Initial experience with staged buccal graft (Bracka) hypospadias reoperations

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.

What are the factors affecting glanular dehiscence after hypospadias surgery?

BACKGROUND

Glanular dehiscence (GD) is one of the main complications after hypospadias surgery. There is a limited number of publications regarding GD in the literature.

OBJECTIVE

The aim of this work is to reveal the factors that affect GD after a literature review.

EVIDENCE ACQUISITION

A literature search for relevant articles was performed in database using the search term glans dehiscence without setting date range limit or any other limits. All articles related to GD after hypospadias surgery were included in this study. After collecting the information from full text articles, 71 articles were included in this systematic review. In these studies, localization of hypospadic meatus, type of surgery, and other clinical data which were thought to behave as risk factors for GD were obtained. Chi-Square test was used to evaluate the differences between the parameters, where p < 0.05 was taken as statistically significant.

RESULTS

After evaluating the 71 articles that met the inclusion criteria, 309 cases (3.48%) of GD after 8858 hypospadias repairs were obtained in this review. GD rates were found significantly high for proximal hypospadias (5%), two-stage hypospadia repairs (5%) and re-do hypospadias repair (8.75%) (p = 0.002, 0.022, and 0.004, respectively). Glans width <14 mm, urethral plate (UP) width <7 mm, hypospadias surgeries performed before 6 months of age and after puberty, and caudal block anesthesia increased the rate of GD.

CONCLUSIONS

The rate of GD increases after proximal, cripple and staged hypospadias surgeries, a glans width <15 mm and UP width <8 mm, postpubertal surgeries, and caudal anesthesia use during surgery.

Outcomes of islanded scrotal raphe flap employment for skin shortage in complicated hypospadias repair

BACKGROUND

Ventral skin deficiency in complicated hypospadias is a difficult problem to treat. The aim of our study is to report our technique and outcomes of vascularized islanded scrotal raphe flap for ventral skin deficiency in complicated hypospadias.

METHODS

A retrospective review was conducted at Northwest General Hospital & Research Centre, Peshawar, from January 2012 to January 2019. Complicated hypospadias patients who underwent two-stage surgery employing islanded scrotal flap were identified. Patients underwent surgery in two stages: scar tissue removal, chordee correction and buccal mucosal graft in the first stage; neourethral tubularization, water proofing, and skin coverage with vascularized islanded scrotal raphe flap in the second stage. The primary outcome was 6-month flap survival rate. Secondary outcomes were 6-month complication rate (fistula, persistent chordee, distal stenosis) and end-of-follow-up patient self-reported satisfaction rate.

RESULTS

A total of 1845 patients underwent hypospadias surgery, of which 380 patients had complications. Scrotal raphe flap was used in 45 patients. Mean age was 14.09 (±8.02) years. Mean follow-up was 29.78 (±12.18) months. Mean number of previous surgeries was 4.31 (±2.59). The flap survived in all cases. Nine patients (20%) developed complications. One patient (2.2%) developed distal stenosis. Eight patients (17.8%) developed fistulas, one of whom additionally had persistent chordee. Five fistulas closed spontaneously within 3 months, while the rest were repaired surgically after 6 months. All patients self-reported satisfaction with results at end-of-follow-up.

CONCLUSIONS

Islanded Scrotal Raphé flap is a promising option for treating complicated hypospadias when there is significant ventral deficiency of skin, as it not only provides vascularized pliable skin but also fascia as a waterproofing layer.

Triangular extension of hinge flaps: A novel technique to resolve stomal stenosis and prevent restenosis in staged buccal mucosal urethroplasty

OBJECTIVES

To verify the utility of triangular extension of a hinge flap in buccal mucosal staged urethroplasty to resolve stomal stenosis after the first stage and ultimately prevent restenosis.

METHODS

A total of 23 patients (triangular extension group) were studied in 2013-2019. In the first stage, buccal mucosa was transplanted, and an extended triangle portion of the mucosa was placed beside the proximal and/or distal stoma that was created when the stricture segment of the urethra was resected. In the second stage, during tubularization of the urethral plate, an incision was made at the stoma to increase the caliber to which the triangular extension was inserted. The procedure was considered successful when a 17-Fr flexible cystoscope passed through the reconstructed urethra at 6 months after the second-stage urethroplasty and no additional surgery or bougie dilation required. The clinical course of the triangular extension group was compared with 24 patients who underwent conventional staged urethroplasty (control group).

