Management of the patient with failed hypospadias surgery presenting in adulthood

Adult non-urethral complications after hypospadias repair in childhood: presentation, treatment and outcomes

Purpose

This study aimed to evaluate a group of adult patients with non-urethral complications after hypospadias repair in childhood, their surgical treatment, and outcomes.

Materials and methods

We analyzed 97 patients, mean age 22.5 years, who were treated in our center between January 2009 and December 2020, for non-urethral complications after previous hypospadias repair in childhood. Non-urethral complications were defined as glans deformity, residual curvature and trapped penis due to insufficient penile skin. A radical surgical approach was used to correct all deformities, in a one-stage or a two-stage procedure. A successful outcome was defined as a straight penis with good length, anatomically regular glans, and cosmetically acceptable appearance, without need for additional surgeries. Sexual function was evaluated using International Index of Erectile Function.

Results

Mean follow-up was 75 months (ranged from 24 to 168 months). One-stage and two-stage repair were performed in 85.5% and 14.5% of cases, respectively. A higher success rate was noted after one-stage repair (94% compared to 86%). Complications included four cases of penile curvature with late onset, one case of glans dehiscence and partial skin necrosis. Erectile dysfunction was determined in 24% of patients.

Discussion

Non-urethral complications may occur many years after primary hypospadias repair, with a strong impact on the quality of life. Treatment is individualized and usually involves a radical surgical approach to correct all associated deformities and to achieve successful cosmetic and psychosexual outcomes.

Risk factors of penile resurfacing in re-operative hypospadias repair: A retrospective analytical study

INTRODUCTION

In re-operative hypospadias repair, scarred urethral plate, and deficient unhealthy penile skin are usually problematic. Difficulties are not only in urethroplasty but also in penile skin coverage. Penile skin coverage after urethroplasty with good viable skin decreases the complication rate and increases the satisfaction with repair. Studies reporting variables that increase the risks of the need for penile resurfacing in re-operative hypospadias are lacking.

OBJECTIVES

To determine the risk factors of the need for penile resurfacing techniques (PRSTs) in re-operative hypospadias.

STUDY DESIGN

A retrospective analysis of the redo hypospadias cases operated in-between January 2010 and December 2020 was done. Surgical data of the previous repairs, the indications for intervention, and the penile shaft coverage techniques at the time of the last repair were collected and analyzed. Patients' records were reviewed and categorized into two main groups. Group one include patients with simple skin closure, and group two include patients in whom penile resurfacing was done. Univariate analysis and Stepwise logistic regression measured the risk factors of the need for penile resurfacing techniques.

RESULTS

Out of 223 re-operative hypospadias, simple skin closure was done in 105 (group 1). Penile skin resurfacing (Byars flaps, Heineke-Mikulicz technique, and Z-Plasty) was in 55 (group 2a). In 63 patients (group 2b), scrotal flaps and skin grafts (split and full thickness) were the PRSTs. Patients ages, proximal hypospadias, number of prior surgery, one-stage repair, penile skin use in repair especially flap techniques, more than one complication in the same case, and unsatisfactory skin appearance increased the risk for PRSTs. Each previous repair increases the odds ratio of penile and non-penile resurfacing 1.9 and 3.2 folds respectively. One-stage repair increases odds of PRSTs 4 folds.

DISCUSSION

We analyzed the risk factors of the need for penile resurfacing techniques in the re-operative hypospadias cases. Step-wise logistic regression showed that the number of previous repairs and one-stage repair are the independent risk factors of penile resurfacing. Also, it showed that the number of prior surgeries is the only independent risk factor for non-penile skin resurfacing.

CONCLUSION

Number of previous repair is the independent risk factors of penile resurfacing and non-penile skin use in resurfacing. Previous repair in one-stage is an independent risk factor of the need for penile resurfacing.

Scrotal septal flap and two-stage operation for complex hypospadias: A retrospective study

BACKGROUND

Complex hypospadias is a surgical challenge.

AIM

To present the long-term outcomes of two-stage repair of complex hypospadias using a scrotal septal flap.

METHODS

This was a retrospective study of patients with complex hypospadias who were operated on between January 1^st, 2001, and January 1^st, 2019, at a single hospital using a scrotal septal flap (two-stage surgery) or prepuce flap (one-stage surgery; control group). In the scrotal group, the urethra was first repaired using oral mucosa; in the second stage, a scrotal septal flap was used as a second imper-meable layer. Maximal/average urinary flow rates after surgery were compared. All patients were followed for ≥ 6 mo (range: 6-96 mo).

RESULTS

Ninety-seven patients were included (46 in the scrotal group and 51 in the prepuce group). The maximal urinary flow rate was 15.4 ± 2.1 mL/s in the scrotal group and 14.3 ± 3.0 mL/s in the control group (P = 0.035). The average urinary flow rate was 8.4 ± 2.3 mL/s in the scrotal group and 7.5 ± 1.5 mL/s in the control group (P = 0.019). The proportion of patients achieving good therapeutic effects was higher in the scrotal group than in the control group [24 (52.2%) vs 16 (31.4%), P = 0.042; 34 (73.9%) vs 25 (49.0%), P = 0.014]. The scrotal flap two-stage surgery was independently associated with a higher maximal urinary flow rate (OR = 2.416, 95%CI: 1.026-5.689, P = 0.044) and with a higher average flow rate (OR = 2.484, 95%CI: 1.054-5.854, P = 0.038).

CONCLUSION

In complex hypospadias, a scrotal septal flap could be a versatile and reliable option for resurfacing the penis.

Accessory penis: A rare method of peno-urethral separation of sexual function and voiding following successful complex hypospadias reconstruction with a free ileum flap

Hypospadias is a congenital malformation of the male genitalia. The reconstructive objectives are to obtain voiding with laminar flow and satisfactory sexual function. Several urethroplasty techniques have been described, but for perineal or revisional cases no single technique has shown robust success. In this study, we describe the expanded use of intestinal flaps for urethral reconstruction and report a peculiar request from a patient to undergo peno-urethral separation after successful hypospadias repair with a free ileum flap. A 51-year-old male patient with perineal hypospadias underwent several urethral reconstructive procedures with poor outcomes. A free ileum flap was attempted as a substitute for the urethra. Following successful reconstruction, separation of the neo-urethra (ileum) from the penile body was performed to address the patient's sexual expectations. A free ileum flap proved to be a reliable urethral substitute in perineal hypospadias reconstruction, with a successful outcome. The peno-urethral separation with the creation of an "accessory penis," however peculiar, optimized the results in terms of both sexual and urinary function. Anatomical restoration of the urethra and patient-reported expectations are the key to successful hypospadias reconstructive procedures. Sexual function outcomes and the patient's perception of success should not be underestimated, even when urinary function has been restored.