Tubularized, incised plate urethroplasty for distal hypospadias

The effectiveness of double dorsal dartos flap for urethroplasty coverage in distal hypospadias repair: A single surgeon approach to preventing urethrocutaneous fistula

PURPOSE

The concept of interposing double dorsal preputial flaps to cover the urethroplasty was introduced in 2005 to reduce the risk of urethrocutaneous fistula (UCF). Our study aims to compare the postoperative outcomes of urethroplasty for distal hypospadias between two groups: one receiving single preputial flap coverage and another receiving double flap coverage.

MATERIALS AND METHODS

We conducted a retrospective analysis study of boys with primary distal hypospadias who underwent surgery by the same experienced surgeon, at our department between 2010 and 2021. The study population was divided into two groups: Group A, which underwent urethroplasty coverage with single dorsal preputial flap, and Group B, which underwent coverage with double flap. Postoperative complications were compared between the two groups.

RESULTS

We collected 105 cases, comprising 51 in Group A and 54 cases in Group B. The mean age at surgery was 29 months in Group A and 24 months in Group B. Post-operative follow-up period ranged from 6 months to 8 years. Functional and cosmetic outcomes were judged excellent in 88.7%. Only 10 boys experienced complications requiring reoperation. UCF occurred in 5 patients from Group A, while no cases were reported in Group B (p = 0.024). Meatal stenosis was identified in three patients in Group A and in two patients in Group B (p = 1). No other complications, such as glans dehiscence or penile torsion, were noted.

CONCLUSION

Double dorsal dartos flap is an effective method for covering the new urethra and can be recommended in the treatment of patients with virgin distal hypospadias.

Adulthood cosmetic and sexual outcomes of the patients who underwent hypospadias repair in childhood

This study aimed to assess the cosmetic and sexual outcomes of childhood hypospadias repair after puberty. Among 672 patients who underwent hypospadias repair between 2001 and 2017, 243 sexually active patients were included in the study. At their last visit, cosmetic and sexual evaluation were done through the Penile Perception Score, the Hypospadias Objective Scoring Evaluation, IIEF, MSHQ-EjD. The levels of erectile dysfunction(ED) severity were determined according to erectile function domain of IIEF. The median follow-up after the last surgery was 16 [IQR (13-18)] years, and median patient age at the time of study was 19.67 [IQR(18-22)] years. Patients were divided into two subgroups as follows: Group I; Repairs using grafts (n = 120, 49.4%) and Group II; Graft-free repairs (n = 123, 50.6%). The rate of dissatisfaction with penile appearance was higher in Group I (16.7% vs. 4.9%, p = 0.003). Mild ED was more frequent in Group I (14.2% vs. 3.3%, p = 0.007); while none of the patients had either moderate or severe ED. Other domains of sexual function were observed to be similar in both groups. The need for unwanted interventions due to complications, and surgeries requiring grafts were found to be risk factors for ED development and dissatisfaction with penile appearance in adulthood. Those who underwent graft-free hypospadias repair experience better cosmetic and sexual outcomes when compared to grafted repairs, yet, satisfactory results were achieved in almost 90% of the grafted repairs.

Snodgrass (tubularized incised plate) versus Mathieu repair of distal hypospadias: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Distal hypospadias accounts for the majority of hypospadias. Mathieu and Snodgrass techniques are widely used for repair of distal hypospadias but their comparative efficacy and reported outcomes are still debated. We conducted a systematic review and meta-analysis to compare the outcomes of these two techniques.

METHODS

Electronic databases and trial registries were searched for randomized controlled trials (RCTs) comparing Mathieu and Snodgrass techniques for primary distal hypospadias repair. Outcome measures included complication rates and cosmetic outcomes. Risk of bias assessment was performed using the ROB2. Data was analyzed using Review Manager 5.4; Trial Sequential Analysis (TSA) also was conducted for important outcomes.

RESULTS

Twelve RCTs were eligible for inclusion. The Snodgrass technique showed a significantly lower incidence of urethrocutaneous fistula (UCF) (RR 0.48, 95% CI [0.30-0.77]). However, there was no significant difference in the incidence of meatal stenosis (MS) between the two (RR 1.64, 95% CI [0.85-3.15]). TSA supports the findings for outcome UCF but not for MS. Operative time was shorter with the Snodgrass technique.

CONCLUSION

This SRMA indicates a lower incidence of UCF with Snodgrass technique compared to the Mathieu technique in distal hypospadias repair. However, there was no significant difference in the risk of MS.

The impact of audiovisual information on parental anxiety levels prior to hypospadias surgery: A prospective single center cohort study

BACKGROUND

Most parents have anxiety before a pediatric surgical procedure. Parental anxiety may impair the parents' ability to cope with new or stressful situations while their children are undergoing surgery. By effectively improving the education of parents regarding the diagnosis, treatment, and potential complications of hypospadias and surgical repair, it might be feasible to reduce their anxiety during this process.

OBJECTIVE

To determine whether structured audiovisual information would reduce parents' anxiety levels compared to classic verbal information.

MATERIAL AND METHODS

The diagnosis was made and, treatment options were explained, and State-Trait Anxiety Inventory Form - State Anxiety (STAI-I) forms were filled out by parents at the first consultation. In the second consultation, parents were divided into structured audio-visual-information (Group-1) and classic verbal information (Group-2) groups. Following these consultations, all parents in both groups filled out STAI-I again. Parents filled out the forms for the last time on the postoperative-14th-day and the results were compared.

RESULTS

A total of 124 (51.2%) parents were informed with structured-audiovisual-informational material and 118 parents (48.8%) were informed with classic verbal information. First STAI-I scores were 57.65 ± 5.17 and 56.91 ± 5.28 for Group-1 and Group-2, respectively, and there was no difference between the groups (p = 0.709). The STAI-I scores after the second consultation were 44.82 ± 5.65 and 49.42 ± 2.81 for Group-1 and Group-2, respectively. Parental anxiety decreased in both groups following the second consultation. Notably, a statistically significant superiority was found between the groups in favor of Group-1 (p = 0.001).

DISCUSSION

Parents whose children will undergo hypospadias surgery experience significant anxiety. We observed that informing patients adequately and in appropriate language using a suitable method was associated with less anxiety. Preoperative parental anxiety is influenced by several variables, including parent age, parent gender, child age, lack of knowledge, and concerns over complications or pain. Although we are unable to alter the factors of child age and parent gender, we can impact parents' concerns regarding postoperative pain and anesthesia by enhancing their comprehension of the procedure via providing them of sufficient and accurate information.

CONCLUSION

Providing parents with structured audio-visual information about the preoperative and postoperative period before hypospadias surgery is associated with lower parental anxiety levels. Supplying structured audiovisual information regarding the preoperative and postoperative periods can help parents have an improved comprehension of the procedure and minimize their anxiety.

Characteristics and management of post-circumcision Urethrocutaneous Fistula: a retrospective study in surgical units in Cameroon

Background

Urethrocutaneous fistula (UCF) is one of the major complications of circumcision. The risk factors associated with UCF are not clear-cut but its repair remains a challenge for urological surgeons. The aim of this study was to highlight the epidemiological, and clinical features and outcomes obtained from the management of UCF in the context of a country with limited medical resources where ritual circumcision is widely practiced.