RESULTS

In total, 20 patients from each group underwent second-stage surgery. No patients in the triangular extension group required additional revision surgery because of stomal stenosis after first-stage surgery, whereas five (20%) control patients did. Urethroplasty was successful in 19 patients (95%) in the triangular extension group and in 19 patients (95%) in the control group. Uroflowmetry after the second-stage surgery indicated that the mean maximum urinary flow rate was 21.5 and 15.8 mL/s after triangular extension and the control procedure, respectively (P = 0.027).

CONCLUSIONS

The triangular extension technique reduces the need for revision surgery and prevents postoperative restenosis.

Buccal Mucosa Tube Graft for Failed Hypospadias Repair: Worth it or Not?

OBJECTIVE

To report the outcome of buccal mucosa tube graft (BMTG) over time in correcting failed hypospadias.

METHODS

We conducted a retrospective analysis, reviewing charts of all 69 patients who underwent BMTG to repair hypospadias between January 2005 and October 2016. Twenty-one patients were excluded, leaving 48 eligible study subjects. In patients with penile curvatures, corrective procedures (including urethral division, corporoplasty, and local skin flap) took place prior to grafting.

RESULTS

Mean age at surgery was 8.96 years, and mean duration of follow-up was 73.10 ± 30.31 months. A mean of 1.88 previous surgeries was recorded. During follow-up, only 7 patients (14.5%) were complication free. The other 41 patients required at least 1 additional procedure. Stricture-free rates were 50%, 35.4%, and 27% at 1, 3, and 12 months after BMTG, respectively. Among 37 patients with postoperative stricture, 25 were treated only by endoscopic procedures. Single operation prior to BMTG (P= .004) and usage of larger catheter size (>8Fr) (P = .029) were confirmed significant factors associated with better stricture-free survival after BMTG by log-rank test. After several additional procedures, 46 patients (95.8%) reported normal urination with mean maximal urinary flow of 9.55 mL/s and post-void residual of 16.08 mL for at least 12 months on last visit.

CONCLUSION

BMTG after failed hypospadias repair seems prone to complications, primarily urethral stricture. However, a large number of patients with postoperative stricture could be treated simply by endoscopic procedures. Given the better results of staged approach, BMTG should be only applied to highly selected patients with failed hypospadias.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias

INTRODUCTION

To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair.

MATERIAL AND METHODS

Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated.

RESULTS

Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream.

CONCLUSIONS

Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

Two-stage repair of proximal hypospadias with moderate to severe chordee using inner preputial skin graft: prospective evaluation of functional and cosmetic outcomes

OBJECTIVE

To critically evaluate inner preputial graft (IPG) used in staged proximal hypospadias with severe chordee regarding cosmetic and functional outcomes.

PATIENTS AND METHODS

In this prospective study, patients with primary proximal hypospadias with moderate to severe chordee (> 30°) after penile degloving were considered candidates for staged repair between June 2011 to July 2017. After transection of the urethral plate (UP) and penile straightening, the bare shaft was covered with IPG. Tubularization of the graft was done as a second stage. Cosmetic and functional outcomes were assessed using HOSE score and uroflowmetry (UF). Additionally, factors influencing success were analyzed.

RESULTS

In all, 38 consecutive cases were included. Native meatus was at proximal penile in 17, penoscrotal in 11, scrotal in 7, and perineal in 3 cases. Median age was 26 and 32 months at the first stage and the second stage, respectively. Preoperative testosterone was given for ten patients with a small penis and/or severe curvature. The mean follow-up was 18 ± 8.2, median 15 months. Grafts took well in all cases after the first stage except one. Cosmetic success achieved in 33 (86.8%). A total of ten complications occurred in six cases. Unplanned intervention was needed in 5/38 cases. Functionally, UF study revealed normal flow in 7/23 (30.4%), equivocal in 11/23(47.8%), and obstructed flow in 5/23(21.7%).

CONCLUSION

Inner preputial graft use in proximal hypospadias with moderate to severe chordee seems to have a good technical outcome and functionally mimic the normal urethral function and could be considered an ideal option for substitution urethroplasty.

A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease

To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.

Staged repair of redo and crippled hypospadias: analysis of outcomes and complications

INTRODUCTION

Residual curvature, scarred or absent urethral plate, shortage of skin, and paucity of vascularized tissues and flaps are all obstacles to overcome during repair of redo and cripple hypospadias after failed reconstruction. Limited articles address the outcome of repair of these cases using different grafts.

OBJECTIVE

An analysis of outcomes and complications after the repair of redo and cripple hypospadias in a cohort of children operated by a single surgeon is presented, and data are retrieved from a prospectively designed database.

