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

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.

A comparison of 467 uroflowmetry results in repaired hypospadias vs. normal male flows

INTRODUCTION

There are currently no clinical criteria for obstructed urinary flow after hypospadias repair surgery. Previous studies have utilized adult and pediatric nomograms and flow shapes to define obstruction, however these methods are limited by a lack of standardization and lack of interrater reliability when determining flow shapes, respectively. The idealized voider derived flow indexes offer a way to track uroflowmetry results in a volume and age agnostic manner.

OBJECTIVE

We sought to evaluate all our hypospadias patients over a 10-year period and identify patients without complications and those with complications and determine their respective flow parameters. Our secondary objective is to identify which uroflowmetry parameters are the most significant predictors of urethral stricture and meatal stenosis at the time of the uroflowmetry study.

STUDY DESIGN

Retrospective chart review was used to compile demographic information, details of hypospadias repair surgeries, and uroflowmetry results from pediatric hypospadias repair patients. Subjects were divided into distal, midshaft, and proximal groups based on the initial location of their urethral meatus. Flows from the hypospadias repair groups were compared to flows from normal age matched controls from a previous study. We compared flows from hypospadias repair patients with no complications present with those who had urethral stricture or meatal stenosis present at the time of uroflowmetry. Binary logistic regression and ROC analysis was used to assess different uroflowmetry parameters' ability to detect the presence of obstructed urine flow.

RESULTS

467 uroflowmetry studies from 200 hypospadias repair patients were included in the database. Compared to controls, the hypospadias repair groups tended to have significantly lower Qmax, Qavg, Qmax FI, Qavg FI, and longer ttQmax. Significant differences in flow parameters were observed when comparing hypospadias repair patients with and without flow obstructing complications at the time of uroflowmetry. Binary logistic regression including various uroflowmetry parameters showed Qmax FI had a significant effect on the odds of observing the absence of a stricture in proximal and distal hypospadias cases.

DISCUSSION

Of the uroflowmetry parameters analyzed, binary logistic regression and the likelihood ratio of a positive result all point to Qmax FI as the better parameter to use to detect the presence of complications in patients who have undergone distal or proximal hypospadias repair surgery.

CONCLUSION

We have established normal parameters for post-operative hypospadias repair patients which can be used to follow patients over time and allow for the identification of complications by keeping track of flow indexes which are volume and age agnostic.

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.

Concomitant repair of meatal stenosis and urethral fistula does not increase the risk of fistula recurrence post-hypospadias surgery

OBJECTIVES

To evaluate whether meatal stenosis treated concomitantly with urethral fistula repair alters the results of fistula closure.

METHODS

A retrospective cohort study, included were all children who underwent local fistula closure following hypospadias repair between 2006-2017. Patients who underwent reoperative urethroplasty were excluded. Data were extracted from electronic records, and missing data were supplied by telephone interviews. Characteristics of patients and fistulas were compared between children who underwent fistula closure only and those who underwent meatoplasty for meatal stenosis during the same surgery. The primary endpoint was fistula recurrence.

RESULTS

In total, 106 local repairs of urethrocutaneous fistulas were performed during the study period, and 25 of them included concomitant meatoplasty for meatal stenosis. There was no difference in terms of location, size, and number of fistulas or the number of recurrent fistulas between the 81 patients who underwent fistula closure only and the 25 who underwent concomitant meatoplasty. The fistula recurrence rate was 17/81 (21%) for the fistula only group and 5/25 (20%) for the fistula and meatoplasty group after a median follow-up of 7 and 8 years, respectively. Meatoplasty was required in a subsequent procedure in 5/81 in the former group vs. 3/25 patients in the latter group.

CONCLUSIONS

The presence and repair of meatal stenosis does not alter the recurrence rate of urethrocutaneous fistulas repaired concomitantly following hypospadias repair.

Repair of distal hypospadias by construction of neourethra from augmented urethral plate with two lateral strips of glans skin and coverage with dartos flap followed by skin closure with preputial flap: single center series

Introduction

Hypospadias is one of the most common anomalies in boys. Many surgical techniques for reconstruction of distal hypospadias have been described, each method having a different success rate. Our objective in this study is the assessment of the surgical technique for repair of distal hypospadias by construction of a neourethra from the augmented urethral plate with two lateral strips of glanular skin, coverage with a dartos flap, and followed by skin closure with preputial skin flap.

Material and methods

From March 2016 to November 2018, repair of distal hypospadias was performed in 56 children with a mean age of 3.2 years (range 2 to 8 years old). Minimum follow-up was 12 months, maximum up to 24 months. Success was defined by cosmetic appearance of the penis, parent perception of penile appearance, and urinary function. Uroflowmetry was done in 22 children at the 12 months follow-up. Parents evaluation of procedure was done by questionnaire using the pediatric penile perception score (PPPS).

Results

The results were successful with straight penile shaft, conical glans, slit-like meatus located at the tip of the glans, with no rotation, and normal micturition. Five children had urethrocutaneous fistula (8.9%) that were treated with simple closure. Parents reported 'very satisfactory' (98.2%) and 'satisfactory' (1.8%).

Conclusions

The described technique of repair of distal hypospadias in children with different variants of urethral plate width and glans size showed good results, both operator's and parent's perception of the results being very satisfactory. This technique is categorised stage 2a in the IDEAL (Idea, Development, Evaluation, Assessment, and Long-term study) staging system for surgical innovations.

Chronological Changes In Uroflowmetry After Hypospadias Repair: An Observational Study

Aim

Urinary flow after urethroplasty is of paramount importance. The aim of this study is to evaluate the progression of uroflowmetry (UF) parameters after different distal and proximal hypospadias repair techniques.

