Skin Graft for 2-stage Treatment of Severe Hypospadias: Back to the Future?

Complication rates of proximal hypospadias: meta-analyses of four surgical repairs

INTRODUCTION

Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques.

METHODS

The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included.

RESULTS

Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin.

DISCUSSION

The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short.

CONCLUSION

This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.

Posterior hypospadias: Evaluation of a paradigm shift from single to staged repair

INTRODUCTION

Repair of posterior hypospadias is a current dilemma. Single versus staged repair is the main question to answer. The answer is not easily reached due to lack of comparative studies. Hence such studies are not available, the reports of a change from one approach to the other one are important to point out the results of each procedure in the same hands and in the same center. Herein, we report our results of the repair of posterior hypospadias shifting from single stage to staged repair.

PATIENTS AND METHODS

65 children were operated in a single Centre in the period from 2011-2016 using single stage repair by dorsal island flap in the first 40 children and then a shift to staged repair involved 25 children repaired using Bracka procedure, children are evaluated for the outcome and for the development of complications during the period of follow up.

RESULTS

The mean age of children operated using single stage technique was 2.8 years (0.83-12.0), Onlay repair was performed in 29 cases (72.5%), while a tube was performed in 11 cases (27.5%). The success rate was 55% with 45% complication rate, in the form of infection in (2.5%), partial dehiscence in (10%), urethrocutaneous fistula in (15%), meatal stenosis in (12.5%), urethral diverticulum in (5%). 25 children were operated using staged repair according to Bracka using inner preputial graft in fresh cases and buccal graft in redo cases. Mean age of 4.5 years (7 months-18 years), 15 primary cases and 10 redo cases, 12 penoscrotal, 11 scrotal and 2 perineal cases, preputial graft in 17, buccal graft in 8, 25 children completed their second stage, tunica vaginalis cover was used in 23 children, localized penile skin dartos was used in 2 children, the overall success after second stage was 80%, complications were in the form of 4 fistulas (16%), hematoma and complete disruption in a redo case (4%). There is a significant statistical difference in the incidence of complications between both groups in favor of lower complication rate (20%) in the staged group versus the single stage group (45%) with a P = 0.0419.

CONCLUSION

Staged repair considerably improves complication rate of posterior hypospadias reconstruction compared to single stage repair using pedicled island flap. More follow up and continuous reporting of honest complication rate is needed to improve the outcome of a complex pathology and to help the choice of the best procedure.

Current challenges with proximal hypospadias: We have a long way to go

BACKGROUND AND PURPOSE

Proximal hypospadias repair has continued to challenge the pediatric urologist despite great efforts to develop better techniques for repair.

METHODS

In this article, we review the literature regarding modern proximal hypospadias repair approaches and outcomes. We also present our current approach to proximal hypospadias repair surgery and outcome tracking. Finally, we review the literature on surgical outcome tools that may help us standardize research.

RESULTS

Proximal hypospadias repair has significant variability in technique. Overall modern data would suggest that we require great improvement in our surgical management of this challenging problem. Though tools exist to begin to standardize the reporting of hypospadias outcomes, collaborative efforts are still required for future research.

CONCLUSION

Future research in proximal hypospadias repair needs to utilize new reporting tools as well as engage in collaborative efforts between institutions.

Two-stage graft urethroplasty for proximal and complicated hypospadias in children: A retrospective study

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 Q_max = 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.

Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues

INTRODUCTION

The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair.

METHODS

We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002-2012) for relevant articles, using the terms 'proximal hypospadias', 'posterior hypospadias' 'single stage', 'multiple stage', and 'complications'. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate.

RESULTS AND CONCLUSIONS

The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.

Split dorsal dartos flap transposed ventrally as a bed for preputial skin graft in primary staged hypospadias repair

OBJECTIVE

To describe a modification of the 2-stage repair using a dorsal split dartos fascia flap, as a well vascularized bed for the graft in the first stage.The 2-stage repair is a commonly used technique in proximal hypospadias or in hypospadias with severe chordee, or in cases with urethral plate of poor or dubious quality.

METHODS

Between 2006 and 2009, 32 patients underwent a staged hypospadias repair: 8 (25.0%) midshaft with chordee and/or poor urethral plate, 14 (43.8%) proximal penile, 7 (21.9%) peno-scrotal, and 3 (9.4%) perineal hypospadias. Plication was necessary in 27 (84.4%). All cases received a preputial skin graft. Median age at the first stage was 21 months (range 15-26); median follow-up was 35 months (range 20-55) and the median time between the 2 stages was 8 months (range 6-12).

RESULTS

Graft take was 100% after the first stage. Follow-up after second-stage repair showed 31 of 32 (96.8%) had a successful functional outcome (straight erection; good, single urine stream; voiding in a standing position) and cosmetic outcome (slitlike meatus positioned at the tip of the glans, "normal looking circumcised penis"); one fistula occurred. One patient has mild residual ventral curvature.

CONCLUSION

Using a vascularized dorsal split dartos flap ventrally underneath and laterally of the skin graft in the first stage offers the advantages of an excellent graft take and the provision of versatile dartos tissue for a waterproofed and secured urethroplasty.

The two-stage repair for severe primary hypospadias

OBJECTIVES

The repair of severe primary hypospadias represents a major surgical challenge. After initial enthusiasm for single-stage procedures, many paediatric urologists have turned to the alternative two-stage approach after experiencing disappointing results. A single surgeon's experience of the two-stage procedure is reported.

