Outcome analysis of staged preputial graft technique for primary proximal hypospadias with and without post-operative vacuum physiotherapy

PURPOSE

Management of proximal hypospadias remains challenging. We assessed the results of staged preputial graft repairs (SPG) for proximal hypospadias and hypothesize that post-operative vacuum physiotherapy (VP) improves graft suppleness and overall outcomes.

MATERIALS AND METHODS

Retrospective analysis of n = 71 patients with proximal hypospadias and severe ventral penile curvature (PC) of ≥50° after degloving. PC was corrected using ventral transverse incisions of the tunica albuginea (VTITA) without applying a tourniquet, taking care to avoid injuring the underlying erectile tissue. The ventral raw area at the penile shaft, including VTITA, were covered with either divided and partially mobilized urethral plate, or with the inner preputial graft itself. During the second stage, a tunica vaginalis flap was often used to cover the tubularized neourethra. Outcomes and post-op complications were assessed after each stage, comparing patients who received vacuum physiotherapy (VP+, n = 49) with those who did not (VP-, n = 22).

RESULTS

Mean PC was 66°, average follow-up duration was 13.01 months, and overall complication rate was 22.5%. Only 6 of 49 VP + patients experienced complications (12.24%; 4 fistulas; 2 urethral strictures) and no recurrence of PC after second stage was observed in this group. VP- patients displayed a significantly higher rate of complications, with 10 of 22 cases (45.45%) exhibiting fistula development (n = 5) and glans dehiscence (n = 5). Recurrence of mild PC after first-stage repair was comparable between patient groups (12% VP+, 18% VP-) and easily corrected by simple graft tubularization or dorsal plication during second-stage repair.

CONCLUSIONS

Staged repair using VTITA is effective for correcting proximal hypospadias with severe chordee. VP appears to promote and expedite graft suppleness and significantly improves patient outcomes.

Risk factors for postoperative complications following one-stage proximal hypospadias repair involving the disconnection of the urethral plate: a retrospective study

BACKGROUND

Children with hypospadias are at risk of serious physical and mental health problems, including abnormal urination, sexual dysfunction, and infertility. The sole available treatment is the surgical restoration of genital appearance and function. Proximal hypospadias (PH) correction is more challenging and carries a higher risk of complications than does distal hypospadias correction, with a higher likelihood of postoperative complications requiring additional surgery, resulting in considerable economic and psychological strain for families. Herein, we aimed to identify factors associated with complications following one-stage PH repair with urethral plate disconnection.

METHODS

We retrospectively analyzed data from 236 children who underwent PH repair at our center between December 2020 and December 2022. We collected information on age, surgical procedure, length of the reconstructed urethra (LRU), glans width (GW), ventral curvature, surgical approach, preoperative androgen use, suture type, presence of prostatic utricle, body mass index, season of surgery, anesthesia type, low birth weight, preterm birth, follow-up period, and complications. Surgical complications included urethral fistulas, urethral diverticula, anastomotic strictures, urethral strictures, glans dehiscence, and penile curvature recurrences. The study population was divided into complication and no-complication groups, and univariate and multivariate analyses were conducted.

RESULTS

Of the 236 patients with PH who had a median follow-up of 10.0 (8.0, 14.0) months, 79 were included (33.5%) in the complication group and 157 were included (66.5%) in the no-complication group. In the univariate analysis, age (P < 0.001), LRU (P < 0.001), degree of penile curvature (P = 0.049), and PH with prostatic utricle (P = 0.014) were significantly associated with complications after PH repair. In the multivariate logistic regression analysis, LRU (P<0.001, odds ratio [OR] = 3.396, 95% confidence interval [CI]: 2.229-5.174) and GW (P = 0.004, OR = 0.755, 95%CI: 0.625-0.912) were independent factors influencing postoperative complications. The optimal LRU threshold was 4.45 cm (area under the curve, 0.833; sensitivity, 0.873; specificity, 0.873; P<0.001, OR = 3.396, 95% CI: 2.229-5.174).

CONCLUSIONS

LRU and GW are independent factors affecting PH complications. An LRU of < 4.45 cm and an increased GW can reduce the risk of complications.

