Proximal Hypospadias With Severe Chordee: Single Stage Repair Using Corporeal Tunica Vaginalis Free Graft

Cell-Based Therapy for Urethral Regeneration: A Narrative Review and Future Perspectives

Urethral stricture is a common urological disease that seriously affects quality of life. Urethroplasty with grafts is the primary treatment, but the autografts used in clinical practice have unavoidable disadvantages, which have contributed to the development of urethral tissue engineering. Using various types of seed cells in combination with biomaterials to construct a tissue-engineered urethra provides a new treatment method to repair long-segment urethral strictures. To date, various cell types have been explored and applied in the field of urethral regeneration. However, no optimal strategy for the source, selection, and application conditions of the cells is available. This review systematically summarizes the use of various cell types in urethral regeneration and their characteristics in recent years and discusses possible future directions of cell-based therapies.

A meta-analysis comparing dorsal plication and ventral lengthening for chordee correction during primary proximal hypospadias repair

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.

Comparison of Outcome and Success Rate of Onlay Island Flap and Dorsal Inlay Graft in Hypospadias Reconstruction: A Prospective Study

Background

Chordee correction, urethroplasty, and tissue reconstruction are performed to correct and retain standard functionality of the penis in hypospadias. Conventional reconstruction techniques, such as onlay island flap and the dorsal inlay graft, can be performed based on the classification of hypospadias. However, the outcomes and complication rates have not been widely studied. Thus, we aimed to provide preliminary evidence regarding the efficacy and safety of both approaches in hypospadias reconstruction.

Patients and Methods

A prospective study with two time evaluations of 14 and 180 days post-operatively was performed at the Urology outpatient clinic from October 2014 to September 2019. A proportion comparison of success rate, time to the complication, operation time, catheterization duration, uroflowmetry parameter post-surgery, and mean scores comparison of PPPS were measured as the intended outcomes.

Results

In a total of 59 pediatric hypospadias, patients who had undergone reconstruction are included in this study. Higher subjects’ age and severe chordee severity were more common in the dorsal inlay graft group (age=7.50 [1–26] months; severe chordee 45.8%) compared to the onlay island flap group (age=4.0 [1–67] months; severe chordee 31.4%), both groups showed similar satisfaction regarding meatal shape and position (P=0.618), glands shape (P=0.324), penile skin shape (P=0.489), and general cosmetic appearance (P=0.526). Complication occurrence and time to complication duration of both groups were also not statistically significant (P=0.464 and P=0.413). There are no significant differences in Q_max, Q_mean, voided volume, and PVR of both groups (P=0.125, 0.136, 0.076, 0.260, respectively). Significant differences in operation times and catheterization duration are found in this study (P<0001).

Conclusion

Outcome evaluation regarding functional, complication and patient satisfaction comparing onlay flap and dorsal inlay graft for hypospadias patients is scarce. This study found that both procedures can be considered safe with comparable incidence of complications.

Recurrent Ventral Curvature with Long-Term Follow-up after Transverse Preputial Island Urethroplasty

OBJECTIVE

 This study was aimed to assess the long-term outcomes of recurrent ventral curvature (VC) repaired in early childhood after transverse preputial island flap urethroplasty.

MATERIALS AND METHODS

 A total of 378 patients underwent transverse preputial island flap urethroplasty between January 2000 and January 2005 at our hospital. Of these patients, 43 were invited for assessment of VC after puberty. The age at surgery, types of hypospadias, degrees of recurrent VC, and surgical procedures were analyzed.

RESULTS

 The study included 43 patients with a mean age of 15.9 years (range, 12.3-17.9). The average age at the time of primary surgery was 1.9 years (range, 1.2-3.6). Of 43 patients, recurrent VC was identified in 14 (32.5%). In total, 8 out of 16 patients (50.0%) were successfully treated by urethral plate transection with skin release during the primary surgery, and 6 out of 27 patients (28.6%) underwent additional dorsal plication (DP; p = 0.093). Severe recurrent VC was observed in four, moderate curvature was observed in four, and mild curvature was observed in six cases. Recurrent VC was present more often in patients with complications (34.6 vs. 24.1%, p = 0.331), especially in severe urethral strictures that required open surgical reconstruction (p = 0.039).

