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

Grafts vs. flaps: a comparative study of Bracka repair and staged transverse preputial island flap urethroplasty for proximal hypospadias with severe ventral curvature

Introduction

Bracka repair and staged transverse preputial island flap urethroplasty are both significant methods in treating proximal hypospadias. They utilize the flap and graft techniques, respectively, to achieve a satisfactory success rate. This study aimed to compare the outcomes of these 2 methods in the treatment of proximal hypospadias with severe ventral curvature.

Methods

We retrospectively analyzed 117 cases of proximal hypospadias with severe ventral curvature who had undergone either Bracka repair (n = 62) or staged transverse preputial island flap urethroplasty (n = 55). All operations were performed by a single surgeon, and the choice of method was determined by the surgeon's preference based on his experience. Cosmetic outcome was evaluated with Pediatric Penile Perception Score (PPPS). Patients' characteristics including age, penis length, glans diameter, length of the urethral defect and ventral curvature degree, cosmetic outcomes, and complication rates were all compared.

Results

There was no significant difference in age, penis length, glans diameter, length of the urethral defect, or ventral curvature degree. In the Bracka group, there were 5 patients with fistula, 1 patient with stricture, and 1 case of dehiscence. In the staged transverse preputial island flap urethroplasty group, there were 4 patients with fistula, 1 with stricture, and 2 with diverticulum. The scores of shaft skin and general appearance were consistently higher in the Bracka group than in the staged transverse preputial island flap urethroplasty group. The differences in complication rate and cosmetic outcome were not statistically different (P > 0.05).

Conclusions

Bracka repair and staged transverse preputial island flap urethroplasty are both satisfactory staged surgical options for proximal hypospadias with severe ventral curvature and have similar complication rates. Bracka repair may create a better appearance, but more studies are needed to confirm this finding. Pediatric surgeons should consider additional factors, such as the patient's specific condition, parents' inclination, and personal experience, rather than safety, to make the best choice between the 2 methods.

Application of a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering for the single-stage repair of severe hypospadias

Objective

To assess the outcome of a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering (BFIC) for the single-stage repair of severe hypospadias in children.

Materials and methods

A retrospective study was performed on 40 children with hypospadias who were treated in our hospital from December 2017 to February 2022. The inclusion criteria were as follows: (1) the patient had proximal hypospadias, or penile curvature over 30° after degloving the penis; and (2) the patient underwent surgery for hypospadias for the first time. A free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering was performed, and all patients were followed up for more than 6 months.

Results

After degloving the foreskin, the urethral orifice was retracted to the perineum and scrotum in 20 cases, penoscrotal in 8 cases, and penile in 12 cases. Single-stage repair was achieved without complications in 34 (85%) patients. The remaining six patients experienced postoperative complications: urethrocutaneous fistula occurred in five cases and glans dehiscence with urethrocutaneous fistula in one case. No urethral diverticulum occurred in any case. A neomeatus with a vertically oriented slit-like appearance was achieved at the tip of the glans in all cases, with one exception.

Conclusion

The single-stage operation with a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering in the treatment of severe hypospadias achieves favorable functional and cosmetic outcomes.

Comparison of outcomes in three surgical techniques for proximal hypospadias: staged transverse preputial island flap urethroplasty versus single-stage repairs

To evaluate and compare the outcomes and complications of three different surgical techniques for treating primary proximal hypospadias with ventral curvature (VC) ≥30°, we retrospectively reviewed the medical records of patients who underwent primary repair of proximal hypospadias with VC ≥30° after degloving at Beijing Children's Hospital Affiliated to Capital Medical University (Beijing, China) from January 2019 to January 2021. A total of 152 patients were divided into three groups: transverse preputial island flap (TPIF) combined with Duplay, modified Koyanagi, and staged TPIF, which were performed on 55, 16, and 81 patients, respectively. A total of 39 (25.7%) patients had complications. Complications rates were similar for the TPIF combined with the Duplay group (40.0%) and modified Koyanagi group (50.0%) but lower for the staged TPIF group (11.1%; P < 0.01). The incidence of urethrocutaneous fistulas was significantly higher in TPIF combined with Duplay group (21.8%) compared to staged TPIF group (4.9%; P = 0.01). In univariate analysis, the length of the urethral defect was the single factor that could predict complications; the cutoff was 4.55 cm. More patients in the long urethral defect group than in the short one had complications (34.1% vs 15.7%, P = 0.01). These results indicate that staged TPIF produced a better outcome, whereas more patients in the TPIF combined with Duplay group presented with two or more complications.

