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

Background

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

Methods

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

Results

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

Conclusion

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

Modified snodgrass hypospadias repair using the lembert suturing technique

BACKGROUND

Surgical repair of hypospadias deformity is a challenging and complex issue. However, the technique of Snodgrass and its modifications attend promising functional and cosmetic results.

PURPOSE

To assess the Lembert suturing technique effectiveness as a modification of the Snodgrass technique in lowering an urethrocutanous fistula rate.

PATIENTS AND METHODS

Fifty boys with mid-shaft and distal hypospadias were repaired using the modified Snodgrass technique utilizing the interrupted Lembert suturing technique in neourethroplasty. Patients with previous failed operations or severe chordee were excluded from the study.

RESULTS

None of the patients develops UCF apart from one who developed complete wound dehiscence following severe wound infection. Mild meatal stenosis is seen in two patients, and one patient experienced a small area of superficial skin sloughing.

Recurrent ventral curvature after proximal TIP hypospadias repair

EXTENDED SUMMARY

Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened while preserving the urethral plate to use TIP repair. That is usually done by dorsal plication (DP). However, we reported recurrent VC was commonly found after DP in boys with proximal urethroplasty complications, and have diagnosed VC in patients similarly straightened by WS. We reviewed our proximal TIP patients and now report their recurrent VC.

METHODS

We used a prospectively-maintained database to identify all patients with proximal TIP by WS and document recurrent VC. Penile straightening was primarily done by midline DP using 5-0 or 6-0 polypropylene, and/or other maneuvers including combinations of urethral plate elevation off the corpora, mobilization of the urethra to the external sphincter, and ventral corporotomies. Recurrent VC was suspected by a characteristic 'hunched-over' appearance and resistance to lifting the glans cephalad (Figure), and confirmed in all cases by artificial erection intraoperatively.

RESULTS

58 of the 77 patients with follow up had VC straightened. Recurrent VC was diagnosed in 26%. It was suspected during this review in another 10% who had recurrent urethroplasty complications which we now know often indicate VC, or urethral plate elevation with no treatment for corporal disproportion. This recurrent VC was objectively measured in nearly half those diagnosed, averaging 52 (30-75). It was diagnosed before puberty in all cases. There was no difference in recurrent VC in those managed with DP alone versus those straightened by DP and/or other maneuvers.

DISCUSSION

The finding that 1 of every 4 patients had recurrent VC after proximal TIP, and that as many as 1 of every 3 might have had that complication, is concerning. During most the study the extent of VC was visually estimated, and most patients were thought to have <45° with no tension on the UP after straightening. We reported 70% of patients operated elsewhere for proximal hypospadias and presenting with urethroplasty complications had recurrent VC ≥ 30° following earlier DP. In that series, in the current patients, and in an earlier report by Braga et al., an intact urethral plate correlated with increased risk for recurrent VC. Despite our improved ability to diagnose recurrent VC, we have not found it in boys who underwent STAG repair with urethral plate transection.

CONCLUSIONS

Recurrent VC after proximal TIP repair occurred in at least 1 of every 4 patients despite DP and/or additional maneuvers to straighten the penis while preserving the urethral plate. Accordingly, we now only perform proximal TIP when there is little (<30°) or no VC.

Outcome of surgical management of urethral stricture following hypospadias repair

INTRODUCTION

Reconstruction of urethral strictures in patients with a history of hypospadias repair is controversial. The authors policy has been that if a residual healthy urethral plate is present, single-stage urethroplasty is recommended. However, if the urethral plate is fibrotic or absent or if lichen sclerosus is present, two-stage repair is utilized.

OBJECTIVES

In this study, the authors report their experience in management of patients with urethral stricture and prior hypospadias surgery.

STUDY DESIGN

Between 1993 and 2015, 62 patients with urethral stricture and a prior history of hypospadias repair underwent urethroplasty. Patients were divided into two groups; patients in group 1 (n = 39) found to have a healthy residual urethral plate and underwent single-stage urethral stricture repair using either an island skin flap or a buccal mucosa graft. Patients in group 2 (n = 23) had either a scarred urethra or evidence of lichen sclerosus and underwent staged repair using a buccal mucosa graft. Post-operatively, patients were evaluated at 3 months, 6 months, 1 year, and then annually.

RESULTS

The median age of the patients was 10.5 years (2.5-33 years). The mean stricture length was 6.3 cm in group 1 and 7.1 cm in group 2. Overall success rate was 87.1% in group 1; a urethral fistula occurred in one patient (7.1%) who underwent skin flap onlay repair and one patient (4.5%) with a buccal mucosa graft. Recurrent urethral stricture was also diagnosed in one patient (7.1%) after repair using an island skin flap and in two patients (9%) following buccal mucosa graft. In group 2, three patients (13%) developed graft contracture and were revised before the second stage. Two patients (8.6%) had glans dehiscence following second stage urethroplasty. The final success rate in group 2 was 90.4%.

DISCUSSION

Both single-stage and 2-stage repair showed successful outcome in management of urethral stricture following hypospadias repair. However, the authors continue to believe that the status of the urethral plate dictates the type of surgery to be utilized. In accordance to the previously published data, the study results also further support promising outcomes of application of buccal mucosa in surgical management of these patients.

CONCLUSION

In patients with urethral stricture after hypospadias surgery who have a healthy residual urethral plate, single-stage repair using buccal mucosa graft is a viable option with high success rate. In patients with scarred urethral plate, a 2-stage repair is recommended.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Modified tubularized incised plate urethroplasty reduces the risk of fistula and meatal stenosis for proximal hypospadias: a report of 63 cases

PURPOSE

To report the feasibility of modified tubularized incised plate (TIP) urethroplasty technique for proximal hypospadias in 63 cases.

