Effect of suturing technique and urethral plate characteristics on complication rate following hypospadias repair: a prospective randomized study

Surgical repair techniques in hypospadias with unfavorable urethral plate: A systematic review and network meta-analysis

INTRODUCTION

Hypospadias is one of the most common urogenital malformations in male newborns. Numerous techniques exist for repairing hypospadias, including urethral advancement, tubularized incised plate (TIP), flaps, and graft-tubularized incised plate (GTIP). However, it remains unclear which approach is optimal in cases with an unfavourable urethral plate.

OBJECTIVE

This systematic review and network meta-analysis compares efficacy, complication rates, and patient outcomes of the various surgical procedures used to repair hypospadias with an unfavorable urethral plate.

STUDY DESIGN

Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA) guidelines were used to conduct a search of PubMed, Cochrane Library, Embase, and Science Direct databases up to May 4, 2024. Studies were rigorously screened and evaluated using Cochrane Risk of Bias 2.0. A random-effects meta-analysis was conducted using R-Studio to combine effect estimates. Included were peer-reviewed publications of randomized controlled trials, prospective cohort studies, and retrospective studies involving male patients diagnosed with hypospadias and "unfavorable urethral plate".

RESULTS AND DISCUSSION

A total of 20 studies representing n = 1483 patients were included, screened, and displayed low risk of bias. Four studies were included in the network meta-analysis. Narrow meatus were found to be more prevalent in TIP urethroplasty, while glans dehiscence was less common with flaps. Additionally, TIPs and GTIP displayed lower incidence of diverticulum compared to flaps. The network meta-analysis indicated no significant differences between the three procedures in terms of fistula complication (Flap [OR 0.41; 95 % CI 0.11-1.50] and GTIP [OR 0.52; 95 % CI 0.17-1.57]). GTIP procedures were associated with fewer overall complications (OR 0.37; 95 % CI [0.19-0.75]).

CONCLUSION

Flap and GTIP techniques may display lower complication rates than TIP in cases of unfavorable urethral plate, with modest superiority of the GTIP approach. Flap and GTIP techniques may therefore be optimal for repairing hypospadias in cases of unfavorable urethral plate, although high-quality comparative studies are needed to confirm this finding.

Topography-guided Anatomical Reassembly for Distal Penile Hypospadias Without Chordee: A Comprehensive Illustration and Midterm Results of a Novel Approach

OBJECTIVE

To provide a comprehensive illustration of the newly introduced "topography-guided anatomical reassembly" approach, which has shown promising early results, and to report the midterm outcomes of an extended series.

METHODS

This is a prospective cohort study of all patients presenting to the author's facility with distal penile hypospadias without chordee between June 2018 and January 2023. Redo cases, circumcised cases, and cases with non-preservable plates are excluded. The procedure follows the most recently introduced principle of the topography-guided anatomical reassembly approach for distal penile hypospadias, that is, the exclusive zipping-up of the unfolded spongiosal plate.

RESULTS

A subset of 97 boys met the enrollment criteria. The hypospadias meatus was coronal or sub-coronal in 35 boys, distal penile in 45 boys, and mid-penile in 17 boys. The mean age at the time of surgical correction was 8.11 months. The mean operative time was 66.7 minutes. After a mean follow-up of 27 months, 5 urethrocutaneous fistulae were reported as the following: 3 glanular and 2 sub-coronal. Meatal disfigurement with downward stream deviation was reported in 2 more patients. Two more occurrences of meatal recession were identified, yet surgical correction was not necessary. The overall reoperation rate settled at 7%.

CONCLUSION

The proposed topography-guided anatomical reassembly technique for distal hypospadias is simple, effective, and highly feasible at midterm follow-up of the given series. Maintaining the integrity of well-developed penile tissues eliminates the possibility of unforgivable tissue damage and avoids the need for challenging revision procedures.

Efficacy comparison between Mathieu combined urethral plate incision and onlay island flap urethroplasty for distal hypospadias in patients with urethral plate stenosis

The aim of the study was to compare the efficacy of Mathieu combined urethral plate incision (Mathieu-IP) versus onlay island flap urethroplasty in patients with distal hypospadias complicated by urethral stenosis. The clinical data of 70 patients with distal hypospadias complicated by urethral plate stenosis treated in the Department of Urology, Anhui Provincial Children's Hospital (Hefei, China), from May 2019 to May 2022, were retrospectively analyzed. Thirty-eight patients underwent Mathieu-IP (Mathieu-IP group) and 32 underwent onlay island flap urethroplasty (Onlay group). Follow-ups at 1 month, 6 months, and 12 months postoperatively assessed operative time, complications, urethral meatus morphology, and family satisfaction. The Mathieu-IP group had significantly shorter operative time (mean ± standard deviation [s.d.]: 81.58 ± 5.18 min) versus the Onlay group (mean ± s.d.: 110.75 ± 6.05 min; P < 0.05). Surgical success rates were 78.9% (Mathieu-IP group) and 75.0% (Onlay group), with no significant difference ( P > 0.05). Complications were comparable between the groups. The Mathieu-IP group resulted in a vertical slit-shaped urethral meatus in 89.5% versus 13.8% in the Onlay group ( P < 0.05). Family satisfaction with general penile appearance and skin shape showed no significant differences, but the Mathieu-IP group had higher satisfaction with meatal position ( P < 0.05). Mathieu-IP offers simplicity, safety, and shorter operative time compared to Onlay. Both the techniques effectively treat urethral plate stenosis in distal hypospadias, with reduced postoperative complications compared to tubularized incised plate urethroplasty. Mathieu-IP results in a vertical slit-shaped urethral meatus which enhances urinary stream, indicating its potential for broader adoption.

Widening of narrow urethral plates with lateral skin in TIP hypospadias repair: single center series

BACKGROUND

To compare the outcomes of hypospadias repair using tubularized incised plate (TIP) urethroplasty and modified TIP with lateral skin to widen the urethral plate (WTIP).

MATERIALS AND METHODS

Data were obtained from pre-pubertal boys who underwent primary hypospadias repair between May 2018 and July 2023. The cases were divided into two groups; one group underwent TIP with urethral plate ≥ 6 mm width and the other group with urethral plate width < 6 mm underwent WTIP. WTIP urethroplasty was performed by widening incisions on the outer margins of the urethral plate to incorporate penile and glandular skin lateral to the urethral plate to facilitate tubularization. Complication rates and urinary functions were compared.

RESULTS

A total of 157 patients were enrolled in this study. Eighty-eight cases with narrow urethral plate were subjected to WTIP urethroplasty, and the rest were subjected to TIP urethroplasty. The preoperative glans width in WTIP group was less than that in TIP group (P < 0.001), and 44.3% had midshaft meatus in WTIP group compared to 17.4% in TIP group (P < 0.001). However, the incidences of postoperative complications (17.6% vs. 21.6%, P = 0.550) were not statistically different between the TIP and WTIP groups. In addition, both groups did not differ significantly in postoperative uroflowmetry assessment.

CONCLUSIONS

The described technique helps to create an adequately caliber aesthetic neomeatus and facilitates tubularization, especially in hypospadias with a narrow urethral plate. Our data suggest that augmentation of a narrow urethral plate with WTIP has a similar surgical outcome to that of the TIP procedure in patients with a wide urethral plate.

Modified versus Classical Tubularised Incised Plate Urethroplasty in Hypospadias: A Comparative Study

BACKGROUND

Hypospadias is a wide-world congenital malformation that accounts for 1 of 300 live male births. Many procedures were considered for its management. As the tubularised incised plate (TIP) urethroplasty, the most prevalent technique, caused many complications, several modifications were applied to the original operation to improve the outcomes and alleviate complications. The aim of this study was to compare the outcome of the ordinary TIP urethroplasty with the technique modified without dissection of the glans penis.

MATERIALS AND METHODS

A total of 82 patients with a mean age of 18.8 (±14.8) months, were randomly assigned to undergo TIP with either complete glans wings mobilisation (Group A, n = 42 patients) or without glans dissection (Group B, n = 40 patients). To evaluate the effect of modified TIP urethroplasty without glanular dissection for treatment of distal hypospadias in contrast to classical TIP repair.

