Autologous platelet-rich plasma covering urethroplasty versus dartos flap in distal hypospadias repair: A prospective randomized study

Effect of Nintedanib on healing and fibrosis in rats with experimentally induced urethral injury

AIM

We aimed to determine the effectiveness of Nintedanib treatment, which has known antifibrotic effect, in preventing fibrosis after urethral trauma.

MATERIAL AND METHODS

Twenty-three adult Sprague-Dawley rats were divided randomly into 3 different groups: Sham, Urethral injury group (UI) and Urethral injury+ Nintedanib (UI+N). The urethral injury model was made with a pediatric urethrotome knife. Nintedanib was administered at a dose of 50mg/kg by oral gavage for 14 days at the same time every day. After 14 days of treatment, all rats were performed penectomy under general anesthesia. Urethral tissue was evaluated histopathologically (congestion, inflammatory cell infiltration and spongiofibrosis) and immunohistochemically (transforming growth factor (TBF) Beta-1 and vascular endothelial growth factor receptor 2 (VEBFR2)).

RESULTS

Histopathological findings: Group UI had higher scores in all categories (congestion, inflammatory cell infiltration, and spongiofibrosis), followed by Group UI+N and Group Sham, respectively. A statistically significant difference was found between Group UI and Group UI+N in terms of the scores of histopathological parameters (p<0.05). Immunohistochemical findings: Group UI had higher scores in both categories, followed by Group UI+N and Group Sham, respectively. A statistically significant difference was found between Group UI and Group UI+N in TGF Beta-1 and VEGF scores (p<0.05).

CONCLUSION

We found that Nintedanib administration after urethral trauma reduced inflammation and fibrosis histologically and immunohistochemically. The positive effect of Nintedanib on inflammation and fibrosis after urethral trauma reported in this animal study is encouraging for a potential clinical human application.

Use of an Autologous Platelet-Rich Concentrate in Hypospadias Repair: A Systematic Review and Meta analysis

Background

There is unanimous agreement amongst hypospadias surgeons to use an intermediate layer to cover the neourethra. Dartos fascia and tunica vaginalis (TV) flaps are the most preferred tissues to be used. Tissue glue, sealants and biomaterials are also useful where there is a paucity of local tissue to cover the neourethra. But these blood-derived products have associated infectious and allergic risks. The autologous human platelet concentrate (APC) contains biologically active factors and is safe for wound healing and soft tissue reconstruction. It has been used by few surgeons as an intermediate layer in hypospadias repair. This systematic review and meta-analysis aim to systematically compare the outcomes of hypospadias surgery in children with or without using APCs.

Methods

This systematic review and meta-analysis was conducted as per the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Meta-analysis protocol was registered with INPLASY. A systematic, detailed search was carried out by the authors in the electronic databases, including Medline, Embase, CENTRAL, Scopus, Google Scholar and clinical trial registry. Studies were selected and compared based on primary outcome measures like urethra-cutaneous fistula, meatal stenosis, wound infection and operative time. Statistical analysis was performed using a fixed-effect model, pooled risk ratio and I2 heterogeneity.

Results

Four randomized studies with a total of 355 patients were included. Pooled analysis for outcome of urethra-cutaneous fistula (UCF) showed no significant difference between the groups with APC and without APC. Pooled analysis for the other outcome like meatal stenosis, wound infection and total complications showed a decrease in incidence of these complications in groups with APC.

Conclusion

This meta-analysis shows that there is a reduction in the incidence of wound infection, meatal stenosis and total complications in patients where APC was used to cover the neourethra, although no such difference was observed in UCF rates.

Biologic adjuvant urethral coverings for single-stage primary hypospadias repairs: A systematic review and pooled proportional meta-analysis of postoperative urethrocutaneous fistulas

BACKGROUND

The use of barrier layers between the neourethra and skin is associated with lower rates of post-operative urethrocutaneous fistula (UCF) following hypospadias surgery. Recent studies have evaluated the ability of biologic adjuvant urethral coverings (BAUCs) - namely acellular matrix (AM), tissue adhesives (TAs), and autologous platelet-rich plasma or fibrin (PRP/PRF) - to prevent wound complications following hypospadias surgery. In general, however, these studies are small and conducted at single institutions.

OBJECTIVE

To assess the effect of BAUCs on the rate of UCF following single-stage primary hypospadias repair.

