Tubularization of the incised urethral plate (Snodgrass procedure) for primary hypospadias surgery

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.

A cover flap reduces the rate of fistula after urethroplasty whatever the severity of hypospadias

OBJECTIVE

To determine which patients should benefit from the interposition of a well-vascularized flap between the neourethra and the penile skin and if it should be performed even in mild hypospadias.

PATIENTS AND METHODS

A retrospective study on patients with a primary hypospadias repair was performed (2003-2017). Only patients undergoing urethroplasty based on the principle of a tubularization were selected to ensure comparable groups. Patients were assigned in two groups according to the use or not of a cover flap. Univariate analysis and adjusted logistic regression were used to evaluate the relation between postoperative complications, the severity of hypospadias, the use of flap and patients' characteristics.

RESULTS

Three-hundred and seventy-six patients were included with anterior (59.3%), midshaft (27.4%) and posterior hypospadias (13.3%). The median follow-up was 54 months (24 months-17 years). The overall rate of fistula was 11.7% (n = 44). Comparing the outcome in children with flap (n = 217) to controls (n = 159) showed that the use of a flap reduces the rate of fistula (6.5 vs 18.9%, p < 0.001). Stratification of the study according to the phenotype reveals that the more severe the hypospadias, the more protective was the flap (OR = 2.6 for anterior, 5.5 for midpenile, 7.1 for posterior hypospadias). The flap remains nevertheless significantly effective whatever the phenotype (p < 0.05 for anterior, p = 0.01 for midpenile, p = 0.02 for posterior hypospadias).

CONCLUSIONS

The more severe the hypospadias, the more effective is the cover flap to avoid fistula. It remains nevertheless suitable even in anterior hypospadias and the use of a cover flap should not be limited to the surgery of severe phenotypes.

MMP-2 and TIMP-2 expression, quantitative analysis and biomechanical changes in scar hypertrophy after autologous free transplantation of rabbit oral mucosa and scrotal skin

This study aimed to investigate the long-term scar hypertrophy in the rabbit transplanted oral mucosa and scrotal skin with changed matrix environment, as well as the scar location expression, quantitative analysis of matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of metalloproteinase-2 (TIMP-2) and biomechanical changes in the transplanted tissues. The split-thickness skin grafts were collected from the oral mucosas and scrotal skins of 30 male rabbits, and prepared into reelpipes for autologous transplantation into the rabbit back muscular tissues. Samples were collected to carry out elastic tensile mechanical detection and histological observation. The maximum longitudinal tensile displacement of scrotal skin before 8 weeks of transplantation was greater than that after 8 weeks of transplantation (P < 0.05). The expression intensities of MMP-2 and TIMP-2 in the oral mucosa and in scrotal skin at 2 W time point were higher than those at T _o time point (P < 0.05). The expression quantities of TIMP-2 in oral mucosa and scrotal skin during 8-24 W were higher than those of MMP-2 (P < 0.05). At 8 W time point, the TIMP-2/MMP-2 ratio in scrotal skin was higher than that in oral mucosa (P < 0.05). MMP-2 and TIMP-2 expression in normal oral mucosa and scrotal skin is weak, but their expression is remarkably up-regulated after 2 weeks of transplantation, revealing that scar formation was related to the high expression of MMP-2 and TIMP-2. At the 8th-24th weeks, the AOD values of TIMP-2 in oral mucosa and scrotal skin are apparently higher than those of MMP-2; moreover, the TIMP-2/MMP-2 ratio in scrotal skin at the 8th week was higher than that in oral mucosa, which can well explain the earlier scar formation in scrotal skin than in oral mucosa, and it also suggests that the different expression levels between TIMP-2 and MMP-2 may account for the important cause of scar formation.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

The effect of dorsal dartos flaps on complication rates in hypospadias repair: a randomised prospective study

AIM

This study prospectively analysed the effect of using a dartos flap on the complication rates of TIPU (tubularised incised plate urethroplasty) in hypospadias repair.

MATERIAL AND METHODS

Patients having TIPU repair for hypospadias at our university hospital between January 2010 and August 2013 were prospectively divided into two groups. Group 1 had TIPU repair with dorsal dartos flap, whereas group 2 had flapless repair. At the end of the follow-up period (mean 23.3 m, median 20.2), complication rates were compared between two groups.

RESULTS

There were 107 patients in each group. The overall complication rate was 9.3%. The complication rates were 12.1% in group 1 (6 glans dehiscence and 7 fistula) and 6.5% in group 2 (2 glans dehiscence and 5 fistula). The differences between complication rates and fistula were statistically insignificant (p = 0.2511 and p = 0.7710, respectively).

CONCLUSION

Our prospective and randomised study found that the use of dartos flaps in hypospadias offers no statistically significant advantage over flapless repair for complication rates.

