Distal hypospadias: which repair?

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Mathieu technique with incision of the urethral plate versus standard tubularised incised-plate urethroplasty in primary repair of distal hypospadias: A prospective randomised study

Objective

To compare outcomes of the Mathieu incised-plate (Mathieu-IP) technique vs the standard tubularised incised-plate (TIP) technique for primary management of distal hypospadias.

Patients and methods

Between April 2012 and August 2015, 66 patients (aged 15–60 months) with primary distal hypospadias were randomly allocated to two groups. Group 1 included 34 patients who underwent Mathieu-IP repair and Group 2 included 32 patients managed using the TIP technique for primary management of distal hypospadias. Postoperatively, all patients were examined weekly up to 1 month and then at 3 and 6 months. Perioperative data, complications and outcomes of both procedures were statistically analysed and compared.

Results

There were no statistically significant differences in patient demographics between the groups at baseline. There was no statistically significant difference in the mean (SD) operative time between Groups 1 and 2, at 95 (7.6) and 91.2 (8.1) min, respectively. There was no statistically significant difference in the shape of the urine stream at micturition or the neomeatus between the groups postoperatively. The rate of postoperative fistula was significantly higher in Group 2 (TIP) compared to Group 1 (Mathieu-IP), at 18.7% vs 2.9% (P = 0.004). There was no postoperative meatal stenosis in Group 1, which did occur in five patients (15.6%) in Group 2 (P = 0.002).

Conclusion

The Mathieu-IP technique appeared to be better than the standard TIP technique with regard to postoperative fistula formation and meatal stenosis, and with acceptable cosmesis.

A modified onlay island flap vs. Mathieu urethroplasty for distal hypospadias repair: A prospective randomised study

OBJECTIVE

To compare the outcome of a modified onlay island flap (MOIF) with that of the Mathieu urethroplasty for distal hypospadias repair.

PATIENTS AND METHODS

In a prospective randomised study, 60 patients with coronal, subcoronal and distal penile hypospadias, with a urethral plate width of ⩽6 mm, and minimal or no chordee, underwent either MOIF using a midline longitudinal outer preputial skin flap passed ventrally by penile buttonholing through dartos fascia incision, or a Mathieu urethroplasty. Closed envelopes were used for randomly selecting patients for each procedure. The operative duration, complications, cosmetic outcome, urinary stream and relatives' satisfaction were reported for each procedure.

RESULTS

Preoperative data (patients' age and site of urethral meatus) and operative duration were insignificantly different between the groups (P = 0.653, 0.786 and 0.710, respectively). There were no intraoperative complications in either group. The duration of follow-up was insignificantly different between the groups. Patients treated with the MOIF had a statistically significant lower complication rate (P = 0.036), and a better cosmetic outcome, urinary stream and relatives' satisfaction (P < 0.001 for all).

CONCLUSIONS

The MOIF urethroplasty seemed to be better than the Mathieu urethroplasty in patients with distal hypospadias and narrow urethral plates. Further studies including more patients, and a longer follow-up with an objective evaluation of functional outcome should be encouraged to confirm these early results.

Comparative study of Mirs(') (Mushtaq and Shabir) technique of prepuce preserving minimally invasive urethroplasty with Snodgrass urethroplasty for repair of distal hypospadias without chordee…A prospective study

Background:

There is no single, universally applicable technique for hypospadias repair and numerous techniques have been practised from time to time. We compare the results of our new technique (Mirs’ technique also called Mush & Shab's technique) to Snodgross urethroplasty. Mirs’ technique is a modified version of Thiersch-Duplay urethroplasty.

Material and Methods:

This prospective comparative study was carried out in a tertiary care hospital of Northern India over a period of 3 years from March 2010 to March 2013 and included 120 patients of anterior (distal penile, subcoronal, coronal and glanular) hypospadias without chordee. They underwent either Mirs’ technique (group 1 n = 60) or Snodgrass technique (group 2 n = 60). Follow-up was at 1-week, 1-month, 3 months and 6 months.

Results:

The mean operative time was 55 min (range: 43-70 min) in group 1 and 71.9 min (range: 60-81 min) in group 2 (P < 0.001). Urethrocutaneous fistula developed in two and four patients in group 1 and 2, respectively. Fistula closure was done at least 3 months postoperatively, and there was no significant difference in success rate between the two groups. Three cases of glanular dehiscence were detected (one in group 1 and two in group 2); the patient from group 1 had a successful repair using the already preserved prepuce.

