Preputial reconstruction and tubularized incised plate urethroplasty in proximal hypospadias with ventral penile curvature

Long-term outcomes of foreskin reconstruction in distal hypospadias; a cohort study spanning twenty years

INTRODUCTION

Surgical correction of hypospadias aims to achieve normal functionality and appearance. This entails foreskin reconstruction (FR) in countries where the uncircumcised penis constitutes the norm. Long-term data are however scarce.

OBJECTIVE

To investigate the long-term outcome of FR in cohort of patients operated for distal hypospadias combined with approximately 20 years after surgery.

METHODS

The hospital management system was searched for patients operated for distal hypospadias in conjunction with FR between 1997 and 2004. Prospective participants were invited to participate in an online questionnaire. Signed consent allowed for extended medical chart review, with regards to hypospadias grade, surgical procedure and complications.

RESULTS

Response rate of 44.6 %. For 113 participants, median age at primary surgery was 5.2 (1.0-15.5) years. Two-thirds had a distal meatus while the remaining, meatus was mid to distal shaft. Urethroplasties performed were mainly glanular approximation procedures and meatal based flap procedures in 85 %. Foreskin fistula developed in 15 % of cases. There was no significant relationship between urethroplasty procedure or meatal position and risk of foreskin complications. Three layer closure of foreskin resulted in significantly less complications than two layer closure. Twenty years on 95 % of the men still had an intact foreskin, of whom 16.8 % had received treatment for phimosis. Foreskin was retractable in 92.5 % and 74.7 % in the flaccid and erect states respectively. Ninety intact men had had their sexual debut and in those 23.3 % reported foreskin related issues with intercourse. Evolution of foreskin retractability can be seen in the figure.

DISCUSSION

Current results show that three layer FR in conjunction with hypospadias surgery is feasible and that short-term complication rates were comparable with what has previously been published in the literature. Long-term results indicate that FR is durable with regards to anatomical reconstruction however foreskin function especially in relation to sexual function was compromised in about 25 %. Foreskin retractability after surgery predicted retractability in adulthood for the flaccid but not erect penis. Limitations of this study include the retrospective nature of data collection, and that the questionnaire used was not validated. We however achieved a decent response rate and were able to capture important long-term data.

CONCLUSIONS

FR has an acceptable complication rate. Long-term results two decades on are remarkably durable with regards to the anatomical preservation of the prepuce, however functionality was compromised with regards to retractability and sexual function in approximately 25 %.

Glans Anthropometry for Preputial Reconstruction in Hypospadias

Background

Cases of hypospadias present for poor stream or cosmetic appearance. The main aim is to provide a visibly normal phallus. Preputial reconstruction is technical. A properly planned reconstruction based on anthropometry may improve the result. We are presenting our experience of reconstruction based on glans anthropometry.

Aim

The aim of the study was to evaluate the importance of glans anthropometry in preputial reconstruction in cases of hypospadias.

Materials and Methods

All cases of hypospadias operated between June 2014 and March 2022 were included. Glans width was measured at the base. The marking sutures for preputial reconstruction were taken at distance thrice the glans width at base. Those requiring religious circumcision along with repair, associated significant chordee, catheter came out before 2 weeks, or history of any previous penile surgery were excluded. All the cases were subjected to urethroplasty, meatoplasty, and preputioplasty. The results obtained were analyzed.

Results

One hundred and forty-eight out of 159 cases formed the study group. There were 31 glanular, 42 distal penile, 58 mid-penile, and 17 proximal penile hypospadias. Mean glans width at base was 16 mm (range: 11-21 mm). Mean distance of marking suture at prepuce was 38 mm (range: 33-63 mm). Mean follow-up was 12 months (range: 1-36 months). Mean age at presentation was 23 months (range: 14-72 months). Mean operating time was 50 min (range: 45-60 min). Fistula at the base of preputioplasty was seen in four. Dehiscence of preputioplasty was seen in six. Meatal stenosis was seen in three cases.