Urethral Plate Substitution in Two-Stage Hypospadias Repair: Grafts Versus Flaps

BACKGROUND

Choosing between flaps or grafts to substitute the urethral plate in 2-stage hypospadias repair has been a matter of debate with no consensus in the literature. Flaps have reliable blood supply that maybe theoretically less liable for strictures or contractures. Grafts are more versatile, which can be used in primary and recurrent cases when healthy local skin is deficient.In this report, our aim was to compare outcomes of grafts and flaps when used to substitute the urethral plate in two-stage repair of primary proximal hypospadias with ventral curvature.

METHODS

This retrospective study included primary cases of hypospadias with significant curvature who underwent two-stage repair using either grafts or flaps to substitute the urethral plate in the first stage. Cases included in the study were divided into two groups according to the technique of substituting the urethral plate at the first stage of repair. During first part of the study period (2015 through 2018), we mostly used grafts to substitute the urethral plate (group A); later, we shifted to skin flaps (Group B) during the period 2019 through 2021.

RESULTS

The study included 37 boys with primary proximal hypospadias who underwent two-stage hypospadias repair. The meatus position was penoscrotal in 18, scrotal in 16, and perineal in three. Inner preputial graft was used to substitute the urethral plate in 18 cases (group A), while dorsal skin flaps were used in 19 (group B). Out of the 37 cases, 27 were available at follow-up after second stage (group A = 14; group B = 13). Follow up period ranged between 6 and 42 months (mean 19.7; median 18.5). Overall, 14 cases required reoperations for different indications: partial disruptions of distal part of the repair in six, closure of urethro-cutaneous fistula in six, and urethral strictures in two. The rate of complications was higher in group A (10 cases: 71%) compared to group B (4 cases: 31%) (Fisher exact test, p-value = 0.057).

CONCLUSION

Grafts were associated with higher complication rate than flaps when used to substitute the urethral plate in two-stage repair of proximal hypospadias with chordee.

TYPE OF STUDY AND LEVEL OF EVIDENCE

This is non-randomized comparative study (level III evidence).

De-epithelialized overlap flap to secure urethroplasty in second stage hypospadias repair: revisiting the Smith technique

BACKGROUND

The application of a second layer between the neourethra and skin was a major contribution, which has improved the outcome of hypospadias repair. Here, we report our experience of revisiting the original Smith technique using a de-epithelialized overlap flap to support the urethroplasty in staged hypospadias repair.

METHODS

The study included primary cases of proximal hypospadias with significant chordee who underwent two-stage repair during the period 2016 through 2021. The ventral curvature was corrected at first stage by excision of the urethral plate, followed by covering the ventral shaft by skin flaps or inner preputial graft. The second stage (Thiersch -Duplay urethroplasty) was performed six months later. The de-epithelialized overlap flap (double breasting) technique was used to cover the neo-urethra in all cases, which was combined with a dartos scrotal flap to cover the proximal neourethra when indicated.

RESULTS

The study included 17 boys with proximal hypospadias who underwent two-stage repair. Follow up period after the second stage ranged between 6 and 30 months (mean 19.7; median 18.5). Post-operative complications were detected in 7 cases (41%). Most complications were related to distal/glanular disruptions whether partial or complete (5 cases). One case developed a penoscrotal fistula that was closed surgically. Another case (belonging to the group which used preputial graft in the 1st stage) presented 21 months after the second stage with urethral stricture (penoscrotal).

CONCLUSION

Applying the de-epithelialized double-breasting skin closure can offer alternative second layer coverage for the neourethra along the penile shaft in staged repair of proximal hypospadias.

Post-pubertal functional outcomes of one-stage anatomical reconstruction of the corpus spongiosum, bulbo-spongiosus muscle and dartos in 46 children with proximalhypospadias

INTRODUCTION

Anatomical studies of hypospadias show failure of zipping-up of histologically normal urethral plate and corpus spongiosum. With the commonly utilized substitution urethroplasties for proximal hypospadias, a reconstructed urethra of just an "epithelial-lined tube" with no spongiosal support, is apt to long-term urinary and ejaculatory dysfunctions. We completed a one-stage anatomical reconstruction in children with proximal hypospadias whenever the ventral curvature could be reduced to <30° and evaluated the post-pubertal outcomes.