RESULTS

Both techniques showed similar outcomes regarding functional repair, with good to excellent results between 88% and 90% after 6 months of follow-up. Most confronted post-operative complications were wound infection, oedema, urethrocutaneous fistulas and meatal stenosis. Less frequently haematoma, post-operative bleeding and glans dehiscence were encountered. The differences in complication rates between the two studied groups were statistically insignificant except for oedema (P = 0.04), and need for urethral dilatation (P = 0.002) that were more prevalent among patients who were treated with classic TIP repair with complete glans wings mobilisation.

CONCLUSION

From our point of view, it seems that TIP without glanular dissection technique does not outweigh TIP with complete glans wings mobilisation regarding functional outcomes and post-operative complications.

Comparative outcomes among inlay grafted incised plate, onlay preputial flap and tubularized incised plate urethroplasty for the repair of distal penile hypospadias with a narrow urethral plate

PURPOSE

We conducted this study, comparing the outcomes among Transverse Onlay Island Flap, inlay grafted incised plate and our previous records of tubularized incised plate urethroplasty (TIPU) in patients with narrow urethral plates, aiming to determine which method of repair provides a good outcome.

METHODS

This hybrid study included two datasets. The first from a prospective randomized study evaluating outcomes of two treatment modalities; Inlay graft and only flap for distal hypospadias with shallow urethral plate with 80 patients (40 patients in each group) included, the second based on our previous records of TIPU in 40 patients with distal primary hypospadias with narrow urethral plate.

RESULTS

The success rate in inlay graft urethroplasty group (n = 40) was 87.5%; glandular dehiscence occurred in one case (2.5%), fistulas occurred in 2 cases (5%), and narrow meatus occurred in two cases (5%). Success rate in onlay flap urethroplasty group (n = 40) was 82.5%; glandular dehiscence occurred in two cases (5%), fistulas occurred in two cases (5%), and narrow meatus occurred in three cases (7.5%). TIPU group (n = 40) had success rate of 62.5%; glandular dehiscence occurred in eight cases (20%), fistulas occurred in five cases (12.5%), and narrow meatus occurred in seven cases (17.5%), with five cases exhibiting both narrow meatus with fistula.

CONCLUSION

Inlay graft and onlay flap urethroplasty for repair of distal penile hypospadias with narrow urethral plate had higher success rate and fewer complications than traditional TIPU. Moreover, operative time was shorter in TIPU.

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network

BACKGROUND

Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series.

OBJECTIVE

With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network.

STUDY DESIGN

A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation.

RESULTS

Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons.

CONCLUSION

Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Being born small for gestational age (SGA) might be associated with a higher reoperation rate in proximal hypospadias

PURPOSE

Being born small for gestational age (SGA) is associated with a higher frequency and more severe forms of hypospadias as well as with potential developmental differences. This study aims to characterize operative outcomes in SGA boys compared to boys born with normal weight and length for gestational age (appropriate/large for gestational age, AGA/LGA).

METHODS

Demographic data, hypospadias characteristics, associated pathologies and operative outcomes of boys who underwent hypospadias repair at a single center (10/2012-10/2019) were evaluated. Boys were categorized into SGA and non-SGA, which were then compared using unpaired t-tests and chi square tests. To examine the effect of SGA on reoperative risk, a logistic regression model was applied integrating surgical technique, meatal localization and complex hypospadias (narrow glans/plate, curvature, micropenis, bilateral cryptorchidism).

RESULTS

SGA boys accounted for 13.7% (n = 80) of the total cohort (n = 584) and 33% of all proximal hypospadias (n = 99, SGA vs. non-SGA 41.3% vs. 13%, p < 0.001). After a mean follow-up of 18.6 months the reoperation rate for all hypospadias was 17.9% (n = 105). In distal hypospadias there was no difference in reoperation rate between SGA and AGA/LGA boys (p = 0.548, multivariate regression model). For each meatal localization in proximal hypospadias SGA was a significant, independent factor predicting higher reoperation rates (p = 0.019, OR 3.21) in a logistic regression model (Figure ROC).

DISCUSSION

Hypospadias surgery carries a substantial risk for unplanned reinterventions. Apart from meatal localization, there are only a few factors (urethral plate quality, glandular diameter, curvature) reported in literature to be associated with reoperative risk. Intrauterine growth retardation associated with SGA might lead to not only a higher probability of proximal hypospadias but also contribute to a higher risk for complications mediated by developmental differences. Whether these findings could help to tailor surgical strategies or adjuvant measures, as for example the application of preoperative hormonal stimulation remains to be determined in future studies. This study is limited by being a single-center series with limited follow-up resulting in some complications probably not yet detected - however, in the same extent in both groups.

CONCLUSION

Based on this study, 33% of all proximal hypospadias cases occur in boys born SGA. While the reoperation rate in boys with distal hypospadias was not influenced by SGA status, SGA proved to be an independent predictor of a higher risk of reoperation in those with proximal hypospadias. After validation of these findings in other centers, this could be integrated into counseling and risk-stratification.

Outcomes of Tubularized Incised Plate Urethroplasty (TIPU) for Hypospadias at Tikur Anbesa Specialized and Menelik II referral Hospitals: One-year Prospective study"

OBJECTIVES

To evaluate the results and related factors of tubularized incised plate (TIP) urethroplasty at two institutions.

METHODES

This was a prospective cohort analytical study conducted over a period of 12 months. All patients who underwent TIP urethroplasty in the specified period were studied. Quantitative and qualitative data of the intrinsic parameters of the penis were obtained and patients were followed up for an average period of 14.72±3.67 months (range 9-21months) after surgery.

RESULTS

One hundred twenty-nine patients (N = 129) were included in the study. The mean age at surgery was 50.93 months. The mean glans size and pre-incised urethral plate width were 14.34 mm and 8.38mm respectively. The post-operative results were satisfactory with the meatus in a glanular position in 122(94.6%) patients. Overall, 49 patients (38%) developed complications. Eighteen patients (14%) developed early complications whereas forty-two (32.6%) patients had late complications. UCF and Meatal stenosis occurred in 27 (20.9%) & 14 (10.9%) patients respectively. Seven patients developed recurrent hypospadias and dehiscence of glans occurred in eight patients (6.2%).

CONCLUSIONS

TIP can be used to repair for all types of hypospadias in the absence of severe penile curvature. It has more complications rate in proximal than distal hypospadias. Distal hypospadias was the most common type of hypospadias corrected with TIP. UCF and meatal stenosis were the most common complication followed by glans dehiscence and recurrent hypospadias. Glans size, age at surgery, plate width, location of meatus and stretched penile length were the most determinant factors for the outcome.

Urethral complex thickness and thickness index are the independent risk factors for urethroplasty complications after tubularized incised plate hypospadias repair

INTRODUCTION

In tubularized incised plate urethroplasty, the depth of the mid-line relaxing incision is the key factor for urethral plate tubularization without tension. The incision depths will be different from one case to the other even if they have been done by the same surgeon. This difference in depths resulted from the different thicknesses of the urethral plate and the underlying corpus spongiosum (urethral complex).

OBJECTIVES

To evaluate the urethral complex thickness and thickness index as risk factors for the complications of TIPU in penile shaft hypospadias repair.

STUDY DESIGN

All primary penile shaft (distal and mid-penile) hypospadias (with or without mild penile chordee) were operated with TIPU between March 2018 and February 2021. We measured the urethral complex thickness in the hypospadiac and proximal normal parts of urethra pre-operatively with superficial U/S probe. Intraoperative, we measured the urethral plate width before and after the midline relaxing incision, calculate the relative increase in urethral plate width (RIUPW). Stepwise logistic regression assessed the effect of different variables on the complication rate. These variables include; urethral plate width before and after incision, urethral complex thickness, thickness index, RIUPW, site of hypospadiac meatus and patients ages.

RESULTS

10 cases had 11 complications (12.7%). Fistulae were the commonest complication (8.9%). Complication rate has significant negative correlations with many variables on Univariate analysis. Stepwise logistic regression shows that urethral plate thickness and thickness index are the independent risk factors for complications after TIPU in penile shaft hypospadias.

DISCUSSION

Urethral plate width was suggested to be a risk factor for TIPU complications. In our study, Univariate analysis shows that complications were more with plate width ˂8 mm but without significant difference (P = 0.487). Also it shows that post incision width and RIUPW have significant negative correlation with complications rate. Multivariate analysis showed that the urethral complex thickness and thickness index are the independent risk factors for complications after TIPU hypospadias repair (AUC 0.94 95% CI 0.894-0.972 P ˂ 0.001 and 0.965 95% CI 0.921-0.996, respectively).