Complication rates of proximal hypospadias: meta-analyses of four surgical repairs

INTRODUCTION

Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques.

METHODS

The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included.

RESULTS

Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin.

DISCUSSION

The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short.

CONCLUSION

This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.

Urethroplasty for chordee with a paper‐thin hypoplastic urethra: A long‐term study

Objectives

To establish a standard surgical procedure for children with chordee with a paper‐thin hypoplastic urethra, which was based on the degree of curvature and urethral plate quality. To guidelines for the management of this disorder.

Methods

We reviewed 58 cases of chordee with a paper‐thin hypoplastic urethra, managed between March 2006 and September 2020. The age of the patients ranged from 23 to 89 months. Operative details and postoperative complications were analyzed.

Results

Mild‐moderate chordee with a paper‐thin hypoplastic urethra correction was performed using a tubularized incised plate (13 cases) or onlay island flap (five cases) technique after penile degloving. Severe chordee with a paper‐thin hypoplastic urethra required transection of the urethra and underwent a Duckett (11 cases) or staged (29 cases) urethroplasty. Complications in the tubularized incised plate and onlay island flap groups were 7.7% and 20%, respectively. The overall complication rate was 10.3% in the staged group and 27.3% in the Duckett group.

Conclusions

Reconstruction of the entire hypoplastic urethra should be recommended in the management of chordee with a paper‐thin hypoplastic urethra. We propose an algorithm based on the degree of curvature and urethral plate quality. The tubularized incised plate or onlay island flap technique can be used for mild to moderate chordee with a paper‐thin hypoplastic urethra, and the outcome of the tubularized incised plate technique tends to be better than that of the onlay island flap technique. Duckett or staged urethroplasty is suitable for severe chordee with a paper‐thin hypoplastic urethra, and the staged technique can improve the overall success rate.

Utility and safety of hyperbaric oxygen therapy as a rescue treatment in complicated cases of hypospadias: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to define the current evidence and systematically summarize the relevant data regarding the utility and safety of hyperbaric oxygen therapy (HBOT) as an adjunctive treatment in complicated re-operative cases of hypospadias.

METHOD

The authors systematically searched the PubMed, EMBASE, Web of Science, and Scopus databases on August 5, 2021. Patients were divided into two groups, i.e. HBOT and non-HBOT. The main outcomes were graft failure rate and the incidence of complications following urethroplasty. The proportion of patients developing adverse events due to HBOT was the secondary outcome. The pooled risk ratio and heterogeneity were calculated using the Mantel-Haenszel method and the I² statistics respectively. The quality assessment of the included studies was performed using the Downs and Black scale.

RESULT

Four studies constituting 176 patients (101 in the HBOT group) were included (Figure). Variations were observed among these studies in terms of the age of participants, the number and types of previous operations performed, and the protocol of administration of HBOT. The graft failure rate (RR 0.19; 95% CI 0.05-0.73, p = 0.02) and the incidence of complications (RR 0.40, 95% CI 0.20-0.77, p = 0.007) were significantly low in the HBOT versus the non-HBOT group. Apart from myringotomy insertion (n = 10; 9.9%) and claustrophobia (n = 1), no other adverse events were associated with HBOT. All studies had a moderate risk of bias. An almost perfect agreement (kappa = 0.956, p < 0.0001) was observed between the two investigators assessing the risk of bias.

CONCLUSION

The present systematic review and meta-analysis significantly favor the administration of HBOT versus no HBOT in terms of graft failure rate and incidence of complications following urethroplasty. The available data also highlights the safety of HBOT in complicated cases of hypospadias. However, well-designed randomized controlled trials need to be conducted for an optimal comparison between the two treatment groups.

