Suture materials: do they affect fistula and stricture rates in flap urethroplasties?

Post-urethroplasty complications in hypospadias repair: a systematic review and meta-analysis comparing polydioxanone and polyglactin sutures

Background

Polyglactin (PG) and polydioxanone (PDS) sutures are extensively used based on the surgeon's preference. The development of post-reconstruction urethrocutaneous fistula (UCF) is variably attributed to the choice of suture material for urethroplasty. This meta-analysis compares complications of hypospadias repair using PG and PDS sutures.

Methods

The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors conducted thorough searches in databases including MEDLINE, EMBASE, CENTRAL, Scopus, Google Scholar, and clinical trial registries. Outcome measures included UCF, meatal stenosis, wound infection, urethral stricture, glans dehiscence, and overall complications. Quantitative analysis was used with fixed or random-effect models to find the pooled risk ratio and I2 heterogeneity.

Results

The criteria for inclusion were met by five comparative studies with the inclusion of 1244 children altogether. Pooled analysis failed to show a statistically significant difference in the incidence of meatal stenosis, urethral stricture, wound infection, and total complications using PG and PDS sutures. However, it showed a reduction in the incidence of UCF with PDS suture hypospadias repairs (risk ratio=0.66, 95% CI 0.48 to 0.92).

Conclusions

PDS sutures are associated with decreased incidence of UCF than PG after hypospadias repair. The incidence of meatal stenosis, urethral stricture, wound infection, and total complications was not affected by the type of suture material used for repair.

Clinical implications

This meta-analysis suggests decreased incidence of UCF when PDS sutures are used for hypospadias repair which may impact the choice of suture material for repair.

PROSPERO registration number

CRD42023409710.

Comparison of post-urethroplasty complication rates in pediatric cases with hypospadias using Vicryl or polydioxanone sutures

Objective

Hypospadias is a common congenital problem among male newborns. Both rapid absorbable sutures (polyglactin, Vicryl) and delayed absorbable sutures (polydioxanone, PDO) are used in hypospadias repair based on the surgeon's preference. This study was conducted to compare post-urethroplasty complication rates in pediatric patients with hypospadias using Vicryl or PDO sutures.

Methods

This is a retrospective study which was designed and performed on 583 children aged 1–7 years old who had undergone hypospadias repair from January 2012 to December 2018. Required data were obtained from the patients' medical records.

Results

Overall, post-surgical complications were observed in 60 (10.3%) patients comprising urethro-cutaneous fistula (n=39, 6.7%), meatal stenosis (n=10, 1.7%), urethral stricture (n=7, 1.2%), and glans dehiscence (n=4, 0.7%). The mean age of the children with complications was 3.0±1.3 years. According to Kaplan-Meier estimate, the interval between surgery and development of complications was significantly shorter in the Vicryl group (p=0.037). Overall, complications were more prevalent in Vicryl suture than PDO suture (15.1% vs. 5.3%, p<0.001). Regression model revealed that in comparison to the distal type, proximal hypospadias (odds ratio [OR]:103.9, 95% confidence interval [CI]: 32.2–334.9, p<0.001) and mid-shaft hypospadias (OR: 82.9, 95% CI: 25.9–264.6, p<0.001) while using Vicryl suture instead of PDO suture (OR: 62.4, 95% CI: 21.2–183.8, p<0.001) increased the odds of developing post-urethroplasty complications.

Conclusion

We suggest PDO suture in the repair of hypospadias due to its lower complication rate, especially in cases of proximal and mid-shaft hypospadias which can get more complicated than the distal type.

Micro- and Nanostructured Biomaterials for Sutureless Tissue Repair

Sutureless procedures for wound repair and closure have recently integrated nanostructured devices to improve their effectiveness and clinical outcome. This review highlights the major advances in gecko-inspired bioadhesives that relies mostly on van der Waals bonding forces. These are challenged by the moist environment of surgical settings that weaken adherence to tissue. The incorporation of nanoparticles in biomatrices and their role in tissue repair and drug delivery is also reviewed with an emphasis on procedures involving adhesives that are laser-activated. Nanostructured adhesive devices have the advantage of being minimally invasive to tissue, can seal wounds, and deliver drugs in situ. All these tasks are very difficult to accomplish by sutures or staples that are invasive to host organs and often cause scarring.

