Modified Tubularized Incised Plate Urethroplasty for Hypospadias Repair: A Long-Term Results of 764 Patients

Effectiveness of penile ventral curvature correction and the trend of hypospadias repair: a prospective study of the national center in China

BACKGROUND

Hypospadias repair is a complex surgical procedure that involves correcting penile ventral curvature (VC) and performing urethroplasty. This study aims to evaluate the effectiveness of different strategies for VC correction and analyse the trends in hypospadias repair at a national centre in China.

METHODS

Prospective data collection was conducted from 2019 to 2020 for patients undergoing hypospadias repair. The effectiveness of VC correction was assessed based on the degree of VC change with different strategies. Furthermore, the choice of surgical techniques for different types of hypospadias repair was analysed.

RESULTS

A total of 434 patients were included, with a median preoperative VC degree of 50° (35°, 70°). All patients achieved a straight penis postoperatively, with 15.2% undergoing degloving, 28.6% undergoing degloving and dorsal plication (DP), 13.1% undergoing degloving and urethral plate transection (UPT), and 43.1% undergoing degloving, UPT and DP. Degloving alone was effective in correcting VC in 57.6% of patients with VC less than 30°. In our analysis, DP after UPT resulted in a higher degree of correction (25°) compared with DP after degloving alone (20°) (p<0.001). The study identified the current trends in hypospadias repair, with tubularised incised plate urethroplasty (TIP) being the most common technique used in distal hypospadias repair (70.6% of patients) and transverse preputial island flap urethroplasty (TPIFU) being preferred for proximal hypospadias repair (63.0%).

CONCLUSIONS

Degloving alone is effective for correcting VC less than 30°. The majority of patients in our centre underwent UPT, and DP after UPT yielded better results compared with DP after degloving alone. Distal hypospadias repair commonly used TIP, while TPIFU was favoured for proximal hypospadias repair.

TRIAL REGISTRATION NUMBER

ChiCTR1900023055.

A novel triple dartous fixation in hypospadias repair

OBJECTIVE

This study investigates the impact of the use of dartos covering to augment the neourethra on functional and cosmetic results. To evaluate a novel technique demonstrating how to fix dartos flap to cover the neourethra as a barrier in hypospadias repair.

PATIENTS AND METHODS

This study comprised 204 male patients with different degree of hypospadias (DPH = 132, coronal hypospadias = 46, MPH = 26). Their ages ranged from 1 to 23 ys (mean age = 2 ys). Penile chordee was in (DPH = 45, coronal hypospadias = 33, MPH = 26). All patients had abnormal downward directed urinary stream. Hypospadias repair was performed by the classic TIP technique in addition to our novel modification of dartos covering. Patients were submitted to 5 years of follow-up including clinical examination of the functional and cosmetic parameters.

RESULTS

Success rates were reported in 200 patients, 3 patients had complications with subcoronal urethrocutaneous fistula and one patient with complete repair disruption.

CONCLUSION

Triple dartos fixation is a simple technique for all hypospadiologists to minimize urethrocutaneous fistula as common complication of hypospadias repair with good functional and cosmetic results.

A simple technique to repair distal and mid-shaft hypospadias using a de-epithelialized Byars' flap

OBJECTIVE

To describe standard and modified de-epithelialized Byars' flap techniques in tubularized incised plate urethroplasty and evaluate postoperative outcomes.

METHODS

We retrospectively evaluated data for 404 primary hypospadias repair patients who underwent standard (Group A) or modified (Group B) urethroplasty between January 2016 and 2021. Group B's data were analyzed to evaluate whether our modified technique was effective for all hypospadias types.