METHODS

From January 2004 to March 2010, 63 patients underwent one-stage TIP urethroplasty (modified Snodgrass technique repair) using 2-3 of three covering layers (corpus spongiosum, dartos, and tunica vaginalis). The primary meatus was proximal penile, penoscrotal, scrotal, and perineal in 38, 13, 10, and 2 patients, respectively. All patients had chordee that was corrected with dorsal plication. Glanuloplasty was performed in all cases. Complications and cosmetic results were documented after 6-72 months of follow-up.

RESULTS

A total of 63 boys with proximal hypospadias underwent Snodgrass hypospadias repair at a mean age of 8.5 months (range 6-54). Mean operative time was 210 ± 35 min. Patients were followed up with 6-month intervals for up to 6 years postoperatively. After 6 years of follow-up, nine urethrocutaneous fistulae, four bleeding, four meatal stenoses, and one urethral stricture were reported. Cosmetic result was satisfactory according to parent's opinion and another surgeon. No residual chordee was observed in any cases (without artificial correction).

CONCLUSION

In conclusion, this preliminary report can be estimated as an alternative technique with acceptable complication and cosmetic results for proximal hypospadias correction.

Use of Bipedicled Dorsal Penile Flap With Z Release Incision: A New Option in Redo Hypospadias Surgery

OBJECTIVE

To solve the challenge in redo hypospadias surgery, we tried to use a bipedicled dorsal penile flap with a Z release incision in failed hypospadias cases and reported the outcome.

MATERIALS AND METHODS

Thirty male children with 3 or 4 previous unsuccessful hypospadias surgeries were included in our study. Our technique was done after at least 6 months from the last surgery. A flap of the dorsal penile skin was preserved and the skin lateral to the flap was dissected on each side. A small opening was done in the dartos proximal to flap. The glans was withdrawn through this opening with a ventral transposition of the flap. Z-plasty was used to compensate for the deficient dorsal skin; the Z-plasty had 3 limbs and all were made of equal length.

RESULTS

The mean age of the patients was 5.4 ± 1.8 years and the mean follow-up was 2.1 ± 0.7 years. The technique was successful in 80%. Reoperation was required in 3 cases; all cases were managed using a 2-stage buccal mucosal graft. A small fistula at the coronal level developed in 2 cases but closed spontaneously within 1 month. All patients were voiding well and had a vertically oriented meatus at the tip of the glans and satisfactory cosmetic results.

CONCLUSION

Repair of failed hypospadias using a bipedicled dorsal penile skin flap with Z release incision is a safe and simple procedure offering high success rates.

Voiding patterns of adult patients who underwent hypospadias repair in childhood

OBJECTIVE

This study aimed at evaluating the voiding patterns of adult patients who underwent hypospadias repair in childhood.

METHOD

Following IRB approval 103 (22.7%) of 449 adult patients who underwent hypospadias repair between 1978 and 1993 responded to the following questionnaires: International Prostate Symptom Score (I-PSS) and Short Form 12 questionnaire (SF-12). Uroflowmetry (UF) was performed for all patients. The patients were divided into three groups according to the primary meatus localization. Group I had 63 patients (61.5%) treated for glanular hypospadias, group II had 19 patients (18.4%) treated for distal hypospadias, and group III comprised the remaining 21 patients (20.4%) treated for proximal hypospadias.

RESULTS

The mean ± SD I-PSS score for all patients who responded to the questionnaire was 2.3 ± 2.4, and UF was 21.1 ± 4.3 mL/s. The patients from groups I and III had fewer urinary symptoms compared with those of the group II: 1.3 ± 1.5, 5.5 ± 2.4, and 1.6 ± 1.4, respectively (p < 0.0001). With regards to UF, the patients from the groups I and III did better compared with those from the group II: 22.1 ± 4.1 mL/s, 18.91 ± 4.2 mL/s, and 20.11 ± 3.42 mL/s, respectively (p = 0.021) (Figure). The UF was better in patients with normal vs. abnormal IPSS (p = 0.0064). The physical component summary was 49.8 ± 10.3, 51.1 ± 3.6, and 46.4 ± 0.3 in groups I, II, and III, respectively. The mental summary component was 42.64 ± 4.1, 42.2 ± 2.4, and 39.89 ± 2.9 in groups I, II, and III, respectively.

CONCLUSIONS

Most of the adult patients who underwent hypospadias repair in childhood had normal or mild voiding disturbance, with no effects on their physical or mental status.

Reinforcing the ventral penile shaft with pedicled fat/connective tissues before urethroplasty lowers the risk for post-urethroplasty complications in hypospadias

PURPOSE

CHARGE is our technique for reinforcing the ventral penile shaft with pedicled pericordal/scrotal fat, pedicled perimeatal connective tissue, or a combination of these at the time of initial hypospadias surgery. Such pedicled grafts "charge" poorly developed urethral plates and thin ventral foreskin prior to urethroplasty to improve compromised vascular perfusion that could prevent post-urethroplasty complications (post-UPC).

METHODS

We reviewed post-UPC in 179 staged hypospadias repair patients (1997-2015). CHARGE, adopted routinely in 2010 was used in 39 patients (C-group), not indicated in 7 because ventral connective tissue was thick, and not used in 133 (NC-group). Initial hypospadias surgery included foreskin degloving with or without chordectomy, dorsal plication, tunica albuginea incision, or a combination of these.