Urethroplasty by use of turnover flaps (modified mathieu procedure) for distal hypospadias repair in adolescents: comparison with the tubularized incised plate procedure

PURPOSE

The purpose of this study was to examine whether urethroplasty with a turnover flap, as an alternative method of distal hypospadias repair in adolescents, improves the outcome of surgery.

MATERIALS AND METHODS

Between January 2004 and December 2013, a total of 38 adolescents (aged 11-17 years) underwent distal hypospadias repair with either the tubularized incised plate (TIP) procedure (n=25) or the turnover flap procedure (n=13). The turnover flap procedure was performed with a proximal, ventral penile flap that was turned over to cover the urethral plate. Patient demographics, perioperative outcomes, complications, and postoperative uroflowmetry in each surgical group were analyzed retrospectively.

RESULTS

The patient demographics were similar in the two groups. There were no significant differences in perioperative outcomes between the groups, including mean operative time, duration of hospital stay, and urethral catheterization. The number of patients with at least one complication, including wound dehiscence, urethrocutaneous fistula, meatal stenosis, and urethral stricture, was lower in the turnover flap group (1/13, 7.7%) than in the TIP group (11/25, 44%, p=0.030). The incidence of meatal stenosis was lower in the turnover flap group (0/12, 0%) than in the TIP group (6/25, 24%). In postoperative uroflowmetry, the plateau-shaped curve rate was lower in the turnover flap group (1/12, 8.3%) than in the TIP group (5/19, 26.3%); the peak flow was higher (p=0.030).

CONCLUSIONS

The turnover flap procedure is clinically useful for repairing adolescent distal hypospadias because it offers lower complication rates and better functional outcomes than TIP.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Role of the urethral plate characters in the success of tubularized incised plate urethroplasty

Background:

Today, tubularized incised plate (TIP) urethroplasty is the most commonly performed operation for distal and mid-penile hypospadias. Reports from different centers worldwide confirm its nearly universal applicability and low complications rate.

Aim:

Evaluation of the urethral plate characters and its effect on the outcome of TIP urethroplasty.

Materials and Methods:

Between 2010 and 2013, 100 children with primary distal penile hypospadias underwent TIP urethroplasty. Urethral plates were categorized as flat, cleft, and deeply grooved. Postoperatively, patients were followed-up for evaluation of meatal stenosis, fistula formation, and glandular dehiscence at 1^st, 3^rd and 6^th months. Patients were followed-up for urethral calibration by urethral sound 8 Fr at 3^rd and 6 months follow-up. Data were statistically analysed using Epi info program to correlate between the width, plate shape, and complications.

Results:

Mean age at surgery was 4.3 years. Patients were followed-up for an average period of 6.4 months. Pre-operative location of the meatus was reported as coronal in 46, subcoronal in 50 and anterior penile in 4 cases. Urethral plate characters were flat in 26 cases, cleft in 52, and deeply grooved in 22. Urethral plate width was >8 mm in 74 cases and <8 mm in 26. Patients with urethral plate <8 mm had a statistically significant higher fistula rate (P = 0.004) and failed 8 Fr calibrations in 26.9% (P = 0.01) compared with the patients with urethral plate >8 mm. In addition, we also founds higher fistula rate and failed 8 Fr calibrations in flat urethral plate.

Conclusions:

An adequate urethral plate width (>8 mm) is essential for successful TIP repair. Lower success rates with flat plates may need buccal mucosal augmentation to improve the results.

The use of a perimeatal-based penile skin flap to cover the repair of a tubularized incised plate urethroplasty: from experimental surgery to clinical practice

OBJECTIVE

To prospectively evaluate the efficacy and safety of a perimeatal-based penile skin flap for neourethral coverage after repair of distal hypospadias with tubularized incised plate urethroplasty (TIPU).

METHODS

In 12 New Zealand white rabbits a ventral urethral defect was created and reconstruction was accomplished with continuous suture. An epithelialized defect-based flap was harvested from the penile skin to cover the repaired defect. The animals were euthanized on the 28th postoperative day and their penises were processed for microscopic examination. In 32 children with distal hypospadias a TIPU was performed. A penile skin flap was created immediately below the distal end of the neourethra and used to cover the urethroplasty.

RESULTS

Histological examinations revealed complete restoration of continuity of the stratified squamous epithelium without evidence of inflammation or fistula formation with full consistency with the underlying papillary reticular and corium. There were no cases of fistula formation. One patient developed meatal stenosis. All patients had a satisfactory cosmetic appearance and excellent functional results.

CONCLUSION

The formation of a perimeatal-based skin flap is a simple and safe method of providing additional cover for the constructed neourethra after TIPU, minimizing the fistula rate.