Conclusion:

Mirs’ modification of Thiersch-Duplay technique for distal hypospadias is a time saving procedure with a lower overall complication rate. Valuable local tissue is preserved to deal with any complication that may occur. Analgesic requirement was significantly lower in this minimally traumatic technique. As it is less time consuming, simple and easy to learn with a short learning curve, this technique deserves application in cases of distal hypospadias.

Utility of tissue expansion in pediatric phallic reconstruction: a 10-year experience

OBJECTIVE

Boys with complex penile anomalies often undergo multiple operations, leaving a paucity of unscarred skin for further reconstructive procedures. Our objective was to evaluate the ability of tissue expansion to provide local skin for successful phallic reconstruction.

MATERIALS AND METHODS

Eighty boys (mean age of 11.9 years) with hypospadias (n = 42) or epispadias (n = 38) formed the study cohort. All patients had undergone at least one failed reconstructive operation. Indications for tissue expansion included scarcity of penile skin with urethral stenosis, urethrocutaneous fistula, chordee, and/or residual defect. One or two expanders were placed under the skin of the penile shaft and removed at the time of reconstruction.

RESULTS

Average time between expander placement and reconstruction was 10.9 weeks. Mean follow-up time was 25.3 months. Complications during expansion occurred in 33 patients (41.3%). Twenty-two patients (27.5%) had at least one expander removed prematurely and 46.9% were replaced. Expansion yielded adequate tissue for reconstruction in 76 patients (95.0%). Successful outcomes were achieved in 39 patients after initial reconstruction and 25 patients after further intervention, yielding an overall success rate of 80.0%.

CONCLUSION

Tissue expansion is a useful tool with an acceptable rate of complications for phallic reconstruction in patients who have failed prior surgical reconstruction.

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

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

Meatal and corpus spongiosum advancement: a better technique for distal hypospadias repair

OBJECTIVE

Several procedures have been described for repair of distal hypospadias. However, these are not without any complications. Corpus spongiosum advancement is a new technique employed in our patients for distal hypospadias repair with excellent clinical outcome and no post-operative complications.

PATIENTS AND METHODS

A total of 56 patients aged from 24 to 126 months were operated between January 2009 and August 2011. 32 patients had coronal, 9 had glanular and 15 had distal penile hypospadias. The meatus was located within 1 cm of the corona in all the patients. There was minimal or no chordae. All the patients underwent advancement of corpus spongiosum.

RESULT

The mean operating time was 36 min and mean operating blood loss was 15 ml. In three patients, the corpus spongiosum was opened inadvertently during dissection. It was repaired with 5-0 vicryl and stitched to the cavernosal bed. An indwelling catheter was kept for 5 days. None of these three patients had any problem after removal of the catheter. Mean hospital stay was 0.5 days (0-6 days). 42 patients were discharged from the hospital on the day of surgery. Eight patients complained of dysuria on the first day. There were no other complications. The functional and cosmetic results have been excellent. The mean follow-up period was 16 months (8-38 months).

CONCLUSION

Corpus spongiosum advancement is an easy technique, consumes less time and has excellent cosmetic and functional outcome. The procedure is most suitable for children with distal hypospadias without chordae.

Does the type of urinary diversion affect the result of distal hypospadias repair? A prospective randomized trial

PURPOSE

The purpose of this review is to evaluate different techniques in urinary diversion and urethral stenting in hypospadias surgery.

PATIENTS AND METHODS

The surgical procedure included 192 tubularized incised plate (TIP) repairs for distal penile hypospadias. The patients were prospectively randomized into three groups: In group A, a urethral catheter was used as a stent and for diversion of urine (63 patients); in group B we use no urethral stenting (63 patients), only a suprapubic catheter; and in group C we use a suprapubic diversion and we put a small catheter in the anterior urethra only (66 patients). The urethral catheter was removed in group A at the 6th-7th postoperative day and in group C the urethral stent was removed at the 3rd-4th postoperative day. The suprapubic catheter was removed in both groups B and C at the 7th-9th postoperative day. All patients received an injection of antibiotics in the morning of the operation and daily until the day of catheter removal. All of the operations were performed by the same surgeon.