RESULTS

There was no difference in the ratio of different hypospadias types between Groups A (n = 145) and B (n = 259). Median follow-up duration was 35 months. Fistula occurred in 19 patients in Group A and 12 in Group B (statistically significant difference). The total complication rate was statistically significantly different between the groups. In Group B, 3/142 patients with distal hypospadias developed urethrocutaneous fistula vs 4/95 with mid-shaft hypospadias and 5/22 with proximal hypospadias. No difference was noted between the distal and mid-shaft groups. Significant differences were observed when comparing distal and mid-shaft groups with the proximal group; total complication rates were similar. Glans dehiscence and meatal stenosis rates were similar between Groups A and B, and among the hypospadias phenotypes.

CONCLUSION

Our modified procedure is simple to perform and yields excellent results in distal and mid-shaft hypospadias repair.

Tubularized incised plate repair in 473 primary distal hypospadias cases: An evaluation of outcomes according to coverages and stent types

AIM

We have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair.

MATERIALS AND METHODS

Only distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent).

RESULTS

A total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference.

CONCLUSIONS

Spongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training.

Modified snodgrass hypospadias repair using the lembert suturing technique

Background:

Surgical repair of hypospadias deformity is a challenging and complex issue. However, the technique of Snodgrass and its modifications attend promising functional and cosmetic results.

Purpose:

To assess the Lembert suturing technique effectiveness as a modification of the Snodgrass technique in lowering an urethrocutanous fistula rate.

Patients and Methods:

Fifty boys with mid-shaft and distal hypospadias were repaired using the modified Snodgrass technique utilizing the interrupted Lembert suturing technique in neourethroplasty. Patients with previous failed operations or severe chordee were excluded from the study.

Results:

None of the patients develops UCF apart from one who developed complete wound dehiscence following severe wound infection. Mild meatal stenosis is seen in two patients, and one patient experienced a small area of superficial skin sloughing.

Complications Following Primary Repair of Non-proximal Hypospadias in Children: A Systematic Review and Meta-Analysis

Purpose: The aim of this study was to systematically review the literature on the complications and postoperative outcomes of children with non-proximal hypospadias. Methods: Electronic databases including PubMed, Embase, and Cochrane Library CENTRAL were searched systematically from January 1990 to June 2020 for the literature that reported the postoperative outcomes of patients with non-proximal hypospadias. Non-proximal hypospadias encompassed distal and mid-penile hypospadias. Results: We included 44 studies involving 10,666 subjects. Urethrocutaneous fistula (UCF) was the most common complication with an incidence of 4.0% (95% CI, 3.1-5.0%). Incidence of overall complications was 8.0% (95% CI, 6.3-9.8%). Meta-regression analysis revealed that length of urethral stent indwelling (coefficient 0.006; 95% CI, 0.000-0.011; p = 0.036) and penile dressing (coefficient 0.010; 95% CI, 0.000-0.021; p = 0.048) were two risk factors for UCF. Multivariate meta-regression analysis did not identify any independent risk factors for UCF. No differences were found between stent and stentless groups in non-proximal hypospadias regarding incidences of UCF (OR, 0.589; 95% CI, 0.267-1.297), meatal stenosis (OR, 0.880; 95% CI, 0.318-2.437), and overall complications (OR, 0.695; 95% CI, 0.403-1.199). No differences were found between foreskin preservation and circumcision in terms of complications either. Conclusions: UCF is the most common complication following hypospadias repair with an incidence of 4.0%. Independent risk factors for UCF were not identified in the current research. Distal hypospadias repair without stent indwelling is not likely to compromise the postoperative outcome. Further studies should be designed to explore the differences between different surgical approaches and the potential risk factors for complications following hypospadias repair.

Buck's fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome

BACKGROUND

Hypospadias is a common problem encountered in surgical practice and its repair is challenging because of various complications. Urethro-cutaneous fistula is the most common postoperative complication (incidence of 0-33%). Different types of intermediate protective layers have been used in attempts to decrease UCF formation; however, no single surgical technique is ideal.

OBJECTIVE

The aim of this study was to compare use of dartos fascia and Buck's fascia as intermediate layers in prevention of the formation of UCF.

