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

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.

Tubularized incised plate urethroplasty and grafted tubularized incised plate urethroplasty: systematic review, meta-analysis and trial sequential analysis

Background

Hypospadias is one of the most common genital birth defects. There are around 300 various techniques available for the repair of hypospadias. This study aims to compare the reported outcomes of Tubularized incised plate urethroplasty (TIP) and Grafted TIP (GTIP) repair in children undergoing primary hypospadias repair.

Methods

This meta-analysisadhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and we framed our research question using the population, intervention, control and outcomes format. We conducted comprehensive electronic searches across various databases, employing a Boolean search strategy with predefined search terms. Only randomized controlled trials (RCTs) were included for quantitative analysis.

Results

Totally, 10 RCTs met our inclusion criteria for quantitative analysis. The results indicated that urethrocutaneous fistula, glans dehiscence, and stricture rates were comparable between the two groups. The incidence of meatal stenosis was found to be significantly lower in the GTIP group with a relative risk (RR) of 0.32 (95% confidence interval (CI) 0.15 to 0.67).

Conclusion

The coucomes UCF, glans dehiscence, and stricture rates were comparable between the two groups. Notably, the incidence of meatal stenosis was found to be significantly lower in the grafted TIP group. In terms of operative time, our quantitative synthesis demonstrated that the TIP group had a shorter operative time than the GTIP group with significant heterogeneity.

Promising results for hypospadias repair using alloderm® (Regen): A randomized controlled trial

INTRODUCTION;: Hypospadias is a congenital disorder of urethra in which meatus is not at its correct place and occurs in 1 of 250 live male birth. Many techniques have been used for the repair of hypospadias and to decrease the incidence of fistula. Alloderm has been recently used for the repair of urologic congenital defects, and reconstructive surgeries, but not used in hypospadias in a randomized controlled trial. Therefore, the aim of this study was to assess the efficacy of Alloderm® (Regen) to reduce fistula rate in hypospadias repair.

METHODS & MATERIALS

This was a randomized controlled trial. Sixty patients were divided into two groups, 30 children underwent surgery using Alloderm® (Regen) as the Alloderm group and 30 without using it as controls. In the Alloderm group, 21 underwent primary surgery (12 mid-shaft hypospadias who underwent concurrent chordee correction and urethroplasty, and 9 penoscrotal who underwent 2 stage surgery, chordee was first corrected and then 6 months later TIP was performed), and 9 underwent fistula repair due to previous surgeries. In the control group, 24 patients underwent primary surgery (15 mid-shaft, and 9 penoscrotal) and 6 fistula repair the same as the Alloderm group but without using Alloderm.

RESULTS

There was no meaningful difference between the two groups regarding age (P = 0.634). There was no meaningful difference regarding the operation type between the two groups (P = 0.371). There was no meaningful difference regarding the meatal location between the two groups (P = 0.781). There were no significant post-operative complications in the both groups. No bleeding or diverticulum occurred. Recurrence of fistula occurred in one patient in the Alloderm group after fistula repair and in 2 in the control group. Overall, In the Alloderm group, 3 (2 after TIP and 1 after fistula repair) patients and in the control group 8 (6 after TIP, 2 after fistula repair) patients developed fistulas after surgery (10% vs 26.7%). There was a statistically meaningful difference regarding fistula formation between the two groups using Chi-square test (P = 0.014).

CONCLUSION

Alloderm® (Regen) can be used for hypospadias and fistula repair with very few complications and good results. Fistula was less probably occurred in the Alloderm group compared to the standard repair of hypospadias.

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.

Comparison of lingual mucosa and buccal mucosa grafts used in inlay urethroplasty in failed hypospadias of pre-pubertal boys in a Chinese group

Objective

The purpose of this study was to compare the outcomes of the buccal mucosa and lingual mucosa used in children who received multiple failed hypospadias surgeries.

Method

We conducted a retrospective study of 62 children who received buccal or lingual mucosa graft urethroplasty in our hospital between 2012 and 2015. The ages ranged from 3.5–11 y. All cases included multiple failed hypospadias procedures, and the subjects received previous operations 2–3 times. All patients underwent one-stage operations. Thirty-three cases were treated with lingual mucosa grafts. The patient ages ranged from 3.5 to 11 y (median 7.5 y), and they had previous operations 2–3 times (mean 2.8±0.7). Grafts ranged from lengths of 2–6 cm (mean 5.1±0.46 cm) and widths of 0.5–1.5 cm (mean 1.2± 0.16 cm). Our follow-up was 5 to 12 m (mean 8.3±1.2 m). Twenty-nine cases were treated with buccal mucosa grafts. The patient ages ranged from 4 to 9.2 y (median 7.0 y), and they had previous operations 2–3 times (mean 2.5±0.2). Grafts ranged from lengths of 2–5.3 cm (mean 4.9± 0.28 cm) and widths of 0.5–1.5 cm (mean 1.0±0.11 cm). Our follow-up was 5 to 12 m (mean 7.9±0.5 m). The results were tested with SPSS 18.0. The rates of complications were compared by a chi-square test, and pre-operative conditions were compared by t test.

Results

For the outcomes of the two groups, there was no significant difference between the groups in terms of age, preoperative surgery time, and the length and width of the grafts (p>0.05). For the lingual mucosa graft group, fistula: 2/33 (6.0%), stricture: 1/33(3.0%), ventral curvature: 2/33(6.0%), complications: 5/33(15.0%), success rate: 28/33(84.8%), Hose score: 14.34±0.95, peak flow: 6.5 ml/s-12.0 ml/s, and mean peak flow: 9.3±0.4 ml/s. For the buccal mucosa graft group, fistula: 2/29(6.8%), stricture: 2/29(6.8%), ventral curvature: 1/29 (3.4%), complication rate: 5/29(17.0%), success rate: 24/29 (83.0%), Hose score: 14.28±1.03, peak flow: 6.5 ml/s-12.0 ml/s, and mean peak flow: 9.2±0.2 ml/s. There were no differences between the two groups for overall success, complication rates, peak flow, and the Hose scores(P>0.05).

Conclusion

The lingual mucosal graft and the buccal mucosa graft both achieved good outcomes, and the lingual mucosa graft made up for the shortcomings of the buccal mucosa graft, which provided a reliable way to treat the multiple failed hypospadias surgeries in pre-pubertal boys.

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.