Redo hypospadias surgery: current and novel techniques

Buccal versus skin graft for two-stage repair of complex hypospadias: an Egyptian center experience

Background

Urethral reconstruction in complex hypospadias poses a significant challenge. We report our 10-year experience with buccal mucosa graft (BMG) in the two-stage repair of complex hypospadias and compare its results to the skin graft.

Methods

We retrieved the data of 15 patients with complex hypospadias who underwent two-stage repair using the BMG at our institution. The data were compared to 13 patients who underwent skin graft during the same period.

Results

The median follow-up duration was 14 (12–17) months in the BMG group and 16 (13.5–22.5) months in the skin graft group. Patients in the BMG had a numerically lower incidence of the diverticulum, wound dehiscence, fistula, and infection than the skin graft group, however, without statistically significant difference (p > 0.05). On the other hand, the incidence of meatal stenosis and urethral stricture was significantly lower in the BMG group (0% each) compared to the skin graft group (30.8% each; p = 0.02). At the same time, there were no reported cases of graft contracture. The frequency of donor site morbidity was significantly higher in the skin graft group compared to the BMG group (p = 0.003). The BMG led to a lower incidence of postoperative straining than the skin graft (0% vs. 38.5%, p = 0.03). Only one patient needed revision surgery after skin graft, compared to no case in the BMG (p = 0.27).

Conclusion

The present study demonstrates the feasibility and durable outcomes of the BMG in the setting of two-stage repair of complex hypospadias.

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.

Novel use of Asopa technique for penile urethrocutaneous fistula repair

PURPOSE

To evaluate the feasibility of ventral urethrotomy, dorsal inlay (Asopa) technique in management of urethrocutaneous fistula. The Asopa technique has been employed for management of urethral stricture repair but has not been described in adult penile urethrocutaneous fistula.

METHODS

This is a retrospective review of IRB-approved databases of patients undergoing urethral reconstruction from two urologic reconstruction units. In this technique, the fistulous tract is circumscribed and excised, leaving a larger ventral urethral defect with healthy edges. The ventral-sagittal urethrotomy is extended, a dorsal urethrotomy made, and a graft inlaid dorsally to augment the urethral caliber prior to tension-free closure of the ventral urethrotomy.

RESULTS

From 2010 to 2019, ten patients underwent repair of urethrocutaneous fistula using the Asopa technique. Median patient age was 33.5 years (IQR 35.5). All fistulae involved penile urethra, eight had concomitant adjacent urethral stricture. Five patients failed prior hypospadias repair, three developed fistulae after surgery for penile urethral stricture, and two developed fistulae after extensive debridement (hidradenitis and Fournier's gangrene). Of these ten patients, oral mucosa graft was used in nine and preputial graft in one to augment the urethra. At median follow-up of 50.5 months (IQR 26.5), 80% (8/10) of patients demonstrated durably patent urethra, with no recurrence of fistula.

CONCLUSION

The Asopa technique is an established option for augmenting urethral caliber for urethral stricture disease. We demonstrate in our series that this technique can be applied to patients with urethrocutaneous fistulae.