Comparative Study of Snodgrass and Mathieu's Procedure for Primary Hypospadias Repair

Objective. Present study was undertaken to compare the results of two single stage hypospadias repairs, namely, Tubularized Incised Plate (TIP) repair and Mathieu's repair. Methods. The study included 100 patients of distal penile hypospadias, from January, 2008 to January, 2013. After a detailed history, local examination was performed with reference to the site of meatus, shape of glans, and presence of chordee. TIP repair was performed in 52 patients and Mathieu's repair in 48 patients. On follow-up, the patients were examined for the position of meatus, shape of meatus, urinary stream, urethrocutaneous fistula, and stricture formation. Results. The mean age of presentation was 6.2 ± 3.2 years (range 1.5–15years). The mean operative time was 63.7 ± 14.3 (45–90) minutes and 95.0 ± 19.1 (70–125) minutes in TIP and Mathieu's repair, respectively.Complications after surgery were urethero cutaneous fistula in 3(5.76%) and 7 (14.5%), meatal stenosis in 3(5.33%) and 4(8.33%), wound infection in 19.2% and 8.3% cases in TIP repair and Mathieu repair, respectively. The shape of meatus was slit-like and vertically oriented in 48(92.3%) patients who had undergone TIP repair. Conclusion. The Snodgrass repair is significantly faster, with more natural cosmetic appearance of the meatus than the Mathieu's repair.

Can spongioplasty prevent fistula formation and correct penile curvature in TIP urethroplasty for hypospadias?

OBJECTIVE

To clarify whether spongioplasty decreases the complications rate and the degree of penile curvature in TIP urethroplasty.

METHODS

From 2007 to 2011, 47 patients underwent TIP repair. Thirty-seven underwent spongioplasty, while 10 did not because their bifurcated spongy tissues could be not clearly identified. We investigated whether spongioplasty reduced the incidencerates of complications such as urethrocutaneous fistula. We also evaluated whether spongioplasty contributed to resolving or decreasing penile curvature. In addition, we assessed how many of the patients that underwent spongioplasty did not have to undergo dorsal plication.

RESULTS

Among the 47 patients who underwent TIP repair, postoperative complications occurred in 3 (8%) of the 37 patients that underwent spongioplasty and 1 (10%) of the 10 who did not. Spongioplasty did not decrease the complications rate of TIP repair. As 15 of the 47 patients demonstrated a straight penis before spongioplasty, the effect of spongioplasty on the correction of penile curvature was analyzed in 32 patients. Dorsal plication was avoided in 19 patients (59%) because their penile curvature had been decreased to within the permissible range (<15°) by spongioplasty.

CONCLUSION

We conclude that spongioplasty can not replace dartos flap coverage of the neourethra after TIP urethroplasty because it did not produce a significant reduction in the complications rate; however, spongioplasty could be used as an additional procedure because it reduced the degree of penile curvature and allowed dorsal plication to be avoided in more than half of the hypospadiac patients that displayed moderately severe curvature.

Coverage of urethroplasty in pediatric hypospadias: randomized comparison between different flaps

OBJECTIVES

The use of covering urethroplasty with flaps in hypospadias surgery has been well recommended. Various techniques have been described for flap harvesting. The aim of the present study was to compare the outcome and complication rate of dorsal preputial flaps and ventral dartos flaps.

METHODS

A total of 130 patients were prospectively evaluated from January 2008 to December 2011. Using the tubularized incised plate urethroplasty procedure, urethroplasty was carried out by a single surgeon. Patients were randomly divided in two groups: group A (57 patients), in which a preputial flap was carried out using three different techniques; and group B (73 patients), in which a single or a double ventral dartos flap was used.

RESULTS

A total of 41 complications occurred in 24 patients. Urethrocutaneous fistulas were observed in 14.9%, quite equally distributed between groups A and B. There was only one urethrocutaneous fistula in a patient treated with the double ventral dartos flaps. Five cases (3.8%) of glans dehiscence were observed: four after single ventral dartos flap and one after dorsal preputial flap. Six patients in group A and seven in group B experienced meatal stenosis. In three cases of iatrogenic torsion of the penis, a dorsal preputial flap was laterally transposed. Finally, a lower complication rate was observed for double ventral dartos flap versus the other techniques.

CONCLUSIONS

The use of a double ventral dartos flap should represent the first-line technique for coverage of distal urethroplasty.

Multicentric experience on double dartos flap protection in tubularized incised plate urethroplasty for distal and midpenile hypospadias

PURPOSE

We report a multicenter experience using double dartos flap to protect the neourethra in TIP urethroplasty for distal and midpenile hypospadias.