RESULTS

The mean ages of our patients were 3, 5, and 5 years in groups A, B, and C, respectively. The mean hospital stay was 5 days (3-8). Follow-up ranged from 8 to 48 months (mean of 21.5 ± 10.1 months). Bladder spasm was observed in 33% of our patients in group A while there were no cases of spasm in the other two groups with a statistically significant difference (p < 0.05). Fistula was reported in eight patients (12.7%) of our urethral catheter group A, while it was observed in three patients (2.3%) of our suprapubic diversion groups B and C with a statistically significant difference between the two groups (p < 0.05). Meatal stenosis was reported in eight patients in group B (12.7%; nonstented group) versus three patients of both groups A and C (2.4%; stented groups) with a statistically significant difference (p < 0.05).

CONCLUSION

Suprapubic diversion is an important step in hypospadias repair as it provides a better success rate with a significantly lower rate of occurrence of fistula. However, the addition of a stent in the anterior urethra to suprapubic diversion avoids the development of meatal stenosis and also avoids the bladder spasm observed with a urethral catheter.

Kutlay technique for hypospadias repair

OBJECTIVE

Although many techniques have been described, new techniques with a wide range of therapeutic options are needed. The Kutlay technique is a novel technique that is based on the reconstruction of the neourethra with two horizontal meatal-based skin flaps. In the present study, the data of 31 patients who underwent surgery with the Kutlay technique are presented.

PATIENTS AND METHODS

Thirty-one patients with hypospadias with an average age of 5.6 years who did not have previous hypospadias repair were operated on with the Kutlay technique. Ten patients had chordee. Among those patients, three patients were circumcised.

RESULTS

The patients were followed up for 4-13 months (average, 9.3 months). During the follow-up period, a fistula was observed in only one patient. None of the patients developed neourethral dehiscence, meatal stenosis, urethral stricture, wound infection, penile torsion, hematoma, or persistent or recurrent chordee. On uroflowmetry studies, the maximum flow rate of the patients was approximately 10.5 ml/s (range, 6-17 ml/s). The patients were observed to void with a single straight urinary stream in a forward direction.

CONCLUSION

The Kutlay technique is a technique that is easily applied in patients with chordee and that provides a low risk of fistulas and acceptable functional and esthetic results. The factors that reduce the risk of fistula are the lack of the superposition of the suture lines of the skin and the urethra, the reconstruction of the urethra with well-vascularized flaps, and the replacement of the neourethra in its appropriate location through the tunnel created in the glans.

Penile curvature incidence in hypospadias: can it be determined?

The aim was to retrospectively determine the real incidence of congenital penile curvature in various forms of hypospadias, in order to indicate intraoperative assessment and correction of curvature. We analyzed 842 patients with hypospadias who underwent surgery from 2003 to 2010, classified into two groups. First group was intraoperatively checked for curvature as a routine procedure, while a curvature in the second group was assessed mostly in severe hypospadias. Results are analyzed using Fisher's and chi-square tests. In total, 238 cases (28.3%) of associated curvature were confirmed. Curvature was significantly more frequent in the first group, regarding hypospadias in general (P < 0.01), as well as distal (P < 0.05) and midshaft forms (P < 0.01). Penile curvature is common figure in hypospadias, including distal types. Intraoperative testing for associated curvature should be considered as a routine procedure in hypospadias repair.

Hypospadias surgery past, present and future

PURPOSE OF REVIEW

Hypospadias surgery has been in continuous evolution for many years with steadily improving reported results. Despite this many unanswered questions on its cause, management and outcomes remain. Recent research has done little to clarify most matters.

RECENT FINDINGS

There is increasing evidence of a balance of genetic and developmental factors in the development of hypospadias, but there is doubt whether the incidence of hypospadias is increasing or not. Many technical aspects of hypospadias repair and variations of perioperative management seem to have little effect on outcome, whereas the age at which surgery is performed may. Although efforts are being made to relate anatomical findings to outcome, a lack of objective assessment and standardization is a handicap. Severe hypospadias, particularly that associated with significant chordee, remains challenging although strategies for management are being developed. The future may lie in development of autologous tissue culture for these severe cases.

SUMMARY

Further development of hypospadias surgery would benefit from objective, standardized methods of describing anatomy and outcome measures to facilitate effective comparison of techniques and procedures.

