Results of 265 consecutive proximal hypospadias repairs using the Thiersch-Duplay principle

The GUDplay technique: A shift of paradigm in glans reconstruction for midshaft and penoscrotal hypospadias with moderate chordee. A proposal of a new approach

INTRODUCTION

After 5 years experience with the GUD (glandular urethral disassembly) technique for distal hypospadias, we present the GUDplay technique, incorporating Thiersch-Duplay tubularization of the plate till the coronal area, disassembling the glans aggressively and refurbishing the glans.

METHODS

We defined the urethral plate and designed an inverted Y incision to open the glans in two wings. The glans was entirely detached from the corpora to gain a great mobility that allowed minor cranial mobilization of the urethra and caudal rotation of the wings. In sequence, there are well-known steps: Duplay urethroplasty, spongioblasts and a Dartos flap to cover the neourethra. The glans was connected to the urethra by 6.0 PDS sutures except in the ventral meatus and the glans wings are joined in the midline.

RESULTS

The 5-year-old patient had midshaft hypospadias without previous surgery. The catheter was removed after a week and the healing appears to be good.

DISCUSSION

We combined principles of total glans deconstruction in association to Duplay tubularization and then lifted it up to the tip of the glans divided in two wide and mobile wings. We have treated a small series of 6 cases without complications and mean follow-up of 6.2 months.

Separation of the glanular part of the urethral plate, mobilization of the distal part of the neourethra, and creation of the glanular groove: a new modification of second-stage Thiersch-Duplay urethroplasty in proximal hypospadias repair

PURPOSE

To evaluate the effect of separation of the glanular part of the urethral plate from the underlying glans penis with creation of a glanular groove for free accommodation of the neourethra as a new modification of Thiersch-Duplay urethroplasty in proximal hypospadias repair.

PATIENTS AND METHODS

Between January 2016 and January 2022, 35 patients with proximal hypospadias underwent a modified Thiersch-Duplay two-stage procedure. The glanular portion of the urethral plate was either separated from the underlying glanular tissue or discarded if found scared with mobilization of the distal portion of the neourethra to reach the tip of the glans penis. In all patients, a few millimeter of glanular tissue is excised to create a glanular groove in which the neourethra is embedded freely.

RESULTS

35 patients were involved in this study. The patient's age at the time of operation ranged from 18 months to 10 years (median 3.7 years). The mean follow-up period was 15.7 months (ranging from 12 to 18 months). Two patients developed urethrocutaneous fistula; while, none of the patients had meatal stenosis, urethral stricture, or meatal retraction. All patients have a slit-like meatus at the tip of the penis and a good cosmetic conical shape glans appearance.

CONCLUSION

We believe that in Thiersch-Duplay urethroplasty, separation of the urethral plat from the underlying glanular tissue and creation of good glandular groove to accommodate the neourethra is associated with adequate glanular closure and minimization of post-operative meatal stenosis, glanular dehiscence, and meatal retraction.

[Outpatient surgery for penile hypospadias in pediatric urology: A monocentric experience with a mean follow-up of 3 years]

INTRODUCTION

Hypospadias is one of the most common congenital anomalies in men. Outpatient surgery has been proposed but is not widespread. The aim of this study was to evaluate our experience of outpatient surgery for penile hypospadias repair and to specify the constraints for a result similar to a conventional inpatient procedure.

PATIENTS AND METHODS

Observational, retrospective and single-center study, including all the patients operated on hypospadias for the first time by one of the 3 senior surgeons, between January 2011 and March 2018. Peno-scrotal and perineal hypospadias were excluded because systematically hospitalized.

RESULTS

One hundred sixty-six patients were included. 67 patients (40,4%) were treated on an outpatient basis. The mean age at the time of procedure was 15.6 (6-51) months. Forms with curvature were almost exclusively hospitalized (1 vs. 25, P<0.001). There was no significant difference for anterior penile forms (60 vs. 81, P=0.06). Middle and posterior hypospadias were more often hospitalized, although outpatient experience exists. There were no more complications in the outpatient group.

CONCLUSION

Outpatient hypospadias surgery seems to be achievable in most of the cases, provided that medical care is standardized and multidisciplinary, the staff is trained and involved and a specific organization is put in place in the department. Evaluation of the socio-family environment is therefore fundamental.