RESULTS

Subject demographics were similar. NC had significantly more post-UPC than C (25 versus 0; p<.01) comprising stenosis (n=14), fistula (n=7), diverticulum (n=2), and wound infection (n=2) that developed after a mean of 0.7±0.2years (range: 1day-2.8years). Extra time taken for CHARGE was less than 15minutes in all cases. Mean follow-up after urethroplasty (years) was significantly shorter in C (1.5±1.0 versus 5.7±3.8) (p<.01), but almost double the time taken to develop post-UPC.

CONCLUSION

CHARGE would appear to prevent post-UPC.

LEVEL OF EVIDENCE

Retrospective Comparative Study - Level III.

Unexpected outcome of a modification of Bracka repair for proximal hypospadias: High incidence of diverticula with flaps

INTRODUCTION

Various graft and flap techniques have been proposed for urethral reconstruction in proximal hypospadias repair. The Bracka repair involving the transfer of inner prepuce like a Wolfe graft mostly results in satisfactory results besides a high fistula rate.

AIM

The aim was to decrease the high fistula rate with Bracka repair; we wanted to use the advantages of vascularized skin in the Bracka method. The aim of this study was to evaluate our results with this modification.

STUDY DESIGN

Our modification involves using a flap instead of a graft. In the first stage, chordee was corrected by transection of the urethral plate and dorsal midline plication when necessary. Instead of a graft as suggested by Bracka, inner preputial skin with ample blood supply was transferred and stitched to the denuded ventral penile surface. In the second stage after 6 months, this flap was tubularized in the Thiersch-Duplay fashion. Hospital records of patients who had undergone two stage modified Bracka repair between June 2007 and July 2012 were reviewed, including complaints, complications, and need for interventions.

RESULTS

Thirty-eight patients had undergone this operation. Four patients were lost to follow-up. The main complaint was obstructed urinary flow. Voiding symptoms were first attributed to urethral stenosis, but were, however, found to be due to diverticulum and vortex of the urine in the dilated urethra. Twenty-one patients (61%) had voiding problems and 10 patients (29%) had urinary tract infections. Fistula was observed in 23 and diverticula were observed in 24 patients. Of these, 16 patients had both fistula and diverticula. Only two patients (5%) were free of complications and totally satisfied with the operation, and 23 of the 34 patients had complications requiring intervention (Figure).

DISCUSSION

Inner preputial flaps used in proximal hypospadias repairs are prone to diverticula formation. They become redundant in time requiring reoperation, thus decreasing the success rate. Careful fixation of the flap to the corpora and allowing time for additional attachment of the urethral plate substitution through fibrotic activity could not overcome this complication.

CONCLUSION

Our modification of the Bracka technique using a flap for the plate resulted in a high rate of complications (in particular diverticulum formation) and was therefore abandoned. We recommend careful use of flaps in hypospadias surgery and long-term follow-up studies to evaluate actual functional and cosmetic results.

Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias

PURPOSE

To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique.

METHODS

We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra.

RESULTS

There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture.

CONCLUSIONS

Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.

Staged segmental urethroplasty for scrotal/perineal hypospadias: a new concept

PURPOSE

We report the efficacy of staged segmental urethroplasty (SSUP) versus non-staged urethroplasty (NSUP) for treating scrotal/perineal hypospadias (SPH).

METHODS

Between 1997 and 2015, 29 SPH patients underwent UP (SSUP: n = 15; NSUP: n = 14). Incidences of urethrocutaneous fistula (UF), stenosis of the neourethra (SNU), diverticula formation, and residual chordee (RC) were compared. Differences were statistically significant if p < 0.05.

RESULTS

The difference in mean age at NSUP (3.2 ± 1.3 years) and at the final stage of SSUP (5.5 ± 2.4 years) was significant (p < 0.05). Mean operative times for NSUP and SSUP (total for all stages) were not significantly different (231.5 ± 117.5 versus 272.5 ± 99.4 min); however, the incidence of postoperative complications was significantly less in SSUP (n = 1; UF) compared with NSUP (n = 6; 2 cases of UF, 3 cases of SNU, and 1 case of RC; (p < 0.05). Mean follow-up was significantly shorter in SSUP; 1.4 ± 1.2 years versus 7.0 ± 4.5 years in NSUP (p < 0.05).

CONCLUSION

SSUP would appear to be effective for treating SPH because of a significantly lower incidence of UF, SNU and RC during the first postoperative year, the period when complications have been reported to arise most frequently.

TIP hypospadias repair: A pediatric urology indicator operation

OBJECTIVE

We review development and evolution of TIP hypospadias repair, including technical changes made to improve its results. We also discuss general risk factors for hypospadias surgical complications.

METHODS

We describe use of a database with prospective data entry to first identify our most common complications and their frequency, and then to monitor results of technical modifications made to reduce their occurrence. Multiple logistic regression of various factors recorded in the database was done to identify those predicting increased risk for urethroplasty complications.

RESULTS

Fistula and glans dehiscence are the two most common complications we encountered after TIP repair. Changes in urethral plate tubularization and barrier layers covering the neourethra resulted in a significant reduction in fistulas after proximal TIP. Changes in glansplasty sutures and use of preoperative testosterone to increase glans size did not reduce likelihood for dehiscence, whereas increasing the extent of glans wings dissection did. Logistic regression analysis confirmed proximal meatal location and reoperation predicted increased complications, but also identified glans width ≤ 14 mm as an independent risk factor for hypospadias urethroplasty complications.

CONCLUSIONS

Systematic, prospective data collection facilitated identification of complications and their risk factors, and provided a means to assess results of modifications made to address them. Limiting the algorithm used for hypospadias repair increases expertise in those techniques used. Reported low surgical volumes for proximal hypospadias repair suggest subspecialization of these cases be carried out so that designated surgeons can achieve sufficient volume to analyze their results and make improvements.