STUDY DESIGN

This was a prospective, comparative study conducted over a period of 2 years from January 2014 to December 2015. Patients with primary hypospadias without or with mild ventral penile curvature were included in the study. Patients were categorised into two groups, A and B, with alternate patients assigned to each group. Patients in group A underwent Snodgrass repair with urethroplasty by two-layer subepithelial closure and dartos tissue as an intermediate layer. Patients in group B underwent a urethral repair followed by Buck's fascia repair as intermediate layer and glanuloplasty after excision of a triangular skin strip on either side of the urethral plate. Patients were followed at regular intervals for a minimum of 6 months and complications were noted.

RESULTS

Over a period of 2 years, 160 patients were included in the study: 80 patients in group A and 80 patients in group B. The age of patients ranged from 1 year to 4.6 years, with a mean age of 1.8 years. Postoperative complications are listed in the summary table.

DISCUSSION

A protective intermediate layer between the neourethra and the skin can be used to reduce fistula formation. We describe a technique of urethroplasty using Buck's fascia as intermediate layer and glanuloplasty, with excellent results. Buck's fascia over the corpora spongiosum which is deficient ventrally in hypospadias is not completely absent, and can be easily used to cover the neourethra, needs minimal dissection and hence vascularity of tissues is preserved (summary Fig.). We used this Buck's fascia as a second protective layer over the neourethra in an attempt to decrease UCF formation, and compared it with use of dartos fascia. In our study, UCF occurred in 2.5% of patients in the Buck's fascia group and 12.5% of patients in the dartos group, a statistically significant difference. We believe that the native Buck's fascia lateral to spongiosum is a more appropriate, natural, and strong layer to cover the neourethra.

CONCLUSION

Use of Buck's fascia as an intermediate layer along with glanuloplasty is simple and very effective in preventing UCF formation and glanular dehiscence. We recommend the use of Buck's fascia as an intermediate layer to cover the neourethra to reduce incidence of postoperative complications and improve results.

Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias

PURPOSE

To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique.

METHODS

We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra.

RESULTS

There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture.

CONCLUSIONS

Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.

Meta-analysis of complication rates of the tubularized incised plate (TIP) repair

OBJECTIVE

To determine overall complication rates of the tubularized incised plate (TIP) repair and assess the effects of technical modifications, length of follow-up and geographical location of reported results.

MATERIALS AND METHODS

A systematic literature search was undertaken, using Medline and Pubmed, in order to identify relevant articles. Random effects models were used to estimate pooled complication rates. Meta-regression was performed for each outcome by using mixed effects models with type of hypospadias (primary distal, primary proximal and secondary) as predictors.

RESULTS

Of the 189 articles that were identified, 49 studies (4675 patients) were included in the analysis. Fistula and re-operation rates were significantly higher in secondary repairs (15.5% and 23.3%) compared to primary proximal (10.3% and 12.2%) and primary distal (5.7% and 4.5%) (P = 0.045 and P < 0.001, respectively). Technical modifications reduced fistula rates from 10.3% to 3.3% (P = 0.003) and re-operation rates from 13.6% to 2.8% (P = 0.001). The rate of meatal stenosis was highest in the secondary repairs, with follow-up >1 year (12.7%). Comparison of geographical location showed that complication rates for all but one variable were significantly lower in North America when compared to Europe and the rest of the world. Mean meatal stenosis rates were 1.8% in North America, 3.4% in Europe and 8.2% in the rest of the world (P = 0.002). This remained significant in a multivariable model incorporating repair technique and length of follow-up (P = 0.046). Mean rates of urethral stricture, fistula and re-operation followed a similar pattern (P = 0.045, P = 0.009 and P < 0.001, respectively). Mean follow-up was shortest in the North American group, at 11.9 months, compared to Europe, at 17.8 months, and the rest of the world, at 18.9 months.

