Grafted tubularised incised plate: A right option in the management of failed mid-penile and distal hypospadias

Introduction

Hypospadias is a common congenital anomaly of the urogenital system. The goal of the initial repair is to correct any curvature, ensuring that the penis is straight, allowing for successful intercourse, to create a functional neourethra to direct the urinary stream in a forward direction and to produce a cosmetically normal-appearing penis with a slit-like meatus at the tip of the glans. Failures and complications do occur. Failed hypospadias repair is often associated with penile skin loss or deficient local tissue, which leaves the penis short, scarred and hypovascular. Repair of a failed hypospadias surgery represents one of the most challenging and difficult tasks. We retrospectively evaluated our series of children who underwent reoperative grafted tubularised incised plate (G-TIP) repair for a mid-penile or distal penile hypospadias.

Materials and Methods

With permission obtained from the university/institutional ethics committee, we retrospectively reviewed the inpatient and outpatient records of all children ≤18 years of age who underwent a reoperative G-TIP hypospadias repair.

Results

During the study period, a total of 22 children (mean age: 6.8 years) underwent reoperative G-TIP repair. The mean number of previous repairs was 1.36. Nine (40.9%) of the children had persisting chordee. Complications were noted in five (22.7%) children.

Conclusion

G-TIP is a good option in the management of mid-penile or distal penile failed hypospadias repairs. Although complications are noted, they are easily manageable.

A New 3-Stage Approach for Reoperative Hypospadias

BACKGROUND

Most hypospadias patients undergo 1 surgical procedure and go on to live normal lives. However, there is a small subset of patients who have remaining functional complications after their repair. Patients presenting with diffuse scarring of the urethral plate and a shortage of penile skin for closure are referred to as "hypospadias cripples." We present our experience using tissue expanders in the treatment of reoperative hypospadias with skin deficiency.

METHODS

We retrospectively reviewed hospital records from 2009 to 2019. Five hypospadias cripple patients were encountered. A multidisciplinary team involving plastic surgery and pediatric urology collaborated a 3-stage reconstructive plan:Stage 1-Scar excision and buccal mucosal graft harvestStage 2-Dorsal tissue expander placementStage 3-Tissue expander explantation, creation of neourethra, and skin closure.

RESULTS

Successful skin closures were achieved in all patients. There were no cases of expander explanation. Average time between tissue expander placement and final reconstruction ranged from 3 to 4 months. Complications included 2 cases of penile cellulitis, 1 with an associated abscess, and 2 limited urethrocutaneous fistulas, which were addressed with an additional operative procedure.

CONCLUSIONS

The 3-stage approach is advantageous in treating hypospadias cripple patients. This population can benefit greatly from tissue expander placement after buccal result with an acceptable complication rate. Using a multidisciplinary approach is beneficial in treating these complex patients.

Comparison of Dartos flap and spongioplasty in Snodgrass urethroplasty in distal penile hypospadias

Background

Hypospadias surgery has been continuously evolving, although there is no single technique which can be said to be perfect and suitable for all types of hypospadias. Tubularized incised plate (TIP) urethroplasty (Snodgrass procedure) is presently the most common surgical procedure performed for distal penile hypospadias (DPH). The aim of this study was to compare the outcome of TIP urethroplasty using Dartos flap (DF) and spongioplasty as second layer in DPH.

Methods

A total of 30 patients of DPH were repaired using TIP urethroplasty with DF or spongioplasty as second layer from January 2017 to June 2018. Out of 30 patients, TIP with DF was done in 15 patients (group A) and TIP with spongioplasty was done in the remaining 15 patients (group B). Preoperative mean age and weight were comparable in both groups. Postoperative complications, namely, postoperative edema, residual chordee, urethrocutaneous fistula (UCF), meatal stenosis and final cosmesis, were recorded.

Results

In both groups, complications included postoperative edema (Gp A-1Gp B-1), residual chordee (Gp A-1, Gp B-1), UCF (Gp A-3, Gp B-4), meatal stenosis (Gp A-1, Gp B-5) and poor cosmesis (Gp A-3, Gp B-4). Wound infection was managed with appropriate antibiotics, and meatal stenosis responded to calibration in five patients.

Although it seems that DF has a better outcome clinically, the difference between the two techniques was statistically not significant.

Conclusion

DF as an additional cover to TIP is associated with an acceptable complication and has good cosmesis compared with spongioplasty; however, the difference is not statistically significant.