Evaluation of Onlay Island Flap Technique in Shallow Urethral Plate Hypospadiasis

Background:

Hypospadias is one of the most common congenital genital anomalies in males that necessitates to be operated early in infancy (when 6 to 9 months old). On the other hand, hypospadias is a challenging field of pediatric urology with multiple reconstruction techniques. A perfect hypospadias repair is supposed to return urethral continuity with sufficient caliber, eradicate phallus curvature, and supply an acceptable appearance with low complications.

Objectives:

This study aimed to evaluate the outcomes of using onlay island flap technique in the repair of hypospadias with shallow urethral plate.

Patients and Methods:

In this prospective study within June 2012 to December 2013, we performed onlay island flap procedure to repair hypospadias with shallow urethral plate measuring less than 6 millimeter. This technique was selected for all types of hypospadiasis except subcoronal type. Nesbit’s dorsal plication procedure was established for chordee. In cases with very small glans, urethroplasty was performed without glansplasty.

Results:

Twenty three patients with mean age of 30 (range 10 - 60) months underwent onlay island flap repair; all had a shallow urethral plate < 6 mm, 3 had a very small glans, and 18 had chordee. Meatus was located in distal shaft in 5 cases, mid shaft in 8, proximal in 6 and penoscrotal type in 4 patients. Chordee was corrected with Nesbit’s dorsal plication in 16 cases. Complications were: meatal stenosis in 2 cases and urethrocutaneous fistula in 2 patients, all of which were repaired surgically. Mean follow up time was 13 (3 - 20) months. All cases that had glansplasty have excellent esthetic appearance.

Conclusions:

This technique offers acceptable results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.

Modified Tubularized Incised Plate Urethroplasty Repair: Frenuloplasty and Long-Term Results in 155 Patients

To describe a modification of tubularized incised plate (TIP) urethroplasty which we refer to as "frenuloplasty". We retrospectively reviewed 155 children who underwent TIP urethroplasty between June 2008 and August 2011 in our institution. In our technique, the circumcision incision went on through the mucocutaneous junction obliquely in order to form frenular wings instead of linear circumscribing incision joined the urethral plate vertically. The little triangle-shaped skin flaps between the oblique mucocutaneous incisions and urethral plate incisions were excised. The glans wings and frenular wings were re-approximated without tension after uretroplasty. The mean age of the patients was 4.63 ± 3.82 years. The mean follow-up was 15.94 ± 5.46 months. Location of hypospadias was distal penile in 126 patients (81.3 %) and mid-shaft in 29 (18.7 %). The following complications occurred in 21 patients (13.5 %): urethrocutaneous fistula formation in 7 (4.5 %), meatal stenosis in 14 (9 %) and no dehiscence. We suppose that there is no incompletely formed prepuce but a ventral fusion defect in the midline. Frenuloplasty reduces the necessity of ventral preputial flaps and provides satisfactory cosmetic outcomes with the appearence of normal circumcised penis.

Normalized Urinary Flow at Puberty after Tubularized Incised Plate Urethroplasty for Hypospadias in Childhood

PURPOSE

An obstructive urinary flow pattern is frequently seen after tubularized incised plate urethroplasty for hypospadias. However, the significance of this finding has not been determined and long-term results are few. We describe postoperative long-term uroflowmetry results after puberty in males who underwent tubularized incised plate urethroplasty in childhood.

MATERIALS AND METHODS

A total of 126 boys underwent tubularized incised plate urethroplasty for distal penile to mid shaft hypospadias at Queen Silvia Children's Hospital in Gothenburg between 1999 and 2003. Of the patients 48 were toilet trained at surgery. We report on 40 patients who had data available at 2 and 12 months postoperatively, 7 years postoperatively and at puberty (median age 15.0 years, range 13.7 to 17.1). Of the patients 31 had distal and 9 had mid penile hypospadias. Clinical examination, urinary medical history, uroflowmetry and ultrasound measuring residual urine were performed. Maximum urinary flow was correlated to age and voided volume, using Miskolc nomograms for comparison of percentiles.

RESULTS

At 1 year postoperatively 15 boys (37.5%) had normal urinary flow (above 25th percentile), compared to 16 (40%) at 7 years and 38 (95%) at puberty (p <0.0001). Improvement was significant in patients with distal (p <0.0001) and mid penile hypospadias (p = 0.008), as well as in patients who did (p = 0.0078) and did not undergo intervention (p <0.0001). During followup 5 patients underwent meatotomy due to obstructive symptoms and 4 underwent dilation. Three of these 9 patients had lichen sclerosus.

CONCLUSIONS

There is great potential for normalization of urinary flow at puberty for boys with hypospadias treated with tubularized incised plate urethroplasty. Unless symptoms occur, a conservative approach seems preferable.

Tunica vaginalis flap is superior to inner preputial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias

AIMS

The aims of this study are 1. to compare outcome of standard tubularised incised plate urethroplasty (TIP) repair using dartos flap in distal vs. midshaft hypospadias and 2. to determine whether tunica vaginalis flap (TVF) is superior to dartos flap in midshaft hypospadias in reducing early complications.

METHODS

All patients who underwent TIP repair between 2004 and 2011 by the same surgeon were divided into three groups based on type of hypospadias and choice of waterproofing layer: Group A: Distal hypospadias; inner prepucial dartos flap (n = 36); Group B: Midshaft hypospadias; inner prepucial dartos flap (n = 26); Group C: Midshaft hypospadias; TVF (n = 21). Early outcomes were compared between the groups using Fisher's exact test.