Grade of hypospadias is the only factor predicting for re-intervention after primary hypospadias repair: a multivariate analysis from a cohort of 474 patients

BACKGROUND

There is an ongoing quest on how to minimize complications in hypospadias surgery. There is however a lack of high-quality data on the following parameters that might influence the outcome of primary hypospadias repair: age at initial surgery, the type of suture material, the initial technique, and the type of hypospadias.

OBJECTIVES

The objective of this study was to identify independent predictors for re-intervention in primary hypospadias repair.

STUDY DESIGN

We retrospectively analyzed our database of 474 children undergoing primary hypospadias surgery. Univariate and multivariate logistic regression was performed to identify variables associated with re-intervention. A p-value <0.05 was considered statistically significant and therefore considered as a prognostic factor for re-intervention.

RESULTS

Distal penile hypospadias was reported in 77.2% (n = 366), midpenile in 11.4% (n = 54) and proximal in 11.4% (n = 54) of children. Initial repair was based on an incised plate technique in 39.9% (n = 189), meatal advancement in 36.0% (n = 171), an onlay flap in 17.3% (n = 82) and other or combined techniques in 5.3% (n = 25). In 114 patients (24.1%) re-intervention was required (n = 114) of which 54 re-interventions (47.4%) were performed within the first year post-surgery, 17 (14.9%) in the second year and 43 (37.7%) later than 2 years after initial surgery. The reason for the first re-intervention was fistula in 52 patients (46.4%), meatal stenosis in 32 (28.6%), cosmesis in 35 (31.3%) and other in 14 (12.5%). The median time for re-intervention was 14 months after surgery [range 0-114]. Significant predictors for re-intervention on univariate logistic regression (polyglactin suture material versus poliglecaprone, proximal hypospadias, lower age at operation and other than meatal advancement repair) were put in a multivariate logistic regression model. Of all significant variables, only proximal hypospadias remained an independent predictor for re-intervention (OR 3.27; p = 0.012).

DISCUSSION

The grade of hypospadias remains according to our retrospective analysis the only objective independent predicting factor for re-intervention in hypospadias surgery. This finding is rather obvious for everyone operating hypospadias. Curiously midpenile hypospadias cases were doing slightly better than distal hypospadias in terms of re-intervention rates. Our study however has also some shortcomings. First of all, data was gathered retrospectively and follow-up time was ill-balanced for several variables. We tried to correct this by applying sensitivity analysis, but possible associations between some variables and re-intervention might still be obscured by this. Standard questionnaires to analyze surgical outcome were not available. Therefore, we focused our analysis on re-intervention rate as this is a hard and clinically relevant end point.

CONCLUSIONS

This retrospective analysis of a large hypospadias database with long-term follow-up indicates that the long-lasting debate about factors influencing the reoperation rate in hypospadias surgery might be futile: in experienced hands, the only variable that independently predicts for re-intervention is the severity of hypospadias, the only factor we cannot modify. This retrospective multivariate analysis of a large hypospadias database with long-term follow-up suggests that the only significant independent predictive factor for re-intervention is proximal hypospadias. In our series, technique did not influence the re-intervention rate.

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.

A bio-inspired swellable microneedle adhesive for mechanical interlocking with tissue

Achieving significant adhesion to soft tissues while minimizing tissue damage poses a considerable clinical challenge. Chemical-based adhesives require tissue-specific reactive chemistry, typically inducing a significant inflammatory response. Staples are fraught with limitations including high-localized tissue stress and increased risk of infection, and nerve and blood vessel damage. Here inspired by the endoparasite Pomphorhynchus laevis, which swells its proboscis to attach to its host's intestinal wall, we have developed a biphasic microneedle array that mechanically interlocks with tissue through swellable microneedle tips, achieving ~3.5-fold increase in adhesion strength compared with staples in skin graft fixation, and removal force of ~4.5 N cm(-2) from intestinal mucosal tissue. Comprising a poly(styrene)-block-poly(acrylic acid) swellable tip and non-swellable polystyrene core, conical microneedles penetrate tissue with minimal insertion force and depth, yet high adhesion strength in their swollen state. Uniquely, this design provides universal soft tissue adhesion with minimal damage, less traumatic removal, reduced risk of infection and delivery of bioactive therapeutics.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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