Diagnosis and Treatment of Hypospadias With Megameatus Intact Prepuce

Purpose: To evaluate the diagnosis and treatment methods of hypospadias with megameatus intact prepuce (MIP). Materials and Methods: A retrospective analysis was performed in 27 MIP children, 13 of whom underwent tubularized incised plate urethroplasty (TIP procedure), 7 underwent the Duplay procedure, 5 underwent the Mathieu procedure, 1 underwent meatal advancement and glanuloplasty (MAGPI procedure), and 1 underwent the glans approximation procedure (GAP). The patients were followed for 6-36 months to evaluate the surgical outcomes by the Pediatric Penile Perception Score (PPPS). Results: A total of 27 patients with a mean age of 8.12 ± 3.0 years were enrolled in this study, and 25 cases (25/27, 92.6%) were accidentally discovered during the first visit for phimosis. The patients had a formed urethra of 0.5 to 1.5 cm. Complications occurred in 4 of the 27 patients (14.81%): 2 patients with urethral fistula and 2 patients with meatal stenosis. One patient had a case of self-healed urethral fistula, and the remaining 3 patients underwent reoperation. The post-operative effect was satisfactory in all patients, and the urinary flow and stream during urination were normal. The overall average PPPS score of non-operative surgeons and parents was satisfactory. There were no significant differences in meatus appearance, glans appearance, skin appearance, and general appearance PPPS score among the Mathieu, TIP, and Duplay surgical procedures. Conclusions: MIP clinical manifestations are concealed and usually noted when circumcision is attempted. The suitable procedure for each patient should be tailored according to the anatomic features, and several techniques can be used with good functional and cosmetic results.

Outcomes of staged lingual mucosal graft urethroplasty for redo hypospadias repair

BACKGROUND

The objective of this study was to present the outcomes for redo hypospadias repair using lingual mucosal graft (LMG).

PATIENTS AND METHODS

Between June 2012 and February 2017, 47 patients underwent staged LMG urethroplasty for redo hypospadias repair. The inclusion criteria were previous failed hypospadias repair with a paucity of local skin that interferes with correction using skin flaps and demands graft urethroplasty. During the first stage, a well-vascularized bed on the tunica albuginea was created. Then, the harvested LMG was secured to the prepared bed. The second-stage urethroplasty was carried out after six months. In this stage, tubularization of the previously implanted LMG was performed. In four cases, tubularization was difficult owing to graft contracture. This difficulty was managed by using the dorsally degloved penile skin as the onlay island flap in three cases and the buccal mucosa onlay graft in the fourth case. In all cases, a second protective layer from the dartos or tunica vaginalis was developed to cover the neourethra.

RESULTS

The median (interquartile range [IQR]) age of patients at the first stage was 5 (4-6) years, and the median (IQR) duration between both stages was 7 (6-8) months. The median (IQR) follow-up after the second stage was 15 (13-16) months. The median (IQR) number of previous operations was 2 (2-3). The median (IQR) length of the LMG was 3 (2.5-4) cm, and the median (IQR) width was 1 (1-2) cm. No donor-site major complications, but mild oral discomfort in the first week after graft harvesting, were reported in 39 (83%) patients. After the second stage, complications were reported in nine (19.2%) patients, meatal stenosis in five and fistula in four. The reported success rate was 80.9%.

DISCUSSION

Reconstruction of previously failed hypospadias is a challenge owing to local tissue scarring and a paucity of adjacent healthy tissue. In this study, the LMG was used in two-stage redo hypospadias repair after previous repair failure. In the present study, a success rate of 80.9% was reported after the second stage. According to this study and the published series, harvesting the LMG is associated with minimal immediate donor-site complications and no long-term morbidity. Another advantage of the LMG is easy harvesting with effortlessly reachable tongue in comparison with the buccal mucosa that is deep and requires application of a mouth retractor.

CONCLUSIONS

Two-stage LMG urethroplasty is a reliable procedure for salvage urethroplasty. Lingual mucosal graft harvesting is easy, with minor oral complications.

Tubularized incised plate urethroplasty for distal and midpenile hypospadias reoperation: A single institute experience

Objective:

Our study aimed to evaluate our experience in tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation.

Patients and methods:

This was a retrospective study in which we reviewed the medical records of 56 patients who underwent tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Tubularized incised plate urethroplasty was performed using a surgical technique like the primary tubularized incised plate repair based on the Snodgrass’s method. We recorded complications and functional outcomes of redo procedures.

Results:

We reviewed 56 patients who ranged in age from 2–16 years (mean 7.02±3.8 years). The overall complication rate was 33.9% ( n=19). Eight patients (14.3%) had fistula, six had meatal stenosis (10.7%), four had dehiscence (7.1%), and one had neourethral stenosis (1.8%). The complications occurred in 13 of mid-penile cases representing 50% of mid-penile cases but occurred in six cases of distal-penile cases (20%). The success rate of tubularized incised plate urethroplasty reoperation was 94.6% after repair of fistula and meatal stenosis by simple closure of fistula and meatoplasty.

Conclusion:

Tubularized incised plate urethroplasty is a safe and effective alternative procedure for hypospadias reoperations. The outcome is favorable if the urethral plate has no scars and with distal meatal location. The complication rate increases if the third redo is done and with midpenile meatal location.

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.

Two-stage hypospadias repair with a free graft for severe primary and revision hypospadias: A single surgeon's experience with long-term follow-up

INTRODUCTION

Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation.

OBJECTIVE

To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up.

MATERIALS AND METHODS

Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n = 208): indications for a two-stage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n = 93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months.

RESULTS

For the primary repairs (n = 208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n = 93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8).

DISCUSSION

In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the two-stage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%.

