Role of uroflowmetry before and after hypospadias repair

Advantages of Urethroplasty Terminating at the Corona for Severe Hypospadias: Complications, Uroflowmetry, and Esthetics

PURPOSE

Mid-shaft/proximal (msp) and penoscrotal/scrotal/perineal (pssp) hypospadias treated by urethroplasty (UP) terminating at the corona (UPC) or UP terminating at the tip of the glans (UPG) were compared.

METHODS

UP performed at a single institute (n = 234) between 2003 and 2020 were grouped as: msp-UPC (n = 23), msp-UPG (n = 75), pssp-UPC (n = 81), and pssp-UPG (n = 55) to compare data obtained from medical records for post-UP complications (PUC; urethral stenosis, urethrocutaneous fistula, diverticulum formation, and bleeding; n = 234), post-UP uroflowmetry (PUF; average flow rate (Qave), maximum flow rate (Qmax), voiding time (VT), voided volume (VV) and urine flow curves) in 57 UP patients [msp-UPC (n = 5), msp-UPG (n = 12), pssp-UPC (n = 32), pssp-UPG (n = 8)] and 9 controls, and post-UPC esthetics (EST; n = 104). P < 0.05 was considered significant.

RESULTS

Mean ages at UP (years) were: msp-UPC (3.1 ± 3.0), msp-UPG (3.3 ± 1.4), pssp-UPC (4.6 ± 2.4), and pssp-UPG (3.4 ± 1.4); p < 0.0001 by ANOVA test. Overall, there were significantly more PUC in pssp-UPG compared with pssp-UPC except for bleeding. Ages at PUF assessment were similar. Mean Qave (mL/s) for pssp-UPG (4.0 ± 1.0) was significantly less than pssp-UPC (5.9 ± 2.5; p < 0.05) and both were significantly less than controls (6.9 ± 1.8; p < 0.05, p < 0.01, respectively). Mean Qmax (mL/s) for pssp-UPC (11.4 ± 4.8) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.05) and for controls (14.9 ± 4.4) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.01). All VT (seconds) were similar to controls; all urine flow curves were normal. For EST in UPC (n = 104), 3 cases requested meatal advancement.

CONCLUSIONS

UPC may be a valid option for treating pssp hypospadias because of significant differences in PUC/PUF and minimal EST issues compared with UPG.

LEVEL OF EVIDENCE

Prognosis Study Level-Ⅱ.

The long-term consequences of the hypospadias salvage repair issue

PURPOSE

To present the long-term results of redo-hypospadias at our tertiary referral center following a failed prior repair.

METHODS

One hundred sixty-four individuals with a history of unsuccessful repairs qualified for our retrospective cohort study. Our inclusion criteria were as follows: pre-operative data that was accessible, redo-hypospadias that was successfully repaired, and at least three years of follow-up at the last hospital visit.

RESULTS

The mean patient age was 91.3 ± 21.1 months. The mean follow-up after successful repair was 41.3 ± 3.1 months. Ninety-two (group A) had one prior repair, and 72 (group B) had 2 or 3 repairs. Group A underwent six primary techniques: 32 underwent Onlay Island Flap (OIF), 10 underwent Mathieu, 12 underwent Tubularized Incised Plate Urethroplasty (TIPU), 8 underwent Urethral Mobilization (UM), and 34 underwent Buccal Mucosal Graft (BMG) { dorsal inlay Graft Urethroplasty (DIGU) in 4 and staged BMG in 30 patients}. In group B, four procedures were used: TIPU in 4, UM in 6, and BMG in 62 (staged BMG in 50 cases and DIGU in 12).

CONCLUSIONS

The selected type of repair will depend on many factors, like residual healthy local skin and expertise. Safe techniques for repair of redo hypospadias after its 1st failure include TIPU, Mathieu, UM, OIF, and DIGU for distal varieties. After 2nd or 3rd repair DIGU, UM, and TIPU can be performed in distal types, while staged BMG can be applied for proximal ones.

Rathod KK, Jadhav AS, Saxena R. Pattern of Preoperative Uroflowmetry in Hypospadias Patients and Age-matched Control Patients

Aim

Patients with hypospadias often present with voiding difficulties after successful repairs. We sought to analyze the degree of uroflowmetric anomalies that may be present in children with hypospadias before a surgical repair. We, thus, undertook this study to compare the pattern of preoperative uroflowmetry study in hypospadias patients and a comparable age-matched control group.