METHODS

We conducted a systematic review of studies reporting the rate of postoperative UCF in pediatric patients undergoing single-stage, primary hypospadias repairs using either AM, TA, or PRP/PRF as a layer interposed between the neourethra and skin. We then performed a pooled proportional meta-analysis of post-operative UCF. Patients within each study who underwent comparable surgery but did not receive a BAUC were used as controls.

RESULTS

10 studies were included in our review. The meta-analysis included 280 patients from 7 studies who underwent hypospadias repairs with BAUCs. The pooled incidence of UCF was 10% (95% CI 6-14%). Mean follow-up ranged 5-23.5 months in the 5/7 studies reporting specific durations, and ≥6 month and 14-30 months, respectively, in the other two studies. Patients in whom a BAUC was used had significantly lower odds of UCF than control patients (OR 0.39, 95% CI 0.24-0.64, p = 0.0002). In subgroup analyses, significant superiority held for AM and TA; proximal or penoscrotal cases; transverse preputial island flap (TPIF) technique; when both cases and controls had local flaps; and when neither cases nor controls had flaps.

DISCUSSION

The use of BAUCs was associated with decreased rates of post-operative UCF in single-stage primary hypospadias repairs and may be most beneficial in more severe cases and when used in addition to local flaps or when using a flap is not possible. In 2/3 studies of PRP/PRF and 2/4 studies of tubularized incised plate (TIP) technique, dartos flaps were used in controls but not BAUC patients, which may explain the lack of benefit demonstrated for these subgroups. This meta-analysis is limited by the quality of evidence in the included studies, which are not uniformly randomized. Furthermore, the follow-up durations and methods for assessing complications are not standardized between included studies.

CONCLUSION

The meta-analysis herein suggests that using BAUCs may reduce UCF rates following hypospadias surgery. Rigorous prospective evaluation is needed to validate this benefit.

Autologous platelet gel improves outcomes in tubularized incised plate repair of hypospadias

BACKGROUND

hypospadias is one of the most widespread male congenital anomalies, occurring in 1:250 to 1:300 live births. Several repair techniques have been developing to improve the outcomes.

PURPOSE

a randomized prospective controlled study was adopted to evaluate effectiveness of autologous platelet gel in healing promotion and improving the outcomes of hypospadias repair.

METHODS

thirty children who aged between 6 months and 12 years were recruited and subdivided into two groups; group A had tubularized incised plate (TIP) repair with autologous platelet gel application and group B had TIP repair without autologous platelet gel.

RESULTS

there was no significant difference in duration of operation between both groups. All patients in groups A and B had slit-like meatus shape in the distal glans. While all those of group A had one urine stream, yet only 11 of group B had one. There were complications that happened exclusively in group B such as spray stream (27%) and fistula (20%). Whereas other complications occurred insignificantly more in group B than in A including meatal stenosis (53 versus 27%), glans dehiscence, (20 versus 7%), bleeding (33 versus 13%), infection (33 versus 27%), edema (27% versus13), respectively. The incidence of skin necrosis was equal in both groups.

CONCLUSION

autologous platelet gel usage in TIP hypospadias repair can be a reliable technique to promote wound healing, and to limit of postoperative surgical complications.

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.

Single-stage versus staged interposition urethroplasty for glandular hypospadias with severe penile curvature: 15-year experience

Purpose

Our study examined the benefit of an alternative interposition urethroplasty (IU) procedure for glandular hypospadias (GH) with severe penile curvature (SPC). The technique involved transecting and reconstructing the urethra to preserve the distal glandular and coronal urethra and correct the curvature. We compared procedural characteristics, outcomes, and surgical complications for the single-stage and staged IU techniques.

Methods

We retrospectively studied 44 patients with GH with SPC who underwent single-stage or staged IU between March 2005 and June 2020. Demographics, operative details, complications, and uroflometry findings were analyzed.

Results

The median age at initial surgery was 37.5 months. Ten patients underwent single-stage IU repair, and 34 patients underwent staged IU repair. The median length of the interposition neourethra was 3.2 cm (2.2–4.3). The median follow-up duration was 58 months, and the overall complication rate was 13.6%. Complications were noted in 30% (3/10) and 8.8% (3/34) of patients in the single-stage and staged IU groups, respectively (p > 0.05). Fistula formation was noted in one and three patients in the single-stage and staged groups, respectively (8.8% vs. 10%, p > 0.05). Two cases of urethral stricture were documented in the single-stage group only. No chordee recurrence or urethral diverticula was noted in any of the patients.

Conclusion

IU is a reliable and durable technique for GH with SPC. It avoided penile shortening, preserved the distal urethra, and reduced the risk of chordee recurrence. The staged IU technique had more superior outcomes compared to the single-stage IU technique.