Methods

In this cohort study, cases that underwent primary hypospadias repair at our institution between March 2010 and December 2018 were included when uncomplicated, asymptomatic and toilet-trained. UF findings and post void residual were described after each specific technique.

Results

In all, 88 patients were eligible. Time to last UF ranged from 35 to 138 months postoperatively. Significant increase started 36 months after distal tubularized incised plate urethroplasty (TIP) and afterwards than Mathieu technique. While was noticed 24 and 36 months after Onlay technique and proximal TIP, respectively; however, TIP showed steady significant increase atall time intervals. Duckett repair exhibited insignificant change in maximum flow rate (Qmax) values, buccal mucosal graft (BMG) and inner preputial graft (IPG), significant increase in the Qmax values after 6 and 24 months, respectively, then remained steady high. Transposed preputial flap (TPF) showed significant increase at 6-12 months only, then remained steady lower than the other two techniques. Obstructed flow was 37% after distal TIP, 30% after Mathieu, 25% after proximal TIP, 66.7% after Duckett repair, and 33.3% after TPF. There were no obstructed cases after BMG and IPG.

Discussion

Improvement by time varied between techniques. After repair most cases are below the 50th percentile, implying that the reconstructed urethra is not functioning as a normal urethra. Staged repair for proximal hypospadias is preferable to a heroic one-stage procedure.

Conclusion

Choice of the surgical technique for hypospadias repair had impact on the improvement of Qmax values. TIP improved 36 months postoperatively. However, for proximal cases staged graft repair had earlier improvement and higher Qmax values than proximal TIP and Onlay techniques.

Can Grafted Tubularized Incised Plate Urethroplasty be Used to Repair Narrow Urethral Plate Hypospadias? Its Functional Evaluation Using Uroflowmetry

Aim:

Using uroflowmetry, the aim of this study is to determine the functional results of the grafted tubularized incised plate (GTIP) urethroplasty used to repair poor urethral plate hypospadias.

Settings and Design:

Seventy-one patients (mean age: 5.7 years, follow-up: 1–5.5 years) were selected from those who underwent surgery using the GTIP technique from 2013 to 2015 at our institution.

Methods:

Patients included were able to void voluntarily and had no fistula. The flow pattern, maximum urinary flow rate (Q_max), voided volume (vv), average flow rate, and voiding time were measured. The results were expressed as percentiles and interpreted according to Siroky nomogram. The Q_max was considered normal if >25^th percentile, as equivocally obstructed when in the 5^th–25^th percentile, and obstructed if <5^th percentile.

Results:

Hypospadias was distal in 45, mid penile in 17 and proximal penile in 9. The uroflow curve was bell-shaped in 24 (30%), interrupted in 9 (14%), slightly flattened in 31 (46%), and a plateau in 7 (10%). Flow rate nomograms revealed that 49 (68%) were above the 25^th percentile, 9 (17%) were below the 5^th percentile, and 13 (15%) were between these ranges. Eleven patients showed improvement in the flow curve and maximum urinary flow rate (Q_max) in follow-up uroflowmetry.

Conclusion:

GTIP repair provides satisfactory functional results. A long-term follow-up is needed to confirm these results.

Role of uroflowmetry before and after hypospadias repair

Aims:

To study the role of uroflowmetry in the preoperative and early postoperative period in children undergoing hypospadias repair.

Materials and Methods:

Twenty-six cases undergoing hypospadias repair over 1 year (tubularized incised plate [TIP] Snodgrass [17 patients], TIP with Snodgraft [5 patients], Duckett's onlay flap [2 patients], and Duckett's tube [2 patients] urethroplasty) were prospectively evaluated with preoperative ultrasound and uroflowmetry and postoperative uroflowmetry at 3 months after the surgery and at 6 and 9 months interval if these dates fell within the study period on follow-up. The parameters studied were maximum flow rate (Q_max), average flow rate (Q_av), total voided volume, voiding time, and type of curve. Preoperative and postoperative uroflow data were compared.

Results:

Twenty-six cases comprised of anterior hypospadias (n = 8), mid penile (n = 11), and posterior hypospadias (n = 7). Fourteen patients had obstructed flow rates preoperatively. While 69% patients (18/26) had obstructed flow rates at 3 months postoperatively, it dropped to 43% at 9 months. Following TIP (Snodgrass) repair, 88% (15/17) had obstructed flow rates postoperatively. Best results were seen in patients undergoing circumferentially epithelialized urethral reconstruction (TIP with Snodgraft, Duckett's onlay flap, and Duckett's tube).

Conclusions:

Abnormal uroflow is an inherent aspect of hypospadias in 50% of the cases. Both preoperative and postoperative uroflow evaluation is necessary for meaningful conclusion. Patients with preoperative normal flow rates but obstructed postoperative flow rates need clinical evaluation. Obstructive flow rates are more common after TIP (Snodgrass) repair. The urinary flow rates improve with time.

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

INTRODUCTION

Although two-stage graft urethroplasty is widely used, the literature regarding the complication rates and functional characteristics of reconstructed neourethra is relatively modest.

OBJECTIVES

The aim was to analyze the complication rates and uroflow data of boys who have previously undergone a two-stage graft urethroplasty procedure for proximal and complicated hypospadias.

PATIENTS AND METHODS

We retrospectively reviewed the clinical outcomes of 52 boys with proximal (n = 44) and complicated (n = 8) hypospadias who underwent two-stage graft urethroplasty repair (median age of 15 months and 3 years respectively) between 2004 and 2015. Fifteen toilet-trained boys without fistulas underwent uroflowmetry. The uroflow data were plotted on age-volume-dependent normograms with normal controls. The median follow-up was 34 months (8 months-8 years).