STUDY DESIGN

Thirty-one children with a median age of 96 months (18-216, interquartile range [IQR]: 78), who underwent previous surgeries three to five times, were operated in the period from late 2011 to August 2017 in a single center by a single surgeon (first author); the first-stage repair was performed by using an inner prepuce graft in three children and oral grafts in 28 children. Penile straightening by degloving and removal of ventral scarred tissues are followed by development of glanular wings and grafting of the ventral surface.

RESULTS

Eleven distal penile hypospadias and 20 posterior hypospadias were operated. First-stage repair was revised in three children; 25 children, eight distal and 17 posterior hypospadias, underwent second-stage repair with a median age of 84 months (18-216, IQR: 60). The success rate after the second-stage repair was 56% (14 children), and complications were encountered in 11 children in the form of penoscrotal fistulae in four, complete dehiscence in one, and glanular dehiscence in six children. After closure of fistulae, the overall success rate increased to 72%. Although complications were more common among children with posterior hypospadias (nine children) than children with distal hypospadias (two children), no statistical significance was reached (p = .234), with no effect of age on complications (p = .233), no effect of the position of the meatus on glanular dehiscence (p = .624), and no effect of age on glanular dehiscence (p = .114).

CONCLUSION

Repair of redo and crippled hypospadias using staged graft repair in children could be achieved with a satisfactory overall success rate of 72%. Glanular dehiscence is the main complication; however, it is not considered by parents of children in the series, necessitating intervention. The lowest complication rate is expected among those with a position of the meatus more distal, however, not proven statistically in the series.

Penile urethral stricture disease

Patients affected by a urethral stricture account for a considerable cost to all healthcare systems. The estimated prevalence of all urethral stricture in the UK is 10/100,000 men during youth, increasing to about 40/100,000 by age 65 years and to more than 100/100,000 thereafter. A penile urethral stricture is a narrowing of the lumen of the urethra due to ischaemic fibrosis of the urethral epithelium and/or spongiofibrosis of the corpus spongiosum occurring within the penile urethra. Its aetiology is largely idiopathic but other important causes are failed hypospadias repair and lichen sclerosus, which account for 60% of all cases. Strictures of the anterior urethra account for 92% of cases: bulbar strictures are more frequent (46.9%), followed by penile (30.5%) and combined bulbar/penile (9.9%), that is, 40.4% of all men presenting with stricture will have a penile urethral stricture alone or in combination with a bulbar urethral stricture. There are several options for the treatment of penile urethral strictures ranging from less invasive treatments, including urethral dilatation and direct vision internal urethrotomy, to more complex augmentation graft and flap urethroplasty. The aim of the present review is to describe the aetiology and epidemiology of anterior urethral strictures and the available options reported in literature for their treatment.

Level of evidence: 1a

Contemporary outcomes of hypospadias retrieval surgery in adults

OBJECTIVE

To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae.

PATIENTS AND METHODS

We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty.

RESULTS

Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up.

CONCLUSIONS

Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

Management of the patient with failed hypospadias surgery presenting in adulthood

The management of patients who have had complications of primary surgery for the resolution of a hypospadiac deformity remains a therapeutic challenge. Adults with complications following childhood hypospadias repairs are undoubtedly a difficult population to treat, as there is usually a cosmetic deformity, lower urinary tract symptoms, and resulting psychosexual consequences. A surgeon's experience has been and still remains an important factor in determining subsequent surgical outcomes, particularly with more severe or complex cases. The purpose of this review is to evaluate the complications of hypospadias repair that present in adults and review published experience in treating them.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lingual mucosal graft two-stage Bracka technique for redo hypospadias repair

Objectives

To report our initial experience in redo hypospadias repair with a lingual mucosal graft (LMG) using a two-stage Bracka technique.

Patients and methods

This study was prospectively conducted and included 26 patients with hypospadias with failed previous repairs. All the patients had a LMG using a two-stage Bracka technique. In the first stage, the harvested LMG, from the ventro-lateral surface of the tongue, was implanted in a well-prepared vascularised bed in the ventral aspect of the penis. After 6 months, tubularisation of the well-taken graft was completed. Tunica vaginalis or a dartos flap was used as second-layer coverage of the neourethra. Success was defined as acceptable aesthetic and functional outcomes without any additional surgical interventions.

Results

The mean (SD) patient age was 5.15 (1.6) years. The mean (SD) LMG length was 3.82 (0.9) cm and the width was 1.5 (0.5) cm. The mean (SD) number of previous repairs was 2.76 (1.1). The mean (SD) follow-up was 12 (2) months. Donor-site complications included: pain in all patients, with a pain score of >3 on the visual analogue pain scale (0–10) in 10 (38%); and speech problems in 19 (73%). First-stage complications were graft loss (n = 2) and contracture (n = 1). The second stage was completed in 23 patients resulting in the following significant complications: meatal stenosis plus fistula (n = 2), breakdown (n = 1). Successful hypospadias repair was achieved in 77% (20/26) of the patients.