CONCLUSION

The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Tubularized incised plate urethroplasty for the treatment of penile fistulas after hypospadias repair

OBJECTIVE

Urethrocutaneous fistula is the most common complication of hypospadias repair. Tubularized incised plate urethroplasty (TIPU) has been used for the management of distal fistulas. This study reports the usage of TIPU in the treatment of large penile fistulas.

MATERIALS AND METHODS

Between April 2002 and September 2012, 15 patients with large penile fistulas who were managed with TIPU were included in the study. The fistulas were sited along the penile shaft from proximal to distal penile localization. Glanular and coronal fistulas were excluded. The surgical technique was completed according to the standard TIPU technique. The surrounding scar tissue of the fistula was circumferentially excised, and the urethral plate at the level of the fistula was incised to provide performance of loose urethral tubularization. A urethral stent was kept for 5-7 days.

RESULTS

The mean age of the patients was 7.3 ± 3.1 years. Primary operation of these patients was tubularized preputial island flap (n = 6), on-lay preputial island flap (n = 4), and TIPU (n = 5). The sites of the hypospadias fistulas were as follows; penoscrotal (three), mid-penile (eight) and subcoronal (four). Fistulas recurred in two patients after fistula repair. The postoperative follow up of the patients was 12.4 ± 7.7 months.

CONCLUSION

TIPU may be used safely for the treatment of fistulas after hypospadias repair.

Which type of urethroplasty in failed hypospadias repair? An 8-year follow up

OBJECTIVE

To report our 8-year follow up for redo hypospadias repair.

METHODS

A total of 56 patients with previous failed hypospadias repair were included in our study. Patients' data were analyzed regarding age, number of previous repairs, meatal location, procedure performed, operative time and complications. Patients were followed up for 3 to 102 (mean 52) months.

RESULTS

Patient age ranged from 15 to 204 (mean 90.7) months. Forty-two patients had a single previous hypospadias repair, eleven had two previous repairs and three had four previous repairs. Of the 56 patients, 16 underwent oral mucosal graft urethroplasty, 15 onlay island flap, 14 parameatal flap, 10 tubularized incised plate urethroplasty, and 1 tubularized preputial flap. Complications were encountered in 16 (28.5%) patients in the form of graft contracture in 3, meatal stenosis in 2, urethral stricture in 2 including the patient with tubularized flap, urethra-cutaneous fistula in 7, bleeding in 1 and skin disruption in 1. The final complication rate was 25%.

CONCLUSIONS

Decision making in redo hypospadias surgery depends mainly on local tissue availability and the degree of tissue scarring. The characteristics of oral mucosal graft make it suitable for urethroplasty in the absence of local donor tissues. A long-term follow up for redo hypospadias repair is required to assess the late neourethral stricture and residual penile curvature.

A new use of scrotal septal skin flap in repairing hypospadias

In our study, we introduce the use of a scrotal septal skin flaps in repair of hypospadias. Between June 2006 and October 2008, 30 patients were treated by using a penile local flap to reconstruct the urethra, and a scrotal septal skin flap to cover the wound located on the ventral side of the penis. Of 30 patients, 4 presented with urine leakage, but this condition healed spontaneously after 2 to 4 weeks. Urine leakage healed without problem in the remaining patients, and they had unobstructed urinary flow. Additionally, they all were satisfied with genital appearance after the reconstruction. We conclude that our method is a convenient means to cover the wound at the ventral side of the reconstructed urethra by using a scrotal septal skin flap during hypospadias repair. This procedure provides good urinary function and satisfactory appearance to the patients. In addition, this method solves the problem of very limited local tissue for urethral reconstruction in the hypospadias patient.

Single-stage dorsal inlay full-thickness genital skin grafts for hypospadias reoperations: extended follow up

PURPOSE

To report our extended experience with single-stage genital skin graft urethroplasty for complex hypospadias reoperations.

MATERIALS AND METHODS

Thirty-one patients with failed hypospadias surgery were included. The urethral plate had been removed or was scarred in all. After excision of fibrotic tissue a free full-thickness skin graft was quilted to the corpora cavernosa. The neourethra was then tubularized followed by glanuloplasty. Voiding cystograms, urethral ultrasound and flow measurements were performed in all. Outcome was considered a failure when postoperative instrumentation was needed.

RESULTS

Follow up was 78.45 +/- 18.18 months. Shaft skin was used in 13 and internal prepuce in 18. Average graft length was 3.66 +/-1.56cm. Eighteen patients required glanuloplasty. Initial graft healing was successful in all. There was no postoperative infection involving the inlay. We did not note complications from the graft donor sites. Four patients underwent redo surgery yielding a complication rate of 12.9%. Urethral stricture of the proximal anastomosis was most frequent.

CONCLUSIONS

This single-stage approach using dorsal inlay skin grafts is reliable, creating a substitute urethral plate in the long term. Complication rates are equivalent to those of staged strategies. This is a safe option for hypospadias reoperations if the urethral plate is compromised.

Critical outcome analysis of staged buccal mucosa graft urethroplasty for prior failed hypospadias repair in children

PURPOSE

Although staged buccal mucosa graft urethroplasty is a well accepted technique for salvage urethroplasty, there are few reports on this procedure for redo hypospadias repair in children.