Efficacy of one- and two-stage segment urethroplasty for severe chordee with congenital short urethra

Objectives

The aim of this study was to analyze the efficacy of segment urethroplasty to treat severe chordee with congenital short urethra and compared one‐stage and two‐stage segment urethroplasty. This procedure involved urethral transection to correct the chordee, and urethroplasty was performed to restore natural penile length.

Methods

We retrospectively studied a cohort of patients with severe chordee and congenital short urethra who underwent one‐ or two‐stage segment urethroplasty at our institution between February 2006 and May 2020. We evaluated the efficacy of the procedures based on the incidence of complications.

Results

A total of 37 children were included in this study: 25 were treated with two‐stage segment urethroplasty and 12 were treated with one‐stage segment urethroplasty. The median length of neourethra in the one‐stage repair group (3.21 cm) was similar to that in the two‐stage repair group (3.23 cm; P > 0.05). Of the 37 patients, 32 (86.5%) were cured after urethroplasty. There were three patients with complications in the one‐stage repair group (one urethral fistula and two urethral strictures) and two patients with fistula in the two‐stage repair group. Among the five patients with complications, the three fistulas were successfully repaired through reoperation and the two urethral strictures were cured after urethral dilatation. No patient had diverticulum or recurrent chordee.

Conclusions

Segment urethroplasty achieved satisfactory outcomes in the treatment of severe chordee with congenital short urethra. This can restore natural penile length, and the recurrence rate of severe chordee is low. The overall success rate of the two‐stage procedure tends to be better than that of the one‐stage procedure.

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.

Tissue Engineering of the Urethra: From Bench to Bedside

Tissue engineering (TE) is a promising approach for repair/substitution of damaged tissues and organs. Urethral strictures are common and serious health conditions that impair quality of life and may lead to serious organ damage. The search for ideal materials for urethral repair has led to interest of scientists and surgeons in urethral TE. Over the last decades, a significant amount of preclinical studies and considerable progress have been observed. In contrast, urethral TE has made slow progress in clinical practice so far. To address this, we conducted a systematic review of the literature on clinical applications of TE constructs for urethral repair in the last three decades. In summary, the TE approach is promising and effective, but many issues remain that need to be addressed for broader adoption of TE in urethral repair. Better design of trials, better cooperation of research groups and centralization could lead to reduction of costs and slowly proceed to commercialization and routine use of TE products for urethral reconstruction.

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.

Single-stage versus staged interposition urethroplasty for glandular hypospadias with severe penile curvature: 15-year experience

Purpose

Our study examined the benefit of an alternative interposition urethroplasty (IU) procedure for glandular hypospadias (GH) with severe penile curvature (SPC). The technique involved transecting and reconstructing the urethra to preserve the distal glandular and coronal urethra and correct the curvature. We compared procedural characteristics, outcomes, and surgical complications for the single-stage and staged IU techniques.

Methods

We retrospectively studied 44 patients with GH with SPC who underwent single-stage or staged IU between March 2005 and June 2020. Demographics, operative details, complications, and uroflometry findings were analyzed.

Results

The median age at initial surgery was 37.5 months. Ten patients underwent single-stage IU repair, and 34 patients underwent staged IU repair. The median length of the interposition neourethra was 3.2 cm (2.2–4.3). The median follow-up duration was 58 months, and the overall complication rate was 13.6%. Complications were noted in 30% (3/10) and 8.8% (3/34) of patients in the single-stage and staged IU groups, respectively (p > 0.05). Fistula formation was noted in one and three patients in the single-stage and staged groups, respectively (8.8% vs. 10%, p > 0.05). Two cases of urethral stricture were documented in the single-stage group only. No chordee recurrence or urethral diverticula was noted in any of the patients.

Conclusion

IU is a reliable and durable technique for GH with SPC. It avoided penile shortening, preserved the distal urethra, and reduced the risk of chordee recurrence. The staged IU technique had more superior outcomes compared to the single-stage IU technique.

Triangular extension of hinge flaps: A novel technique to resolve stomal stenosis and prevent restenosis in staged buccal mucosal urethroplasty

OBJECTIVES

To verify the utility of triangular extension of a hinge flap in buccal mucosal staged urethroplasty to resolve stomal stenosis after the first stage and ultimately prevent restenosis.

