1
|
Al-Salihi M, Abbas T, Albakr A, Vallasciani S, Elkadhi A, Salle JLP. Outcome analysis of staged preputial graft technique for primary proximal hypospadias with and without post-operative vacuum physiotherapy. J Pediatr Urol 2023; 19:699.e1-699.e7. [PMID: 37558593 DOI: 10.1016/j.jpurol.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/16/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE Management of proximal hypospadias remains challenging. We assessed the results of staged preputial graft repairs (SPG) for proximal hypospadias and hypothesize that post-operative vacuum physiotherapy (VP) improves graft suppleness and overall outcomes. MATERIALS AND METHODS Retrospective analysis of n = 71 patients with proximal hypospadias and severe ventral penile curvature (PC) of ≥50° after degloving. PC was corrected using ventral transverse incisions of the tunica albuginea (VTITA) without applying a tourniquet, taking care to avoid injuring the underlying erectile tissue. The ventral raw area at the penile shaft, including VTITA, were covered with either divided and partially mobilized urethral plate, or with the inner preputial graft itself. During the second stage, a tunica vaginalis flap was often used to cover the tubularized neourethra. Outcomes and post-op complications were assessed after each stage, comparing patients who received vacuum physiotherapy (VP+, n = 49) with those who did not (VP-, n = 22). RESULTS Mean PC was 66°, average follow-up duration was 13.01 months, and overall complication rate was 22.5%. Only 6 of 49 VP + patients experienced complications (12.24%; 4 fistulas; 2 urethral strictures) and no recurrence of PC after second stage was observed in this group. VP- patients displayed a significantly higher rate of complications, with 10 of 22 cases (45.45%) exhibiting fistula development (n = 5) and glans dehiscence (n = 5). Recurrence of mild PC after first-stage repair was comparable between patient groups (12% VP+, 18% VP-) and easily corrected by simple graft tubularization or dorsal plication during second-stage repair. CONCLUSIONS Staged repair using VTITA is effective for correcting proximal hypospadias with severe chordee. VP appears to promote and expedite graft suppleness and significantly improves patient outcomes.
Collapse
Affiliation(s)
- Muthana Al-Salihi
- Department of Surgery, Division of Urology, Sidra Medicine, Doha, Qatar; Department of Surgery, Weill Cornel Medicine - Qatar, Doha, Qatar
| | - Tariq Abbas
- Department of Surgery, Division of Urology, Sidra Medicine, Doha, Qatar; Department of Surgery, Weill Cornel Medicine - Qatar, Doha, Qatar
| | - Ahmed Albakr
- Urology Department, Hamad Medical Corporation, Qatar
| | | | | | - J L Pippi Salle
- Department of Surgery, Division of Urology, Sidra Medicine, Doha, Qatar.
| |
Collapse
|
2
|
Scougall K, Bryce J, Baronio F, Boal RL, Castera JR, Castro S, Cheetham T, Costa EC, Darendeliler F, Davies JH, Dirlewanger M, Gazdagh G, Globa E, Guerra-Junior G, Guran T, Herrmann G, Holterhus PM, Akgül AK, Markosyan R, McElreavey K, Miranda ML, Nordenstrom A, O’Toole S, Poyrazoglu S, Russo G, Schwitzgebel V, Stancampiano M, Steigert M, Ahmed SF, Lucas-Herald AK. Predictors of surgical complications in boys with hypospadias: data from an internationa registry. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000599. [PMID: 37860275 PMCID: PMC10582860 DOI: 10.1136/wjps-2023-000599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/25/2023] [Indexed: 10/21/2023] Open
Abstract
Background Complications are frequently reported after hypospadias repair and there is a need to understand the factors that influence their occurrence. Methods Data from boys with hypospadias born between 2000 and 2020 were obtained from the International Disorders of Sex Development (I-DSD) Registry. Logistic regressions, fisher's exact tests and spearman's correlation tests were performed on the data to assess associations between clinical factors and complication rates. Results Of the 551 eligible boys, data were available on 160 (29%). Within the cohort, the median (range) External Masculinization Score (EMS) was 6 (2, 9). All presented with one or more additional genital malformation and 61 (38%) presented with additional extragenital malformations. Disorders of androgen action, androgen synthesis and gonadal development were diagnosed in 28 (18%), 22 (14%) and 9 (6%) boys, respectively. The remaining 101 (62%) patients were diagnosed as having non-specific 46,XY Disorders of Sex Development. Eighty (50%) boys had evidence of abnormal biochemistry, and gene variants were identified in 42 (26%). Median age at first hypospadias surgery was 2 years (0, 9), and median length of follow-up was 5 years (0, 17). Postsurgical complications were noted in 102 (64%) boys. There were no significant associations with postsurgical complications. Conclusions Boys with proximal hypospadias in the I-DSD Registry have high rates of additional comorbidities and a high risk of postoperative complications. No clinical factors were significantly associated with complication rates. High complication rates with no observable cause suggest the involvement of other factors which need investigation.