METHOD

This is a retrospective analysis of prospectively maintained data on one-stage anatomical repair of proximal hypospadias between 2003 and 2021. In children with proximal hypospadias, the corpus spongiosum, bulbo-spongiosus muscle (BSM), Bucks', and Dartos' layers of the shaft were anatomically re-aligned prior to assessing the ventral curvature visually. When the curvature was >30°, the urethral plate was divided at the glans for a 2-stage procedure, and those patients were excluded from the study. Otherwise, the anatomical repair was continued (this series). The Hypospadias Objective Scoring Evaluation (HOSE) and the Paediatric Penile Perception Score (PPPS) were used for post-pubertal assessment.

RESULTS

Prospective records provided details of 105 patients with proximal hypospadias who had complete primary anatomical repair. The median age at surgery was 1.6 years, and 15.9 years at the post-pubertal assessment. Forty-one (39%) had complications that necessitated re-operations. Thirty-five (33.3%) patients had complications involving the urethra. For fistula and diverticula, eighteen cases required only one corrective procedure, while one required two. Other 16 patients required an average of 1.78 corrective operations for severe chordee and/or breakdown, with 7 requiring Bracka's 2-stage procedure.

RESULTS OF PUBERTAL REVIEW

Fifty patients (47.6%) were over 14 years old; 46 (92.0%) had pubertal reviews and scoring, while four were lost to follow-up. The mean HOSE score was 14.8/16, and the mean PPPS score was 17.8/18. Five patients had residual curvature of >10°. 17 and 10 patients, respectively, were unable to comment on glans firmness and ejaculation quality. During erections, 26/29 (89.7%) patients reported a firm glans, and 36/36 (100%) reported normal ejaculations.

CONCLUSION

This study proves the need for reconstruction of normal anatomy for normal post-pubertal function. In all proximal hypospadias, we strongly recommend anatomical reconstruction (zipping up) of the corpus spongiosum and BSM. When the curvature can be reduced to <30°, a complete one-stage reconstruction is possible; otherwise, anatomical reconstruction of the bulbar and proximal penile urethra is recommended, reducing the length of the epithelial-lined substitution tube for the distal shaft and glans.

Enlarged prostatic utricle and vagina masculinus in boys with disorders of sex development

PURPOSE

To determine the prevalence, radiological characteristics, and clinical symptomatology of enlarged prostatic utricles and vagina masculinus in boys with disorders of sex development.

METHODS

Over 10 years (from February 2012 to March 2022), 102 boys with severe hypospadias underwent voiding cystourethrography. All patients presented with disorders of sex development and Y material in the karyotype (46,XY karyotype, 46,XY/45,X mosaic, etc.). The age of the patients at the first examination ranged from 4 days to 27 months (mean age 2.7 months).

RESULTS

Voiding cystourethrography revealed the presence of a cyst posterior to the urethra in 66 patients (64.7% of cases). There were 15 cases of "vagina masculinus" and 51 of enlarged prostatic utricles. These dilations were classified according to the Ikoma classification and cyst size. In more than 2/3 of cases, the cysts were small (less than 20 mm), and in less than 8% of cases, these cysts were large. In addition, retrograde opacification revealed the presence of vesicoureteral reflux in 20% of boys with a male vagina. The most severe hypospadias with a scrotal or perineal meatus are most at risk of developing an enlarged prostatic utricle, and 80% of patients with Ikoma Grade III had a scrotal or perineal meatus.

CONCLUSION

This study shows that the prevalence of enlarged prostatic utricles and vagina masculinus is high in patients with severe hypospadias. Therefore, their search should be systematic, and for clinical and therapeutic interest, the enlarged prostatic utricles should be classified according to cyst size.

Small Intestinal Submucosa for corporeal body grafting in patients with proximal hypospadias and severe chordee: Long term follow-up assessing erectile function and genital self-perception

BACKGROUND

Proximal hypospadias and severe ventral chordee are often challenging to repair. To preserve penile length in chordee repair, Small Intestinal Submucosa (SIS) corporal grafting is often performed with potential long-term complications including recurrent curvature and erectile dysfunction (ED). There is a paucity of data evaluating sexual function in mid, late and post-pubertal patients.

OBJECTIVE

We aimed to assess long-term outcomes of genital self-perception and erectile function in mid, late and post-pubertal patients who underwent single-layer (1-ply) SIS corporal body grafting for correction of severe chordee.