A new technique for correction of distal penile hypospadias

The major aims of correction of hypospadias include construction of a neourethra, removal of the chordee, and reduction of the probability of postoperative fistulization. Here, we describe a new technique that can be easily used in cases with subcoronal distal penile hypospadias (even those with chordee) for the construction of the urethra using meatus-based transverse flaps. This new technique was used in 10 patients (mean age, 4.6 years). There were no complications such as fistula formation, chordee recurrence, hematoma formation, or flap necrosis during the follow-up period (mean follow-up period, 13.4 months). We believe that this surgical technique can be used in cases with chordee, carries a low risk of fistula formation, has the advantage of the use of richly vascular flaps for construction of the urethra, and yields a better cosmetic result. Hence, it can safely be used for surgical correction of distal hypospadias.

Combined Mathieu and Snodgrass urethroplasty for hypospadias repair: a prospective randomized study

OBJECTIVES

To evaluate the outcomes of combined Mathieu and Snodgrass urethroplasty for distal hypospadias repair and to compare them with the two techniques separately.

METHODS

Between January 2006 and February 2009, patients with distal hypospadias were prospectively randomized to undergo one of the three following urethroplasty techniques: Mathieu urethroplasty, Snodgrass urethroplasty or a combination of the two. Operative time, intraoperative, early and late postoperative complications were reported for each procedure.

RESULTS

101 patients were included in this study. The Mathieu technique was used for 30 patients, Snodgrass repair was carried out in 37 patients and 34 patients underwent the combined technique. Operative time ranged from 43 to 120 min. Eight patients developed urethrocutaneous fistulae. Meatal stenosis was encountered in five cases. Thirty-seven patients had rounded meatus, while a slit-like urethral opening was found in 64 cases.

CONCLUSIONS

In our hands, the combined Mathieu and Snodgrass urethroplasty technique provided a better cosmetic outcome than the Mathieu technique with no incidence of meatal stenosis as seen with the Snodgrass technique.

Hypospadias repair and glans augmentation using a modified Mathieu technique

PURPOSE

To describe a modification in Mathieu (perimeatal-based flap urethroplasty) technique that incorporates glans augmentation into the procedure and is applicable for hypospadias patients with small glans and shallow urethral grooves.

PATIENTS AND METHODS

Fifty-four children with primary hypospadias and small glans underwent either the new double-faced Mathieu (DF-Mathieu) technique (33 patients) or tubularized incised plate (TIP) procedure (21 patients). DF-Mathieu perimeatal-based skin flap was meant to cover the distance from urethral orifice to the tip of the glans and flip back to fill the gap between glans wings. Patients were followed up for 20 months (12-30). TIP group underwent the conventional procedure.

RESULTS

The mean age in DF-Mathieu and TIP group was 43.1 and 39.8 months, respectively. Post-operative results in DF-Mathieu group revealed one urethral fistula and no urethral break down or necrosis. In TIP group, there were one glans fistula (4.7%) and one meatal stenosis (4.7%). Overall success rate was 97% in DF-Mathieu and 90.5% in TIP operation. After 6 months, all DF-Mathieu patients had slit-like meatus and their cosmetic results were satisfactory.

CONCLUSION

Double-faced Mathieu technique seems applicable in patients with shallow urethral grooves when TIP procedure may increase the risk of complications. Unlike its predecessor, this technique eliminates the tension on glans wing sutures and the risk of subsequent neo-urethral break down.

A modified tubularised incised plate urethroplasty technique and a revised hypospadias algorithm

To simplify and standardize surgical management of hypospadias, a modified tubularised incised plate (TIP) urethroplasty (Snodgrass) technique has been described and a revised hypospadias management algorithm has been formulated. The study aims to evaluate the viability of the described procedure in different types of hypospadias and tests the validity of the algorithm. The modification described is recruitment of penile and glandular skin lateral to the urethral plate to facilitate tubularisation. The algorithm starts with penile degloving with preservation of urethral plate. Snodgrass repair was done in cases with no chordee and where skin chordee resolved by skin take down. Modified Snodgrass repair was done in cases where urethral plate was narrow. Another modification proposed by us is single layer penile skin closure instead of an added dartos flap, which was done in both classical and modified Snodgrass repair. Cases of severe chordee not resolved by skin take down were repaired by transverse preputial island flap (TPIF) and Bracka's technique. Dorsal plication was not used as an orthoplasty modality. It was possible to repair 68.89% of the cases by Snodgrass repair. These patients either had no chordee or had superficial skin tethering (skin chordee) which resolved on degolving. All these cases were coronal, distal and mid penile hypospadias. Remaining cases were mid, proximal and penoscrotal with true fibrous chordee and were repaired by TPIF or Bracka's technique. The Snodgrass technique had a fistula rate of 9.67%. Acceptably, low fistula rate and simple execution make the proposed modification of classical Snodgrass repair a viable option. The proposed algorithm proves to be a useful tool for standardised and logical preoperative decision making. It also defines indications of the three techniques vis-à-vis the type of hypospadias.

