% (n = 171), an onlay flap in 17.3% (n = 82) and other or combined techniques in 5.3% (n = 25). In 114 patients (24.1%) re-intervention was required (n = 114) of which 54 re-interventions (47.4%) were performed within the first year post-surgery, 17 (14.9%) in the second year and 43 (37.7%) later than 2 years after initial surgery. The reason for the first re-intervention was fistula in 52 patients (46.4%), meatal stenosis in 32 (28.6%), cosmesis in 35 (31.3%) and other in 14 (12.5%). The median time for re-intervention was 14 months after surgery [range 0-114]. Significant predictors for re-intervention on univariate logistic regression (polyglactin suture material versus poliglecaprone, proximal hypospadias, lower age at operation and other than meatal advancement repair) were put in a multivariate logistic regression model. Of all significant variables, only proximal hypospadias remained an independent predictor for re-intervention (OR 3.27; p = 0.012). DISCUSSION The grade of hypospadias remains according to our retrospective analysis the only objective independent predicting factor for re-intervention in hypospadias surgery. This finding is rather obvious for everyone operating hypospadias. Curiously midpenile hypospadias cases were doing slightly better than distal hypospadias in terms of re-intervention rates. Our study however has also some shortcomings. First of all, data was gathered retrospectively and follow-up time was ill-balanced for several variables. We tried to correct this by applying sensitivity analysis, but possible associations between some variables and re-intervention might still be obscured by this. Standard questionnaires to analyze surgical outcome were not available. Therefore, we focused our analysis on re-intervention rate as this is a hard and clinically relevant end point. CONCLUSIONS This retrospective analysis of a large hypospadias database with long-term follow-up indicates that the long-lasting debate about factors influencing the reoperation rate in hypospadias surgery might be futile: in experienced hands, the only variable that independently predicts for re-intervention is the severity of hypospadias, the only factor we cannot modify. This retrospective multivariate analysis of a large hypospadias database with long-term follow-up suggests that the only significant independent predictive factor for re-intervention is proximal hypospadias. In our series, technique did not influence the re-intervention rate.
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Affiliation(s)
| | - Filip Poelaert
- Department of Urology, Ghent University Hospital, Gent, Belgium
| | | | | | - Erik Van Laecke
- Department of Urology, Ghent University Hospital, Gent, Belgium
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium.
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