CONCLUSION

 Although the patients in our study represent only a small portion of the overall hypospadias population, it is notable that 32.5% of these patients showed recurrent VC, including 28.6% of patients with transection plus DP. We suggest long-term follow-up of hypospadias at least during adolescence or even into adulthood.

Tunica vaginalis graft for recurrent urethrocutaneous fistula repair after hypospadias surgery

OBJECTIVES

To evaluate the outcomes of recurrent urethrocutaneous fistula repair using tunica vaginalis graft as an intermediate protective layer.

METHODS

We retrospectively reviewed the data of 45 children with recurrent urethrocutaneous fistula who underwent tunica vaginalis graft repair between February 2011 and January 2019. The repair was carried out at least 6 months after a previous fistula repair. Follow up at an outpatient clinic was scheduled on a weekly basis for 1 month, then monthly for 6 months and then annually. During follow up, every patient was evaluated by history taking. The site of repair and the act of micturition were inspected. Urine analyses together with culture and sensitivity tests were carried out if required. Successful repair was defined as the absence of recurrence, with good force and caliber of the urinary stream.

RESULTS

This study included 45 patients with recurrent urethrocutaneous fistula who were managed with a tunica vaginalis graft as a second layer. The mean age of patients was 6.7 ± 2.8 years. The mean postoperative hospital stay was 5.5 ± 0.7 days. The repair was successful for 43 (95.6%) patients, and urethrocutaneous fistula recurrence was reported for two (4.4%) patients, which were repaired after 6 months. In all patients, the cosmetic appearance of the penis was satisfactory without torsion or ventral chordee.

CONCLUSION

Tunica vaginalis graft is a simple and fast procedure that is highly effective as a protective second layer for recurrent urethrocutaneous fistula repair.

Recurrent chordee in 59 adolescents and young adults following childhood hypospadias repair

BACKGROUND

As children transition to adolescence, penile curvature may recur several years, sometimes, decades later. Herein we review our experience with a group of symptomatic patients, their surgical repairs and outcome.

MATERIAL & METHODS

Reviews were done on the charts of 59 symptomatic adolescents aged 14-21 years who presented with recurrent penile curvature, causing either sexual dysfunction or significant deformity and had undergone surgical correction between 2000 and 2017. Their initial hypospadias repairs were: TIP & dorsal midline plication (28), Tiersch-Duplay (T-D) urethroplasty and Nesbit dorsal repair [9], prepuce mucosal island onlay and Nesbit repair [6], Two-stage Byar repair and ventral dermal graft (3 patients). 13/59 patients were repaired elsewhere, and their records were unavailable. Surgical correction included one stage dorsal replication and skin detethering (32patients), one-stage urethral mobilization and corporal/dermal grafts (12patients), staged corporal/dermal graft and skin coverage followed by urethroplasty (Grafted TIP) 8-12 months later (15patients), and 11/59 had urethral fistula, which were repaired concomitantly.

RESULTS

55 out of 59 patients were followed up for 6-48 months (median 30 months) by periodic office visits, and 2-4 weeks in 4 patients whose subsequent follow up was by email. Of the 55 patients, 53 healed well, and 2patients developed wound breakdown and scarring, which resulted in mild recurrent curvature but to a lesser degree than preoperatively. The other 4 patients who corresponded by email were pleased with the surgical outcome. Of the total 59 patients, 28 reported satisfactory sexual activity. None of the patients who had corporal/dermal grafts reported erectile abnormalities.

