Management of severe hypospadias

Urethral Mobilisation and Glanuloplasty Technique for Primary and Second-Stage Repair of Hypospadias: A Single Hospital Experience

Background Over the years, the technique used to correct hypospadias has undergone several modifications to improve outcomes and reduce complication rates. In this study, a modification has been made to the second stage of the two-stage repair of proximal hypospadias. This modification utilises urethral mobilisation and glanuloplasty, traditionally used to repair distal hypospadias, in the second stage of repair of proximal hypospadias. This study aims to assess the implications of this modification on the outcomes in addition to adding to the pre-existing literature on the outcomes of urethral mobilisation and glanuloplasty in the repair of distal hypospadias. Methodology A prospective study was conducted at Salmaniya Medical Complex in Bahrain between January 2016 and December 2021. All patients with either proximal or distal hypospadias who underwent a surgical repair using the urethral mobilisation and glanuloplasty technique were included. The following cases were excluded: patients with proximal hypospadias who did not undergo a first-stage repair, those with a hypoplastic urethra, and those aged 14 years or more. Results The mean operative time for the proximal hypospadias group was 78 minutes, while it was 62 minutes in the distal hypospadias group. Furthermore, the catheter remained in situ for a mean of three days postoperatively in the proximal hypospadias group. Overall, four of 35 patients (11.4%) experienced complications in the proximal hypospadias group. Of these, there were two (5.7%) cases of meatal stenosis, two (5.7%) cases of wound dehiscence, and no cases of diverticula or urethrocutaneous fistulas. Meanwhile, in the distal hypospadias group, one of 117 patients (0.9%) experienced a complication; the complication was meatal stenosis. there was a significant correlation between the age of patients and the complication rate (p = 0.06). The operative time was also found to be a significant factor influencing the occurrence of complications. The follow-up duration ranged between five months and 12 months. All patients had good cosmetic outcomes. Conclusions This study found that urethral mobilisation and glanuloplasty for the second-stage repair of proximal hypospadias resulted in lower complications than the traditional two-stage operation and a short duration of urinary catheterisation. There is a need to conduct studies with longer follow-up durations and objective measures of function to provide a better comparison between the different techniques used.

Safety and Effectiveness of Meatal Mobilization (MEMO) Technique for Glandular, Coronal, and Subcoronal Hypospadias Repair in Children: A 5-Year Single-Center Study with 105 Hypospadias

BACKGROUND

This study aims to compare outcomes of treatment, in terms of early and late complications, between the Snodgrass and meatal mobilization (MEMO) techniques in children operated on because of distal hypospadias.

METHODS

The medical records of 127 children who underwent glandular, coronal, or subcoronal hypospadias repair between 1 January 2019 and 31 December 2023 were retrospectively reviewed. A total of 105 children met the inclusion criteria and were included in further analysis. The inclusion criteria were pediatric patients who underwent glandular, coronal, or subcoronal hypospadias repair using MEMO (n = 49) or the Snodgrass technique (n = 56) as a comparative group. The primary outcome of this study was the incidence of early and late complications with two different surgical techniques. Secondary outcomes were the duration of surgery, the length of hospital stay, the number of readmissions or unplanned returns to the operating room, and repeat surgeries between groups.

RESULTS

The median age of all patients was 17 (interquartile range, IQR 13, 29) months, with a median follow-up of 26 (IQR 17, 34) months. Regarding the type of hypospadias, the majority of patients in both groups were categorized as coronal and subroronal hypospadias. Regarding the incidence of postoperative complications, a significantly lower incidence of postoperative complications was found in the MEMO group compared to the Snodgrass group (n = 4; 8.2% vs. n = 14; 25%; p = 0.037). An urethrocutaneous fistula was the most common complication in the Snodgrass group (n = 8; 14.3%), while in the MEMO group, only one patient (2%) developed a fistula (p = 0.034). The incidence of meatal stenosis (p = 0.621) and wound infections (p > 0.999) was low in both groups. No further complications were recorded during the follow-up period. Duration of surgery (41 min (IQR 38, 47) vs. 51 min (IQR 45.5, 61); p < 0.001), duration of hospitalization (1 day (IQR 1, 2) vs. 3 days (IQR 2, 6); p < 0.001), and time to catheter removal (3 days (IQR 2.5, 5) vs. 6 days (IQR 6, 8); p < 0.001) were significantly lower in patients operated on with MEMO compared to the Snodgrass technique. Only one case of readmission due to severe wound infection which led to suturing line dehiscence was recorded in the Snodgrass group. The incidence of redo surgery was significantly lower in the MEMO group than in the Snodgrass group (n = 3; 6.1% vs. n = 11; 19.6%; p = 0.048).