DISCUSSION

The present meta-analysis has shown that the lowest complication rates for the TIP repair are when it is applied to primary distal hypospadias. Complication rates are higher for all variables when the TIP repair is used for primary proximal hypospadias. Lower complication rates than those reported in this TIP review have been documented in some studies using a staged repair for correction of primary proximal or secondary hypospadias [11,12,68], implying that a staged approach may be superior to the TIP repair in these settings. Documentation of follow-up duration was limited, making assessment of the impact of length of follow-up difficult. Geographical location had a noticeable effect on outcome, with all but one complication being lower in the North American than the other groups. Mean follow-up was shortest in North America and it is suggested that the short follow-up in the North American studies may have led to under-reporting of late complications.

CONCLUSION

The TIP repair has evolved to incorporate modifications that have significantly lowered complications. Higher complication rates are seen with secondary and proximal repairs; however, limited, published long-term data impair a true assessment of outcome.

Distal hypospadias repair in infants without a postoperative stent

PURPOSE

To review our experience with infants undergoing distal hypospadias repair without a postoperative stent to determine if an unacceptable complication rate might justify its use.

METHODS

Children <1 year of age who underwent distal hypospadias repair by a single surgeon were identified through a prospectively maintained database. The use of a postoperative urethral stent was recorded for each case. Demographics, meatus position, operative technique and complications were also recorded. Patients older than 1 year or with hypospadias proximal to a subcoronal position were excluded.

RESULTS

Eighty-nine patients without a stent were identified in addition to 21 patients who had a stent for a minimum of 3 days. At 3 months follow-up, 4/89 (4.49 %) patients in the stentless group required circumcision revision. 1 patient experienced urinary retention. 1/21 (4.76 %) patients with a postoperative stent required reoperation for meatal stenosis.

CONCLUSIONS

The complication rate for infants undergoing distal hypospadias repair is low, does not appear to be significantly increased by forgoing a postoperative urethral stent. Avoiding a stent likely reduces a variety of associated adverse events and needs for short-term follow-up.

Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: A prospective study

INTRODUCTION

Additional cover after neourethra formation to decrease the fistula rate, has been described using the dartos, tunica, denuded skin and corpus spongiosum. The use of corpus spongiosum alone to cover the neourethra is infrequent. The objective of this study was to evaluate the efficacy of spongioplasty alone as an intervening layer in the prevention of urethral fistula following tubularized incised plate urethroplasty (TIPU).

MATERIALS AND METHODS

A prospective study was performed including 113 primary hypospadias cases undergoing TIPU with spongioplasty from June 2010 to March 2012. Correction of chordee was carried out by penile degloving alone in 5, mobilization of urethral plate with spongiosum in 22 and combination of both in 45 cases. Intra-operatively, spongiosum was taken to be poorly developed if it was thin and fibrous, moderate if good spongiosal tissue with good vascularization and well-developed if healthy robust spongiosum, which became bulkier than native spongiosum after tubularisation. Spongioplasty was done in a single layer after mobilization of spongiosum, starting just proximal to the native meatus and into the glans distally.

RESULTS

The mean age of the patients was 11.53 years. The type of hypospadias was distal, mid and proximal in 81, 12 and 20 cases respectively. Spongiosum was poorly developed in 13, moderate in 53 and well-developed in 47 cases. The mean hospital stay was 8-10 days and follow-up ranged from 6 months to 2 years. Urethral fistula was seen in six patients (11.3%) with moderate spongiosum (distal 1, mid 1 and proximal 4), and three (23.03%) with poorly developed spongiosum (one each in distal, mid and proximal) with an overall 7.96% fistula rate. None of the patients with well-developed spongiosum developed a fistula. Poorer spongiosum correlated with a greater number of complications (P = 0.011). Five out of thirteen cases with poor spongiosum (38.46%) had proximal hypospadias, i.e. more proximal was the hypospadias, poorer was the development of the spongiosum (P = 0.05). Meatal stenosis was seen in two patients (1.76%) with proximal hypospadias, one with moderate and the other with poorly developed spongiosum. More proximal was the hypospadias, greater were the number of complications (P = 0.0019).

