Byars two-stage procedure for hypospadias after urethral plate transection

Application of the modified Byars staged procedure for severe hypospadias repair

ABSTRACT

This study aimed to introduce a modified Byars staged procedure and investigate its application value in patients with severe hypospadias. We retrospectively analyzed the clinical data of patients with severe hypospadias admitted to the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between October 2012 and October 2022. In total, 31 patients underwent the conventional Byars procedure (conventional group), and 45 patients underwent the modified Byars staged procedure (modified group). Our modified strategy was built upon the standard Byars procedure by incorporating glansplasty during the first stage and employing a Y-shaped flap in conjunction with a glandular tunnel for urethroplasty during the second stage. Notably, there were no statistically significant differences in the preoperative baseline characteristics, duration of surgery, amount of blood loss, or occurrence of postoperative complications, including urethral fistula, stricture and diverticulum, or penile curvature, between the conventional and modified groups. However, there was a significantly lower incidence of coronal sulcus fistula (0 vs 16.1%, P = 0.02) and glans dehiscence (0 vs 12.9%, P = 0.02) in the surgical group than that in the conventional group. In addition, the modified group exhibited a notably greater rate of normotopic urethral opening (100.0% vs 83.9%, P = 0.01) and a higher mean score on the Hypospadias Objective Penile Evaluation (HOPE; mean ± standard error of mean: 8.6 ± 0.2 vs 7.9 ± 0.3, P = 0.02) than did the conventional group. In conclusion, the modified Byars staged procedure significantly reduced the risks of glans dehiscence and coronal sulcus fistula. Consequently, it offers a promising approach for achieving favorable penile esthetics, thereby providing a reliable therapeutic option for severe hypospadias.

Effectiveness of penile ventral curvature correction and the trend of hypospadias repair: a prospective study of the national center in China

BACKGROUND

Hypospadias repair is a complex surgical procedure that involves correcting penile ventral curvature (VC) and performing urethroplasty. This study aims to evaluate the effectiveness of different strategies for VC correction and analyse the trends in hypospadias repair at a national centre in China.

METHODS

Prospective data collection was conducted from 2019 to 2020 for patients undergoing hypospadias repair. The effectiveness of VC correction was assessed based on the degree of VC change with different strategies. Furthermore, the choice of surgical techniques for different types of hypospadias repair was analysed.

RESULTS

A total of 434 patients were included, with a median preoperative VC degree of 50° (35°, 70°). All patients achieved a straight penis postoperatively, with 15.2% undergoing degloving, 28.6% undergoing degloving and dorsal plication (DP), 13.1% undergoing degloving and urethral plate transection (UPT), and 43.1% undergoing degloving, UPT and DP. Degloving alone was effective in correcting VC in 57.6% of patients with VC less than 30°. In our analysis, DP after UPT resulted in a higher degree of correction (25°) compared with DP after degloving alone (20°) (p<0.001). The study identified the current trends in hypospadias repair, with tubularised incised plate urethroplasty (TIP) being the most common technique used in distal hypospadias repair (70.6% of patients) and transverse preputial island flap urethroplasty (TPIFU) being preferred for proximal hypospadias repair (63.0%).

CONCLUSIONS

Degloving alone is effective for correcting VC less than 30°. The majority of patients in our centre underwent UPT, and DP after UPT yielded better results compared with DP after degloving alone. Distal hypospadias repair commonly used TIP, while TPIFU was favoured for proximal hypospadias repair.

TRIAL REGISTRATION NUMBER

ChiCTR1900023055.

The effect of staged TIP urethroplasty on proximal hypospadias with severe chordee

Background

Proximal hypospadias with severe chordee is still a formidable challenge for most pediatric urologists, and the treatment approach remains controversial. Here, we describe a modified two-stage technique to repair proximal hypospadias with severe chordee.