CONCLUSIONS

Recurrent curvature in adolescents following hypospadias repair, may be caused by peri-urethral and skin fibrosis and/or disproportionate growth of the relatively hypoplastic ventral corporal wall or the reconstructed urethra. Surgical correction of symptomatic patients by dorsal shortening or ventral lengthening procedures depends on the degree of curvature following skin degloving of the penis. We have been recommending to parents of children born with proximal hypospadias who had what appeared to be a good surgical result to follow up after puberty.

Modified tubularized incised plate urethroplasty reduces the risk of fistula and meatal stenosis for proximal hypospadias: a report of 63 cases

PURPOSE

To report the feasibility of modified tubularized incised plate (TIP) urethroplasty technique for proximal hypospadias in 63 cases.

METHODS

From January 2004 to March 2010, 63 patients underwent one-stage TIP urethroplasty (modified Snodgrass technique repair) using 2-3 of three covering layers (corpus spongiosum, dartos, and tunica vaginalis). The primary meatus was proximal penile, penoscrotal, scrotal, and perineal in 38, 13, 10, and 2 patients, respectively. All patients had chordee that was corrected with dorsal plication. Glanuloplasty was performed in all cases. Complications and cosmetic results were documented after 6-72 months of follow-up.

RESULTS

A total of 63 boys with proximal hypospadias underwent Snodgrass hypospadias repair at a mean age of 8.5 months (range 6-54). Mean operative time was 210 ± 35 min. Patients were followed up with 6-month intervals for up to 6 years postoperatively. After 6 years of follow-up, nine urethrocutaneous fistulae, four bleeding, four meatal stenoses, and one urethral stricture were reported. Cosmetic result was satisfactory according to parent's opinion and another surgeon. No residual chordee was observed in any cases (without artificial correction).

CONCLUSION

In conclusion, this preliminary report can be estimated as an alternative technique with acceptable complication and cosmetic results for proximal hypospadias correction.

Urethral Reconstruction Using Mesothelial Cell-Seeded Autogenous Granulation Tissue Tube: An Experimental Study in Male Rabbits

Objective. This study was to evaluate the utility of the compound graft for tubularized urethroplasty by seeding mesothelial cells onto autogenous granulation tissue. Methods. Silastic tubes were implanted subcutaneously in 18 male rabbits, of which nine underwent omentum biopsies simultaneously for in vitro expansion of mesothelial cells. The granulation tissue covering the tubes was harvested 2 weeks after operation. Mesothelial cells were seeded onto and cocultured with the tissue for 7 days. A pendulous urethral segment of 1.5 cm was totally excised. Urethroplasty was performed with mesothelial cell-seeded tissue tubes in an end-to-end fashion in nine rabbits and with unseeded grafts in others as controls. Serial urethrograms were performed at 1, 2, and 6 months postoperatively. Meanwhile, the neourethra was harvested and analyzed grossly and histologically. Results. Urethrograms showed cell-seeded grafts maintained wide at each time point, while strictures formation was found in unseeded grafts. Histologically, layers of urothelium surrounded by increasingly organized smooth muscles were observed in seeded grafts. In contrast, myofibroblasts accumulation and extensive scarring occurred in unseeded grafts. Conclusions. Mesothelial cell-seeded granulation tissue tube can be successfully used for tubularized urethroplasty in male rabbits.

Management of High-Grade Penile Curvature Associated With Hypospadias in Children

Penile curvature is a frequent feature associated with hypospadias with also a great variability of severity among each patient. While the low-grade curvature (<30°) can be relatively easily corrected by simple techniques like penile degloving and dorsal plication, severe cases often demand more complex maneuvers to manage it. A great number of surgical techniques have been developed to adequately correct curvatures greater than 30°; however, each one of them should be individualized to different patients and local conditions encountered. In this article, we will review the evaluation of the pediatric patient with penile curvature associated with hypospadias with a special attention to high-grade cases, their management, indications for surgical treatment, and several surgical options for their definitive treatment.