METHODS

A total of 394 patients underwent tubularized incised plate urethroplasty for primary distal and midpenile hypospadias using double dartos flap protection by ten pediatric surgeons and urologists at five different institutions.

RESULTS

Tubularized incised plate urethroplasty protected by a double dartos flap was simple to perform and flaps were easy to obtain. Complications occurred in 23 patients (5.83%): fistulas 1.01% (4 cases), stenosis 0.25% (1 case), mild stenosis 2.53% (10 cases), dehiscence of ventral cutis 0.50% (2 cases) and penile torsion 1.26% (5 cases). All fistulae had a spontaneous resolution.

CONCLUSION

Double dartos flap to protect tubularized incised plate urethroplasty is safe with a low complication rate. The neourethra is covered entirely with a double layer of vascularized tissue and the double coverage appears a good choice for preventing urethrocutaneous fistula formation.

Snodgrass hypospadias repair with onlay overlapping double-layered dorsal dartos flap without urethrocutaneous fistula: experience of 156 cases

OBJECTIVE

To evaluate the neourethra covering created by a vascularized overlapping double-layered dorsal dartos flap for preventing urethrocutaneous fistula in the Snodgrass hypospadias repair (tubularized incised plate).

PATIENTS AND METHODS

Between March 2003 and January 2008, 156 boys (mean age, 4.5 years) were enrolled for hypospadias repair. Preoperative position of the urethral meatus was subcoronal in 37, at the distal shaft in 61 and mid-shaft in 58 boys. All patients underwent the Snodgrass hypospadias repair. The neourethra was then covered with an overlapping double-layered dorsal dartos flap before glans and skin closure.

RESULTS

All 156 patients underwent successful reconstruction. With a mean follow up of 23 months (range 6-42), all boys had a satisfactory subjective cosmetic and functional result with a vertically oriented, slit-like meatus at the tip of the glans. No urethrocutaneous fistula or urethral stenosis occurred.

CONCLUSION

As the neouretha covering is an integral part of the Snodgrass hypospadias repair, a dorsal well vascularized double-layered dartos flap is a good choice for preventing urethrocutaneous fistula formation.

Outcome of pediatric hypospadias repair in adulthood

PURPOSE

To review the evolution of the technique of hypospadias repair.

METHODS

A search of Pubmed, Medline and the Journal of Pediatric Urology was performed, and papers dealing with surgical techniques for hypospadias repair were critally reviewed. Special emphasis was given to papers on the effects in the long term of hypospadias repair on voiding and sexual dysfunction.

RESULTS

The techniques for hypospadias repair have evolved over the years. The most popular technique now is tubularized incised plate urethroplasty. Long-term results with the use of the new techniques of the hypospadias repair in terms of voiding and sexual problems should be addressed.

CONCLUSION

There is a need for valid studies on the outcomes of hypospadias repair in adults that were performed in childhood in terms of cosmetic appearance, voiding and sexual performance.

Current concepts in hypospadias surgery

Anatomical anomalies in hypospadias are an abnormal ventral opening of the urethral meatus, abnormal ventral curvature of the penis and abnormal distribution of the foreskin around the glans with a ventrally deficient hooded foreskin. The techniques of hypospadias surgery continue to evolve. The current standard of care for hypospadias repair includes not only a functional penis adequate for sexual intercourse and urethral reconstruction offering the ability to stand to urinate, but also a satisfactory cosmetic result. Tubularized incised plate repair has been the mainstay for distal hypospadias. In cases of proximal hypospadias, one-stage repairs such as the Duckett repair or the Koyanagi repair have been well established, while two-stage repairs remain important alternatives. Whether dorsal plication or ventral lengthening should be used to correct penile curvature is still controversial, and long-term results are required. Efforts have been made in this decade to improve cosmetic appearance, constructing a slit-like meatus or performing foreskin reconstruction, and to prevent onerous complications.

Tubularized incised plate urethroplasty for distal hypospadias: A literature review

The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. As a result, several articles have been published concerning various aspects and subtle variations of this procedure. The aim of this review is to critically and systematically analyze the published complication rates of TIP repair for distal hypospadias in children. We also reviewed the surgical modifications that have been introduced to the original technique and discussed the potential impact on the final outcome of the Snodgrass procedure.

Ventral based dartos flap for the prevention of the urethrocutaneous fistula urethroplasty

BACKGROUND

Urethrocutaneous fistula is a common complication of urethroplasty for hypospadias even when a microsurgical technique is applied.

METHODS

From January 1999 to November 2006, we applied the ventral based dartos flap wrapping technique to prevent the occurrence of urethrocutaneous fistula in 34 patients with hypospadias.

RESULTS

Hypospadias was repaired without fistula formation in 31 patients while three patients developed a tiny fistula, which was later closed successfully by a simple procedure.