Comparison of Urethrocutaneous Fistula Rate After Single Dartos and Double Dartos Tubularized Incised Plate Urethroplasty in Pediatric Hypospadias

Background and objective

Tubularized incised plate (TIP) urethroplasty is an easy and popular technique for repairing hypospadias, however urethrocutaneous fistula (UCF) is a frequently reported complication. Different techniques are used to reduce this complication. We aimed to compare the rate of UCF after single dartos and double dartos TIP urethroplasty in children with distal and mid penile hypospadias.

Methods

A randomized controlled trial (NCT 04699318) was conducted in the Department of Pediatric Surgery, Mayo Hospital, Pakistan from August 2017 to February 2018, after ethical approval. After informed consent, a total of 60 patients with distal and mid penile hypospadias who were uncircumcised, had no chordee, and/or previous surgery, were randomly allocated in two groups using computer generated table numbers. Group A underwent single dartos TIP urethroplasty and Group B underwent double dartos TIP urethroplasty. Catheter was removed on day 10 post-operatively in both groups and primary outcome (UCF) was noted after a week of catheter removal. Rate of UCF was compared using chi square and p-value of <0.05 was taken as significant. Data was stratified to check for effect modifiers.

Results

Out of 60 children, eight (13.3%) developed UCF. In Group A, seven (23.3%) developed UCF and in Group B, one (3.3%) developed UCF (p-value 0.02). In both groups, no patient (0%) had urethral disruption, penile torsion, skin necrosis or meatal stenosis.

Conclusion

Additional covering of neo-urethra by a double dartos layer significantly reduces fistula rate after tubularized incised plate urethroplasty in both primary distal and mid penile hypospadias.

PRP in wound healing applications

Platelets play a crucial role in hemostasis, tissue regeneration and host defense. Based on these settings, platelet-rich plasma (PRP) and its derivatives are therapeutically used to promote wound healing in several scenarios. This review summarizes the biological mechanisms underlying the most traditional as well as innovative applications of PRP in wound healing. These mechanisms involve the combined action of platelet-derived growth factors and cytokines, together with the role of plasma-derived fibrillar, antioxidant and homeostatic factors. In addition, regenerative treatments with PRP consist of personalized and non-standardized methods. Thus, the quality of PRP varies depending on endogenous factors (e.g., age; gender; concomitant medication; disease-associated systemic factors; nutrition) and exogenous factors (anticoagulants and cellular composition). This review also analyses whether these factors affect the biological mechanisms of PRP in wound healing applications.

Comparison of effect between dartos fascia and tunica vaginalis fascia in TIP urethroplasty: a meta-analysis of comparative studies

Background

Tubularized incised plate (TIP) urethroplasty is the most commonly performed procedure for hypospadias. Several flap procedures have been recommended to decrease the postoperative complication rate in TIP repair, but no single flap procedure is ideal. This study aimed to compare the outcomes of dartos fascia (DF) and tunica vaginalis fascia (TVF) as intermediate layers in TIP urethroplasty.

Methods

We searched PubMed, EMBASE, the Cochrane Library, Web of Science, clinicaltrials.gov, and other sources for comparative studies up to April 16, 2020. Studies were selected by the predesigned inclusion criteria. The primary outcomes were postoperative complications. The secondary outcomes were functional and cosmetic outcomes.

Results

The pooled RR with 95% CI were calculated. We extracted the relevant information from the included studies. Only 6 comparative studies were included. No secondary outcomes were reported. The RR of the total complications rate for DF was 2.41 (95% CI 1.42–4.07, P = 0.0001) compared with TVF in TIP repair. For each postoperative complication, the RRs were 6.48 (2.20–19.12, P = 0.0007), 5.95 (1.13–31.30, P = 0.04), 0.62 (0.25–1.52, P = 0.29), and 0.75 (0.23–2.46, P = 0.64) for urethrocutaneous fistula, prepuce-related complications, meatal/urethral stenosis, and wound-related complications, respectively.

Conclusions

This meta-analysis reveals that compared to DF, TVF is a better option in TIP repair in terms of decreasing the incidence of the total postoperative complications, urethrocutaneous fistula, and prepuce-related complications. However there is limited evidence for functional and cosmetic outcomes. Overall, larger prospective studies and long-term follow-up data are required to further demonstrate the superiority of TVF over DF.

Trial registration

PROSPERO CRD42019148554.