Hypospadias

Objective. The great possibility of variations in the clinical presentation of hypospadia, makes its therapy challenging. This has led to the development of a number of techniques for hypospadia repair. This article assesses past and present concepts and operative techniques with the aim of broadening our understanding of this malformation. Materials and Methods. The article not only reviews hypospadia in general with its development and clinical presentation as well as historical and current concepts in hypospadiologie on the basis of available literature, but it is also based on our own clinical experience in the repair of this malformation. Results and Conclusion. The fact that there are great variations in the presentation and extent of malformations existent makes every hypospadia individual and a proposal of a universal comprehensive algorithm for hypospadia repair difficult. The Snodgrass technique has found wide popularity for the repair of distal hypospadias. As far as proximal hypospadias are concerned, their repair is more challenging because it not only involves urethroplasty, but can also, in some cases, fulfil the dimensions of a complex genital reconstruction. Due to the development of modern operating materials and an improvement in current surgical techniques, there has been a significant decrease in the complication rates. Nonetheless, there still is room and, therefore, need for further improvement in this field.

Fibrosis in tubularized skin flaps in rats, using silicon catheters with two different degrees of flexibility. Experimental model

PURPOSE

Microscopically evaluate the intensity of fibrosis in tubularized skin flaps on the back of Wistar rats, using silicon molds with different degrees of flexibility.

METHODS

Twenty rats were submitted to three tubularized skin flaps on their backs. In two tubular flaps, we placed, as a mold, silicon catheters with different degrees of flexibility and removed them on the seventh day after the surgery. They were divided into two groups and euthanized, on the seventh and twenty-first days respectively after the surgery for the collection of the pieces, coloration with Masson tricromic, quantification of the area of each sample and comparison among the groups.

RESULTS

Fibrosis was less intense on the tubular flaps where a catheter was not used as a mold. No significant difference was verified among the pieces with the silicon catheters, but there was a tendency of less fibrosis on the tubules with the most flexible catheter.

CONCLUSION

There was no significant difference among the two catheter types. Fibrosis was less intense in the flaps where the mold was not used.

Combined use of Mathieu procedure with plate incision for hypospadias repair: a randomized clinical trial

OBJECTIVES

To introduce a simple and effective technique for urethroplasty of distal hypospadias, using the advantages of both standard techniques of Snodgrass and Mathieu to reduce or eliminate the shortcomings of each.

METHODS

Forty patients with primary distal hypospadias were randomized between two groups (20 in each). Patients in group I underwent standard Snodgrass urethroplasty, whereas those in group II were operated with our novel technique, Mathieu-Incised Plate (Mathieu-IP), comprising preparation of a parameatal-based skin flap as in the Mathieu procedure together with modifications (adopted from Snodgrass urethroplasty) such as a complete longitudinal incision on the urethral plate as well as coverage of the neourethra with an inner preputial flap. Operative data and outcomes of both procedures were analyzed prospectively after 1 year of follow-up.

RESULTS

Both groups were age matched (group I: 7.05 +/- 4.85 years; group II: 7.31 +/- 2.17 years), and there were no significant differences in mean operative time (95 minutes versus 100 min in groups I and II, respectively). There were significant differences between the two groups in terms of complications. Whereas 3 cases of posturethroplasty meatal stenosis and 2 of urethrocutaneous fistula (5 complications, 25%) were detected in the Snodgrass group, neither of these complications occurred in the Mathieu-IP group. All 40 patients benefited from a slit-like meatus.

CONCLUSIONS

Combining the Mathieu procedure with plate incision could be considered a promising simple technique to achieve a normally shaped meatus and to reduce the rate of meatal-related complications, the major concern with the Snodgrass procedure.