RESULTS

There was no significant difference in the age distribution or duration of follow up between the groups. There was no significant difference in terms of, glans dehiscence or meatal stenosis between the groups. In Group A, 0/36 had ventral skin necrosis and 3/36 (8.3%) developed urethrocutaneous fistula. In Group B, there was significantly higher ventral skin necrosis (6/26; 23%) and urethrocutaneous fistula (8/26; 30.7%) compared to Group A (p = 0.04). In Group C, there was significantly less ventral skin necrosis (0/21) and urethrocutaneous fistula (1/21; 4.7%) compared to group B (p = 0.03). There was no significant difference in outcomes between Group A and Group C.

CONCLUSION

1. TIP repair using inner prepucial dartos flap has significantly higher complications when used for midshaft hypospadias compared to distal hypospadias. 2. Tunica vaginalis flap reduces the fistula rate and is superior to inner prepucial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias.

Comparative outcomes of the tubularized incised plate and transverse island flap onlay techniques for the repair of proximal hypospadias

PURPOSE

The optimal management of proximal hypospadias remains uncertain. In this study, the surgical outcomes of tubularized incised plate repair (TIP) and transverse island flap (TVIF) onlay urethroplasty in boys with hypospadias were compared.

METHODS

A total of 176 patients with proximal hypospadias underwent TIP (n = 83) or TVIF onlay repairs (n = 93) by a single surgeon and were evaluated retrospectively. No patient received a testosterone injection prior to surgery. A retrospective review of their medical records collected data regarding age at surgery, chordee, dorsal plication, hypospadias site, penoscrotal transposition, bifid scrotum, congenital hernia, undescended testis and any postoperative complications, including fistula, recurrent curvature, dehiscence, diverticulum, meatal stenosis and urethral stricture. The pediatric penile perception score (PPPS) was completed by parents to evaluate their perception of cosmetic outcomes.

RESULTS

There was no statistical difference in age or any of the anatomical and clinical features of hypospadias. The median follow-up duration was 22 months (range 12-48 months) and 25 months (14-51 months) for the TIP and TVIF onlay groups, respectively. The overall complication rate in the TVIF onlay group was 21.5% (20/93), which was higher than 18.1% (15/83) in the TIP group, but the difference was not statistically significant (P = 0.569). The most common complication was urethrocutaneous fistula, occurring in 9.6% (8/83) of the TIP group and 10.8% (10/93) of the TVIF onlay group. There were no significant differences in the rate of any complication and the overall PPPS between the two groups.

CONCLUSION

TIP and TVIF onlay are clinically equivalent for the repair of proximal hypospadias.

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

INTRODUCTION

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

METHODS

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

RESULTS AND CONCLUSIONS

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

Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood

PURPOSE

We evaluated sexual function and psychosexual adjustment in adults who underwent hypospadias repair in childhood.

MATERIALS AND METHODS

After receiving institutional review board approval, 119 of 449 adult patients (26.6%) who underwent hypospadias repair between 1978 and 1993 responded to questionnaires on penile appearance and sexual life. Patients were divided into 3 groups according to primary meatal location in childhood, including group 1-45 (37.8%) with glanular hypospadias, group 2-56 (48.2%) with distal hypospadias and group 3-18 (14%) with proximal hypospadias.

RESULTS

All group 1 and 2 patients, and 11% in group 3 were satisfied with the penile appearance. Of group 1 patients 8.9% reported mild erectile dysfunction, as did 50% and 72.2% in groups 2 and 3, respectively. A total of 99 patients (83.2%) complained of premature ejaculation. All group 1 and 2 patients reported excellent self-esteem and relationship on the Self-Esteem and Relationship questionnaire. Most group 3 patients were satisfied with their relationship and only 1 (5.6%) was not satisfied. Two-thirds of the patients in groups 1 and 2 reported that sexual quality of life was excellent and the others described it as good. In group 3 sexual quality of life was somewhat decreased in all patients and 1 (5.6%) had poor sexual quality of life. Physical and mental component summaries were satisfactory in all patients reviewed.

CONCLUSIONS

Our data show that the high incidence of mild erectile dysfunction and premature ejaculation should not be disregarded and requires appropriate counseling before surgery.

Treatment of adults with complications from previous hypospadias surgery

PURPOSE

Adults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.

MATERIALS AND METHODS

We reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.

RESULTS

A total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).

CONCLUSIONS

Managing problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.

Tubularized incised plate repair for penoscrotal hypospadias: role of surgeon's experience

OBJECTIVE

To give a retrospective analysis of factors affecting outcome of tubularized incised plate (TIP) repair for penoscrotal hypospadias.

METHODS

Data of all patients who underwent TIP repair for penoscrotal hypospadias by a single surgeon were retrieved. Follow-up was carried out every 3 months within the first year and annually thereafter. Repairs were divided into 2 groups: Group 1 included surgeries performed in the first 2 years after fellowship training, and group 2 included repairs performed afterward. Chi-square test was used for statistical analysis. Statistical significance was defined as P<.05.

RESULTS

Data for 90 patients were retrieved for july 2001 through march 2009: Group 1 included 20 patients and group 2 included 70. The neourethra was covered with spongioplasty in 25 and dartos flap in 65. The overall success rate was 86%. Group 2 patients showed a statistically significant higher success rate of 91% compared with only 65% for group 1. Use of dartos flap was associated with statistically significant higher success (92%) compared with coverage of the neourethra with spongioplasty (68%). In group 1, use of dartos flap was associated with statistically significant better success (82% vs 33%). In group 2 patients, use of dartos flap showed no statistically better success (94% vs 81%).