RESULTS AND COMPLICATIONS

Complications were identified in three patients (6%) after the first stage (i.e. contracture of the graft) and in 20 patients (38.4%) after the second stage, including meatal stenosis (n = 8, 15.3%), urethral stricture (n = 4, 7.6%), urethrocutaneous fistula (n = 8, 15.3%), glandular dehiscence (n = 1, 1.9%), and diverticulum (n = 1, 1.9%). The patients with failed hypospadias experienced fewer complications than those who underwent the two-stage procedure for primary repair (25% and 45%, respectively). The reoperation rate was 36.8%. Eleven of the 15 toilet-trained boys were asymptomatic but exhibited flow rates below the normal range (median Q_max = 7 mL/s, range 3.5-16.7). Only one of the boys with a low flow rate was confirmed to have urethral stenosis under general anesthesia.

DISCUSSION

In our study, primary hypospadias repair requiring urethral plate transection elicited worse outcomes than those observed in the prior failed hypospadias cases. However, because of our study's retrospective design, we were unable to accurately assess the initial position of the meatus in the redo hypospadias cases. Our data also demonstrated that the majority of cases without any voiding symptoms exhibited flow rates that were below the normal range despite no urethral stricture under general anesthesia. These findings indicate that urethras reconstructed via two-stage graft urethroplasty repair are not functionally equivalent to normal urethras, at least prior to puberty.

CONCLUSION

Two-stage graft urethroplasty repair was successful in 62% of cases after the second-stage procedure, but one-third of the boys required a reoperation after the two-stage planned repair. We demonstrated that although we used a urethral tissue substitute, the urine flow patterns of the patients without strictures were abnormal.

Long-term functional outcomes of distal hypospadias repair: a single center retrospective comparative study of TIPs, Mathieu and MAGPI

INTRODUCTION

Tubularized Incised-Plate (TIP) urethroplasty is currently the preferred technique for distal hypospadias repair. Nevertheless, concerns have been raised on the long-term functionality of the reconstructed neourethra.

OBJECTIVE

The aim of this study is to evaluate long-term uroflowmetry parameters' evolution after TIP surgery over a long-term follow-up including the adolescent period. TIP patients were compared to normal children using established Miskolc nomograms, as well as to patients who underwent Mathieu and Meatal Advancement and Glanuloplasty (MAGPI) surgery repairs for distal hypospadias.

STUDY DESIGN

Files from patients who underwent primary distal hypospadias repair at our institution between January 1, 1997 and January 31, 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (TIP vs. Mathieu vs. MAGPI) was performed according to the following postoperative time interval endpoints: 0-6 months, 6-12 months, 12-24 months, 24-48 months, 4-6 years, 6-10 years and >10 years. Maximal urinary flow rate (Qmax) in relation to Voiding Volume (VV) adjusted for Age or Body Surface Area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques.

RESULTS

153 patients met the inclusion criteria: 70 (43%) TIP, 24 (17%) Mathieu and 59 (35%) MAGPI. Overall, Qmax increases progressively according to time and age and in particular during the period covering adolescence with a similar trend regardless of the type of surgery. Uroflowmetry profiles in terms of Qmax, VV and PVR were equivalent between surgeries at each examined time point. At 10 years of follow-up postopertively, mean Qmax were 17.2 ml/s, 18.8 ml/s and 21.6 ml/s respectively with no significant difference detected between groups (p = 0.344). Compared to normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax< 5th percentile of nomograms was more prevalent in patients aged 2-7 years old at 60% but decreased to less than 10%in patients aged >13 years for all procedures combined (see abstract figure) but without detected differences between surgery types (p = 0.276).

DISCUSSION

After sub-optimal obstructive maximal urinary flows in the early postoperative period, hypospadias patients treated with TIP exhibit favourable long-term evolution with age and during adolescence in particular compared to normal children. In addition, a similar trend was found for patients treated with Mathieu and MAGPI with no significant differences detected between procedures. Nevertheless, because of the relatively small sample size we cannot exclude that a statistical difference between surgeries would have been detected if the study was adequately powered on every endpoint. Nevertheless and also as suggested by the values obtained, this potential difference may be quite small and not clinically relevant.

CONCLUSION

These results suggest that the obstructive urinary flow pattern observed in patients early on is possibly an intrinsic feature associated to the malformation itself and may be less of a consequence of the surgical technique.

Is it safe to solely use ventral penile tissues in hypospadias repair? Long-term outcomes of 578 Duplay urethroplasties performed in a single institution over a period of 14 years

OBJECTIVES

Urethral plate tubulization (Thiersch-Duplay procedure) is a widespread procedure mostly used for distal hypospadias. Concerns of long-term outcome have led to this review of the results of a series of 578 cases.

PATIENTS AND METHODS

A retrospective review was conducted of 578 patients treated in a single institution following the same procedure and with the same follow-up. Most patients had distal hypospadias (517/578) and were operated on between 12 and 24 months of age (343 patients). The mean follow-up was 25.6 months (6 months-17 years). Evaluation was focused on urethral complications related to inadequate healing of the reconstructed urethra (fistula, urethral dehiscence, urethral stenosis and clinical dysuria). Complications were arbitrarily categorized into early (when occurring less than one year after surgery) and late (after one year). All data were submitted to statistical analysis.

RESULTS

Of the 578 patients, 153 (26.5%) had unsatisfactory outcomes, of which 118 (20.4%) had inadequate urethral healing. Of these, 97 appeared early (57%) and 73 appeared late (43%). Fistula and dehiscence were significantly more frequent in the first post-operative year (p<0.0001), whereas stenosis of the reconstructed urethra was more frequent after one year. Follow-up and age at last consultation were significantly higher in patients with complications. Limits and flaws of this study focused on the absence of consensus on evaluation of hypospadias surgery. The paucity of literature on long-term outcomes of urethral plate tubulization was highlighted. A possible explanation of late stenosis of the reconstructed urethra was the poor growth capacity of the dysplastic tissues located beyond the division of the corpus spongiosum. Urethroplasties solely using ventral tissues may represent an additional risk of late failure, as they may not grow with the rest of the genital tubercle.