Materials and Methods

A total of 90 children underwent preoperative uroflowmetry in the Department of Pediatric Surgery at All India Institute of Medical Sciences (AIIMS), Jodhpur, India, between January 2019 and December 2020. Thirty patients with hypospadias and sixty age-matched controls who presented to the outpatient department without any associated urological or neurological anomalies were included in the study. Uroflowmetry parameters such as maximum urine flow rate (Qmax), average urine flow rate (Qavg), voided volume (VV), urination duration, duration of reaching maximum speed, and urine flow curves of the cases and the control group were measured and compared.

Results

The median age of patients at the time of uroflowmetry in the hypospadias group was 7 years, while the same for the control group was 7.5 years. Median maximum urinary flow rates (Qmax) (10.7 vs. 14.45 mL/s, P = 0.01278), average urinary flow rates (Qavg) (6.5 vs. 8.5 mL/s, P = 0.0124), the ratio of maximum urinary flow rates with VV (Qmax/VV) (0.043 vs. 0.053, P = 0.0264) was found to be significant (P < 0.05). These values were significantly lower in the hypospadias group (P < 0.05). The voiding time (43.5 vs. 30 s, P = 0.0285) was significantly higher in the hypospadias group. However, there was no difference in the VV per micturition (219.5 vs. 270.0 mL, P = 0.40) and time to maximum flow rate (10 vs. 10, P = 0.43). Flow curve pattern analysis revealed plateau-shaped curves in 60% of the hypospadias group compared to 27% in the control group, while bell-shaped curve was seen in 37% of the hypospadias group as compared to 65% in the control group which were statistically significant (P = 0.003415). No statistically significant association was found between meatal localization and the uroflowmetry parameters.

Conclusion

Children with hypospadias have abnormal uroflowmetry even before surgical correction and have a significantly low maximum urine flow rate. These uroflow anomalies may be due to meatal stenosis or hypoplastic proximal urethra. We postulate that these preoperative abnormal uroflow patterns in patients with hypospadias may contribute to voiding difficulties in repaired hypospadias cases. A greater understanding of the factors behind these uroflowmetric anomalies may allow surgeons to proactively tackle these intraoperatively, leading to better outcomes for patients with hypospadias.

Comparison of clinical effects between microscopic surgery and conventional surgery in children with penile hypospadias and difference analysis of postoperative urodynamics

Objective

To compare and analyze the clinical effects of microscopic surgery and conventional surgery in children with penile hypospadias and the differences in postoperative urodynamic indexes.

Methods

It was a clinical comparative study. A total of 80 children with penile hypospadias admitted to Beijing Children's Hospital Affiliated to Capital Medical University Baoding Hospital from July 2018 to September 2022 were selected and randomly divided into two group. The experimental group were treated with microscopic urethroplasty, while the control group were treated with traditional urethroplasty. The operative effect, operation time, total intraoperative blood loss, postoperative hospital stay and incidence of surgical complications were compared and analyzed between the two groups. All the children were followed up for two years, and the changes in urodynamic parameters including maximum urine flow rate (Qmax), average urine flow rate (Qavc), urine flow time (FT), peak time (TQmax) and residual urine (PVR) were compared before, two weeks after, six months after and two years after surgery.

Results

The efficacy of the experimental group was significantly higher than that of the control group (p=0.013). The intraoperative blood loss and postoperative hospital stay in the experimental group were significantly better than those in the control group (p=0.000). The incidences of urinary leakage and urethral stricture in the experimental group were lower than those in the control group (p<0.05). The Qmax level in the experimental group was higher than that in the control group at six months and two years after surgery, while the FT level was lower than that of the control group (p<0.05).

Conclusion

Microscopic surgery is a method with significant clinical value in the treatment of penile hypospadias.

The Effect of the Duckett procedure on the Outcome and Prognosis of Children with Suburethral Cleft

Background

Hypospadias is one of the most common malformations of the male genitourinary system. In recent years, the incidence of hypospadias is increasing year by year, which seriously affects normal urination and sexual function. Repairing hypospadias has always been a challenge in paediatric urology, requiring a variety of surgical techniques and science and art that requires intensive study. Despite the availability of over 300 surgical procedures and continuous improvement, there is still a high level of surgical complications. It is crucial to choose an appropriate and effective surgical method for the treatment of hypospadias.

Aims

This study aimed to investigate the outcome and prognosis of children with hypospadias, using transverse cut foreskin island flap coiled urethroplasty (the Duckett procedure).

Materials and Methods

A retrospective study was conducted on 100 children with hypospadias who underwent surgery in our hospital from December 2018 to December 2021. Based on the degree of hypospadias and the degree of penile curvature both in line with the Duckett procedure, the comparison group was treated with a one-stage Duckett procedure and the treatment group was treated with a staged Duckett procedure. The differences in the surgical condition, inflammatory factor levels, and complications between the two groups of children were observed and compared.