LEVEL OF EVIDENCE: 4

Neomodified Koyanagi technique for severe hypospadias with one-stage sealed Y-shaped penis foreskin vascular protection surgery

Proximal hypospadias defects represent the most challenging aspect of maintaining blood supply to the flap, which eventually leads to a high rate of complications. We modified a sealed Y-shaped penis foreskin vascular protection technique, which can repair the urethra in a single stage. The inner plate of the foreskin was cut along the coronal sulcus, and both sides of the urethral plate were cut as deep as Buck's fascia. The "Y"-shaped foreskin flaps on both sides of the mouth that are continuous with the urethral plate were sutured to form a new urethral skin tube. The urethral skin tube was turned to the ventral side, and the foreskin was reshaped and sutured. A total of 89 children had their urinary catheters removed 4 weeks after the operation. All children were evaluated at least once a year for 3 consecutive years. There were 11 patients with urine leakage that occurred after the operation. These children, diagnosed with urine leakage, underwent successful repair after the leakage occurred. There were no urethral strictures after the operation. The one-time success rate of this operation was 87.6% (78/89), and the incidence of urethral fistula was 12.6% (11/89). The results showed that sealed Y-shaped penis foreskin vascular protection surgery was safer and had a higher operation rate than the traditional hypospadias repair technique. Modifying Koyanagi repair by our improved Koyanagi hypospadias repair is an excellent technique with relatively low complication rates.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is it safe to solely use ventral penile tissues in hypospadias repair? Long-term outcomes of 578 Duplay urethroplasties performed in a single institution over a period of 14 years

OBJECTIVES

Urethral plate tubulization (Thiersch-Duplay procedure) is a widespread procedure mostly used for distal hypospadias. Concerns of long-term outcome have led to this review of the results of a series of 578 cases.

PATIENTS AND METHODS

A retrospective review was conducted of 578 patients treated in a single institution following the same procedure and with the same follow-up. Most patients had distal hypospadias (517/578) and were operated on between 12 and 24 months of age (343 patients). The mean follow-up was 25.6 months (6 months-17 years). Evaluation was focused on urethral complications related to inadequate healing of the reconstructed urethra (fistula, urethral dehiscence, urethral stenosis and clinical dysuria). Complications were arbitrarily categorized into early (when occurring less than one year after surgery) and late (after one year). All data were submitted to statistical analysis.

RESULTS

Of the 578 patients, 153 (26.5%) had unsatisfactory outcomes, of which 118 (20.4%) had inadequate urethral healing. Of these, 97 appeared early (57%) and 73 appeared late (43%). Fistula and dehiscence were significantly more frequent in the first post-operative year (p<0.0001), whereas stenosis of the reconstructed urethra was more frequent after one year. Follow-up and age at last consultation were significantly higher in patients with complications. Limits and flaws of this study focused on the absence of consensus on evaluation of hypospadias surgery. The paucity of literature on long-term outcomes of urethral plate tubulization was highlighted. A possible explanation of late stenosis of the reconstructed urethra was the poor growth capacity of the dysplastic tissues located beyond the division of the corpus spongiosum. Urethroplasties solely using ventral tissues may represent an additional risk of late failure, as they may not grow with the rest of the genital tubercle.

CONCLUSION

Significant short and late complications occur with techniques tubularizing the urethral plate, mostly fistulae in the first post-operative year and urethral stenosis after 1 year following surgery. Urethroplasties using ventral tissues may not grow at the same pace as the rest of the genital tubercle and may explain late urethral dysfunction. This series confirms the necessity of long-term follow-up of hypospadias reconstructions.

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.

Proximal hypospadias with small flat glans: the lateral-based onlay flap technique

PURPOSE

The lateral-based onlay (LABO) technique for patients with proximal hypospadias associated with flat glans and report of the follow-up.

MATERIALS AND METHODS

Between January 2004 and December 2010, the LABO technique was performed in 107 patients. The principle is to use the lateral foreskin adjacent to the glans as the onlay flap. Patient age ranged between 8 months and 2 years (mean, 11 months). The records of 98 patients who maintained regular follow-up were reviewed. All the patients had proximal hypospadias with flat or incomplete cleft glans and did not have a deep chordee. Follow-up period ranged from 12 months to 8 years (mean, 32 months). A transurethral silastic catheter was used for 7 days.

RESULTS AND COMPLICATIONS

Satisfactory results were obtained in 93 patients (95%). Two children developed fistula, 2 developed glans dehiscence, and 1 child had skin prolapsing from the meatus that required excision.