MATERIALS AND METHODS

We reviewed patients who underwent staged buccal mucosa graft urethroplasty for redo hypospadias repair. Age, quality of graft before tubularization, meatal position, presence of balanitis xerotica obliterans and complications were recorded.

RESULTS

A total of 30 patients underwent 32 repairs during a 5-year period. Mean age at first stage was 7 years (range 1 to 17) and mean interval between stages was 9.3 months (5 to 13). Mean followup after second stage was 25 months (range 10 to 46). Meatal position before first stage was proximal in 44% of patients, mid shaft in 39% and distal in 16%. Nine patients had biopsy proved balanitis xerotica obliterans. There were no donor site complications. Four patients underwent a redo grafting procedure. Complications after second stage occurred in 11 of 32 repairs (34%), consisting of urethral stenosis in 5, glanular dehiscence in 3 and urethrocutaneous fistula in 3. A third of the patients had some degree of graft fibrosis/induration after the first stage. These patients were prone to more complications at second stage (9 of 11, 82%), compared to patients without these unfavorable findings (4 of 21, 19%; p<0.001). Presence of balanitis xerotica obliterans and meatal position were not significant factors associated with adverse outcomes.

CONCLUSIONS

Staged buccal mucosa graft urethroplasty is a suitable technique for salvage urethroplasty. Complications after second stage were seen in approximately a third of patients, mainly those with fibrotic/indurated grafts.

Management of hypospadias cripples with two-staged Bracka's technique

Patients labelled as 'hypospadias cripples' pose a challenge to reconstructive surgeons because of the complexity of the problem and limited options for reconstruction. The two-staged Bracka method is a versatile technique that is relatively easy to learn and applicable in difficult cases of salvage hypospadias. Over a period of 8 years, we applied this technique to 100 patients with hypospadias cripples who had previously undergone multiple (3-16) procedures. In the first stage, a full-thickness graft of skin or buccal mucosa was used for urethral plate reconstruction after release of chordee. Stage II was carried out at least 6 months after the first procedure. Meatal opening at the tip of the glans was achieved in 94 patients, straightening of the penis in 96 and proper urinary stream in 92 patients. Fistula formation occurred in nine patients. In our opinion, the two-staged Bracka technique is a useful strategy to deal with the myriad abnormalities encountered in crippled hypospadias. This technique not only creates a neourethra successfully, but also gives the penis a near-normal shape and appearance.

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.

Initial experience with 'inverted U' staged buccal mucosa graft (bracka) for hypospadias repair

OBJECTIVE

To describe a modification of the Bracka procedure ('inverted U'), used to enlarge the graft and diminish the risk of graft contracture compromising the subsequent urethral reconstruction.

MATERIAL AND METHODS

Inverted U Bracka procedure was performed in 10 children in whom previous hypospadias correction had failed. The surgical steps are identical to the original Bracka procedure. The only modification is reconfiguration to enlarge the graft.

RESULTS

Significant contraction of the graft was not seen in any patient and the second stage was performed uneventfully. After the second surgery there were two complications: one fistula and one wound infection.

CONCLUSION

In this preliminary study, the modification avoided significant contracture of the graft giving a more predictable size of the neourethra for the second-stage procedure. An amplified series is necessary to confirm this initial result.

Management of urethrocutaneous fistula following hypospadias repair

Urethrocutaneous fistulas complicating hypospadias repair appear a common problem. There appears less data in the literature regarding the risk and management of recurrent fistulas. A retrospective review of urethrocutaneous fistulas complicating hypospadias repair was performed to evaluate their aetiology, management and outcome. Between 1993 and 2003, 1,753 patients had a hypospadias repair at our institution. Overall 123 (7%) boys developed a fistula, although detailed information was available on 117 patients only. Median age was 3.5 years at the time of fistula repair; 13% had anterior, 57% had middle and 30% had posterior hypospadias. The most common primary surgical procedure was a Durham Smith two-stage repair in 29% (n = 34), followed by a Tubularised Incised Plate urethroplasty in 19% (n = 22) and an Onlay in 14% (n = 16). Thirty-one (27%) patients developed a recurrent fistula, 9 (29%) of which recurred following a second repair. None recurred after a third repair. The risk of a recurrent fistula after an initial distal fistula repair was 12.5% and after a posterior fistula was 62% (chi(2) = 15.4, P = 0.001). Use of a stent, suture type, numbers of fistula and closure attempts did not influence the recurrence rate. Undiagnosed distal obstruction was thought to be related to 27 of 117 first fistula repairs (23%) and 4 of 31 second fistula repairs (13%). The risk of recurrent urethrocutaneous fistula was increased in those boys with a posterior fistula, following a simple repair or when there was evidence of distal urethral obstruction.

Single stage dorsal inlay buccal mucosal graft with tubularized incised urethral plate technique for hypospadias reoperations

AIM

To report the experience with single stage dorsal inlay buccal mucosal grafts using the Snodgrass technique for complex redo cases.