CONCLUSION

The thickness of the urethral plate and the underlying spongiosum is the determining factor for TIPU success. We can use it as an objective reproducible assessment tool for urethral plate quality and to predict TIPU complications.

Hypospadias in toddlers: a multivariable study of prognostic factors in distal to mid-shaft hypospadias and review of literature

Background

Tubularized incised plate urethroplasty is the most common hypospadias repair technique. However, there are unanswered questions and debates about the anatomical prognostic factors affecting the repair outcomes. This study tried to address some of the problems in the studies compromising the results of the current body of literature.

Methods

A prospective cohort of 101 males aged 1–3 years undergoing primary distal to mid-shaft hypospadias repair were enrolled in the study. Complications including edema, erection, inadvertent removal of the urethral stent, surgical wound infection, bladder spasm, hematoma, and hemorrhage were evaluated. Studies in the current literature were reviewed to achieve a better perspective for future investigations.

Results

Persistent complications were found in 16 cases (15.8%) including fistula formation, the persistence of chordee, meatal stenosis, glans, and urethral dehiscence. The mean follow-up time was 6.6±3.4 months. In the single-variable analysis, the meatal location, the length and width of the urethral plate, and the reversible acute postoperative events were significantly associated with the complications. Furthermore, fistula formation was associated with acute surgical site infection (p<0.001). However, the multivariable regression study revealed the presurgical meatal location to be the only statistically significant factor (p=0.03). Notably, the glans diameter or glanular groove shape, urethral plate dimensions, or presence of mild chordee were not independently associated with the outcomes (p>0.05).

Conclusions

Our study on the toddlers with hypospadias surgery revealed that the location of urethral meatal was the main predicting factor in the development of major complications. Furthermore, the fistula formation at the infected surgical site emphasizes the importance of postsurgical care.

Urethral Plate Characteristics in Cases of Non-proximal Hypospadias May Not Be Associated With a Higher Risk of Complications When a Two-Stage Repair Is Applied

PURPOSE

To investigate whether a two-stage repair of distal- and mid-shaft hypospadias (non-proximal hypospadias) could eliminate the risk factors resulting from adverse urethral plate characteristics and eventually reduce complication rates.

METHODS

We retrospectively reviewed all cases of primary surgical repair of non-proximal hypospadias performed in our center between 2009 and 2018. In all cases where adverse urethral plate characteristics were found, such as meatal stenosis, a shallow urethral groove, a thick web of tissue between the native meatus and the urethral groove or in the presence of a very "thin," skin-like distal urethra, a two-stage repair was routinely undertaken. In cases of native meatal stenosis, a meatotomy, and meatoplasty were performed. In cases of a very "thin" distal urethra we incised the skin proximally up to the point of a normal urethral fold and a meatoplasty was performed at that point. Hypospadias repair was then performed in a second operation, 3-6 months following the first procedure. Urethroplasty, both in cases of a single-stage repair and in cases of a two-stage repair, was always performed using the Thiersch-Duplay technique. Patients with a follow-up of less than 12 months were excluded from this study.

RESULTS

Over a period of 10 years, 208 boys underwent primary surgical repair of non-proximal hypospadias. Eighty-nine of the 208 patients (42.8%) underwent single-stage hypospadias repair. Two-stage repair of the hypospadias was required in 119 (57.2%) of the patients. The overall complication rate was 3.4% in the group operated in a single stage and 7.6% in the group that required a two-stage repair (p = 0.09). The most frequent complication reported was urethrocutaneous fistula (p = 0.31), followed by meatal stenosis (p = 0.37), urethral stricture (p = 0.08) and wound dehiscence (p = 0.16). There was no significant difference between the complication rates of the two groups.

CONCLUSION

Patients with distal hypospadias and poor urethral plate characteristics repaired in a two-stage approach have comparable low-complications to those with favorable urethral plate characteristics repaired in a single-stage.

Does the suturing technique (continuous versus interrupted) have an impact on the outcome of tubularized incised plate in hypospadias repair with adequate urethral plate? A prospective randomized study

INTRODUCTION

Hypospadias is one of the most common anomalies of male external genitalia. The aim of hypospadias repair is to achieve a normal phallus with a satisfactory functional and cosmetic result and to develop a single and consistent urinary stream while in standing position. The introduction of tubularized incised plate (TIP) urethroplasty by Snodgrass in 1994 resulted in revolutionizing management of different types of hypospadias. While there is consensus on the use of absorbable sutures in hypospadias repair, there are no specific guidelines for the suturing technique and the technique itself remains debatable.

OBJECTIVE

To compare the outcome of interrupted- and continuous-suture in hypospadias repair using TIP technique.

STUDY DESIGN

This was a prospective randomized study. It comprised 260 uncircumcised hypospadiac boys with adequate urethral plate who underwent TIP repair. Boys with glanular, recurrent, proximal hypospadias and inadequate urethral plate were excluded from the study. The boys were randomized into two groups: Group A consisted of 130 boys who underwent TIP repair using continuous subcuticular suture urethroplasty and Group B of 130 boys who underwent TIP repair using interrupted subcuticular suture urethroplasty.

RESULTS

The operative time was of lower statistical significance in group A (P = 0.006) while the rate of complications were of higher statistical significance in group A (P = 0.027). Urethrocutaneous fistulae occurred in 20 patients (14 in Group A and six in Group B), which is a statistically significant difference (P = 0.048). On the other hand, superficial wound infection, partial glans dehiscence, meatal stenosis, urethral stricture, and aesthetic appearance were statistically insignificant.

DISCUSSION AND CONCLUSION

The effect of suturing techniques in bowel anastomosis has been studied and it has been found that the use of an interrupted-suturing technique results in a decreased complication rate compared to continuous suturing. This agrees with our study where the running sutures groups was associated with a higher complication rate compared to interrupted sutures.

Glans–urethral meatus–shaft score and penile parameters as preoperative assessment tools for hypospadias surgery outcome

Background

Our prospective study aims to assess if penile parameters and GMS score can predict the postoperative outcome of patients with hypospadias repaired with the TIP technique.

Methods

This prospective study included patients (6 months–11 years old) with coronal, distal or mid penile hypospadias who underwent Tubularized incised plate (TIP) urethroplasty technique from 2015 to 2017. All patients were assessed preoperatively using GMS score. GMS score included a scale for each component, with the more unfavorable characteristics assigned higher scores. Penile length, urethral plate length, and penoscrotal length were measured using a ruler. Glans width was measured by using a caliper ruler. Demographics and complications were assessed within 3 months of the procedure.

Results

There was a statistically significant difference between complicated and non-complicated patients regarding GMS score, glans width, penoscrotal length, penile length, and urethral plate length/penile length ratio. According to the ROC curve, the cutoff values for GMS score, glans width and penoscrotal length were 6, 14 mm and 5 cm, respectively. The area under the ROC curve for penile length and for urethral plate/penile length ratio was poor and so we could not get a specific cutoff value for either parameters. According to Stepwise logistic regression, the GMS score was the only significant independent parameter while controlling all the other factors. Any increase in the GMS score by one unit would increase the risk of complications 3 times.

Conclusion

GMS score and penile parameters are good predictors and complete each other in preoperative assessment for hypospadias patients. Patients with a high GMS score (above 6) have a higher risk of complication and patients with a Glans width of 14 mm or more and a penoscrotal length of 5 cm or more are associated with less risk of complication.

Narrow urethral plate augmentation in anterior and middle hypospadias repair: Onlay flap VS. Inlay graft. A prospective randomized comparative study

INTRODUCTION

The measurement of the urethral plate width (as an objective parameter) and its effect of this width on the results of tubularized incised plate urethroplasty (TIPU) have been reported in two series and both authors reported that a urethral plate width < 8 mm is associated with higher complication rates. The augmentation of the urethral plate either by dorsal inlay graft urethroplasty (DIGU) or Onlay flap has been compared with the original TIPU in different degrees of hypospadias with better surgical results in augmented cases.

OBJECTIVE

To evaluate the surgical results of longitudinal Onlay preputial flap (LOF) vs (DIGU) techniques in augmentation of the narrow urethral plate.

STUDY DESIGN

Primary anterior and middle hypospadias cases with narrow urethral plates were randomly allocated into two groups; group one operated by DIGU and group two operated by (LOF). The Success rate, individual complication rate, and operative times were compared.

