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Hammouda HM, Shahat AA, Safwat AS, Taha TM. The long-term consequences of the hypospadias salvage repair issue. BMC Pediatr 2024; 24:58. [PMID: 38243172 PMCID: PMC10797878 DOI: 10.1186/s12887-024-04534-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024] Open
Abstract
PURPOSE To present the long-term results of redo-hypospadias at our tertiary referral center following a failed prior repair. METHODS One hundred sixty-four individuals with a history of unsuccessful repairs qualified for our retrospective cohort study. Our inclusion criteria were as follows: pre-operative data that was accessible, redo-hypospadias that was successfully repaired, and at least three years of follow-up at the last hospital visit. RESULTS The mean patient age was 91.3 ± 21.1 months. The mean follow-up after successful repair was 41.3 ± 3.1 months. Ninety-two (group A) had one prior repair, and 72 (group B) had 2 or 3 repairs. Group A underwent six primary techniques: 32 underwent Onlay Island Flap (OIF), 10 underwent Mathieu, 12 underwent Tubularized Incised Plate Urethroplasty (TIPU), 8 underwent Urethral Mobilization (UM), and 34 underwent Buccal Mucosal Graft (BMG) { dorsal inlay Graft Urethroplasty (DIGU) in 4 and staged BMG in 30 patients}. In group B, four procedures were used: TIPU in 4, UM in 6, and BMG in 62 (staged BMG in 50 cases and DIGU in 12). CONCLUSIONS The selected type of repair will depend on many factors, like residual healthy local skin and expertise. Safe techniques for repair of redo hypospadias after its 1st failure include TIPU, Mathieu, UM, OIF, and DIGU for distal varieties. After 2nd or 3rd repair DIGU, UM, and TIPU can be performed in distal types, while staged BMG can be applied for proximal ones.
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Affiliation(s)
- Hisham M Hammouda
- Pediatric Urology Division, Urology Department, Assiut University, Assiut, Egypt.
| | - Ahmed A Shahat
- Pediatric Urology Division, Urology Department, Assiut University, Assiut, Egypt
| | - Ahmed S Safwat
- Pediatric Urology Division, Urology Department, Assiut University, Assiut, Egypt
| | - Taha M Taha
- Pediatric Urology Division, Urology Department, Assiut University, Assiut, Egypt
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Noureldin YA, Gharib TM, El Attar KA, El Karamany TM, Al Adl AM. Extended TIP vs. Standard TIP for primary distal hypospadias repair: randomized study for comparing functional and cosmetic outcomes. Scand J Urol 2021; 55:466-473. [PMID: 34494931 DOI: 10.1080/21681805.2021.1973091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of this study was to critically evaluate distal extension of the midline urethral plate incision, extended tubularized incised plate (e-TIP) technique, with the standard TIP and investigating predictors of functional and cosmetic success. METHODS In a prospective study, consecutive patients with primary distal hypospadias presented for repair were randomized to undergo either extended TIP (e-TIP) or standard TIP (s-TIP) technique. Cosmetic outcome was evaluated postoperatively using Hypospadias-Objective-Penile-Evaluation (HOPE) score and measurement of ventral-glans-closure-length (VGCL) and meatal length (ML). Functional outcome was evaluated by maximal flow rate (Qmax), average flow rate (Qave), and postvoid residual urine (PVR). The effect of preoperative parameters on the outcome was assessed with regression analysis. RESULTS In all 94 cases, out of 110 randomized, were available for analysis. Forty-six in e-TIP group and 48 cases in s-TIP group with comparable preoperative demographics. Median (inter-quartile range) of postoperative total HOPE-score was 57(45-60) vs. 55(44-60) for e-TIP and s-TIP (p < 0.001), respectively. The mean (SD) ratio of VGCL/ML was 87% (26) versus 46% (12) for e-TIP vs. s-TIP, respectively (p < 0.001). Both complications and functional outcomes were comparable. Urethral plate (UP) width and the use of e-TIP technique were significant predictors of successful cosmetic outcome in regression analysis (p = 0.019 and p = 0.001), respectively. CONCLUSION Extension of midline urethral plate can potentially create a vertical slit-like meatus located at the glans tip without compromising the functional outcome, thus providing better cosmetic outcome compared with the standard technique. The UP width was a significant predictor of superior cosmetic outcome.
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Affiliation(s)
- Yasser A Noureldin
- Urology Department, Faculty of Medicine, Benha University, Benha, Egypt.,Division of Urology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Winberg H, Anderberg M, Arnbjörnsson E, Stenström P. Urinary flow measurement in hypospadias correlated to surgical procedure and risk of development of urethra-cutaneous fistula. J Pediatr Urol 2020; 16:306.e1-306.e8. [PMID: 32295743 DOI: 10.1016/j.jpurol.2020.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/07/2020] [Indexed: 10/24/2022]
Abstract
AIM To explore the correlation between fistula development and urinary flow measurements after hypospadias repair with emphasis on patients with urethrocutaneous fistula complications and to identify risk factors for fistula development. METHODS Urinary flow was examined in boys operated on for hypospadias. Outcome of maximum urinary flow (ml/s) (Qmax), voided volume for age (ml) (Volume), and pathological flow pattern (n) (Curve) was compared between the Byars, Mathieu, and Tubularized Incised Plate (TIP) surgical repair methods and between the groups of those who had and had not developed a fistula. Logistic regression analysis was performed for age at operation, genetics, comorbidity, or urinary flow measurements regarding the development of urethrocutaneous fistula. RESULTS Seventy-three boys underwent hypospadias repair. Overall, the urinary flow measurements differed significantly between the three reconstructive methods, being favorable for the Mathieu procedure regarding Qmax (p < 0.01), volume (p = 0.04), and frequency of pathological voiding curve (p < 0.01; Table). The frequency of urethrocutaneous fistula was 18% (13/73) and did not differ significantly between the three different reconstructive surgery methods (Byar 33%, Mathieu 32%, and TIP 12%; p = 0.22). Urinary flow measurements did not differ between patients with and without fistula complications regarding Qmax 10 ml/s (4-16) vs. 8 ml/s (2-18), voided volume 74 ml (35-171) vs. 71 ml (9-270), or abnormal urinary flow pattern (23% vs. 30%). On logistic regression analysis, age at operation, genetics, comorbidity, and urinary flow measurement parameters did not turn out to be independent risk factors for development of urethrocutaneous fistula after hypospadias repair. DISCUSSIONS The study demonstrated significant differences between the urinary flow measurement results between the three different repair methods, favoring the Mathieu procedure. A low Qmax was a common postoperative finding. Urinary flow measurements did not differ between boys developing fistula and those who did not. No risk factors for fistula development were identified. The study did not support that it would be possible, at an early postoperative stage, to identify those with an upcoming postoperative fistula neither with urinary flow measurements nor through risk factors. No similar reports have studied the possibility of using postoperative urinary flow measurements to determine patients at risk of fistula development after hypospadias repair. CONCLUSIONS Urinary flow measurements were favorable after hypospadias reconstruction with Mathieu compared with Byars and TIP. Furthermore, urinary flow measurements did not differ between reconstructed with and without a fistula complication. No risk factor for fistula development was identified.
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Affiliation(s)
- Hans Winberg
- Department of Pediatric Surgery, Skåne University Hospital, 221 85, Lund, Sweden; Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden.
| | - Magnus Anderberg
- Department of Pediatric Surgery, Skåne University Hospital, 221 85, Lund, Sweden; Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden.
| | - Einar Arnbjörnsson
- Department of Pediatric Surgery, Skåne University Hospital, 221 85, Lund, Sweden; Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden.
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skåne University Hospital, 221 85, Lund, Sweden; Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden.
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Abbas TO, Charles A, Ali M, Pippi Salle JL. Long-term fate of the incised urethral plate in Snodgrass procedure; A real concern does exist. Urol Case Rep 2020; 32:101216. [PMID: 32435593 PMCID: PMC7232082 DOI: 10.1016/j.eucr.2020.101216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/20/2020] [Indexed: 01/10/2023] Open
Abstract
We present here a case of a patient post tabularized incised plate urethroplasty for distal hypospadias without chordee who developed urethral stenosis and acquired curvature along the territory of the incised plate necessitating a redo surgery. The histological analysis of the incised urethral plate revealed absence of smooth muscles, vessels and elastin fibers within the area of the incised plate which could explain the poor compliance of this segment and the development of the curvature. To our knowledge, this case is the first in humans displaying the long-term histological findings of healing post tabularized incised plate urethroplasty.