Collapse
Affiliation(s)
| | | | - Federico Baronio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola, Bologna, Italy
| | - Rachel L Boal
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | | | | | - Tim Cheetham
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | | | | | | | | | | | - Evgenia Globa
- Ukrainian Research Center of Endocrine Surgery Endocrine Organs and Tissue Transplantation, Kyiv, Ukraine
| | | | | | | | - Paul-Martin Holterhus
- University Hospital of Schleswig-Holstein Campus Kiel/Christian-Albrechts-University of Kiel, Kiel, Germany
| | | | - Renata Markosyan
- Yerevan State Medical University Endocrinology Clinic, Yerevan, Armenia
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Durante L, Ghidini F, Panchieri F, Bovolenta E, Bagnara V, Esposito C, Castagnetti M. Glans dehiscence after severe hypospadias repair. Is it a real complication? Clues from a study in post-pubertal patients. Pediatr Surg Int 2023; 39:101. [PMID: 36737577 PMCID: PMC9898378 DOI: 10.1007/s00383-023-05387-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Glans dehiscence (GD) is reportedly a common complication after proximal hypospadias repairs. However, the need for surgical correction is controversial. The aim of this study was to assess awareness, risk factors, and outcome of GD in post-pubertal patients. The agreement with surgeon assessment was also evaluated. METHODS The design was retrospective. All consecutive patients treated for proximal hypospadias between 2000 and 2011 were included. The presence of GD was self-reported, and the participants could optionally upload a photograph for surgeon assessment. Cosmetic and functional outcomes were assessed by validated questionnaires (HOSE, PPPS, KINDL®, IIEF-5). Results were compared between patients with and without GD. RESULTS Of 219 patients, 34 (16%) participated. Fourteen of them (41%) self-reported GD. Eighteen patients (8%) also uploaded a photograph and, in ten of them (56%), the surgeon noted the presence of GD with poor agreement [k = - 0.444 (95 CI - 0.856 to - 0.033)] with patient report. Patients self-reporting GD had had more frequently a penile curvature at diagnosis (12/14 = 86%, p = 0.01), and had undergone a single-staged repair (100% vs. 65%, p = 0.03). No difference was found in cosmetic and functional outcomes. Results were similar also comparing groups with and without GD as assessed by the surgeon. CONCLUSION GD was a common finding after severe hypospadias repair. It was more common in case of surgeon assessment with poor agreement between patients and surgeons. GD did not prove to have clear clinical implications. Therefore, in our opinion, surgical repair of GD should be recommended only on patients request.
Collapse
Affiliation(s)
- Ludovica Durante
- Paediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Italy
| | - Filippo Ghidini
- Paediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Italy
| | - Francesco Panchieri
- Paediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Italy
| | - Eleonora Bovolenta
- Paediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Italy
| | - Vincenzo Bagnara
- Pediatric Surgery Unit, Policlinico "G.B. Morgagni", Catania, Italy
| | - Ciro Esposito
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Marco Castagnetti
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Via VIII Febbraio, 2, Padua, Italy.
- Pediatric Urology Unit, Bambino Gesù Children Hospital and Research Center, Rome, Italy.
| |
Collapse
|
4
|
Castagnetti M, El-Ghoneimi A. Surgical management of primary severe hypospadias in children: an update focusing on penile curvature. Nat Rev Urol 2022; 19:147-160. [PMID: 35039660 DOI: 10.1038/s41585-021-00555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 11/09/2022]
Abstract
Over the past two decades, assessment and treatment of associated curvature has emerged as a major issue in treating patients with proximal hypospadias. However, the cut-off for defining a curvature as clinically significant is still unclear, as not all patients are bothered by the same degree of curvature and, although the need for a method to assess the curvature objectively has been emphasized, no standard method yet exists. Curvature is multifactorial. The same degree of curvature can be due to any possible combination of skin and/or subcutaneous dartos tethering, a short urethral plate and an intrinsic corpora disproportion. Different strategies can be used to treat curvature, depending on the underlying cause, surgeon preferences, and the goals of the repair. In the past 10 years, use of urethral plate transection and ventral lengthening procedures has increased, although the lack of long-term follow-up data on ventral lengthening procedures suggests that the use of such procedures should be selective. Furthermore, straightening manoeuvres are influenced by the technique used for subsequent urethroplasty and, in turn, may influence the success rate of the urethroplasty. This Review provides a comprehensive overview of the major developments from the past 10 years in the management of severe proximal hypospadias in children.
Collapse
Affiliation(s)
- Marco Castagnetti
- Paediatric Urology Unit, Department of Surgery, Bambino Gesù Children Hospital and Research Institute, Rome, Italy. .,Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy.
| | - Alaa El-Ghoneimi
- Department of Paediatric Surgery and Urology, Reference Centre for Rare Urinary Tract Malformations (MARVU), Hôpital Robert Debré, APHP, Université de Paris, Paris, France
| |
Collapse
|
5
|
Li J, Liu P, Yang Z, Wang X, Fan S, Li Z, Song H, Zhang W. Reoperation frequency after transverse preputial Island flap urethroplasty "Duckett's technique" in treatment of severe hypospadias: A single center study. Front Pediatr 2022; 10:1030649. [PMID: 36699300 PMCID: PMC9869034 DOI: 10.3389/fped.2022.1030649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/09/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Transverse Preputial Island Flap Urethroplasty (TPIFU) is one of the most common techniques for treating severe hypospadias. Studies on the reoperation frequency after TPIFU is lacking. In the present study, we reported our clinical outcomes of severe hypospadias treated with one-staged TPIFU and analyzed the operation frequency. METHODS We retrospectively analyzed the clinical data of severe hypospadias patients who underwent one-stage TPIFU from December 2018 to December 2019 in the department of Urology at Beijing Children's Hospital. A stepwise approach was used to manage the curvature. Severe hypospadias was defined as those residual curvature was higher than 30° after degloving. Urethroplasty complications included fistula, urethral stricture, and diverticulum. The short-term cure was identified as no complications occurring for 12 months after the date of last-time surgery. The reoperation rate and operation frequency of TPIFU were analyzed. RESULTS A total of 136 patients who underwent one-stage TPIFU were included in the study. The follow-up after primary urethroplasty ranged from 22 to 50 months. The median age at primary surgery was 22.5 months (range from 13 to 132 months). After primary TPIFU surgery, 53 (39%) patients underwent additional surgical interventions to treat postoperative complications. Among them, 24 patients (17.6%) developed fistula, 17 patients (12.5%) developed urethral stricture and 11 patients (8.1%) developed diverticulum. After the second surgery, five patients remained fistula, five patients remained urethral stricture, and seven patients remained diverticulum. Overall, 61% (85 patients) met the cured standard after the primary operation, and the two operations cure rate was 87.5% (119 patients). 91.2% (124 patients) were cured in three operations. CONCLUSIONS Although the complication rates after primary TPIFU were relatively high, more than half of patients achieved short-term cured through a single operation, and the cure rate after two or three operations was acceptable.
