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Cousin I, Basmaison C, Cousin E, Lebonvallet N, Germouty I, Leven C, De Vries P. Complication rates of proximal hypospadias: meta-analyses of four surgical repairs. J Pediatr Urol 2022; 18:587-597. [PMID: 36058812 DOI: 10.1016/j.jpurol.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/28/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Ianis Cousin
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire de Brest, Hôpital Augustin Morvan, 4 Avenue Foch, 29200 Brest, France; Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France.
| | - Camille Basmaison
- Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France
| | - Elie Cousin
- Department of Pediatry, Centre Hospitalier Universitaire de Rennes, 16 Boulevard de Bulgarie 35200 Rennes, France
| | - Nicolas Lebonvallet
- Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France
| | - Isabelle Germouty
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire de Brest, Hôpital Augustin Morvan, 4 Avenue Foch, 29200 Brest, France
| | - Cyril Leven
- Department of Pharmacology, Centre Hospitalier Régional Universitaire de Brest, Hôpital de la Cavale Blanche, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Philine De Vries
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire de Brest, Hôpital Augustin Morvan, 4 Avenue Foch, 29200 Brest, France; Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France
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Experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee: A single institution study with intermediate follow up. J Pediatr Surg 2022; 57:1404-1408. [PMID: 34217511 DOI: 10.1016/j.jpedsurg.2021.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 11/21/2022]
Abstract
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).
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A meta-analysis comparing dorsal plication and ventral lengthening for chordee correction during primary proximal hypospadias repair. Pediatr Surg Int 2022; 38:389-398. [PMID: 35048166 DOI: 10.1007/s00383-022-05065-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Recurrent chordee (RC) is an important complication of proximal hypospadias repair. In this meta-analysis we compared RC incidence following dorsal plication (DP) versus ventral lengthening (VL). METHODS We searched the databases to identify all papers between 2001 and 2021 pertaining to proximal hypospadias and recurrent chordee. Duplicate publications, review articles and incomplete articles were excluded. Meta-analysis of heterogeneity was reported with I2 statistics. The pooled outcomes were compared to Chi square/Fishers exact test. RESULTS A total of 17 articles were included covering 582 patients. The I2 statistics for prevalence of RC among different publications showed no heterogeneity for DP (I2 = 0%) and low heterogeneity for VL (I2 = 26%). RC was noticed in 31/122 (25.4%; 95% CI 18%-33%) among patients who had DP alone while it was significantly lower, 24/460 (5.3%; 95% CI 4%-8%) when VL was used (p = 0.0001). When compared to DP, all VL techniques had significantly lower incidence of RC. Among the VL techniques lowest incidence of RC was found for ventral corporotomies (4%) followed by small-intestinal- submucosa (SIS 4.2%) and tunica vaginalis flap (TVF)/free graft-TVFG (5%). Among the VL subtypes: the proportion of RC with use of TVF (4/70, 5.7%) and TVFG (3/69, 4.3%) for corporoplasty was comparable (p = 1); single-layer SIS was associated with significantly less RC (1/90, 1.1%) than 4-layer SIS (5/51, 9.8%; p = 0.02). CONCLUSION For correction of severe ventral chordee during primary proximal hypospadias repair, dorsal plication carries a higher risk of recurrence compared to ventral lengthening procedures.
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Castagnetti M, El-Ghoneimi A. Surgical management of primary severe hypospadias in children: an update focusing on penile curvature. Nat Rev Urol 2022; 19:147-160. [PMID: 35039660 DOI: 10.1038/s41585-021-00555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Marco Castagnetti
- Paediatric Urology Unit, Department of Surgery, Bambino Gesù Children Hospital and Research Institute, Rome, Italy. .,Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy.
| | - Alaa El-Ghoneimi
- Department of Paediatric Surgery and Urology, Reference Centre for Rare Urinary Tract Malformations (MARVU), Hôpital Robert Debré, APHP, Université de Paris, Paris, France
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Lin H, Wang YY, Li SB, Chen ZT, Su LJ. Staged transverse preputial island flap urethroplasty for some proximal hypospadias with moderate-to-severe chordee. BMC Urol 2021; 21:182. [PMID: 34949173 PMCID: PMC8697458 DOI: 10.1186/s12894-021-00948-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 12/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to assess the outcome of staged transverse preputial island flap (TPIF) urethroplasty for repairing certain cases of primary proximal hypospadias with moderate-to-severe chordee in children. METHODS Nighty-two consecutive boys who underwent either one-stage or staged TPIF urethroplasty for the repair of proximal hypospadias with moderate-to-severe chordee between August 2015 and December 2019 were evaluated retrospectively. Patients were divided into two groups: one-stage TPIF urethroplasty group (n = 44) and staged TPIF urethroplasty group (n = 48). We noted and compared the postoperative complications, including urethrocutaneous fistula, urethral diverticula, residual penile curvature, and urethral stricture in both groups. RESULTS Both groups were followed up for 1-5 years, with an average of 3 years. No cases of residual or recurrence of penile chordee were reported in either group. In Group A, 9 patients (9/44, 20.4%) had postoperative urethrocutaneous fistula, and all patients underwent urinary fistula repair or urethroplasty. In Group B, postoperative urethrocutaneous fistula occurred in 2 cases (2/48, 4.1%), and one patient developed a urethrocutaneous fistula after the first operation, which was successfully repaired during the second operation. A urethrocutaneous fistula occurred in 1 case after completion of the second-stage operation; urethral fistula repair was performed successfully 6 months later. There were 2 cases of urethral stricture in Group A (2/44, 4.5%) and none in Group B. There were 6 cases of urethral diverticulum in Group A (6/44, 13.6%) and no cases of urethral diverticulum in Group B. The operative success rates were 61.3% and 95.8% in Group A and Group B, respectively (P < 0.001). CONCLUSIONS Compared with one-stage TPIF urethroplasty, staged TPIF urethroplasty in the treatment of certain cases of primary proximal hypospadias with moderate-to-severe chordee resulted in fewer postoperative fistulas, urethral strictures and urethral diverticula. The staged TPIF urethroplasty procedure was effective in reducing the operation difficulty and complication rate of hypospadias, improving the curative effect of complex hypospadias and having good clinical application value.