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Affiliation(s)
- Tariq O Abbas
- Division of Pediatric Urology, Departement of Surgery, Sidra Medicine, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar.,Weill Cornel Medical College-Qatar, Doha, Qatar.,Regenerative Medicine Research Group, Dapartment of Health Science and Technology, Aalborg Univerisity, Aalborg, Denmark
| | - Adrian Charles
- Weill Cornel Medical College-Qatar, Doha, Qatar.,Pathology Department, Sidra Medicine, Doha, Qatar
| | - Mansour Ali
- Weill Cornel Medical College-Qatar, Doha, Qatar.,Department of Surgery, Sidra Medicine, Doha, Qatar
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Pan P. Can Grafted Tubularized Incised Plate Urethroplasty be Used to Repair Narrow Urethral Plate Hypospadias? Its Functional Evaluation Using Uroflowmetry. J Indian Assoc Pediatr Surg 2019; 24:247-251. [PMID: 31571754 PMCID: PMC6752077 DOI: 10.4103/jiaps.jiaps_151_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Aim: Using uroflowmetry, the aim of this study is to determine the functional results of the grafted tubularized incised plate (GTIP) urethroplasty used to repair poor urethral plate hypospadias. Settings and Design: Seventy-one patients (mean age: 5.7 years, follow-up: 1–5.5 years) were selected from those who underwent surgery using the GTIP technique from 2013 to 2015 at our institution. Methods: Patients included were able to void voluntarily and had no fistula. The flow pattern, maximum urinary flow rate (Qmax), voided volume (vv), average flow rate, and voiding time were measured. The results were expressed as percentiles and interpreted according to Siroky nomogram. The Qmax was considered normal if >25th percentile, as equivocally obstructed when in the 5th–25th percentile, and obstructed if <5th percentile. Results: Hypospadias was distal in 45, mid penile in 17 and proximal penile in 9. The uroflow curve was bell-shaped in 24 (30%), interrupted in 9 (14%), slightly flattened in 31 (46%), and a plateau in 7 (10%). Flow rate nomograms revealed that 49 (68%) were above the 25th percentile, 9 (17%) were below the 5th percentile, and 13 (15%) were between these ranges. Eleven patients showed improvement in the flow curve and maximum urinary flow rate (Qmax) in follow-up uroflowmetry. Conclusion: GTIP repair provides satisfactory functional results. A long-term follow-up is needed to confirm these results.
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Affiliation(s)
- Pradyumna Pan
- Ashish Hospital and Research Centre, Pediatric Surgery Unit, Jabalpur, Madhya Pradesh, India
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Abbas TO, Yalcin HC, Pennisi CP. From Acellular Matrices to Smart Polymers: Degradable Scaffolds that are Transforming the Shape of Urethral Tissue Engineering. Int J Mol Sci 2019; 20:E1763. [PMID: 30974769 PMCID: PMC6479944 DOI: 10.3390/ijms20071763] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 12/24/2022] Open
Abstract
Several congenital and acquired conditions may result in severe narrowing of the urethra in men, which represent an ongoing surgical challenge and a significant burden on both health and quality of life. In the field of urethral reconstruction, tissue engineering has emerged as a promising alternative to overcome some of the limitations associated with autologous tissue grafts. In this direction, preclinical as well as clinical studies, have shown that degradable scaffolds are able to restore the normal urethral architecture, supporting neo-vascularization and stratification of the tissue. While a wide variety of degradable biomaterials are under scrutiny, such as decellularized matrices, natural, and synthetic polymers, the search for scaffold materials that could fulfill the clinical performance requirements continues. In this article, we discuss the design requirements of the scaffold that appear to be crucial to better resemble the structural, physical, and biological properties of the native urethra and are expected to support an adequate recovery of the urethral function. In this context, we review the biological performance of the degradable polymers currently applied for urethral reconstruction and outline the perspectives on novel functional polymers, which could find application in the design of customized urethral constructs.
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Affiliation(s)
- Tariq O Abbas
- Laboratory for Stem Cell Research, Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark.
- Pediatric Surgery Department, Hamad General Hospital, 3050 Doha, Qatar.
- College of Medicine, Qatar University, 2713 Doha, Qatar.
- Surgery Department, Weill Cornell Medicine⁻Qatar, 24144 Doha, Qatar.
| | | | - Cristian P Pennisi
- Laboratory for Stem Cell Research, Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark.
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Drlík M, Kočvara R, Sedláček J, Dítě Z, Vítková I, Komarc M. Distal urethral plate adhesions: New anatomical perspective in hypospadias. J Pediatr Urol 2018; 14:164.e1-164.e5. [PMID: 29183664 DOI: 10.1016/j.jpurol.2017.10.011] [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: 07/07/2017] [Accepted: 10/09/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We found midline epithelial adhesions in the glandar urethral plate in patients with hypospadias. After dissolution, a blind epithelized channel becomes visualized inside of the plate pointing to immature embryonic luminization. In addition it reveals that the epithelized surface of the distal urethral plate is larger than previously considered. OBJECTIVE To determine the incidence and extent of these new anatomical details of urethral plate in hypospadias patients. METHODS We prospectively assessed the detailed anatomy of the urethral plate in 72 consecutive patients with hypospadias. We recorded the presence of adhesions in the middle of the glandar urethral groove that can be easily dissoluted (dissolution line - D-line). We recorded the plate width before and after D-line dissolution, the presence of the hidden blind channel at continuation of D-line (channel type-A) and of the visible blind channel between D-line and urethral hypospadiac meatus (type-B) (Figure). In 62 patients, where the urethral plate tubularization was considered (Duplay, TIP), septs between channels were opened in the midline and a final width of the plate was measured by rolling the plate around a tube. RESULTS Midline adhesions (D-line) were found in all 72 patients. Mean length of D-line was 5.13 ± O.17 mm. Mean plate width before dissolution was 5.9 ± 0.15 mm, and after dissolution 7.8 ± 0.16 mm. A blind channel of type A was detected in 22 patients (31%), type B in 24 (33%), type A and B in 16 (22%), and none in 10 patients (14%). Mean final plate width after D-line dissolution and opening of septs between channels in 62 patients with urethral plate tubularization was 8.7 ± 0.15 mm. DISCUSSION The main contribution of our study is a new perspective of distal urethral plate anatomy that enables enlargement of the epithelized surface of the distal urethral plate by dissolution of the preexisting epithelized groove and opening of epithelized channels within the plate. To the best of our knowledge, this anatomical anomaly has not been described previously. CONCLUSIONS The distal urethral plate of all hypospadias patients is partially "folded" in the midline by epithelial adhesions of different depth and extent that may be easily dissoluted. In half of the patients (53%) the "folded" part of the plate continues proximally as a blind channel inside the urethral plate (type A channel). Opening of these structures together with the well-known urethral plate pits (type B channel) helps augment the width and the overall epithelized surface of the distal urethral plate.
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Affiliation(s)
- Marcel Drlík
- Division of Paediatric Urology, Department of Urology, General Teaching Hospital, Charles University First Faculty of Medicine, Prague, Czech Republic.