Methods

We retrospectively identified 53 children referred for proximal hypospadias with severe chordee from July 2016 to July 2019, who underwent a two-stage urethroplasty. In group 1, the children were repaired with staged tubularized incised plate (TIP) urethroplasty, while Byars’ two-stage urethroplasty was attempted in group 2. We corrected chordee by releasing all remaining attachments to the corpora after degloving the penis, transceting the urethral plate, and dorsal plication. The mean age of patients in the first stage of surgery was 26.6 months in group 1 and 24.8 months in group 2. Postoperative complications in the two groups included: fistula, urethral stricture, urethral diverticulum, and glanular dehiscence.

Results

A total of 20 cases were repaired with staged TIP urethroplasty (group 1), and 33 cases were repaired with Byars’ two-stage urethroplasty (group 2). The length of follow-up in group 1 was 39.8 ± 10.1 months, and in group 2, it was 38.1 ± 8.7 months (P > 0.05). After the second stage of surgery, 1 case (5%) in group 1 and 11 cases (33.3%) in group 2 developed a urinary fistula (P < 0.05). One case (5%) in group 1 and three cases (9.1%) in group 2 had urethral stricture (P > 0.05). All strictures were cured by repeated dilation, and no patient required reoperation. No cases in group 1 and one case (3%) in group 2 had urethral diverticulum (P > 0.05). There was no residual chordee in both groups. Two cases (10%) in group 1 and 13 cases (39.3%) in group 2 required reoperation (P < 0.05).

Conclusions

Staged urethroplasty is appropriate to repair proximal hypospadias with severe chordee. Particularly, staged TIP urethroplasty is a good choice for patients with proximal hypospadias and severe chordee, especially those with better penile development, wider urethral plate, larger glans, and deeper navicular fossa of the urethra.

Experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee: A single institution study with intermediate follow up

PURPOSE

We present our modified technique of using the inner preputial flap to cover the penile shaft, while removing the subcutaneous tissue of the distal part of the flap to act similar to graft. Herein, we present our experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee.

PATIENTS AND METHODS

The current study was a single-institution retrospective study between January 2016 and December 2020. Thirty-one patients with proximal hypospadias with chordee were included and underwent our modified technique. We excluded re-operative hypospadias and incomplete follow-up cases (<6 month of follow up). Patient demographics, outcomes and complications in the form of fistula formation, diverticulum, metal stenosis, stricture formation and glans dehiscence were reviewed.

RESULTS

A total of 31 patients were included in the study and underwent our modified technique. The median age was 18 months (9-60) & IQR 15-25). The median follow up was 40 months. Overall, success was achieved in 24 cases (77.4%). Complications occurred in seven cases (22.6%) and included urethrocutanous fistula in three patients (9.7%), diverticulum in two patients (6.5.%), metal stenosis in one patient (3.2%) and glans dehiscence in one patient (3.2%).

CONCLUSION

Our technique provides a favourable outcome with a low complication rate for repair of proximal severe hypospadias.

LEVEL OF EVIDENCE

Case Series Study (Level IV).

Surgical management of primary severe hypospadias in children: an update focusing on penile curvature

Over the past two decades, assessment and treatment of associated curvature has emerged as a major issue in treating patients with proximal hypospadias. However, the cut-off for defining a curvature as clinically significant is still unclear, as not all patients are bothered by the same degree of curvature and, although the need for a method to assess the curvature objectively has been emphasized, no standard method yet exists. Curvature is multifactorial. The same degree of curvature can be due to any possible combination of skin and/or subcutaneous dartos tethering, a short urethral plate and an intrinsic corpora disproportion. Different strategies can be used to treat curvature, depending on the underlying cause, surgeon preferences, and the goals of the repair. In the past 10 years, use of urethral plate transection and ventral lengthening procedures has increased, although the lack of long-term follow-up data on ventral lengthening procedures suggests that the use of such procedures should be selective. Furthermore, straightening manoeuvres are influenced by the technique used for subsequent urethroplasty and, in turn, may influence the success rate of the urethroplasty. This Review provides a comprehensive overview of the major developments from the past 10 years in the management of severe proximal hypospadias in children.