Patients and methods

From February 2010 to December 2022, 35 patients underwent surgical repair for post-circumcision UCF in two tertiary hospitals in Yaounde, Cameroon. Simple closure, Thiersch-Duplay-Snodgrass and Mathieu techniques were performed.

Results

The mean age of patients was 7.4 ± 4.1 years with a range of 2 to 21 years; the median age at circumcision was 24 months (12; 48). Most (95%) of circumcisions were performed by paramedical staff. The majority of patients (n = 26) consulted for a bifid stream, Three-quarters of fistulae were located at the corona. Small fistulae represented 74.28% (n = 26) of cases as opposed to large fistulae (25.71%). More than 70% of patients underwent a simple closure. The therapeutic results were satisfactory in 91.4% of cases (n = 32) after an average follow-up of 91.85 ± 51.92 months. There were no statistically significant differences between the patients with coronal fistula and patients with distal penile fistula concerning demographic, clinical and surgical characteristics.

Conclusion

Urethrocutaneous fistula is a major and frequent complication of circumcision mostly practiced by non-qualified personnel on children aged 24 months. The usual presentation is micturition with a bifid stream occurring on average 3 months after circumcision. Coronal fistulas are the commoner location. Simple closure, Thiersch-Duplay-Snodgrass and Mathieu technique appear to be safe with the advantages of low recurrence rate. An accurate diagnosis with a timeframe respecting the principles of fistula surgery combined with regular follow-up is mandatory for good long-term results with a low recurrence rate. Further prospective studies on the factors affecting the formation of urethrocutaneous fistula should be performed to prevent this complication of circumcision.

Comparison of outcome of TIP urethroplasty with or without Buck's Fascia repair

OBJECTIVE

TIP is the most common preformed type of Urethroplasty. The intermediate barrier is used as a waterproofing layer to prevent fistula formation. Many tissues have been utilized as a barrier layer, with varying success rates. The search for a better intermediate layer will continue. In this study, we aim to evaluate the role of Buck's Fascia as a covering for the neo-urethra to prevent fistula formation in patients who underwent Snodgrass Urethroplasty.

METHODS

This prospective study was conducted between 2018 and 2022. Patients were randomly assigned to either Group 'A' or Group 'B'. Group A included patients who underwent the Snodgrass procedure with a Buck's Fascia cover, while Group B included patients whose neo-urethra was covered with the dartos flap. These patients were closely monitored for the development of short- and long-term complications in both groups, and the results were recorded.

RESULTS

The study involved 164 patients, who underwent midpenile and distal hypospadias repair using the Snodgrass technique. In Group 'A' (84 patients), the neo-urethra was covered with Buck's Fascia, while in Group 'B' (80 patients), the neo-urethra was covered with the dartos flap. The mean age of the children was (23.06 ± 16.12) months in group 'A' & (26.06 ± 14.07) months in group 'B'. mean operating time was (40 ± 11.43) minutes, in Group 'A', and (70 ± 17.43) minutes, in Group 'B'. Meatal stenosis occurred in 3.57% of children in Group 'A' and 10% of patients in Group 'B'. Urethral fistulas were encountered in 2.35% of cases in Group 'A'and 10% in Group 'B'. The difference between the groups was statistically significant.

Modified PATIO technique for urethrocutaneous fistula after hypospadias repair: Experience from a tertiary referral hospital

INTRODUCTION

Urethrocutaneous fistula (UCF) is a common complication after hypospadias repair with an incidence of 5-10%. Several techniques are described for its repair: small UCFs are frequently corrected by isolation, excision, and closure with apposition of a protective second layer. In 2008 Malone described the PATIO technique: the fistula tract is turned inside out in the urethral lumen preventing contact with passing urine without direct urethral sutures.

OBJECTIVE

Aim of our study is to present our outcomes using a modified version of the PATIO technique, with a more reproducible isolation of the tract and without its fixation at the urethral meatus.

STUDY DESIGN

We retrospectively reviewed all cases of UCFs corrected with a modified PATIO technique at our center between 2016 and 2020. Data collected from electronical clinical notes were age at UCF closure, location of UCF, presence of meatal stenosis and clinical outcomes. Data are presented as median and IQR.

RESULTS

In the study period we performed 425 urethroplasties for distal and mid penile hypospadias. The incidence of UCFs was 7% (30/425) and 25 patients underwent UCF correction with modified PATIO. Median age at repair was 4.5 years (IQR: 2.5-6.2). At a median follow-up of 3 years (IQR: 2-4) recurrence was observed in 5 cases out of 24 with one patient who was lost at follow-up (20.8%). One case was corrected successfully with re-do modified PATIO technique, while 4 are awaiting repair. One cases was lost at follow-up. UFC-recurrence was homogeneously distributed along the study period.

DISCUSSION

Risk factors for UCF recurrence are mostly the type of hypospadias, neo-urethral length, and quality of the urethral plate. Among the many existing techniques, we propose a modified version of Malone's PATIO repair. We believe that the use of four stay-suture to isolate the fistula allows a well-defined dissection of the tract along its surface, compared to the use of a single stay-suture. In our experience, there is no need to keep and fix the traction on the fistula tract to the urethral meatus, probably reflecting the efficacy of the fistula closure during the introflection, which is then maintained without traction. Limitations to our study include the retrospective nature of the review, the small sample size of the cohort and the absence of control groups.

CONCLUSIONS

Our results appear consistent with literature regarding the efficacy of PATIO principles in treating UCF. Modified PATIO seem to be particularly reproducible, showing encouraging results.

Single dartos flap versus double dartos flap in hypospadias repair: A systematic review and meta-analysis with trial sequential analysis and fragility index

INTRODUCTION

Hypospadias is a common congenital urogenital anomaly. Despite advancements in surgical techniques, still it presents challenges in management. An important aspect of hypospadias repair is the use of protective layers to cover neourethra. This review focuses on comparing the Single Dartos Flap (SDF) and Double Dartos Flap (DDF) techniques, used to cover the neourethra. These techniques differ in terms of the number of dartos layers used to cover the neourethra.

METHODS

This systematic review, follows PRISMA guidelines, included six RCTs from PubMed/MEDLINE, Cochrane Library, Scopus, Web of Science, and CINAHL. Patients with hypospadias repair with use of SDF or DDF were analyzed for outcome, Urethrocutaneous fistula, meatal stenosis, glans dehiscence, penile torsion and cosmetic outcomes. Statistical analysis was done using Review Manager, with TSA and FI ensuring result robustness.

RESULTS

Six studies met inclusion criteria, and risk of bias assessment indicated low risk across all domains. Meta-analysis results favored DDF over SDF for reducing urethrocutaneous fistula (RR 0.37, 95% CI 0.20-0.68) but showed no significant difference in meatal stenosis and glans dehiscence. DDF also associated with lower risk of penile torsion (RR 0.05, 95% CI 0.01-0.35).

CONCLUSION

The systematic review, based on randomized controlled trials (RCTs), provides evidence supporting the use of DDF over SDF in hypospadias repair, particularly in distal hypospadias using the TIP procedure. The article emphasizes the potential advantages of DDF in reducing UCF but further robust evidence is needed to confirm these results based on the findings of TSA and FI.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Cumulative sum learning curve analysis of tubularized incised plate repair for hypospadias: a study of a single surgeon with a single surgical procedure

Purpose

To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis.

