The Bracka two-stage repair for severe proximal hypospadias: A single center experience

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.

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.

Efficacy of fibrin sealant as waterproof cover in improving outcome in hypospadias surgery

BACKGROUND

This prospective comparative study aims to assess the efficacy of fibrin sealant to improve outcomes in paediatric patients operated for hypospadias.

MATERIALS AND METHODS

Forty consecutive patients with hypospadias were randomised into two groups of twenty patients each. The first group underwent hypospadias repair, technique depending on the type of hypospadias, whereas in the second group, fibrin sealant was used to reinforce the urethroplasty. Assessment was done with respect to the type of hypospadias, type of repair done, operative time, immediate post-operative complications (early ooze and skin flap-related complications), intermediate complications (urethra-cutaneous fistula) and delayed post-operative complications (penile torsion and poor cosmetic outcome) at follow-up. We also compared the overall improvement in outcome among the two groups.

RESULTS

First Group: The mean operative time was 1 h and 45 min. Complications were seen in nine patients: Early ooze (n = 2); skin flap-related complications (n = 3); fistula (n = 7); poor cosmetic outcome (n = 7) and penile torsion (n = 4). Second Group (Fibrin Sealant): The mean operative time was 1 h and 30 min. Post-operative complications were observed in five patients: Coronal fistula (n = 3) and poor cosmetic outcome (n = 3). On comparing, the differences in outcomes of ooze, skin flap-related complications and torsion were found to be statistically significant with P < 0.05. The differences in the urethra-cutaneous fistula and cosmetic appearance were not found to be statistically significant. The difference in overall improvement in complications was found to be statistically significant.

CONCLUSION

Fibrin sealant, when applied over the urethroplasty suture line as a waterproof cover, may help to improve the outcome in patients with hypospadias.

Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade

BACKGROUND

Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade.

METHODS

A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes.

RESULTS

The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load.

CONCLUSIONS

Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.

Evaluation of tunica vaginalis free graft as a better alternative to tunica vaginalis pedicled flap for providing waterproof cover in Stage II hypospadias repair

BACKGROUND

Tunica vaginalis (TV) flap has been used by many surgeons as a waterproof layer to cover neourethra. We present our experience in using free TV graft as an alternative to TV flap for providing waterproof cover in second-stage hypospadias repair.

MATERIALS AND METHODS

A retrospective review of ten patients with severe hypospadias who underwent Stage II hypospadias repair over a period of 15 months was carried out. Free TV graft was used to cover neourethra in all the patients.

RESULTS

The median age of patients was 3.5 years. Six patients had proximal hypospadias with severe chordee and four patients had peno-scrotal hypospadias. Eight patients had undergone Byars procedure and two patients had undergone Bracka's procedure during the first stage repair in the same institute. The mean operative time for Stage II repair using free TV graft was 150 min (standard deviation ± 15 min). All patients passed urine in good stream following stent/feeding tube removal. The average duration of hospital stay was 11 days. None of our patients developed urethrocutaneous fistula. Only one patient had superficial surgical site infection. All patients are well on follow-up after 6 months.

CONCLUSION

Free TV graft could be used in place of TV flap as an intermediate waterproof cover to reduce the incidence of urethrocutaneous fistula in staged II hypospadias repair; however, studies involving a larger number of patients would be required to draw conclusions.

Comparison of Penile Appearance and Outcomes Between Prefabricated Urethra and Pre-implanted Urethral Plate for Treatment of Children With Severe Hypospadias: A Retrospective Study

Objective: To compare the effect of prefabricated urethra and pre-implanted urethral plate in the treatment of severe hypospadias in children. Methods: We retrospectively analyzed the clinical data of 53 patients who diagnosed as severe hypospadias underwent staging urethroplasty from January 2015 to January 2018 in the Department of Pediatric Surgery, First People's Hospital, Zunyi City. The patients were divided into two groups: group A (n = 25) were treated with prefabricated urethra and group B (n = 28) were treated with pre-implanted urethral plate. After the second stage surgery, the ratios of complications such as urethral fistula, urethral stenosis, urethrocele, and recurrence chordee were compared. The penis was scored from meatus, glans, shaft skin, general appearance by the parents, blinded urologists according to The Pediatric Penile Perception Score, and the scores were compared too. Results: All patients were followed up after two stage operations for an average of 28 months. Glans dehiscence occurred in two patients (8%), urethral orifice stenosis occurred in one (4%) and urethral fistula occurred in three (12%) in group A. No urethral stenosis, urethrocele and recurrence chordee was observed. One patient presented urethral plate inactivation (3.6%), two patients presented urethral fistula (7.1%) and one patient presented urethral stenosis (3.6%) in group B. No urethrocele, glans dehiscence and recurrence chordee was observed. The total complication rate in group A was 24 and 14.3% in group B, respectively, and the difference was not statistically significant (P = 0.582). The differences between two groups scored by parents in glans (P = 0.030) was statistically significant. The differences between two groups scored by operators in meatus (P = 0.041), shaft skin (P = 0.000), glans (P = 0.001), and general appearance (P = 0.007) were statistically significant. The differences between two groups scored by counterparts in meatus (P = 0.006), shaft skin (P = 0.003), glans (P = 0.010), and general appearance (P = 0.014) were statistically significant. Conclusion: Both prefabricated urethra and pre-implanted urethral plate methods are suitable for correction of severe hypospadias as staging surgery in children. In general, pre-implanted urethral plate is more worthy of spread because it is much more applied in patients with small glans and achieve good appearance of penis.