CONCLUSION

Significant short and late complications occur with techniques tubularizing the urethral plate, mostly fistulae in the first post-operative year and urethral stenosis after 1 year following surgery. Urethroplasties using ventral tissues may not grow at the same pace as the rest of the genital tubercle and may explain late urethral dysfunction. This series confirms the necessity of long-term follow-up of hypospadias reconstructions.

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.

Utility and cost-effectiveness of uroflowmetry in a busy pediatric urology practice

INTRODUCTION

Uroflowmetry (UF) is frequently employed in daily pediatric urology practice for diagnostic and follow-up purposes. We assess the utility and cost-effectiveness of UF in the management of patients seen at a tertiary care centre.

METHODS

We retrospectively reviewed the charts of consecutive patients who had a UF between January 1, 2010 and March 31, 2010. We collected data on demographics, diagnosis, UF parameters and the impact of the UF on management. The impact on management was defined as indication for surgery, introduction of new medications and bladder retraining based on clinical and UF findings.

RESULTS

In total, 524 patients were included in the study. In 63 (12%) patients, UF was performed as part of the evaluation at the first clinic appointment. The most common diagnoses were voiding dysfunction (VD) 41%, hypospadias 26%, vesicoureteric reflux (VUR) 16%, monosymptomatic nocturnal enuresis (NE) 8%, posterior urethral valves 5% and meatal stenosis (MS) 4%. In the VD group, UF contributed to a management decision in 25.2% of patients. In the MS group, surgical intervention was based on symptoms and supported by the UF in 41% of patients; in the PUV group, 50% of patients demonstrated high (>20 cc) post-void residual, which aided in management decisions. In contrast, there were virtually no changes in management supported by the UF in the NE, VUR and hypospadias groups. Overall, UF parameters had a direct influence in the management decisions in only 67 (12.8%) patients. Nonetheless, a repeat test was ordered for 44.5% of patients.

CONCLUSIONS

In an era of financial restraints and in a busy tertiary pediatric urology practice, judicious use of UF for specific indications may translate into a more cost-effective use of time and resources. As expected, patients with VD were the ones that benefited most from the test, as did patients with symptomatic MS and PUV.

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.

Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes

Objectives

To objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score.

Patients and methods

In a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3 months after surgery, the flow pattern, maximum (Q_max), and mean urinary flow rate (Q_ave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system.

Results

The native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5–14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3–24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3–14) years showed an abnormal Q_max below the fifth percentile in four (15%), with the Q_ave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13–16). Two patients had a small, single subcoronal fistula.

Conclusion

Extending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.

Combined Use of the Mathieu and Incised Urethral Plate Techniques for Repair of Distal Penile Hypospadias

Though both the Mathieu and incised urethral plate techniques are individually described for single-stage repair of distal penile hypospadias, each has its own shortcomings. We describe the combination of the two techniques by taking their advantages and reducing their limitations. Thirteen patients belonging to the age group of 3-22 years with distal penile hypospadias and mild chordee were operated by this technique with a mean follow-up of 8 months. One patient had urethrocutaneous fistula, and another patient had partial skin necrosis which healed spontaneously without fistula. Both of these complications occurred in adult patients. None developed urethral stenosis, and the cosmesis of the glans was excellent in all cases. This technique is very helpful in patients having small flat glans and shallow urethral groove.

How do asymptomatic toilet-trained children void following tubularized incised-plate hypospadias repair?

PURPOSE

: To evaluate the functional outcome in the form of urinary flow rates in asymptomatic children following uncomplicated tubularized incised plate urethroplasty (TIPU) hypospadias repair.

METHODS

: We reviewed the records of children who underwent TIPU at our institution between April 1997 and September 2007 and included only asymptomatic toilet-trained children who had an uncomplicated postoperative course and had undergone uroflometry not less than 1 year postoperatively. Unfavourable voiding parameters were either a plateau curve, a peak flow below the 5th percentile range in nomogram or a post-void residual (PVR) more than 20% of the total functional capacity of the bladder. Uroflowmetry findings were analyzed against variables, including the surgeon, the severity of hypospadias, the presence of a hypoplastic urethra, the use of double layer closure, the performance of a spongioplasty and the use of a stent. Serial uroflowmetries, when available, were compared with respect to the initial flow study.

RESULTS

: In total, 59 patients were eligible for the study. The mean age at surgery was 2.4 years. Hypospadias was distal penile in 50 (85%) and mid and proximal penile in 9 (15%). Mean follow-up was 3.3±2 (1-9.5) years. The uroflow curve was bell-shaped in 18 (30%), interrupted in 8 (14%), slightly flattened in 27 (46%) and plateau in 6 (10%). Flow rate nomograms revealed that 40 (68%) were above the 20th percentile, 10 (17%) were below the 5th percentile and 9 (15%) were between these ranges. PVR was >20% of the pre-void volume in 9 children (15%). No patient demonstrated all three unfavourable parameters together. The groups of children with unfavourable functional voiding parameters were compared to the children with favourable parameters specifically with respect to the possible predictors of outcome. Follow-up uroflometry in 17 patients showed improvement in the flow curve, flow rate and PVR with significant improvement of maximum urinary flow rate (Qmax) and PVR values.

CONCLUSIONS

: Asymptomatic, urodynamic abnormalities were observed in our study following uncomplicated TIPU repair. These abnormalities were not related to the variation of the technique among surgeons. Spontaneous improvement has been noted on serial flow studies.