Methods

We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency.

Results

CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min [interquartile range (IQR) = 125-155] to 92 min (IQR = 80-100) (P < 0.001), CR decreased from 28 (28%) to 8 (5.3%) (P < 0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P < 0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P = 0.013, P = 0.006, and P = 0.028, respectively).

Conclusions

Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99,231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.

Separation of the glanular part of the urethral plate, mobilization of the distal part of the neourethra, and creation of the glanular groove: a new modification of second-stage Thiersch-Duplay urethroplasty in proximal hypospadias repair

PURPOSE

To evaluate the effect of separation of the glanular part of the urethral plate from the underlying glans penis with creation of a glanular groove for free accommodation of the neourethra as a new modification of Thiersch-Duplay urethroplasty in proximal hypospadias repair.

PATIENTS AND METHODS

Between January 2016 and January 2022, 35 patients with proximal hypospadias underwent a modified Thiersch-Duplay two-stage procedure. The glanular portion of the urethral plate was either separated from the underlying glanular tissue or discarded if found scared with mobilization of the distal portion of the neourethra to reach the tip of the glans penis. In all patients, a few millimeter of glanular tissue is excised to create a glanular groove in which the neourethra is embedded freely.

RESULTS

35 patients were involved in this study. The patient's age at the time of operation ranged from 18 months to 10 years (median 3.7 years). The mean follow-up period was 15.7 months (ranging from 12 to 18 months). Two patients developed urethrocutaneous fistula; while, none of the patients had meatal stenosis, urethral stricture, or meatal retraction. All patients have a slit-like meatus at the tip of the penis and a good cosmetic conical shape glans appearance.

CONCLUSION

We believe that in Thiersch-Duplay urethroplasty, separation of the urethral plat from the underlying glanular tissue and creation of good glandular groove to accommodate the neourethra is associated with adequate glanular closure and minimization of post-operative meatal stenosis, glanular dehiscence, and meatal retraction.

Tubularized incised plate urethroplasty and grafted tubularized incised plate urethroplasty: systematic review, meta-analysis and trial sequential analysis

Background

Hypospadias is one of the most common genital birth defects. There are around 300 various techniques available for the repair of hypospadias. This study aims to compare the reported outcomes of Tubularized incised plate urethroplasty (TIP) and Grafted TIP (GTIP) repair in children undergoing primary hypospadias repair.

Methods

This meta-analysisadhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and we framed our research question using the population, intervention, control and outcomes format. We conducted comprehensive electronic searches across various databases, employing a Boolean search strategy with predefined search terms. Only randomized controlled trials (RCTs) were included for quantitative analysis.

Results

Totally, 10 RCTs met our inclusion criteria for quantitative analysis. The results indicated that urethrocutaneous fistula, glans dehiscence, and stricture rates were comparable between the two groups. The incidence of meatal stenosis was found to be significantly lower in the GTIP group with a relative risk (RR) of 0.32 (95% confidence interval (CI) 0.15 to 0.67).

Conclusion

The coucomes UCF, glans dehiscence, and stricture rates were comparable between the two groups. Notably, the incidence of meatal stenosis was found to be significantly lower in the grafted TIP group. In terms of operative time, our quantitative synthesis demonstrated that the TIP group had a shorter operative time than the GTIP group with significant heterogeneity.

Comparing two surgical techniques in distal hypospadias repair: Urethral mobilization vs. urethral plate tubularization

OBJECTIVES

While numerous techniques have been described for hypospadias repair, the Tubularized Incised Plate (TIP) procedure is currently the most frequently used method. On the other hand, urethral mobilization techniques have less frequent preference. In this study, we aimed to compare the outcomes of these two techniques in patients with distal hypospadias, particularly those with the urethral meatus located at the coronal and subcoronal.

MATERIAL AND METHODS

A total of 75 patients with distal hypospadias underwent surgery. Patients with glanular and midpenile hypospadias whose meatus was not located at the coronal and subcoronal levels were excluded from the study. 43 patients underwent surgery performing the Eccentric Circummeatal-Based Flap with Limited Urethral Mobilization (ECMB) method, while the remaining 32 patients were treated with the TIP. We analyzed age at surgery, urethral meatus position, ventral or glanular curvature, catheterization duration, and complications.

RESULTS

The mean age at operation was 2.6 (±1.1) years. The position of the meatus was coronal in 48 patients (64%), and subcoronal in 27 (36%). Complications consist of fistula in two patients, meatal stenosis in seven patients, and preputial redundancy in two patients. No glans retraction, wound infection or glans dehiscence was observed in any patient. Complication rates were compared and no statistically significant difference was found between the two methods (P>0.05).

CONCLUSION

Mobilization techniques may be a preferable and safe option for young surgeons due to their relative ease of perform.

Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair

INTRODUCTION

Hypospadias is a syndrome of penile maldevelopment. The primary goal of hypospadias surgery is to create a penis with normal appearance and function. Historically, the outcome of hypospadias repair has been assessed based on the need for reoperation due to urethroplasty complications (UC), including fistula formation, dehiscence, meatal stenosis, or development of a urethral stricture. The Glans-Urethral Meatus-Shaft (GMS) score is a standardized tool to predict UC. Analysis of the cosmetic outcomes of hypospadias repair based on the appearance of the reconstructed penis has been validated, and standardized scores have been published. The Hypospadias Objective Penile Evaluation (HOPE) score is a validated questionnaire used to assess postoperative cosmetic outcomes. Although predictors of surgical outcomes and UC have been well documented, predictors of optimal cosmetic outcomes are lacking in the literature. Furthermore, reoperation due to cosmetic considerations has been poorly reported.

OBJECTIVE

To identify predictors of cosmetic outcomes after hypospadias repair and to assess the reoperation rate according to cosmetic considerations.

MATERIALS AND METHODS

This prospective cohort study included 126 boys who underwent primary hypospadias repair. The severity of hypospadias, degree of penile curvature, glans width, preoperative HOPE, and GMS scores were documented. The standard technique for single-stage repairs, the tubularized incised plate urethroplasty, was performed. The primary endpoint was cosmetic outcomes evaluated by the HOPE score questionnaire six months postoperatively. Optimal cosmetic results were defined by HOPE scores ≥ 57.

RESULTS

The study population consisted of the following cases: 87 (69%) subcoronal, 32 (25%) shaft, and 7 (6%) proximal hypospadias. Among the study participants, 102 boys (81%) had optimal cosmetic results (HOPE ≥ 57), and 24 boys (19%) had surgeries with suboptimal cosmetic outcomes (HOPE < 57). Ancillary procedures were performed in 21 boys (16%), of which 14 (11%) were solely for cosmetic considerations, and 7 were secondary to UC. Using the Receiver Operating Characteristic analysis of potential predictors of optimal cosmetic outcomes, the preoperative HOPE score had the highest area under the curve (AUC = 0.79; 95% CI 0.69-0.89, p < 0.001). After multivariable analysis, the degree of penile chordee (p = 0.013), glans width (p = 0.003), GMS score (p = 0.007), and preoperative HOPE score (p = 0.002) were significant predictors of cosmetic outcomes. Although meatal location predicted suboptimal cosmetic results in univariate analysis, it was not a factor in multivariable analysis.