CONCLUSION

We conclude that the ventral based dartos flap wrapping technique could be an alternative to the dorsal dartos flap for covering the neourethra with a vascularized flap because the procedure is very simple, and complications rarely occur.

Dorsal inlay graft urethroplasty for primary hypospadiac repair

OBJECTIVE

Tubularized incised plate urethroplasty has become a popular technique for repairing distal and proximal hypospadias in many institutions. Dorsal inlay graft urethroplasty has been used in our institution since 2003 to reduce the risk of meatal stenosis. In the present study, we evaluated the results of the dorsal inlay graft procedure.

METHODS

A total of 28 patients with no deep groove and no severe curvature underwent one-stage urethroplasty using an inner preputial-based dorsal inlay graft. The medical records of all patients were retrospectively reviewed with regard to complication rate and cosmetic appearance.

RESULTS

Mean patient age at surgery was 21 months (range, 14 months to 4.6 years). Preoperatively the urethral meatus was coronal in two cases, distal shaft in 17, proximal shaft in six and penoscrotal in three. Nine patients required testosterone therapy before surgery. Mean operative time was 200 min (range, 154-249 min). Mean length of inlay graft was 20.9 mm (range, 12-30 mm). In all patients, a straight penis was achieved without dorsal plication of the corposa cavernosa, and the neomeatus with a slit-like appearance was positioned at the glans tip. At a mean of 22 months of follow up, a urethrocutaneous fistula developed in only one patient (3.6%), requiring repair surgery 6 months after urethroplasty. No patient had meatal stenosis, neourethral stricture or urethral diverticulum along the inlay graft.

CONCLUSION

Dorsal inlay graft urethroplasty is an effective method for hypospadiac repair and leads to good cosmetic outcome with low risk of complications.

Recent advances in external genitalia

In the last decade, significant progress in the knowledge and management of external genital anomalies has been achieved, including an improved understanding of epidemiology and pathophysiology of these anomalies, the identification of etiologic genetic defects, and significant improvements in surgical approaches that have decreased complications and improved cosmetic outcomes. We highlight the most clinically important advances of the commonly encountered external genital anomalies.

Suture materials: do they affect fistula and stricture rates in flap urethroplasties?

INTRODUCTION

The effect of suture materials on urethroplasty complications is debated. Indeed, materials with a delayed absorption might either reduce the incidence of fistulas by ensuring a prolonged approximation of neo-urethral edges or increase the risk of urethral strictures due to a prolonged tissue reaction during suture absorption. We retrospectively evaluated the role of suture materials in the complication rate of urethroplasty procedures performed in our institution over a 10-year period.

PATIENTS AND METHODS

Three hundred and thirty-six boys undergoing a flap procedure (parameatal based, preputial tube, or onlay preputial flap) for hypospadias repair were considered for this study. The patients were stratified into two groups according to the suture material used for urethroplasty. Polyglactin (Vicryl), a polyfilament with intermediate absorption, was used in 254 group A patients, whereas polydioxanone (PDS), a monofilament with prolonged absorption, was used in 82 group B patients. The success of a one-stage repair and stricture and fistula rates were evaluated.

RESULTS

A successful one-stage repair was achieved in 82% of the group A and in 83% of the group B patients (p = 0.97). No statistically significant differences were noted in fistula and/or stricture rates in the two groups, even considering each procedure separately.

CONCLUSIONS

This series suggests that suture materials do not affect the complication rate in flap urethroplasty procedures. Appropriate technique, meticulous surgery, and surgeon experience seem to be more crucial factors. A randomized trial is warranted.

Tubularized Incised Plate Urethroplasty: 5 Years’ Experience

OBJECTIVE

To evaluate the results of tubularized incised plate (TIP) urethroplasty in a series of primary hypospadias repairs.

PATIENTS AND METHOD

The medical records of 360 children (Mean age: 4.3 years, range: 2-14 years) with primary hypospadias undergoing TIP urethroplasty repair and treatment of complications were reviewed. A good result is a direct urinary steam through a slit and vertically oriented meatus and mild angled urinary stream through a slightly regressed meatus is a satisfactory result.

RESULTS

The sum of good (74%) and satisfactory results (3%) was the overall success rate (77%) which was increased to 95% after a second surgical procedure for the treatment of complications. In 30 patients with single fistula (8%), fistula healed spontaneously in 2 patients and 20 patients had successful fistula closure. Redo TIP urethroplasty (n = 30) was performed for dehiscence (n = 15, 3%), neourethral stricture (n = 3, 1%) and multiple fistula with meatal stenosis (n = 12, 3%). The complication rate after redo TIP urethroplasty is 30%. Twenty-four (7%) patients underwent meatoplasty for meatal stenosis.