Retalhos tubulares de pele de ratos com dois tipos de cateter de silicone

OBJETIVO: Avaliar o processo inflamatório e a fibrose em retalhos tubulares confeccionados na pele do dorso de ratos Wistar, moldados com cateteres de silicone com diferenças de resistência à compressão diametral. MÉTODO: Vinte ratos Wistar foram submetidos à confecção de três retalhos tubulizados de pele em região dorsal. Um retalho não foi moldado e os outros dois receberam, respectivamente, como molde interno, durante um período de sete dias, cateteres de silicone com diâmetros iguais e diferentes resistências à compressão diametral. Os animais foram divididos em dois grupos e sacrificados, respectivamente, no sétimo e vigésimo primeiro dia após a cirurgia. Realizou-se estudo histopatológico para a avaliação da fibrose e do processo inflamatório. RESULTADOS: Não foram encontradas diferenças significativas quanto à presença de fibrose ou processo inflamatório entre os três grupos estudados. CONCLUSÃO: A presença do cateter de silicone, independente de sua resistência à compressão diametral, não aumentou a intensidade da reação inflamatória e da fibrose nas margens suturadas de retalhos tubulares da pele de ratos Wistar.

Quality assessment of hypospadias repair with emphasis on techniques used and experience of pediatric urologic surgeons

OBJECTIVES

To assess outcomes in hypospadias repair at our institution, as compared with the literature, with repair technique and surgeon considered as risk factors.

METHODS

The results of 299 primary hypospadias corrections were analyzed. All procedures were performed by three experienced pediatric urologists. Mean patient age at operation was 16.3 months. Follow-up was between 6 months and 5.5 years. Distal hypospadias repair was carried out in 242 patients, with tubularized incised plate reconstruction in 100 patients, advancement in 128, and the Mathieu technique in 14.

RESULTS

During follow-up, complications occurred overall in 93 patients (31%). For distal hypospadias complications occurred in 59 patients (24%). The most common findings for distal hypospadias were urethral fistulas (14.4%). The complication rate depended on the severity of the anomaly (0 glanular, 28% pericoronal, and 63% proximal) and the chosen technique (16% advancement technique versus 60% tubular techniques). We found statistically significant differences in complication rates between operating surgeons.

CONCLUSIONS

Complications after hypospadias surgery are frequent. They are multifactorial and depend mainly on the type of the anomaly, the chosen technique, and the experience of the surgeon. More studies are needed to obtain an internationally accepted quality indicator for the outcome of hypospadias repair.

Estudo comparativo de retalhos tubulares de pele de ratos com dois tipos de cateter como molde

OBJETIVO: A tubulização de retalhos de pele é um artifício técnico muito empregado na correção de hipospádias. Existem controvérsias quanto aos riscos e benefícios do uso de sondas para moldar a neo-uretra e promover a derivação urinária. O objetivo deste trabalho é avaliar o processo inflamatório, a fibrose e a circunferência interna de retalhos tubulares, em pele de dorso de ratos Wistar, com a utilização de cateteres de dois tipos de material, silicone e polivinil. MÉTODO: Vinte animais foram submetidos à confecção de três retalhos tubulizados de pele em região dorsal: um deles com cateter de silicone usado como molde interno, outro com cateter de polivinil, e o terceiro sem cateter. Foram divididos em dois grupos e mortos, respectivamente, no sétimo e vigésimo primeiro dias após a cirurgia. Realizou-se mensuração da circunferência do retalho e estudo histopatológico para a avaliação da fibrose e do processo inflamatório nos dois grupos de animais. RESULTADOS: Nos retalhos onde não se usou molde, observou-se que as circunferências eram menores no vigésimo primeiro dia. A reação inflamatória e a fibrose foram mais intensas nos retalhos tubulares em que se usou cateter de polivinil. Não se verificou diferença significativa entre os retalhos sem cateter e aqueles em que o cateter de silicone foi usado. CONCLUSÕES: A presença do cateter de silicone não aumenta a intensidade da reação inflamatória e da fibrose nas margens suturadas de retalhos tubulares da pele de ratos Wistar. É possível deduzir que a presença do cateter de silicone diminuiria a possibilidade de formação de fístulas ou de estenoses e colaboraria para a manutenção de um calibre neo-uretral mais amplo no pós-operatório tardio.