CONCLUSIONS

Over 80% of boys undergoing hypospadias repair achieved optimal cosmetic outcomes. More than 10% of cases underwent ancillary procedures, secondary solely to cosmetic considerations. Predictors of optimal cosmetic outcomes after hypospadias surgery included degree of chordee, glans width, and preoperative HOPE and GMS scores, which were the best predictors of satisfactory cosmetic results. Although meatal location is the main predictor of UC, it was not a predictor for cosmetic outcomes. Factors affecting cosmetic outcomes should be clearly explained to parents during the preoperative consultation.

Evaluation of Tubularized Incised Plate Urethroplasty with Spongioplasty-Dartosoraphy Reinforcement in Pediatric Hypospadias: A Randomized Controlled Study

INTRODUCTION

 The original description of tubularized incised plate urethroplasty (TIPU) was provided by Snodgrass in 1994. The results were significantly improved by several modifications. To decrease the incidence of complications, interposing a vascularized flap after tubularization of the neourethra is recommended. The extent to which the type of interposed tissue has a direct effect on the rate of complications and cosmetic outcomes after TIPU repair is considered the answer to the main hypothesis of this study.

MATERIALS AND METHODS

 This prospective controlled randomized trial was conducted in the Department of Pediatric Surgery, Al-Azhar University, Cairo, Egypt, between May 2019 and May 2023. A total of 220 patients were included in this study. Patients were randomly assigned to either group A or group B. Group A included 110 patients who underwent TIPU with spongioplasty-dartosoraphy reinforcement. The other 110 patients (group B) underwent TIPU with dorsal dartos flap interposition, without spongioplasty.

RESULTS

 Complications developed in 34 of 220 patients (15.4%). In group A, complications developed in 11 of 110 patients (10.0%). In group B, complications occurred in 23 of 110 patients (20.9%). Although the fistula rate, glanular dehiscence, disruption, and meatal stenosis were not significantly different between the study groups, the skin necrosis rate was significantly lower in group A than in group B. The overall complication rate was significantly lower in group A than in group B. Also, the difference in the mean Hypospadias Objective Scoring Evaluation between the two groups was statistically significant.

CONCLUSION

 TIPU with spongioplasty-dartosoraphy reinforcement is an effective modification of conventional TIPU. This modification appears to reduce the rate of complications and yield better cosmetic outcomes.

The long-term consequences of the hypospadias salvage repair issue

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.

Does local injection of long acting corticosteroid improve postoperative outcome of hypospadias repair? A randomized controlled trial

PURPOSE

To assess the safety and efficacy of local corticosteroid injection during hypospadias repair.

METHODS

Between May 2021 and March 2023 children less than 10 years who were admitted for hypospadias repair were divided by random allocation into two groups. We injected local corticosteroid 2 ml proximal to coronal sulcus in group A while in group B we didn't. All types of hypospadias were included in the study. We excluded patients older than 10 years and those with pre-existing complicated hypospadias (multiple fistulae and multiple surgeries), or bleeding diatheses. Pre-operative, intraoperative and postoperative variables were compared between the two groups.

RESULTS

A total of 120 patients (60 in each group) were enrolled in the study. The mean ages and preoperative variables were not significantly different. The site of hypospadias and the type of surgery were comparable in both groups. (Table) There were no significant differences between both groups regarding average blood loss and operative time in each type of surgical repair. There was a significant higher incidence of intraoperative and postoperative penile oedema in group B (P-value < 0.001) while the incidence of skin discolouration was higher in group A. Postoperative complications, described as Clavian classification, were significantly higher in group B. The incidences of superficial skin infection, meatal stenosis, urethral fistula, and recurrence with the need for redo repair were significantly higher in group B (P-value: 0.002, 0.018, 0.032, and 0.001, respectively).

CONCLUSION

Local corticosteroid injection during hypospadias repair minimize the penile oedema and decrease the incidence of postoperative functional and cosmetic complications.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of functional and cosmetic outcomes of Extended-Tubularized incised plate for mid-shaft and distal hypospadias as a modification of Snodgrass repair: a cross-sectional study

Background

Hypospadias is a congenital abnormality of anterior urethral and penile development where the urethral meatus is ectopically located on the ventral aspect of the penis. It is a relatively common condition affecting ~1 in 250 male birth. Extended-Tubularized Incised Plate (E-TIP) is a modification of Snodgrass repair by extending the midline incision to the apical part of the glans resulting in a more normal appearing location of the meatus and straight urinary stream without increasing the risk of complications.

Aim of study

To evaluate functional and cosmetic outcomes of E-TIP repair for mid-shaft and distal hypospadias as a modification of Snodgrass repair.

Patient and method

A prospective cross-sectional study including 53 cases of mid-to-distal hypospadias repaired with the E-TIP technique between November 2019 and February 2022 in Baghdad. The authors start with the standard technique described by Snodgrass, but the midline incision of the urethral plate extended up to the apical part of the glans tip, and tabularization started distally creating a slit-like a neomeatus. Outcome assessment depended on an objective evaluation of the following parameters: maximum flow rate, post-void residual, Hypospadias Objective Score Evaluation (HOSE) score, and direction of the urinary stream.

Results

The mean age was 3.4±2.1 years, ranging from 0.6 to 9 years. The mean duration of follow-up was 14.4±6.9 months, and the location of the meatus was coronal in 16 patients (30%), subcoronal in 25 (47%), and mid-distal shaft in 12 (23%). The glans width was greater than or equal to 14 mm in 46 patients (87%) and less than 14 mm in 7 (13%). Q.max was above the fifth percentile of age-related uroflowmetry nomograms for healthy children 5-15 years old in 29 boys (93.5%) and below the fifth percentile in 2 (6.5%). Post-void residual urine was less than 10% of voided volume in 28 out of 31 boys (90%) and greater than 10% in 3 (10%). Regarding cosmetic outcomes, 50 boys (94%) had good penile appearance and their HOSE score greater than or equal to 14 with a slit-like meatus located at the tip of the glans, while 3 (6%) of them their score was less than 14. The overall mean HOSE score postoperatively for all patients was 15±0.9. Six patients (11%) had a deviated urinary stream and 47 (89%) had a straight stream.

Conclusion

E-TIP repair is a good alternative to standard Snodgrass repair for mid-shaft to distal hypospadias with a good functional and cosmetic outcome, particularly the neomeatus position at the tip of the glans, which is similar to the normal one without increasing the risk of meatal stenosis.