| | - Radim Kočvara
- Division of Paediatric Urology, Department of Urology, General Teaching Hospital, Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Josef Sedláček
- Division of Paediatric Urology, Department of Urology, General Teaching Hospital, Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Zdeněk Dítě
- Division of Paediatric Urology, Department of Urology, General Teaching Hospital, Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Ivana Vítková
- Department of Pathology, General Teaching Hospital, Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Martin Komarc
- Department of Methodology, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
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Comparision of uroflow parameters before and after hypospadias surgery. ANNALS OF PEDIATRIC SURGERY 2018. [DOI: 10.1097/01.xps.0000516077.70198.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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A Critical Analysis of Stented and Unstented Tubularized Incised Plate Urethroplasty Through a Prospective Randomized Study and Assessment of Factors Influencing the Functional and Cosmetic Outcomes. Urology 2017. [DOI: 10.1016/j.urology.2017.04.056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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10
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El Darawany HM, Al Damhogy ME. Urethral Mobilization as an Alternative Procedure for Distal Hypospadias Repair. Urology 2017; 104:183-186. [DOI: 10.1016/j.urology.2017.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 11/16/2022]
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Two-stage graft urethroplasty for proximal and complicated hypospadias in children: A retrospective study. J Pediatr Urol 2016; 12:286.e1-286.e7. [PMID: 27020542 DOI: 10.1016/j.jpurol.2016.02.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/18/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Although two-stage graft urethroplasty is widely used, the literature regarding the complication rates and functional characteristics of reconstructed neourethra is relatively modest. OBJECTIVES The aim was to analyze the complication rates and uroflow data of boys who have previously undergone a two-stage graft urethroplasty procedure for proximal and complicated hypospadias. PATIENTS AND METHODS We retrospectively reviewed the clinical outcomes of 52 boys with proximal (n = 44) and complicated (n = 8) hypospadias who underwent two-stage graft urethroplasty repair (median age of 15 months and 3 years respectively) between 2004 and 2015. Fifteen toilet-trained boys without fistulas underwent uroflowmetry. The uroflow data were plotted on age-volume-dependent normograms with normal controls. The median follow-up was 34 months (8 months-8 years). RESULTS AND COMPLICATIONS Complications were identified in three patients (6%) after the first stage (i.e. contracture of the graft) and in 20 patients (38.4%) after the second stage, including meatal stenosis (n = 8, 15.3%), urethral stricture (n = 4, 7.6%), urethrocutaneous fistula (n = 8, 15.3%), glandular dehiscence (n = 1, 1.9%), and diverticulum (n = 1, 1.9%). The patients with failed hypospadias experienced fewer complications than those who underwent the two-stage procedure for primary repair (25% and 45%, respectively). The reoperation rate was 36.8%. Eleven of the 15 toilet-trained boys were asymptomatic but exhibited flow rates below the normal range (median Qmax = 7 mL/s, range 3.5-16.7). Only one of the boys with a low flow rate was confirmed to have urethral stenosis under general anesthesia. DISCUSSION In our study, primary hypospadias repair requiring urethral plate transection elicited worse outcomes than those observed in the prior failed hypospadias cases. However, because of our study's retrospective design, we were unable to accurately assess the initial position of the meatus in the redo hypospadias cases. Our data also demonstrated that the majority of cases without any voiding symptoms exhibited flow rates that were below the normal range despite no urethral stricture under general anesthesia. These findings indicate that urethras reconstructed via two-stage graft urethroplasty repair are not functionally equivalent to normal urethras, at least prior to puberty. CONCLUSION Two-stage graft urethroplasty repair was successful in 62% of cases after the second-stage procedure, but one-third of the boys required a reoperation after the two-stage planned repair. We demonstrated that although we used a urethral tissue substitute, the urine flow patterns of the patients without strictures were abnormal.
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Liu MMY, Holland AJA, Cass DT. Assessment of postoperative outcomes of hypospadias repair with validated questionnaires. J Pediatr Surg 2015; 50:2071-4. [PMID: 26455467 DOI: 10.1016/j.jpedsurg.2015.08.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE A standardized assessment for the optimal repair of hypospadias remains elusive. This study utilized validated questionnaires to assess the postoperative functional, cosmetic, and psychosocial outcomes of hypospadias repair. MATERIALS AND METHODS 172 patients who underwent hypospadias repair under the care of a single surgeon were identified. 25 agreed for follow-up using the validated questionnaires of Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Scale (PPPS), and Pediatric Quality of Life Inventory (PedsQL™4.0). RESULTS Mean follow-up was 59months postoperatively (range 7-113months). Techniques used included tubularized incised plate urethroplasty, meatal advancement and glanuloplasty, and a 2-stage repair. 23 of 25 patients achieved a HOSE score of 14 or more (maximum of 16). The PPPS scores correlated with severity of the hypospadias. Those with glanular hypospadias (mean score=10) scored higher than those with coronal (mean score=9) and penile/penoscrotal hypospadias (mean score=7). There was no correlation between PedsQL™4.0 scores and the severity of hypospadias or procedure used. CONCLUSION Validated questionnaires revealed generally good functional, cosmetic, and early psychosocial outcomes after hypospadias repair. The use of validated questionnaires in routine follow-up sessions may facilitate objective assessment of both functional outcomes and patient satisfaction.
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Affiliation(s)
- Mona M Y Liu
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Westmead, Australia.
| | - Andrew J A Holland
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Westmead, Australia
| | - Danny T Cass
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Westmead, Australia
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Long-term functional outcomes of distal hypospadias repair: a single center retrospective comparative study of TIPs, Mathieu and MAGPI. J Pediatr Urol 2015; 11:68.e1-7. [PMID: 25824882 DOI: 10.1016/j.jpurol.2014.09.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 09/02/2014] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Tubularized Incised-Plate (TIP) urethroplasty is currently the preferred technique for distal hypospadias repair. Nevertheless, concerns have been raised on the long-term functionality of the reconstructed neourethra. OBJECTIVE The aim of this study is to evaluate long-term uroflowmetry parameters' evolution after TIP surgery over a long-term follow-up including the adolescent period. TIP patients were compared to normal children using established Miskolc nomograms, as well as to patients who underwent Mathieu and Meatal Advancement and Glanuloplasty (MAGPI) surgery repairs for distal hypospadias. STUDY DESIGN Files from patients who underwent primary distal hypospadias repair at our institution between January 1, 1997 and January 31, 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (TIP vs. Mathieu vs. MAGPI) was performed according to the following postoperative time interval endpoints: 0-6 months, 6-12 months, 12-24 months, 24-48 months, 4-6 years, 6-10 years and >10 years. Maximal urinary flow rate (Qmax) in relation to Voiding Volume (VV) adjusted for Age or Body Surface Area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques. RESULTS 153 patients met the inclusion criteria: 70 (43%) TIP, 24 (17%) Mathieu and 59 (35%) MAGPI. Overall, Qmax increases progressively according to time and age and in particular during the period covering adolescence with a similar trend regardless of the type of surgery. Uroflowmetry profiles in terms of Qmax, VV and PVR were equivalent between surgeries at each examined time point. At 10 years of follow-up postopertively, mean Qmax were 17.2 ml/s, 18.8 ml/s and 21.6 ml/s respectively with no significant difference detected between groups (p = 0.344). Compared to normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax< 5th percentile of nomograms was more prevalent in patients aged 2-7 years old at 60% but decreased to less than 10%in patients aged >13 years for all procedures combined (see abstract figure) but without detected differences between surgery types (p = 0.276). DISCUSSION After sub-optimal obstructive maximal urinary flows in the early postoperative period, hypospadias patients treated with TIP exhibit favourable long-term evolution with age and during adolescence in particular compared to normal children. In addition, a similar trend was found for patients treated with Mathieu and MAGPI with no significant differences detected between procedures. Nevertheless, because of the relatively small sample size we cannot exclude that a statistical difference between surgeries would have been detected if the study was adequately powered on every endpoint. Nevertheless and also as suggested by the values obtained, this potential difference may be quite small and not clinically relevant. CONCLUSION These results suggest that the obstructive urinary flow pattern observed in patients early on is possibly an intrinsic feature associated to the malformation itself and may be less of a consequence of the surgical technique.
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Al-Adl AM, El-Karamany TM, Bassiouny AS. Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes. Arab J Urol 2014; 12:116-26. [PMID: 26019935 PMCID: PMC4435762 DOI: 10.1016/j.aju.2014.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 02/01/2014] [Accepted: 02/05/2014] [Indexed: 11/25/2022] Open
Abstract
Objectives To objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score. Patients and methods In a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3 months after surgery, the flow pattern, maximum (Qmax), and mean urinary flow rate (Qave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system. Results The native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5–14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3–24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3–14) years showed an abnormal Qmax below the fifth percentile in four (15%), with the Qave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13–16). Two patients had a small, single subcoronal fistula. Conclusion Extending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.
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Safwat AS, Elderwy A, Hammouda HM. Which type of urethroplasty in failed hypospadias repair? An 8-year follow up. J Pediatr Urol 2013; 9:1150-4. [PMID: 23725854 DOI: 10.1016/j.jpurol.2013.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 04/15/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To report our 8-year follow up for redo hypospadias repair. METHODS A total of 56 patients with previous failed hypospadias repair were included in our study. Patients' data were analyzed regarding age, number of previous repairs, meatal location, procedure performed, operative time and complications. Patients were followed up for 3 to 102 (mean 52) months. RESULTS Patient age ranged from 15 to 204 (mean 90.7) months. Forty-two patients had a single previous hypospadias repair, eleven had two previous repairs and three had four previous repairs. Of the 56 patients, 16 underwent oral mucosal graft urethroplasty, 15 onlay island flap, 14 parameatal flap, 10 tubularized incised plate urethroplasty, and 1 tubularized preputial flap. Complications were encountered in 16 (28.5%) patients in the form of graft contracture in 3, meatal stenosis in 2, urethral stricture in 2 including the patient with tubularized flap, urethra-cutaneous fistula in 7, bleeding in 1 and skin disruption in 1. The final complication rate was 25%. CONCLUSIONS Decision making in redo hypospadias surgery depends mainly on local tissue availability and the degree of tissue scarring. The characteristics of oral mucosal graft make it suitable for urethroplasty in the absence of local donor tissues. A long-term follow up for redo hypospadias repair is required to assess the late neourethral stricture and residual penile curvature.
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Affiliation(s)
- Ahmed S Safwat
- Pediatric Urology Section, Urology Department, Assiut University, Egypt.