METHODS

From May 2004 to December 2005, a total of 53 patients aged from 3 to 34 years old (average 11.62 +/- 7.18 years) with failed previous hypospadias surgery were included in the present study. Indications included urethral strictures and repair breakdown. The unhealthy urethra was unroofed from the meatus in the ventral midline, a buccal mucosal graft was inlayed between the incised urethral plate and fixed to the corpora cavernosa. The neourethra was tubularized, and covered with subcutaneous (dartos) tissue and penile skin. Glanuloplasty was also performed in all cases. Outcome analysis included clinical follow-up, and endoscopy in 2 selected cases.

RESULTS

The buccal mucosal graft was 3.0-7.5 cm in length and 0.7-2.0 cm in width. All patients required glanuloplasty, with buccal mucosal grafts extended to the tip of the glans. After a follow-up of 14-30 months (mean 22.6 months), the total complication rate was 15.1%, with five cases of fistula and three cases of stricture.

CONCLUSION

Inlaying dorsal buccal mucosal grafts applying the Snodgrass technique is a reliable method for creating a substitute urethral plate for tubularization. The recurrent rate of urethral stricture and fistula is at an acceptable level for redo cases. This approach represents an effective, simple and safe option for reoperations.

[Correction of hypospadias by the Snodgrass method. Indications and results]

Tubularisation of the urethral plate with a medial incision was popularized by Snodgrass in the late 1990s. Since then this procedure has emerged throughout the world as the method of choice for correction of primary hypospadias. The procedure is applied as the technique of choice for primary correction of hypospadias, regardless of the level of the hypospadic meatus and the width of the original urethral plate, and is also used in various situations for secondary hypospadias surgery.. The complication rate is about 5-10 % in primary cases and between 10% and 20% in revision surgery for hypospadias repair.

[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%.

Reoperative hypospadias

PURPOSE OF REVIEW

To review recent publications on the surgical treatment of hypospadias failures, including prognostic factors, which may influence final outcome in hypospadias surgery.

RECENT FINDINGS

Interim good outcomes for single-stage dorsal inlay grafting in patients with multiple failed repairs would suggest a greater role for this new technique over other available options. Slowly emerging long-term data confirm our suspicion that a good result early on is not necessarily indicative of a satisfactory long-term outcome.

SUMMARY

Hypospadias surgery remains a considerable technical challenge and improvement will come from the development of specialized units.

Dorsal Double-Layer Dartos Flap for Preventing Fistulae Formation in the Snodgrass Technique

INTRODUCTION

The Snodgrass technique and its modifications have become a preferred method for all varieties of hypospadias in the past decade. However, fistula is the most common complication of this technique. The aim of this study was to investigate the importance of the single and double flap to prevent fistula formation in the Snodgrass procedure.

MATERIALS AND METHODS

Tubularized incised plate urethroplasty, using a single or the double flap, was undertaken in 74 consecutive boys (median age 6.6 years old, range 1-15) within the last 4 years. In the first 29 patients (group 1), a dorsolateral flap was rotated laterally for covering the neourethra and in the remaining 45 patients (group 2) the neourethra was covered with dorsal double dartos flaps.

RESULT

In group 1, fistula in 4 patients and partial glanular dehiscence in 1 patient were detected. There was no fistula formation in group 2.

CONCLUSION

For preventing fistula formation, urethral covering by a well-vascularized dorsal double-layer dartos flap should be the basic part of the Snodgrass procedure.

Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients

OBJECTIVES

To determine the key points for a successful redo hypospadias procedure using tubularized incised plate urethroplasty operation.

METHODS

A retrospective chart review of a cohort of 100 patients (Mean age: 4.5 years, range: 2-12) who had undergone a redo tubularized incised plate urethroplasty operation was performed. Fischer exact and Chi square tests were used for statistical analysis.

RESULTS

The incidence of complications of tubularized incised plate urethroplasty reoperation after failed repairs of meatal advancement and glanuloplasty procedure (n: 14), meatal based flap (n: 36), and tubularized incised plate urethroplasty (n: 50) were 29% (n: 4), 22% (n: 8) and, 28% (n: 14) respectively (P > 0.05). The overall complication rate was 26% (n: 26). Eighteen patients (18%) had fistula, five had meatal stenosis (5%), two had dehiscence (2%) and one had neourethral stenosis (1%). Postoperatively, fistula was closed in 18 patients and 5 underwent meatoplasty. Two patients with dehiscence and one with neourethral stenosis underwent an unsuccessful third redo tubularized incised plate urethroplasty reoperation and they were candidates for a complex hypospadias repair (3%). The ultimate success rate of tubularized incised plate urethroplasty reoperation after treatment of complications was 97%.

CONCLUSION

Tubularized incised plate urethroplasty is a safe and efficacious alternative procedure for hypospadias reoperations if the urethral plate has no scars and outcome is favourable if the first failed hypospadias repair is a meatal based flap procedure. The complication rate increases if the urethral plate has been previously incised in the midline and a redo third redo must be avoided.

Mathieu and Barcat repair with a V incision sutured meatoplasty for secondary hypospadias surgery

AIM

Today single-stage methods are more frequently selected for hypospadias repair than multistaged methods, but complications cannot always be avoided. We employed two kinds of meatal based flip-flap urethroplasty procedures for those with an unsuccessful primary hypospadias repair.