CONCLUSION

TIP urethroplasty can be used to repair primary hypospadias. After a learning curve and attention to surgical details, cosmetic and functional outcome become excellent. Redo TIP urethroplasty can be performed in the treatment of complications.

Tubularized incised-plate urethroplasty for distal and proximal hypospadias

OBJECTIVE

To describe the tubularized incised-plate (TIP) urethroplasty for distal and proximal hypospadias.

PATIENTS AND METHODS

TIP urethroplasty was undertaken in 83 consecutive boys (mean age 14.1 months, sd 7.8) within the past 3 years; 65 (78%) had distal and 18 (22%) proximal penile hypospadias. This was the primary attempt at hypospadias repair in all children.

RESULTS

All patients were assessed 7 days after surgery at the time of dressing and catheter removal, and subsequently at a median of 4 months in the clinic, before being discharged. The overall late complication rate was 12% and 10% required a second operation. There was a urethrocutaneous fistula in three (5%) of those with distal and in one of the 18 with proximal penile hypospadias (P = 0.56). Glans dehiscence in distal hypospadias occurred in one (1%) and three, respectively (P = 0.01). Secondary surgery for fistula repair and glans closure was successful in all patients. All children void with a single straight urinary stream in a forward direction, and have a normally situated vertical slit-like glanular meatus.

CONCLUSIONS

TIP urethroplasty is a versatile, simple operation with good cosmetic results, which uses the urethral plate to its maximum potential.

The Modified Snodgrass Hypospadias Repair: Reducing the Risk of Fistula and Meatal Stenosis

PURPOSE

The Snodgrass hypospadias repair is fast becoming the procedure of choice for distal hypospadias at many centers. Multiple series document excellent cosmetic outcome in conjunction with low complication rates. Modifications to the original procedure are presented, which may further limit the risk of complications.

MATERIALS AND METHODS

A retrospective review was performed of all Snodgrass procedures performed by a single surgeon in a 3.5-year period. None of the boys had undergone prior hypospadias surgery. Cases of relatively narrow urethral plates (less than 8Fr) or a "flat glans" were not corrected using the Snodgrass procedure, but rather were corrected using a modified Barcat repair. In this series the repair incorporated several modifications including 1) the urethral plate was incised all the way from the meatus to the tip of the glans, 2) most importantly, the urethral plate was tubularized starting at the meatus and working proximally, and 3) the meatus was calibrated such that, even before tubularization, it would accept a 10 to 12Fr bougie.

RESULTS

A total of 110 boys underwent repair by at a mean age of 9.5 months (range 5 to 60). At followup ranging up to 3.5 years no child had clinically apparent meatal stenosis and in only 1 child a fistula developed (1%).

CONCLUSIONS

The tubularized incised plate urethroplasty has revolutionized the management of distal hypospadias. The modifications to the Snodgrass hypospadias repair described coupled with careful patient selection permit a high rate of success with minimal morbidity.

Distal hypospadias: which repair?

OBJECTIVE

To compare the function, complications and cosmesis after a modified Thiersch-Duplay and Mathieu unstented urethroplasty.

PATIENTS AND METHODS

Over a 5-year period 381 consecutive patients (not randomized) with distal hypospadias were evaluated. A modified Thiersch-Duplay with dorsal incised urethral plate tubularization (group A) was undertaken in 170 (45%) and a parameatal based flip-flap Mathieu hypospadias repair (group B) in 211 (55%). No urinary diversion or stent was used in any of the 381 patients.

RESULTS

In both groups the mean (sd) follow-up was 3.1 (1.4) years. All 381 patients voided spontaneously after surgery and none developed urinary retention needing catheterization. In groups A and B, respectively, the overall late complications were 12 (7.1%) and 32 (15.2%) (P=0.001), with urethrocutaneous fistula in six (3.5%) and 26 (12.3%; P=0.001); secondary surgery for fistula repair was successful in all boys in A and 89% in B. The glanular meatus was a vertical slit in all in group A and 86% in B (P=0.02). In both groups, 71% of the children who are now toilet-trained and standing to void have a good calibre, single and straight urinary stream in a forward direction.

CONCLUSIONS

Stenting or urinary diversion is unnecessary after distal hypospadias surgery. The functional results were good in those standing to void. A more natural vertical slit-like glanular meatus was easily created using the modified Thiersch-Duplay urethroplasty, with a lower fistula rate.

Tubularized incised plate (TIP) hypospadias repair

In the past 6 years TIP urethroplasty has become a preferred technique for distal hypospadias repair, and has also been used for proximal lesions and reoperations. In this article technical aspects of the procedure are described and published outcomes reviewed. TIP hypospadias repair has gained widespread acceptance because of its versatility, low complication rate and reliable creation of a vertically-oriented meatus.