CONCLUSIONS

MEMO is a safe and effective technique that can be used for the treatment of distal hypospadias. It showed excellent outcomes, cosmetic results, and a low incidence of complications as well as a significantly shorter duration of surgery compared to the Snodgrass technique.

Evaluation of Double-Faced Tubularized Preputial Flap versus Duckett’s Procedure for Repair of Penoscrotal Hypospadias with Significant Penile Curvature: A Comparative Study

Background

Proximal hypospadias, with significant curvature, is one of the most challenging anomalies. Great diversity and a large number of procedures described over the last 4 decades confirmed the fact that no single procedure has been universally accepted or successful. So, the aim of this study is to evaluate double-faced tubularized preputial flap (DFPF) versus transverse tubularized inner preputial flap (Duckett's procedure) as regards surgical outcomes, complications rate, and cosmetic results for repair of penoscrotal hypospadias with chordee. Patients and Methods. This was a prospective comparative study on 144 children with primary penoscrotal hypospadias with moderate or severe chordee, conducted at New Damietta and Assuit hospitals, Al-Azhar University, from March 2016 to March 2022. The patients were randomly divided into two equal groups; group A (n = 72) underwent DFPF, and group B (n = 72) underwent Duckett's procedure.

Results

No significant difference was identified as regards demographic data. The follow-up period ranged from 20 to 66 months (mean of 28 months after DFPF and 31 months after Duckett's repair), and the complication rate was 20.1% (29 of 144 children). There were statistically significant differences between the two groups as regards the urethral stricture, penile rotation, and total complication rate. HOSE score was adopted for assessment of surgical outcomes, urine stream, and cosmetic results.

Conclusions

The DFPF technique is feasible and reliable for one-stage repair of penoscrotal hypospadias with chordee and can be considered as a good option as it ensures better surgical and cosmetic outcomes with lower incidence of complications.

The effect of staged TIP urethroplasty on proximal hypospadias with severe chordee

Background

Proximal hypospadias with severe chordee is still a formidable challenge for most pediatric urologists, and the treatment approach remains controversial. Here, we describe a modified two-stage technique to repair proximal hypospadias with severe chordee.

Methods

We retrospectively identified 53 children referred for proximal hypospadias with severe chordee from July 2016 to July 2019, who underwent a two-stage urethroplasty. In group 1, the children were repaired with staged tubularized incised plate (TIP) urethroplasty, while Byars’ two-stage urethroplasty was attempted in group 2. We corrected chordee by releasing all remaining attachments to the corpora after degloving the penis, transceting the urethral plate, and dorsal plication. The mean age of patients in the first stage of surgery was 26.6 months in group 1 and 24.8 months in group 2. Postoperative complications in the two groups included: fistula, urethral stricture, urethral diverticulum, and glanular dehiscence.

Results

A total of 20 cases were repaired with staged TIP urethroplasty (group 1), and 33 cases were repaired with Byars’ two-stage urethroplasty (group 2). The length of follow-up in group 1 was 39.8 ± 10.1 months, and in group 2, it was 38.1 ± 8.7 months (P > 0.05). After the second stage of surgery, 1 case (5%) in group 1 and 11 cases (33.3%) in group 2 developed a urinary fistula (P < 0.05). One case (5%) in group 1 and three cases (9.1%) in group 2 had urethral stricture (P > 0.05). All strictures were cured by repeated dilation, and no patient required reoperation. No cases in group 1 and one case (3%) in group 2 had urethral diverticulum (P > 0.05). There was no residual chordee in both groups. Two cases (10%) in group 1 and 13 cases (39.3%) in group 2 required reoperation (P < 0.05).

Conclusions

Staged urethroplasty is appropriate to repair proximal hypospadias with severe chordee. Particularly, staged TIP urethroplasty is a good choice for patients with proximal hypospadias and severe chordee, especially those with better penile development, wider urethral plate, larger glans, and deeper navicular fossa of the urethra.