Patient Perspectives and Outcomes in Adult Hypospadias Repair

Background Hypospadias is a common congenital anomaly that needs repair at an early age (six months to one year). Ironically, many cases in India present late due to a lack of healthcare facilities, poverty, and illiteracy. Adult patients are different from children as they are aware of their genitalia. They are concerned with the aesthetics and, predominantly, the potency. In this study, we present the perspectives and outcomes of 111 adult cases of hypospadias. Methodology In this retrospective study conducted between January 2010 and December 2020, 111 patients aged more than 14 years who were diagnosed with hypospadias of any level with or without mild-to-moderate chordee were included. Hypospadias repair using a tubularized incised plate (TIP) urethroplasty technique was performed, and patients after surgery were followed up at three months, six months, and 12 months for any complications with physical examination, uroflowmetry, and patient-related outcomes (PROs). Results Age varied from 14 years to 32 years (mean = 19.88 years, SD = 5.93). The most frequent meatus positions after chordee adjustment were distal (n = 64, 57.65%), middle (n = 25, 22.52%), and proximal (n = 22, 19.82%). Among these, four patients had penoscrotal transposition. Chordee was present in 65.7% (n = 73) of the cases. (<30° in 38.7%, n = 43; 30°-60° in 23.4%, n = 26, and >60° in 3.6%, n = 4). Chordee was corrected using many techniques, including ventral corporotomies. Urethroplasty was done using TIP and spongioplasty in 89% (n = 99), and one patient underwent inner preputial onlay flap urethroplasty. Snodgraft was used to augment the urethral plate in 10 cases. The success rate of one-stage surgery was 74.77% in our series, which significantly correlated with PROs. Uroflow varied from 12 mL/second to 18 mL/second, and in the majority of the cases, the flow rate improved over time. The most common complication was urethrocutaneous fistula in 11 (11.8%) patients, followed by glanular dehiscence in nine (8.1%) patients. Conclusions Adult patients undergoing primary hypospadias repair generally show good outcomes. Patients can have an acceptable mild degree of residual chordee and torsion, which correlate well with PROs. In our series, hypospadias fistula was the most common complication of hypospadias surgery, followed by glanular dehiscence.

A meta-analysis: single or double dartos flap layer in tubularized incised plate urethroplasty to prevent urethrocutaneous fistula?

Backgrounds

Urethrocutaneous fistula is one of the most common complications after urethroplasty. This meta-analysis aims to evaluate the superiority of double dartos flap to single dartos flap in preventing fistula during tubularized incised plate urethroplasty (TIPU), which is one of the most frequently used operations for hypospadias.

Methods

We extracted clinical trials under the following included criteria: (1) children with TIPU; (2) a comparison of single and double flap layer; and (3) record of complications with the following excluded criteria: (1) non-comparison and (2) lack of data. Finally, 13 studies from PubMed, Cochrane Library, Scopus, and Embase have been investigated, with a total of 1,185 patients from 2005 to 2022. The quality assessment was conducted according to the Cochrane handbook and the Newcastle-Ottawa scale. A mixed-effect model was utilized to weigh the risk of fistula, phallic rotation, meatal stenosis, and wound dehiscence by the Review Manager V.5.4 software.

Results

The double dartos flap layer group excels in descending the risk of postoperative fistula [odds ratio (OR) = 9.56; 95% confidence interval (CI) (4.76, 19.22); P < 0.00001] and phallic rotation [OR = 31.26; 95% CI (9.60, 101.84); P < 0.00001], while there are no differences in the rate of meatal stenosis [OR = 1.49; 95% CI (0.73, 2.70); P = 0.31] and wound dehiscence [OR = 2.30; 95% CI (0.80, 6.63); P = 0.12].

Conclusions

The routine utility of a double dartos flap layer is recommended as a potential treatment during the tubularized incised plate urethroplasty.

Systematic Review Registration

identifier PROSPERO CRD42022366294.

Urethral advancement and glanuloplasty versus tubularized incised plate urethroplasty for distal hypospadias repair: a prospective randomized study

BACKGROUND

About one in 200 to one in 300 male births has hypospadias. The prevalence of this congenital anomaly varies worldwide. The meatus is located distally in approximately 70% of cases. Several surgical techniques were described for distal hypospadias repair; despite this, there is no ideal approach. This study compares urethral advancement &glanuloplasty, and TIP techniques in terms of feasibility, duration of operation, and complications. Patients and.

METHODS

This prospective randomized comparative study was conducted at Al-Azhar University Hospitals from April 2022 to October 2022. Fifty-seven cases with different types of hypospadias were assessed for eligibility. Among them, seven cases were excluded due to the presence of severe chordee (n = 3), proximal variant (n = 2), and recurrent cases of hypospadias (n = 2). Fifty cases were randomly divided into two groups using a 1:1 ratio (computer-generated randomization). Twenty-five cases were subjected to urethral advancement and glanuloplasty, and the rest were subjected to tubularized incised plate (TIP) urethroplasty.

RESULTS

The mean age of all studied cases was 4.2 years. Approximately 52% had coronal or sub-coronal meatus, whereas 48% had glandular meatus. Both groups were matched according to age and meatus location (p > 0.05). No statistically significant difference was observed between the two groups regarding duration of operation, postoperative pain, and postoperative hospital stay. In addition, both groups did not differ significantly in late complications (meatal stenosis, meatal retraction, fistula, and glans dehiscence).

CONCLUSIONS

Both urethral advancement &glanuloplasty, and TIP urethroplasty have comparable short-term outcomes. Urethral advancement and glanuloplasty is preferred in certain conditions, especially in circumcised children or those with a narrow urethral plate.

TRIAL REGISTRATION

The study protocol was approved by the Pan African Clinical Trials Registry (number for the registry is: PACTR202211757905870) on (29/11/2022). All procedures were performed per the Helsinki Declaration.

A novel triple dartous fixation in hypospadias repair

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Outcome of spongioplasty alone as second layer of tubularised incised plate urethroplasty in patients with hypospadias

Background

Spongioplasty alone or in combination with local tissue flaps can be used as a second layer for the prevention of complications of tubularised incised plate urethroplasty (TIPU) of hypospadias repair. It can be used when wide urethral plate and well-developed robust spongiosum are present. This study aims to review the success rate and complications of TIPU performed utilising spongioplasty alone as a second layer in Type 3 well-developed robust spongiosum.

Methods

This is a retrospective observational study conducted between January 2015 and December 2019 at a tertiary care centre. A total of 21 patients aged 4–15.4 years with primary hypospadias having a Type 3 well-developed robust spongiosum, Glans score ≤ 2, Meatal score ≤ 4, and Shaft score ≤ 3 underwent TIPU using spongioplasty alone as a second layer. The hospital stay ranged from 10 to 14 days and follow-up from 12 to 36 months.

Results

Hypospadias was distal in 12 (57.1%), mid in 5 (23.8%), and proximal penile in 4 (19.1%) patients. The mean Glans Meatus Shaft score was 6.1 (G = 1.25, M = 2.95, S = 1.9) with a range of 3–9. An early post-operative complication of preputial oedema and bladder spasm developed in 1 (4.7%) patient each. Meatal stenosis developed in 1 (4.7%) patient. None developed urethrocutaneous fistula. At 3 months all patients had good urinary flow (> 15 ml/s) and good cosmesis. All the patients/parents (in case of minors) were satisfied with the result.

Conclusion

Spongioplasty alone as the second layer after TIPU for primary penile hypospadias in patients with well-developed robust spongiosal tissue is associated with minimal, easily manageable complications.

The effect of staged TIP urethroplasty on proximal hypospadias with severe chordee

Background

Proximal hypospadias with severe chordee is still a formidable challenge for most pediatric urologists, and the treatment approach remains controversial. Here, we describe a modified two-stage technique to repair proximal hypospadias with severe chordee.

Methods

We retrospectively identified 53 children referred for proximal hypospadias with severe chordee from July 2016 to July 2019, who underwent a two-stage urethroplasty. In group 1, the children were repaired with staged tubularized incised plate (TIP) urethroplasty, while Byars’ two-stage urethroplasty was attempted in group 2. We corrected chordee by releasing all remaining attachments to the corpora after degloving the penis, transceting the urethral plate, and dorsal plication. The mean age of patients in the first stage of surgery was 26.6 months in group 1 and 24.8 months in group 2. Postoperative complications in the two groups included: fistula, urethral stricture, urethral diverticulum, and glanular dehiscence.