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Affiliation(s)
- Hai Lin
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China.
| | - Yu-Yun Wang
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Shi-Bing Li
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Ze-Ting Chen
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Liang-Ju Su
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
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Babu R, Chandrasekharam VVS. 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. J Pediatr Urol 2021; 17:681-689. [PMID: 34099397 DOI: 10.1016/j.jpurol.2021.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/08/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Ramesh Babu
- Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.
| | - V V S Chandrasekharam
- Pediatric Surgery, Pediatric Urology and MAS, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India
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Ali MM, El-Hawy MM, Galal EM, Tawfiek ER, Anwar AZ. Results of two-stage transverse preputial island flap urethroplasty for proximal hypospadias with chordee that mandate division of the urethral plate. Cent European J Urol 2021; 74:89-94. [PMID: 33976922 PMCID: PMC8097640 DOI: 10.5173/ceju.2021.0245.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/12/2020] [Accepted: 12/27/2020] [Indexed: 11/22/2022] Open
Abstract
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%.
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Affiliation(s)
- Mostafa M Ali
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Mamdouh M El-Hawy
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Ehab M Galal
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Ehab R Tawfiek
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Ahmed Z Anwar
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
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Badawy H, Dawood W, Soliman AS, Fahmy A, Mahfouz W, Moussa A, Assem A, Aboulfotouh Eid A, Elsayed S, Gawan A, Hanno A, Youssef M. Staged repair of proximal hypospadias: Reporting outcome of staged tubularized autograft repair (STAG). J Pediatr Surg 2020; 55:2710-2716. [PMID: 32854924 DOI: 10.1016/j.jpedsurg.2020.07.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/09/2020] [Accepted: 07/24/2020] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Haytham Badawy
- Department of Urology, University of Alexandria, Alexandria, Egypt.
| | - Waleed Dawood
- Department of Urology, University of Alexandria, Alexandria, Egypt
| | | | - Ahmed Fahmy
- Department of Urology, University of Alexandria, Alexandria, Egypt
| | - Waly Mahfouz
- Department of Urology, University of Alexandria, Alexandria, Egypt
| | - Ahmed Moussa
- Department of Urology, University of Alexandria, Alexandria, Egypt
| | - Akram Assem
- Department of Urology, University of Alexandria, Alexandria, Egypt
| | | | - Shaymaa Elsayed
- Department of Pediatrics, University of Alexandria, Alexandria, Egypt
| | - Ahmed Gawan
- Department of Urology, University of Alexandria, Alexandria, Egypt
| | - Ahmed Hanno
- Department of Urology, University of Alexandria, Alexandria, Egypt
| | - Mohammed Youssef
- Department of Urology, University of Alexandria, Alexandria, Egypt
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Morlacco A, Gobbi D, Esposito C, Castagnetti M. Edges-On-Dartos: An Easy Way to Improve Graft Performance in Staged Hypospadias Repair. Urology 2020; 144:245-248. [PMID: 32711013 DOI: 10.1016/j.urology.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/02/2020] [Accepted: 07/12/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To present a technical tip to be incorporated in the first stage of a 2-stage graft repair of proximal hypospadias associated with curvature, aiming at widening the graft bed and enhancing mobility of the lateral portions of the graft for subsequent urethroplasty. METHODS After penile straightening, the dorsal dartos layer, carefully preserved attached to the dorsal penile skin used for penile coverage, is anchored to the lateral edges of the denuded corpora cavernosa with 3 to 4 interrupted 6-0 resorbable stiches on each side. The dartos creates a sort of hammock in-between the corpora, on which the central portion of the graft is quilted as in standard staged graft repair, and the skin margins laterally. Therefore, it widens the graft bed by 3-4 mm on each side. The lateral portions of the graft, laying on dartos, also remain supple for subsequent tabularization. RESULTS Between 2017 and 2019, the technique was used in 16 cases (range 10-19 months). None of these patients required re-grafting because of severe longitudinal graft shrinkage. CONCLUSION The described modification seems a simple tip to be incorporate in staged graft urethroplasty. Putative advantages include that a wider graft can compensate for some graft shrinkage occurring in-between stages; during the second stage, it can facilitate dissection and improve mobility of the lateral graft portions for tubularization, and make retrieval of a dartos flap for urethroplasty coverage easier. Prospective evaluation and comparative data are needed.
