Results of single staged hypospadias surgery to repair penoscrotal hypospadias with bifid scrotum or penoscrotal transposition

The modified Ulaanbaatar procedure: Reduced complications and enhanced cosmetic outcome for the most severe cases of hypospadias

INTRODUCTION/OBJECTIVE

Proximal hypospadias is one of the most challenging conditions that pediatric urologists have to deal with. Many procedures have been devised over the years, but nothing has been proven to be the best option. Although there have been some attempts at correcting severe hypospadias in one procedure, most have advocated a staged approach. The classic approach - laying penile skin or a graft within a split glans followed by glanuloplasty at the second stage - by definition requires two operations on the glans. In the Ulaanbaatar procedure the distal glanular urethra is constructed at the first stage, allowing for a single glans procedure and thus potentially better cosmetic outcomes. The present study discusses experience with the Ulaanbaatar procedure for severe hypospadias.

STUDY DESIGN

The study retrospectively reviewed every child who underwent both stages of this procedure at the present institution. It reviewed age, associated diagnoses, surgical technique and outcomes.

SURGICAL TECHNIQUE

The first stage was analogous to a classic first-stage procedure with regard to division of the urethral plate and correction of penile curvature. However, an island flap of preputial skin was mobilized and tubularized to create the glanular urethra. No attempt was made to bridge the native meatus and this reconstructed urethra, and the remaining penile skin was placed between the two. The second stage was performed 6 months later by tubularizing the penile skin between the two meatuses.

RESULTS

The series consisted of 34 boys. Mean age at surgery was 18.3 months (range 6-118). Nineteen underwent evaluation for genital ambiguity at birth (56%). Thirty (88%) received pre-operative testosterone or human chorionic gonadotropin (HCG). After urethral plate transection, persistent curvature was addressed during the first stage, with dorsal plication in 12 (35%), urethral plate transection alone in six (18%) or ventral grafting with small intestinal submucosa in 16 (47%). Twenty-three boys (67%) had the neourethra tunneled through the glans, and 11 (33%) had the glans split followed by glanuloplasty. Average time between the two stages was 7 months (range 4.0-13.9). Four patients (12%) developed urethral diverticula that required repair. One developed recurrent epididymitis related to an abnormal ejaculatory duct (no stricture) and underwent vasectomy. No patient developed a fistula. Mean length of follow-up was 15.2 months (range 0.3-55.5).

DISCUSSION

This modification of the classic staged hypospadias repair may allow for better cosmetic outcome, since the majority of boys required no formal glanuloplasty. There were reduced complications, perhaps because the urethral defect acted like a controlled fistula, allowing for better tissue healing prior to final urethral reconstruction.

Two Stages Repair of Proximal Hypospadias: Review of 700 Cases

Objective:

Surgical repair of hypospadias is challenging and problematic even for the most experienced specialists, and this is especially true when severe and complicated case is confronted. Many operations had been described for the management of this deformity.

Materials and Methods:

During the period from May 2004 to December 2015, we performed 700 cases with proximal hypospadias, at our institute in the Department of Pediatric Surgery by a single surgeon. Data were collected retrospectively and included patient's age at operation, degree of the hypospadias, degree of associated chordee, complications, and cosmetic outcome. All patients underwent 2 two-stage procedures with 9–12 months interval in between.

Results:

Seven hundred patients with proximal hypospadias were operated upon in a period of 11 years. Byars's 2 two-stage operation was used in all 700 cases. Neither complete disruption nor urethral diverticula occurred 2 two-stage procedures in the 700 patients. 677 (96.7%) patients had no complication. Fistula was present in 21 (3%) patients. There was no case of meatal stenosis in our study.

Conclusion:

Two stages procedure using the principles of Byar's technique is a versatile operation that can be used for 2 two-stage procedures the proximal hypospadias. It decreases the rate of fistula formation, disruption, and stenosis and gives a satisfactory cosmetic appearance.

A New Modification of the Koyanagi Technique for the One-stage Repair of Severe Hypospadias

OBJECTIVE

To describe a new modification of the Koyanagi technique for the one-stage repair of severe hypospadias and its short-term outcomes.

PATIENTS AND METHODS

Our modified Koyanagi technique was performed in 24 patients with severe hypospadias between February 2012 and January 2015. The age of the patients ranged from 1.9 to 11.9 years (mean = 3.5 years). The flap design was similar to the Koyanagi technique, but our modified technique highlighted the following points: after the chordee was completely corrected, the urethral plate was recreated using foreskin, and then a U-shaped incision was made on the original and recreated urethral plate (as in the Duplay technique); a pedicled flap of the tunica vaginalis or scrotal dartos was used for additional coverage of the neourethra.