Results

A total of 20 cases were repaired with staged TIP urethroplasty (group 1), and 33 cases were repaired with Byars’ two-stage urethroplasty (group 2). The length of follow-up in group 1 was 39.8 ± 10.1 months, and in group 2, it was 38.1 ± 8.7 months (P > 0.05). After the second stage of surgery, 1 case (5%) in group 1 and 11 cases (33.3%) in group 2 developed a urinary fistula (P < 0.05). One case (5%) in group 1 and three cases (9.1%) in group 2 had urethral stricture (P > 0.05). All strictures were cured by repeated dilation, and no patient required reoperation. No cases in group 1 and one case (3%) in group 2 had urethral diverticulum (P > 0.05). There was no residual chordee in both groups. Two cases (10%) in group 1 and 13 cases (39.3%) in group 2 required reoperation (P < 0.05).

Conclusions

Staged urethroplasty is appropriate to repair proximal hypospadias with severe chordee. Particularly, staged TIP urethroplasty is a good choice for patients with proximal hypospadias and severe chordee, especially those with better penile development, wider urethral plate, larger glans, and deeper navicular fossa of the urethra.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODES

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Role of tunica vaginalis flap and dartos flap in tubularized incisional plate for primary hypospadias repair: A retrospective monocentric study

BACKGROUND

In the tubularized incised plate (TIP) procedure, flap interposition between the skin and neourethra is highly recommended to decrease the postoperative fistula rate. However, there is no consensus regarding the ideal flap for this procedure. This study aimed to report our experiences in the one-stage TIP hypospadias surgery utilizing dartos flap (DF) (penile skin subcutaneous tissue) and tunica vaginalis flap (TVF) (parietal layer of the testis) as a tissue coverage of neourethra.

METHODS

In a retrospective study from Sep 2018 to May 2021, 16 cases of hypospadias with different types, ranging from midpenile to penoscrotal types, were managed with TIP urethroplasty using DF or TVF as a tissue coverage of neourethra were enrolled. The demographic characteristics of the participants, type of hypospadias, outcome, and complications were analyzed and compared.

RESULTS

We used TVF and DF as soft tissue coverage in 11 (68.8%) and 5 (31.3%) patients, respectively. The mean age was 56.38 ± 47.83 months. Mid-penile, proximal, and penoscrotal hypospadias were presented in 3 (18.8%), 8 (50.0%), and 5(31.2%) patients, respectively. The total success rate was 14 (87.5%), while 2 (12.5%) patients developed a urethrocutaneous fistula, which required delayed closure later. In comparison between TVF and DF groups: the TVF was applied in all patients with moderate and severe chordee and all patients with penoscrotal hypospadias, and six patients with proximal hypospadias, while only three patients with mild chordee and two patients with proximal hypospadias used the DF and showed statistical significance between groups (p < 0.001 and 0.012) respectively. The success rate was 90.9% vs. 80.0% in TVF and DF groups, respectively, with no statistical significance between groups (p = 1.000).

CONCLUSIONS

In the primary TIP repair, the TVF is a practical option as a DF for the interposition cover of a neourethra, especially in penoscrotal and proximal hypospadias with severe chordee.

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

INTRODUCTION

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Masculinizing surgery in disorders/differences of sex development: clinician- and participant-evaluated appearance and function

OBJECTIVES

To report the long-term follow-up outcomes of masculinizing surgery in disorders/differences of sex development (DSD), including both physicians' and patients' perspectives on appearance and functional outcome, including sexuality.

PATIENTS AND METHODS

In total, 1040 adolescents (age ≥16 years) and adults with a DSD took part in this multicentre cross-sectional clinical study in six European countries in 2014/2015. Of those, 150 living in other than the female gender had some kind of masculinizing surgery: hypospadias repair, orchidopexy, breast reduction and/or gonadectomy. The study protocol included medical data collection, an optional genital examination, and patient-reported outcomes including satisfaction with appearance and current sexual functioning.

RESULTS

Diagnoses included partial and mixed gonadal dysgenesis (45,XO/46,XY; n = 38), Klinefelter syndrome/46,XX males (n = 57), and various 46,XY DSDs (n = 42; e.g. partial androgen insensitivity syndrome, severe hypospadias) and 13 with other diagnoses. Of the participants, 84 underwent hypospadias surgery, 86 orchidopexy, 52 gonadectomy and 32 breast reduction (combinations possible). Physicians evaluated anatomical appearance at genital examination as poor in approximately 11% of patients. After hypospadias surgery, 38% of participants reported that they were (very) dissatisfied with anatomical appearance and 20% with function. The physician and patient evaluations were moderately correlated (r = 0.43).

CONCLUSION

The majority of participants were neutral to satisfied with the appearance and function in the long-term after masculinizing surgery. Given the initial severe phenotype and a risk of unsatisfactory results after masculinizing surgery in DSD, treatment should be handled by experienced multidisciplinary teams in order to optimize the postoperative results.

Adult distal hypospadias repair is safe and easy

The success level of hypospadias repair in adults still needs to be established on a more extensive scaled study. Therefore, we conducted this study to document the success level of hypospadias repair in adults. This study presents the results of 620 adult distal hypospadias patients treated with TIPU operation. A retrospective study was performed for adult patients who underwent TIPU operations from February 2016 to September 2020. Patients who had distal hypospadias after the age of 16 were included in our study. The average operation time was between 35 and 65 min (50 min.). Complications developed in 79 (12.7%) patients: 37 urethral fistulas, 24 meatal stenosis, 11 anastomotic stenosis and 7 had a complete failure. In conclusion, primary adult distal hypospadias surgery is safe and easy. The complication rates are similar when compared to the paediatric group. As the surgical experience advances, the success of the operation increases in direct proportion.

At The Forefront of Penile Surgical Reconstruction: A Bibliometric Study of the 100 Most-Cited Articles

PURPOSE

The citation count of a scientific article is considered as the recognition it received from this field. The purpose of this bibliometric analysis was to identify the top 100 most-cited scientific articles in penile surgical reconstruction.

METHODS

The Web of Science database was used to extract the top 100 most-cited articles. Individual articles were reviewed to identify the authorship, published journal, journal impact factor (IF), primary disease, article type, institution and country of origin, and year of publication.

RESULTS

The top 100 most-cited articles were published between 1947 and 2013. The number of citations ranged from 23 to 233. Journal of Urology contributed the most articles (n = 36). Articles with a high level of evidence like prospective analysis (n = 5), systematic review and meta-analysis (n = 2), and guideline (n = 1) were all published after 2000. The average citation per year of articles published in high-IF journals was significantly higher than that of other articles (p = 0.0129). There was a positive linear correlation between citation count per year and publication year (r² = 0.26, p < 0.001). Among the top 100 articles, 74 articles were interlinked via citation of each other. The major topic of co-citation network was the application of flaps in penile reconstruction.