Collapse
Affiliation(s)
- Jiayi Li
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Pei Liu
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenzhen Yang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xinyu Wang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Songqiao Fan
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zonghan Li
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hongcheng Song
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Weiping Zhang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| |
Collapse
|
6
|
Shirazi M, Haghpanah A, Dehghani A, Haghpanah S, Ghahartars M, Rahmanian M. Comparison of post-urethroplasty complication rates in pediatric cases with hypospadias using Vicryl or polydioxanone sutures. Asian J Urol 2021; 9:165-169. [PMID: 35509477 PMCID: PMC9051349 DOI: 10.1016/j.ajur.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 02/22/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022] Open
Abstract
Objective Hypospadias is a common congenital problem among male newborns. Both rapid absorbable sutures (polyglactin, Vicryl) and delayed absorbable sutures (polydioxanone, PDO) are used in hypospadias repair based on the surgeon's preference. This study was conducted to compare post-urethroplasty complication rates in pediatric patients with hypospadias using Vicryl or PDO sutures. Methods This is a retrospective study which was designed and performed on 583 children aged 1–7 years old who had undergone hypospadias repair from January 2012 to December 2018. Required data were obtained from the patients' medical records. Results Overall, post-surgical complications were observed in 60 (10.3%) patients comprising urethro-cutaneous fistula (n=39, 6.7%), meatal stenosis (n=10, 1.7%), urethral stricture (n=7, 1.2%), and glans dehiscence (n=4, 0.7%). The mean age of the children with complications was 3.0±1.3 years. According to Kaplan-Meier estimate, the interval between surgery and development of complications was significantly shorter in the Vicryl group (p=0.037). Overall, complications were more prevalent in Vicryl suture than PDO suture (15.1% vs. 5.3%, p<0.001). Regression model revealed that in comparison to the distal type, proximal hypospadias (odds ratio [OR]:103.9, 95% confidence interval [CI]: 32.2–334.9, p<0.001) and mid-shaft hypospadias (OR: 82.9, 95% CI: 25.9–264.6, p<0.001) while using Vicryl suture instead of PDO suture (OR: 62.4, 95% CI: 21.2–183.8, p<0.001) increased the odds of developing post-urethroplasty complications. Conclusion We suggest PDO suture in the repair of hypospadias due to its lower complication rate, especially in cases of proximal and mid-shaft hypospadias which can get more complicated than the distal type.
Collapse
Affiliation(s)
- Mehdi Shirazi
- Shiraz Nephro-urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdolreza Haghpanah
- Shiraz Nephro-urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Corresponding author.
| | - Anahita Dehghani
- Shiraz Nephro-urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Ghahartars
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Rahmanian
- Medical School, MPH Department, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
7
|
Chan YY, D'Oro A, Yerkes EB, Rosoklija I, Balmert LC, Lindgren BW, Gong EM, Liu DB, Johnson EK, Chu DI, Cheng EY. Challenging proximal hypospadias repairs: An evolution of technique for two stage repairs. J Pediatr Urol 2021; 17:225.e1-225.e8. [PMID: 33388263 DOI: 10.1016/j.jpurol.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars' flaps. STUDY DESIGN A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with <6 months follow-up and incomplete operative reports were excluded. Risk of complications (fistula, dehiscence, diverticulum, meatal stenosis, stricture) were evaluated following urethroplasty and stratified by first-stage repair technique. As technique refinements have been made since 2012, comparisons between two temporal subgroups (those who underwent repair in 2007-2012 and in 2013-2017) were made. RESULTS 78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4-128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14-0.65) and inlay grafts (HR 0.32; 95% CI 0.11-0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars' flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p = 0.001), but differences in complication rates by first-stage technique were not statistically significant. DISCUSSION In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars' flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising. CONCLUSION Approach to the first stage of two-stage repairs affects outcomes. Pedicled preputial flaps and inlay grafts were associated with lower complication risks than Byars' flaps. Refinement of technique and patient selection may have resulted in fewer complications in the short term. However, long-term follow-up is needed.