PATIENTS AND METHODS

From 1997 to 2005, a meatal based flip-flap urethroplasty was performed as a secondary hypospadias surgery on 17 patients. Basically we attempted the Mathieu repair, but when the wings of the glans were not generously widened and the urethral groove was not sufficiently deep we applied the Barcat procedure. While 11 patients were repaired with the Mathieu technique, six patients underwent the Barcat repair. The V incision sutured meatoplasty was added to obtain a natural ventral slit-like meatus.

RESULTS

Ten of the 11 patients who underwent the Mathieu repair had a good outcome, but one patient developed a urethrocutaneous fistula. None of the six patients repaired with the Barcat procedure encountered postoperative complications. Cosmetically, a vertical slit was constructed near the normal neomeatus with the Mathieu and V incision sutured (MAVIS) meatoplasty and the Barcat and V incision sutured (BAVIS) meatoplasty.

CONCLUSIONS

The Mathieu or the Barcat meatal based flip-flap urethroplasty procedure is feasible as a salvage surgery for those with relatively short urethral defects and adequate mobile ventral skin if an exact procedure is selected. Excellent cosmetic results could be obtained by adding the technique of V incision sutured meatoplasty.

Tunneled Tunica Vaginalis Flap is an Effective Technique for Recurrent Urethrocutaneous Fistulas Following Tubularized Incised Plate Urethroplasty

PURPOSE

In the last several years the use of the tubularized incised plate hypospadias repair has greatly increased. The most significant complication after this mode of urethroplasty is urethrocutaneous fistula development. Tunneled tunica vaginalis flap is a well described technique for repair of urethrocutaneous fistula. However, to our knowledge its use after tubularized incised plate repair has not yet been described. We present our results with this technique.

MATERIALS AND METHODS

We retrospectively reviewed all patients undergoing repair of urethrocutaneous fistula after initial tubularized incised plate repair between January 2001 and December 2005. We analyzed the initial number and location of fistulas, number of previous urethrocutaneous fistula repairs, duration of surgery, and intraoperative and postoperative complications.

RESULTS

A total of 16 boys (median age 2.2 years) underwent tunica vaginalis flap repair at our institution for urethrocutaneous fistula following initial failed tubularized incised plate repair. Of these patients 4 had not previously undergone urethrocutaneous fistula repair and 12 had undergone 1 to 4 failed repair attempts. All boys had a subcoronal fistula and 8 had additional fistulas along the penile shaft, 4 each with 3 and 4 fistulas, including 1 penoscrotal fistula. Mean surgical time was 45 minutes, and no intraoperative or postoperative complications occurred. After a mean followup of 18 months (range 4 to 36) no patient had recurrence of urethrocutaneous fistula.

CONCLUSIONS

Tunneled tunica vaginalis flap repair is a highly successful technique for the treatment of urethrocutaneous fistula after initial failed tubularized incised plate repair. The technique is technically simple to perform, and we encountered no complications. Tunneled tunica vaginalis flap repair should be considered for treating urethrocutaneous fistula following initial failed tubularized incised plate hypospadias surgery, particularly in a repeat surgical setting.

Tubularized incised plate (TIP) in previously operated (redo) hypospadias

OBJECTIVE

We report our experience of using the tubularized incised plate (TIP) technique for repair of hypospadias in patients who had undergone one or more failed attempts at repair.

METHODS

A total of 30 children (age range 2-10 years; mean 4.3 years) with hypospadias presented to our unit for redo hypospadias. The number of prior repairs was as follows: one in 17 patients, two in eight patients and three in five patients. The meatus was at the distal shaft in 19 cases, mid shaft in eight cases, and proximal shaft in three cases. Preoperatively 13 patients had fistulae, and none had residual chordee. The urethral plates were judged to be surgically altered in 11 patients and unaltered in 19 patients. The neourethra was then reconstructed using the Snodgrass TIP technique. Follow-up urethral calibration was performed to assess the results. All patients were discharged same day postoperatively. All patients were followed up at 1 week, 3 weeks, 6 weeks, 3 months, 6 months and 1 year. Patients were contacted in June/July 2005 and brought back for re-evaluation of the results.

RESULTS

The cosmetic and functional results were satisfactory as judged by the parents. Overall complications were encountered in 7 patients (23%). Complications included six fistulae, five were associated with meatal stenosis and one with infection. Stand alone meatal stenosis occurred in three other cases of which only one required intervention. Fistula repair was successfully performed 6 months later in five patients with associated meatoplasty. One case had a revised repair. One case required meatotomy.

CONCLUSION

The TIP procedure is a viable option with satisfactory cosmetic and functional results for the correction of a previously failed hypospadias repair.

The concept of tubularized incised plate hypospadias repair for different types of hypospadias

PURPOSE

Using the concept of tubularized incised plate (TIP) urethroplasty technique for proximal, distal, primary, secondary and complicated cases of hypospadias.