CONCLUSIONS

The analysis of top 100 most-cited articles facilitates the comprehensive recognition of current focus in the field of penile surgical reconstruction, which is the exploration of flaps and development of new techniques in penile reconstruction. In the future, more attention should be paid to evidence-based medicine to provide high-level evidence for research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Application of Allogeneic Human Acellular Dermal Matrix Reduces the Incidence of Fistula in Hypospadias Repair

BACKGROUND

Urethrocutaneous fistula is one of the most common complications arising from hypospadias surgery. The purpose of our study was to investigate the effectiveness and safety of allogeneic human acellular dermal matrix (HADM) application as a means of preventing the occurrence of urethrocutaneous fistula following hypospadias surgery.

METHODS

This is a non-randomized study of 219 cases (out of 270 patients with hypospadias) which satisfied inclusion and exclusion criteria. These patients were divided into two groups: 101 HADM patients, and 118 control patients (who did not receive HADM). In the control group, 77 boys were treated by single-stage urethroplasty (TIP) and 41 underwent staged urethroplasty (Thiersch-Duplay). In the HADM group, 59 boys underwent the TIP and 42 underwent the Thiersch-Duplay. In the postoperative period, we recorded the incidence of infection, urethrocutaneous fistula, and urethral stricture complications in these two groups of patients. The effectiveness and safety of HADM in preventing urethrocutaneous fistula following hypospadias surgery were evaluated according to these indicators.

RESULTS

In the control group, following the operation there were 16 cases of infection, 38 cases of urethrocutaneous fistula after extubating, and 5 cases of urethral stricture. In the HADM group, there were 19 cases of postoperative infection, 12 cases of urethrocutaneous fistula after extubating, and 5 children with urethral stricture. In comparing the two groups, it was found that the postoperative infection rate (13.6 vs. 18.8%) and the incidence of urethral stricture (4.2 vs. 5.0%) were not statistically significant (P > 0.05), while the postoperative urethrocutaneous fistula rate (32.2 vs. 11.9%) was statistically significant (P < 0.001).

CONCLUSION

It is found that HADM application can significantly reduce the incidence of urethrocutaneous fistula complications, without increasing the risk of infection and urethral stricture.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasonographic Evaluation of the Hypospadiac Penis in Children

INTRODUCTION

Identifying key anatomical features of the hypospadiac penis is crucial to better understanding this pathology and guiding surgical reconstruction plans, thereby achieving superior functional and cosmetic outcomes.

OBJECTIVE

To Assess the feasibility and precision of penile ultrasonography (PUG) in determining key structural features for hypospadias cases (including distal extent of the spongiosal component of the urethral plate, to elucidate the healing process following tubularised incised-plate urethroplasty).

PATIENTS AND METHODS

Twenty-five children with hypospadias were assessed using PUG prior to surgical repair and then again under general anesthesia. Preoperative images were acquired using ultrasonography in sagittal and transverse planes, then later compared with anatomical findings obtained during surgical repair of urethral hypoplasia.

RESULTS

Median patient age was 1.2 years (range 0.5-12) and hypospadias types included coronal 17/25 (68%), mid-penile 5/25 (20%), and proximal penile 3/25 (12%). Distinct layers of the corpus spongiosa and mucosal layer, Buck fascia, tunica albuginea, glans, corpora cavernosa, and penile skin were delineated so that their spatial inter-relationship could be assessed. Distal extent of the spongiosal component of the urethral plate was determined by the mid-glans B-B line. The extent of urethral hypoplasia identified by PUG was relatively similar to measurements obtained intraoperatively.

CONCLUSION

PUG is a feasible and accurate approach to evaluating penile configuration in children with hypospadias. Distal extent of the spongiosal component of the urethral plate was accurately determined, hence PUG could potentially be used to improve surgical planning and appraisal of current repair procedures.

Pediatric urology research in 2020: A bibliometric analysis of the top 100 most cited articles

BACKGROUND

Pediatric Urology deals with genitourinary diseases. Present study aimed to collect the top-cited article in Pediatric Urology in order to define the most debated and studied topics.

METHODS

The journals reported in "Urology & Nephrology" category of the 2019 edition of Journal Citation Reports, together with the most relevant journals of "Transplantation," "Pediatrics," and "Surgery" categories, were browsed. The articles of interest in Pediatric Urology with more than 50 citations were collected. A bibliometric analysis was performed to collect the top 100 cited articles.

RESULTS

The top-cited articles were published in 27 journals (23%), with a median impact factor of 2.676 (IQR 1.981-5.642). Seventeen of them (63%) belonged to "Urology and Nephrology" category. The median number of citations was 82 (IQR 64-113). The most productive journal, with 23 articles, was "The Journal of Urology." Forty-eight top-cited articles were Guidelines or Reviews of the literature and only four papers were randomized controlled trials. The most relevant topic was "congenital anomalies" with 18 articles. As to minimally invasive surgery, eight studies were identified. All of them dealt with robotic-assisted laparoscopic surgery. Two articles reported the current evidence about transitional care.

CONCLUSIONS

The top-cited articles were dispersed among journals of different areas. Current scientific literature deal with congenital anomalies, more specifically with obstructive uropathies and hypospadias. In the last decade, one of the most relevant innovation in pediatric urology was the introduction of robotic surgery. Transitional care has become a timely topic.

Symptomatic corpus spongiosum defect in adolescents and young adults who underwent distal hypospadias repair during childhood

INTRODUCTION AND OBJECTIVE

Several popular surgical techniques have been described for the repair of distal hypospadias; however, the role of repairing the corpus spongiosum was rarely discussed. Herein we review our experience with adolescents who underwent hypospadias repair during childhood. Their main complaints were partially or totally related to spongiosum deficiency, the surgical outcomes are also discussed.

METHODS

Between 2007 and 2018, 25 patients aged between 13 and 28 years of age (median 19 years) were operated upon to repair the deficiency or absence of corpus spongiosum in addition to a Thiersch-Duplay urethroplasty. Their records indicated that the primary hypospadias repairs during childhood included MAGPI (N = 10) and TIPU (N = 9), in 6 patients the repair of the distal hypospadias was unknown. The main complaints were; abnormal urinary stream which patients described as spraying and/or dripping of urine (N = 10) and distal urethral swelling during voiding and dripping of urine post voiding (N = 15). Eight patients reported that they were treated for symptomatic recurrent urinary tract infections by their primary physicians. In 5 patients, the urethral wall was thin and covered with adherent epidermis only. In 20 patients, the laterally displaced spongiosum pillars were well-defined, 4 of whom exhibited mild chordee. In 14 patients the spongiosum pillars were mobilized and approximated using interrupted absorbable sutures. Four patients had spongiosum deficiency and urethral swelling resulting in mild diverticulum formation. The urethral wall was plicated and covered with the spongiosum and/or dartos flaps. In 4 patients the spongiosum pillars were fixed and could not be mobilized to provide a tension-free closure. In these cases, a dartos flap harvested from the scrotum, and used to cover the urethral wall and was sutured on either side to the spongiosum pillars. 12/25 patients underwent glandular contouring and/or meatoplasty simultaneously to improve the penile esthetics.

RESULTS

The follow-up period varied between 18 months and 7 years (mean 3.5 years). 24/25 patients reported a normal steady urinary stream, absence of urethral swelling during voiding and none (22) or minimal (2) postvoid droplets of urine which soiled the underwear. One patient developed glans dehiscence and is voiding through a coronal meatus; he declined further surgery. None developed symptomatic urinary infection. The spongioplasty corrected the mild curvature in all 4 patients.