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.

Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade

BACKGROUND

Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade.

METHODS

A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes.

RESULTS

The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load.

CONCLUSIONS

Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.

Comparative study of one-stage and the novel two-stage urethroplasty using the transected urethral plate and transverse preputial island flap (TPIF) for severe hypospadias: a single-center experience

BACKGROUND

To evaluate a novel two-stage method of urethroplasty using a transected urethral plate and transverse preputial island flap (TPIF) for proximal hypospadias with severe chordee.

METHODS

We retrospectively analyzed 91 cases of proximal hypospadias, who had undergone either one-stage or two-stage urethroplasty. Comparisons between the two groups were made based on age, glans diameter, the length of the urethral defect, and the rate of complications.

RESULTS

There was no significant difference in age at surgery, glans diameter, and the length of urethral defect between the two groups. In the one-stage group, 18 cases of urinary fistula and one case each of glans dehiscence, urethral diverticulum, and urethral diverticulum with concurrent glans dehiscence, were reported. All patients were treated using urinary fistula repair or urethroplasty. In the novel two-stage group, no cases of urinary fistula were reported after the secondary urethroplasty. However, 4 cases showed dehiscence at the glans, 2 were treated through reoperation but the 2 other 2 patients reoperation. The success rate was 62.50% and 88.57% in the one-stage and two-stage groups, respectively (P<0.05).

CONCLUSIONS

Two-stage urethroplasty using a tubularized urethral plate and TPIF can significantly reduce the incidence of urethral fistula of the proximal hypospadias with severe chordee. However, it may increase the number of operations that need to be performed on children who do not need staged surgery. Although we could not prove it through this study, we believe that the necessity of two-stage urethroplasty should be determined based on the development of the glans, the severity of penile curvature, and the length of the urethra defect.

Results of two-stage transverse preputial island flap urethroplasty for proximal hypospadias with chordee that mandate division of the urethral plate

Introduction

Reconstruction of proximal hypospadias with chordee remains a difficult task. Our work aims to evaluate the role of two-stage transverse preputial island flap urethroplasty for repair of proximal hypospadias with chordee.

Material and methods

This is a retrospective study including 57 children who underwent two-stage transverse preputial island flap urethroplasty. Glans meatus shaft (GMS) score was applied to 24 cases. Patient’s characteristics, operative details and complications were assessed. Hypospadias objective scoring evaluation was used for postoperative assessment.

Results

The mean age at the first stage operation was 23.6 months (9–84); the mean time interval between the first and second stage operations was 8.1 months (6–12) and the mean follow-up duration was 52.1 months (24–96). Urethral meatus was proximal penile in 18 patients, penoscrotal in 24 and scrotal in 15. The mean degree of ventral curvature (VC) was 51.5° (30–90). After the second stage operation, postoperative complications occurred in 16 (28.1%) patients with urethrocutaneous fistula in 6 (10.5%) cases, diverticulum in 3 (5.3%), glans dehiscence in 5 (8.8%) and meatal stenosis in 2 (3.5%). All cases of glans dehiscence occurred in severe hypospadias and small glans. Moderate GMS score was present in 10 (41.7%) cases and severe GMS in 14 (58.3%). Complications occurred in 7 (29.1%) patients with 5 (20.8%) with a severe GMS score and 2 (8.3%) with a moderate GMS score. The hypospadias objective scoring evaluation showed satisfactory results, with 39 (68.4%) patients achieving a score of 16 points.

Conclusions

Two-stage transverse preputial flap is a good choice for repair of proximal hypospadias with an acceptable complication rate of 28.1%.