RESULTS

39 cases completed the study. No significant differences in patients' characteristics were detected. In the DIGU group, one case (5.3%) complicated with fistula and glandular dehiscence wherein in the LOF group, 7 cases (35%) Complicated with 5 fistulae, 2 glanular dehiscences, one flap loss, one diverticulum (p= .02). No significant differences in the rates of individual complications.

DISCUSSION

Variables affecting the success of hypospadias repairs are many. Urethral plate quality is an important variable among these variables. The definition of urethral plate quality is usually subjective. In the DIGU group, only 1/19 (5.3%) case had two complications, fistula and glandular dehiscence. Mouravas et al., in their comparative study between TIPU and G-TIP without mention of urethral plate width reported a significant reduction of the overall complications and urethral stenosis without significant reduction in fistula rate. In their G-TIP group, only 2 cases out of 24 (8.3%) were complicated with one fistula and one glandular dehiscence where in the TIPU group, 7 cases (30.4%) were complicated with one glandular dehiscence and 6 cases with urethral stenosis. In the LOF group, fistula in 5/20 cases (25%) was the commonest complication followed by glandular dehiscence in 2 cases (10%). Diverticulum and flap loss occurred in one case for each (5%). In the multivariate analysis of 474 patients' cohort by Spinoit et al., there were no significant differences between the risk of re-intervention after TIP and Onlay flap in anterior and middle hypospadias (25.8% vs. 18.8%), and (22.2% vs. 20%) respectively.

CONCLUSION

Our data suggest that augmentation of the narrow urethral plate with DIGU has a better surgical outcome than with LOF. No significant difference in cosmetic outcomes detected.

Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair

INTRODUCTION

The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The 'M' component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in 'meatal mismatch.'

OBJECTIVE

To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development.

STUDY DESIGN

We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with <6 months of follow-up.

RESULTS

Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0-20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44-6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29-3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09-0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings.

DISCUSSION

Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias.

CONCLUSIONS

Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development.

Urethral plate in tubularized incised plate urethroplasty: how wide is enough?

Background

Previous reports found that a preincision urethral plate (UP) width <8 mm increased the occurrence of urethroplasty complications (UCs) in tubularized incised plate (TIP) hypospadias repair. However, is the classification of the UP width based on an 8 mm cut-off value to predict the outcome of TIP urethroplasty objective enough or universally applicable? The purpose of our study was to assess the effect of the UP width on the outcomes of TIP hypospadias repair in the Eastern population we served.

Methods

We retrospectively reviewed the records of patients who underwent TIP hypospadias repair by the same surgeon between August 2013 and December 2019 in our hospital. Data were collected, including demographics, intrinsic parameters of the penis, surgical parameters and subsequent surgical outcomes. The data were analyzed and the cut-off value of the UP width was calculated using a receiving-operator curve.

Results

Primary TIP urethroplasty was carried out in 116 patients with a mean age of 35.89±29.40 months. The meatal location was distal in 49 patients, midshaft in 56 patients and proximal in 11 patients. The mean glans width was 12.28±1.36 mm, the mean UP width was 5.74±1.37 mm, the mean neourethral length was 1.96±1.32 cm, and the mean operation duration was 87.52±11.47 min. During a median follow-up of 42 (range: 6 to 80) months, UCs developed in 12 patients, and the UP width was significantly related to the occurrence of UCs (P=0.014). According to the 6 mm cut-off value of the UP width by the receiver operating characteristic curve, patients were divided into two groups. Group A (UP width ≥6 mm) included 69 patients, and Group B (UP width <6 mm), 47 patients. UCs occurred in 3 patients in Group A vs. 9 patients in Group B, P=0.010.

Conclusions

UP width is a potential risk factor for UCs after TIP hypospadias repair. Using this technique with an UP width ≥6 mm is sufficient to result in a good outcome of hypospadias repair.

Tubularized Reconstructed Plate Urethroplasty: An Alternative Technique for Distal Hypospadias Repair

OBJECTIVE

To report current results of a new surgical technique, tubularized reconstructed plate urethroplasty (TRPU) in distal hypospadias repair which allows the tubularization of urethral plate without incision or grafting.

METHODS

This study is a prospective single surgeon series. Between January 2019 and March 2020, total of 158 patients underwent hypospadias repair, and 29 selected patients had TRPU procedure. Demographic data, duration of follow-up, complications were recorded. A vertical incision is made starting from halfway up the glans. This incision creates a diamond like defect which enables wedge removal of a segment of spongiosum tissue from the base of urethral plate extending to the hypospadiac meatus. Vertical incision is closed horizontally. The urethral plate is stretched and loosened from the base and re-secured into its bed using quilting stitches. Reconstructed urethral plate ensures the required width to allow the formation of neourethra of adequate circumference, followed by a formal glansplasty.

RESULTS

Preoperative glans width was 13.4 ± 0.9 mm, urethral plate width was 6.1 ± 0.9 mm. Mean postoperative follow-up period was 13.6 months. All patients had successful functional outcome and cosmetically satisfying appearance. None of the patients required meatal calibration. The total complication rate was 3.4%.

CONCLUSION

Native urethral plate itself is used as a natural flap to increase the surface area of the urethral plate in this new perspective of urethroplasty method. We believe that TRPU procedure provides an alternative approach for the formation of neourethra and it is a successful and relatively simple procedure with low complication rates, good cosmetic results and promising successful functional short-term outcome.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in Indonesia

INTRODUCTION

Hypospadias is one of the most common congenital malformations with a worldwide increasing trend over the years. Despite advancements in hypospadias repair, complications still occur. One of the most common complications of hypospadias repair surgery is Urethrocutaneous fistula. Studies attempting to analyze the association between the complication and risk factors are always beneficial, especially for studies performed in different areas of the world. We hypothesize that several evaluated risk factors among Indonesian hypospadias patients could be associated with the occurrence of urethrocutaneous fistula after the repair procedure.

OBJECTIVE

To determine the risk factors associated with urethrocutaneous fistula after hypospadias repair surgery by collecting and analyzing data obtained from multiple centers in Indonesia.

MATERIALS AND METHODS

A nationwide, retrospective study with 12 hospitals in Indonesia of children with a diagnosis of hypospadias was conducted. The collected data, taken from patients admitted in 2018, from each center's medical records consisted of patient identity, repair technique used, neourethra length, percutaneous cystostomy, and splint size as independent variables speculated to be possible risk factors correlated to the presence of urethrocutaneous fistulae. Binomial logistic regression analysis was performed using SPSS 21.0 to determine the relationship between urethrocutaneous fistulae as a post-repair complication and possible risk factors.

RESULTS

We collected 591 hypospadias cases from 12 centers in 9 cities in Indonesia. Most patients came when they were already at the age of more than four years old (60.4%). The chordee-only and failed urethroplasty groups are excluded from the analysis as they are not classified as true hypospadias. Most repairs were performed by using the Tubular Incised Plate (TIP) with Thiersch-Duplay technique (44.16%). Most of the reconstructed neourethra are 2-3 cm in length (32.13%). The 8 Fr urethral splint (46.41%) was mostly used during the operation. Most surgeons decided not to perform cystostomy throughout the procedure (61.03%) based on personal preferences. Urethrocutaneous fistula was found in 80 patients (15.27%) out of the total patients who underwent the surgery. The binomial logistic regression analysis shows that age (OR = 1.398, p = 0.015), the decision to not perform cystostomy (OR = 2.963, p = 0.014), and splint size (OR = 1.243, p = 0.023) are significantly associated (p < 0.05) with the development of urethrocutaneous fistula.

CONCLUSION

Age and splint size are significant risk factors for urethrocutaneous fistula after hypospadias repair in Indonesia, whereas performing percutaneous cystostomy during the repair decreases the risk for urethrocutaneous fistula occurrence.

Snodgrass vs Snodgraft operation to repair the distal hypospadias in the narrow urethral plate

BACKGROUND

Using the Snodgraft technique in patients with urethral plate less than 8 mm to repair distal hypospadias is still debatable. Some authors assume that augmentation may be beneficial. We aimed to compare the outcomes of the Snodgrass vs Snodgraft procedure in patients with a narrow urethral plate less than 8 mm.

METHODOLOGY

This prospective randomized study included 60 children who had been treated by the Snodgrass or Snodgraft procedure for repair of distal penile hypospadias with narrow urethral plate from March 2017 to September 2018. They were randomized into two subgroups. Group 1 (30 patients) underwent tubularized incised plate urethroplasty, whereas the second group (30 patients) underwent the Snodgraft procedure by using the inner prepuce. Operative details, postoperative period, and complications were reported and statistically analyzed using IBM SPSS software package version 20.0.