Comparison of variables affecting the surgical outcomes of tubularized incised plate urethroplasty in adult and pediatric hypospadias

INTRODUCTION

The American Academy of Pediatrics recommends operating on hypospadias between the ages of 6-12 months. Since most births in developed countries are conducted in a hospital, parents are likely to be well informed and counseled about the hypospadias. However, significant numbers of births in developing countries are still conducted at home, with illiteracy, poverty and ignorance often leading to late presentation at the hospital. Reported hypospadias-repair complication rates are higher in adults compared with those having surgery in childhood. The present study's objective was to evaluate the factors affecting surgical outcome in hypospadias patients undergoing tubularized and tubularized incised plate urethroplasty (TIPU) in adulthood compared with childhood.

MATERIALS AND METHODS

A prospective study of 60 adult patients >16 years, and 60 pediatric patients <5 years who underwent TIPU for primary hypospadias between May 2008 and May 2012. Patients were operated on by a single surgeon, under similar circumstances, and were pre-operatively examined to assess meatal location, chordee, and torsion; they were also examined intra-operatively for quality of spongiosum and urethral plate width. The outcomes were assessed by patient/parents for satisfaction regarding cosmesis, urinary stream and complications.

RESULTS

The age of the patients varied from 16 to 27 years, with a mean of 20.8 years in adults, and 6 months to 5 years, with a mean of 2.1 years, in children. The type of hypospadias, degree of curvature, quality of spongiosum and urethral plate width were comparable in both groups, but complication rates were higher in adults (16.7%) than in the pediatric (6.7%) group (Figure 1A-D). Meatal stenosis responded well to dilatation, but fistulae required revision surgery and had a cure rate of 100%. The median follow-up was 37 months in adults, and 39 months in children.

DISCUSSION

The higher complication rates in adults may be due to more frequent erections; increased susceptibility to infection along with relatively reduced vascularity lead to poor wound healing and increased complication rates. The limitation of the study was the small number of patients with mid and proximal hypospadias having lesser incidences in comparison with distal hypospadias. Adequate number of patients in these subgroups could have further strengthened the statistical correlation. Secondly, there was no objective criterion like uroflowmetry to assess urinary stream.

CONCLUSIONS

Complication rates were higher in adults undergoing TIPU compared with pediatric patients, which was also statistically significant in distal hypospadias. The important factors in surgical outcome were: severity of hypospadias, degree of curvature, quality of spongiosum, and urethral plate width.

The contemporary role of 1 vs. 2-stage repair for proximal hypospadias

This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved-a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and-depending on technique-have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.

Factors affecting post-pubertal penile size in patients with hypospadias

Objectives

To evaluate actual post-pubertal penile size and factors affecting it in hypospadias patients, we retrospectively reviewed medical charts.

Patients and methods

Hypospadias patients whose external genitalia were categorized into Tanner stage 5, and whose stretched penile length was evaluated at 15 years old or older from April 2008 to April 2015, were enrolled in the present study. Stretched penile length was measured by a single examiner. Actual post-pubertal stretched penile length and factors affecting the post-pubertal stretched penile length were estimated. Statistical analysis was performed using Mann–Whitney U test and univariate and multivariate linear regression models for the determination of independent factors.

Results

Thirty patients met the inclusion criteria. Median age at evaluation was 17.2 years. Thirteen and 17 had mild and severe hypospadias, respectively. Endocrinological abnormality was identified in 5. Multivariate analysis showed that the severity of hypospadias and endocrinological abnormality were significant factors affecting stretched penile length. Stretched penile length in 25 patients without endocrinological abnormality was significantly longer than that in those with endocrinological abnormality (p = 0.036). Among patients without endocrinological abnormality, stretched penile length in 13 with severe hypospadias was significantly shorter than that in 12 with mild hypospadias (p = 0.004).

Conclusions

While the severity of hypospadias and endocrinological abnormality at post-pubertal evaluation were factors affecting post-pubertal penile size, stretched penile length in patients with severe hypospadias was shorter even in cases without endocrinological abnormality. These results suggest that severe hypospadias is not only a disorder of urethral development, but also a disorder of penile development.