Conclusion

Preputial reconstruction improves the cosmetic appearance of the hypospadiac penis. Reconstruction based on glans anthropometry improves the result and avoids complications.

A prospective study comparing modified foreskin reconstruction versus circumcision with tubularized incised plate urethroplasty for distal and mid penile hypospadias

BACKGROUND

In Asian countries and the Hispanic populations, parents of many hypospadias patient demands prepuce to be saved. Foreskin reconstruction is a technique for achieving the nearly natural appearance of hypospadias penis. In most distal and selected mid-penile hypospadias it may be performed. Numerous specialists, however, support circumcision for the concern that foreskin reconstruction may endanger the repair of urethroplasty leading to the risk of formation of fistulas.

AIM

To evaluate the surgical complications and outcome of modified foreskin reconstruction (MFR) versus circumcision with tubularized incised plate urethroplasty for distal and mid penile hypospadias.

METHODS

This prospective comparative study included 80 children with distal and mid penile hypospadias treated from 2017 to 2019 in tertiary referral hospital. Group 1, n = 40 underwent TIPU and MFR, and Group 2 included 40 patients for TIPU with circumcision.

RESULTS

In group 1, patients ranged from 2.2 to 6.5 years (mean 4.6 ± 1.52 years) and in group 2 ranged 2.6-7 years (mean 4.59 ± 1.43 years). Specific to group 1 preputial edema was seen in 29 patients at 2nd weeks, completely disappeared by 8^thweek. Retraction of prepuce was possible in 18 patients by 21 days and all but one by 6 months Foreskin wound gaping was seen in 1 at day 12 postoperatively and was repaired subsequently. Meatal stenosis was seen in one in both group, responded to urethral dilation by 6 weeks. Three patients from group 1 and 2 from group 2 developed urethral fistula which was subsequently closed. The complication rate was not statistically significant. Secondary phimosis was not seen in this study. A wide preputial opening was achieved during reconstruction in all patients in group 1.

DISCUSSION

One of the notable features, the absence of the prepuce, makes the patient conscious of the surgical procedure they had undergone. The specific complication of the preputial reconstruction is the presence of a non-retractile prepuce at the end of the surgery, secondary phimosis, preputial wound gaping, and dehiscence. In some patients, the distal portion of the prepuce becomes narrow, after vertical reconstruction. To prevent phimosis, the technique was improvised by taking transverse sutures in the distal part combined with midline approximation of the foreskin. This widens the preputial ring enabling smooth retraction of the reconstructed prepuce.

CONCLUSIONS

TIPU with MFR is an effective procedure for distal and selected mid penile hypospadias without increasing urethroplasty complications.

Preputial reconstruction in hypospadias repair

OBJECTIVE

In principle, the prepuce can be reconstructed during hypospadias repair, but the procedure has not gained wide acceptance and preputial reconstruction (PR) is surrounded by several controversies.

MATERIAL AND METHODS

A review is provided of the technique for PR, how PR combines with the other steps of hypospadias repair, the risks of complications related to the urethroplasty and specific to PR, and the results of PR with particular regard to the relevance for the patient and his family.

RESULTS

PR can be important for patients requiring hypospadias repair and their parents. It can be performed in almost all patients with distal hypospadias except perhaps those with the most asymmetrical prepuces or severe ventral skin deficiency. PR does not seem to increase urethroplasty complications, but combination of PR with tubularisation of the urethral plate urethroplasty seems to offer the best chance of success. Specific complications occur in around 8% of patients and include partial or complete dehiscence of the prepuce and secondary phimosis. To prevent the latter, the reconstructed prepuce should be easily retractile at the end of surgery. Technical modifications can help to achieve this goal. Cosmetically, reconstructed prepuces are not fully normal, but the abnormality could be less important for a patient and his parents that the complete absence of the prepuce.

CONCLUSION

On the basis of the evidence summarised above, an algorithm for PR in patients with distal hypospadias is proposed. PR can be offered to the vast majority of distal hypospadias patients, although some modification of the technique for hypospadias repair can be required. Retractility of the reconstructed prepuce at the end of surgery seems paramount for final success.