CONCLUSIONS

TIP is a valid procedure for repair of penoscrotal hypospadias with chordee<30 degrees. The overall success (86%) is satisfactory. Surgeon's experience is the pillar for better success.

A model of delivering multi-disciplinary care to people with 46 XY DSD

In 2006, a consensus statement was jointly produced by the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society of Paediatric Endocrinology (ESPE) concerning the management of disorders of sex development (DSD) [1]. A recommendation provided by this consensus was that evaluation and long-term care for people affected by DSD should be performed at medical centers with multi-disciplinary teams experienced in such conditions. Here we provide our team's interpretation of the 2006 consensus statement recommendations and its translation into a clinical protocol for individuals affected by 46 XY DSD with either female, or ambiguous, genitalia at birth. Options for medical and surgical management, transitioning of care, and the use of mental health services and peer support groups are discussed. Finally, we provide preliminary data to support the application of our model for delivering multi-disciplinary care and support to patients and their families.

Interposition of dartos flaps to prevent fistula after tubularized incised-plate repair of hypospadias

OBJECTIVE

To evaluate the effect of urethral coverage by a single- or double-layered dorsal dartos flap after tubularized incised-plate (TIP) repair of hypospadias on fistula formation.

PATIENTS AND METHODS

In this retrospective study we evaluated sequential patients with hypospadias who underwent TIP urethroplasty with a dorsal dartos interpositional flap between April 2008 and December 2009. We reviewed their medical records for the site of hypospadias, previous hypospadias repair, single- or double-layered dartos flap and postoperative complications. The patients were divided into two groups; in group A the urethra was covered by a single layer of dartos fascia, and in group B the urethra was covered by double layers of dartos flap.

RESULTS

Of 91 patients who opted for hypospadias repair during the time of the study, 62 had a TIP urethroplasty with a dorsal dartos flap; of these 62, three did not fulfil the requirement of the minimum follow-up, so 59 were eligible for the study (32 in group A and 27 in group B). Preoperative clinical data were comparable in both groups. At a mean of 12.2 months of follow-up, there was no reported fistula in group B, while two patients in group A developed a urethrocutaneous fistula (P = 0.19). Meatal stenosis occurred in two patients in group A and one in group B (P = 0.66).

CONCLUSION

There was no significant difference in subsequent urethrocutaneous fistula between a double-layered dorsal dartos flap and single layer for covering the urethra as a part of TIP urethroplasty for repairing hypospadias.

Tubularized incised plate proximal hypospadias repair: Continued evolution and extended applications

OBJECTIVE

We report additional technical modifications and extended application of proximal TIP hypospadias repair in consecutive patients operated by a single surgeon.

MATERIALS

During a 39-month period, 36 patients underwent primary proximal hypospadias surgery, with 26 undergoing TIP and 10 two-stage repair for a thin urethral plate (UP) (1) or ventral penile curvature (VC) requiring UP transection (9). Of the TIP repairs, 16 had UP elevation from the corpora cavernosa to facilitate VC straightening while maintaining the UP for urethroplasty. All TIP patients underwent two-layer urethroplasty with tunica vaginalis coverage over the neourethra.

RESULTS

With mean follow up of 12 months (2-38) in 24 TIP patients, 16 had calibration and 11 urethroscopy 6-12 months postoperatively. Complications occurred in three (13%), glans dehiscence (2) and neourethral stricture (1), which represents a significant reduction versus our prior reports. Non-randomized preoperative testosterone in 8/24 with follow up did not influence complication rates. TIP incision of the elevated UP did not divide it into separate strips, or impair vascularity.

CONCLUSIONS

Dissection of the UP from the corpora facilitates correction of VC while preserving the plate, without increasing TIP urethroplasty complications. Overall, complication rates for TIP have significantly diminished with technical modifications and experience. The role for neoadjuvant hormonal therapy remains unclear. Despite straightening VC preserving the UP, intraoperative assessment deemed it unsuitable for TIP in one case (4%).

Assessment of urethral plate appearance through digital photography: do pediatric urologists agree in their visual impressions of the urethral plate in children with hypospadias?

OBJECTIVE

There is a paucity of literature on a definition or set criteria evaluating urethral plate (UP) quality. We sought to determine whether pediatric urologists are in agreement in their assessment of UP quality.

MATERIALS AND METHODS

A cohort of 21 pediatric urologists attending a national annual meeting were surveyed with a questionnaire inquiring about practice patterns and perceived impressions of UP quality. Nineteen sequentially projected, standardized, digital photographs, depicting plates with variable meatal locations, were presented. Intra- and inter-rater agreement among pediatric urologists was estimated by calculating the Kappa statistic (kappa).

RESULTS

Thirty percent of respondents had more than 15years of practice and one-third repair 10 or more hypospadias per month. Measurement of level of agreement in the impression of UP quality of the 18 projected photographs revealed poor inter-rater agreement (kappa=0.06, P=0.0003), which was not improved by focusing on particular meatal locations or surgeon experience.

CONCLUSIONS

Despite the inherent shortcomings of digital photography, this study highlights the potential subjectivity and lack of agreement on UP quality. Disagreement seems to be present irrespective of level of the defect or surgeon experience. Setting standards and improving agreement is likely to enhance reporting and interpretation of data in hypospadias studies.

Outcome of proximal hypospadias repair using three different techniques

OBJECTIVE

To evaluate the outcome of proximal hypospadias repair using three different techniques.

PATIENTS AND METHODS

The study involved 194 boys with primary proximal hypospadias. The meatus was proximal penile, penoscrotal, scrotal and perineal in 98, 64, 30 and 2 patients, respectively. Tubularized incised plate (TIP) urethroplasty, onlay island flap (OIF) urethroplasty and two-stage repair were used in 96, 57 and 41 patients, respectively. Preoperative anatomical description and postoperative complications were recorded with evaluation of the final functional and cosmetic outcomes for each technique.