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Inclusion and Exclusion Criteria to Overcome Bias and Reach a Valid Conclusion for Interpositional Flap Coverage in Primary Hypospadias Repair With Tubularized Incised Plate Urethroplasty. Ann Plast Surg 2013; 71:581-5. [DOI: 10.1097/sap.0b013e31825516a0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ardelt PU, Cederquist M, Schoenthaler M, Miernik A, Frankenschmidt A. The glandular resection and central embedding modification (GRACE) in Duckett and Barcat hypospadias repair. Urol Int 2013; 90:358-64. [PMID: 23391997 DOI: 10.1159/000346109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 11/24/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We recently reported a novel modification of the Barcat technique termed glandular resection and central embedding (GRACE). Here, we report results from a large patient population and apply this modification also to Duckett hypospadias repair. PATIENTS AND METHODS We retrospectively evaluated 488 patients who had undergone primary or secondary hypospadias repair by Barcat or Duckett using the GRACE modification. RESULTS For all GRACE repairs, cosmetic appearance was favorable regarding meatal position, shape and overall appearance. Maximum and average flow were above the 5th percentile in at least 95%. In Barcat and Duckett repairs, urethrocutaneous fistulas occurred in 5 and 30.7%, urethral strictures in 3 and 20.8%, and meatal strictures in 5 and 25.3%, respectively. CONCLUSIONS The initially reported favorable cosmetic and functional results were confirmed both for Duckett and Barcat repair using the GRACE modification. Complication rates were favorably low for Barcat and higher, but consistent with published results, for Duckett repair.
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Affiliation(s)
- Peter U Ardelt
- Department of Urology, University of Freiburg Medical School, Freiburg, Germany.
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Robinson A, Harry L, Stevenson J. Assessment of long term function following hypospadias reconstruction: Do flow rates, flow quality and cosmesis improve with time? Results from the modified Bretteville technique. J Plast Reconstr Aesthet Surg 2013; 66:120-5. [DOI: 10.1016/j.bjps.2012.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 06/13/2012] [Accepted: 07/17/2012] [Indexed: 10/28/2022]
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Jesus LE, Schanaider A, Patterson G, Marchenko A, Aitken KJ, Leslie B, Bagli DJ, Pippi-Salle JL. Urethral compliance in hypospadias operated by tubularized incised urethral plate (TIP) with and without a dorsal inlay graft: an experimental controlled study. World J Urol 2012; 31:971-5. [DOI: 10.1007/s00345-012-1004-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 11/28/2012] [Indexed: 11/29/2022] Open
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Perera M, Jones B, O'Brien M, Hutson JM. Long-term urethral function measured by uroflowmetry after hypospadias surgery: comparison with an age matched control. J Urol 2012; 188:1457-62. [PMID: 22906660 DOI: 10.1016/j.juro.2012.04.105] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE Long-term outcomes of hypospadias surgery, particularly urinary function, have not been examined thoroughly. Uroflowmetry can be used to evaluate long-term functional outcomes by assessing flow shape and the rate of micturition. We assessed urethral function using uroflowmetry in adolescents after undergoing hypospadias repair in infancy and compared this with age matched controls. MATERIALS AND METHODS After human research ethics committee approval (HREC 28111A), 17 boys 13 to 15 years old with no history of urological or neurological disorders underwent uroflowmetry (65 separate voids) to determine standard values for boys of this age. Then 60 boys age 13 to 15 years who had undergone treatment for hypospadias in early infancy were seen for long-term followup and underwent uroflow assessment. RESULTS Standard urinary flow rates were established in the 13 to 15-year-old control group and represented on a nomogram. In the boys who underwent hypospadias surgery the urine flow rates were significantly lower compared to the control nomogram (p <0.0001), with half the patients having uroflow rates below 1 SD from the control mean but without symptoms. Boys with significant preoperative chordee were more likely to have poorer urinary flow (p <0.04). A poor urinary flow rate also was significantly associated with post-void residual bladder volume (p <0.03). There was no correlation with original meatal location, number of operations, presence of postoperative complications, current anatomy and lower urinary tract symptoms (eg post-void dribble, hesitancy, incontinence). CONCLUSIONS At long-term followup after hypospadias surgery urinary flow rates were significantly lower compared to age matched controls but still fell within the normal range. In the hypospadias cohort there was no significant association with lower urinary tract symptoms and poor urinary flow. Detection of poor urinary flow may indicate incomplete bladder emptying. The presence of severe chordee preoperatively is a significant risk factor for poor urinary flow rates on long-term followup.
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Affiliation(s)
- Marlon Perera
- Douglas Stephens Surgical Research Unit, Murdoch Childrens Research Institute, Melbourne, Australia
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Eassa W, He X, El-Sherbiny M. How much does the midline incision add to urethral diameter after tubularized incised plate urethroplasty? An experimental animal study. J Urol 2011; 186:1625-9. [PMID: 21862070 DOI: 10.1016/j.juro.2011.03.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Indexed: 10/17/2022]
Abstract
PURPOSE We objectively quantified the gain in urethral diameter and the effect of stenting after tubularized incised plate urethroplasty in a rabbit hypospadias model. MATERIALS AND METHODS We created a hypospadias model in 12 New Zealand white male rabbits by excising the ventral urethra. A 3 cm tattoo line was made longitudinally in the dorsal urethral plate midline. Two weeks later a 2 cm relaxing incision was made in the middle part of the tattooed line. The stretched incision width between the tattooed edges was measured, followed by urethral plate tubularization. Six rabbits were stented and 6 were nonstented. Two weeks later the animals were sacrificed and the distance separating the tattoo was measured at the midpoint of the tattooed line. Transverse sections at this point were examined histologically. RESULTS All animals survived the procedures. Stents were removed at 7 days in 4 rabbits and fell out in 2 at 4 and 2 days, respectively. The mean ± SD incision width of 5.5 ± 1.6 mm (range 3 to 8) at tubularization became 2 ± 0.5 mm (range 1 to 3) after healing (p <0.002). Mean width of the healed incision was 1.7 ± 0.4 (range 1 to 2) vs 2.3 ± 0.5 mm (range 1.5 to 3) in the nonstented and stented groups, respectively (p <0.06). Rabbits with a stenting duration of less than 7 days were excluded from the last analysis. Histologically all incisions healed completely with an intact epithelium. CONCLUSIONS The initial width of the midline relaxing incision significantly decreased after complete epithelialization. The average gain in urethral width was only 2 mm. Stenting appeared to increase the width of the healed incisions but not in a statistically significant manner.
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Affiliation(s)
- Waleed Eassa
- Division of Urology, Montreal Children's Hospital, McGill University Health Center and Montreal Children's Hospital Research Institute, Montreal, Quebec, Canada
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Leslie B, Jesus LE, El-Hout Y, Moore K, Farhat WA, Bägli DJ, Lorenzo AJ, Pippi Salle JL. Comparative Histological and Functional Controlled Analysis of Tubularized Incised Plate Urethroplasty With and Without Dorsal Inlay Graft: A Preliminary Experimental Study in Rabbits. J Urol 2011; 186:1631-7. [DOI: 10.1016/j.juro.2011.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Indexed: 11/27/2022]
Affiliation(s)
- Bruno Leslie
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Lisieux E. Jesus
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Yaser El-Hout
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Katherine Moore
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Walid A. Farhat
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Darius J. Bägli
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Armando J. Lorenzo
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - João L. Pippi Salle
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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González R, Ludwikowski BM. Importance of urinary flow studies after hypospadias repair: a systematic review. Int J Urol 2011; 18:757-61. [PMID: 21883491 DOI: 10.1111/j.1442-2042.2011.02839.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A systematic review was performed of publications relating to the results of urinary flow studies after hypospadias repair dating back to 1978, when what appears to be the first publication on this topic was found. The literature search was performed using the key words "hypospadias" combined with "urinary flow", "urine flow", "uroflow", "uroflowmetry", and "long-term". We also reviewed the abstracts and full-length articles cited in the reference list of selected articles. Criteria for inclusion in the present systematic review included descriptions of patient selection, surgical technique, the severity of disease (proximal vs distal), and the method used to determine uroflow, as well as a definition of urethral obstruction. In all, 339 article titles were found. Of these, 25 abstracts appeared relevant and the full text of these articles were reviewed, with 22 of the papers included in this review. Sixteen reports had appeared in the literature since 2001, compared with six between 1978 and 2000, suggesting an increasing interest in this topic. On the basis of the results of the present systematic review, we recommend that asymptomatic children operated on for hypospadias in infancy should have one flow study after toilet training, with that study repeated if the results are abnormal. It appears that early abnormal flows improve spontaneously, so that children operated on after toilet training who are asymptomatic should undergo their first uroflow measurement 1 year after surgery. Children with obstructed flow parameters or borderline flows should be followed until adulthood, until long-term follow up studies clarify the significance of abnormal flow parameters. Given the present findings, we anticipate that in the next two decades urologists will need to treat a number of men with strictures resulting from hypospadias repairs performed in childhood.