Conclusion

Lingual mucosa is a reliable and versatile graft material in the armamentarium of two-stage Bracka hypospadias repair with the merits of easy harvesting and minor donor-site complications.

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.

One-stage dorsal lingual mucosal graft urethroplasty for the treatment of failed hypospadias repair

The aim of this study was to retrospectively investigate the outcomes of patients who underwent one-stage onlay or inlay urethroplasty using a lingual mucosal graft (LMG) after failed hypospadias repairs. Inclusion criteria included a history of failed hypospadias repair, insufficiency of the local skin that made a reoperation with skin flaps difficult, and necessity of an oral mucosal graft urethroplasty. Patients were excluded if they had undergone a failed hypospadias repair using the foreskin or a multistage repair urethroplasty. Between January 2008 and December 2012, 110 patients with failed hypospadias repairs were treated in our center. Of these patients, 56 underwent a one-stage onlay or inlay urethroplasty using LMG. The median age was 21.8 years (range: 4–45 years). Of the 56 patients, one-stage onlay LMG urethroplasty was performed in 42 patients (group 1), and a modified Snodgrass technique using one-stage inlay LMG urethroplasty was performed in 14 (group 2). The median LMG urethroplasty length was 5.6 ± 1.6 cm (range: 4–13 cm). The mean follow-up was 34.7 months (range: 10–58 months), and complications developed in 12 of 56 patients (21.4%), including urethrocutaneous fistulas in 7 (6 in group 1, 1 in group 2) and neourethral strictures in 5 (4 in group 1, 1 in group 2). The total success rate was 78.6%. Our survey suggests that one-stage onlay or inlay urethroplasty with LMG may be an effective option to treat the patients with less available skin after failed hypospadias repairs; LMG harvesting is easy and safe, irrespective of the patient's age.

Hypospadias repair during adulthood: Case series

Purpose

We report our complications and success rate in adult hypospadias repair.

Patients and Methods

This was a retrospective study of patients aged ≥17 years who underwent hypospadias repair during 2006-2014. We analyzed two groups, one with primary repair and the other that had secondary repair after failed childhood hypospadias surgery. Outcome was compared between the two groups and among different surgical procedures. Descriptive statistics and Fisher's exact test were used and significance level was set at P < 0.05.

Results

Forty patients were included, of which 26 presented for a secondary repair and 14 for primary repair. The meatus was distal in 15 patients, mid-penile in 16, and penoscrotal in 9. The median age of patients at the time of surgery was 21 years (standard deviation [SD] =4, range 17-30). The median follow-up period was 37 months (SD = 8, range 5-75). In the primary repair group, the success rate was 71% (10/14), whereas in the secondary repair group, the success rate was 55% (14/26). The overall complication rate was 60%. Following a subsequent repair, the overall success rate reached 95% (38/40). There was no significant difference in success or complications between patients who presented with primary or secondary hypospadias or between methods of repair.

Conclusion

Delayed hypospadias repair in adults is associated with a high success rate of 95% with no difference between primary and secondary repair. Secondary repair however may require more than one procedure most of the time.

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

INTRODUCTION

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS AND COMPLICATIONS

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

DISCUSSION

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

CONCLUSION

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

[URETHROPLASTY FOR COMPLICATED ANTERIOR URETHRAL STRICTURES]

(Objectives) To compare efficacy and outcome of urethroplasty for complicated anterior urethral strictures. (Methods) Twelve patients, included 3 boys, with anterior urethral stricture underwent urethroplasty after the failure of either urethral dilatation or internal urethrotomy. We evaluated pre- and post-operative Q max and surgical outcome. (Results) Four patients were treated with end-to-end anastomosis, included a case of bulbar urethral elongation simultaneously, one patient was treated with augmented anastomotic urethroplasty, three patients were treated with onlay urethroplasty with prepucial flap, one patient was treated with tubed urethroplasty with prepucial flap (Ducket procedure) and three patients were treated with onlay urethroplasty with buccal mucosal graft. Postoperative Qmax improved in all patients without major complications and recurrence during follow-up periods ranging from 17 to 102 months (mean 55 months). (Conclusions) Urethroplasty is an effective therapeutic procedure for complicated anterior urethral stricture.

Tunneled buccal mucosa tube grafts for repair of proximal hypospadias

PURPOSE

Buccal mucosa is the favored graft material for patients with long urethral defects and a paucity of skin. Since 2007, we have used the novel tunneled buccal mucosa tube graft urethroplasty technique in these patients. We describe this operative technique and report our surgical and functional outcomes.