CONCLUSION

TIPU with spongioplasty reconstructs a near normal urethra with low complications. Better developed and thicker spongiosum results in lower incidence of fistula and meatal stenosis. More proximal hypospadias is associated with poorer spongiosum. We recommend spongioplasty to be incorporated as an essential step in all patients undergoing tubularized incised-plate repair for hypospadias.

Use of BioGlue Surgical Adhesive in Hypospadias Repair

PURPOSE

To prospectively evaluate the efficacy of albumin glutaraldehyde tissue adhesive (BioGlue) in the surgical treatment of patients with hypospadias.

MATERIALS AND METHODS

Two groups of 20 patients each who underwent hypospadias repair were included in the study. In the first group we utilized BioGlue as an additional protective layer to the suture line of the neo-urethra, while patients in the second group were operated on utilizing a routine surgical technique.

RESULTS

There were no statistical differences between patients from the 2 groups in terms of surgical complications. Urethrocutaneous fistula was revealed in 4 (20%) patients after repair with BioGlue and in 3 (15%) patients from the control group (p = 0.686), suture line breakdown in 4 (20%) and in 1 (5%) patients (p = 0.478), meatal stenosis in 1 (5%) and in 1 (5%) patient (p = 1). Furthermore more patients in the BioGlue group (n = 12, 60%) demonstrated poor cosmetic results compared to the control group where most patients - 19 (95%) had acceptable cosmetic outcomes (p = 0.007).

CONCLUSIONS

Our data showed no benefits of BioGlue use in hypospadias repair.

Hypospadias surgery past, present and future

PURPOSE OF REVIEW

Hypospadias surgery has been in continuous evolution for many years with steadily improving reported results. Despite this many unanswered questions on its cause, management and outcomes remain. Recent research has done little to clarify most matters.

RECENT FINDINGS

There is increasing evidence of a balance of genetic and developmental factors in the development of hypospadias, but there is doubt whether the incidence of hypospadias is increasing or not. Many technical aspects of hypospadias repair and variations of perioperative management seem to have little effect on outcome, whereas the age at which surgery is performed may. Although efforts are being made to relate anatomical findings to outcome, a lack of objective assessment and standardization is a handicap. Severe hypospadias, particularly that associated with significant chordee, remains challenging although strategies for management are being developed. The future may lie in development of autologous tissue culture for these severe cases.

SUMMARY

Further development of hypospadias surgery would benefit from objective, standardized methods of describing anatomy and outcome measures to facilitate effective comparison of techniques and procedures.

Overnight urethral stenting after tubularized incised plate urethroplasty for distal hypospadias

OBJECTIVES

The duration of urethral stenting after tubularized incised plate (TIP) urethroplasty for hypospadias varies among surgeons. Typically the catheter is left for up to 7 days with the goal of minimizing post-operative complications. We describe our experience with overnight stenting for distal TIP hypospadias repair.

MATERIALS AND METHODS

A retrospective chart review was performed on patients who underwent TIP hypospadias repair from 2003 to 2008. Patients who had their urethral catheter overnight were included in this analysis. Outcomes analyzed were the rates of: urethrocutaneous fistula, meatal stenosis, urethral stricture and urinary tract infections.

RESULTS

A total of 64 patients underwent outpatient TIP hypospadias repair. Forty-nine patients had overnight urethral stenting with at least 12 months follow-up and were included in the analysis. Five of the 49 patients (10.2%) developed urethrocutaneous fistula. Of these five patients, two had undergone re-do hypospadias repair. The fistula rate in primary repairs was 3/45 (6.7%). There were no incidences of meatal stenosis, urinary tract infections or urethral strictures.

CONCLUSION

In our experience, overnight urethral stenting for TIP hypospadias repair does not significantly affect the rates of urethrocutaneous fistula, meatal stenosis and urinary tract infections. Patients who have had a primary TIP hypospadias repair may have their urethral catheter removed safely on post-operative day one.