RESULTS

The operative time was longer for patients who underwent the Snodgraft procedure: 78 (55-95) and 110 (80-140) minutes in groups 1 and 2, respectively. In group 1, there was one case of meatal stenosis which was resolved by urethral dilation using the local anesthetic cream in the outpatient clinic. In addition, there was another case of distal penile fistula. In group 2, there was a case of complete wound disruption and another of distal penile fistula. There was no significant difference in the complication rate in any group.

CONCLUSION

The operative time was longer in group 2 than in group 1 but with comparable outcomes. The Snodgraft procedure is not superior to the Snodgrass operation in the narrow healthy urethral plate.

Assessment of the effect of urethral plate width on outcome of hypospadias repair

BACKGROUND

The paradigm for hypospadias repair is a straight penis with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the parents of the patient.

OBJECTIVE

To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate.

PATIENTS AND METHODS

This study was a prospective evaluation of patients operated for hypospadias. The urethral plate width (UPW) of the patients were measured preoperatively using vernier calipers. The patients were categorized into groups A and B. Group A patients have a UPW <8 mm, whereas group B patients have a UPW ≥8 mm. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair.

RESULTS

Overall, 47 patients had their hypospadias repaired during the study period. But, only 42 patients who had their distal hypospadias repaired using tubularized incised plate urethroplasty were evaluated. There were 20 patients (47.6%) in group A and 22 patients (52.4%) in group B, with a mean urethral plate of 7.3 mm ± 0.50 SD. The mean UPW in group A was 5.6 mm ± 1.22 SD and the mean UPW in group B was 8.8 mm ± 0.88 SD. Overall, mean HOPE score was 40.0 ± 6.83 SD. Group A patients had a mean HOPE score of 38.7 ± 7.49 SD, whereas Group B patients had a mean HOPE score of 41.2 ± 6.08 SD. P-value was 0.725, which is not statistically significant. Relating good urinary stream (15 in group A and 20 in group B) with the width of the urethral plate statistically (using Spearman correlation technique) gave a P-value of 0.03 (P < 0.05), which is statistically significant.

CONCLUSION

Our findings indicate that the cosmetic outcome of hypospadias repair may not be determined by UPW, but the functional outcome may be predicted by the width of the urethral plate.

Comprehensive evaluation of grafting the preservable narrow plates with consideration of native plate width at primary hypospadias surgery

INTRODUCTION

Dorsal inlay graft urethroplasty using inner-face preputial graft was described as an adjunct method to the classic tubularized incised plate (TIP) urethroplasty, aiming at reducing the risk of neourethral stenosis.

OBJECTIVES

To evaluate the impact of dorsal inlay grafting of preservable narrow plates, in relation to native plate width.

METHODS

Consecutive children with penile hypospadias with narrow plate (width < 8 mm) were evaluated prospectively between Jan 2014 and Jun 2018. Included cases were stratified into two groups: group A (plate width: 4 to <8 mm) and group B (plate width: < 4 mm). All cases were approached by TIP urethroplasty, with dorsal inlay grafting (inner-face prepuce). Cases with significant chordee (non-preservable plates), circumcised cases, and redo cases were excluded.

RESULTS

A total of 104 hypospadias cases with narrow plates were included in this study. Among group A (n = 81), the need for postrepair urethral dilations was reported in two cases (2.5%) vs seven cases (30%) in group B (n = 23) (P-value < 0.001). Another two cases (2.5%) in group A developed urethrocutaneous fistulae vs three cases (13%) in group B (P-value = 0.0624). Surgical repair of the reported five cases with fistulae, revealed an ample neourethral wall; disclosing well-taken grafts in both groups.

DISCUSSION

Few published studies evaluated grafting the incised plate in penile hypospadias. To the authors knowledge, this is the first study that selectively evaluated the impact of grafting narrow plates in relation to its native pre-incision width.

CONCLUSIONS

According to the presented authors' experience, 4 mm width is the border line of clinical relevance that defines poor urethral plate. Grafting that plate failed to compensate for its native poor characteristics; however, it offered a valuable neourethral wall that proved indispensable when redo surgery deemed necessary, without adding grafting-related problems. Nevertheless, further extended comparative studies came across as a necessity to verify the long-term outcomes of grafting the incised poor plates.

Width proportion of the urethral plate to the glans can serve as an appraisal index of the urethral plate in hypospadias repair

OBJECTIVES

To find a new appropriate evaluation for urethral plate quality in hypospadias repair, with particular interest in the width proportion of the urethral plate to the glans, serving as an appraisal index.

METHODS

Data were prospectively collected from prepubertal boys who underwent primary tubularized incised plate hypospadias repair between January 2014 and April 2016 in one center. Intrinsic parameters of the penis (meatal location, glans width, urethral plate width and curvature degree) were measured during the operation. Urethroplasty complications were recorded during follow up. The correlation between width proportion of the urethral plate to the glans and urethroplasty complications was analyzed.

RESULTS

Primary tubularized incised plate repair was carried out in 442 patients (mean age 2.8 years, range 0.5-12 years). At mean follow up of 26 months (range 12-38 months), urethroplasty complications occurred in 59 (13.3%) patients. The width proportion of the urethral plate to the glans was weakly correlated to both the glans width and meatal location. The width proportion of the urethral plate to the glans ranged from 0.18 to 0.73, with a mean of 0.39. The cut-off value of width proportion of the urethral plate to the glans was determined to be 0.36 by the receiver operating characteristic curve. Urethroplasty complications occurred in 17 out of 254 patients (6.7%) with width proportion of the urethral plate to the glans >0.36, and 42 out of 188 patients (22.3%) with width proportion of the urethral plate to the glans ≤0.36. The width proportion of the urethral plate to the glans ≤0.36 showed an increased odds of 4.819-fold (95% confidence interval 2.548-9.112, P < 0.001) risk of urethroplasty complications compared with width proportion of the urethral plate to the glans >0.36. Midshaft and proximal meatal location also increased the risk of urethroplasty complications.

CONCLUSIONS

The present study highlights the value of the width proportion of the urethral plate to the glans for objectivity and accuracy in urethral plate evaluation, which in turn serves as an independent factor influencing outcomes in tubularized incised plate repair.

Pre-incision urethral plate width does not impact short-term Tubularized Incised Plate urethroplasty outcomes

INTRODUCTION

Two reports have found that urethral plate (UP) widths <8 mm before tubularized incised plate (TIP) incision increased urethroplasty complications. The present study measured pre-incision UP width in consecutive boys undergoing TIP to determine if it affected outcomes.

METHODS

The present study followed the method previously used by Holland and Smith, and Sarhan et al. to measure UP width before creating glans wings or performing midline plate incision in consecutive patients with primary hypospadias and ventral curvature <30°, who all underwent TIP repair (Summary Fig.). Glans width at its widest point was also measured. Multiple logistic regression assessed urethroplasty complications (fistula, glans dehiscence, meatal stenosis/urethral stricture, diverticulum) based on pre-incision UP width, glans width, patient age, and meatal location.

RESULTS

The UP widths were determined in 224 consecutive primary TIP repairs during 2012-2015: 200 distal, 11 midshaft, and 13 proximal. The UP width was <8 mm in 192/224 (86%) patients. Mean pre-incision width was 6.1 mm (SD 1.5, range 2-11), without difference in UP widths according to meatal location (P = 0.06). Mean post-incision UP width was 12 mm (SD 2.2, range 10-16). Mean change in width after incision (delta/original UP width) was 116% (SD 63, range 20-250). There was follow-up in 186 patients for a mean of 6 months. Urethroplasty complications (five fistulas, six glans dehiscence) were diagnosed in 11 (6%): 9/165 distal, 1/9 midshaft, and 1/12 proximal repairs. There was no difference in those <8 vs ≥8 mm (11/160 vs 0/26, P = 0.17). Similarly, UP width was not different between patients with and without urethroplasty complications. Multiple logistic regression in these 186 patients - including meatal location, UP width, glans width, and age - found only glans width <14 mm was associated with increased odds of urethroplasty complications (OR 19.2, 95% CI 3.5-106, AUC = 0.799).