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Fasching G, Arneitz C, Gritsch-Olipp G. Foreskin reconstruction and preservation of a thin distal urethra: a challenge in tubularized incised plate urethroplasty. Pediatr Surg Int 2011; 27:755-60. [PMID: 21445547 DOI: 10.1007/s00383-011-2891-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this retrospective study was to evaluate the functional and cosmetic outcome of tubularized incised plate urethroplasty (TIPU) with preputial reconstruction and preservation of a thin distal urethra when applicable. METHODS The records of 64 boys with hypospadias, who underwent TIPU between 2000 and 2007 were analyzed. 33 (52%) underwent foreskin reconstruction and a thin distal urethra was preserved and incorporated in 19 (30%) patients. The Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), and uroflowmetry were evaluated in 55 boys (86%) after a mean of 4.8 years. RESULTS All patients had a vertically oriented meatus. The overall rate of fistula occurrence was 9% and of wound dehiscence, 5%. Among 33 preputial reconstructions, two (6%) patients had dehiscence and three (9%) had a fistula. No cases of stricture or stenosis occurred. There were significantly more complications with reconstruction of the foreskin (p = 0.012) and preservation of a thin distal urethra (p = 0.021). Uroflowmetry was normal in 76% of patients. PPPS and HOSE revealed excellent results. CONCLUSION TIPU produces excellent cosmetic and functional results with few complications; complications are more common after foreskin reconstruction and use of a thin distal urethra.
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Interposition of dartos flaps to prevent fistula after tubularized incised-plate repair of hypospadias. Arab J Urol 2011; 9:123-6. [PMID: 26579282 PMCID: PMC4150563 DOI: 10.1016/j.aju.2011.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/12/2011] [Accepted: 06/27/2011] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the effect of urethral coverage by a single- or double-layered dorsal dartos flap after tubularized incised-plate (TIP) repair of hypospadias on fistula formation. PATIENTS AND METHODS In this retrospective study we evaluated sequential patients with hypospadias who underwent TIP urethroplasty with a dorsal dartos interpositional flap between April 2008 and December 2009. We reviewed their medical records for the site of hypospadias, previous hypospadias repair, single- or double-layered dartos flap and postoperative complications. The patients were divided into two groups; in group A the urethra was covered by a single layer of dartos fascia, and in group B the urethra was covered by double layers of dartos flap. RESULTS Of 91 patients who opted for hypospadias repair during the time of the study, 62 had a TIP urethroplasty with a dorsal dartos flap; of these 62, three did not fulfil the requirement of the minimum follow-up, so 59 were eligible for the study (32 in group A and 27 in group B). Preoperative clinical data were comparable in both groups. At a mean of 12.2 months of follow-up, there was no reported fistula in group B, while two patients in group A developed a urethrocutaneous fistula (P = 0.19). Meatal stenosis occurred in two patients in group A and one in group B (P = 0.66). CONCLUSION There was no significant difference in subsequent urethrocutaneous fistula between a double-layered dorsal dartos flap and single layer for covering the urethra as a part of TIP urethroplasty for repairing hypospadias.
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Pandey A, Gangopadhyay AN, Kumar V, Sharma SP, Gupta DK, Gopal SC. Functional Evaluation of Mid and Distal Penile Hypospadias Surgery with Special Reference to Uroflowmetry. Curr Urol 2011. [DOI: 10.1159/000327473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Braga LH, Lorenzo AJ, Suoub M, Bägli DJ. Is Statistical Significance Sufficient? Importance of Interaction and Confounding in Hypospadias Analysis. J Urol 2010; 184:2510-5. [DOI: 10.1016/j.juro.2010.08.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Indexed: 10/18/2022]
Affiliation(s)
- Luis H. Braga
- Division of Urology, McMaster Children's Hospital and McMaster University, Hamilton (LHB) and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Armando J. Lorenzo
- Division of Urology, McMaster Children's Hospital and McMaster University, Hamilton (LHB) and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Suoub
- Division of Urology, McMaster Children's Hospital and McMaster University, Hamilton (LHB) and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Darius J. Bägli
- Division of Urology, McMaster Children's Hospital and McMaster University, Hamilton (LHB) and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Scarpa MG, Castagnetti M, Berrettini A, Rigamonti W, Musi L. Urinary function after Snodgrass repair of distal hypospadias: comparison with the Mathieu repair. Pediatr Surg Int 2010; 26:519-22. [PMID: 20169443 DOI: 10.1007/s00383-010-2569-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate urinary function in patients with distal hypospadias undergoing repair by the tubularized incised-plate urethroplasty (TIP or Snodgrass), compare the results with those in patients treated by the Mathieu technique, and show the potential issues inherent to the evaluation of such results. PATIENTS AND METHODS A cross-sectional assessment was performed of uncomplicated distal hypospadias operated on during a 3-year period, already toilet trained, and able to void volitionally. Evaluation included clinical assessment urinary symptoms and urinary stream, and uroflowmetry. RESULTS Out of 83 patients operated on during the study period, 10 (12%) developed complication and 32 were not toilet trained or refused to participate in the study. Median follow-up in the remaining 41 patients included in the study was 20 (3-36) months. None of these patients presented voiding symptoms or urinary stream abnormalities. Uroflowmetry was normal in 30 cases and obstructive in 11 (27%). An obstructive flow pattern was more common in patients undergoing TIP versus Mathieu repair, 8 of 19 (42%) versus 3 of 22 (14%), respectively (P = 0.07). Four TIP cases with an obstructive uroflow pattern were managed conservatively. CONCLUSIONS Although both the TIP and the Mathieu repair allow good results in terms of urinary function after distal hypospadias repairs, the TIP technique seems more likely to be associated with urine flow pattern abnormalities. The actual clinical relevance of this finding remains ill defined.
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Early Hypospadias Surgery May Lead to a Better Long-Term Psychosexual Outcome. J Urol 2009; 182:1744-9. [DOI: 10.1016/j.juro.2009.02.089] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Indexed: 11/22/2022]
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Kwon T, Song GH, Song K, Song C, Kim KS. Management of Urethral Fistulas and Strictures after Hypospadias Repair. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.1.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Taekmin Kwon
- Department of Urology, University of Ulsan College of Medicine, Seoul, Korea
| | - Gee Hyun Song
- Department of Urology, University of Ulsan College of Medicine, Seoul, Korea
| | - Kanghyon Song
- Department of Urology, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheryn Song
- Department of Urology, University of Ulsan College of Medicine, Seoul, Korea
| | - Kun Suk Kim
- Department of Urology, University of Ulsan College of Medicine, Seoul, Korea
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Hammouda HM, Hassan YS, Abdelateef AM, Elgammal MA. New concept in urethral advancement for anterior hypospadias. J Pediatr Urol 2008; 4:286-9. [PMID: 18644531 DOI: 10.1016/j.jpurol.2008.01.208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 01/09/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We report on our experience with urethral mobilization and advancement as a treatment for anterior hypospadias. PATIENTS AND METHODS From January 2004 to March 2007, 55 out of 160 children with anterior hypospadias were managed by urethral mobilization and advancement; 46 had a mean follow-up period of 25 months (range 6-38) and are the subjects of this report. Their ages ranged from 2.5 to 12 years with mean age 4.5 years. The dissection began proximally in the avascular plane above the tunica albuginea covering each corpus cavernosum medially until reaching beneath the corpus spongiosum up to the hypospadiac meatus. Tension-free urethral anastomosis was achieved. The ventral glans was incised deeply at the interballanitic groove. The two glans wings and ventral glanular mucosal flaps were mobilized laterally. Interrupted sutures were placed through the tunica albuginea of corpus spongiosum to the corpora cavernosa. The mobilized urethra was wrapped by dartos fascia. The urethral stent was removed 24h postoperatively. RESULTS Three-fold urethral mobilization was sufficient to achieve tension-free urethral anastomosis. A slit-like orthotopic meatus, with conically shaped glans and straight penis, was achieved in all but one subcoronal case with mid-glans meatal retraction during our early experience. Postoperative urethral fistula was not recorded in any patient. Satisfactory urinary stream for parents and child was reported in 42/46. Peak flow rate was within normal range (upper 50% percentile) in all. CONCLUSION Urethral mobilization should begin proximally. Three-fold penile urethral mobilization, deep interballanitic incision and wide dissection of the glans can provide a slit-like orthotopic meatus with conical glans and straight penis in cases of anterior hypospadias without hypoplastic distal urethra and persistent ventral curvature after penile skin degloving, regardless of the presence of unhealthy, narrow urethral plate, shallow glanular groove, and flat or small glans.
