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

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

INTRODUCTION

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

CD73-positive pediatric urethral mesenchymal stem-like cell-derived small extracellular vesicles stimulate angiogenesis

Introduction

Angiogenesis plays an important role in the repair of urethral injury, and stem cells and their secretomes can promote angiogenesis. We obtained pediatric urethral mesenchymal stem-like cells (PU-MSLCs) in an earlier study. This project studied the pro-angiogenic effect of PU-MSLC-derived small extracellular vesicles (PUMSLC-sEVs) and the underlying mechanisms.

Materials and methods

PUMSLCs and PUMSLC-sEVs were cultivated and identified. Then, biological methods such as the ethynyl deoxyuridine (EdU) incorporation assay, Cell Counting Kit-8 (CCK-8) assay, scratch wound assay, Transwell assay, and tube formation assay were used to study the effect of PUMSLC-sEVs on the proliferation, migration, and tube formation of human umbilical vein endothelial cells (HUVECs). We explored whether the proangiogenic effect of PUMSLC-sEVs is related to CD73 and whether adenosine (ADO, a CD73 metabolite) promoted angiogenesis. GraphPad Prism 8 software was used for data analysis.

Results

We observed that PUMSLC-sEVs significantly promoted the proliferation, migration, and tube-forming abilities of HUVECs. PUMSLC-sEVs delivered CD73 molecules to HUVECs to promote angiogenesis. The angiogenic ability of HUVECs was enhanced after treatment with extracellular ADO produced by CD73, and PUMSLC-sEVs further promoted angiogenesis by activating Adenosine Receptor A2A (A2AR).

Conclusions

These observations suggest that PUMSLC-sEVs promote angiogenesis, possibly through activation of the CD73/ADO/A2AR signaling axis.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dorsal inlay inner preputial graft repair versus ventral-only preputial graft repair in primary distal penile hypospadias with narrow urethral plate

Background

Tubularized incised plate (TIP) is the most common technique used for distal hypospadias repair with good outcome but with a high rate of urethral stricture. Inner preputial-free graft can be used as an inlay graft in the incised area of the narrow urethral plate, also can be used as an onlay graft for urethroplasty in hypospadias repair to avoid this complication.

Patients and Methods

A comparative prospective randomized study was conducted on two groups of hypospadias patients with narrow urethral plate. Group A: dorsal inlay inner preputial graft repair was performed (grafted TIP [G-TIP]) and Group B: ventral onlay preputial graft repair was performed. The assessment of outcome and hypospadias objective scoring evaluation (HOSE) score was done at 2 weeks and 6 months.

Results

Group A included 55 patients for whom dorsal inlay inner preputial graft repair was performed (G-TIP), and Group B which was planned to be conducted on 55 patients using onlay preputial graft (onlay graft) but was terminated after 15 cases due to high failure rate (33%). Group A showed better success rate 96% and better HOSE score (score 16) at 2 months and 6 months 83.6% and 88.2% versus 26.7% and 33.3% in Group B. Postoperative complications showed a statistically significant difference; glans dehiscence (3.6% vs. 40%), wound infection (1.8% vs. 33.3%), and skin sloughing (3.6% vs. 26.7%) in Groups A and B, respectively.

Conclusion

G-TIP is a good technique for the management of distal hypospadias with narrow urethral plate with good success rate, cosmetic outcome, and with less complications compared to onlay graft.

Ultrasonographic Evaluation of the Hypospadiac Penis in Children

INTRODUCTION

Identifying key anatomical features of the hypospadiac penis is crucial to better understanding this pathology and guiding surgical reconstruction plans, thereby achieving superior functional and cosmetic outcomes.

OBJECTIVE

To Assess the feasibility and precision of penile ultrasonography (PUG) in determining key structural features for hypospadias cases (including distal extent of the spongiosal component of the urethral plate, to elucidate the healing process following tubularised incised-plate urethroplasty).

PATIENTS AND METHODS

Twenty-five children with hypospadias were assessed using PUG prior to surgical repair and then again under general anesthesia. Preoperative images were acquired using ultrasonography in sagittal and transverse planes, then later compared with anatomical findings obtained during surgical repair of urethral hypoplasia.

RESULTS

Median patient age was 1.2 years (range 0.5-12) and hypospadias types included coronal 17/25 (68%), mid-penile 5/25 (20%), and proximal penile 3/25 (12%). Distinct layers of the corpus spongiosa and mucosal layer, Buck fascia, tunica albuginea, glans, corpora cavernosa, and penile skin were delineated so that their spatial inter-relationship could be assessed. Distal extent of the spongiosal component of the urethral plate was determined by the mid-glans B-B line. The extent of urethral hypoplasia identified by PUG was relatively similar to measurements obtained intraoperatively.

CONCLUSION

PUG is a feasible and accurate approach to evaluating penile configuration in children with hypospadias. Distal extent of the spongiosal component of the urethral plate was accurately determined, hence PUG could potentially be used to improve surgical planning and appraisal of current repair procedures.

What are the factors affecting glanular dehiscence after hypospadias surgery?

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.

Cosmetic outcomes of grafted tubularized incised plate urethroplasty in primary distal penile hypospadias: prospective comparative study with the classic Snodgrass repair

Background

To compare the outcomes between classic tubularized incised plate (C-TIP), known as Snodgrass urethroplasty, and grafted TIP (G-TIP) in the repair of primary distal penile hypospadias.