Collapse
Affiliation(s)
- Yvonne Y Chan
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anthony D'Oro
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ilina Rosoklija
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Lauren C Balmert
- Department of Preventative Medicine/Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce W Lindgren
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Edward M Gong
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dennis B Liu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David I Chu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Earl Y Cheng
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
8
|
Omran M, Sakr A, Elgalaly H, Fawzy A, Abdalla M. Narrow urethral plate augmentation in anterior and middle hypospadias repair: Onlay flap VS. Inlay graft. A prospective randomized comparative study. J Pediatr Urol 2021; 17:216.e1-216.e8. [PMID: 33308949 DOI: 10.1016/j.jpurol.2020.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/03/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mohamed Omran
- Department of Urology, Faculty of Medicine, Zagazig University, Sharkia Governorate, Zagazig City, 44519, Egypt.
| | - Ahmed Sakr
- Department of Urology, Faculty of Medicine, Zagazig University, Sharkia Governorate, Zagazig City, 44519, Egypt
| | - Hazem Elgalaly
- Department of Urology, Faculty of Medicine, Zagazig University, Sharkia Governorate, Zagazig City, 44519, Egypt
| | - Amr Fawzy
- Department of Urology, Faculty of Medicine, Zagazig University, Sharkia Governorate, Zagazig City, 44519, Egypt
| | - Mohamed Abdalla
- Department of Urology, Faculty of Medicine, Zagazig University, Sharkia Governorate, Zagazig City, 44519, Egypt
| |
Collapse
|
9
|
Cui X, He Y, Huang W, Chen L, Wang Y, Zhou C. Clinical efficacy of transverse preputial island flap urethroplasty for single-stage correction of proximal hypospadias: a single-centre experience in Chinese patients. BMC Urol 2020; 20:118. [PMID: 32758190 PMCID: PMC7404920 DOI: 10.1186/s12894-020-00686-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 07/27/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study was designed to summarize the clinical outcomes of transverse preputial island flap urethroplasty for single-stage correction of proximal hypospadias in our hospital. Method This study retrospectively analysed the clinical data, including the preoperative general information, intraoperative and postoperative data, and follow-up data, of 155 children with proximal hypospadias who were admitted to our hospital from January 2009 to January 2019. Results During follow-up, a total of 92 postoperative complications occurred, and 41 patients underwent reoperation. There were 49 patients with urinary fistula, 26 patients with urethral stricture, 9 patients with urethral diverticulum and 8 patients with urinary tract infection. Regarding the family members’ satisfaction with the cosmetic appearance of the penis, the satisfaction rate with the urinary meatus was 85.2%, the satisfaction rate with the glans appearance was 87.7%, the satisfaction rate with the the appearance of the foreskin of the penis was 92.3%, and the satisfaction rate with the overall penis shape was 89.0%. Conclusion Proximal hypospadias is a serious condition that is often combined with severe chordee, and transverse preputial island flap urethroplasty for single-stage correction is an effective surgical procedure for treating this condition.
Collapse
Affiliation(s)
- Xu Cui
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yuanbin He
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Wenhua Huang
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Liu Chen
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yunjin Wang
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Chaoming Zhou
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China.
| |
Collapse
|
10
|
Morlacco A, Gobbi D, Esposito C, Castagnetti M. Edges-On-Dartos: An Easy Way to Improve Graft Performance in Staged Hypospadias Repair. Urology 2020; 144:245-248. [PMID: 32711013 DOI: 10.1016/j.urology.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/02/2020] [Accepted: 07/12/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To present a technical tip to be incorporated in the first stage of a 2-stage graft repair of proximal hypospadias associated with curvature, aiming at widening the graft bed and enhancing mobility of the lateral portions of the graft for subsequent urethroplasty. METHODS After penile straightening, the dorsal dartos layer, carefully preserved attached to the dorsal penile skin used for penile coverage, is anchored to the lateral edges of the denuded corpora cavernosa with 3 to 4 interrupted 6-0 resorbable stiches on each side. The dartos creates a sort of hammock in-between the corpora, on which the central portion of the graft is quilted as in standard staged graft repair, and the skin margins laterally. Therefore, it widens the graft bed by 3-4 mm on each side. The lateral portions of the graft, laying on dartos, also remain supple for subsequent tabularization. RESULTS Between 2017 and 2019, the technique was used in 16 cases (range 10-19 months). None of these patients required re-grafting because of severe longitudinal graft shrinkage. CONCLUSION The described modification seems a simple tip to be incorporate in staged graft urethroplasty. Putative advantages include that a wider graft can compensate for some graft shrinkage occurring in-between stages; during the second stage, it can facilitate dissection and improve mobility of the lateral graft portions for tubularization, and make retrieval of a dartos flap for urethroplasty coverage easier. Prospective evaluation and comparative data are needed.
Collapse
Affiliation(s)
- Alessandro Morlacco
- Pediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology; University of Padova, Padua, Italy
| | - Dalia Gobbi
- Pediatric Surgery Unit, Treviso Hospital, Treviso, Italy
| | - Ciro Esposito
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Marco Castagnetti
- Pediatric Urology Unit, Department of Surgery, Oncology, and Gastroenterology; University of Padova, Padua, Italy.