RESULTS

Mean age at presentation was 14.43 months (range 6-31). Mean follow-up after second stage was 32.9 months (range 11-54). Complications were encountered in 27 cases (13.9%) with no statistically significant differences between techniques; however, a significantly higher complication rate was found among patients with scrotal and perineal hypospadias and in patients with associated scrotal lesions. Urethrocutaneous fistula was the most common complication, being encountered in 7.7% of patients with a significantly higher rate among patients with scrotal hypospadias (16.7%).

CONCLUSIONS

Single-stage repair of proximal hypospadias can be successfully performed when plate preservation is possible, while two-stage repair is applicable when plate transection is necessary. Functional and cosmetic outcomes are satisfactory, with no statistically significant advantage with any technique.

Original Koyanagi urethroplasty versus modified Hayashi technique: outcome in 57 patients

OBJECTIVE

To compare outcomes of the original Koyanagi technique with the Hayashi modification in severe hypospadias, i.e. hypospadias with a division of the corpus spongiosum located behind the penile midshaft associated with marked hypoplasia of the ventral aspect of the penis and a non-preservable urethral plate. Choice of technique for treating severe hypospadias is discussed.

PATIENTS AND METHODS

Twenty-six patients (group I) were operated in Lyon using the original Koyanagi procedure and 31 (group II) underwent a modified Hayashi procedure in Paris. Most patients received preoperative androgenic stimulation. Mean follow up was 25 months (group I) and 34 months (group II).

RESULTS

Sixteen patients (61.5%) in group I and 19 (61.3%) in group II developed complications leading to 21 additional procedures in each group. Urethral dehiscence was found in 11/26 patients in group I (42.3%), and in 6/31 patients in group II (19.3%); fistulae were respectively found in 5/26 (19.2%) and 12/31 (38.7%), and stenosis in 9/26 (34.6%) and 5/31 (16.1%) patients. Urethrocele was found in 7/26 (26.9%) and 5/31 (16%) patients, respectively. Twelve (group I) and 7 (group II) patients are awaiting re-operation.

CONCLUSION

Although the complication rate is quite similar between the original and the modified Koyanagi procedure, the Hayashi technique seems to provide a better distal blood supply to the reconstructed urethra.

Effect of suturing technique and urethral plate characteristics on complication rate following hypospadias repair: a prospective randomized study

PURPOSE

We studied the effect of suturing technique and the impact of urethral plate characteristics on the complication rate following tubularized incised plate urethroplasty.

MATERIALS AND METHODS

We prospectively studied 80 boys (mean age 4.5 years, range 3 to 7) with primary hypospadias in a randomized fashion between January 2004 and May 2005. Of the patients 64 had anterior and 16 had mid penile hypospadias. Patients were allocated into 2 groups according to suture technique, with continuous sutures used in 40 boys and interrupted sutures in 40. We evaluated urethral plate depth, length and width before and after incision. Correlation between suture technique, plate type, width and length, and complication rate was performed.

RESULTS

Mean followup was 3 years. Success rates were 90% and 69% for anterior and mid penile hypospadias, respectively (p = 0.037). Complications developed in 11 patients (13.8%) and consisted of fistula (8), dehiscence (2) and meatal stenosis (3). On univariate analysis the suture technique, depth and length of urethral plate, width after incision and presence of hypoplasia had no impact on complication occurrence. However, urethral plate width before incision was significantly related to complication occurrence (p = 0.048).

CONCLUSIONS

Suture technique has no influence on the outcome of tubularized incised plate urethroplasty. Urethral plate characteristics do not affect the complication rate except for plate width, which significantly affects the outcome. Adequate urethral plate width (8 mm or greater) is essential for successful tubularized incised plate repair.

Outcome of severe hypospadias repair using three different techniques

OBJECTIVE

To compare the outcomes of three different urethroplasty techniques (onlay, buccal mucosa, Koyanagi type I) used in the reconstruction of severe hypospadias.

PATIENTS AND METHODS

Over 10 years (1997-2007), 300 severe hypospadias cases were treated with a mean follow up of 2 years (1-105 months); 203 were operated by the same surgeon of whom 184 completed follow up. Three main techniques were used according to the quality of the urethral plate: onlay urethroplasty (133), buccal graft urethroplasty (25) and Koyanagi type I (26). The mean age at surgery was 36 months (8-298); 76 required preoperative androgen stimulation (onlay 37, buccal 11, Koyanagi 26); 18 required a corporoplasty to straighten the penis (onlay 13, buccal 3, Koyanagi 2).

RESULTS

Thirty-eight onlay (28.5%); 14 buccal (56%); 16 Koyanagi (61.5%) urethroplasties had a complication. The fistula rate was 15% for the onlay group; 32% for the buccal mucosa group; 19.2% for the Koyanagi cases. The dehiscence rate was, respectively, 11.3%, 20% and 42.3%. The stricture rate was, respectively, 1.5%, 20% and 34.6%. Urethrocele was found in seven Koyanagi patients. Final functional and cosmetic results were satisfactory in 126/133 (94.7%) onlay, 20/25 (80%) buccal and 14/26 Koyanagi (53.8%) urethroplasties. Primary cases had better results (89%) than redo cases (75.9%). Patients submitted to preoperative androgen therapy developed more complications (onlay: 40.5% vs 23.9%; buccal: 70% vs 43.7%).