Bracka verses Byar's two-stage repair in proximal hypospadias associated with severe chordee: a randomized comparative study

INTRODUCTION

Proximal hypospadias associated with severe chordee represents a major surgical challenge and the debate over its optimal treatment is ongoing. The objective of this study is to compare the outcome of two-stage Bracka and Byar's repair in proximal hypospadias.

MATERIALS AND METHODS

This study was conducted from January 2013 to February 2018 in a tertiary care centre. Patients of hypospadias with severe chordee who required urethral plate transection were included in the study. Patients were randomly divided into two groups by simple randomization method. Bracka staged repair was done in Group A and Byar's staged repair in Group B. Postoperatively complications including graft loss, flap necrosis, fistula formation, meatal stenosis, stricture, diverticula formation, residual chordee were noted in both the groups and compared. p value of < 0.05 was considered statistically significant.

RESULTS

Over a period of 5 years, 74 patients in group A and 68 patients in group B were operated. Fistula occurred in 6.8% and 10.2% in group A and group B, respectively (p value 0.629). Meatal stenosis was seen in 4% in group A and 3% in group B (p value 0.731). Stricture was seen in 1% in each group (p value 0.339). Diverticula formation was seen in 2% in group B and none of the patient in group A (p value 0.960). None of the patient had recurrence of chordee in either group.

CONCLUSION

Bracka and Byar's two-stage repair have similar postoperative outcome and the choice between the two depends up on the surgeon's choice and experience rather than scientific evidence.

Two-stage repair of proximal hypospadias with moderate to severe chordee using inner preputial skin graft: prospective evaluation of functional and cosmetic outcomes

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.

Correction of Residual Ventral Penile Curvature After Division of the Urethral Plate in the First Stage of a 2-Stage Proximal Hypospadias Repair

PURPOSE OF REVIEW

The first stage of a 2-stage proximal hypospadias repair involves division of the urethral plate and correction of any residual ventral penile curvature (VPC). Options to correct residual VPC include dorsal corporal shortening or ventral corporal lengthening techniques. This review discusses these options and suggests an approach to management.

RECENT FINDINGS

Recent reports of 2-stage proximal hypospadias repairs indicate low rates of recurrent VPC with either dorsal corporal shortening or ventral corporal lengthening. Dorsal corporal shortening with dorsal plication may be preferentially used for mild to moderate residual VPC after division of urethral plate and ventral corporal lengthening reserved for severe residual VPC. Ventral corporal lengthening with grafts has been associated with urethroplasty complications after the second stage hypospadias surgery. Ventral corporal lengthening with relaxing incisions of corpora has been reported, but concerns about adverse effects require longer term studies. Little guidance exists to choose the best technique for VPC correction during first stage hypospadias repair after division of urethral plate. Reported literature suggests good results with dorsal plication techniques and ventral corporal lengthening. A practical approach is to use dorsal plication techniques for mild to moderate residual VPC after division of urethral plate (<45°) and reserve ventral corporal lengthening for severe residual VPC (>45°).

Primary hypospadias repair techniques: A review of the evidence

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.

Primary hypospadias repair techniques: A review of the evidence

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.

Two-stage graft urethroplasty for proximal and complicated hypospadias in children: A retrospective study

INTRODUCTION

Although two-stage graft urethroplasty is widely used, the literature regarding the complication rates and functional characteristics of reconstructed neourethra is relatively modest.

OBJECTIVES

The aim was to analyze the complication rates and uroflow data of boys who have previously undergone a two-stage graft urethroplasty procedure for proximal and complicated hypospadias.

PATIENTS AND METHODS

We retrospectively reviewed the clinical outcomes of 52 boys with proximal (n = 44) and complicated (n = 8) hypospadias who underwent two-stage graft urethroplasty repair (median age of 15 months and 3 years respectively) between 2004 and 2015. Fifteen toilet-trained boys without fistulas underwent uroflowmetry. The uroflow data were plotted on age-volume-dependent normograms with normal controls. The median follow-up was 34 months (8 months-8 years).