| |
Collapse
|
11
|
Hadidi AT. Perineal hypospadias: back to the future Chordee Excision & Distal Urethroplasty. J Pediatr Urol 2018; 14:424.e1-424.e9. [PMID: 30297228 DOI: 10.1016/j.jpurol.2018.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 08/11/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Perineal hypospadias correction has swung from two-stage repair in the 1960s to one-stage repair in the 1980s and back to two-stage repair in the 2000s. The author's experience with a technique in which Chordee Excision and Distal Urethroplasty (CEDU) was performed at the first operation leaving a 1-cm segment as perineal urethrotomy to be reconstructed at the second operation is presented. PATIENTS AND METHODS Between January 2013 and December 2016, the CEDU technique was performed in 63 patients with perineal hypospadias. The records of 59 patients who maintained regular follow-up were reviewed. The principle is to excise the hypoplastic urethral plate, atretic corpus spongiosum, and longitudinal layer of tunica albuginea; split the glans in the midline; and reconstruct a healthy urethral plate using preputial and lateral skin flaps to the tip of the glans. Distal urethroplasty was performed leaving 1 cm at the proximal end to be reconstructed 3-6 months later. This principle was used by Duplay in the 1880s. Patient age ranged between 6 months and 2 years (mean 8 months). All the patients had perineal hypospadias and bifid scrotum with severe deep chordee. Follow-up period ranged from 17 to 53 months (mean 36). A transurethral Silastic catheter was inserted for 4 days. Three months later, the remaining 1 cm of the new urethra was reconstructed, and final adjustment of the glans and foreskin was performed. RESULTS Satisfactory results were obtained in 54 patients (90%). Three children experienced glans dehiscence that was corrected in the second stage, one child developed fistula after the second operation, and one developed diverticulum. The fistula and diverticulum were corrected at the third operation successfully. DISCUSSION It was necessary in this series to divide the urethral plate and excise the hypoplastic corpus spongiosum and the outer longitudinal layer of tunica albuginea to correct the associated deep chordee. The lateral skin flaps receive double blood supply from the base of the penis and the preputial vessels. This natural urinary diversion allows early removal of the catheter, reduces the discomfort of the patient, and allows the new urethra to heal without urine irritation for 3 months. Long-term follow-up for 15 years is necessary to assess the technique objectively. CONCLUSIONS The CEDU technique diverts urine away from the site of urethroplasty for 3 months without a catheter. It reduces the hospital stay and patient discomfort. It produces satisfactory results and has become a the standard technique in perineal hypospadias.
Collapse
Affiliation(s)
- A T Hadidi
- Hypospadias Centre, Department of Pediatric Surgery, Emma and Sana Klinikum Offenbach Hospitals, Germany.
| |
Collapse
|
12
|
Rynja SP, de Jong TPVM, Bosch JLHR, de Kort LMO. Proximal hypospadias treated with a transverse preputial island tube: long-term functional, sexual, and cosmetic outcomes. BJU Int 2018; 122:463-471. [PMID: 29624839 DOI: 10.1111/bju.14234] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study long-term urinary and sexual function, and cosmetic outcomes in adult patients who underwent single-stage transverse preputial island tube (TPIT) for proximal hypospadias repair in childhood. Long-term data on outcomes of patients with proximal hypospadias with severe coexisting curvature and insufficient urethral plate are scarce, but are necessary to decide which repair technique is most beneficial. PATIENTS, SUBJECTS AND METHODS Patients with proximal hypospadias operated with TPIT (TPIT Group) were compared to patients with distal hypospadias repair (Distal Group) and to a control group of male medical students (Control Group). Participants completed the International Prostate Symptom Score, the International Index of Erectile Function (IIEF-15), additional non-validated questions, and performed uroflowmetry. Cosmesis was assessed in the patients with hypospadias using the Pediatric Penile Perception Score (PPPS); stretched penile length was also measured. RESULTS Of the 121 eligible patients with hypospadias, 54 with either TPIT or distal hypospadias repairs participated. The TPIT Group comprised 12 patients (median age of 20.0 years) and the Distal Group comprised 42 patients (median age of 19.6 years). The complication rates were similar, at 8 of the 12 patients in the TPIT Group vs 26/42 (62%) in the Distal Group (P = 0.76). Urinary outcomes were similar in the TPIT, Distal, and the Control (comprised of 148 medical students with a median age of 21.0 years) groups. The TPIT Group had a lower maximum urinary flow rate compared to the Control Group, at 24.1 vs 28.6 mL/s (P < 0.05). IIEF-15 scores were similar in the TPIT, Distal and Control groups, except for 'Orgasmic Function' (7.5 vs 10.0 vs 10.0, respectively; P < 0.01). Although the TPIT Group had a smaller penile length compared to the Distal Group (10.1 vs 12.9 cm, P < 0.01), PPPS outcomes were similar. CONCLUSION In these TPIT patients, long-term urinary, sexual and cosmetic outcomes were similar to those in patients with distal hypospadias repairs and controls.
Collapse
Affiliation(s)
- Sybren P Rynja
- University Medical Center (UMC), Utrecht, The Netherlands
| | - Tom P V M de Jong
- University Children's Hospital UMC Utrecht, Utrecht, The Netherlands
| | | | | |
Collapse
|
13
|
Current challenges with proximal hypospadias: We have a long way to go. J Pediatr Urol 2017; 13:457-467. [PMID: 28549608 DOI: 10.1016/j.jpurol.2017.03.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/17/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Proximal hypospadias repair has continued to challenge the pediatric urologist despite great efforts to develop better techniques for repair. METHODS In this article, we review the literature regarding modern proximal hypospadias repair approaches and outcomes. We also present our current approach to proximal hypospadias repair surgery and outcome tracking. Finally, we review the literature on surgical outcome tools that may help us standardize research. RESULTS Proximal hypospadias repair has significant variability in technique. Overall modern data would suggest that we require great improvement in our surgical management of this challenging problem. Though tools exist to begin to standardize the reporting of hypospadias outcomes, collaborative efforts are still required for future research. CONCLUSION Future research in proximal hypospadias repair needs to utilize new reporting tools as well as engage in collaborative efforts between institutions.