Looking beyond the dartos fascia and tunica vaginalis: reviewing the stance of common adjuvant covering biomaterials in hypospadiology

Hypospadias, one of the commonest congenital anomalies in boys, can have a spectrum of clinical presentation based on the location of the meatus and the presence of chordee. The surgical repair of hypospadias involves great precision, especially in proximal varieties and redo/complex cases of hypospadias. Hypospadiologists have put in tremendous efforts to improve the outcomes of these children. The utilization of adjuvant biomaterials is one such effort that has gained significant attention over the recent years. Biomaterials are used to cover the urethral suture line in instances where the ideal covering agents (dartos fascia and tunica vaginalis) are unavailable. We reviewed the mechanism of action, current stance, and advantages/disadvantages of three commonly used adjuvant agents, i.e. autologous platelet concentrates, tissue glues, and acellular dermal matrixes. Although individual studies have highlighted the therapeutic benefits of these adjuvants, the available literature has a limited level of evidence. Moreover, it is believed that the application procedure of these covering agents needs to be scrutinized in future studies. In addition, it is suggested that the application of any covering agent right up to the meatus is non-anatomical and redundant. Well-designed randomized controlled trials with a uniform application procedure and comparing different covering agents need to be conducted in the future before any definite conclusion is drawn.

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.

Parental decisional regret after surgical treatment in young boys born with hypospadias

BACKGROUND/PURPOSE

Parental decisional conflict and decisional regret are aspects in parental adjustment to childhood elective surgery. This study assessed correlates of parental decisional regret in parents of young boys treated for hypospadias.

METHODS

Parents of 261 boys treated for hypospadias at the Radboudumc between 2006 and 2014 were approached to complete questionnaires on socio-demographics, clinical details, postoperative outcomes, decisional conflict and decisional regret.

RESULTS

Of the 97 participating parents, 50.5% reported some form of decisional regret, in 11.3% this was moderate to strong. Decisional conflict (β = .68, p < .001) and psychosocial behavior problems of the child (β = .20, p < .05) significantly predicted decisional regret. Demographic and medical variables did not correlate with parental decisional regret.

CONCLUSIONS

A substantial number of parents report some form of decisional regret regarding the elective surgery for hypospadias in their child. Although most parents only show mild forms of regret, in the perspective of discussions on this surgery in early childhood, future research could shed more light on the interrelationship between medical and psychosocial factors in the process of decision-making around surgery, in boys with hypospadias and their parents.

Comparison of Dartos flap and spongioplasty in Snodgrass urethroplasty in distal penile hypospadias

Background

Hypospadias surgery has been continuously evolving, although there is no single technique which can be said to be perfect and suitable for all types of hypospadias. Tubularized incised plate (TIP) urethroplasty (Snodgrass procedure) is presently the most common surgical procedure performed for distal penile hypospadias (DPH). The aim of this study was to compare the outcome of TIP urethroplasty using Dartos flap (DF) and spongioplasty as second layer in DPH.

Methods

A total of 30 patients of DPH were repaired using TIP urethroplasty with DF or spongioplasty as second layer from January 2017 to June 2018. Out of 30 patients, TIP with DF was done in 15 patients (group A) and TIP with spongioplasty was done in the remaining 15 patients (group B). Preoperative mean age and weight were comparable in both groups. Postoperative complications, namely, postoperative edema, residual chordee, urethrocutaneous fistula (UCF), meatal stenosis and final cosmesis, were recorded.

Results

In both groups, complications included postoperative edema (Gp A-1Gp B-1), residual chordee (Gp A-1, Gp B-1), UCF (Gp A-3, Gp B-4), meatal stenosis (Gp A-1, Gp B-5) and poor cosmesis (Gp A-3, Gp B-4). Wound infection was managed with appropriate antibiotics, and meatal stenosis responded to calibration in five patients.Although it seems that DF has a better outcome clinically, the difference between the two techniques was statistically not significant.

Conclusion

DF as an additional cover to TIP is associated with an acceptable complication and has good cosmesis compared with spongioplasty; however, the difference is not statistically significant.

Dorsal midline incision: A versatile technique for correction of meatal stenosis during hypospadias repair

Objectives:

To our knowledge, the incidence of congenital meatal abnormalities associated with hypospadias varies from 9.6% to 31%, of which meatal stenosis is the most common, affecting 9.1–16.7% of patients. Traditionally, meatal stenosis has been dealt with by meatal dilatation, although ventral meatotomy until the normal urethra is encountered has also been used. Here, we report the outcome of a technique where, during hypospadias repair, a dorsal midline incision was performed instead of a ventral urethral incision, starting at the narrow meatus and subsequently extending proximally to treat the meatal stenosis.

Methods:

Patients having distal hypospadias with meatal stenosis were included in this study. In this technique, a dorsal midline incision was extended until normal calibre urethra was encountered. Patients with chordee >15°, proximal hypospadias, redo cases, glans width <14 mm, where separation of the skin from the underlying urethra was not possible and with a follow-up of less than three months were excluded from the study. A total of 73 patients were operated on using this technique. Results were assessed with regards to urethrocutaneous fistula (UCF) and stricture formation.