Results

The length of hospital stay and VAS score in the treatment group were significantly lower than those in the control group, and the operation time and intraoperative bleeding were higher than those in the control group, with a statistical significance (P < 0.05). The success rate of one operation was higher than that of the comparison group, but the statistical comparison was not statistically significant (P > 0.05). There was no statistically significant difference in the inflammatory response between the two groups before surgery (P > 0.05), while the difference in CRP, IL-6, and calcitoninogen between the two groups after surgery was significant and lower in the comparison group than in the treatment group, which was statistically significant (P < 0.05). The clinical outcome of the children in both groups showed that the excellent rate of 92.00% in the treatment group was significantly higher than that of 74.00% in the comparison group, while the incidence of complications was significantly lower than that of the comparison group, and the difference was statistically significant (P < 0.05). Complications in children with poor surgical outcomes in both groups occurred mainly, early urethral stricture and cured by urethral dilatation or condition without improvement cured by urethrotomy.

Conclusion

A comparative study of hypospadias treated with the staged Duckett procedure was more effective in relieving postoperative pain and inflammatory reactions in children, reducing postoperative complications and improving healing efficiency, providing some reference value for hypospadias surgery.

Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results

INTRODUCTION

Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need for a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-years pilot study on stented/un-stented distal urethroplasties.

MATERIALS AND METHODS

A total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by the same pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5). Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge. The median follow-up was 6.4 years (range 1.5-8.1). All patients received at least one post-operative clinical-cosmetic examination (HOSE). The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P < 0.05) for statistical analysis.

RESULTS

Of 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P = 1.000).

CONCLUSION

Long-term follow-up is mandatory to know redo-urethroplasty rate and cosmetic outcome after distal stented/un-stented repair. Further studies are needed to evaluate the role of catheter placement and the definitive outcome in distal urethroplasty.

Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results

INTRODUCTION

Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need of a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-year pilot study on stented/un-stented distal urethroplasties.

MATERIALS AND METHODS

A total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by one pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5). Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge. The median follow-up was 6.4 years (range 1.5-8.1). All patients received at least one post-operative clinical-cosmetic examination (HOSE). The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P<0.05) for statistical analysis.

RESULTS

Of 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P=1.000).

CONCLUSION

Long-term follow-up is mandatory to know redo-urethroplasty rate and cosmetic outcome after distal stented/un-stented repair. Further studies are needed to evaluate the role of catheter placement and the definitive outcome in distal urethroplasty.

Outcome of Buck’s fascia repair with wingless glanuloplasty in distal penile hypospadias

Background

Hypospadias surgery is technically demanding and is often encountered with complications like fistula and glanular dehiscence. To prevent these complications we have instituted Buck’s fascia repair (BFR) with wingless glanuloplasty (WLP) in the cases of distal penile hypospadias (DPH) deemed to be suitable for TIP repair. The aim of this prospective study was to assess the outcome of Buck’s fascia repair (BFR) with minimal wingless glanuloplasty (WGP).

Methods

This prospective study included 50 patients with coronal, subcoronal and midpenile hypospadias who received a tubularization of incised plate (TIP) repair. The exclusion criteria were glanular hypospadias, Thiersch Duplay repair, proximal penile hypospadias, previous penile surgeries, uncorrectable chordee, glans size < 14 mm, flat glanular groove and preoperative testosterone therapy.

Results

Over a period of 3 years, 50 patients with mean age of 3.5 ± 0.8 years were recruited for the study. Meatal position was coronal, subcoronal and midpenile in 6, 24 and 20 patients, respectively. Fistula occurred in one patient (2%) and meatal stenosis in one. Straining on micturition was noted in two patients that needed dilatation in postoperative period. None of the patients had glanular dehiscence. Surgeon acceptability of the procedure was good. Cosmetic results were also fair.

Conclusion

Buck’s fascia repair with Wingless glanuloplasty is a good repair for the distal penile hypospadias. It is effective and is associated with low fistula rates and glanular dehiscence. It is technically simple procedure involving minimal dissection. However, caution should be observed in midpenile hypospadias to avoid tight repair in subcoronal region.

Validity and reliability of a home-based, guardian-conducted video voiding test for voiding evaluation after hypospadias surgery

Purpose

To investigate the validity and reliability of a home-based, guardian-conducted video voiding test for assessing postoperative voiding function after hypospadias surgery.