Penile enhancement with rectus muscle fascia and testicular tunica vaginalis grafts: an experimental animal study

PURPOSE

To enhance rat penises experimentally with rectus muscle fascia (RMF) and testicular tunica vaginalis grafts (TVG).

METHODS

Twelve Wistar albino rats were distributed into two equal Groups, A and B. There were six rats in each group. RMF and TVG were used to enhance rat penises in Groups A and B, respectively. Circumferences of the penises were measured preoperatively and at three different times after the operation. Two, two and eight rats were killed 10 days, 1 month and 2 months after the operation, respectively, for histopathological examinations.

RESULTS

When we compared the measurements of preoperative and immediately postoperative circumferences, the mean increase was 23.4 ± 2.9 % in Group A and 19.9 ± 1.7 % in Group B. According to paired t test, the difference was significant (p < 0001), but the comparison between preoperative and postoperative first-month measurements was not found to be significant (p > 0.05). Histological examinations revealed an intensive inflammatory process at 10 days after the operation. Grafts were found to be totally absorbed in the first- and second-month examinations.

CONCLUSION

In our study, implanted TVG and RMF could not survive because of insufficient vascularization and failure to maintain satisfactory surgical success. More studies are needed to increase the effectiveness of surgical techniques.

The use of dermal graft in severe chordee hypospadias repair: experience from Vietnam

PURPOSE

Severe chordee with hypospadias may require repair by ventral corporoplasty with a free graft before urethroplasty. We report an 11 year experience with one-stage and two-stage hypospadias repair using dermal grafts.

MATERIALS AND METHODS

From 12/1997 to 12/2008, 47 hypospadias with severe chordee were repaired using a ventral dermal graft to correct the chordee. Forty cases were repaired in two stages; the remaining seven patients had adequate preputial skin and were repaired in one stage. In 28 cases the neourethra was covered with both tunica vaginalis and penile dartos flap while 12 were covered only with penile dartos flap. Patients ranged from 12 to 152 months of age. Follow-up ranged from 6 months to 4 years.

RESULTS

28 patients with both tunica vaginalis and dartos flap had 7 urethral fistulas and 2 developed meatal stenosis. 12 patients with only penile dartos flap had 3 fistulas and 2 had meatal regression. The seven patients who underwent a one-stage repair had good results with a straight penis and no evidence of urethral fistula or urethral stenosis.

CONCLUSIONS

Dermal graft can be performed in one or two stage hypospadias repair. Complication rates are similar to other standard repairs for proximal hypospadias.

Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience

It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20-60 months) and 35 months (18-60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.

Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair

INTRODUCTION

We previously described urethral plate (UP) dissection and urethral mobilization from the corpora cavernosa to achieve or facilitate straightening ventral curvature while preserving the UP for TIP in boys with proximal hypospadias. The original patients had similar complications to those undergoing proximal TIP without UP elevation. Subsequently an increased occurrence of neourethra strictures in those with UP elevation and urethral mobilization was recognized, and is now reported.

MATERIALS

Information on consecutive patients with proximal TIP repair with and without UP elevation and urethral mobilization by a single surgeon was reviewed in a database with pre-determined data points entered on the day of service.

RESULTS

There were 76 proximal TIP patients with follow up, 29 with and 47 without UP elevation and urethral mobilization, with strictures developing in 5 (17%) and 0, respectively, p = 0.01. All strictures were symptomatic (UTI, urinary retention), 0.1-1.0 cm long, and diagnosed at ≤1.5 years after surgery.

CONCLUSIONS

UP elevation and urethral mobilization with TIP resulted in focal devascularization of the neourethra with symptomatic stricture development. Although most patients with these straightening maneuvers did not have stricture, we no longer recommend UP elevation and urethral mobilization with proximal TIP repair.