DISCUSSION

The data show that pre-incision UP width is not an independent risk factor for urethroplasty complications. However, it is possible that technical factors, such as how deeply the dorsal incision is made or size of the urethral stent, might contribute to this finding by other authors. After watching the TIP repair, Smith stated that the plate incision was deeper than he made. Sarhan et al. reported a mean change of 57% in UP width after incision, whereas the present one was double at 116% (i.e. from 6 mm pre-incision to 12 mm post incision), and they used an 8-Fr catheter. While they stated that they incised the plate deeply, the lower percentage increase in width suggests that it was not as deep as was recommended.

CONCLUSIONS

The UP width before incision did not increase urethroplasty complications. Surgeons do not need to measure or categorize the UP to determine suitability for TIP repair, as long as the plate incision is made deeply to the corpora.

Comparison of interrupted- and continuous-suture urethroplasty in tubularised incised-plate hypospadias repair: A prospective study

Objective

To compare the effect of interrupted- and continuous-suture urethroplasty on complication rates in Snodgrass tubularised incised-plate (TIP) hypospadias repair.

Patients and methods

This was a prospective randomised study comprising 100 boys (age range 1–5 years) with primary subcoronal, distal- and mid-penile hypospadias who underwent repair from October 2010 to March 2015 in a tertiary care hospital. Boys with glanular, recurrent, and proximal hypospadias were excluded from the study. The boys were prospectively randomised into two groups: Group A, comprised 50 boys who underwent interrupted subcuticular suture Snodgrass TIP urethroplasty; and Group B, comprised 50 boys who underwent continuous subcuticular suture Snodgrass TIP urethroplasty. Outcomes were assessed in terms of complication rates and aesthetic appearance during follow-up.

Results

There was no significant difference in the occurrence of complications between the groups. There were 21 complications, with 10 occurring in Group A and 11 in Group-B. Urethrocutaneous fistula was the most common complication in both groups (six in Group A and seven in Group B), the fistulae were <2 mm in nine patients and 3–5 mm in the remaining four. Partial glans dehiscence occurred in one patient in each group. One patient from each group also had superficial wound infection, meatal stenosis and urethral stricture respectively, all of which were managed conservatively. The resultant urinary stream was single and good in all patients of both groups.

Conclusions

The type of suture technique had no significant effect on complication rates after Snodgrass hypospadias repair and thus the choice of technique depends on surgeon preference.

Mathieu technique with incision of the urethral plate versus standard tubularised incised-plate urethroplasty in primary repair of distal hypospadias: A prospective randomised study

Objective

To compare outcomes of the Mathieu incised-plate (Mathieu-IP) technique vs the standard tubularised incised-plate (TIP) technique for primary management of distal hypospadias.

Patients and methods

Between April 2012 and August 2015, 66 patients (aged 15–60 months) with primary distal hypospadias were randomly allocated to two groups. Group 1 included 34 patients who underwent Mathieu-IP repair and Group 2 included 32 patients managed using the TIP technique for primary management of distal hypospadias. Postoperatively, all patients were examined weekly up to 1 month and then at 3 and 6 months. Perioperative data, complications and outcomes of both procedures were statistically analysed and compared.

Results

There were no statistically significant differences in patient demographics between the groups at baseline. There was no statistically significant difference in the mean (SD) operative time between Groups 1 and 2, at 95 (7.6) and 91.2 (8.1) min, respectively. There was no statistically significant difference in the shape of the urine stream at micturition or the neomeatus between the groups postoperatively. The rate of postoperative fistula was significantly higher in Group 2 (TIP) compared to Group 1 (Mathieu-IP), at 18.7% vs 2.9% (P = 0.004). There was no postoperative meatal stenosis in Group 1, which did occur in five patients (15.6%) in Group 2 (P = 0.002).

Conclusion

The Mathieu-IP technique appeared to be better than the standard TIP technique with regard to postoperative fistula formation and meatal stenosis, and with acceptable cosmesis.

Primary hypospadias repair techniques: A review of the evidence

This review summarizes data regarding commonly used surgical techniques to repair distal and proximal hypospadias. We review evidence concerning indications for various procedures used in primary hypospadias repair, and their complications, urinary function and esthetic results. Available evidence suggests TIP is preferable to Mathieu for distal hypospadias correction. Current data do not identify a clear preference between TIP and onlay flap for proximal repair when there is ventral curvature <30°, or between various flap and graft options when curvature is >31°. A review of objective data helps clarify decision-making for distal hypospadias repair. Additional objective evidence is needed to identify preferred options for proximal hypospadias repair. Measuring glansplasty dimensions (meatal size and distance from meatus to corona) may improve urinary function assessments, and provide additional objective data for decision-making between various surgical techniques.

Primary hypospadias repair techniques: A review of the evidence

This review summarizes data regarding commonly used surgical techniques to repair distal and proximal hypospadias. We review evidence concerning indications for various procedures used in primary hypospadias repair, and their complications, urinary function and esthetic results. Available evidence suggests TIP is preferable to Mathieu for distal hypospadias correction. Current data do not identify a clear preference between TIP and onlay flap for proximal repair when there is ventral curvature <30°, or between various flap and graft options when curvature is >31°. A review of objective data helps clarify decision-making for distal hypospadias repair. Additional objective evidence is needed to identify preferred options for proximal hypospadias repair. Measuring glansplasty dimensions (meatal size and distance from meatus to corona) may improve urinary function assessments, and provide additional objective data for decision-making between various surgical techniques.

Is glans penis width a risk factor for complications after hypospadias repair?

INTRODUCTION

Recent studies have suggested that a smaller glans penis size may be associated with a higher likelihood of complications after hypospadias repair. Accurate identification of risk factors other than the well-understood variable of meatal location would allow development of better prognostic models and individualized risk stratification.

OBJECTIVE

To test the hypothesis that a smaller width of the glans penis predicts adverse outcomes after hypospadias surgery.

METHODS

Prospectively recorded clinical data were reviewed from a single-institution registry of primary hypospadias repairs performed between 2011 and 2014. Follow-up records were examined for occurrence of complications. Urethroplasty complications were defined to include meatal stenosis, dehiscence, urethrocutaneous fistula, urethral stricture, and/or urethral diverticulum. The subset of meatal stenosis and dehiscence were regarded as glanular complications. Regression analyses were performed to determine association between glans width and occurrence of complications. Because pre-operative androgen stimulation is known to increase glans penis size, separate subgroup analyses were included of patients with and without pre-operative use of testosterone cream.

RESULTS

A total of 159 patients met criteria for inclusion in the study cohort: 140 patients underwent a single-stage repair, while 19 patients had a two-stage repair. The median glans penis width was 15 mm (range 10-22). Eighty-four patients (53%) received testosterone cream pre-operatively and had a significantly wider glans penis than the 75 patients who did not (median 15.5 vs 14 mm; P < 0.001). Median clinical follow-up was 7 months (IQR 1-12), with a minimum time elapsed since surgery of 10 months at the time of chart review. Twenty-four patients (15%) had one or more urethroplasty complications, including 11 (7%) with glanular complications. Overall, there was no statistically significant association between glans width and urethroplasty complications (P = 0.26) or glanular complications (P = 0.90) (Summary Table). Subgroup analyses of patients with and without pre-operative testosterone also revealed no significant associations between glans width and complications.

CONCLUSIONS

Glans penis width was not a risk factor for complications after hypospadias repair. This finding differs from the results of other recent studies and encourages further research into the value of measuring penile parameters in patients undergoing hypospadias repair.

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.

TIP hypospadias repair: A pediatric urology indicator operation

OBJECTIVE

We review development and evolution of TIP hypospadias repair, including technical changes made to improve its results. We also discuss general risk factors for hypospadias surgical complications.

METHODS

We describe use of a database with prospective data entry to first identify our most common complications and their frequency, and then to monitor results of technical modifications made to reduce their occurrence. Multiple logistic regression of various factors recorded in the database was done to identify those predicting increased risk for urethroplasty complications.

RESULTS

Fistula and glans dehiscence are the two most common complications we encountered after TIP repair. Changes in urethral plate tubularization and barrier layers covering the neourethra resulted in a significant reduction in fistulas after proximal TIP. Changes in glansplasty sutures and use of preoperative testosterone to increase glans size did not reduce likelihood for dehiscence, whereas increasing the extent of glans wings dissection did. Logistic regression analysis confirmed proximal meatal location and reoperation predicted increased complications, but also identified glans width ≤ 14 mm as an independent risk factor for hypospadias urethroplasty complications.