Collapse
|
14
|
Snodgrass W, Bush N. Staged Tubularized Autograft Repair for Primary Proximal Hypospadias with 30-Degree or Greater Ventral Curvature. J Urol 2017; 198:680-686. [DOI: 10.1016/j.juro.2017.04.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
|
15
|
Intermediate-Term Followup of Proximal Hypospadias Repair Reveals High Complication Rate. J Urol 2017; 197:852-858. [DOI: 10.1016/j.juro.2016.11.054] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 11/20/2022]
|
16
|
Sullivan KJ, Hunter Z, Andrioli V, Guerra L, Leonard M, Klassen A, Keays MA. Assessing quality of life of patients with hypospadias: A systematic review of validated patient-reported outcome instruments. J Pediatr Urol 2017; 13:19-27. [PMID: 28089292 DOI: 10.1016/j.jpurol.2016.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/08/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential. OBJECTIVE To identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population. METHODS A systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains. RESULTS A total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae. CONCLUSIONS While many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.
Collapse
Affiliation(s)
- K J Sullivan
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada
| | - Z Hunter
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada
| | - V Andrioli
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada
| | - L Guerra
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada
| | - M Leonard
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada
| | - A Klassen
- Department of Pediatrics, McMaster University, 3N27, 1280 Main Street West, Hamilton, ON, Canada; Department of Clinical Epidemiology & Biostatistics, McMaster University, 3N27, 1280 Main Street West, Hamilton, ON, Canada
| | - M A Keays
- Department of Pediatric Surgery, Division of Urology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON, Canada.
| |
Collapse
|
17
|
|
18
|
Abstract
Hypospadias surgery is a humbling art form. The evolution of surgical techniques has made distal hypospadias outcomes favorable, but recent publications suggest that our complication rates for proximal hypospadias are much higher than previously reported. To explain these shortcomings, we examine the literature and focus on the lack of standardized documentation, the subsequent inability to objectify the severity of the phenotype, and the underestimation of complications due to lack of long-term follow up. The variability in surgical technique and the fact that the literature abounds with small case series from single institutions also limits our ability to compare outcomes. We believe that the use of standardized and scored phenotype assessments from diagnosis through the extended postoperative period will allow for improved scientific assessment of outcomes. This will facilitate multi-institution collaboration and tabulation of outcomes, allowing rapid data accumulation and assessment for this rare disorder. As surgeons, we must follow boys through puberty into adulthood and must honestly report our results in order to advance our surgical approach to this complicated problem.
Collapse
Affiliation(s)
- Christopher J Long
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas A Canning
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
19
|
Long CJ, Canning DA. Hypospadias: Are we as good as we think when we correct proximal hypospadias? J Pediatr Urol 2016; 12:196.e1-5. [PMID: 27296789 DOI: 10.1016/j.jpurol.2016.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Hypospadias surgery is a humbling art form. Although outcomes with distal hypospadias are favorable, recent publications have suggested that the complication rates are much higher than previously anticipated for proximal hypospadias. The present review examined the literature concerning proximal hypospadias, to explore some of the inadequacies and identify some of the reasons behind these shortfalls in the reported data. METHODS A systematic review of the published literature was conducted using keywords relevant to proximal hypospadias and long-term outcomes. RESULTS The literature for hypospadias was reviewed, and outcomes for distal vs proximal variants were compared. The quality of the literature for proximal hypospadias was examined, and the shortcomings that led to underreporting of the surgical outcomes were identified. Special focus was on the lack of standardized documentation, the subsequent inability to objectify the severity of the phenotype, and the underestimation of complications due to lack of long-term follow-up. There was also a great deal of variability in the utilized techniques, and the literature was filled with small case series from single institutions. To enable scientific assessment of outcomes, it is proposed that the following be implemented: acceptance and incorporation of standardized phenotype assessment scores in the pre-operative period, objective intraoperative hypospadias characterization, and postoperative score assessment. CONCLUSIONS Treatment of proximal hypospadias is much less successful than the distal variant. A specialty wide commitment to standardize the hypospadias language is required to make advancement in surgical outcomes. Boys need to be followed through puberty into adulthood, and honest reporting of outcomes must be discussed so that surgical techniques for this complicated disease process can be advanced.
Collapse
Affiliation(s)
- C J Long
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Wood Center, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - D A Canning
- Division of Urology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Wood Center, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| |
Collapse
|
20
|
Pippi Salle JL, Sayed S, Salle A, Bagli D, Farhat W, Koyle M, Lorenzo AJ. Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period. J Pediatr Urol 2016; 12:28.e1-7. [PMID: 26279102 DOI: 10.1016/j.jpurol.2015.06.011] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 06/25/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled. OBJECTIVE To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias. METHODS Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later. RESULTS A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR. CONCLUSIONS Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes.