Tubularized urethral replacement using tissue-engineered peritoneum-like tissue in a rabbit model

INTRODUCTION

This study aims to investigate whether mesothelial cells could function as seed cells to construct tissue-engineered peritoneum-like tissue for urethral reconstruction in a rabbit model.

MATERIALS AND METHODS

Bladder acellular matrices were prepared and trimmed to 1.5 × 1 cm. Nine male rabbits underwent omentum biopsy and autologous mesothelial cells were isolated. After in vitro expansion, the cells were seeded onto the matrices and incubated for 7 days. In 18 rabbits, a pendulous urethral segment 1.5 cm long was totally excised and urethroplasty was performed with tubularized matrices seeded with cells in 9 animals and without cells in 9 as controls. Urethrography was performed at 1, 2 and 6 months postoperatively. Meanwhile, the neourethras were harvested and analyzed grossly and histologically.

RESULTS

Histological analysis of the cell-seeded grafts revealed a loose collagen matrix covered with a single layer of mesothelim. Serial urethrography indicated a wide urethral caliber without stricture formation in animals implanted with cell-seeded matrices, while all animals of the control group developed stricture. Histological analysis of the implanted cell-seeded matrices demonstrated a normal urethral architecture by 1 month, composed of multilayers of urothelium surrounded by smooth muscle bundles, which became increasingly organized with time. By 6 months, the neourethra could be hardly distinguished from native urethra both grossly and histologically.

CONCLUSIONS

Autologous mesothelial cells could be successfully used as seed cells for tubularized urethral reconstruction in male rabbits.

The influence of perioperative factors on primary severe hypospadias repair

Hypospadias is one of the most common congenital malformations of the male genitalia. Severe cases present with associated curvature greater than 30° and the meatus opening proximally to the penoscrotal junction. The perioperative management of patients with primary severe hypospadias is variable. Systematic evaluation of the upper urinary tract and the search for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias, and should be limited to severe cases with associated extraurinary malformations. Detection of a disorder of sex development is key for gender assignment and prognosis, but the identification of cases warranting a full work-up and the influence of such a diagnosis on the success of hypospadias repair is controversial. Preoperative hormonal stimulation allows for penile growth irrespective of the administration route. Associated morbidity is minimal, but its influence on the success of surgery is still unknown. An age of 6-18 months is generally recommended for surgery, but no trial data support this policy. Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery, whereas postoperative antibiotic prophylaxis and type of dressing have minimal impact on surgical success. Overall, most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined. Clinicians should be made aware of the evidence supporting any single intervention in order to standardize their management policies. We hope the issues outlined here will prompt researchers to design new studies to address the clinically relevant questions.

General considerations in hypospadias surgery

Nonsystemic review of the literature was done for timing of surgery, preoperative evaluation and plan, anesthesia, suture materials, magnification, tissue handling, stent and diversion problems, intra and postoperative care, dressing, and follow-up protocol. The best time for hypospadias repair is between 6 and 18 months. Preoperative evaluation in proximal hypospadias includes hormonal and radiological examination for intersex disorders, as well as for upper tract anomalies along with routine evaluation. General anesthesia is a rule but local blocks help in reducing the postoperative pain. Magnification, gentle tissue handling, use of microsurgical instruments, and appropriate-sized stent for adequate period help in improving the results. Hormonal stimulation is useful to improve growth and vascularity of urethral plate and decrease the severity of chordee in poorly developed urethral plate with severe curvature. Urethral plate preservation urethroplasty with spongioplasty is the procedure of choice in both proximal and distal hypospadias. Algorithms are proposed for management of hypospadias both with curvature and without curvature. Two-stage urethroplasty has its own indications. A good surgical outcome may be achieved following basic surgical principles of microsurgery, fine suture materials, choosing one or two-stage repair as appropriate, proper age of surgery, and with good postoperative care. Future of hypospadiology is bright with up coming newer modalities like laser shouldering, robotics, and tissue engineering.