STUDY DESIGN

Patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting between 2001 and 2015 were retrospectively identified. Patients were evaluated for erectile and sexual function using the modified erection hardness score (mEHS) and the modified sexual health inventory for men (mSHIM). Perceived function and straightness were measured with Hypospadias Objective Scoring Evaluation (HOSE). Penile self-perception was assessed using the Pediatric Penile Perception Score (PPPS). Results were compared to an age-matched healthy control group. Categorical variables were analyzed using Fisher's exact test, and continuous variables using paired and unpaired t-test and ANOVA.

RESULTS

Nineteen patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting and 18 controls participated in the study with a median age of 17 years for both groups. In the mEHS, 12 (63.2%) hypospadias-patients and 14 (87.5%) controls rated their erections as completely hard and very rigid. In the mSHIM, 1 (5.2%) hypospadias-patient was classified as having moderate ED. A total of 16 hypospadias-patients (84%) and 16 controls (88.9%) reported being very satisfied or satisfied with the straightness of their penis. No significant difference was observed in the mEHS, mSHIM and PPPS between groups (p < 0.05). The straightness of the erection was rated lower by participants, than by the pediatric urologist. In the HOSE, 12 (63.2%) hypospadias-patients and 16 (88.9%) controls obtained an acceptable score.

DISCUSSION

Our findings indicate favorable long-term outcomes in ED and genital self-perception; only 5% of our population reported having a mild-moderate to moderate presentation of ED, and there were no reports of severe ED. The overall PPPS satisfaction rates were statistically similar for the control and hypospadias groups. The small sample population limits the significance of our findings.

CONCLUSION

Corporal body grafting with 1-ply SIS suggests positive long-term outcomes in genital self-perception and erectile function, with mid, late and post-pubertal patients who underwent hypospadias repair having comparable results to age-matched healthy controls.

A multicenter study on surgical procedure selection and risk factor analysis of postoperative complications after TIP and Duckett hypospadias repair

BACKGROUND

Hypospadias is a common congenital malformation in pediatric urology with surgery being the only curative treatment. Although there are hundreds of surgical methods for hypospadias, no single method can treat all types, and there are still high rates of postoperative complications. We performed this study to investigate surgical procedure selection and perform risk factor analysis of postoperative complications in hypospadias repair.

METHODS

Retrospective analysis was performed of complete clinical and follow-up data of children with hypospadias who were treated and followed up at 15 children's clinical centers in Mainland China from December 2018 to December 2019. Children were divided into groups according to Barcat classification and surgical methods in order to analyze the surgical choice for different types of hypospadias and the influencing factors of different surgical methods for complications.

RESULTS

In total, 1011 patients were followed up for 26 months. According to Barcat classification, there were 248 cases of distal type hypospadias, 214 of intermediate, and 549 of proximal type. Transverse preputial island flap urethroplasty (Duckett) and tubularized incised plate urethroplasty (TIP) were performed in 375 (37.1%) and 336 cases (33.2%), respectively. The postoperative complication rate of distal hypospadias was 23.4% (15.8-57.1%), mid shaft 29.0% (22.7-40.0%), and proximal 43.7% (30.2-52.9%). Among the 375 patients in Duckett group, 192 had complications. Multivariate logistic analysis showed that the length of prepuce island flap (OR = 3.506, 95% CI: 2.258-5.442) was an independent risk factor for complications after Duckett operation (P < 0.001). In TIP group, there were 336 cases with 84 complications. Multivariate logistic analysis showed that the width of urethral plate after longitudinal resection (OR = 0.836, 95% CI: 0.742-0.942) and glans width (OR = 0.851, 95% CI: 0.749-0.965) were independent risk factors for postoperative complications after TIP (P = 0.003, P = 0.012).

CONCLUSION

Several anatomical features play a role during the selection process among the different surgical approaches, including glans size, urethral plate width, and the meatal position. The width of the urethral plate and glans width were risk factors for postoperative complications after TIP. The length of prepuce island flap was a risk factor for complications after Duckett operation.

Experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee: A single institution study with intermediate follow up

PURPOSE

We present our modified technique of using the inner preputial flap to cover the penile shaft, while removing the subcutaneous tissue of the distal part of the flap to act similar to graft. Herein, we present our experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee.