CONCLUSIONS

Systematic, prospective data collection facilitated identification of complications and their risk factors, and provided a means to assess results of modifications made to address them. Limiting the algorithm used for hypospadias repair increases expertise in those techniques used. Reported low surgical volumes for proximal hypospadias repair suggest subspecialization of these cases be carried out so that designated surgeons can achieve sufficient volume to analyze their results and make improvements.

Glans size is an independent risk factor for urethroplasty complications after hypospadias repair

INTRODUCTION

We hypothesized small glans size could increase urethroplasty complications (UC) following hypospadias repair. To test this, we measured glans width at its widest point in consecutive patients with hypospadias, and following a protocol for surgical decision-making, we then assessed post-operative UC using pre-determined definitions. We now report analysis of glans size as a potential additional independent risk factor for UC after hypospadias repair.

METHODS

Consecutive prepubertal patients undergoing hypospadias repair (2009-2013) had maximum glans width measured using calipers (Fig. 1). There were no differences in surgical technique for urethroplasty or glansplasty in this series based on the measured size of the glans. Multivariate logistic regression analyzed UC (fistula, glans dehiscence, diverticulum, stricture and/or meatal stenosis) based on glans size while adjusting for patient age, meatus (distal or midshaft/proximal), type of repair (TIP, inlay, 2-stage), surgeon, and primary or reoperative repair. Glans size was analyzed as both a continuous and dichotomous variable, with small glans defined as <14 mm.

RESULTS

Mean glans size was 15 mm (10-27 mm) in 490 boys (mean 1.5 years) undergoing 432 primary repairs (380d/19mid/33prox), and 58 reoperations (28d/7mid/23prox). Increasing age between 3 months and 10 years did not correlate with increasing glans size (R = 0.01, p = 0.18). 17% had small glans <14 mm. UC occurred in 61 (13%) primary TIP, 2-stage, and reoperative repairs, including 20/81 (25%) patients with small glans <14 mm, versus 41/409 (10%) in patients with glans width ≥14 mm (p = 0.0003). On multivariate analysis, small glans size (OR 3.5, 95% CI 1.8-6.8), reoperations (OR 3.0, 95% CI 1.4-6.5) and mid/proximal meatus (OR 3.1, 95% CI 1.6-6.2) were independent risk factors for UC. Surgeon, repair type, and patient age did not impact risk for UC. Analysis with glans size as a continuous variable demonstrated each 1 mm increase in size decreased odds of UC (OR 0.8, 95% CI 0.7-0.9).

CONCLUSIONS

Our analysis of prospectively-collected data from a standardized management protocol in 490 consecutive boys undergoing hypospadias repair adds small glans size, defined as width <14 mm, to proximal meatal location and reoperation as an independent risk factor for UC. Best means to modify this factor remain to be determined. Our data suggest that others analyzing potential risks for hypospadias UC should similarly measure and report glans width.

Complications of hypospadias surgery: Experience in a tertiary hospital of a developing country

BACKGROUND

Over 300 different operations have been described for the management of hypospadias. In recent times, the numbers of operations used in various centres have gradually reduced as the principles necessary to ensure adequate cosmetic and functional results with minimum complications are better understood. The aim of this article was to review the different types of operations used for managing hypospadias in a tertiary hospital in a developing country, to analyse the complications of surgery and discuss the factors that contribute to complications.

MATERIALS AND METHODS

Patient folders, theatre, and ward records were used to obtain the required information. The age at surgery, types of hypospadias at presentation, types of operations done and complications were analysed.

RESULTS AND CONCLUSION

With three main types of operations, tubularised incised plate urethroplasty and meatal advancement and glanuloplasty incorporated for anterior hypospadias (glanular, coronal, subcoronal, distal, midpenile), and lateral based flap urethroplasty for posterior hypospadias (proximal penile, penoscrotal, scrotal, perineal), most hypospadias were corrected with acceptable complication rates.

A modified onlay island flap vs. Mathieu urethroplasty for distal hypospadias repair: A prospective randomised study

OBJECTIVE

To compare the outcome of a modified onlay island flap (MOIF) with that of the Mathieu urethroplasty for distal hypospadias repair.

PATIENTS AND METHODS

In a prospective randomised study, 60 patients with coronal, subcoronal and distal penile hypospadias, with a urethral plate width of ⩽6 mm, and minimal or no chordee, underwent either MOIF using a midline longitudinal outer preputial skin flap passed ventrally by penile buttonholing through dartos fascia incision, or a Mathieu urethroplasty. Closed envelopes were used for randomly selecting patients for each procedure. The operative duration, complications, cosmetic outcome, urinary stream and relatives' satisfaction were reported for each procedure.

RESULTS

Preoperative data (patients' age and site of urethral meatus) and operative duration were insignificantly different between the groups (P = 0.653, 0.786 and 0.710, respectively). There were no intraoperative complications in either group. The duration of follow-up was insignificantly different between the groups. Patients treated with the MOIF had a statistically significant lower complication rate (P = 0.036), and a better cosmetic outcome, urinary stream and relatives' satisfaction (P < 0.001 for all).

CONCLUSIONS

The MOIF urethroplasty seemed to be better than the Mathieu urethroplasty in patients with distal hypospadias and narrow urethral plates. Further studies including more patients, and a longer follow-up with an objective evaluation of functional outcome should be encouraged to confirm these early results.

Further analysis of the Glans-Urethral Meatus-Shaft (GMS) hypospadias score: correlation with postoperative complications

INTRODUCTION AND OBJECTIVE

The Glans-Urethral Meatus-Shaft (GMS) score is a concise and reproducible way to describe hypospadias severity. We classified boys undergoing primary hypospadias repair to determine the correlation between GMS score and postoperative complications.

STUDY DESIGN

Between February 2011 and August 2013, patients undergoing primary hypospadias repair were prospectively scored using the GMS classification. GMS scoring included a 1-4 scale for each component: G - glans size/urethral plate quality, M - meatal location, and S - degree of shaft curvature, with more unfavorable characteristics assigned higher scores [Figure]. Demographics, repair type, and complications (urethrocutaneous fistula, meatal stenosis, glans dehiscence, phimosis, recurrent chordee and stricture) were assessed. Total and individual component scores were tested in uni- and multivariate analysis.

RESULTS

Two-hundred and sixty-two boys (mean age 12.3 ± 13.7 months) undergoing primary hypospadias repair had a GMS score assigned. Mean GMS score was 7 ± 2.5 (G 2.1 ± 0.9, M 2.4 ± 1, S 2.4 ± 1). Mean clinical follow-up was 17.7 ± 9.3 months. Thirty-seven children (14.1%) had 45 complications. A significant relationship between the total GMS score and presence of any complication (p < 0.001) was observed; for every unit increase in GMS score the odds of any postoperative complication increased 1.44 times (95% CI, 1.24-1.68). Urethrocutaneuous fistula was the most common complication, occurring in 21 of 239 (8.8%) of single-stage repairs. Patients with mild hypospadias (GMS 3-6) had a 2.4% fistula rate vs. 11.1% for moderate (GMS 7-9) and 22.6% for severe (GMS 10-12) hypospadias (p < 0.001). Degree of chordee was an independent predictor of fistula on multivariate analysis; S4 (>60° ventral curvature) patients were 27 times more likely to develop a fistula than S1 (no curvature) boys (95% CI, 3.2-229).

DISCUSSION

The GMS score is based on anatomic features (i.e. glans size/urethral plate quality, location of meatus, and degree of chordee) felt to most likely impact functional and cosmetic outcomes following hypospadias repair. We demonstrated a statistically significant increase in the likelihood of any postoperative complication with every unit increase in total GMS score. The concept that factors aside from meatal location affect hypospadias repair and outcomes is not novel, and degree of ventral curvature and urethral plate quality are often cited as important factors. In our series, boys with greater than 60° of ventral curvature undergoing a single-stage repair were 27 times more likely to develop a fistula than those without chordee on multivariate analysis, making severe curvature an independent predictor of urethrocutaneous fistula formation. That meatal location did not retain significance on multivariate analysis highlights the importance of considering the entire hypospadias complex when determining severity, rather than just evaluating the position of the meatus. Our study has several limitations that warrant consideration. While GMS scores were assigned prospectively, the data was collected retrospectively, subjecting it to flaws inherent with such study design. Furthermore, type of repair is influenced by surgeon preference and subjective assessment of hypospadias characteristics not incorporated in our scoring system (i.e. tissue quality, urethral hypoplasia, penoscrotal transposition). Despite these limitations, our study demonstrates a strong correlation between the GMS classification and surgical complications, furthering supporting its potential as a tool to standardize hypospadias severity and gauge postoperative complications.