Long-term urethral function measured by uroflowmetry after hypospadias surgery: comparison with an age matched control

PURPOSE

Long-term outcomes of hypospadias surgery, particularly urinary function, have not been examined thoroughly. Uroflowmetry can be used to evaluate long-term functional outcomes by assessing flow shape and the rate of micturition. We assessed urethral function using uroflowmetry in adolescents after undergoing hypospadias repair in infancy and compared this with age matched controls.

MATERIALS AND METHODS

After human research ethics committee approval (HREC 28111A), 17 boys 13 to 15 years old with no history of urological or neurological disorders underwent uroflowmetry (65 separate voids) to determine standard values for boys of this age. Then 60 boys age 13 to 15 years who had undergone treatment for hypospadias in early infancy were seen for long-term followup and underwent uroflow assessment.

RESULTS

Standard urinary flow rates were established in the 13 to 15-year-old control group and represented on a nomogram. In the boys who underwent hypospadias surgery the urine flow rates were significantly lower compared to the control nomogram (p <0.0001), with half the patients having uroflow rates below 1 SD from the control mean but without symptoms. Boys with significant preoperative chordee were more likely to have poorer urinary flow (p <0.04). A poor urinary flow rate also was significantly associated with post-void residual bladder volume (p <0.03). There was no correlation with original meatal location, number of operations, presence of postoperative complications, current anatomy and lower urinary tract symptoms (eg post-void dribble, hesitancy, incontinence).

CONCLUSIONS

At long-term followup after hypospadias surgery urinary flow rates were significantly lower compared to age matched controls but still fell within the normal range. In the hypospadias cohort there was no significant association with lower urinary tract symptoms and poor urinary flow. Detection of poor urinary flow may indicate incomplete bladder emptying. The presence of severe chordee preoperatively is a significant risk factor for poor urinary flow rates on long-term followup.

Importance of urinary flow studies after hypospadias repair: a systematic review

A systematic review was performed of publications relating to the results of urinary flow studies after hypospadias repair dating back to 1978, when what appears to be the first publication on this topic was found. The literature search was performed using the key words "hypospadias" combined with "urinary flow", "urine flow", "uroflow", "uroflowmetry", and "long-term". We also reviewed the abstracts and full-length articles cited in the reference list of selected articles. Criteria for inclusion in the present systematic review included descriptions of patient selection, surgical technique, the severity of disease (proximal vs distal), and the method used to determine uroflow, as well as a definition of urethral obstruction. In all, 339 article titles were found. Of these, 25 abstracts appeared relevant and the full text of these articles were reviewed, with 22 of the papers included in this review. Sixteen reports had appeared in the literature since 2001, compared with six between 1978 and 2000, suggesting an increasing interest in this topic. On the basis of the results of the present systematic review, we recommend that asymptomatic children operated on for hypospadias in infancy should have one flow study after toilet training, with that study repeated if the results are abnormal. It appears that early abnormal flows improve spontaneously, so that children operated on after toilet training who are asymptomatic should undergo their first uroflow measurement 1 year after surgery. Children with obstructed flow parameters or borderline flows should be followed until adulthood, until long-term follow up studies clarify the significance of abnormal flow parameters. Given the present findings, we anticipate that in the next two decades urologists will need to treat a number of men with strictures resulting from hypospadias repairs performed in childhood.

Foreskin reconstruction and preservation of a thin distal urethra: a challenge in tubularized incised plate urethroplasty

PURPOSE

The aim of this retrospective study was to evaluate the functional and cosmetic outcome of tubularized incised plate urethroplasty (TIPU) with preputial reconstruction and preservation of a thin distal urethra when applicable.

METHODS

The records of 64 boys with hypospadias, who underwent TIPU between 2000 and 2007 were analyzed. 33 (52%) underwent foreskin reconstruction and a thin distal urethra was preserved and incorporated in 19 (30%) patients. The Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), and uroflowmetry were evaluated in 55 boys (86%) after a mean of 4.8 years.

RESULTS

All patients had a vertically oriented meatus. The overall rate of fistula occurrence was 9% and of wound dehiscence, 5%. Among 33 preputial reconstructions, two (6%) patients had dehiscence and three (9%) had a fistula. No cases of stricture or stenosis occurred. There were significantly more complications with reconstruction of the foreskin (p = 0.012) and preservation of a thin distal urethra (p = 0.021). Uroflowmetry was normal in 76% of patients. PPPS and HOSE revealed excellent results.

CONCLUSION

TIPU produces excellent cosmetic and functional results with few complications; complications are more common after foreskin reconstruction and use of a thin distal urethra.

Urinary function after Snodgrass repair of distal hypospadias: comparison with the Mathieu repair

PURPOSE

To evaluate urinary function in patients with distal hypospadias undergoing repair by the tubularized incised-plate urethroplasty (TIP or Snodgrass), compare the results with those in patients treated by the Mathieu technique, and show the potential issues inherent to the evaluation of such results.

PATIENTS AND METHODS

A cross-sectional assessment was performed of uncomplicated distal hypospadias operated on during a 3-year period, already toilet trained, and able to void volitionally. Evaluation included clinical assessment urinary symptoms and urinary stream, and uroflowmetry.

RESULTS

Out of 83 patients operated on during the study period, 10 (12%) developed complication and 32 were not toilet trained or refused to participate in the study. Median follow-up in the remaining 41 patients included in the study was 20 (3-36) months. None of these patients presented voiding symptoms or urinary stream abnormalities. Uroflowmetry was normal in 30 cases and obstructive in 11 (27%). An obstructive flow pattern was more common in patients undergoing TIP versus Mathieu repair, 8 of 19 (42%) versus 3 of 22 (14%), respectively (P = 0.07). Four TIP cases with an obstructive uroflow pattern were managed conservatively.