Does Preputial Reconstruction Increase Complication Rate of Hypospadias Repair? 20-Year Systematic Review and Meta-Analysis

INTRODUCTION

We performed a systematic review of the literature on preputial reconstruction (PR) during hypospadias repair to determine the cumulative risk of preputial skin complications and the influence of PR on urethroplasty complications, namely, fistula formation and overall reoperation rate of the repair.

MATERIALS AND METHODS

A systematic search of the literature published after 06/1995 was performed in 06/2015 using the keyword "hypospadias." Only studies on the outcome of PR in children, defined as dehiscence of the reconstructed prepuce or secondary phimosis needing circumcision, were selected. A meta-analysis of studies comparing PR vs. circumcision was performed for the outcomes "hypospadias fistula formation" and "reoperation rate."

RESULTS

Twenty studies were identified. Nineteen reported the outcome of PR in 2115 patients. Overall, 95% (2016/2115) of patients undergoing PR had distal hypospadias. The cumulative rate of PR complications was 7.7% (163/2115 patients), including 5.7% (121/2115 patients) preputial dehiscences and 1.5% (35/2117 reported patients) secondary phimoses needing circumcision. A meta-analysis of seven studies comparing patients undergoing PR vs. circumcision showed no increased risk of urethral fistula formation associated with PR, odds ratio (OR) (Mantel-Haenszel, Fixed effect, 95% CI), 1.25 (0.80-1.97). Likewise, two studies comparing the overall reoperation rate did not show an increased risk of reoperation associated with PR, OR (Mantel-Haenszel, Random effect, 95% CI), 1.27 (0.45-3.58).

CONCLUSION

PR carries an 8% risk of specific complications (dehiscence of reconstructed prepuce or secondary phimosis needing circumcision), but does not seem to increase the risk of urethroplasty complications, and the overall reoperation rate of hypospadias repair.

Comparative outcomes of the tubularized incised plate and transverse island flap onlay techniques for the repair of proximal hypospadias

PURPOSE

The optimal management of proximal hypospadias remains uncertain. In this study, the surgical outcomes of tubularized incised plate repair (TIP) and transverse island flap (TVIF) onlay urethroplasty in boys with hypospadias were compared.

METHODS

A total of 176 patients with proximal hypospadias underwent TIP (n = 83) or TVIF onlay repairs (n = 93) by a single surgeon and were evaluated retrospectively. No patient received a testosterone injection prior to surgery. A retrospective review of their medical records collected data regarding age at surgery, chordee, dorsal plication, hypospadias site, penoscrotal transposition, bifid scrotum, congenital hernia, undescended testis and any postoperative complications, including fistula, recurrent curvature, dehiscence, diverticulum, meatal stenosis and urethral stricture. The pediatric penile perception score (PPPS) was completed by parents to evaluate their perception of cosmetic outcomes.

RESULTS

There was no statistical difference in age or any of the anatomical and clinical features of hypospadias. The median follow-up duration was 22 months (range 12-48 months) and 25 months (14-51 months) for the TIP and TVIF onlay groups, respectively. The overall complication rate in the TVIF onlay group was 21.5% (20/93), which was higher than 18.1% (15/83) in the TIP group, but the difference was not statistically significant (P = 0.569). The most common complication was urethrocutaneous fistula, occurring in 9.6% (8/83) of the TIP group and 10.8% (10/93) of the TVIF onlay group. There were no significant differences in the rate of any complication and the overall PPPS between the two groups.

CONCLUSION

TIP and TVIF onlay are clinically equivalent for the repair of proximal hypospadias.

Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues

INTRODUCTION

The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair.

METHODS

We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002-2012) for relevant articles, using the terms 'proximal hypospadias', 'posterior hypospadias' 'single stage', 'multiple stage', and 'complications'. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate.

RESULTS AND CONCLUSIONS

The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.