Methods

Parents of all children presented to our tertiary care institution with primary distal penile hypospadias were asked to participate in this study. Patients were equally randomized using closed envelope method into two groups; Group A underwent repair using G-TIP and Group B underwent repair using the C-TIP. Circumcised cases and/or cases with penile chordee > 30 degrees were excluded from this study. Urethral catheter was kept for 7 to 10 days after surgery. The success rate and cosmetic outcomes assessed by HOSE score were evaluated at 6-month postoperatively.

Results

A total of 55 patients were recruited in each group. One hundred and seven patients of the 110 patients (54 and 53 in groups A and B, respectively) were evaluated at 6-month postoperatively using HOSE score. All preoperative data were comparable in both groups. Success was documented in 49/54 patients (90.7%) in group A. The five failures were secondary to two cases of glans dehiscence and three cases of residual postoperative chordee. Whereas, success was documented in 48/53 patients (90.5%) in group B. Complications were: a case of meatal stenosis, three cases of fistula, and a case of combined meatal stenosis and fistula. The HOSE score was comparable between the two groups (15.4 ± 1.09 vs. 15.6 ± 0.55; p = 0.29). However, the operative time was statistically longer in the G-TIP compared with the C-TIP (91.4 ± 6.2 min vs. 85.2 ± 6.3 min; p < 0.001), respectively.

Conclusion

The G-TIP urethroplasty provided comparable results with C-TIP in terms of cosmoses, success rate, and complications. However, G-TIP was accompanied with significantly longer operative time.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

DISCUSSION

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

CONCLUSIONS

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

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

INTRODUCTION

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Comparing the outcomes of tubularized incised plate urethroplasty and dorsal inlay graft urethroplasty in children with hypospadias: a systematic review and meta-analysis

BACKGROUND

Excellent outcomes have been reported following the widely accepted tubularized incised plate urethroplasty (TIPU) and its relatively recent modification, the dorsal inlay graft urethroplasty (DIGU). However, there is a lack of consensus on which technique offers more favorable postoperative outcomes.

AIMS

To systematically compare the reported outcomes of the TIPU and DIGU techniques in children undergoing primary hypospadias repair.

DESIGN

A systematic review and meta-analysis of randomized and observational studies.

METHODS

An electronic database search was conducted up to May 2018. Sources included Medline, Embase, Cochrane library, CINAHL, Web of Science, and Google Scholar as well as trial registries and grey literature sources. Studies were selected if they compared the postoperative complications of TIPU and DIGU in children. Secondary outcomes included standardized cosmetic scores and urinary flow studies. A meta-analysis of reported complications was performed using a random-effects model.

RESULTS

Two randomized, two prospective, and two retrospective studies met the inclusion criteria. TIPU and DIGU were performed in 350 and 267 patients, respectively. Pooled analysis did not demonstrate a significant difference regarding postoperative urethrocutaneous fistula, meatal/urethral stenosis, wound dehiscence, or total complications. Subgroup analysis according to hypospadias severity did not alter initial findings. Statistical analysis of secondary outcomes was not feasible due to insufficient data. Most studies were of low methodological quality with a high risk of bias.

CONCLUSIONS

There is no strong evidence to suggest that either technique offers more favorable outcomes. Until more robust randomized trials exist, decisions regarding the appropriate repair should be based on the surgeon's experience and outcomes.

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

Aim:

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

Settings and Design:

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

Methods:

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

Results:

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

Conclusion:

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

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

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

INTRODUCTION

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Pre-incision urethral plate width does not impact short-term Tubularized Incised Plate urethroplasty outcomes

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.

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

Objective

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

Patients and methods

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

Results

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

Conclusion

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

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Microvasculature and healing potential of the inner versus outer preputial skin: preliminary immunohistochemical observations

PURPOSE

To assess healing potential of the inner and the outer layers of the prepuce and to determine which layer is better for hypospadias neourethral reconstruction.

MATERIALS AND METHODS

The study has been carried out to assess the microvessels density and epidermal growth factor receptor (EGFR) concentration in the inner and the outer preputial layers. Specimens from the outer and the inner prepuce were harvested during hypospadias repair in 26 children. Control specimens were collected during elective circumcision of 10 normal and age-matched children. Sections were prepared, and immunohistochemical staining was done using monoclonal antibodies of CD34 (vascular marker) and of the EGFR. CD34-positive microvessels were assessed under the outer and the inner layers of the prepuce and were counted in five high-power fields under each layer. Expression of EGFR in both layers was assessed using H-score system.

RESULTS

The density of microvessels and EGFR expression are significantly higher in control group either for inner or for outer preputial layers (p < 0.05). Microvessels density in the inner prepuce in hypospadias group is slightly higher than that of the outer prepuce (p < 0.05). However, the wider lumen and well-developed wall of the microvessels in the outer layer may compensate for decreased number in comparison with the inner layer. Expression of EGFR was reduced in both inner and outer layers of the hypospadias prepuce with no significant difference (p > 0.05).

CONCLUSION

In hypospadias patients, the healing potential of both inner and outer prepuce is nearly similar. However, it is markedly reduced than that of normal prepuce. It seems that both layers can be used for hypospadias repair without obvious preference to either of them. The usual tradition to use inner prepuce in hypospadias repair has no scientific evidence.