CONCLUSION

The Glans-Urethral Meatus-Shaft (GMS) classification provides a means by which hypospadias severity and reporting can be standardized, which may improve inter-study comparison of reconstructive outcomes. There is a strong correlation between complication risk and total GMS score. Degree of chordee (S score) is independently predictive of fistula rate.

Recent advances in understanding/management of hypospadias

Hypospadias is the second most common birth anomaly, affecting 1 of every 300 males. The abnormal position of the urinary opening, and associated downward curvature of the penis in some cases, potentially impact both urinary and sexual function. Modern surgical correction most often involves tubularization of the urethral plate, those tissues which normally should have completed urethral development. This article discusses recent progress in hypospadias repair. Prospective data collection in consecutive patients promotes better understanding of both patient and technical factors that influence surgical complications. Patients with a proximal urinary opening near or within the scrotum, those failing prior to repairs, and/or those with a small glans diameter have increased likelihood for urethroplasty complications. Quality review of reliable data led to two layer urethroplasty covered with tunica vaginalis in proximal repairs, significantly reducing postoperative fistulas. Neither preoperative androgens used to grow a small diameter glans, nor a change in sutures used to approximate the glans wings reduced wound dehiscence, but a recent technical modification of the glansplasty with more extensive dissection before suturing has. The observation that reoperation increases risk for further complications three-fold suggests the less common proximal repairs and reoperations should be subspecialized so that designated surgeons can gain greater expertise. In addition, surgeons performing hypospadias repair must better define the complications that occur so that scientific reporting of outcomes becomes more standardized. Standardized objective means to assess results are also needed so that surgeons performing different repairs can compare outcomes.

Comparison of transverse island flap onlay and tubularized incised-plate urethroplasties for primary proximal hypospadias: a systematic review and meta-analysis

Purpose

This meta-analysis was conducted to compare postoperative outcomes between transverse island flap (TVIF) onlay and tubularized incised-plate (TIP) urethroplasties for primary proximal hypospadias.

Materials and Methods

A comprehensive literature search updated to 21^st May 2014 was carried out for relevant studies. After literature identification and data extraction, odds ratio (OR) with 95% confidential interval (CI) was calculated to compare postoperative complication rate between TVIF onlay and TIP. Meta-regression and subgroup analyses were applied to find potential affective factors.

Results

A total of 6 studies including 309 patients receiving TVIF onlay and 262 individuals subjected to TIP met inclusion criteria. The synthetic data suggested that TVIF onlay and TIP were comparable in terms of total complication rate (OR 0.85, 95% CI 0.56–1.30, p = 0.461), fistula (OR 0.68, 95% CI 0.38–1.21, p = 0.194), recurrent curvature (OR 1.16, 95% CI 0.43–3.12, p = 0.766), dehiscence (OR 0.95, 95% CI 0.33–2.74, p = 0.920), diverticulum (OR 1.90, 95% CI 0.53–6.78, p = 0.321), meatal stenosis (OR 0.74, 95% CI 0.20–2.77, p = 0.651) and urethral stricture (OR 1.49, 95% CI 0.41–5.50, p = 0.545), without significant heterogeneity for each comparison group. Meta-regression and subgroup analyses revealed no significant findings. One-way sensitivity analysis indicated that the results were stable. No publication bias was detected using both funnel plot and Egger’s test. Also, there were no obvious differences observed in cosmetic and functional outcomes.

Conclusions

This meta-analysis suggests that TVIF onlay and TIP urethroplasties are clinically equivalent. Given the inherent limitations of included studies, this conclusion should be interpreted with caution and wait to be confirmed by more well-designed randomized controlled trials with high quality in the future.

Cumulative summation (CUSUM) charts in the monitoring of hypospadias outcomes: a tool for quality improvement initiative

OBJECTIVE

Cumulative summation (CUSUM) charting is a statistical tool that allows an individual surgeon or surgical department to monitor any binary outcome and rapidly detect when complications are outside the acceptable limits. We applied CUSUM statistical analysis to hypospadias repair to utilize the results in our own quality Improvement process.

MATERIALS AND METHODS

An institutional review board-approved retrospective review of all patients who underwent hypospadias repair by a single fellowship trained pediatric urologist at a single institution between September 2004 to July 2009 was performed. To graphically represent the complication rates and to assess for unacceptable rates, the use of CUSUM control charting was employed.

RESULTS

In our retrospective review, there were a total of 184 patients who underwent a total of 203 surgeries. Using CUSUM analysis, our incidence of major complications was within acceptable limits until approximately the first 150 operations had been performed, at which time the complication rate fell below the lower limit, indicating performance exceeded expectations.

CONCLUSION

CUSUM statistical charting was successfully applied to the retrospective monitoring of hypospadias outcomes at our institution. This is the first known publication in which CUSUM charts were used to evaluate complications of hypospadias repair.

Role of penile biometric characteristics on surgical outcome of hypospadias repair

PURPOSE

To assess influence of penile biometric characteristics on surgical outcome of tubularized incised plate (TIP) repair for hypospadias.

METHODS

We prospectively studied 42 boys with distal hypospadias that underwent TIP urethroplasty. Biometric assessment prior to surgery consisted of classifying glans shape, urethral plate (UP) length and width, prepuce vascularization and penile size, using a caliper rule, according to previous definitions. Surgical outcome was assessed according to the occurrence of dehiscence, fistula or urethral stricture.

RESULTS

There was no statistical difference among groups concerning postoperative complications. Glans shape: grooved (24/57 %), shallow (9/21 %) and conical (9/21 %). UP width: <10 mm (26/62 %) and ≥10 mm (16/38 %). UP length was evaluated in 29 patients: <10 mm in (12/41 %) and ≥10 mm (17/59 %). Prepuce vascularization: one predominant blood vessel (17/41 %), two predominant blood vessels (8/19 %), H-like form with communication between two well-developed blood vessels (6/14 %) and net-like form with no predominant blood vessels (11/26 %). Penile size was measured in 28 patients under 50th percentile (25/89 %).

CONCLUSION

Glans shape, UP width, UP length, prepuce vascularization and penile size do not significantly affect the complication rate of TIP repair in distal hypospadias. Most of the patients with distal hypospadias presented with penile size under mean length for age suggesting some form of mild hypogonadism.

The GMS hypospadias score: assessment of inter-observer reliability and correlation with post-operative complications

OBJECTIVE

An agreed upon method for describing the severity of hypospadias has not been established. Herein we assess the inter-observer reliability of the GMS hypospadias score and correlate it with the risk of a post-operative complication.

METHODS

A 3-component method for grading the severity of hypospadias was developed (GMS). Eighty-five consecutive patients presenting for hypospadias repair were graded independently by at least 2 surgeons using the GMS criteria. Scores were compared statistically to determine agreement between the observers. The outcomes of these patients were then reviewed to determine how the GMS score correlates to the risk of a surgical complication.

RESULTS

The G, M, and S scores had excellent agreement between observers. The GMS total score was exactly the same or differed by one point in 79/85 (93%) of patients. The complication rate was 5.6% for patients with a GMS score of 6 or less, but was 25.0% for patients with a GMS score greater than 6.

CONCLUSIONS

The GMS score provides a concise method for describing the severity of hypospadias and appears to have high inter-observer reliability. The GMS score also appears to correlate with the risk of a surgical complication.

Age of patient is a risk factor for urethrocutaneous fistula in hypospadias surgery

OBJECTIVE

There is still much debate regarding the effect that age at hypospadias operation has on the rate of complications. The aim of this study was to evaluate whether patient age is a risk factor for surgical complications when using the tubularized incised plate (TIP) urethroplasty technique.

METHODS

Between 2005 and 2011, 307 pediatric patients with distal or mid-penile hypospadias underwent the TIP procedure. Demographic and surgical data were evaluated.

RESULTS

The complications recorded across all age groups were: fistula, meatal stenosis, glans dehiscence and urethral stenosis. Fistula was the most frequent complication in 10-14 year olds compared to the younger patient groups, and this difference was statistically significant.

CONCLUSION

Age and surgical technique should be taken into consideration when planning hypospadias surgery, since the complication rate increases with patient age. The TIP technique is a safe procedure with a low rate of fistula formation in distal and mid-penile hypospadias repair for patients of any age during the prepubertal period.