CONCLUSION

Two striking results are the low number of severe hypospadias cases requiring an additional corporoplasty, and the increased complication rate found in androgen-stimulated patients. The excellent results of the onlay procedure could be related to the use of dorsal preputial tissue, which in hypospadias is characterized by a well-balanced protein platform compared to the ventral tissues.

The comparison of Belt-Fuqua and "TIPU" techniques in proximal penile hypospadias cases: retrospective analysis of 65 cases

OBJECTIVE

We have compared our success and complication rates using the single-step "TIPU" (tubularized incised plate urethroplasty) and two-step Belt-Fuqua techniques in patients with proximal penile hypospadias.

PATIENTS AND METHODS

Sixty-five patients with proximal penile hypospadias were operated on in our clinic between 1998 and 2008: 31 by the "TIPU" technique and 34 by the Belt-Fuqua technique. The correction of the chordee was accomplished with dorsal plication and corporal body grafting in 18 patients in the "TIPU" group and at the first stage in all patients in the Belt-Fuqua group.

RESULTS

The mean age of the patients was 6.2 years in the "TIPU" group and 6.6 years in the Belt-Fuqua group. The mean follow-up duration was 9.2 and 7.9 months, respectively. The overall complication rate was 22.6% in the "TIPU" group and 11.8% in the Belt-Fuqua group. In both groups, the cosmetic appearance of a natural vertical slit glanular meatus situated at the normal position on the glans was achieved.

CONCLUSION

The two-step Belt-Fuqua technique is accepted as a good alternative treatment modality because of low complication rates and good results in selected cases with proximal penile hypospadias.

High odds for freedom from early complications after tubularized incised-plate urethroplasty in 1-year-old versus 5-year-old boys

OBJECTIVE

We present two parallel case series on outcome after tubularized incised-plate urethroplasty (TIP repair) for hypospadias in 1-year-old versus 5-year-old boys.

PATIENTS AND METHODS

Over a 2-year period two groups (1 year old, n=57 and 5 years old, n=65) of boys were operated in parallel using the TIP repair. Main endpoints were set as incidence of fistula, meatal stenosis and foreskin dehiscence/phimosis. A logistic regression model was used to predict the odds for freedom from either 'any complication' or fistula in 1-year-old boys versus 5-year-old boys.

RESULTS

Five-year-old boys had a significantly higher incidence of fistula (26% vs. 7%, P<0.01) and 'any complication' (50% vs. 18%, P<0.001) than the 1-year-old boys. The odds ratio for freedom from 'any complication' and fistula was 4.8:1 (P<0.001) and 4.7:1 (P=0.009), respectively, in favor of the 1-year-old group. Avoiding foreskin reconstruction gave increased odds for freedom of "any complication" (4.2:1, P=0.034), but was an insignificant factor concerning freedom from fistula.

CONCLUSION

These data substantiate why boys with hypospadias should be corrected early. Foreskin reconstruction increases postoperative problems but does not increase the rate of postoperative fistulae.

Hypospadias outcome in the first 3 years after completing a pediatric urology fellowship

INTRODUCTION

The requirements of hypospadias surgery today not only include the creation of a straight phallus with optimal meatal placement but also call for excellent cosmetic outcomes with minimal complications. Specialty fellowship training as well as advanced surgical materials and techniques allow for consistent, successful results. We report the outcomes of hypospadias surgeries performed by two academic Pediatric Urologists in the first 3 years of practice after completing a 2-year fellowship.

PATIENTS AND METHODS

A retrospective chart review of all patients with hypospadias treated by two surgeons (DF and JC) between July 2004 and August 2007 was performed. The two surgeons had completed a 2-year Pediatric Urology fellowship at two different institutions (Johns Hopkins and Texas Children's Hospital). Level of hypospadias, patient age, type of repair and follow up as well as complications were recorded. Midshaft and distal hypospadias were classified as distal.

RESULTS

In all, 187 patients were operated on. No significant difference in numbers and complications occurred between the two surgeons. Distal hypospadias was found in 149, proximal in 29, and penoscrotal or perineal was found requiring a two-stage repair in nine patients. Distal hypospadias was repaired using either dorsal plate incision with tubularization (TIP) (n=112) or meatal advancement and glanuloplasty (MAGPI) (n=37). All proximal lesions were repaired using TIP. All patients were seen after 1-2 weeks, and 6 and 12 months postoperatively. Fistulae occurred in 10 patients (three in distal, four in proximal, and three in two-stage repairs) for an overall fistula rate of 5.3%. Meatal obstruction occurred in three distal repairs and one two-stage repair, diverticulum in one proximal. No complications occurred with MAGPI repairs. All complications, except for one, were successfully repaired in a single operation.

CONCLUSION

Modern hypospadias surgical techniques pioneered through decades of surgical innovation can now be successfully transferred to the new generation of specialty-trained Pediatric Urologists. Modern pediatric fellowship training allows performing distal hypospadias repair with a minimal fistula rate of 2.8%. Proximal hypospadias remain more challenging with complication rates of 13.8% for one-stage and 33.3% for two-stage repairs.

[Hypospadias repair with Snodgrass' technique]

Retrospective study of 124 patients (average age: 3.8 years) with midpenile hypospadias: 48.3% (60 children), distal penile: 45.9% (57) and coronal 5.6% (7), of which the 25.8% (16) presented ventral curvature and the 4.8% (6) resulting from the complication of another previous technique. All of them were operated according to Snodgrass' technique, removing the catheter between the 6th and 7th day in most of them. The global rate of complications was of 12%: 9 fistulae (7.2%) and 6 meatal stenosis (4.8%). Aesthetic result was satisfactory in all cases, getting glans covered by foreskin in 57.3%.

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.