MATERIALS AND METHODS

Between 2007 and 2013, 37 males with proximal hypospadias underwent tunneled buccal mucosa tube graft urethroplasty. After the penile shaft was optimized at a prior stage a free buccal graft was tubularized and tunneled under the intact ventral shaft skin and into the glans. We retrospectively reviewed all charts to report our results. We assessed uroflowmetry and bladder ultrasound for post-void residual urine.

RESULTS

The overall complications rate in 34 patients with more than 1-year followup was 32% (11), including fistula in 5, proximal stricture in 4 and meatal stenosis in 2. In the first 10 patients a total of 7 complications (70%) developed but there were only 4 complications in the next 24 (16%). Surgeon experience was the only significant predictor of complications (p = 0.003). We obtained uroflow and post-void residual urine data on 13 of 37 patients, of whom 9 achieved a normal flow pattern and post-void residual urine, and 4 had a blunted flow pattern.

CONCLUSIONS

The novel technique of the tunneled buccal mucosa tube graft in patients with proximal hypospadias represents a good alternative for a long urethroplasty in patients with a paucity of skin. After the learning curve plateaus the rate and degree of complications decrease. Furthermore, voiding function is adequate, as assessed by uroflow studies and post-void residual urine measurement.

Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience

It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20-60 months) and 35 months (18-60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.

Buccal grafts for urethroplasty in pre-pubertal boys: what happens to the neourethra after puberty?

OBJECTIVE

Buccal mucosa grafts (BMG) are often used in complex urethral reconstruction. Following pubertal endogenous androgen stimulation (EAS) in prepubertal boys, there are concerns that the neourethra may not grow proportionally to the phallus. To address the paucity of literature on the topic, this article reports on data for post-pubertal follow up after pre-pubertal BMG urethroplasties (BMGU).

PATIENTS AND METHODS

Retrospective chart review of boys who underwent staged BMGU before the age of 12 years at a single referral center between 2000 and 2010 and who were followed up until after puberty. Demographic information, initial meatal location, quality of graft before tubularization, flow rate parameters (FRP) and complications were captured.

RESULTS

Of the 137 patients who underwent staged BMGU during the study period, 10 satisfied the inclusion criteria. Mean patient age at first stage BMGU was eight years (range five to eleven years). The mean follow-up was 40.6 months (9-66 months). The grafts were harvested from the cheek and lower lip in seven and three cases, respectively. The mean interval between the first and second stage was 15.8 months (6-87 months). Complications included one urethro-cutaneous fistula and two cases of glanular dehiscence. The final position of the meatus was glanular in nine boys and coronal in one. Importantly, no recurrent ventral curvature (VC) was found during the second stage BMGU or reported after puberty. All patients demonstrated normal maximum flow after puberty (mean 25.7 ml/s).

CONCLUSION

Buccal mucosa grafts appear to grow proportionally to the phallus after pubertal EAS. No recurrent VC or inadequate FRP were observed in this series. Despite the small number of subjects, the results are reassuring and support continued use of BMG in the pediatric pre-pubertal population.

Use of buccal mucosa in hypospadias repair

Hypospadias is an embryological disorder that results in an abnormal ventral positioning of the urethral meatus. Among multiple surgical techniques described to correct this anomaly, the use of buccal mucosa grafts has gained popularity among pediatric urologists, pediatric surgeons and plastic surgeons. Buccal mucosa grafts have shown favorable histological changes that result in an excellent scaffold for urethral reconstructive surgery. This review describes the evolution of the use of buccal mucosa grafts in hypospadias repair.

Single stage ventral onlay buccal mucosal graft urethroplasty for navicular fossa strictures

INTRODUCTION

The correction of fossa navicularis strictures poses a distinct reconstructive challenge as it requires attention to cosmesis, in addition to urethral patency. Different graft and flap based repairs have been described with variable success rates. However, the ideal management remains unclear. The feasibility and efficacy of a single stage ventral onlay buccal mucosa graft urethroplasty (VOBMGU) for navicular fossa strictures (NFS) was evaluated in the present study.

SUBJECTS AND METHODS

All patients with NFS attending urology out-patient department from March, 2009 onward accepting VOBMGU were evaluated prospectively. Patients with minimum 1 year of follow-up were included for analysis. The technique involves opening the diseased stenosed meatus ventrally up to the corona. The diseased mucosa is excised leaving a midline strip of native urethral mucosa on the dorsal side. The buccal mucosal graft (BMG) is fixed on either side of this strip over a 24 Fr. silicone catheter. The glans wings are apposed in midline taking anchoring bites on the mucosal graft ventrally. Post-operatively patients were reviewed at 1, 3, 6 and 12 months and annually thereafter. Cosmetic acceptance and splaying of the urinary stream was assessed with individual questionnaires.

