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

Outcome analysis of staged preputial graft technique for primary proximal hypospadias with and without post-operative vacuum physiotherapy

PURPOSE

Management of proximal hypospadias remains challenging. We assessed the results of staged preputial graft repairs (SPG) for proximal hypospadias and hypothesize that post-operative vacuum physiotherapy (VP) improves graft suppleness and overall outcomes.

MATERIALS AND METHODS

Retrospective analysis of n = 71 patients with proximal hypospadias and severe ventral penile curvature (PC) of ≥50° after degloving. PC was corrected using ventral transverse incisions of the tunica albuginea (VTITA) without applying a tourniquet, taking care to avoid injuring the underlying erectile tissue. The ventral raw area at the penile shaft, including VTITA, were covered with either divided and partially mobilized urethral plate, or with the inner preputial graft itself. During the second stage, a tunica vaginalis flap was often used to cover the tubularized neourethra. Outcomes and post-op complications were assessed after each stage, comparing patients who received vacuum physiotherapy (VP+, n = 49) with those who did not (VP-, n = 22).

RESULTS

Mean PC was 66°, average follow-up duration was 13.01 months, and overall complication rate was 22.5%. Only 6 of 49 VP + patients experienced complications (12.24%; 4 fistulas; 2 urethral strictures) and no recurrence of PC after second stage was observed in this group. VP- patients displayed a significantly higher rate of complications, with 10 of 22 cases (45.45%) exhibiting fistula development (n = 5) and glans dehiscence (n = 5). Recurrence of mild PC after first-stage repair was comparable between patient groups (12% VP+, 18% VP-) and easily corrected by simple graft tubularization or dorsal plication during second-stage repair.

CONCLUSIONS

Staged repair using VTITA is effective for correcting proximal hypospadias with severe chordee. VP appears to promote and expedite graft suppleness and significantly improves patient outcomes.

Partial mobilisation of the neurovascular bundle for ventral penile curvature correction: A proof-of-concept study

Background:

To lift the neurovascular bundle (NVB) is a critical step during dorsal plications for ventral penile curvature correction. Indeed, this procedure may hesitate in nerves and vascular damage. Herein, we present a revolutionary approach of partial NVB mobilisation that avoids dissection among 10 and 2 o’clock positions decreasing the risk of injuring nerves and vessels.

Methods:

We assessed ventral penile curvature after penile degloving, marking the level of maximal bending. Bilateral para urethral incisions were made and the Buck’s fascia carefully mobilised from the tunica albuginea. The mobilisation of NVB was carried until 10 and 2 o’clock, avoiding the area between 10 and 2 o’clock positions, where nerves and vessels are more concentrated. The 10 and 2 o’clock positions correspond also to the dorsal edges of the two cavernosa cylinders, where plications are more effective. Penile straightening after surgery was defined as residual curvature less than 10 degrees.

Results:

Between 2016 and 2020, we have operated 33 men and 32 boys with ventral penile curvature. The severity of penile curvature was mid (<30 degrees) in 13 (20%) patients, moderate (30–60 degrees) in 33 (51%) patients, and severe (> 60 degrees) in 19 (29%) patients. Penile straight was achieved for all patients. We recorded three haematoma, three glans skin erosion, and one curvature recurrence after 13 months of follow-up. No patient reported erectile dysfunction.

Conclusion:

This proof-of-concept study shows that partial NVB mobilisation is technically easier and safer compared to complete NVB mobilisation, without compromising the success of surgery.

Level of evidence:

Not applicable

Prospective Assessment of Patient-perceived Short-term Changes in Penile Appearance After Urethroplasty

OBJECTIVE

To define the incidence and associations of patient-reported penile curvature and shortening after urethroplasty. Alterations in penile curvature or length post-urethroplasty are associated with patient dissatisfaction but are poorly described.

METHODS

From 2011 to 2019, 387 patients completed enrollment in a prospective single-centre study assessing patient-reported outcomes pre-operatively and 6-months post-urethroplasty. Primary outcomes of perceived penile shortening and curvature were assessed at 6-months follow-up. Descriptive statistics were used to summarize findings while univariate and multivariate binary logistic regression was used to identify associations between loss of penile length or chordee with other clinical factors.

RESULTS

Of the 387 patients, mean age was 49.5 years with mean stricture length of 4.5 cm. Postoperatively, 12.7% of patients perceived penile curvature (8.0% "somewhat", 4.7% "severe") and 22.8% of patients perceived penile shortening (14.5% "somewhat", 8.3% "a lot"). Multivariate binary logistic regression identified stricture location (P = .02) to be associated with perceived curvature while prior urethroplasty (P = .17), type of urethroplasty (P = .08) and other factors were not. Specifically, penile (O.R. 4.27, 95%CI 1.56-11.68, P = .005) and panurethral (O.R. 10.15, 95%CI 3.46-29.77, P <.001) locations were independently associated with this outcome. In a multivariate model, panurethral strictures (O.R. 4.23, 95%CI 1.10-16.20, P = .04) and hypospadias (O.R. 5.46, 95%CI 1.32-22.70, P = .02) were associated with patient perceived shortening while other factors such as age (P = .19), type of urethroplasty (P = .14) and other etiologies or locations were not.

CONCLUSION

Clinically significant changes in penile appearance are more common post-urethroplasty than generally thought. Stricture location and etiology are important predictors of these patient-perceived changes.

Assessing in-hospital morbidity after urethroplasty using the European Association of Urology Quality Criteria for standardized reporting

PURPOSE

To conduct a rigorous assessment of in-hospital morbidity after urethroplasty according with the European Association of Urology (EAU) guidelines for complication reporting.

METHODS

We retrospectively (2015-2019) identified 469 consecutive patients receiving urethroplasty (e.g. bulbar urethroplasty with grafts, penile urethroplasty with/without grafts/flaps, Johanson, de novo or revision perineostomy, end-to-end anastomosis, meatoplasty and/or meatotomy) at our tertiary care institution. Complications were graded with Clavien-Dindo score and Comprehensive Complication Index (CCI). Complications were classified in: bleeding no gastrointestinal, cardiac, gastrointestinal, genitourinary, infectious, neurological, oral, wound, miscellaneous, and pulmonary. Logistic regression tested for predictors of in-hospital complications and prolonged hospitalization (> 75th percentile). Kaplan-Meier and Cox regression investigated the effect of complications on failure after urethroplasty.

RESULTS

Overall, 161 (34.3%) patients experienced at least one complication. Of those, 47 (10%) experienced two or more complications and 59 (12.6%) experienced at least one Clavien-Dindo ≥ II complication. Only two patients had Clavien-Dindo III complications. Infectious was the most frequent complication, and de novo or revision perineostomy was associated with the highest rate of complications. The occurrence of any complications, as well as complication with Clavien-Dindo ≥ II were associated with prolonged hospitalizations, but not with higher rates of post-urethroplasty failure.

CONCLUSIONS

Complications after urethroplasty were common events, but rarely with severe sequelae. Infectious were the most common complications and perineostomy was the type of urethroplasty with the highest rate of complications. The application of the EAU recommendations allowed the identifications of a higher number of complications after urethroplasty if compared with previous reports based on unsupervised chart review.