Collapse
Affiliation(s)
- J L Pippi Salle
- Division of Urology, Sidra Medical and Research Center, Doha, Qatar.
| | - S Sayed
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - A Salle
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - D Bagli
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - W Farhat
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - M Koyle
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| | - A J Lorenzo
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Canada.
| |
Collapse
|
21
|
Ghidini F, Sekulovic S, Castagnetti M. Parental Decisional Regret after Primary Distal Hypospadias Repair: Family and Surgery Variables, and Repair Outcomes. J Urol 2015; 195:720-4. [PMID: 26518112 DOI: 10.1016/j.juro.2015.10.118] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Decisional regret is defined as distress after making a health care choice and can be an issue for parents electing distal hypospadias repair for their sons. We assessed the influence on decisional regret of variables related to the family, surgery and outcomes. MATERIALS AND METHODS Charts for 372 patients undergoing primary distal hypospadias repair between 2005 and 2012 were reviewed, and validated questionnaires, including the Decisional Regret Scale, Pediatric Penile Perception Score and Dysfunctional Voiding and Incontinence Scoring System, were administered to parents. RESULTS Data were available for 172 of 372 families (response rate 46.2%). Of 323 parents 128 (39.6%) presented with moderately strong decisional regret, with good agreement within couples. Predictors of decisional regret included intermediate parental educational level (OR 3.19, 95% CI 1.52-6.69), patient not being the first born (OR 2.01, 95% CI 1.07-3.78), family history of hypospadias (OR 4.42, 95% CI 1.96-9.97), initial desire to avoid surgery (OR 2.07, 95% CI 1.04-4.12), younger age at followup (OR 0.81, 95% CI 0.72-0.91), presence of lower urinary tract symptoms (OR 4.92, 95% CI 1.53-15.81) and lower Pediatric Penile Perception Score (OR 0.86, 95% CI 0.75-0.99). Decisional regret was unrelated to parental desire to avoid circumcision, surgical variables, development of complications and duration of followup. CONCLUSIONS Decisional regret is a problem in a significant proportion of parents electing distal hypospadias repair for their sons. In our experience family variables seemed to be predictors of decisional regret, while surgical variables did not. Predictors of decisional regret included worse parental perception of penile appearance and the presence of lower urinary tract symptoms. However, the latter could be unrelated to surgery. Irrespective of the duration of followup, decisional regret seems decreased in parents of older patients.
Collapse
Affiliation(s)
- Filippo Ghidini
- Section of Pediatric Urology, Urology Unit, University Hospital of Padova, Padua, Italy
| | - Sasa Sekulovic
- Section of Pediatric Urology, Urology Unit, University Hospital of Padova, Padua, Italy
| | - Marco Castagnetti
- Section of Pediatric Urology, Urology Unit, University Hospital of Padova, Padua, Italy.
| |
Collapse
|
22
|
McNamara ER, Schaeffer AJ, Logvinenko T, Seager C, Rosoklija I, Nelson CP, Retik AB, Diamond DA, Cendron M. Management of Proximal Hypospadias with 2-Stage Repair: 20-Year Experience. J Urol 2015; 194:1080-5. [PMID: 25963188 DOI: 10.1016/j.juro.2015.04.105] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE We describe our experience with 2-stage proximal hypospadias repair. We report outcomes, and patient and procedure characteristics associated with surgical complications. MATERIALS AND METHODS We retrospectively studied patients with proximal hypospadias who underwent staged repair between January 1993 and December 2012. Demographics, preoperative management and operative technique were reviewed. Complications included glans dehiscence, fistula, meatal stenosis, nonmeatal stricture, urethrocele/diverticula and residual chordee. Cox proportional hazards model was used to evaluate the associations between time to surgery for complications and patient and procedure level factors. RESULTS A total of 134 patients were included. Median patient age was 8.8 months at first stage surgery and 17.1 months at second stage surgery, and median time between surgeries was 8 months. Median followup was 3.8 years. Complications were seen in 71 patients (53%), with the most common being fistula (39 patients, 29.1%). Reoperation was performed in 66 patients (49%). Median time from urethroplasty to surgery for complication was 14.9 months. Use of preoperative testosterone decreased risk of undergoing surgery for complication by 27% (HR 0.73, 95% CI 0.55-0.98, p = 0.04). In addition, patients identified as Hispanic were at increased risk for undergoing surgery for complications (HR 2.40, 95% CI 1.28-4.53, p = 0.01). CONCLUSIONS We review the largest cohort of patients undergoing 2-stage hypospadias repair at a single institution. Complications and reoperation rates were approximately 50% in the setting of complex genital reconstruction.
Collapse
Affiliation(s)
- Erin R McNamara
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Harvard-Wide Pediatric Health Services Research Fellowship, Boston, Massachusetts.