Further experience with the tubularized-incised urethral plate technique for hypospadias repair

OBJECTIVES

To report further experience of hypospadias repair using the tubularized-incised urethral plate (TIP) technique and to evaluate the role of postoperative neourethral dilatation as a method of preventing complications.

PATIENTS AND METHODS

The study included 64 patients (aged 2-18 years) who underwent TIP repair of hypospadias; 47 required a primary and 17 a secondary repair. After removing the stent they were randomized into two groups; group 1 (38 patients) underwent regular neourethral dilatation for 12 weeks and group 2 (26 patients) did not. Patients were followed for a mean (range) of 28 (6-52) months.

RESULTS

The functional and cosmetic results were excellent in all patients in group 1, except for slight meatal regression in one patient (3%). In group 2, 17 patients had excellent results; eight (31%) were re-operated upon to correct complications, six developed a fistula (four of which were associated with meatal stenosis) and two developed a neourethral stricture.

CONCLUSIONS

TIP urethroplasty is a versatile technique that provides an excellent functional and cosmetic outcome. Regular urethral calibration after repair should be considered as an integral part of the technique, to prevent neourethral and/or meatal stenosis with subsequent fistula formation.

A comprehensive analysis of a tubularized incised plate hypospadias repair

OBJECTIVES

To critically evaluate my experience using a modified tubularized incised plate (TIP) hypospadias repair.

METHODS

Sixty-four boys, 7 months to 11 years old (mean age 22.9 months), underwent a TIP urethroplasty by a single pediatric urologist for primary hypospadias. The hypospadias defects included 53 distal and 11 midshaft. The incision of the urethral plate was always deep and proximal but never extended the entire length of the plate. In 25 cases (39%), the incision was less than one half the length of the urethral plate. A two-layer urethroplasty was always obtained. A vascularized subcutaneous pedicle was always placed onto the urethroplasty. This pedicle was ventrally based in 56 of the repairs (87.5%). Postoperative urethral stents were not used in 52 boys (81.3%), including 7 with midshaft repairs. All children were scheduled for a postoperative evaluation at 1 month. A confidential phone survey was later conducted by someone other than the surgeon. The parents were asked if they were satisfied or dissatisfied with the direction and caliber of the urinary stream, chordee correction, and overall general appearance.

RESULTS

The clinical evaluation was performed in 54 boys (84.7%) not earlier than 1 month after the repair. The examination revealed a conical glans, slit meatus, circumferential mucosal collar, and a straight phallus in all cases. No cases of fistula, stricture, or dehiscence occurred. A follow-up phone survey 3 to 43 months (mean 21 months) postoperatively was obtained from the parents of 40 patients. Without exception, the parents were satisfied with the urinary stream, chordee correction, and overall appearance.

CONCLUSIONS

Without incising the entire urethral plate and stenting the repair, a TIP urethroplasty can still be expected to provide excellent results when correcting distal and midshaft hypospadias. Parents were satisfied with the long-term cosmetic and functional results obtained with a TIP urethroplasty.

Recent advances in hypospadias: current surgical technique and research in incidence and etiology

Surgical techniques to repair hypospadias have undergone remarkable advances in recent years with the development and widespread use of dorsal urethral plate incision to facilitate urethroplasty. Clinical studies of the technique have shown excellent cosmesis and low complication rates for dorsal plate incision (DPI) in distal hypospadias repair, and have demonstrated the efficacy of expanding the use of the DPI in conjunction with other surgical techniques in more proximal repairs. There have been reports of increasing overall incidence of hypospadias in Scandinavian and US populations, but this might not be a uniform trend. There is, in fact, wide variation in the reported incidence of hypospadias among different countries. Many countries have not shown increased rates of hypospadias; furthermore, in countries noted previously to have an increased incidence of hypospadias, rates have leveled off since 1985. Investigations into the etiology of hypospadias have shown potential links to estrogen effects in utero from increased phytoestrogen intake in maternal vegetarian diets, and rare cases of genetic mutations in 5-alpha reductase type II.

Functional evaluation of tubularized-incised plate repair of midshaft-proximal hypospadias using uroflowmetry

OBJECTIVE

To determine objectively, using uroflowmetry, the functional results of the tubularized-incised plate urethroplasty to repair midshaft-proximal hypospadias.

PATIENTS AND METHODS

Twenty-one patients (mean age 4 years, mean follow-up 1.8 years) were selected from those undergoing surgery between January 1996 and January 1998 at our institution. All patients had midshaft-proximal hypospadias and were treated using the Snodgrass technique. Patients were included if they were able to void volitionally and had no fistula. The flow pattern, maximum (Qmax) and mean flow rate (Qave) were measured; the results were expressed as percentiles and compared with published values from normal children. The Qmax and Qave were considered normal if > 25th percentile, as equivocally obstructed when in the 5-25th percentile and obstructed if < 5th percentile.