MATERIAL AND METHODS

From June 2002 to December 2003 TIP urethroplasty was performed in 15 patients between the age of 1-18-year-old with penosecrotal, mid shaft and subcoronal hypospadias. In 13 of them TIP urethroplasty used as the primary repair while in two of them as secondary repair.

RESULTS

No clinically important complications were observed in those boys who underwent primary reconstruction. One of them had meatal stenosis at the early postoperative period which was corrected by dilatation of the external meatus by feeding catheter at intervals up to 2 months postoperatively. Three boys had very narrow fistula which just allow leak of few drops of urine through urination. One boy with penoscrotal hypospadias who underwent two-stage repair had fistula.

CONCLUSION

The concept of TIP urethroplasty is the procedure of choice for the treatment of proximal hypospadias and, it seems to be suitable for distal, secondary and even complicated hypospadias reconstruction. The advantages of this procedure include its simplicity, low complication rates and very good appearance of the glance with normal meatus.

Investigation of factors affecting result of distal hypospadias repair: comparison of two techniques

OBJECTIVES

To evaluate the factors affecting the results, as well as the success of two techniques, by retrospectively investigating cases of distal hypospadias in which the patients had undergone Mathieu urethroplasty or tubularized incised plate urethroplasty.

METHODS

We retrospectively evaluated 117 patients who underwent distal hypospadias repair. A percutaneous suprapubic catheter (Cistofix) and urethral split catheter were placed as a diversion in the 41 patients undergoing Mathieu urethroplasty. The Cistofix and urethral catheter were placed in 35 patients and a urethral catheter was placed in 41 of the patients who underwent tubularized incised plate urethroplasty. The success rates were compared according to the surgical technique, age, hypospadias status (primary or secondary), type of urinary diversion, and presence of chordee.

RESULTS

No statistically significant difference in the success rate was found between the two techniques. Furthermore, the different types of diversion used in tubularized incised plate urethroplasty did not affect the success rate. When the success of primary hypospadias repair (n = 84) was compared with secondary hypospadias repair (n = 33), success in patients with secondary hypospadias was low. No difference was observed when operational success was compared in terms of patient age (older versus younger than 5 years of age) or the presence or absence of chordee.

CONCLUSIONS

Our results have shown that tubularized incised plate urethroplasty should be preferred for distal hypospadias because of the better cosmetic results, invasive urinary diversions should be avoided, and the most importance should be given to the initial surgical intervention.

Interim outcome of the single stage dorsal inlay skin graft for complex hypospadias reoperations

PURPOSE

Despite high success rates for primary hypospadias repair, some cases require multiple procedures for ultimate reconstruction. We report our experience with single stage dorsal inlay urethroplasty using skin grafts for complex reoperations.

MATERIALS AND METHODS

A total of 31 patients (mean age 13.8 years) with failed previous hypospadias surgery were included in the study. Indications included fistulas, strictures, diverticula and repair breakdown. The urethral plate had been removed or was severely scarred in all patients. A free penile or groin skin graft was sutured and quilted to the corpora cavernosa, guaranteeing sufficient blood supply. The neourethra was tubularized and covered with a tunica vaginalis or dartos flap, followed by glanuloplasty. Outcome analysis included urethrograms, urethral ultrasound and flow measurements.

RESULTS

Foreskin was used in 15 cases, penile skin in 12 and inguinal skin in 4. Average graft length was 3.92 cm. A total of 20 patients required glanuloplasty with a skin graft extended to the tip of the glans. After a mean followup of 30.71 months 5 patients underwent redo surgery, for a complication rate of 16.1%. Urethral stricture of the proximal anastomosis was the most frequent finding.

CONCLUSIONS

This single stage approach using dorsal skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged procedures. Foreskin should be used as a graft donor site to optimize the outcome if available. This approach represents a safe option for reoperations even if the urethral plate or midline penile skin is grossly scarred.

Modified tubularized incised plate urethroplasty (Snodgrass) procedure for hypospadias repair

OBJECTIVES

To report the outcomes in a large series using a modified tubularized incised plate (TIP) urethroplasty (Snodgrass) technique with a local de-epithelialized skin flap to cover the urethroplasty. The use of the TIP urethroplasty (Snodgrass) technique has gained wide acceptance among pediatric urologists for the correction of hypospadias repair because of its good cosmesis, low complication rate, and reliability in creating a vertically oriented meatus.

METHODS

A total of 101 boys, aged 6 months to 3 years, with distal (n = 85), mid-shaft (n = 8), or proximal (n = 8) hypospadias underwent one-stage repair using a modified TIP repair with a local de-epithelialized skin flap to cover the urethroplasty. Charts were reviewed for each patient to determine the complications, reoperations, cosmesis, and functional results after surgery.

RESULTS

With at least 6 months of follow-up, all patients had achieved excellent functional and cosmetic results, with the meatus at the tip of the penis on follow-up. Three repairs for meatal stenosis and two for fistula were needed.

CONCLUSIONS

The modified TIP procedure is a safe and reliable technique. It provides excellent cosmesis with a low reoperation rate.