Staged repair of proximal hypospadias: Reporting outcome of staged tubularized autograft repair (STAG)

INTRODUCTION

Proximal hypospadias (PPH) repair is a challenge. Dilemma exists whether to do it in single or staged repair. Staged repair is our adopted procedure which was recently modified by Snodgrass into staged tubularized autograft repair (STAG), in which attention was given to ventral straightening of the penis together with some other technical details. Herein, we report our experience with STAG in a cohort of primary posterior hypospadias.

PATIENTS AND METHODS

In the period from 2011 to 2018 we operated 43 primary posterior hypospadias. Two principal surgeons (HB, MY) and multiple assistants operate children the same way, and data are recorded in a prospectively designed data base. In all children, inner prepuce graft was utilized, when curvature is more than 30 degrees, plate transection with or without ventral corporotomies were adopted.

RESULTS

Forty-three children with PPH and ventral curvature more than 30 degrees underwent first stage with median age 12 months (6-132 IQR16). Penile curvature was corrected by plate transection in 27 children (62.8%), ventral corporotomies in 16 children (37.2%). Graft take was successful in 90.7%, 4 children needed revision of fibrotic graft. Second stage was completed in 37 children, success was 56.8%, 21.6% fistula, 24.3% glanular dehiscence. Overall success after third surgery to correct complications was 78.4%. In a mean follow up of 3.2 years, we had recurrence of curvature in 2 children taking success rate to 72.9%. No meatal stenosis, no diverticulum, no stricture, no urethral dehiscence was encountered. Cosmetic appearance was excellent in follow up.

CONCLUSION

STAG achieves proper straightening of the penis and allows for reconstruction of a good urethra, yet urethrocutaneous fistula and glanular dehiscence remain the main complications. Follow up is important to address results of ventral corporotomies.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

Level IV case series with no comparison group.

Buck's fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome

BACKGROUND

Hypospadias is a common problem encountered in surgical practice and its repair is challenging because of various complications. Urethro-cutaneous fistula is the most common postoperative complication (incidence of 0-33%). Different types of intermediate protective layers have been used in attempts to decrease UCF formation; however, no single surgical technique is ideal.

OBJECTIVE

The aim of this study was to compare use of dartos fascia and Buck's fascia as intermediate layers in prevention of the formation of UCF.

STUDY DESIGN

This was a prospective, comparative study conducted over a period of 2 years from January 2014 to December 2015. Patients with primary hypospadias without or with mild ventral penile curvature were included in the study. Patients were categorised into two groups, A and B, with alternate patients assigned to each group. Patients in group A underwent Snodgrass repair with urethroplasty by two-layer subepithelial closure and dartos tissue as an intermediate layer. Patients in group B underwent a urethral repair followed by Buck's fascia repair as intermediate layer and glanuloplasty after excision of a triangular skin strip on either side of the urethral plate. Patients were followed at regular intervals for a minimum of 6 months and complications were noted.

RESULTS

Over a period of 2 years, 160 patients were included in the study: 80 patients in group A and 80 patients in group B. The age of patients ranged from 1 year to 4.6 years, with a mean age of 1.8 years. Postoperative complications are listed in the summary table.

DISCUSSION

A protective intermediate layer between the neourethra and the skin can be used to reduce fistula formation. We describe a technique of urethroplasty using Buck's fascia as intermediate layer and glanuloplasty, with excellent results. Buck's fascia over the corpora spongiosum which is deficient ventrally in hypospadias is not completely absent, and can be easily used to cover the neourethra, needs minimal dissection and hence vascularity of tissues is preserved (summary Fig.). We used this Buck's fascia as a second protective layer over the neourethra in an attempt to decrease UCF formation, and compared it with use of dartos fascia. In our study, UCF occurred in 2.5% of patients in the Buck's fascia group and 12.5% of patients in the dartos group, a statistically significant difference. We believe that the native Buck's fascia lateral to spongiosum is a more appropriate, natural, and strong layer to cover the neourethra.

CONCLUSION

Use of Buck's fascia as an intermediate layer along with glanuloplasty is simple and very effective in preventing UCF formation and glanular dehiscence. We recommend the use of Buck's fascia as an intermediate layer to cover the neourethra to reduce incidence of postoperative complications and improve results.

The Effect of Staged Transverse Preputial Island Flap Urethroplasty for Proximal Hypospadias with Severe Chordee

PURPOSE

We compare the effects of staged tranverse preputial island flap urethroplasty and the Byars 2-stage procedure in patients with proximal hypospadias and severe chordee.

MATERIALS AND METHODS

We studied 87 consecutive children referred for proximal hypospadias with severe chordee between March 2011 and March 2014. Of the cases 42 were repaired with staged tranverse preputial island flap (group 1) and 45 were managed by 2-stage Byars urethroplasty (group 2). Mean ± SD age at first stage surgery was 26.6 ± 13.3 months in group 1 and 24.8 ± 14.7 months in group 2. Postoperative complications in both groups were assessed regarding fistulas, urethral strictures, diverticula, meatal stenosis and glanular dehiscence.

RESULTS

After the second stage 2 patients (4.8%) in group 1 and 10 (23.2%) in group 2 had urethrocutaneous fistulas (p <0.05). One patient (2.4%) in group 1 and 2 patients (4.4%) in group 2 had urethral strictures (p >0.05). All patients with stricture were cured by repeated dilation and no patient required reoperation. One patient (2.4%) in group 1 and no patient in group 2 had diverticulum (p >0.05). No patient in either group had signs or symptoms of meatal stenosis or residual chordee. Three patients (7.1%) in group 1 and 12 (26.7%) in group 2 needed reoperation (p <0.05).

CONCLUSIONS

Two-stage urethroplasty, particularly tranverse preputial island flap partial urethroplasty, is appropriate for treating patients with proximal hypospadias and severe chordee. Use of the tranverse preputial island flap can decrease complications associated with the second stage and significantly improve the success rate.