RESULTS AND COMPLICATIONS

Complications were identified in three patients (6%) after the first stage (i.e. contracture of the graft) and in 20 patients (38.4%) after the second stage, including meatal stenosis (n = 8, 15.3%), urethral stricture (n = 4, 7.6%), urethrocutaneous fistula (n = 8, 15.3%), glandular dehiscence (n = 1, 1.9%), and diverticulum (n = 1, 1.9%). The patients with failed hypospadias experienced fewer complications than those who underwent the two-stage procedure for primary repair (25% and 45%, respectively). The reoperation rate was 36.8%. Eleven of the 15 toilet-trained boys were asymptomatic but exhibited flow rates below the normal range (median Q_max = 7 mL/s, range 3.5-16.7). Only one of the boys with a low flow rate was confirmed to have urethral stenosis under general anesthesia.

DISCUSSION

In our study, primary hypospadias repair requiring urethral plate transection elicited worse outcomes than those observed in the prior failed hypospadias cases. However, because of our study's retrospective design, we were unable to accurately assess the initial position of the meatus in the redo hypospadias cases. Our data also demonstrated that the majority of cases without any voiding symptoms exhibited flow rates that were below the normal range despite no urethral stricture under general anesthesia. These findings indicate that urethras reconstructed via two-stage graft urethroplasty repair are not functionally equivalent to normal urethras, at least prior to puberty.

CONCLUSION

Two-stage graft urethroplasty repair was successful in 62% of cases after the second-stage procedure, but one-third of the boys required a reoperation after the two-stage planned repair. We demonstrated that although we used a urethral tissue substitute, the urine flow patterns of the patients without strictures were abnormal.

Posterior urethral valves: Risk factors for progression to renal failure

INTRODUCTION

Posterior urethral valves (PUVs) are the most common etiology for congenital urethral obstruction and congenital bilateral renal obstruction. PUVs produce a spectrum of urologic and renal sequelae. Our aims were to assess outcomes of PUV patients, to determine whether vesicoureteral reflux (VUR) is a risk factor for progression to renal failure, and to identify other risk factors for poor outcomes.

MATERIALS AND METHODS

We conducted a retrospective analysis of PUV patients from 2006 to 2014. Data collected included demographics, initial renal ultrasound (RUS) findings, creatinine at presentation and nadir, pre- and postoperative VUR status, presence or absence of recurrent urinary tract infections (UTIs), and surgical intervention(s). Univariate and multivariate analyses were used to determine risk factors for renal failure.

RESULTS

Of 104 patients, 42.3% (44/104) were diagnosed prenatally, 31.8% (14/44) of whom underwent prenatal intervention. Postnatally, 90.4% (94/104) initially underwent transurethral resection of PUVs (TUR-PUVs). Vesicostomy was the next most common index surgery (4.8%). Forty-two percent (44/104) required >1 surgery. The predominant second surgery was repeat TUR-PUV in 16 patients. At last follow-up (mean 28.8 months after initial surgery), 20.2% had chronic kidney disease (CKD) of at least stage IIIA, and 8.6% had progressed to end-stage renal disease (ESRD). Antenatal diagnosis, prematurity, abnormal renal cortex, and loss of corticomedullary differentiation (CMD) on initial RUS were associated with CKD and ESRD on univariate analysis, as were elevated creatinine on presentation and at nadir. Presence of pre- or postoperative VUR and recurrent UTIs were associated with the need for multiple surgeries, but not with poor renal outcomes. On multivariate analysis, nadir creatinine was the only independent predictor of final renal function.