RESULTS

A total of six patients underwent VOBMGU. Average flow rate at 3 months post-operatively was 12 ml/s. The end result was cosmetically highly acceptable. There was no fistula in any of the cases. With a median follow-up of 37 months, only one patient had a recurrence of stricture in a proximal site.

CONCLUSIONS

VOBMGU is a viable technique for reconstruction of NFS with promising short term results. However, long-term follow-up is necessary.

Current management of urethral stricture

The surgical treatment of urethral stricture diseases is continually evolving. Although various surgical techniques are available for the treatment of anterior urethral stricture, no one technique has been identified as the method of choice. This article provides a brief updated review of the surgical options for the management of different sites and different types of anterior urethral stricture. This review also covers present controversies in urethral reconstruction. Among the various procedures available for treating urethral stricture, one-stage buccal mucosal graft urethroplasty is currently widely used. The choice of technique for urethroplasty for an individual case largely depends on the expertise of the surgeon. Therefore, urologists working in this field should keep themselves updated on the numerous surgical techniques to deal with any condition of the urethra that might surface at the time of surgery.

Failed hypospadias in paediatric patients

Failed hypospadias refers to any hypospadias repair that leads to complications or causes patient dissatisfaction. The complication rate after hypospadias repairs ranges from 5-70%, but the actual incidence of failed hypospadias is unknown as complications can become apparent many years after surgery and series with lifelong follow-up data do not exist. Moreover, little is known about uncomplicated repairs that fail in terms of patient satisfaction. Risk factors for complications include factors related to the hypospadias (severity of the condition and characteristics of the urethral plate), the patient (age at surgery, endocrine environment, and wound healing impairment), the surgeon (technique selection and surgeon expertise), and the procedure (technical details and postoperative management). The most important factors for preventing complications are surgeon expertise (number of cases treated per year), interposition of a barrier layer between the urethroplasty and the skin, and postoperative urinary drainage. Major complications associated with failed hypospadias include residual curvature, healing complications (preputial dehiscence, glans dehiscence, fistula formation, and urethral breakdown), urethral obstruction (meatal stenosis, urethral stricture, and functional obstruction), urethral diverticula, hairy urethra, and penile skin deficiency.

Two-stage repair for severe proximal hypospadias using oral mucosal grafts: combination of a modified Bracka method and a modified Byars flap method

One-stage repair is a conventional treatment of hypospadias. If hypospadias is severe as in the scrotal type and perineal type, penile curvature sometimes cannot be corrected by dorsal midline plication alone. In addition to resection of the urethral plate, ventral grafting becomes necessary for insufficient skin and subcutaneous tissue. In recent years, there has been renewed interest in 2-stage repair for such severe cases and salvage of failed cases with scarring. In the present study, novel 2-stage urethroplasty was performed in 6 cases to repair severe proximal hypospadias which required resection of the urethral plate. This novel method consisted of a combination of a modified Bracka method using oral mucosal grafts and a modified Byars flap of the dorsal foreskin. Good results were obtained using this novel method.

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.

Effect of human urine on the tensile strength of sutures used for hypospadias surgery

INTRODUCTION

Hypospadias is the most common congenital condition affecting between 1 in 250 and 300 live births. Even in experienced hands, surgery to repair this congenital defect can have a high complication rate. Wound dehiscence is reported to occur in 5% and fistula formation in 6%-40% depending on technique. The choice of suture material has been shown to affect the complication rate although there is (currently) no consensus about the best suture material to use. Ideally, the sutures used for urethroplasty should be absorbable while maintaining sufficient mechanical strength to support the wounds until they are self-supporting and able to resist urinary flow. Previous studies have compared the effects of human urine on different suture materials especially catgut. However, catgut is now banned in Europe. Our study examined the tensile and breaking strength as well as rate of degradation for four types of absorbable suture now commonly used for hypospadias repairs in the UK.

MATERIAL AND METHODS

We examined the effect of prolonged storage (up to 27 days) in human urine on 6/0 gauge Vicryl, Vicryl Rapide, Monocryl and polydioxanone (PDS) sutures. These four suture materials are commonly used by the senior plastic consultant surgeon (NK) for hypospadias repairs. 50 mm sections of these suture materials were stored in either urine or saline as control. At specified time points, each suture was placed in a uniaxial load testing machine to assess the stress-strain profile and the mechanical load required to break the suture was measured.