Results:

Five (6.85%) patients developed UCF: one (5%) in the subcoronal group, two (8.0%) in the distal penile group and two (14.3%) in the mid-penile hypospadias group. Postoperatively, only one patient had meatal stenosis.

Conclusion:

We think hypospadiac meatal stenosis is best treated by a dorsal midline incision, as it does not lead to a proximal shift of the meatus, and this defect heals by re-epithelisation without significant scarring, which in turn decreases the possibility of UCF. That is why the fistula rate in our study was 6.85%, which is lower than in various published series.

Two simple modifications can potentially change the future of proximal hypospadias surgery. Our series and a review of the literature

Background/Objective

To draw a hint towards two simple modifications that could potentially decrease the complication rate.

Patients and Methods

It was a single center, single operator and retrospective study. All patients with severe hypospadias operated according to koyanagi with or without modifications were presented. The surgical technique was described. Complications like fistula, stenosis, dehiscence and urethral diverticulum were studied.

Results and Limitations

Nineteen patients were included and presented in a chronological manner. The first four patients were operated according to the original koyanagi technique. The next 15 patients were operated according to koyanagi and the urethroplasty was covered by a tunica vaginalis flap. In 10 of them, glanduloplasty was done primarily and in the last 5 patients, glanduloplasty was done as a secondary procedure. The complication rates were 100% in the original koyanagi group, and 0% in the subset were glanduoplasty was deferred.

Conclusions

Systematically covering the urethroplasty with a tunica vaginalis flap and deferring the glanuloplasty might ameliorate the results of the koyanagi technique.

Fixation of the glans penis and urethral catheter to the abdominal skin to avoid wound dehiscence after a hypospadias surgery: A comparative study

OBJECTIVE

To evaluate the effect of glanular and urethral catheter fixation to the abdominal skin on wound dehiscence.

MATERIAL AND METHODS

After a standard tubularized incised plate urethroplasty (TIPU) for hypospadias repair, 128 patients were divided into two groups based on glanular and urethral catheter fixation to the abdominal skin as follows: no glanular and urethral catheter fixation (Group A) and glanular and urethral catheter fixation (Group B). Groups A and B included 61 and 67 patients, respectively.

RESULTS

No significant difference was determined between the groups with respect to age, meatal localization, and length of hospital stay. Wound dehiscence was noted in 13.1% and 2.9% patients in Groups A and B, respectively, after surgery (p=0.029, odds ratio=4.9). Patients in Group B had no excessive analgesic usage and unpleasant scarring due to the glans suture.

CONCLUSION

Glanular and urethral catheter fixation to the lower abdominal skin considerably reduced wound dehiscence after hypospadias repair.

Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience

It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20-60 months) and 35 months (18-60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.

Does androgen stimulation prior to hypospadias surgery increase the rate of healing complications? - A preliminary report

OBJECTIVE

Androgens have a positive effect on penile growth in children, but they may also have a repressive effect on the healing process. The aim of this prospective study was to compare the outcomes of onlay urethroplasty with and without preoperative androgen stimulation in patients with severe hypospadias.

PATIENTS AND METHOD

Of 300 severe hypospadias cases treated at a single institution, 126 operated on by the same surgeon had complete follow-up data, and 30 of these received preoperative androgen treatment (human chorionic gonadotrophin and/or systemic testosterone) 1-24 months before surgery.

RESULTS

Thirty-five patients presented with a complication (27.7%) of whom 26 (20.6%) had a fistula or dehiscence. Among patients on androgen stimulation there was a 30% healing complication rate (9/30) whereas for those without this was 17.7% (17/96). When androgenic treatment was given > 3 months prior to surgery the healing complication rate was 21.7% (5/23), and when < 3 months prior to surgery the rate reached 57% (4/7). Mean follow up was 41 months (10-97).

CONCLUSION

Although the numbers were too small in this series to reach statistical significance, the tissular interactions of androgens in the healing process reported by dermatologists should alert the hypospadiologists and lead to a further prospective study to define the optimal protocol for stimulation of the penis in specific cases without affecting outcome.

Long-term psychosocial adjustments, satisfaction related to gender and the family equations in disorders of sexual differentiation with male sex assignment

PURPOSE

The varied management and counseling in disorders of sexual differentiation (DSD) depends a lot on the socioeconomic structure. A follow-up study was designed to evaluate the outcome in terms of patient satisfaction with strong socio-cultural issues.