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Affiliation(s)
- H M Hammouda
- Pediatric Urology Unit, Urology Department, Assiut University Hospital, Assiut 71111, Egypt.
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Frimberger D, Campbell J, Kropp BP. Hypospadias outcome in the first 3 years after completing a pediatric urology fellowship. J Pediatr Urol 2008; 4:270-4. [PMID: 18644528 DOI: 10.1016/j.jpurol.2008.01.203] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Accepted: 01/04/2008] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The requirements of hypospadias surgery today not only include the creation of a straight phallus with optimal meatal placement but also call for excellent cosmetic outcomes with minimal complications. Specialty fellowship training as well as advanced surgical materials and techniques allow for consistent, successful results. We report the outcomes of hypospadias surgeries performed by two academic Pediatric Urologists in the first 3 years of practice after completing a 2-year fellowship. PATIENTS AND METHODS A retrospective chart review of all patients with hypospadias treated by two surgeons (DF and JC) between July 2004 and August 2007 was performed. The two surgeons had completed a 2-year Pediatric Urology fellowship at two different institutions (Johns Hopkins and Texas Children's Hospital). Level of hypospadias, patient age, type of repair and follow up as well as complications were recorded. Midshaft and distal hypospadias were classified as distal. RESULTS In all, 187 patients were operated on. No significant difference in numbers and complications occurred between the two surgeons. Distal hypospadias was found in 149, proximal in 29, and penoscrotal or perineal was found requiring a two-stage repair in nine patients. Distal hypospadias was repaired using either dorsal plate incision with tubularization (TIP) (n=112) or meatal advancement and glanuloplasty (MAGPI) (n=37). All proximal lesions were repaired using TIP. All patients were seen after 1-2 weeks, and 6 and 12 months postoperatively. Fistulae occurred in 10 patients (three in distal, four in proximal, and three in two-stage repairs) for an overall fistula rate of 5.3%. Meatal obstruction occurred in three distal repairs and one two-stage repair, diverticulum in one proximal. No complications occurred with MAGPI repairs. All complications, except for one, were successfully repaired in a single operation. CONCLUSION Modern hypospadias surgical techniques pioneered through decades of surgical innovation can now be successfully transferred to the new generation of specialty-trained Pediatric Urologists. Modern pediatric fellowship training allows performing distal hypospadias repair with a minimal fistula rate of 2.8%. Proximal hypospadias remain more challenging with complication rates of 13.8% for one-stage and 33.3% for two-stage repairs.
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Affiliation(s)
- Dominic Frimberger
- Department of Urology, University of Oklahoma Health Sciences Center, 920 Stanton L Young Boulevard, WP 3150, Oklahoma City, OK 73104, USA.
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Abstract
Anatomical anomalies in hypospadias are an abnormal ventral opening of the urethral meatus, abnormal ventral curvature of the penis and abnormal distribution of the foreskin around the glans with a ventrally deficient hooded foreskin. The techniques of hypospadias surgery continue to evolve. The current standard of care for hypospadias repair includes not only a functional penis adequate for sexual intercourse and urethral reconstruction offering the ability to stand to urinate, but also a satisfactory cosmetic result. Tubularized incised plate repair has been the mainstay for distal hypospadias. In cases of proximal hypospadias, one-stage repairs such as the Duckett repair or the Koyanagi repair have been well established, while two-stage repairs remain important alternatives. Whether dorsal plication or ventral lengthening should be used to correct penile curvature is still controversial, and long-term results are required. Efforts have been made in this decade to improve cosmetic appearance, constructing a slit-like meatus or performing foreskin reconstruction, and to prevent onerous complications.
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Affiliation(s)
- Yutaro Hayashi
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
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Halachmi S, Pillar G. Congenital urological anomalies diagnosed in adulthood - management considerations. J Pediatr Urol 2008; 4:2-7. [PMID: 18631884 DOI: 10.1016/j.jpurol.2007.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 03/01/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Despite worldwide availability of prenatal ultrasound, many patients are diagnosed in adult life with congenital anomalies such as ureteropelvic junction obstruction (UPJO), undescended testicle (UDT), ureterocele, hypospadias, vesicoureteral reflux (VUR) and primary obstructing megaureter (POM). The aim of this review was to describe these clinical conditions and their suggested management based on the available medical literature. REVIEW Adult UPJO is not a rare condition; symptomatic patients should be treated rather than observed. Treatment options are nephrectomy for non-functioning kidneys and reconstructive surgery for functioning renal units. The adult UDT has low fertility potential and increased cancer risk; hence most of the data in the literature indicate performing an orchiectomy. Adult ureteroceles are usually related to single systems and they are intravesical and less obstructive. For symptomatic patients endoscopic incision showed high efficacy for symptom elimination with minimal side effects. Primary hypospadias correction in the adult patient is feasible, but success rates are low compared to the pediatric age group. Secondary correction, whether primary correction was performed in childhood or adulthood, is a challenging task with a high complication rate. Treatment decisions regarding adult patients with VUR are difficult to make as the available data are inconsistent; there is no strict evidence that reflux in an adult is directly related to renal growth impairment, ascending pyelonephritis, and/or embryo loss in a pregnant woman. In contrast to the pediatric age group, adult POM is usually a symptomatic condition and related to a high complication rate including infections, stone formation and renal failure. Spontaneous resolution is rare and hence active surgical management is advocated. CONCLUSION Congenital urological anomalies identified in adulthood are not rare and pose a management challenge to the urologist. For most of the reviewed diseases, evidence-based management direction is difficult due to a lack of randomized trials and long-term follow up.
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Affiliation(s)
- Sarel Halachmi
- Pediatric Urology Service, The Department of Urology and Pediatrics, Rambam Medical Center and The Faculty of Medicine, Technion - Israeli Institute of Technology, Haifa, Israel.
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Kim MK, Kim YG. Hypospadias Repair: Recent Concept and Development in Surgical Techniques. Korean J Urol 2008. [DOI: 10.4111/kju.2008.49.12.1059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Myung Ki Kim
- Department of Urology, Chonbuk National University Medical School, Jeonju, Korea
| | - Young Gon Kim
- Department of Urology, Chonbuk National University Medical School, Jeonju, Korea
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Savanelli A, Esposito C, Settimi A. A prospective randomized comparative study on the use of ventral subcutaneous flap to prevent fistulas in the Snodgrass repair for distal hypospadias. World J Urol 2007; 25:641-5. [PMID: 17912528 DOI: 10.1007/s00345-007-0215-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 09/07/2007] [Indexed: 10/22/2022] Open
Abstract
We evaluated the importance of urethral coverage using vascularized subcutaneous ventral flaps for the prevention of fistulas in patients undergoing distal hypospadias repair. Our prospective study included 130 patients, aged 9 months to 12 years, who underwent distal hypospadias repair using tubularized incised plate urethroplasty (TIPU), from January 2001 through January 2006. Patients were assigned to one of two groups by a computer-generated random selection: 65 patients underwent non-covered urethroplasty (NCU group); another group of 65 patients underwent covered urethroplasty (CU group) with a vascularized subcutaneous ventral flap. The results were evaluated by two pediatric surgeons unaware of the type of treatment each patient had undergone. Successful results were achieved in 99/130 patients (76.2%). We recorded 31 (23.8%) post-operative complications: 20 patients presented with a urethrocutaneous fistula (15 patients in the NCU group and 5 in the CU group); five with urethral stenosis (3 in the NCU and 2 in the CU group); and six with skin dehiscence of the preputioplasty (3 patients in each group). We analyzed the results using the chi2 test and the only statistically significant difference between the two groups (p < 0.05) was in terms of incidence of fistulas. Urethrocutaneous fistulas seem to be the most frequent complication of distal hypospadias after TIPU repair. Urethral coverage should be part of the Snodgrass procedure because it significantly reduces the formation of fistulas. A well-vascularized subcutaneous ventral flap represents, in our experience, a simple and optimal choice for the prevention of fistulas.