| | - Anthony J Schaeffer
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tanya Logvinenko
- Clinical Research Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ilina Rosoklija
- Divison of Urology, Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alan B Retik
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Diamond
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc Cendron
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
23
|
Effects of oral testosterone undecanoate treatment for severe hypospadias. Int Urol Nephrol 2015; 47:875-80. [DOI: 10.1007/s11255-015-0972-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/31/2015] [Indexed: 11/26/2022]
|
24
|
Zheng DC, Yao HJ, Cai ZK, Da J, Chen Q, Chen YB, Zhang K, Xu MX, Lu MJ, Wang Z. Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience. Asian J Androl 2015; 17:94-7. [PMID: 25248656 PMCID: PMC4291885 DOI: 10.4103/1008-682x.137688] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/27/2014] [Accepted: 07/07/2014] [Indexed: 11/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Da-Chao Zheng
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Hai-Jun Yao
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Zhi-Kang Cai
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Jun Da
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Qi Chen
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Yan-Bo Chen
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Ke Zhang
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Ming-Xi Xu
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Mu-Jun Lu
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Zhong Wang
- Department of Urology, Shanghai 9 People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| |
Collapse
|
25
|
Snodgrass W, Bush N. Recent advances in understanding/management of hypospadias. F1000PRIME REPORTS 2014; 6:101. [PMID: 25580255 PMCID: PMC4229727 DOI: 10.12703/p6-101] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Warren Snodgrass
- University of Texas Southwestern Medical Center and Children's Medical Center1935 Medical District Drive, Dallas, TX 75235USA
| | - Nicol Bush
- University of Texas Southwestern Medical Center and Children's Medical Center1935 Medical District Drive, Dallas, TX 75235USA
| |
Collapse
|
26
|
Xiao D, Nie X, Wang W, Zhou J, Zhang M, Zhou Z, Zhao Y, Gu M, Wang Z, Lu M. Comparison of transverse island flap onlay and tubularized incised-plate urethroplasties for primary proximal hypospadias: a systematic review and meta-analysis. PLoS One 2014; 9:e106917. [PMID: 25197970 PMCID: PMC4157843 DOI: 10.1371/journal.pone.0106917] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 08/01/2014] [Indexed: 11/18/2022] Open
Abstract
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 21st 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.
Collapse
Affiliation(s)
- Dongdong Xiao
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Xin Nie
- Department of General Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Wenyue Wang
- Department of General Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Juan Zhou
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Ming Zhang
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Zhe Zhou
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Yang Zhao
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Meng Gu
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
| | - Zhong Wang
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
- * E-mail: (ML); (ZW)
| | - Mujun Lu
- Department of Urology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, People’s Republic of China
- * E-mail: (ML); (ZW)
| |
Collapse
|
27
|
Hadidi AT. Perineal hypospadias: the Bilateral Based (BILAB) skin flap technique. J Pediatr Surg 2014; 49:218-23. [PMID: 24439613 DOI: 10.1016/j.jpedsurg.2013.09.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 09/29/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to present the "bilateral based skin flap (BILAB) technique" for patients with perineal hypospadias associated with severe deep chordee and report the follow up. OPERATIVE PRINCIPLE The short urethral plate is incised, the hypoplastic corpus spongiosum excised, the glans split in the midline, and a healthy urethral plate is reconstructed from the lateral penile skin and foreskin to the tip of the glans. PATIENTS AND METHODS Between January 2005 and December 2011, the BILAB technique was performed in 68 patients with perineal hypospadias associated with severe chordee as a one or two stage repair. The records of 63 patients who maintained regular follow up were reviewed. The new urethra was reconstructed from the new urethral plate during the same setting in 26 patients. The remaining 37 patients had the urethroplasty performed 3-6 months later as a two stage repair. Patient age ranged from 8 months and 2 years (mean 10 months). Follow-up period ranged from 18 months to 8 years (mean 43 months). RESULTS Satisfactory results were obtained in 54 patients (85%). Two children developed diverticula, two patients developed glans dehiscence, one child developed fistula, and one child had complete wound dehiscence, and urethroplasty was successfully reconstructed 6 months later. Three patients developed scar contraction 6-12 months after surgery. This was corrected by excision of the scarred intermediate layer. CONCLUSIONS The BILAB technique is a reliable technique for patients with perineal hypospadias. It produces slit like meatus at the tip of the glans. The surgeon may decide intra-operatively whether to complete the urethroplasty in one or two stages. Long term follow up until puberty is being carried out.
Collapse
Affiliation(s)
- Ahmed T Hadidi
- Hypospadias Clinic, Department of Pediatric Surgery, Emma and Sana Offenbach Hospitals, Germany.
| |
Collapse
|
28
|
Cimador M, Vallasciani S, Manzoni G, Rigamonti W, De Grazia E, Castagnetti M. Failed hypospadias in paediatric patients. Nat Rev Urol 2013; 10:657-66. [PMID: 23917119 DOI: 10.1038/nrurol.2013.164] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Failed hypospadias refers to any hypospadias repair that leads to complications or causes patient dissatisfaction. The complication rate after hypospadias repairs ranges from 5-70%, but the actual incidence of failed hypospadias is unknown as complications can become apparent many years after surgery and series with lifelong follow-up data do not exist. Moreover, little is known about uncomplicated repairs that fail in terms of patient satisfaction. Risk factors for complications include factors related to the hypospadias (severity of the condition and characteristics of the urethral plate), the patient (age at surgery, endocrine environment, and wound healing impairment), the surgeon (technique selection and surgeon expertise), and the procedure (technical details and postoperative management). The most important factors for preventing complications are surgeon expertise (number of cases treated per year), interposition of a barrier layer between the urethroplasty and the skin, and postoperative urinary drainage. Major complications associated with failed hypospadias include residual curvature, healing complications (preputial dehiscence, glans dehiscence, fistula formation, and urethral breakdown), urethral obstruction (meatal stenosis, urethral stricture, and functional obstruction), urethral diverticula, hairy urethra, and penile skin deficiency.
Collapse
Affiliation(s)
- Marcello Cimador
- Section of Paediatric Urology and Paediatric Surgery Unit, Department for Mother and Child Care and Urology, University of Palermo, Via A. Giordano 3, 90127 Palermo, Italy
| | | | | | | | | | | |
Collapse
|
29
|
Ritchey ML. This Month in Pediatric Urology. J Urol 2013. [DOI: 10.1016/j.juro.2013.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|