METHOD

Of the 1,134 DSD patients being followed up in pediatric intersex clinic, 60 adolescents and adults assigned male sex in childhood were called for follow-up. They were interviewed for psychosocial and family adjustments including level of acceptance of gender, social relationships and future expectations.

RESULTS

The ages ranged from 15 to 25 years (mean, 19.3 ± 3.7 years). The disorders were male pseudo hermaphrodite (MPH)-43, mixed gonadal dysgenesis (MGD)-3, true hermaphrodite (TH)-7 and congenital adrenal hyperplasia (CAH)-7. Of all patients, 85% (51/60) felt satisfied with their gender assignment; 76.9% (46/60) did not feel comfortable with the opposite sex. Penile erections; ejaculation and masculine voice were present in 53, 44 and 47 patients. Facial hair was normal; sparse and absent in 16, 26 and 18 patients, respectively. Stretched penile length was 2.5-9 cm (median, 5.5 cm) and 16/60 patients were satisfied with their penile length; 28 patients required redo surgeries for scrotum diverticulum (1), proximal penile diverticulum (1), stricture urethra (2), hair in the urethra (3), vaginal pouch dilatation (1), orchiopexy (2), residual chordee correction (3), distal urethroplasty (4), urethral fistula repair (21), mastectomy (6) and testicular prosthesis (4). Family support was available to all 85% (51/60) of the patients who had good family relationships. However, only 15% (9/60) felt that they fitted into society. Peer relationships were considered 'good' by 43/60 and poor by 17/60. Two patients had got married and 44.8% (26/58) patients would consider marriage in future. Most patients (42/60) were worried about the smaller size of the phallus and lack of adequate semen, leading to apprehension before marriage. As much as 15 patients had jobs, 15 attended school, 3 attended colleges and 17 illiterate patients were dependent on their families.

CONCLUSIONS

Despite moral, social and economic support provided by the parents, children with DSD continue to have apprehensions in social adjustments.

Surgical options in disorders of sex development (dsd) with ambiguous genitalia

Disorders of sexual development (DSD) include three main groups of patients: (1) The virilised 46,XX DSD essentially represented by congenital adrenal hyperplasia (CAH) ; (2) The undervirilised 46,XY DSD essentially represented by hypospadias; and (3) the chromosomic jigsaws essentially represented by mixed gonadal dysgenesis. It is in this last group that gender assignment remains a difficult decision involving various indicators, which can be split into four categories: (1) the inside sex (i.e., genes, hormones and target tissues); (2) the outside sex (i.e., anatomy of genitalia including size of the genital tubercle, mullerian cavity and potential adult height of the patient); (3) the functional sex (i.e., potential sexuality and fertility); and (4) and the social sex (i.e., the cultural medium in which the child is brought up). The challenge is to outline the future individual identity of the child in the postnatal period using these indicators. Current evolutions of surgical techniques of 'feminisation' and 'masculinisation' are described as well as their outcomes.

Original Koyanagi urethroplasty versus modified Hayashi technique: outcome in 57 patients

OBJECTIVE

To compare outcomes of the original Koyanagi technique with the Hayashi modification in severe hypospadias, i.e. hypospadias with a division of the corpus spongiosum located behind the penile midshaft associated with marked hypoplasia of the ventral aspect of the penis and a non-preservable urethral plate. Choice of technique for treating severe hypospadias is discussed.

PATIENTS AND METHODS

Twenty-six patients (group I) were operated in Lyon using the original Koyanagi procedure and 31 (group II) underwent a modified Hayashi procedure in Paris. Most patients received preoperative androgenic stimulation. Mean follow up was 25 months (group I) and 34 months (group II).

RESULTS

Sixteen patients (61.5%) in group I and 19 (61.3%) in group II developed complications leading to 21 additional procedures in each group. Urethral dehiscence was found in 11/26 patients in group I (42.3%), and in 6/31 patients in group II (19.3%); fistulae were respectively found in 5/26 (19.2%) and 12/31 (38.7%), and stenosis in 9/26 (34.6%) and 5/31 (16.1%) patients. Urethrocele was found in 7/26 (26.9%) and 5/31 (16%) patients, respectively. Twelve (group I) and 7 (group II) patients are awaiting re-operation.

CONCLUSION

Although the complication rate is quite similar between the original and the modified Koyanagi procedure, the Hayashi technique seems to provide a better distal blood supply to the reconstructed urethra.