Choosing an ideal vascular cover for Snodgrass repair

The Use of Preputial Dartos Flap in the Primary Repair of Distal Hypospadias: A Single-centre Experience

Background

An additional flap during the tubularization of incised urethral plate urethroplasty (TIPU) is believed to minimize the postoperative complications. It is still debatable whether using an additional flap is worth the risk given the hazards associated with doing so. This study aims to re-evaluate the benefits and drawbacks of TIPU with or without a preputial dartos (PD) flap.

Materials and Methods

We assessed the results of patients with distal hypospadias who underwent surgery in our institute over the past 2 years. The urethral plate's width, thickness, and depth, the periurethral tissue's quality, and the width of the glans at the mid-glans level determined whether the neourethra was covered with a PD flap or left uncovered. Data on intra-operative blood loss, operating time, length of hospital stay, postoperative complications, and outcome were analysed.

Results

There were 96 patients: 58 received an extra PD flap, whereas the other 38 did not. In the flap group, ventral skin necrosis was a prevalent problem, whereas meatal stenosis predominated in the no-flap group. Both the flap group (25.66%) and the no-flap group (23.86%) experienced comparable postoperative complications (P = 0.503). In comparison to the no-flap group, the flap group showed statistically significant differences (P<0.001) in intra-operative blood loss (22.10 ± 6.96 vs. 10.34 ± 3.02 mL), operating time (96.34 ± 6.661 vs. 71.39 ± 9.76 min), and hospital stay (10.04 ± 0.87 vs. 8.47 ± 1.64 days).

Conclusion

The additional PD flap does not always affect the result of TIPU in terms of complications.

A novel triple dartous fixation in hypospadias repair

OBJECTIVE

This study investigates the impact of the use of dartos covering to augment the neourethra on functional and cosmetic results. To evaluate a novel technique demonstrating how to fix dartos flap to cover the neourethra as a barrier in hypospadias repair.

PATIENTS AND METHODS

This study comprised 204 male patients with different degree of hypospadias (DPH = 132, coronal hypospadias = 46, MPH = 26). Their ages ranged from 1 to 23 ys (mean age = 2 ys). Penile chordee was in (DPH = 45, coronal hypospadias = 33, MPH = 26). All patients had abnormal downward directed urinary stream. Hypospadias repair was performed by the classic TIP technique in addition to our novel modification of dartos covering. Patients were submitted to 5 years of follow-up including clinical examination of the functional and cosmetic parameters.

RESULTS

Success rates were reported in 200 patients, 3 patients had complications with subcoronal urethrocutaneous fistula and one patient with complete repair disruption.

CONCLUSION

Triple dartos fixation is a simple technique for all hypospadiologists to minimize urethrocutaneous fistula as common complication of hypospadias repair with good functional and cosmetic results.

Outcome of spongioplasty alone as second layer of tubularised incised plate urethroplasty in patients with hypospadias

Background

Spongioplasty alone or in combination with local tissue flaps can be used as a second layer for the prevention of complications of tubularised incised plate urethroplasty (TIPU) of hypospadias repair. It can be used when wide urethral plate and well-developed robust spongiosum are present. This study aims to review the success rate and complications of TIPU performed utilising spongioplasty alone as a second layer in Type 3 well-developed robust spongiosum.

Methods

This is a retrospective observational study conducted between January 2015 and December 2019 at a tertiary care centre. A total of 21 patients aged 4–15.4 years with primary hypospadias having a Type 3 well-developed robust spongiosum, Glans score ≤ 2, Meatal score ≤ 4, and Shaft score ≤ 3 underwent TIPU using spongioplasty alone as a second layer. The hospital stay ranged from 10 to 14 days and follow-up from 12 to 36 months.

Results

Hypospadias was distal in 12 (57.1%), mid in 5 (23.8%), and proximal penile in 4 (19.1%) patients. The mean Glans Meatus Shaft score was 6.1 (G = 1.25, M = 2.95, S = 1.9) with a range of 3–9. An early post-operative complication of preputial oedema and bladder spasm developed in 1 (4.7%) patient each. Meatal stenosis developed in 1 (4.7%) patient. None developed urethrocutaneous fistula. At 3 months all patients had good urinary flow (> 15 ml/s) and good cosmesis. All the patients/parents (in case of minors) were satisfied with the result.

Conclusion

Spongioplasty alone as the second layer after TIPU for primary penile hypospadias in patients with well-developed robust spongiosal tissue is associated with minimal, easily manageable complications.