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Affiliation(s)
- Alessandro Morlacco
- Pediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology; University of Padova, Padua, Italy
| | - Dalia Gobbi
- Pediatric Surgery Unit, Treviso Hospital, Treviso, Italy
| | - Ciro Esposito
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Marco Castagnetti
- Pediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology; University of Padova, Padua, Italy.
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The current state of tissue engineering in the management of hypospadias. Nat Rev Urol 2020; 17:162-175. [DOI: 10.1038/s41585-020-0281-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 12/20/2022]
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Tijani KH, Idiodi-Thomas HO, Elebute OA, Alakaloko FM, Ojewola RW, Ademuyiwa AO. Two-stage flap repair of severe hypospadias: Usefulness of the tubularized incised plate urethroplasty. J Pediatr Urol 2017; 13:483.e1-483.e5. [PMID: 28579133 DOI: 10.1016/j.jpurol.2017.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 04/25/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE The use of flaps in the two-stage repair of posterior hypospadias associated with severe chordee has been well established. Despite the almost certain guarantee of flap take, complications such as diverticuli are still relatively high. While different applications of the tubularized incised plate have been described, experience with the application of the technique to the two-stage flap repair is very limited. A previous local review of 15 cases performed at the present institution during the period 1998-2003, using the technique as described by Rekit, revealed fistulae and diverticulum rates of 20% and 27%, respectively. With the primary objective of improving surgical outcome, the midline incision was incorporated into the two-stage flap repair. MATERIALS AND METHODS Between 2004 and 2015, 35 boys (aged 2-15 years) with severe hypospadias that required excision of the urethral plate were operated using the two-stage flap technique. The first stage involved mobilization of preputeal or dorsal penile skin (if circumcised) to the ventral surface, as described by Retik. After a minimum interval of 6 months, the second-stage operation was performed in a way similar to the technique of tubularized incised plate urethroplasty, as popularized by Snodgrass, and involved a preliminary midline incision on the neo-urethral plate followed by tubularization and multilayered closure. RESULTS All but one flap took successfully. The outcome was satisfactory in 80% of patients, and there was a fistula rate of 14% ( Summary Table). One patient had a complete breakdown of the flap and was successfully treated about 12 months later by repeating the second stage of the operation. No case of diverticulum or stricture was recorded. DISCUSSION Even though there was a marginal improvement in the fistula rate, the most striking observation was the complete absence of diverticulum or stricture. With a reported incidence rate of 20-63%, different authors have reported diverticulum formation (despite the absence of distal obstruction) to be a major problem of the two-stage flap technique. Attempts by these authors at reducing the risk of diverticulum by reducing flap size have tended to increase the risk of strictures. This has been the main reason given by some authors for abandoning the technique. The main limitations of the present study included the wide age range of the patients and the small sample size. CONCLUSION The inclusion of a midline incision in a two-stage flap urethroplasty for proximal hypospadias appears to prevent the development of diverticulum.
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Affiliation(s)
- K H Tijani
- Section of Urology, Department of Surgery, College of Medicine, University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Lagos, Nigeria.
| | - H O Idiodi-Thomas
- Section of Pediatric Surgery, Department of Surgery, College of Medicine, University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Lagos, Nigeria
| | - O A Elebute
- Section of Pediatric Surgery, Department of Surgery, College of Medicine, University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Lagos, Nigeria
| | - F M Alakaloko
- Section of Pediatric Surgery, Department of Surgery, College of Medicine, University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Lagos, Nigeria
| | - R W Ojewola
- Section of Urology, Department of Surgery, College of Medicine, University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Lagos, Nigeria
| | - A O Ademuyiwa
- Section of Pediatric Surgery, Department of Surgery, College of Medicine, University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Lagos, Nigeria
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Abstract
The majority of patients with DSD will be found to carry an XY karyotype and be assigned male gender. From a phenotypical standpoint, most will present with proximal hypospadias ± cryptorchidism. In this review article, the authors present the current status of reconstruction of the male genitalia in this setting. The report addresses the following topics: surgical input in the evaluation of the newborn with an undervirilized external genitalia, including gender assignment considerations; controversies surrounding timing and indication for hypospadias surgery in proximal cases as well as use of testosterone; surgical techniques and decision-making process for one- vs. two-stage repairs; complications of hypospadias surgery based on technique used for repair; and long-term follow-up. The high complication rates observed in the treatment of proximal hypospadias attest to its challenging nature. Concentration of experience, tracking carefully identified patient-centered outcomes and long-term follow-up of this patient population are recommended.
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Affiliation(s)
- Rodrigo L P Romao
- IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joao L Pippi Salle
- Division of Urology, Department of Surgery, Sidra Medical and Research Center, PO Box 26999, Doha, Qatar.
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