The effect of plasma rich platelet graft on post-operative complications in mid-penile hypospadias

Hypospadias is one of the most common penile congenital anomalies, which often requires a surgical approach. After the hypospadias is repaired, urethral fistula can occur in around 20% of patients. In this study, we used platelet-rich plasma (PRP) to reduce the urethral fistula and other post-operative complications after hypospadias repair. Only patients with primary mid-penile hypospadias were included study. Patients with forms other than mid-penile hypospadias and cases with previous hypospadias surgery were excluded from the study. A total of 40 hypospadias patients were included in this study. These patients were divided into groups A and B with 20 patients in each group. Hypospadias repair was performed with the Snodgrass TIPU technique on both groups. PRP was used with group A, and PRP was not use with group B. These two groups were compared in terms of early and long-term post-operative complications. Both early and long-term post-operative UCF, urethral stenosis and post-operative infection rates were lower in the group using PRP, group A. PRP has the potential to prevent post-operative complications occurring after hypospadias repair, particularly post-operative infection.

Use of Acellular Dermal Matrix for Urethroplasty Coverage in Proximal Hypospadias Repair: a Pilot Study

Introduction

The complication rates of proximal hypospadias, especially fistula, are much higher than those of distal hypospadias. Urethral coverage is an effective method for reducing fistulas. Acellular dermal matrix (ADM) has been shown to exhibit structural compatibility and biocompatibility, both of which promote tissue healing.

Methods

The present non-randomized study evaluated the efficiency, feasibility, and safety of using ADM for urethroplasty coverage in patients with proximal hypospadias. This prospective study enrolled 35 patients (age range 15–60 months) with proximal hypospadias who underwent operation between September 2018 and March 2019 at Beijing Children’s Hospital (Beijing, China). Urethroplasties were performed by the transverse preputial island flap (TPIF) technique. ADM was applied and sutured over the urethroplasty as an additional covering layer. Patient outcomes were compared with those of 80 non-matched control patients with proximal hypospadias who underwent the same procedure, with dartos as a covering layer.

Results

During a median follow-up of 11.56 months (range 9–15 months), urethral fistula occurred in six patients (17.1%) in the ADM group and 28 patients (35%) in the dartos group. Superficial wound infection was observed in six patients (17.1%) in the ADM group and 10 patients (12.5%) in the dartos group. One patient in the ADM group had diverticulum, compared with five patients (6.25%) in the dartos group. Meatal stenosis and urethral stricture were observed in four patients (11.4%) in the ADM group and six patients (7.5%) in the dartos group; all of these complications were treated conservatively. No glans dehiscence was observed in either group.

Conclusion

Use of ADM may be a safe and efficient covering technique to provide an additional coverage layer for proximal hypospadias repair, thereby reducing the incidence of fistula formation, especially among patients who have poor-quality covering materials.

Complications Following Primary Repair of Non-proximal Hypospadias in Children: A Systematic Review and Meta-Analysis

Purpose: The aim of this study was to systematically review the literature on the complications and postoperative outcomes of children with non-proximal hypospadias. Methods: Electronic databases including PubMed, Embase, and Cochrane Library CENTRAL were searched systematically from January 1990 to June 2020 for the literature that reported the postoperative outcomes of patients with non-proximal hypospadias. Non-proximal hypospadias encompassed distal and mid-penile hypospadias. Results: We included 44 studies involving 10,666 subjects. Urethrocutaneous fistula (UCF) was the most common complication with an incidence of 4.0% (95% CI, 3.1-5.0%). Incidence of overall complications was 8.0% (95% CI, 6.3-9.8%). Meta-regression analysis revealed that length of urethral stent indwelling (coefficient 0.006; 95% CI, 0.000-0.011; p = 0.036) and penile dressing (coefficient 0.010; 95% CI, 0.000-0.021; p = 0.048) were two risk factors for UCF. Multivariate meta-regression analysis did not identify any independent risk factors for UCF. No differences were found between stent and stentless groups in non-proximal hypospadias regarding incidences of UCF (OR, 0.589; 95% CI, 0.267-1.297), meatal stenosis (OR, 0.880; 95% CI, 0.318-2.437), and overall complications (OR, 0.695; 95% CI, 0.403-1.199). No differences were found between foreskin preservation and circumcision in terms of complications either. Conclusions: UCF is the most common complication following hypospadias repair with an incidence of 4.0%. Independent risk factors for UCF were not identified in the current research. Distal hypospadias repair without stent indwelling is not likely to compromise the postoperative outcome. Further studies should be designed to explore the differences between different surgical approaches and the potential risk factors for complications following hypospadias repair.