Materials and Methods

In a single center, patients who had undergone urethroplasty by a single surgeon and postoperative uroflowmetry and video voiding tests conducted between 2008 and 2016 were retrospectively reviewed. Urinary stream was categorized into five grades by three pediatric urologists in a blinded manner. The primary outcome was statistical correlation across raters as measured by Spearman correlation coefficient to validate the interpretation of the video voiding test. The secondary outcome was the reliability of the voiding video test compared with maximum urinary flow rate assessed by uroflowmetry.

Results

Thirty-one patients with hypospadias were enrolled. The patients' average ages were 12.3±3.2 months (range, 8–21 months) and 42.8±3.9 months (range, 35–48 months) at the time of surgery and voiding video tests, respectively. Hypospadias was anterior, penile, and proximal in 1 (3.2%), 18 (58.1%), and 12 (38.7%) patients, respectively. The number of patients with each voiding stream grade was as follows: very poor, 4; poor, 4; fair, 13; good, 4; and very good, 6. All intraclass correlation coefficients of the stream grade among the three observers were >0.95. Correlation between the maximum flow rate obtained by use of conventional uroflowmetry and the video voiding stream grade was validated (rho 0.778, p<0.001).

Conclusions

The home-based guardian-conducted video voiding test is easy to perform and the present results demonstrate its validity and reliability for assessing patients' post-urethroplasty voiding pattern.

Comparing the outcomes of tubularized incised plate urethroplasty and dorsal inlay graft urethroplasty in children with hypospadias: a systematic review and meta-analysis

BACKGROUND

Excellent outcomes have been reported following the widely accepted tubularized incised plate urethroplasty (TIPU) and its relatively recent modification, the dorsal inlay graft urethroplasty (DIGU). However, there is a lack of consensus on which technique offers more favorable postoperative outcomes.

AIMS

To systematically compare the reported outcomes of the TIPU and DIGU techniques in children undergoing primary hypospadias repair.

DESIGN

A systematic review and meta-analysis of randomized and observational studies.

METHODS

An electronic database search was conducted up to May 2018. Sources included Medline, Embase, Cochrane library, CINAHL, Web of Science, and Google Scholar as well as trial registries and grey literature sources. Studies were selected if they compared the postoperative complications of TIPU and DIGU in children. Secondary outcomes included standardized cosmetic scores and urinary flow studies. A meta-analysis of reported complications was performed using a random-effects model.

RESULTS

Two randomized, two prospective, and two retrospective studies met the inclusion criteria. TIPU and DIGU were performed in 350 and 267 patients, respectively. Pooled analysis did not demonstrate a significant difference regarding postoperative urethrocutaneous fistula, meatal/urethral stenosis, wound dehiscence, or total complications. Subgroup analysis according to hypospadias severity did not alter initial findings. Statistical analysis of secondary outcomes was not feasible due to insufficient data. Most studies were of low methodological quality with a high risk of bias.

CONCLUSIONS

There is no strong evidence to suggest that either technique offers more favorable outcomes. Until more robust randomized trials exist, decisions regarding the appropriate repair should be based on the surgeon's experience and outcomes.

Can Grafted Tubularized Incised Plate Urethroplasty be Used to Repair Narrow Urethral Plate Hypospadias? Its Functional Evaluation Using Uroflowmetry

Aim:

Using uroflowmetry, the aim of this study is to determine the functional results of the grafted tubularized incised plate (GTIP) urethroplasty used to repair poor urethral plate hypospadias.

Settings and Design:

Seventy-one patients (mean age: 5.7 years, follow-up: 1–5.5 years) were selected from those who underwent surgery using the GTIP technique from 2013 to 2015 at our institution.

Methods:

Patients included were able to void voluntarily and had no fistula. The flow pattern, maximum urinary flow rate (Q_max), voided volume (vv), average flow rate, and voiding time were measured. The results were expressed as percentiles and interpreted according to Siroky nomogram. The Q_max was considered normal if >25^th percentile, as equivocally obstructed when in the 5^th–25^th percentile, and obstructed if <5^th percentile.

Results:

Hypospadias was distal in 45, mid penile in 17 and proximal penile in 9. The uroflow curve was bell-shaped in 24 (30%), interrupted in 9 (14%), slightly flattened in 31 (46%), and a plateau in 7 (10%). Flow rate nomograms revealed that 49 (68%) were above the 25^th percentile, 9 (17%) were below the 5^th percentile, and 13 (15%) were between these ranges. Eleven patients showed improvement in the flow curve and maximum urinary flow rate (Q_max) in follow-up uroflowmetry.

Conclusion:

GTIP repair provides satisfactory functional results. A long-term follow-up is needed to confirm these results.