CONCLUSIONS

Our finding that creatinine is the only independent risk factor for poor renal outcomes in PUV patients is consistent with the literature. The effect of VUR has been controversial, and our finding that VUR is associated with need for multiple surgeries but not with CKD or ESRD is novel. Limitations include biases inherent to retrospective studies and relatively small sample size. The majority of patients with PUVs (56.7%) required one surgery and maintained renal function with CKD II or better (79.8%) up to 2 years after initial surgery. While multiple factors were associated with poor renal outcomes, nadir creatinine was the only independent predictor. VUR and recurrent UTIs were not associated with poor renal outcomes. Longer follow-up is necessary to identify risk factors for delayed progression of renal disease.

The Effect of Staged Transverse Preputial Island Flap Urethroplasty for Proximal Hypospadias with Severe Chordee

PURPOSE

We compare the effects of staged tranverse preputial island flap urethroplasty and the Byars 2-stage procedure in patients with proximal hypospadias and severe chordee.

MATERIALS AND METHODS

We studied 87 consecutive children referred for proximal hypospadias with severe chordee between March 2011 and March 2014. Of the cases 42 were repaired with staged tranverse preputial island flap (group 1) and 45 were managed by 2-stage Byars urethroplasty (group 2). Mean ± SD age at first stage surgery was 26.6 ± 13.3 months in group 1 and 24.8 ± 14.7 months in group 2. Postoperative complications in both groups were assessed regarding fistulas, urethral strictures, diverticula, meatal stenosis and glanular dehiscence.

RESULTS

After the second stage 2 patients (4.8%) in group 1 and 10 (23.2%) in group 2 had urethrocutaneous fistulas (p <0.05). One patient (2.4%) in group 1 and 2 patients (4.4%) in group 2 had urethral strictures (p >0.05). All patients with stricture were cured by repeated dilation and no patient required reoperation. One patient (2.4%) in group 1 and no patient in group 2 had diverticulum (p >0.05). No patient in either group had signs or symptoms of meatal stenosis or residual chordee. Three patients (7.1%) in group 1 and 12 (26.7%) in group 2 needed reoperation (p <0.05).

CONCLUSIONS

Two-stage urethroplasty, particularly tranverse preputial island flap partial urethroplasty, is appropriate for treating patients with proximal hypospadias and severe chordee. Use of the tranverse preputial island flap can decrease complications associated with the second stage and significantly improve the success rate.

Surgery for Primary Proximal Hypospadias with Ventral Curvature >30°

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.

Complications following Staged Hypospadias Repair Using Transposed Preputial Skin Flaps

PURPOSE

Proximal hypospadias repair using a staged approach is a complex reconstructive operation with the potential for significant complications requiring repeat surgery. We report outcomes of staged hypospadias repair using transposed preputial skin flaps and factors predictive of postoperative complications.

MATERIALS AND METHODS

We retrospectively analyzed patients who underwent staged proximal hypospadias repair using transposed preputial skin flaps between 2002 and 2013. Patient demographics, operative details, complications, reoperations and factors predictive of complications were reviewed.

RESULTS

A total of 56 patients were identified with a mean age of 14.1 months (median 14.3) at first stage. Mean followup was 38.6 months (median 34.1). Complications requiring additional unplanned operation(s) were observed in 38 patients (68%), including fistulas in 32 (57%), diverticula in 8 (14%), meatal stenosis in 5 (9%), urethral stricture in 8 (14%) and glans dehiscence in 3 (5%). In addition, redo first stage repair was performed in 4 patients (7%). Since some patients had more than 1 complication, the total number of complications is greater than the number of patients undergoing a redo operation. On univariate analyses the use of small intestinal submucosa was significantly associated with an increased risk of fistula (91% vs 49%, p = 0.02) and urethral diverticulum (64% vs 24%, p = 0.04). Incision of the tunica albuginea of the corpora was associated with an increased likelihood of fistula (77% vs 44%, p = 0.03). Finally, patients with glans dehiscence were significantly younger at first stage (5.8 vs 14.8 months, p = 0.01).

CONCLUSIONS

The reoperation rate for complications in children undergoing staged hypospadias repair using transposed preputial skin flaps is higher than previously reported.