CONCLUSIONS

Although both the TIP and the Mathieu repair allow good results in terms of urinary function after distal hypospadias repairs, the TIP technique seems more likely to be associated with urine flow pattern abnormalities. The actual clinical relevance of this finding remains ill defined.

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.

Comparative Analysis of Tubularized Incised Plate Versus Onlay Island Flap Urethroplasty for Penoscrotal Hypospadias

PURPOSE

Despite being the dominant technique for repair of distal hypospadias, application of the tubularized incised plate approach for penoscrotal hypospadias remains controversial. We report our experience with severe hypospadias, comparing tubularized incised plate to transverse island flap onlay urethroplasty.

MATERIALS AND METHODS

We retrospectively reviewed consecutive patients with penoscrotal hypospadias presenting between 1998 and 2006. Based on surgeon preference 35 children underwent tubularized incised plate and 40 underwent onlay urethroplasty. Penoscrotal transposition and degree of ventral curvature, type of ventral curvature repair, complication rate, postoperative uroflowmetry pattern in toilet trained patients and number of reoperations were compared between the 2 groups.

RESULTS

Mean patient age at surgery was 17 months (range 9 to 91) for tubularized incised plate urethroplasty and 17.8 months (10 to 58) for the onlay procedure. Urethroplasty was performed over an 8Fr catheter in all patients. With mean followups of 30 months (range 6 to 74) and 38.8 months (16 to 80) the overall complication rates were 60% and 45% for the tubularized incised plate and onlay procedures, respectively. Fistula occurred in 15 patients and repair breakdown in 3 patients (total 51.4%) treated with tubularized incised plate repair, compared to 8 and 2 patients, respectively (25%), treated with onlay repair (p = 0.01). Fistula location also differed significantly between the 2 groups, with proximal fistulas occurring in 11 of 15 tubularized incised plate repairs (73.3%) vs 2 of 8 onlay repairs (25%, p = 0.02). Recurrent ventral curvature was more frequent after onlay urethroplasty (5.7% vs 12.5%, not significant). At a mean age of 5.1 years a plateau uroflow curve (vs normal bell curve) was observed in 16 of 24 children (66.7%) who underwent tubularized incised plate repair and in 7 of 21 (33.3%) who underwent onlay repair (p <0.01).

CONCLUSIONS

In this series the overall complication rate was similar for tubularized incised plate and onlay urethroplasty. Despite similar urethroplasty calibers, the uroflow curves and fistula positions in patients undergoing tubularized incised plate repair suggest that the neourethra distal to the fistula may be relatively narrow, creating flow resistance and leading to proximal fistula. Longer followup and close monitoring are needed before embracing one approach over the other.

Split prepuce in situ onlay hypospadias repair: 17 years of experience

PURPOSE

We report our 17-year experience using split prepuce in situ onlay hypospadias repair, including long-term followup of the first 100 patients initially reported on in 1998.

MATERIALS AND METHODS

We identified 421 patients who underwent in situ onlay repair. Charts were retrospectively reviewed to determine preoperative management, intraoperative details and complications.

RESULTS

In situ onlay repair was used to repair glanular hypospadias in 22 cases (5.2%), coronal hypospadias in 184 (43.7%), distal shaft hypospadias in 152 (36.1%), mid shaft hypospadias in 51 (12.1%), proximal shaft hypospadias in 7 (1.6%) and hypospadias in the penoscrotal region in 5 (1.2%). Repair was successful with 1 procedure in 376 patients (89.4%), which increased to 99.8% after a second procedure. Complications were defined as any problem that gave the surgeon or family reason for concern. Functional complications requiring reoperation occurred in 45 patients (10.6%). Minor complications requiring simple procedures or early postoperative evaluation occurred in 17 patients (4%). Concerns not requiring intervention occurred in 27 patients (6.4%). There were no urethral strictures. Three patients (0.7%) were lost to followup. Repair is pending in 1 patient.

CONCLUSIONS

In situ onlay repair preserves the urethral plate and allows the formation of a well vascularized flap with adequate tissue to completely cover the neourethra, resulting in a low rate of major complications. With longer followup, inclusion of more mid shaft repairs and expansion to more proximal degrees of hypospadias our complication rates are higher than previously reported but there have been no urethral strictures in 17 years of experience. Since complications present at a median of 158 days (mean 570) after the procedure, long-term followup is indicated.

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.

Value of Urinary Flow Patterns in the Follow-Up of Children Who Underwent Snodgrass Operation

The urinary flow patterns and the Toguri nomogram were compared in the intermediate functional results of the tubularized-incised plate urethroplasty (TIPU) to repair distal and midpenile hypospadias by using uroflowmetry. 28 children who were toilet trained, were able to void volitionally, and had no fistulas following hypospadias repair were eligible for the study. The study did not include children who had persistent fistula, meatal stenosis or urethral stricture, and did not return for follow-up. The mean age was 8.4 years and the mean follow-up period was 18 months. The urinary flow pattern, maximum (Q(max)) and average flow rate (Q(ave)) were measured; the results were expressed as percentiles and compared to the Toguri values from normal children. The Q(max) and Q(ave) were considered normal if they were in >25th percentile, equivocally obstructed in the 5-25th percentile and obstructed if <5th percentile. The flow pattern was classified as bell ring shape, plateau or intermittent. According to the Toguri nomogram, 22 of 28 patients (78.5%) were considered normal, 4 patients (14.2%) as equivocally obstructed, and 2 patients (7.1%) as obstructed group. A normal bell-shaped flow curve was obtained in 23 (82.1%) of the children. 4 patients (14.2%) had a plateau flow pattern. Only 1 of the patients had an intermittent shape flow curve. The flow pattern was normal bell-shaped for all of the patients, except 1, with Q(max) above the 25th percentile according to the Toguri nomogram. Of children with Q(max) below the 5th percentile, both of them had a plateau flow pattern and were found to have an asymptomatic meatal stenosis, which was improved with urethral dilatation. However, of the 4 patients with Q(max) between 5 and 25 percentiles, 2 had a plateau flow pattern and the others had a bell-shaped flow pattern. The flow patterns of the 2 patients determined as obstructive by the Toguri nomogram were plateau-shaped. TIPU provides satisfactory functional results for distal and midpenile hypospadias; uroflowmetry is an important noninvasive tool to evaluate this technique. There are no studies in the literature which only used flow patterns for the evaluation of urination for follow-up after the hypospadias repair. Our study showed that the evaluation of obstruction according to the Toguri nomogram may not be necessary in patients with a normal bell-shaped flow pattern in uroflowmetry.