METHODS

A total of 23 patients (triangular extension group) were studied in 2013-2019. In the first stage, buccal mucosa was transplanted, and an extended triangle portion of the mucosa was placed beside the proximal and/or distal stoma that was created when the stricture segment of the urethra was resected. In the second stage, during tubularization of the urethral plate, an incision was made at the stoma to increase the caliber to which the triangular extension was inserted. The procedure was considered successful when a 17-Fr flexible cystoscope passed through the reconstructed urethra at 6 months after the second-stage urethroplasty and no additional surgery or bougie dilation required. The clinical course of the triangular extension group was compared with 24 patients who underwent conventional staged urethroplasty (control group).

RESULTS

In total, 20 patients from each group underwent second-stage surgery. No patients in the triangular extension group required additional revision surgery because of stomal stenosis after first-stage surgery, whereas five (20%) control patients did. Urethroplasty was successful in 19 patients (95%) in the triangular extension group and in 19 patients (95%) in the control group. Uroflowmetry after the second-stage surgery indicated that the mean maximum urinary flow rate was 21.5 and 15.8 mL/s after triangular extension and the control procedure, respectively (P = 0.027).

CONCLUSIONS

The triangular extension technique reduces the need for revision surgery and prevents postoperative restenosis.

Augmentation of the insufficient tissue bed for surgical repair of hypospadias using acellular matrix grafts: A proof of concept study

Acellular matrices produced by tissue decellularisation are reported to have tissue integrative properties. We examined the potential for incorporating acellular matrix grafts during procedures where there is an inadequate natural tissue bed to support an enduring surgical repair. Hypospadias is a common congenital defect requiring surgery, but associated with long-term complications due to deficiencies in the quality and quantity of the host tissue bed at the repair site. Biomaterials were implanted as single on-lay grafts in a peri-urethral position in male pigs. Two acellular tissue matrices were compared: full-thickness porcine acellular bladder matrix (PABM) and commercially-sourced cross-linked acellular matrix from porcine dermis (Permacol™). Anatomical and immunohistological outcomes were assessed 3 months post-surgery. There were no complications and surgical sites underwent full cosmetic repair. PABM grafts were fully incorporated, whilst Permacol™ grafts remained palpable. Immunohistochemical analysis indicated a non-inflammatory, remodelling-type response to both biomaterials. PABM implants showed extensive stromal cell infiltration and neovascularisation, with a significantly higher density of cells (p < 0.001) than Permacol™, which showed poor cellularisation and partial encapsulation. This study supports the anti-inflammatory and tissue-integrative nature of non-crosslinked acellular matrices and provides proof-of-principle for incorporating acellular matrices during surgical procedures, such as in primary complex hypospadias repair.

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.

Staged repair of proximal hypospadias: Reporting outcome of staged tubularized autograft repair (STAG)

INTRODUCTION

Proximal hypospadias (PPH) repair is a challenge. Dilemma exists whether to do it in single or staged repair. Staged repair is our adopted procedure which was recently modified by Snodgrass into staged tubularized autograft repair (STAG), in which attention was given to ventral straightening of the penis together with some other technical details. Herein, we report our experience with STAG in a cohort of primary posterior hypospadias.

PATIENTS AND METHODS

In the period from 2011 to 2018 we operated 43 primary posterior hypospadias. Two principal surgeons (HB, MY) and multiple assistants operate children the same way, and data are recorded in a prospectively designed data base. In all children, inner prepuce graft was utilized, when curvature is more than 30 degrees, plate transection with or without ventral corporotomies were adopted.

RESULTS

Forty-three children with PPH and ventral curvature more than 30 degrees underwent first stage with median age 12 months (6-132 IQR16). Penile curvature was corrected by plate transection in 27 children (62.8%), ventral corporotomies in 16 children (37.2%). Graft take was successful in 90.7%, 4 children needed revision of fibrotic graft. Second stage was completed in 37 children, success was 56.8%, 21.6% fistula, 24.3% glanular dehiscence. Overall success after third surgery to correct complications was 78.4%. In a mean follow up of 3.2 years, we had recurrence of curvature in 2 children taking success rate to 72.9%. No meatal stenosis, no diverticulum, no stricture, no urethral dehiscence was encountered. Cosmetic appearance was excellent in follow up.