Komplizierte Harnröhrenrekonstruktionen bei Erwachsenen und Kindern

The urethral reconstruction is a challenge in the adult, but even more in infant and young male patients. Good knowledge of the anatomy of the penis (blood supply and the course of the nerve fibers) with the availability of microsurgery suturing and instruments improved the outcome significantly. The growing knowledge opened the possibility to reconstruct complicate strictures with grafts. The buccal mucosa flap is one of those improvements, which made a tremendous impact to have a successful outcome. Recently we looked into the outcome of urethral reconstruction of long urethral strictures by using a buccal mucosa only flap. We used a modified technique for hypospadias repair to reconstruct coronar or subcoronar defects by meatal mobilization (MEMO). In cases with a long urethral stricture the success rate was over 90% with a mean follow up of 16 months. In all children the outcome with the MEMO-technique was successful without any major complication with a mean follow-up of 12.5 months.

Unstented Tubularized Incised Plate Urethroplasty Combined with Foreskin Reconstruction for Distal Hypospadias

BACKGROUND AND AIM

Urethral stent has recently been proven to be unnecessary for normal healing in an animal model of tubularized incised plate (TIP) urethroplasty. We report our experience with unstented TIP repair combined with foreskin reconstruction for distal hypospadias in children.

PATIENTS AND METHODS

We retrospectively reviewed the records of 162 children consecutively treated by TIP urethroplasty for a distal or mid-shaft hypospadias without urethral stent over a 6 years period. The mean age +/- SEM at surgery was 15.7 +/- 1.2 months. A foreskin reconstruction was performed with the hypospadias repair in 136 boys (84%). One hundred thirty one children (81%) underwent this surgery as an outpatient procedure.

RESULTS

With a mean follow-up of 12.4 +/- 1.0 months, urethrocutaneous fistula was observed in 9 children (5.6%), and meatal stenosis in 4 (2.5%). Postoperative urinary retention requiring suprapubic catheter insertion was observed in 4 cases (2.5%) without later complications. Cutaneous dehiscence of the reconstructed foreskin occurred in 6 children (4.4%) and phimosis in 13 (9.5%).

CONCLUSIONS

Absence of urethral stent after TIP urethroplasty for distal hypospadias repair does not seem to increase postoperative complication rate. Foreskin reconstruction in distal hypospadias surgery has an acceptable complication rate.

Tubularized incised plate urethroplasty: modification and outcome

BACKGROUND/PURPOSE

To review the outcome of tubularized incised plate (TIP) urethroplasty in the primary treatment of penile hypospadias with minimal chordee and to describe our experience with the lateral flap used to cover the urethroplasty.

METHODS

The charts of all patients with penile hypospadias who underwent primary TIP repair in our hospital between 1996 and 2001 were examined and pre as well as postoperative biodata were recorded. We used the lateral flap to cover the repair rather than a flap harvested from preputual skin as in the original description.

RESULTS

94 patients were identified but only 83 were suitable for analysis. The mean age of the evaluable patients was 2.67 years (range 1-10). The mean of follow-up was 17.49 months (range 1-54). The preoperative meatal position was coronal in 50 (60.2%), distal shaft in 28 (33.7%) and mid shaft in 5 (6.1%) patients. The mean length of the urethral plate was 8 mm (range 5-15) while the mean width of the plate was 6 mm (range 4-8). In 30 patients (36.14%) chordee was present preoperatively. All patients were admitted to the hospital following the TIP urethroplasty with a urethral stent in place. The lateral flap was used to cover the repair in 70 patients. The stent was left for an average of 7.83 days (7-10). The average hospital stay was 8.83 days (7-11). A cosmetically normal vertically oriented slit-like meatus was seen in 78 (94%) patients. The TIP repair revealed an apical meatus in 82 (98.8%) and a conical glanular configuration in 79 (95.20%) patients. The parents observed that the urinary stream and the penile shaft were straight in 75 (90.4%) and 82 (98.8%) patients respectively. Seven patients (8.4%) developed meatal stenosis requiring repeated dilatations; four patients (4.8%) developed urethrocutaneous fistula and one (1.2%) had postoperative bleeding requiring transfusion. Of the 70 patients who had the lateral flap, 3 (4.28%) developed urethrocutaneous fistula.

CONCLUSION

Our experience indicates that the TIP repair gives a good cosmetic and functional outcome with minimal complications. Urethroplasty coverage using the lateral flap is associated with a low incidence of urethrocutaneous fistulae.

Tubularized incised-plate urethroplasty for distal and proximal hypospadias

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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