RESULTS

Fourteen patients were considered normal, four as equivocally obstructed and three as obstructed. Of the second group, one patient had a urethral diverticulum at the native meatus (confirmed by voiding cysto-urethrography) and the remaining three patients had meatal stenosis that responded to dilatation, with normal flow in two and improvement in the other. Of the obstructed group, one patient responded to dilatation and two underwent meatoplasty.

CONCLUSION

The tubularized-incised plate repair provides satisfactory functional results for midshaft-proximal hypospadias; uroflowmetry is an important noninvasive tool to evaluate this technique. A long-term follow-up is needed to confirm these results.

Tubularized incised plate urethroplasty for proximal hypospadias

OBJECTIVE

To review our experience of using the tubularized incised plate (TIP) urethroplasty (useful in the treatment of distal hypospadias) to treat proximal hypospadias.

MATERIALS AND METHODS

From March 1997 to March 2000 primary repairs were carried out on 40 boys (mean age 4.5 years) with proximal hypospadias. After degloving the penile skin the meatus was at the mid-shaft in 10 boys, at the proximal penile shaft in 11, at the penoscrotal junction in 16, at the scrotum in two and at the perineum in one. The 21 patients with a mid or proximal shaft meatus were categorized as having mid-shaft and the other 19 as having posterior hypospadias. Tunica albuginea plication (TAP) was used to correct residual ventral curvature. The method of urethroplasty was adapted from that described by Snodgrass. The key step of the TIP repair is a midline incision of the urethral plate; a subcutaneous tissue flap dissected from the inner prepuce is used to cover the neourethra. An 8 or 10 F nasogastric tube is used as a urethral stent and removed 7 or 8 days after surgery. Follow-up endoscopy and urethral sounding were carried out in 17 of the patients aged < 6 years; the mean follow-up was 12.5 months.

RESULTS

TAP was used to correct penile curvature in nine (23%) of the patients. Excluding stenosis, the TIP repair was successful in 20 (90%) of those with mid-shaft and in 16 of the 19 with posterior hypospadias; for all complications the respective rates were 19 of 22 and 15 of 19. The overall success rate was 88% for all 40 patients with proximal hypospadias; a urethrocutaneous fistula occurred in two of those with mid-shaft and three of those with posterior hypospadias. Urethral meatal stenosis occurred in four (12%) of the patients (two in each group); two were associated with a fistula and the other two had only mild meatal stenosis. The overall complication rate was 17.5% (three and four in the mid and the posterior hypospadias groups, respectively). The meatal stenosis was managed by simple dilatation in three and meatoplasty in one patient. Endoscopically, the mucosa of neourethra was pink and smooth in all 17 patients assessed. The calibre of all 17 neourethra was > or = 8 F and in 13 was > or = 10 F.

CONCLUSION

TIP repair is a reliable method for treating both mid-shaft and posterior hypospadias.

Pediatric reconstructive surgery

The field of reconstructive pediatric urologic surgery is constantly changing. Recent changes in pediatric urologic reconstructive surgery are discussed in the present review. Surgical techniques for treating patients with hypospadias, exstrophy, incontinence, and ambiguous or variant genitalia are also discussed.

Comparison of the perimeatal-based flap (Mathieu) and the tubularized incised-plate urethroplasty (Snodgrass) in primary distal hypospadias

OBJECTIVES

To determine whether the perimeatal-based flap technique or the tubularized incised-plate repair is the more appropriate treatment for distal hypospadias in terms of fistula rate, cosmesis of the meatus and operative duration.

PATIENTS AND METHODS

Between July 1997 and August 1998, 60 children (none of whom had previously undergone a procedure for hypospadias) underwent primary distal hypospadias repair in a prospective randomized trial. Thirty patients were allocated to undergo a Mathieu repair (mean age 24.9 months, range 9-72) and 30 a Snodgrass procedure (mean age 23.1 months, range 7-19). The mean follow-up was 15.4 months.

RESULTS

The mean duration of surgery was significantly lower for the Snodgrass procedure than for the Mathieu repair (75 vs 115 min, P < 0.05). Three children undergoing a Mathieu repair had complications (two a urethrocutaneous fistula and one a meatal stenosis), compared with only one in the Snodgrass group (glanular dehiscence). The resultant meatus was slit-like in all patients undergoing the Snodgrass repair whereas those with a Mathieu repair had a rounded and horizontal meatus.

CONCLUSION

The overall complication rate was lower and the surgery significantly quicker with the Snodgrass urethroplasty, which also had a better cosmetic outcome. The Snodgrass technique is recommended as a primary treatment for distal hypospadias.