Tubularized incised plate proximal hypospadias repair: Continued evolution and extended applications

OBJECTIVE

We report additional technical modifications and extended application of proximal TIP hypospadias repair in consecutive patients operated by a single surgeon.

MATERIALS

During a 39-month period, 36 patients underwent primary proximal hypospadias surgery, with 26 undergoing TIP and 10 two-stage repair for a thin urethral plate (UP) (1) or ventral penile curvature (VC) requiring UP transection (9). Of the TIP repairs, 16 had UP elevation from the corpora cavernosa to facilitate VC straightening while maintaining the UP for urethroplasty. All TIP patients underwent two-layer urethroplasty with tunica vaginalis coverage over the neourethra.

RESULTS

With mean follow up of 12 months (2-38) in 24 TIP patients, 16 had calibration and 11 urethroscopy 6-12 months postoperatively. Complications occurred in three (13%), glans dehiscence (2) and neourethral stricture (1), which represents a significant reduction versus our prior reports. Non-randomized preoperative testosterone in 8/24 with follow up did not influence complication rates. TIP incision of the elevated UP did not divide it into separate strips, or impair vascularity.

CONCLUSIONS

Dissection of the UP from the corpora facilitates correction of VC while preserving the plate, without increasing TIP urethroplasty complications. Overall, complication rates for TIP have significantly diminished with technical modifications and experience. The role for neoadjuvant hormonal therapy remains unclear. Despite straightening VC preserving the UP, intraoperative assessment deemed it unsuitable for TIP in one case (4%).

Demonstration of postoperative effectiveness in ventral lengthening using a tunica vaginalis flap for severe penile curvature with hypospadias

OBJECTIVES

To evaluate the postoperative effectiveness of ventral lengthening with a tunica vaginalis flap. Correcting penile curvature is an essential step in proximal hypospadias surgery. It is logical to lengthen the ventral radius using a graft; however, penile curvature would recur owing to a graft contracture with inadequate vascularization. Although a tunica vaginalis is considered a suitable material to be used as a flap instead of a graft, clinical application of this technique is uncommon. Information regarding the usefulness and effectiveness of this procedure is required.

METHODS

Between 2003 and 2008, we repaired 146 patients with hypospadias and the urethral plate was transected in 39 patients because of severe curvature. Significant severe curvature persisting even after transection of the plate was corrected with ventral corporeal lengthening procedures using a tunica vaginalis flap in 15 patients and postoperative results were evaluated.

RESULTS

Straight penile erection was identified in all 15 boys at home by their parents. In 7 of the 15 boys, artificial erection was performed at the time of additional surgery; 5 degrees of curvature was found in 2 patients and 0 degree in 5.

CONCLUSIONS

At the second session of surgery, we observed that penile straightening was maintained without recurrence of curvature. Additionally, the area in which the tunica vaginalis flap was placed on the ventrum did not contract. Therefore, lengthening the ventral aspect using a tunica vaginalis flap might be an important alternative for correction of severe penile curvature in hypospadias surgery.

Detubularized pedicled vaginal onlay flap urethroplasty: a new method for hypospadias repair of ambiguous genitalia

PURPOSE

We introduce the detubularized pedicled vaginal onlay flap urethroplasty for single stage repair in ambiguous genitalia with perineoscrotal hypospadias and accompanying vagina, and report its preliminary surgical outcome.

MATERIALS AND METHODS

A total of 10 children with severe perineoscrotal hypospadias and genital ambiguity presenting with vagina and urogenital opening underwent single stage reconstruction with vaginal onlay urethroplasty. Through the posterior sagittal or abdominoperineal approach the vagina was released and pulled out, with care taken to preserve its vascular pedicle. Two incisions were made along the lateral margins of the vagina, reaching each other on the upper surface of the vaginal base, converting the vagina into a longitudinal flap twice as long as its original length. The vagina was then trimmed and reconfigured into a suitable sized flap to cover the urethral plate and form a neourethra with the onlay technique. The onlay-tube-onlay technique was also used in 2 patients with insufficient urethral plate. In 5 cases severe ventral chordee was also corrected concurrently with free vaginal graft to the ventral corpus cavernosum without further dorsal plication.