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Affiliation(s)
- Antonio Savanelli
- Department of Pediatric Surgery, Federico II University of Naples, Naples, Italy
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Moriya K, Kakizaki H, Tanaka H, Mitsui T, Furuno T, Kitta T, Higashiyama H, Sano H, Nonomura K. Long-Term Patient Reported Outcome of Urinary Symptoms After Hypospadias Surgery: Norm Related Study In Adolescents. J Urol 2007; 178:1659-62; discussion 1662. [PMID: 17707029 DOI: 10.1016/j.juro.2007.03.176] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Indexed: 11/16/2022]
Abstract
PURPOSE Although there are some reports of the functional outcome after hypospadias surgery, long-term patient reported data on urinary symptoms are sparse. We evaluated the long-term outcome of urinary control in patients with hypospadias who were operated in childhood. MATERIALS AND METHODS A detailed questionnaire was mailed to 33 patients with hypospadias who were between 18 and 26 years old and had undergone the first operation at age 6 years or younger, and to 50 age matched controls. RESULTS A total of 22 patients (66.7%) and 38 controls (76.0%) returned the questionnaire. Mean age was 20.6 years in the hypospadias group and 21.0 years in the control group. Of the 22 patients 8 had mild and 11 had severe hypospadias, while severity was unknown in 3. Straight direction of the urinary stream was noted at a similar rate in the hypospadias and control groups (77% and 71%, respectively). Regarding the urinary stream, no subjects in either group reported it as bad or very bad. Of the hypospadias group 95% of subjects and 89% of controls reported mild or no urinary frequency bother. The incidence of individuals who always or mainly voided while standing was similar in the hypospadias and control groups (91% and 84%, respectively). However, 32% of subjects in the hypospadias group reported moderate or severe terminal dribbling, in contrast to only 3% of controls. When subjects with mild and severe hypospadias were compared, 4 of 11 (36%) with severe hypospadias needed to squeeze the urethra after voiding to eliminate residual urine in the urethra, whereas none with mild hypospadias needed to squeeze the urethra. CONCLUSIONS Although patients with hypospadias mostly have good urinary control, terminal dribbling is not uncommon, especially in those with severe hypospadias.
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Affiliation(s)
- Kimihiko Moriya
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo and Asahikawa Medical College, Asahikawa, Japan.
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Gonzales ET. Is uroflowmetry necessary following hypospadias repair? NATURE CLINICAL PRACTICE. UROLOGY 2007; 4:306-7. [PMID: 17437007 DOI: 10.1038/ncpuro0782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 02/22/2007] [Indexed: 05/14/2023]
Affiliation(s)
- Edmond T Gonzales
- Texas Children's Hospital, Texas Children's Clinical Care Center, Houston, TX 77030, USA.
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Abstract
OBJECTIVE Tubularized incised plate urethroplasty has become a popular technique for repairing distal and proximal hypospadias in many institutions. Dorsal inlay graft urethroplasty has been used in our institution since 2003 to reduce the risk of meatal stenosis. In the present study, we evaluated the results of the dorsal inlay graft procedure. METHODS A total of 28 patients with no deep groove and no severe curvature underwent one-stage urethroplasty using an inner preputial-based dorsal inlay graft. The medical records of all patients were retrospectively reviewed with regard to complication rate and cosmetic appearance. RESULTS Mean patient age at surgery was 21 months (range, 14 months to 4.6 years). Preoperatively the urethral meatus was coronal in two cases, distal shaft in 17, proximal shaft in six and penoscrotal in three. Nine patients required testosterone therapy before surgery. Mean operative time was 200 min (range, 154-249 min). Mean length of inlay graft was 20.9 mm (range, 12-30 mm). In all patients, a straight penis was achieved without dorsal plication of the corposa cavernosa, and the neomeatus with a slit-like appearance was positioned at the glans tip. At a mean of 22 months of follow up, a urethrocutaneous fistula developed in only one patient (3.6%), requiring repair surgery 6 months after urethroplasty. No patient had meatal stenosis, neourethral stricture or urethral diverticulum along the inlay graft. CONCLUSION Dorsal inlay graft urethroplasty is an effective method for hypospadiac repair and leads to good cosmetic outcome with low risk of complications.
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Affiliation(s)
- Hiroshi Asanuma
- Department of Urology, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan.
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Kaya C, Kucuk E, Ilktac A, Ozturk M, Karaman MI. Value of Urinary Flow Patterns in the Follow-Up of Children Who Underwent Snodgrass Operation. Urol Int 2007; 78:245-8. [PMID: 17406135 DOI: 10.1159/000099346] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Accepted: 06/13/2006] [Indexed: 11/19/2022]
Abstract
The urinary flow patterns and the Toguri nomogram were compared in the intermediate functional results of the tubularized-incised plate urethroplasty (TIPU) to repair distal and midpenile hypospadias by using uroflowmetry. 28 children who were toilet trained, were able to void volitionally, and had no fistulas following hypospadias repair were eligible for the study. The study did not include children who had persistent fistula, meatal stenosis or urethral stricture, and did not return for follow-up. The mean age was 8.4 years and the mean follow-up period was 18 months. The urinary flow pattern, maximum (Q(max)) and average flow rate (Q(ave)) were measured; the results were expressed as percentiles and compared to the Toguri values from normal children. The Q(max) and Q(ave) were considered normal if they were in >25th percentile, equivocally obstructed in the 5-25th percentile and obstructed if <5th percentile. The flow pattern was classified as bell ring shape, plateau or intermittent. According to the Toguri nomogram, 22 of 28 patients (78.5%) were considered normal, 4 patients (14.2%) as equivocally obstructed, and 2 patients (7.1%) as obstructed group. A normal bell-shaped flow curve was obtained in 23 (82.1%) of the children. 4 patients (14.2%) had a plateau flow pattern. Only 1 of the patients had an intermittent shape flow curve. The flow pattern was normal bell-shaped for all of the patients, except 1, with Q(max) above the 25th percentile according to the Toguri nomogram. Of children with Q(max) below the 5th percentile, both of them had a plateau flow pattern and were found to have an asymptomatic meatal stenosis, which was improved with urethral dilatation. However, of the 4 patients with Q(max) between 5 and 25 percentiles, 2 had a plateau flow pattern and the others had a bell-shaped flow pattern. The flow patterns of the 2 patients determined as obstructive by the Toguri nomogram were plateau-shaped. TIPU provides satisfactory functional results for distal and midpenile hypospadias; uroflowmetry is an important noninvasive tool to evaluate this technique. There are no studies in the literature which only used flow patterns for the evaluation of urination for follow-up after the hypospadias repair. Our study showed that the evaluation of obstruction according to the Toguri nomogram may not be necessary in patients with a normal bell-shaped flow pattern in uroflowmetry.
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Affiliation(s)
- Cevdet Kaya
- Haydarpaşa Numune Training and Research Hospital, Department of Urology, Istanbul, Turkey.
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Horasanli K, Perk C, Yesildere T, Gumus E, Miroglu C. Healing of the Urethral Plate after Deep Incision: Does Catheterization Change the Course of This Process? Urol Int 2007; 78:249-53. [PMID: 17406136 DOI: 10.1159/000099347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 07/21/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND We aimed to evaluate the sequence of healing process as well as possible effects of stent placement on the healing process after deep urethral plate incision. METHODS A deep urethral plate incision was done at the 12 o'clock position. After that, in the first group (n = 14) the anterior urethra was stented with a silicon catheter. Animals in the second group (n = 14) underwent the same incision procedure, however no stent was placed after this operation. All animals in both groups were again divided into three groups with respect to the follow-up period (7-14 and 21 days). Partial penectomy was performed in all subgroups and histopathologic evaluation performed. RESULTS In the first group after 7 days, limited neovascularization and granulation tissue formation could be noted far away from the epithelial lumen. Evaluation of these specimens during the long-term follow-up (21 days) demonstrated an almost completely healed tissue with a remarkable neovascularization and well-developed granulation tissue. In the second group during 14-21 days, evaluation progression of tissue healing along with increasing vessel formation and re-epithelialization were demonstrated. Although the incision edges did show evident approximation, no sign of fibrosis could be demonstrated in these specimens. CONCLUSION We may say that tissue healing with a desired and complete re-epithelialization could be achieved without inserting a catheter. Prevention of re-approximation along with the limited urinary extravasations to the subepithelial area might be responsible for tissue protection that will limit the long-term aforementioned adverse effects of the procedure.
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Affiliation(s)
- Kaya Horasanli
- 2nd Department of Urology, Sisli Etfal Teaching Hospital, Istanbul, Turkey.
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Liem NT, Dung LA, Tinh ND. Tubularized longitudinal island flap of the mucosa and skin on the dorsum of the penis in the treatment of hypospadias: experience from 176 cases. Asian J Surg 2006; 29:185-7. [PMID: 16877222 DOI: 10.1016/s1015-9584(09)60084-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To report the result of the treatment of hypospadias using tubularized longitudinal island flap of the mucosa and skin on the dorsum of the penis. METHODS Between January 1995 and December 2003, 176 patients were operated on using this technique. Among them, 124 patients had penile hypospadias, 35 had the penoscrotal form, four had the scrotal form and three patients had the perineal form. After removing the whole chordee, a longitudinal pedicle island flap of mucosa and skin was created. The flap was transposed to the ventral side of the penis by the buttonhole manoeuvre, and anastomosed to the meatus. The flap was tubularized creating a neourethra. RESULTS The length of urethral defect varied from 1.5 to 10 cm (mean, 3.5 cm). The single longitudinal flap was used in 171 patients. The combination of a longitudinal flap and a local flap was used in five patients. Fistulae occurred in 13 patients (7.4%). Torsion of the penile axis did not occur in any patient. All children voided with a single straight urinary stream, and had a normal appearance of the meatus. CONCLUSION The technique has a low fistula occurrence rate and a good cosmetic result.