Hypospadias repair with tubularized incised plate. Is uroflowmetry necessary postoperatively?

OBJECTIVE

Hypospadias repair with tubularized incised plate urethroplasty (TIP) produces good cosmesis, but is reported to result in a change in urinary stream postoperatively, with an obstructive pattern. The aim of this retrospective study was to determine whether early uroflowmetry is a good method for diagnosing neourethral stricture.

PATIENTS AND METHOD

In 126 boys, primary TIP repair was performed between 1999 and 2003. Uroflowmetry was performed in potty-trained boys 2 months' postoperatively (68 boys) and both 2 and 12 months (38 boys) after TIP. Boys with obstructed flow and/or clinical symptoms were calibrated in their neourethra.

RESULTS

Forty-nine percent of the boys with distal hypospadias and 87% of the proximal cases had a flow rate of less than 10 ml/s at uroflowmetry 2 months after TIP, but only 12/126 boys (10%) were considered to have a neourethral stricture. There was a spontaneous increase in maximum flow rate between 2 and 12 months after TIP repair both in patients who had been calibrated and in boys in whom no intervention had been performed.

CONCLUSION

Early uroflowmetry appears to be unnecessary, as the voiding history appears to be just as good at alerting a suspicion of urethral stricture after TIP repair. There is a spontaneous normalization of the urinary flow in boys after TIP repair, but the need for long-term follow up beyond puberty is great, especially in cases of proximal hypospadias.

Ten-year review of hypospadias surgery from a single centre

Hypospadias is more common than cleft lip and palate. However, in comparison to the latter, few units have dedicated any team to its correction. Hence, urologists, paediatric surgeons, plastic surgeons, general surgeons and paediatric urologists keep trying various methods of correcting this deformity. That more than 350 procedures have been described for the correction of one anomaly speaks volumes of dissatisfaction with the results. We describe our humble experience with this anomaly over a period of 10 years during which time we were able to treat 1415 cases. However, this paper only describes results of 1206 patients. We use universally only one technique for hypospadias repair and perform this in two stages. This technique has been described by many but lately popularized by Aivar Bracka from UK. Our overall fistula rate has been 3.8% though most of the fistulae occurred in the earlier period. Other complications included repeated UTI (3%) and hair growth in the urethra (0.2%).

Tubularized-incised plate urethroplasty in adults

OBJECTIVE

To evaluate the results of tubularized incised-plate (TIP) urethroplasty for distal and midshaft hypospadias in adults, and to underline technical aspects to decrease complications.

PATIENT AND METHODS

From December 1999 to January 2004, 13 patients with hypospadias and aged 18-26 years had a TIP urethroplasty as a primary repair. Five had distal penile and eight had midshaft hypospadias. In all cases a TIP urethroplasty was used as described for children. Urinary drainage was by a urethral Nelaton catheter connected to a urine bag.

RESULTS

The catheter was removed after 10 days and the patients asked to attend a follow-up at 1, 3 and 6 months and then 6-monthly; the maximum follow-up was 3 years and the minimum was 3 months. One patient developed a fistula after the repair of distal penile hypospadias, which closed spontaneously after a month. All patients with a successful repair voided with a single straight urinary stream in a forward direction. They had a normally situated slit-like glanular meatus.

CONCLUSION

TIP repair in adults is associated good results. There is no difference in terms of wound healing, infection, complication rates and overall success between the TIP repair in children and adults. The cosmetic and functional outcome was comparable to that in children.

Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding?

OBJECTIVES To determine whether physiological phimosis with or without ballooning of the prepuce is associated with noninvasive urodynamic or radiological evidence of bladder outlet obstruction. PATIENTS AND METHODS From August 2001 to October 2002 all boys with a foreskin problem and referred to one paediatric surgeon were assessed in special clinics. Those with physiological phimosis were recruited for the study and had upper tract and bladder ultrasonography (US), followed by uroflowmetry and US-determined postvoid residual urine volumes (PVR). Data were compared between boys with and with no ballooning of the prepuce. The project was approved by the local research ethics committee and informed consent was obtained from all study participants. RESULTS In all, 54 patients were referred for circumcision; 32 boys with physiological phimosis completed the uroflow and US investigations. Ballooning of the foreskin was present in 18 boys (mean age 6.8 years, range 3-12); 14 had physiological phimosis with no ballooning (mean age 6.5 years, range 4-11). Upper tract US and bladder wall thickness were normal in all boys. The mean maximum urinary flow rate (Q(max)) was not significantly different in boys with ballooning and those without (mean 15.3 mL/s, sd 4.4, range 9-24, vs 15.4, sd 2.9, range 10.7-20, P = 0.96). In addition, all Q(max) values were within the normal range when correlated with voided volume and compared with age-related nomograms. Most boys had flow rate patterns showing a normal bell-shaped curve; a few (9%) had subtle changes in the flow-rate profile, with either a plateau-type curve or slow initial increase in flow and prolonged time to achieve Q(max). The two groups had comparable mean PVRs (3.5 mL, sd 5.1, range 0-18 with ballooning vs 6.1, sd 10.7, range 0-38 without, P = 0.37). Only one patient had a marginally abnormal PVR. CONCLUSIONS Physiological phimosis with or without ballooning of the prepuce is not associated with noninvasive objective measures of obstructed voiding. Minor abnormalities in the flow-rate pattern in this patient group deserve further study.