RESULTS

The first 3 operations using the posterior sagittal approach failed due to improper surgical access, and the vagina was discarded. However, we achieved a satisfactory outcome with no failure after switching to an abdominoperineal approach. Immediate postoperative and short-term results revealed no urethrocutaneous fistula, urethral breakdown or necrosis at the distal end of the neourethra. Only 1 patient presented with severe mid shaft ring stricture, which required surgical revision.

CONCLUSIONS

Incorporating the vagina of intersex patients into urethroplasty using detubularized pedicled vaginal onlay flap seems to provide a safe and practical method to treat severe hypospadias with genital ambiguity. Short-term satisfactory results are achievable by choosing the proper surgical approach and preserving the vaginal blood supply. However, longer followup in a large series of patients is needed before applying this method to clinical practice.

Ventral penile lengthening versus dorsal plication for severe ventral curvature in children with proximal hypospadias

PURPOSE

The 2 main approaches to correct severe ventral curvature are dorsal plication of the corpora and ventral corporeal lengthening by tunica albuginea patching. Controversy persists since neither technique has been proved to be superior to the other with respect to initial or long-term outcome. However, to our knowledge a direct comparison of outcome of these 2 procedures has not been previously reported.

MATERIALS AND METHODS

A retrospective review of the records of 100 consecutive patients who underwent repair of penoscrotal or more proximal defects from 1996 to 2004 was performed. Children were divided into 2 groups, including group 1-32 who underwent a ventral penile lengthening procedure and group 2-68 who underwent dorsal plication. Meatal location, preoperative testosterone stimulation, severe ventral curvature (greater than 45 degrees) at the beginning of operation and after degloving, proximal ventral dissection, urethral plate transection and recurrent ventral curvature were compared between the 2 groups.

RESULTS

Mean age was 17 months (range 9 to 56) in patients with ventral penile lengthening and 17.8 months (range 10 to 58) in patients with dorsal plication. Mean followup was 65 (range 29 to 120) and 62 months (range 30 to 116), respectively. Of the 32 group 1 children 30 (93.7%) had penoscrotal or more proximal hypospadias vs 57 of the 68 (83.8%) in group 2. Three of the 32 children who underwent ventral penile lengthening had recurrent ventral curvature vs 19 of the 68 who underwent dorsal plication (9.4% vs 27.9%, p = 0.03). On multivariate analysis dorsal plication remained significantly associated with recurrent ventral curvature independently of the other factors (OR 4.56, 95% CI 1.14-18.28, p = 0.03).

CONCLUSIONS

Dorsal plication was more often associated with recurrent ventral curvature compared to ventral penile lengthening on univariate and multivariate analysis. Future studies adjusting for proximal ventral dissection and urethral plate transection are necessary to further elucidate the role of each technique in the correction of severe ventral curvature in children with proximal hypospadias.

Current concepts in hypospadias surgery

Anatomical anomalies in hypospadias are an abnormal ventral opening of the urethral meatus, abnormal ventral curvature of the penis and abnormal distribution of the foreskin around the glans with a ventrally deficient hooded foreskin. The techniques of hypospadias surgery continue to evolve. The current standard of care for hypospadias repair includes not only a functional penis adequate for sexual intercourse and urethral reconstruction offering the ability to stand to urinate, but also a satisfactory cosmetic result. Tubularized incised plate repair has been the mainstay for distal hypospadias. In cases of proximal hypospadias, one-stage repairs such as the Duckett repair or the Koyanagi repair have been well established, while two-stage repairs remain important alternatives. Whether dorsal plication or ventral lengthening should be used to correct penile curvature is still controversial, and long-term results are required. Efforts have been made in this decade to improve cosmetic appearance, constructing a slit-like meatus or performing foreskin reconstruction, and to prevent onerous complications.