METHODS

Between 1998 and 2003, 62 boys underwent a two-stage reconstruction for primary hypospadias. Indications for staged repair included proximal meatus (mid-shaft [18 patients], peno-scrotal [23] or perineal [two]), moderate or severe chordee (38 patients), poor glans groove, and lichen sclerosis. Inner prepuce was the graft of choice. Median age was 27.6 months at completion of surgery and median follow-up was 26 months.

RESULTS

All grafts took well and none of the 62 patients needed revision. One patient developed a haematoma. Maturation of the graft for at least six months ensured the best conditions for the second-stage closure. Overall the cosmetic and functional results after the second stage were excellent. The outcomes were determined by the parents' and surgeon's assessment of function and the cosmetic appearance. Complications included partial glans dehiscense (three patients), residual mild curvature (three) and meatal stenosis (three).

CONCLUSION

The two-stage repair has proved to be a reliable and reproducible technique with a low complication rate in a difficult cohort of hypospadias patients. Inner preputial skin grafts take very successfully on the ventral surface of the penis, and splitting the glans enables a slit-like meatus to be achieved. Excellent cosmetic results can be anticipated.

The multistage use of buccal mucosa grafts for complex hypospadias: histological changes

PURPOSE

We report our experience using buccal mucosa in the multistage repair of complex hypospadias, and the observed histological changes.

MATERIALS AND METHODS

We evaluated 31 patients (14 adults and 17 children). A total of 19 patients presented after failed hypospadias repair with deficient ventral skin, 5 presented with scrotal hypospadias and 7 presented with perineal hypospadias. Patients who had previously undergone hypospadias repair had 3 to 7 failed trials. Two stage buccal mucosa graft was performed using the Bracka technique. In the first stage residual fibrosis was released, the glans was split and the buccal mucosa graft was sutured to the ventral surface of the penis to form a future urethral plate. Second stage reconstruction was performed after 6 months with interposed scrotal dartos tissue. Buccal mucosa was histologically studied before grafting, and at 6 months after graft uptake and exposure to the air.

RESULTS

Buccal mucosa free graft showed excellent uptake within 5 days in all cases. At 6 months the buccal mucosa was well vascularized and pliable. Minute fistulas occurred in 3 cases (9.7%), which were closed at a later stage. Histological analysis of buccal mucosa tissues before and after graft and prolonged exposure to the air (more than 6 months) was conducted. The buccal mucosa displayed epithelial hyperplasia with mild and focal keratinization. The lamina propria was slightly edematous and minimally infiltrated by mononuclear inflammatory cells. The lamina propria papillae were elongated, extending to 75% of the mucosal thickness compared to the normal buccal mucosa. The buccal mucosal graft displayed good vascularization, similar to that of the normal mucosa.

CONCLUSIONS

Multistage repair using buccal mucosa is an excellent option for urethral reconstruction. It guarantees excellent graft uptake and good vasculature, which improves success. It also provides supple tissue for glanular and urethral reconstruction in cases of severe complex hypospadias.

Ten-year experience with composite bladder mucosa-skin grafts in hypospadias repair

OBJECTIVES

A variety of surgical techniques and flaps have been described for hypospadias repair. We present our 10-year experience using a composite urethroplasty graft consisting of bladder mucosa and skin.

METHODS

We reviewed the records of 294 patients who had undergone hypospadias repair at our institution from 1993 to 2003. The meatus was penile in 221, penoscrotal in 55, and perineal in 18. They all underwent single-stage urethroplasty consisting of a composite tubularized bladder mucosa-skin graft. Patient age at surgery was 2 to 46 years old (mean 8.9).

RESULTS

Urethrocutaneous fistula formation occurred in 27 (9.1%) and urethral strictures in 9 (3.2%), for an overall complication rate of 12.3%. No proximal urethral anastomotic strictures or meatal stenosis developed.

CONCLUSIONS

Our results have demonstrated that composite bladder mucosa-skin flap grafts can be used successfully for urethral reconstruction in proximal, as well as distal, hypospadias repair. The distal tubularized skin flap prevented the occurrence of meatal stenosis.

Proximal Division of the Urethral Plate in Staged Hypospadias Repair

PURPOSE

We describe a new technique for staged hypospadias repair in which the urethral plate is divided proximally at the time of the first stage.

MATERIALS AND METHODS

A total of 14 patients with proximal hypospadias associated with severe chordee were operated on using a new staged technique. At the time of the first stage the urethral plate was divided proximally at the level of the hypospadiac meatus. In 8 of 14 patients the intact plate was then incised and tubularized with the Snodgrass technique. In 6 patients the plate was tubularized at the time of the second stage. Correction of chordee was accomplished with dorsal plication and/or corporal body grafting. Byar's flaps were used to fill in the residual gap between the proximal hypospadiac meatus and the newly tubularized neourethra. The transposed flaps in the area of the urethral defect were then tubularized at the second stage.

RESULTS

Followup ranged from 6 months to 3 years. Complications included a proximal pinpoint fistula and diverticulum in 1 case. An additional patient also had formation of a mild diverticulum that has not required surgical revision. No patients have had any evidence of distal urethral stricture formation.

CONCLUSIONS

Proximal division of the urethral plate and application of the Snodgrass procedure to the staged repair of hypospadias have resulted in improved functional and cosmetic results. The major advantage of this new technique is preservation and use of the native urethral plate in the glans and subcoronal area. When complications occur with this technique, they are less severe compared to those of the traditional staged approach.