[Concepts for correction of penile hypospadias]

The repair of penile hypospadias encompasses correction of the penile curvature, urethral reconstruction, glanuloplasty, and coverage of the penile shaft with skin. A straight penis can be achieved by chordectomy alone or in combination with a dorsal plication technique (Nesbit and modifications). For urethral reconstruction, pedicled foreskin flaps, incision of the urethral plate with subsequent tubularization (Snodgrass, TIP procedure) as well as free buccal mucosa onlays have been used. The operative technique of the respective procedures with their results obtained are described and discussed. The pedicled onlay flap with a complication rate of up to 22% in larger series is the most commonly used technique. Comparable results can be obtained with the free buccal mucosa graft. Long-term data are lacking for final evaluation of the TIP procedure published by Snodgrass.

Functional evaluation of one-stage urethroplasty with parameatal foreskin flaps repair of hypospadias using uroflowmetry

BACKGROUND

Uroflowmetry is a simple, accurate and non-invasive test. In the present study, we aimed to determine the role of uroflowmetry in the evaluation of the functional results of one-stage urethroplasty with parameatal foreskin flaps (OUPF) technique.

METHODS

Twenty-one children who had undergone OUPF repair at our clinic were selected. Selection criteria were that patients were toilet trained and had no fistula. Uroflowmetry was performed using a rotating disk sensor. The maximum flow rate (Qmax) and average flow rate (Qave) were plotted against body surface related flow rate nomograms. The upper 95% tolerance limits for the 5th, 10th, 15th, 20th and 25th percentiles of the normal population were used for comparison. The flow pattern was classified as bell ring, plateau or intermittent.

RESULTS

The median age at the first uroflowmetry was 4.7 years (range 2.5-8.6) and the mean postoperative follow-up period was 25 months (range 1-58). Twelve children had Qmax above the 25th, six between the 5th and 25th and three less than the 5th percentiles of the normal population. A normal bell-shaped flow curve was obtained in 17 (80.6%) of the children. Of the three children with Qmax below the 5th percentile, two children had a plateau flow pattern and were found to have a urethal stricture. Dilation was performed successfully, after which the Qmax returned to the normal range and the symptoms disappeared.

CONCLUSION

The OUPF technique provided satisfactory functional results for hypospadias repair. We advocate the use of uroflowmetry for routine postoperative follow-up.

Tubularized incised plate repair: functional outcome after intermediate followup

PURPOSE

We describe the functional outcome following tubularized incised plate repair of hypospadias in toilet trained children after an intermediate followup.

MATERIALS AND METHODS

Children were included in this study only if they were toilet trained and had flow rate data not less than 6 months after primary tubularized incised plate hypospadias repair or 2 months after any secondary procedure to correct complications. Uroflow data (peak flow, voided volume and post-void residuals) were analyzed and plotted on previously determined age-volume dependent nomograms.

RESULTS

Of the 48 boys 39 required no secondary procedures, while 9 secondary fistula closures were performed in 2, meatotomy in 2 and dilation in 5. After either primary (26) or secondary (7) procedures 33 of the 48 patients (68.7%) had normal peak flow rate and 15 (31.3%) had low peak flow rate. Of the 48 patients 46 had post-void residual urine less than 10% of voided volume.

CONCLUSIONS

Most children will void efficiently with no straining and no post-void residual (1/2) to 4 years after tubularized incised plate hypospadias repair. Of our patients 68.7% have normal peak flow rate. Intermediate followup of larger series and followup at puberty are recommended to resolve the debate concerning the long-term functional outcome of tubularized incised plate hypospadias repair.

Current technique of tubularized incised plate hypospadias repair

INTRODUCTION

Tubularized incised plate urethroplasty has now been successfully applied to all varieties of hypospadias. Given this versatility and the good cosmetic outcomes, the operation has achieved widespread popularity. We review important technical aspects of the repair.

TECHNICAL CONSIDERATIONS

Key steps include preservation of the urethral plate during correction of the ventral curvature, midline incision of the plate for urethroplasty, and subsequent glansplasty. Lessons learned from personal and published experiences are emphasized.

CONCLUSIONS

Tubularized incised plate urethroplasty is currently one of the most popular techniques for hypospadias repair. Attention to important surgical details is needed to obtain optimal functional and cosmetic results.

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.

New surgical techniques in pediatric urology

More sophisticated endoscopic instruments, combined with a better understanding of bladder and urethral pathology, have significantly improved the therapeutic approaches for both posterior urethral valves and ureteroceles. New generation lithotripters have allowed for a safe and efficient method of treating urinary calculi in children, which was once thought too injurious a process with first-generation machines. The rapidly advancing field of laparoscopy, aided by the development of more optically refined and diminutive instruments, has allowed for its application in a wide variety of surgical interventions in pediatric urology. The tubularized incised plate urethroplasty has challenged more traditional approaches to hypospadias repair and is now considered by many pediatric urologists to be the best approach for midshaft and distal hypospadias. The one-stage approach to exstrophy repair may hold the answer to improved continence without a formal bladder neck reconstruction. Finally, the field of tissue engineering leads the way to new advances in autologous biological substitutes in the surgically-challenged patient where there is a shortage of local tissues at the surgeon's disposal.