A simple technique to repair distal and mid-shaft hypospadias using a de-epithelialized Byars' flap

OBJECTIVE

To describe standard and modified de-epithelialized Byars' flap techniques in tubularized incised plate urethroplasty and evaluate postoperative outcomes.

METHODS

We retrospectively evaluated data for 404 primary hypospadias repair patients who underwent standard (Group A) or modified (Group B) urethroplasty between January 2016 and 2021. Group B's data were analyzed to evaluate whether our modified technique was effective for all hypospadias types.

RESULTS

There was no difference in the ratio of different hypospadias types between Groups A (n = 145) and B (n = 259). Median follow-up duration was 35 months. Fistula occurred in 19 patients in Group A and 12 in Group B (statistically significant difference). The total complication rate was statistically significantly different between the groups. In Group B, 3/142 patients with distal hypospadias developed urethrocutaneous fistula vs 4/95 with mid-shaft hypospadias and 5/22 with proximal hypospadias. No difference was noted between the distal and mid-shaft groups. Significant differences were observed when comparing distal and mid-shaft groups with the proximal group; total complication rates were similar. Glans dehiscence and meatal stenosis rates were similar between Groups A and B, and among the hypospadias phenotypes.

CONCLUSION

Our modified procedure is simple to perform and yields excellent results in distal and mid-shaft hypospadias repair.

Outcomes of Tubularized Incised Plate Urethroplasty (TIPU) for Hypospadias at Tikur Anbesa Specialized and Menelik II referral Hospitals: One-year Prospective study"

OBJECTIVES

To evaluate the results and related factors of tubularized incised plate (TIP) urethroplasty at two institutions.

METHODES

This was a prospective cohort analytical study conducted over a period of 12 months. All patients who underwent TIP urethroplasty in the specified period were studied. Quantitative and qualitative data of the intrinsic parameters of the penis were obtained and patients were followed up for an average period of 14.72±3.67 months (range 9-21months) after surgery.

RESULTS

One hundred twenty-nine patients (N = 129) were included in the study. The mean age at surgery was 50.93 months. The mean glans size and pre-incised urethral plate width were 14.34 mm and 8.38mm respectively. The post-operative results were satisfactory with the meatus in a glanular position in 122(94.6%) patients. Overall, 49 patients (38%) developed complications. Eighteen patients (14%) developed early complications whereas forty-two (32.6%) patients had late complications. UCF and Meatal stenosis occurred in 27 (20.9%) & 14 (10.9%) patients respectively. Seven patients developed recurrent hypospadias and dehiscence of glans occurred in eight patients (6.2%).

CONCLUSIONS

TIP can be used to repair for all types of hypospadias in the absence of severe penile curvature. It has more complications rate in proximal than distal hypospadias. Distal hypospadias was the most common type of hypospadias corrected with TIP. UCF and meatal stenosis were the most common complication followed by glans dehiscence and recurrent hypospadias. Glans size, age at surgery, plate width, location of meatus and stretched penile length were the most determinant factors for the outcome.

Tubularized incised plate repair in 473 primary distal hypospadias cases: An evaluation of outcomes according to coverages and stent types

AIM

We have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair.

MATERIALS AND METHODS

Only distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent).

RESULTS

A total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference.

CONCLUSIONS

Spongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training.

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.

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.

Choosing an ideal second layer cover in snodgrass repair for various types of hypospadias

OBJECTIVE

In this study, we aimed to assess the results of tunica vaginalis flap (TVF), dorsal preputial dartos flap (DPF), and spongioplasty alone as additional cover after neourethra formation in a Snodgrass repair for various types of hypospadias as per the selection criteria decided.

MATERIAL AND METHODS

This was a non-randomized experimental study of 97 patients with primary hypospadias treated via Snodgrass repair using various second layers (tunica vaginalis flap, dorsal preputial dartos flap, and spongiosum alone) as per the selection criteria in a single center by a single surgeon. The outcome of the procedure was assessed in terms of cosmesis, chordee correction, urinary stream, and uroflowmetry.

RESULTS

Of the 97 patients, we used dorsal preputial dartos flap in 42 (43.3%), tunica vaginalis in 38 (39.2%), and spongioplasty only in 17 (17.5%) for primary hypospadias. Urethrocutaneous fistula developed in four patients (three in DPF and one in the TVF groups). One patient each had skin necrosis, hematoma, and wound dehiscence in the DPF group. In the spongioplasty only group, one patient had meatal stenosis which was treated by meatoplasty after failing repeated periodic calibration.