CONCLUSION

STAG achieves proper straightening of the penis and allows for reconstruction of a good urethra, yet urethrocutaneous fistula and glanular dehiscence remain the main complications. Follow up is important to address results of ventral corporotomies.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

Level IV case series with no comparison group.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias

INTRODUCTION

To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair.

MATERIAL AND METHODS

Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated.

RESULTS

Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream.

CONCLUSIONS

Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

Two simple modifications can potentially change the future of proximal hypospadias surgery. Our series and a review of the literature

Background/Objective

To draw a hint towards two simple modifications that could potentially decrease the complication rate.

Patients and Methods

It was a single center, single operator and retrospective study. All patients with severe hypospadias operated according to koyanagi with or without modifications were presented. The surgical technique was described. Complications like fistula, stenosis, dehiscence and urethral diverticulum were studied.

Results and Limitations

Nineteen patients were included and presented in a chronological manner. The first four patients were operated according to the original koyanagi technique. The next 15 patients were operated according to koyanagi and the urethroplasty was covered by a tunica vaginalis flap. In 10 of them, glanduloplasty was done primarily and in the last 5 patients, glanduloplasty was done as a secondary procedure. The complication rates were 100% in the original koyanagi group, and 0% in the subset were glanduoplasty was deferred.

Conclusions

Systematically covering the urethroplasty with a tunica vaginalis flap and deferring the glanuloplasty might ameliorate the results of the koyanagi technique.

Chronological Changes In Uroflowmetry After Hypospadias Repair: An Observational Study

Aim

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

Methods

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

Results

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

Discussion

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

Conclusion

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

Outcomes of staged lingual mucosal graft urethroplasty for redo hypospadias repair

BACKGROUND

The objective of this study was to present the outcomes for redo hypospadias repair using lingual mucosal graft (LMG).

PATIENTS AND METHODS

Between June 2012 and February 2017, 47 patients underwent staged LMG urethroplasty for redo hypospadias repair. The inclusion criteria were previous failed hypospadias repair with a paucity of local skin that interferes with correction using skin flaps and demands graft urethroplasty. During the first stage, a well-vascularized bed on the tunica albuginea was created. Then, the harvested LMG was secured to the prepared bed. The second-stage urethroplasty was carried out after six months. In this stage, tubularization of the previously implanted LMG was performed. In four cases, tubularization was difficult owing to graft contracture. This difficulty was managed by using the dorsally degloved penile skin as the onlay island flap in three cases and the buccal mucosa onlay graft in the fourth case. In all cases, a second protective layer from the dartos or tunica vaginalis was developed to cover the neourethra.

RESULTS

The median (interquartile range [IQR]) age of patients at the first stage was 5 (4-6) years, and the median (IQR) duration between both stages was 7 (6-8) months. The median (IQR) follow-up after the second stage was 15 (13-16) months. The median (IQR) number of previous operations was 2 (2-3). The median (IQR) length of the LMG was 3 (2.5-4) cm, and the median (IQR) width was 1 (1-2) cm. No donor-site major complications, but mild oral discomfort in the first week after graft harvesting, were reported in 39 (83%) patients. After the second stage, complications were reported in nine (19.2%) patients, meatal stenosis in five and fistula in four. The reported success rate was 80.9%.

DISCUSSION

Reconstruction of previously failed hypospadias is a challenge owing to local tissue scarring and a paucity of adjacent healthy tissue. In this study, the LMG was used in two-stage redo hypospadias repair after previous repair failure. In the present study, a success rate of 80.9% was reported after the second stage. According to this study and the published series, harvesting the LMG is associated with minimal immediate donor-site complications and no long-term morbidity. Another advantage of the LMG is easy harvesting with effortlessly reachable tongue in comparison with the buccal mucosa that is deep and requires application of a mouth retractor.

CONCLUSIONS

Two-stage LMG urethroplasty is a reliable procedure for salvage urethroplasty. Lingual mucosal graft harvesting is easy, with minor oral complications.

Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia

INTRODUCTION

Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches.

OBJECTIVE

The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia.

STUDY DESIGN

This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings.

RESULTS

Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied.

DISCUSSION

In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population.

CONCLUSION

In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.

Proximal hypospadias repair with bladder mucosal graft: Our 10 years experience

INTRODUCTION AND OBJECTIVE

A great variety of different surgical techniques has been described for proximal hypospadias repair and an ideal tissue has not been determined yet. We present our 10 years of surgical experience using a bladder mucosal graft for urethroplasty.

STUDY DESIGN

Bladder mucosal graft urethroplasty was performed between 2005 and 2015 in 50 patients with severe proximal hypospadias. The mean age of patients was 45.1 months (range 24-164 months). Hypospadias were perineal in 18 patients, scrotal in 22, and penoscrotal in 10. In all cases a chordee correction was performed and median time between the first and the second stages was 12 months (mean 17 months, range 4-68 months). Both foley catheter and a suprapubic cystostomy were positioned and maintained for 2-4 weeks. Follow-up was performed at 1-3 and 6-12 months after surgery, and afterwards annually with clinical examination and flowmetry test.

RESULTS

Mean follow-up was 5.3 years (median 5, range 1-10 years). Mean graft length was 57.4 mm (median 55 mm, range 35-85 mm). Among all the only early complication registered was a postoperative infection in one patient (2%) at the site of anastomosis. The long-term complications observed were urethrocutaneous fistula in nine patients (18%), urethral stricture in 15 patients (30%), meatal stricture in four patients (8%), and prolapse of meatus in seven patients (14%). The mean time of complication occurrence was 15 months (median 15.5 months, range 1-96 months). The functional and cosmetic appearance after surgery was satisfactory in 42/50 patients (84%) during the follow-up period.

DISCUSSION

There is still an open debate regarding the optimal surgical approach for management of severe proximal hypospadias. Compared with other approaches, our technique showed acceptable results even though encumbered by slightly higher complication rates.

CONCLUSION

Our results show that bladder mucosal graft for primary severe proximal hypospadias in selected patients is a possible alternative to other commonly used techniques, with the aim of restoring recovery of the normal continuity of the distal urinary tract see figure below.

Tissue Engineering of the Urethra: A Systematic Review and Meta-analysis of Preclinical and Clinical Studies

CONTEXT

Urethra repair by tissue engineering has been extensively studied in laboratory animals and patients, but is not routinely used in clinical practice.

OBJECTIVE

To systematically investigate preclinical and clinical evidence of the efficacy of tissue engineering for urethra repair in order to stimulate translation of preclinical studies to the clinic.

EVIDENCE ACQUISITION

A systematic search strategy was applied in PubMed and EMBASE. Studies were independently screened for relevance by two reviewers, resulting in 80 preclinical and 23 clinical studies of which 63 and 13 were selected for meta-analysis to assess side effects, functionality, and study completion. Analyses for preclinical and clinical studies were performed separately. Full circumferential and inlay procedures were assessed independently. Evaluated parameters included seeding of cells and type of biomaterial.

EVIDENCE SYNTHESIS

Meta-analysis revealed that cell seeding significantly reduced the probability of encountering side effects in preclinical studies. Remarkably though, cells were only sparsely used in the clinic (4/23 studies) and showed no significant reduction of side effects. ln 21 out of 23 clinical studies, decellularized templates were used, while in preclinical studies other biomaterials showed promising outcomes as well. No direct comparison to current clinical practice could be made due to the limited number of randomized controlled studies.

CONCLUSIONS

Due to a lack of controlled (pre)clinical studies, the efficacy of tissue engineering for urethra repair could not be determined. Meta-analysis outcome measures were similar to current treatment options described in literature. Surprisingly, it appeared that favorable preclinical results, that is inclusion of cells, were not translated to the clinic. Improved (pre)clinical study designs may enhance clinical translation.

PATIENT SUMMARY

We reviewed all available literature on urethral tissue engineering to assess the efficacy in preclinical and clinical studies. We show that improvements to (pre)clinical study design is required to improve clinical translation of tissue engineering technologies.