A MULTICENTER EVALUATION OF TECHNICAL PREFERENCES FOR PRIMARY HYPOSPADIAS REPAIR

PURPOSE

Considerable controversy exists regarding the optimal surgical technique for the repair of mid shaft and proximal hypospadias. We sought to evaluate differences in surgical preferences among an international cohort of pediatric urologists.

MATERIALS AND METHODS

An anonymous questionnaire containing relevant demographic data as well as choices of technique to repair 5 representative hypospadias cases was developed and administered.

RESULTS

Of 121 pediatric urologists contacted 101 completed the survey, representing an 83% response rate. The majority were full-time academic pediatric urologists who performed 6 to 10 hypospadias surgeries monthly. A total of 92 respondents (confidence interval [CI) 0.84 to 0.96) preferred the tubularized incised urethral plate (TIP) technique for the repair of distal hypospadias. Similarly, 82 (CI 0.72 to 0.88) preferred TIP for the repair of mid shaft hypospadias. The 2 most common techniques for repair of proximal hypospadias without chordee, preferred by 43 correspondents each (CI 0.33 to 0.53), were TIP and transverse island flap (TVIF) onlay. For repair of moderate (30-degree to 40-degree) chordee dorsal plication was preferred by 82 respondents, while a ventral approach was preferred by 12. When moderate chordee was associated TVIF onlay was preferred by 35 (CI 0.26 to 0.45) and TIP by 24 respondents (CI 0.16 to 0.34). For severe chordee (greater than 50 degrees) 31 respondents preferred dorsal plication, while 68 chose some form of ventral repair. Among the respondents 37 approach proximal hypospadias associated with severe chordee using a staged procedure, while 40 use a single stage procedure using a TVIF tube (CI 0.30 to 0.50). Using Spearman's rank correlation coefficient, no significant correlations were identified between respondent practice demographics and choice of repair for each hypothetical hypospadias case.

CONCLUSIONS

In this cohort of pediatric urologists we observed that the majority prefers TIP to repair distal and mid shaft hypospadiac defects. Significant variability exists for preferred technique for proximal hypospadias and chordee correction. These results support the need for prospective trials comparing techniques for the repair of proximal hypospadias.

Salvage Mathieu urethroplasty: Reuse of local tissue in failed hypospadias repair

OBJECTIVES

To report our experience with Mathieu urethroplasty for revision of hypospadias repairs. Mathieu perimeatal-based flap urethroplasty remains a popular technique more than seven decades after its description for single-stage hypospadias repair. The excellent results of primary distal hypospadias repair are well documented, but reports of the results using the technique as a salvage procedure are sparse. The reuse of local tissue may be hampered by the presence of scar tissue and reduced vascularity.

METHODS

A total of 40 patients underwent salvage urethral reconstruction. Of the 40 patients, 34 (mean age 70 months, range 11 to 216) underwent salvage Mathieu urethroplasty. All patients underwent surgery at least 6 months after the previous surgery. One, two, and three or more prior procedures had been performed in 22, 6, and 6 patients, respectively. The mean follow-up period was 29 months (range 1 to 84). In 6 patients, local tissue was scarred and immobile, and they underwent the procedure using buccal mucosal grafts.

RESULTS

Satisfactory functional and cosmetic results after the initial procedure were achieved in 25 patients (74%). Two patients underwent reoperation for repair of meatal stenosis, and 5 (15%) underwent simple repair of fistula without the need for urethral reconstruction. Two patients underwent reoperation at other medical centers and were lost to follow-up. Overall, cure was achieved in 32 (94%) of the 34 patients.

CONCLUSIONS

Mathieu urethroplasty is an efficient technique for salvage hypospadias repair. Patient selection is the key to successful repair. Despite the effects of previous surgery, local tissue of adequate quality to facilitate repair exists in most patients.

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.

Initial experience with staged buccal graft (Bracka) hypospadias reoperations

PURPOSE

We report outcomes from staged buccal graft urethroplasty after failed hypospadias surgery.

MATERIALS AND METHODS

When the urethral plate had been excised or was visibly scarred after prior surgery patients underwent staged buccal graft repair. In the first operation persistent penile curvature was corrected, a proximal cutaneous urethrostomy was created, scarred tissues distally were excised and buccal graft was quilted into place for subsequent urethroplasty. At least 6 months later the now revascularized buccal strip was tubularized and covered with a dartos or tunica vaginalis flap.

RESULTS

A total of 25 patients underwent stage 1 repair following an average of 4.4 prior hypospadias surgeries. Complete graft take occurred in 22 (88%) cases while the remaining 3 had focal scar or graft contracture that was successfully patched before tubularization. To date 20 patients have undergone the stage 2. There were no cases of meatal stenosis, neourethral stricture or diverticulum. A fistula occurred in 1 (5%) of 18 cases in which a flap barrier layer was used. Partial glans dehiscence occurred in 4 prepubertal boys with graft obtained from the cheek, and they have undergone successful reoperative glansplasty. All patients completing surgery have a vertical slit neomeatus.

CONCLUSIONS

Staged buccal graft reoperation reliably creates a well vascularized substitute urethral plate for tubularization with low complication rates and good cosmetic outcomes. Inner lip, which is thinner than cheek, may be a better source of graft for the glanular urethra.