CONCLUSIONS

The LABO technique is a reliable technique for patients with proximal hypospadias in the absence of a deep chordee. It has particular value in patients with small or flat glans. With multiple layer closure and careful attention to technical details, a low complication rate (5%) was achieved in correcting this type of proximal hypospadias.

Resultant hypospadias after epispadias repair in bladder exstrophy patients: a difficult surgical task with high complication rate

BACKGROUND/PURPOSE

The aim of this study was to analyze the complication rate in male bladder exstrophy (BE) patients undergoing flap or graft urethroplasty for the repair of resultant hypospadias after epispadias repair.

METHODS

We retrospectively reviewed the charts of 22 male BE patients who underwent 24 urethroplasties for resultant hypospadias between 2000 and 2009. Median patient age was 4.2 (range, 1.5-26.5) years, and median follow-up was 7.5 (range, 0.8-10.3) years. Meatal location after epispadias repair was midshaft in 6 cases and proximal shaft in 15. Complications were compared in relation to meatal position, type of urethroplasty (no graft vs graft), use of second-layer coverage of the urethroplasty, and use of suprapubic diversion.

RESULTS

Overall, complications developed in 12 (50%) patients, including 10 urethrocutaneous fistulas and 2 urethroplasty dehiscence. Univariate analysis failed to show any differences between complicated and uncomplicated cases in all the variables. Only the 3 cases undergoing a 2-stage repair had fully successful outcomes.

CONCLUSIONS

Urethroplasty in patients with BE has a high complication rate. Quality of local tissue and presence of scarring are possibly the 2 major determinants of a poor outcome. A staged repair seems the safest, although this commits the patient to 2 procedures.

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.

Split prepuce in situ onlay hypospadias repair: 17 years of experience

PURPOSE

We report our 17-year experience using split prepuce in situ onlay hypospadias repair, including long-term followup of the first 100 patients initially reported on in 1998.

MATERIALS AND METHODS

We identified 421 patients who underwent in situ onlay repair. Charts were retrospectively reviewed to determine preoperative management, intraoperative details and complications.

RESULTS

In situ onlay repair was used to repair glanular hypospadias in 22 cases (5.2%), coronal hypospadias in 184 (43.7%), distal shaft hypospadias in 152 (36.1%), mid shaft hypospadias in 51 (12.1%), proximal shaft hypospadias in 7 (1.6%) and hypospadias in the penoscrotal region in 5 (1.2%). Repair was successful with 1 procedure in 376 patients (89.4%), which increased to 99.8% after a second procedure. Complications were defined as any problem that gave the surgeon or family reason for concern. Functional complications requiring reoperation occurred in 45 patients (10.6%). Minor complications requiring simple procedures or early postoperative evaluation occurred in 17 patients (4%). Concerns not requiring intervention occurred in 27 patients (6.4%). There were no urethral strictures. Three patients (0.7%) were lost to followup. Repair is pending in 1 patient.

CONCLUSIONS

In situ onlay repair preserves the urethral plate and allows the formation of a well vascularized flap with adequate tissue to completely cover the neourethra, resulting in a low rate of major complications. With longer followup, inclusion of more mid shaft repairs and expansion to more proximal degrees of hypospadias our complication rates are higher than previously reported but there have been no urethral strictures in 17 years of experience. Since complications present at a median of 158 days (mean 570) after the procedure, long-term followup is indicated.

Correction of hypospadias with a vertical preputial island flap: a 23-year experience

PURPOSE

We report our experience using the preputial island flap technique (Scuderi procedure) to correct penile hypospadias.

MATERIALS AND METHODS

A total of 152 patients underwent repair between 1982 and 2004. Nine patients (6%) had proximal hypospadias, 46 (30%) had mid penile hypospadias and 97 (64%) had distal hypospadias. A total of 146 patients (96%) had not previously undergone surgical treatment, while 6 (4%) had undergone surgery.

RESULTS

After the primary repair 3 patients had fistula and 10 had mild stenosis. The immediate success rate was 91.4% (139 of 152 patients), which later increased to 98% (149 of 152) after nonsurgical treatment of the stenoses.

CONCLUSIONS

Preputial island flap urethroplasty is a versatile operation that corrects hypospadias and is particularly indicated if there is associated severe penile curvature, with a low complication rate and superior cosmetic results.

A MULTICENTER EVALUATION OF TECHNICAL PREFERENCES FOR PRIMARY HYPOSPADIAS REPAIR

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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