CONCLUSIONS

Failure to recognize and/or correct the deficient corpus spongiosum during the repair of distal hypospadias during childhood may become symptomatic during adolescence however, the abnormality can be corrected successfully.

Cosmetic outcomes of grafted tubularized incised plate urethroplasty in primary distal penile hypospadias: prospective comparative study with the classic Snodgrass repair

Background

To compare the outcomes between classic tubularized incised plate (C-TIP), known as Snodgrass urethroplasty, and grafted TIP (G-TIP) in the repair of primary distal penile hypospadias.

Methods

Parents of all children presented to our tertiary care institution with primary distal penile hypospadias were asked to participate in this study. Patients were equally randomized using closed envelope method into two groups; Group A underwent repair using G-TIP and Group B underwent repair using the C-TIP. Circumcised cases and/or cases with penile chordee > 30 degrees were excluded from this study. Urethral catheter was kept for 7 to 10 days after surgery. The success rate and cosmetic outcomes assessed by HOSE score were evaluated at 6-month postoperatively.

Results

A total of 55 patients were recruited in each group. One hundred and seven patients of the 110 patients (54 and 53 in groups A and B, respectively) were evaluated at 6-month postoperatively using HOSE score. All preoperative data were comparable in both groups. Success was documented in 49/54 patients (90.7%) in group A. The five failures were secondary to two cases of glans dehiscence and three cases of residual postoperative chordee. Whereas, success was documented in 48/53 patients (90.5%) in group B. Complications were: a case of meatal stenosis, three cases of fistula, and a case of combined meatal stenosis and fistula. The HOSE score was comparable between the two groups (15.4 ± 1.09 vs. 15.6 ± 0.55; p = 0.29). However, the operative time was statistically longer in the G-TIP compared with the C-TIP (91.4 ± 6.2 min vs. 85.2 ± 6.3 min; p < 0.001), respectively.

Conclusion

The G-TIP urethroplasty provided comparable results with C-TIP in terms of cosmoses, success rate, and complications. However, G-TIP was accompanied with significantly longer operative time.

The Plate Objective Scoring Tool (POST): Further Reflections and Extended Applications

Hypospadias is a common birth defect of the male external genitalia. However, there are conflicting arguments about the optimal classification approach and ideal surgical technique. We have introduced the Plate Objective Scoring Tool (POST) to define critical glanular phenotypic landmarks of the urethral plate. We propose that POST can objectively, reproducibly, and accurately determine urethral plate quality, thus permitting robust comparison between the different surgical techniques commonly utilized in hypospadias repair. Furthermore, the POST scoring system represents a versatile tool that can objectively quantify key variables in hypospadiology that are currently not well defined. Further validation of POST should lead to better identification and management of postoperative complications.

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Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results

INTRODUCTION

Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need for a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-years pilot study on stented/un-stented distal urethroplasties.

MATERIALS AND METHODS

A total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by the same pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5). Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge. The median follow-up was 6.4 years (range 1.5-8.1). All patients received at least one post-operative clinical-cosmetic examination (HOSE). The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P < 0.05) for statistical analysis.

RESULTS

Of 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P = 1.000).

CONCLUSION

Long-term follow-up is mandatory to know redo-urethroplasty rate and cosmetic outcome after distal stented/un-stented repair. Further studies are needed to evaluate the role of catheter placement and the definitive outcome in distal urethroplasty.

The Histopathological Effect of Aloe Vera on the Wound Healing Process in a Surgically Created Tubularized Incised Plate Urethroplasty Model on Rats

BACKGROUND

Hypospadias is a common congenital anomaly which is determined as an abnormal urethral opening on the ventral face of penis. The purpose of this rat model study was to research the effect of topically applied Aloe vera after a tubularized incised plate urethroplasty (TIPU).

METHODS

The TIPU model was applied to male Wistar albino rats. A total of 30 rats were randomly grouped into 3 groups of 10. Group I was assigned as the control group, treated with 0.9% saline only twice a day for 15 days. Group II received topical Aloe vera gel once a day and Group III received Aloe vera gel twice a day. Spongiofibrosis was graded as 0: none, 1+:≤10% tissues involved, 2+:10%-49% tissues involved, 3+: ≥ 50% tissues involved.

RESULTS

A higher degree of fibrosis and inflammation was determined in the Group I subjects than in Groups II and III. Fibrosis of grade 3+ was observed in 33% of the control group and not in any of the two Aloe groups (p = 0.043). Inflammation of grade 3+ was seen in 66.7% of the control group, in 10% of Group II, and in 33% of Group III (p = 0.02).

CONCLUSIONS

The topical application of Aloe vera to a surgically created tubularized incised plate urethroplasty model decreased inflammation and fibrosis that may affect the success rates of this operation.

Extended TIP vs. Standard TIP for primary distal hypospadias repair: randomized study for comparing functional and cosmetic outcomes

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.

Comparison of post-urethroplasty complication rates in pediatric cases with hypospadias using Vicryl or polydioxanone sutures

Objective

Hypospadias is a common congenital problem among male newborns. Both rapid absorbable sutures (polyglactin, Vicryl) and delayed absorbable sutures (polydioxanone, PDO) are used in hypospadias repair based on the surgeon's preference. This study was conducted to compare post-urethroplasty complication rates in pediatric patients with hypospadias using Vicryl or PDO sutures.

Methods

This is a retrospective study which was designed and performed on 583 children aged 1–7 years old who had undergone hypospadias repair from January 2012 to December 2018. Required data were obtained from the patients' medical records.

Results

Overall, post-surgical complications were observed in 60 (10.3%) patients comprising urethro-cutaneous fistula (n=39, 6.7%), meatal stenosis (n=10, 1.7%), urethral stricture (n=7, 1.2%), and glans dehiscence (n=4, 0.7%). The mean age of the children with complications was 3.0±1.3 years. According to Kaplan-Meier estimate, the interval between surgery and development of complications was significantly shorter in the Vicryl group (p=0.037). Overall, complications were more prevalent in Vicryl suture than PDO suture (15.1% vs. 5.3%, p<0.001). Regression model revealed that in comparison to the distal type, proximal hypospadias (odds ratio [OR]:103.9, 95% confidence interval [CI]: 32.2–334.9, p<0.001) and mid-shaft hypospadias (OR: 82.9, 95% CI: 25.9–264.6, p<0.001) while using Vicryl suture instead of PDO suture (OR: 62.4, 95% CI: 21.2–183.8, p<0.001) increased the odds of developing post-urethroplasty complications.

Conclusion

We suggest PDO suture in the repair of hypospadias due to its lower complication rate, especially in cases of proximal and mid-shaft hypospadias which can get more complicated than the distal type.

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

INTRODUCTION

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results

INTRODUCTION

Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need of a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-year pilot study on stented/un-stented distal urethroplasties.

MATERIALS AND METHODS

A total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by one pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5). Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge. The median follow-up was 6.4 years (range 1.5-8.1). All patients received at least one post-operative clinical-cosmetic examination (HOSE). The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P<0.05) for statistical analysis.

RESULTS

Of 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P=1.000).

CONCLUSION

Long-term follow-up is mandatory to know redo-urethroplasty rate and cosmetic outcome after distal stented/un-stented repair. Further studies are needed to evaluate the role of catheter placement and the definitive outcome in distal urethroplasty.