CONCLUSION

DPF should be preferably used for distal penile and TVF for mid and proximal penile hypospadias to ensure excellent result with minimum complications. Spongioplasty only as a second layer is sufficient to avoid the complications wherever it is thick and robust.

Using Buck's Fascia as an Integral Covering in Urethroplasty to Restore the Anatomical Structure of the Penis in One-Stage Hypospadias Repair: A Multicenter Chinese Study Comprising 1,386 Surgeries

Objectives: The objective of the study is to investigate the feasibility and efficacy of urethroplasty with a Buck's fascia integral-covering technique (BFIC) to wrap and restore the normal anatomical structure of the penis in one-stage hypospadias surgery. Methods: One-stage surgeries for hypospadias management were performed using BFIC from January 2016 to September 2020 at four high-volume medical centers in China. The technique integrates Buck's fascia with glans wings to mobilize and wrap the urethra and restore penile anatomical relationships. The clinical data, postoperative follow-up data, and complications were recorded, and the results were analyzed. Results: A total of 1,386 patients were included in the study: 1,260 cases of primary hypospadias and 126 cases of re-operations; distal in 382 cases (27.6%), mid-shaft in 639 (46.1%), proximal in 365 (26.3%); tubularized incised plate (TIP) in 748 cases, inlay-graft in 124, onlay-graft in 49, Mathieu in 28, free-tube graft urethroplasty in 406, and 31 of hybrid procedures. One thousand one hundred forty-two patients (82.4%) were found to have penile curvature (>10°) after artificial erection and all corrected by dorsal plication/s or transection of the urethra plate (UP) simultaneously. The median followed-up time was 27 months (6-62). A total of 143 (10.3%) complications were recorded: 114 (9.0%) in the primary operations and 29 (23%) in the re-operations, 15 (3.9%) in distal hypospadias, 61 (9.5%) in mid-shaft, and 67 (18.4%) in proximal. The complication rate in UP preservation and transection was 10.1 and 10.8%, respectively. Of all case complications, there were 73 (5.2%) of fistula, 10 (0.6%) of dehiscence, 22 (1.6%) of meatal stenosis, 21 (1.5%) of stricture, 6 (0.7%) of diverticulum, and resident curvature in 11 cases (1.2%). The overall complication rate in TIP and free-tube procedure was 9.8 and 9.9%, respectively, and fistula occurred in primary TIP of 33 cases (4.9%). Conclusions: Buck's fascia with the glans can be used as an integral covering technique in one-stage distal to proximal hypospadias and primary or re-operative hypospadias repair. It is safe, feasible, and effective for the repair of hypospadias.

Comparison of effect between dartos fascia and tunica vaginalis fascia in TIP urethroplasty: a meta-analysis of comparative studies

Background

Tubularized incised plate (TIP) urethroplasty is the most commonly performed procedure for hypospadias. Several flap procedures have been recommended to decrease the postoperative complication rate in TIP repair, but no single flap procedure is ideal. This study aimed to compare the outcomes of dartos fascia (DF) and tunica vaginalis fascia (TVF) as intermediate layers in TIP urethroplasty.

Methods

We searched PubMed, EMBASE, the Cochrane Library, Web of Science, clinicaltrials.gov, and other sources for comparative studies up to April 16, 2020. Studies were selected by the predesigned inclusion criteria. The primary outcomes were postoperative complications. The secondary outcomes were functional and cosmetic outcomes.

Results

The pooled RR with 95% CI were calculated. We extracted the relevant information from the included studies. Only 6 comparative studies were included. No secondary outcomes were reported. The RR of the total complications rate for DF was 2.41 (95% CI 1.42–4.07, P = 0.0001) compared with TVF in TIP repair. For each postoperative complication, the RRs were 6.48 (2.20–19.12, P = 0.0007), 5.95 (1.13–31.30, P = 0.04), 0.62 (0.25–1.52, P = 0.29), and 0.75 (0.23–2.46, P = 0.64) for urethrocutaneous fistula, prepuce-related complications, meatal/urethral stenosis, and wound-related complications, respectively.

Conclusions

This meta-analysis reveals that compared to DF, TVF is a better option in TIP repair in terms of decreasing the incidence of the total postoperative complications, urethrocutaneous fistula, and prepuce-related complications. However there is limited evidence for functional and cosmetic outcomes. Overall, larger prospective studies and long-term follow-up data are required to further demonstrate the superiority of TVF over DF.

Trial registration

PROSPERO CRD42019148554.