KEY RESULTS

Exposure to urine reduced the tensile and breaking strength of all the suture materials tested. PDS demonstrated the greatest resilience. Vicryl Rapide was the weakest suture and degraded completely by day 6. Vicryl and Monocryl had similar degradation profiles, but Vicryl retained more of its tensile strength for longer.

CONCLUSIONS

There is a balance to be struck between the duration that a suture material must remain in any surgical wound and the risk that it causes foreign body effects. The results of this study suggest that Vicryl has the best characteristics for urethroplasty of the four suture materials tested.

Treatment of adults with complications from previous hypospadias surgery

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Salvage hypospadias repairs

Aim:

Review of our experience and to develop an algorithm for salvage procedures in the management of hypospadias cripples and treatment of urethral strictures following hypospadias repair.

Methods:

This is a retrospective review of hypospadias surgeries over a 41-month period. Out of a total 168 surgeries, 20 were salvage/re-operative repairs. In three children a Duplay repair was feasible, while in four others a variety of single-stage repairs could be done. The repair was staged in seven children – buccal mucosal grafts (BMGs) in five, buccal mucosal tube in one, and skin graft in one. Five children with dense strictures were managed by dorsal BMG inlay grafting in one, vascularized tunical onlay grafting on the ventrum in one, and a free tunical patch in one. Three children were treated by internal urethrotomy and stenting for four weeks with a poor outcome.

Results:

The age of children ranged from 1.5–15 years (mean 4.5). Follow-up ranged from 3 months to 3.5 years. Excellent results were obtained in 10 children (50%) with a well-surfaced erect penis and a slit-like meatus. Glans closure could not be achieved and meatus was coronal in three. Two children developed fistulae following a Duplay repair and following a staged BMG. Three repairs failed completely – a composite repair broke down, a BMG tube stenosed with a proximal leak, and a stricture recurred with loss of a ventral free tunical graft.

Conclusions:

In salvage procedures performed on hypospadias cripples, a staged repair with buccal mucosa as an inlay in the first stage followed by tubularization 4–6 months later provides good results. A simple algorithm to plan corrective surgery in failed hypospadias cases and obtain satisfactory results is devised.

The role of two-stage repair in modern hypospadiology

Hypospadias surgery continues to evolve. The enthusiasm for flap-based urethroplasty is waning and instead there is an increasing preference for urethroplasty that uses either the urethral plate alone or in combination with grafts. From the vast armamentarium of hypospadias repairs that are still in use, the author suggests a simple protocol of just three closely related procedures with which we can now repair almost all hypospadias. The tubularised incised plate (TIP) repair and the ‘Snodgraft’ modification of the TIP principle are simple and effective one-stage solutions when partial circumference urethroplasty is required. Conversely, the Bracka two-stage graft repair remains an ideal and versatile solution when a full circumference urethroplasty is required. It is particularly appropriate for severe primary hypospadias associated with a poor plate and marked chordee and also to replace a scarred, hairy or balanitis xerotica obliterans diseased urethra in re-operative salvage hypospadias.

Utilization of urethral plate in hypospadias surgery

Purpose

Recognition the urethral plate comprises tissues that normally should have created the urethra was an important milestone in hypospadias surgery, giving rise to new operative repairs - most notably the tubularized incised plate technique. This article reviews the current state of the art for hypospadias repair using tubularized, incised plate (TIP).

Materials and Methods

Personal experience and literature reports were reviewed to summarize use of TIP urethroplasty for distal, proximal, and re-operative hypospadias repairs.

Results

The TIP can be used to correct all distal and most proximal hypospadias. The major contraindication is ventral curvature that leads to urethral plate transection for straightening, which is only necessary in some proximal cases. Reoperations can also be performed using TIP provided the urethral plate has been maintained and is not grossly scarred. Complication rates are comparable to previously used techniques, while cosmetic appearance after TIP is considered superior to other available procedures.

Conclusions

Recognition of the urethral plate and its incorporation into the neourethra has revolutionized hypospadias repair. The most commonly used operative procedure today is TIP.