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Affiliation(s)
- Nguyen T Liem
- Department of Surgery, National Hospital of Pediatrics,Dong Da District, Hanoi, Vietnam.
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Wolffenbuttel KP, Wondergem N, Hoefnagels JJS, Dieleman GC, Pel JJM, Passchier BTWD, de Jong BWD, van Dijk W, Kok DJ. Abnormal urine flow in boys with distal hypospadias before and after correction. J Urol 2006; 176:1733-6; discussion 1736-7. [PMID: 16945635 DOI: 10.1016/s0022-5347(06)00614-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE We established the urine flow rate and the effect of surgical correction on that rate in patients with hypospadias. MATERIALS AND METHODS The urine flow rate, voided volume and residual urine were measured using an ultrasound flow probe and bladder scan in boys with distal hypospadias before operative correction in 42 with a mean age of 16 months, 3 and 9 months after operative correction in 28 and 11, respectively, and in a control group of 51 boys 0 to 3 years old (mean age 11 months). Long-term flow data were obtained retrospectively from the records of 63 patients with hypospadias 1 to 10 years after operation. RESULTS Of the controls 37% had mainly intermittent and sometimes fractionated flows, 4% had a plateau phase flow and 59% had mainly bell-shaped flow curves. The average maximum flow rate +/- SD was 6.8 +/- 4.1 ml per second and maximum flow rate/voided volume was 0.26 +/- 0.11 l per second. Of the boys with distal hypospadias 76% produced intermittent flows (fractionated in the majority) before correction. After correction this percent decreased to 50%. The average maximum flow rate was 7.5 +/- 2.5 ml per second before correction, and 6.6 +/- 2.8 and 7.2 +/- 1.8 ml per second 3 and 9 months after operation, respectively. Average maximum flow rate/voided volume was 0.22 +/- 0.12 l per second before, and 0.16 +/- 0.09 and 0.16 +/- 0.09 l per second 3 and 9 months after operation, respectively. In the long-term group maximum flow rate/voided volume was 0.13 +/- 0.11 l per second. The number of patients voiding with a plateau phase increased from 6% before to 13% and 17% after correction, respectively. An obstructive pattern was also observed in 41% of the long-term followup group. CONCLUSIONS An intermittent flow pattern is common in 0 to 3-year-old boys. It appears to be more common and more pronounced or fractionated in boys with distal hypospadias at the same ages. In relation to voided volume patients with hypospadias already produce an abnormally low urine flow rate before correction and even more so thereafter in the short and intermediate term. The corrective procedure increases the occurrence of flows with an obstructive pattern.
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Affiliation(s)
- K P Wolffenbuttel
- Departments of Pediatric Urology and Furore, Erasmus University Rotterdam, Sophia Children's Hospital, Dr Molewaterplein 60, 3016 GJ Rotterdam, The Netherlands.
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Wilcox D, Snodgrass W. Long-term outcome following hypospadias repair. World J Urol 2006; 24:240-3. [PMID: 16523339 DOI: 10.1007/s00345-006-0059-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Accepted: 02/06/2006] [Indexed: 10/24/2022] Open
Abstract
Hypospadias is a common problem affecting approximately one boy in 300; it is usually corrected in the first few years of life. While early outcome data is widely available, little has been reported on the long-term problems that these men suffer. Data suggest that the majority of men have no lasting effects, but up to 40% with severe hypospadias can have some degree of voiding problems. In addition, sexual problems affecting erection, ejaculation and sexual sensation have now been reported in more than 20% of men, although these studies are few and contain only a small number of patients. This limited available data support the need for further long-term studies especially focusing on the more modern techniques.
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Affiliation(s)
- Duncan Wilcox
- Department of Pediatric Urology, The University of Texas Southwestern Medical Center, Dallas, TX 75235, USA.
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Leclair MD, Camby C, Battisti S, Renaud G, Plattner V, Heloury Y. Unstented Tubularized Incised Plate Urethroplasty Combined with Foreskin Reconstruction for Distal Hypospadias. Eur Urol 2004; 46:526-30. [PMID: 15363572 DOI: 10.1016/j.eururo.2004.04.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2004] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM Urethral stent has recently been proven to be unnecessary for normal healing in an animal model of tubularized incised plate (TIP) urethroplasty. We report our experience with unstented TIP repair combined with foreskin reconstruction for distal hypospadias in children. PATIENTS AND METHODS We retrospectively reviewed the records of 162 children consecutively treated by TIP urethroplasty for a distal or mid-shaft hypospadias without urethral stent over a 6 years period. The mean age +/- SEM at surgery was 15.7 +/- 1.2 months. A foreskin reconstruction was performed with the hypospadias repair in 136 boys (84%). One hundred thirty one children (81%) underwent this surgery as an outpatient procedure. RESULTS With a mean follow-up of 12.4 +/- 1.0 months, urethrocutaneous fistula was observed in 9 children (5.6%), and meatal stenosis in 4 (2.5%). Postoperative urinary retention requiring suprapubic catheter insertion was observed in 4 cases (2.5%) without later complications. Cutaneous dehiscence of the reconstructed foreskin occurred in 6 children (4.4%) and phimosis in 13 (9.5%). CONCLUSIONS Absence of urethral stent after TIP urethroplasty for distal hypospadias repair does not seem to increase postoperative complication rate. Foreskin reconstruction in distal hypospadias surgery has an acceptable complication rate.
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Affiliation(s)
- Marc-David Leclair
- Department of Paediatric Urology, Service de Chirurgie Infantile, Hôpital Mère-Enfant, CHU de Nantes, 44093 Nantes Cedex 01, France.
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Babu R, Harrison SK, Hutton KAR. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Int 2004; 94:384-7. [PMID: 15291873 DOI: 10.1111/j.1464-410x.2004.04935.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine whether physiological phimosis with or without ballooning of the prepuce is associated with noninvasive urodynamic or radiological evidence of bladder outlet obstruction. PATIENTS AND METHODS From August 2001 to October 2002 all boys with a foreskin problem and referred to one paediatric surgeon were assessed in special clinics. Those with physiological phimosis were recruited for the study and had upper tract and bladder ultrasonography (US), followed by uroflowmetry and US-determined postvoid residual urine volumes (PVR). Data were compared between boys with and with no ballooning of the prepuce. The project was approved by the local research ethics committee and informed consent was obtained from all study participants. RESULTS In all, 54 patients were referred for circumcision; 32 boys with physiological phimosis completed the uroflow and US investigations. Ballooning of the foreskin was present in 18 boys (mean age 6.8 years, range 3-12); 14 had physiological phimosis with no ballooning (mean age 6.5 years, range 4-11). Upper tract US and bladder wall thickness were normal in all boys. The mean maximum urinary flow rate (Q(max)) was not significantly different in boys with ballooning and those without (mean 15.3 mL/s, sd 4.4, range 9-24, vs 15.4, sd 2.9, range 10.7-20, P = 0.96). In addition, all Q(max) values were within the normal range when correlated with voided volume and compared with age-related nomograms. Most boys had flow rate patterns showing a normal bell-shaped curve; a few (9%) had subtle changes in the flow-rate profile, with either a plateau-type curve or slow initial increase in flow and prolonged time to achieve Q(max). The two groups had comparable mean PVRs (3.5 mL, sd 5.1, range 0-18 with ballooning vs 6.1, sd 10.7, range 0-38 without, P = 0.37). Only one patient had a marginally abnormal PVR. CONCLUSIONS Physiological phimosis with or without ballooning of the prepuce is not associated with noninvasive objective measures of obstructed voiding. Minor abnormalities in the flow-rate pattern in this patient group deserve further study.
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Affiliation(s)
- Ramesh Babu
- Departments of Paediatric Surgery and Radiology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
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Affiliation(s)
- D F Thomas
- Department of Paediatric Urology, St James's University Hospital, Leeds, UK.
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48
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Elbakry A. Healing of unstented tubularized incised plate urethroplasty: an experimental study in a rabbit model. BJU Int 2003; 92:656-7. [PMID: 14511064 DOI: 10.1046/j.1464-410x.2003.t01-6-04442.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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