RESULTS

The operation time lasted from 120 to 150 minutes (mean = 140 minutes). There were 5 patients (20.8%) who developed complications: 4 patients (16.7%) developed a fistula and 1 patient (4.2%) developed dehiscence of the urethra. There were no reported urethral strictures, meatal stenosis, or urethral diverticula. The complications in the 5 patients were successfully addressed with secondary repair, and all patients achieved satisfactory cosmetic and urethral functional results.

CONCLUSION

The modified Koyanagi technique simplified the operation and better preserved the blood supply to the flap. The additional coverage of the neourethra using a pedicled flap of the tunica vaginalis or scrotal dartos significantly decreased the rate of fistula formation. This technique is highly suitable for the one-stage repair of severe hypospadias with penoscrotal transposition.

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

INTRODUCTION

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

METHODS

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

RESULTS AND CONCLUSIONS

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

The influence of perioperative factors on primary severe hypospadias repair

Hypospadias is one of the most common congenital malformations of the male genitalia. Severe cases present with associated curvature greater than 30° and the meatus opening proximally to the penoscrotal junction. The perioperative management of patients with primary severe hypospadias is variable. Systematic evaluation of the upper urinary tract and the search for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias, and should be limited to severe cases with associated extraurinary malformations. Detection of a disorder of sex development is key for gender assignment and prognosis, but the identification of cases warranting a full work-up and the influence of such a diagnosis on the success of hypospadias repair is controversial. Preoperative hormonal stimulation allows for penile growth irrespective of the administration route. Associated morbidity is minimal, but its influence on the success of surgery is still unknown. An age of 6-18 months is generally recommended for surgery, but no trial data support this policy. Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery, whereas postoperative antibiotic prophylaxis and type of dressing have minimal impact on surgical success. Overall, most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined. Clinicians should be made aware of the evidence supporting any single intervention in order to standardize their management policies. We hope the issues outlined here will prompt researchers to design new studies to address the clinically relevant questions.

The modified Koyanagi hypospadias repair for the one-stage repair of proximal hypospadias

Perineal and penoscrotal hypospadias were often managed by two-stage urethroplasty with variable results and significant number of these may need third surgery. Though modified Koyanagi one-stage repair has a learning curve, it has all the advantages of two-stage repair. The aim was to review the results of modified Koyonagi repair from the literature and our own centre experience.

Long-term results with a one-stage complex primary hypospadias repair strategy (the three-in-one technique)

PURPOSE

Complex primary hypospadias repair that warrants urethral plate division is treated mostly in two steps, not necessarily in two surgeries. Our aim was to review long-term results with a one-stage strategy based on reconstruction of the urethral plate with buccal mucosa graft and onlay transverse preputial flap anastomosis protected by a tunica vaginalis flap (the three-in-one concept).

MATERIAL AND METHODS

We were able to report on 35 patients operated for primary scrotal, penoscrotal and perineal hypospadias between March 2002 and June 2008. We reviewed all charts and had phone interviews with patients not seen for the last 24 months. We investigated parameters such as UTI occurrence, fistula, residual curvature, meatal stenosis, urethral diverticula, dehiscence, orchitis and parental perception.

RESULTS

Surgical complications occurred in 13 patients (37%): 4 meatal stenosis, 4 diverticula, 5 fistulae and 2 residual penile curvatures (total 42%). Meatal dilatation was successful in 2 cases, reflected in fistula resolution. The reoperation rate was 31.5% consisting mostly of simple procedures like fistula closure, meatotomy and penile curvature release, and complex diverticula repair in 4 cases. Parental perception was excellent for 57% (20 patients) and good or acceptable for the remaining. Mean follow-up was 4.6 years.

CONCLUSIONS

The one-step strategy is associated with 68.5% success in a single operation, whereas 31.5% will need a second repair. We recognize that meatal problems are mostly associated with fistulae and diverticula; therefore, we recommend a final acceptable proximal glandar opening that will not compromise the neourethra.

Z-plasty for sculpturing of the bifid scrotum in severe hypospadias associated with penoscrotal transposition

PURPOSE

Bifid scrotum is usually associated with scrotal and perineal hypospadias. Conventional surgical repair involves rotation of two scrotal flaps, joining them in the midline, and vertical skin closure. Dimpling of skin can occur, resulting in suboptimal aesthetic results. We describe a technique whereby the bifid scrotum is rebuilt and contoured using single or multiple Z-plasties.

METHODS

We repaired 43 children with scrotal, penoscrotal or perineal hypospadias and varying degrees of bifid scrotum. Age range was 5 months-18 years. Patients were divided into three groups: I) 26 children with primary perineoscrotal hypospadias who underwent two-stage hypospadias repair and had a Z-scrotoplasty during either the first or second stage repair; II) 11 children who had previous hypospadias surgery with vertical closure of scrotum, and who underwent secondary Z-scrotoplasty; III) 6 children with primary posterior hypospadias who had their scrotum repaired with midline vertical closure, serving as control.