Two-stage repair in hypospadias

We provide the reader with a nonsystematic review concerning the use of the two-stage approach in hypospadias repairs. A one-stage approach using the tubularized incised plate urethroplasty is a well-standardized approach for the most cases of hypospadias. Nevertheless, in some primary severe cases, in most hypospadias failures and in selected patients with balanitis xerotica obliterans a two-stage approach is preferable. During the first stage the penis is straightened, if necessary and the urethral plate is substituted with a graft of either genital (prepuce) or extragenital origin (oral mucosa or postauricular skin). During the second stage, performed around 6 months later, urethroplasty is accomplished by graft tubulization. Graft take is generally excellent, with only few cases requiring an additional inlay patch at second stage due to graft contracture. A staged approach allows for both excellent cosmetic results and a low morbidity including an overall 6% fistula rate and 2% stricture rate. Complications usually occur in the first year after the second stage and are higher in secondary repairs. Complications tend to decrease as experience increases and use of additional waterproofing layers contributes to reduce the fistula rate significantly. Long-term cosmetic results are excellent, but voiding and ejaculatory problems may occur in as much as 40% of cases if a long urethral tube is constructed. The procedure has a step learning curve but because of its technical simplicity does not require to be confined only to highly specialized centers.

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.

Complicated urethroplasty: a guide for surgeons

Although straightforward male urethral stricture disease is commonly encountered in the scope of general urologic practice, complex urethral strictures are less common and require a more systematic approach. Complex urethral stricture surgery for long and panurethral strictures, after failed hypospadias repair, and for recurrent posterior urethral distraction defects requires a dynamic treatment paradigm. A multistaged urethral reconstruction is often necessary owing to hostile urethral tissue, especially after multiple previous procedures. A perineal urethrostomy sometimes offers improved quality of life for patients with complex urethral stricture disease, particularly if they have undergone previous failed repairs. Recurrent posterior urethral distraction defects are best treated with excision of the scarred urethral segment and re-anastomosis. Urethral stricture disease after treatment for prostate cancer requires multiple treatment approaches given the often poor tissue quality and likelihood of stricture recurrence.

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.

Algorithm for comprehensive approach to hypospadias reoperation using 3 techniques

PURPOSE

We describe comprehensive hypospadias reoperation based on presence or absence of a supple urethral plate using the 3 surgical techniques of transurethral incised plate, 1-stage inlay graft and 2-stage buccal graft.

MATERIALS AND METHODS

We reviewed prospective data from all reoperative hypospadias urethroplasties performed by one of us (WTS) between 2000 and 2008. Patient age, number of operations, indications for additional surgery, meatal location, reoperative surgical technique and outcomes were extracted.

RESULTS

A total of 133 patients underwent reoperation by transurethral incised plate (69), 1-stage inlay graft (16) or 2-stage buccal graft (48) urethroplasty. Mean number of prior failed repairs was 1.1, 1.9 and 4.3, respectively. Followup was available in 121 patients (91%), with 90 (74%) undergoing 1 successful reoperative urethroplasty. Complications occurred in 19%, 15% and 38% of patients, respectively, and most often consisted of fistulas or glans dehiscence.

CONCLUSIONS

Hypospadias reoperation can be accomplished using these 3 techniques without skin flaps, a potential advantage given the relative paucity of skin after failed repair. Fistulas after transurethral incised plate urethroplasty correlate with barrier layers used, while glans dehiscence is more likely in 2-stage buccal graft repairs when cheek rather than lip is used within the glans.

Histological evaluation of an alternative method of neophalloplasty based on two lower abdominal skin flaps and simultaneous buccal mucosa graft in the ventral surface of the neophallus (two-stage urethroplasty): experimental study in rabbits

OBJECTIVE

To evaluate, in an experimental study in rabbits, a new model of neophalloplasty based on two lower abdominal skin flaps and ventral buccal mucosa graft for planned two-stage urethroplasty procedure.

MATERIAL AND METHODS

Sixteen rabbits were operated and divided into four equal groups which were sacrificed at 2, 4, 8 and 12 weeks. The inflammatory pattern, presence of sub-epithelial fibrosis and epithelial changes in the grafted area were evaluated histologically.

RESULTS

There were no deaths and no dehiscence of the wound was seen. One animal in the 2-week group developed an ulcer in the grafted area. We found minimal contracture of the neophallus, but this was not statistically significant between groups. Buccal mucosa graft showed good uptake in all groups, with vascular support from subcutaneous tissue of the flaps. The grafted area developed epithelial metaplasia, showing a decrease in cell layers with time, with disappearance of the sub-epithelial papillae and appearance of stratum granulosum and keratinization of the epithelial graft surface. A decrease in sub-epithelial fibrosis with replacement of immature by mature (eosinophilic) collagen was found. In the later groups was also observed an important decrease in inflammatory response, and the chorion of the grafted area presented a dilated capillary network, indicating that the process of neoangiogenesis was effective.

CONCLUSION

Buccal mucosa displayed histological integration in the abdominal flaps with epithelial metaplasia in all groups. The surgical aspect of the neophallus was cosmetically acceptable, with minimal contracture.