RESULTS

24 children in Group I and all patients in Group II achieved excellent aesthetic results, with rounded scrotum, no midline dimpling and no major complications. Midline dimple was encountered in 4 patients in Group III.

CONCLUSIONS

In repairing bifid scrotum associated with hypospadias, the principle of Z-plasty can be incorporated in scrotal contouring. This elongates, relaxes and interrupts the longitudinal tension of the midline closure. Multiple Z-plasties avoid contracture and scar formation, which are apt to result in recurrence of bifid scrotum.

Hypospadias repair in a resource-poor region: coping with the challenges in 5 years

OBJECTIVE

To report the challenges and outcomes of hypospadias repair in a developing country such as Nigeria.

PATIENTS AND METHODS

This was a prospective study of children who underwent hypospadias repair at the University of Benin Teaching Hospital in 2003-2007. The challenges and outcome of repair were documented with photographs to assess cosmetic results.

RESULT

A total of 149 operations were performed on 127 children with hypospadias, aged between 9 days and 12 years (mean 2.3 years+/-2.1) with 33 (26.0%) presenting after circumcision; 118 (92.9%) were single and 9 (7.1%) multistage, while 13 had closure of post-hypospadias repair fistulae and redo surgery. Non-availability of suitable pediatric urethral catheters, special dressing materials and microsurgical instruments/sutures, presentation after circumcision, and lack of parents/caregivers' motivation were major challenges. Transurethral urinary diversion, dressing with petroleum jelly impregnated with antibiotic/chloramphenicol ointment, mosquito forceps, scrotal skin flaps, size 6/0 polyglactin sutures, and organized counseling/home visits were employed. Repair was successful in all the children: excellent cosmetic results in 121 (95.3%), fair in 5 (3.9%) and poor in 1 (0.9%). Urethrocutaneous fistula was the main complication with no mortality recorded.

CONCLUSION

Despite the challenges, improvising with available materials, counseling of parents/caregivers, adequate patient recruitment and appropriately timed repairs gave encouraging results.

Surgical correction of penoscrotal transposition associated with hypospadias and bifid scrotum: our experience of two-stage repair

OBJECTIVE

To assess the results of surgical correction of incomplete penoscrotal transposition and bifid scrotum using the Glenn-Anderson technique, and its impact on subsequent definitive urethroplasties and final outcome.

PATIENTS AND METHODS

We retrospectively reviewed 31 children that underwent two-stage repair for incomplete penoscrotal transposition with severe hypospadias and bifid scrotum. Patient age at stage 1 ranged from 12 to 24 months (average 16 months). The operative principle was based on achieving a normal anatomical position of the penis and scrotum using the Glenn-Anderson technique. In cases with associated scrotal or perineal hypospadias this was transformed into a penoscrotal hypospadias. Final stage urethroplasty was performed after a period of 6 months with a modified Thiersch-Duplay technique.

RESULTS

Cosmetic and functional results of the Glenn-Anderson operation were excellent. No major complications were observed. Of 31 patients, 12 (38%) had complications secondary to urethral repair.

CONCLUSION

The Glenn-Anderson technique for reconstruction of penoscrotal transposition and bifid scrotum is a simple technique, free of major complications. The purpose of this intervention is to improve the cosmetic appearance and function of the penis. A minimum period of 6 months between consecutive urethroplasties is important. The final stage guarantees good functional and cosmetic results preserving the prepuce.

COMBINED BUCCAL MUCOSA GRAFT AND LOCAL FLAP FOR URETHRAL RECONSTRUCTION IN VARIOUS FORMS OF HYPOSAPDIAS

PURPOSE

Hypospadias is one of the most common congenital deformities in the male urogenital system. Although there are more than 250 techniques for treating hypospadias, it is often difficult to repair severe hypospadias using conventional methods.

MATERIALS AND METHODS

We combined a buccal mucosa graft with a local onlay flap for urethral reconstruction in cases of severe hypospadias or a failed previous operation. A total of 162 patients with hypospadias (glandular 11, penile 40, penoscrotal 49, scrotal 34 and perineal 28) were treated between July 2000 and November 2003. For patients whose urethral meatus was perineal 2 treatment steps were taken. First, we used the aforementioned method to construct the penile urethra, and then we constructed the scrotal and perineal urethra with a local flap.

RESULTS

Of the 134 nonperineal cases 127 were managed successfully in 1 stage, and 26 of 28 perineal cases were managed successfully in 2 stages. Most patients had a satisfactory penile appearance. A urethral fistula resulted in 8 cases, of which 4 closed spontaneously within 1 month postoperatively. Meatal stenosis occurred in 1 case.

CONCLUSIONS

This technique is simple, safe and reliable, especially in cases of failed previous operation or for salvage hypospadias repair with deficient local tissue.