PATIENTS AND METHODS

The current study was a single-institution retrospective study between January 2016 and December 2020. Thirty-one patients with proximal hypospadias with chordee were included and underwent our modified technique. We excluded re-operative hypospadias and incomplete follow-up cases (<6 month of follow up). Patient demographics, outcomes and complications in the form of fistula formation, diverticulum, metal stenosis, stricture formation and glans dehiscence were reviewed.

RESULTS

A total of 31 patients were included in the study and underwent our modified technique. The median age was 18 months (9-60) & IQR 15-25). The median follow up was 40 months. Overall, success was achieved in 24 cases (77.4%). Complications occurred in seven cases (22.6%) and included urethrocutanous fistula in three patients (9.7%), diverticulum in two patients (6.5.%), metal stenosis in one patient (3.2%) and glans dehiscence in one patient (3.2%).

CONCLUSION

Our technique provides a favourable outcome with a low complication rate for repair of proximal severe hypospadias.

LEVEL OF EVIDENCE

Case Series Study (Level IV).

A meta-analysis comparing dorsal plication and ventral lengthening for chordee correction during primary proximal hypospadias repair

PURPOSE

Recurrent chordee (RC) is an important complication of proximal hypospadias repair. In this meta-analysis we compared RC incidence following dorsal plication (DP) versus ventral lengthening (VL).

METHODS

We searched the databases to identify all papers between 2001 and 2021 pertaining to proximal hypospadias and recurrent chordee. Duplicate publications, review articles and incomplete articles were excluded. Meta-analysis of heterogeneity was reported with I² statistics. The pooled outcomes were compared to Chi square/Fishers exact test.

RESULTS

A total of 17 articles were included covering 582 patients. The I² statistics for prevalence of RC among different publications showed no heterogeneity for DP (I² = 0%) and low heterogeneity for VL (I² = 26%). RC was noticed in 31/122 (25.4%; 95% CI 18%-33%) among patients who had DP alone while it was significantly lower, 24/460 (5.3%; 95% CI 4%-8%) when VL was used (p = 0.0001). When compared to DP, all VL techniques had significantly lower incidence of RC. Among the VL techniques lowest incidence of RC was found for ventral corporotomies (4%) followed by small-intestinal- submucosa (SIS 4.2%) and tunica vaginalis flap (TVF)/free graft-TVFG (5%). Among the VL subtypes: the proportion of RC with use of TVF (4/70, 5.7%) and TVFG (3/69, 4.3%) for corporoplasty was comparable (p = 1); single-layer SIS was associated with significantly less RC (1/90, 1.1%) than 4-layer SIS (5/51, 9.8%; p = 0.02).

CONCLUSION

For correction of severe ventral chordee during primary proximal hypospadias repair, dorsal plication carries a higher risk of recurrence compared to ventral lengthening procedures.

Staged transverse preputial island flap urethroplasty for some proximal hypospadias with moderate-to-severe chordee

BACKGROUND

We aimed to assess the outcome of staged transverse preputial island flap (TPIF) urethroplasty for repairing certain cases of primary proximal hypospadias with moderate-to-severe chordee in children.

METHODS

Nighty-two consecutive boys who underwent either one-stage or staged TPIF urethroplasty for the repair of proximal hypospadias with moderate-to-severe chordee between August 2015 and December 2019 were evaluated retrospectively. Patients were divided into two groups: one-stage TPIF urethroplasty group (n = 44) and staged TPIF urethroplasty group (n = 48). We noted and compared the postoperative complications, including urethrocutaneous fistula, urethral diverticula, residual penile curvature, and urethral stricture in both groups.

RESULTS

Both groups were followed up for 1-5 years, with an average of 3 years. No cases of residual or recurrence of penile chordee were reported in either group. In Group A, 9 patients (9/44, 20.4%) had postoperative urethrocutaneous fistula, and all patients underwent urinary fistula repair or urethroplasty. In Group B, postoperative urethrocutaneous fistula occurred in 2 cases (2/48, 4.1%), and one patient developed a urethrocutaneous fistula after the first operation, which was successfully repaired during the second operation. A urethrocutaneous fistula occurred in 1 case after completion of the second-stage operation; urethral fistula repair was performed successfully 6 months later. There were 2 cases of urethral stricture in Group A (2/44, 4.5%) and none in Group B. There were 6 cases of urethral diverticulum in Group A (6/44, 13.6%) and no cases of urethral diverticulum in Group B. The operative success rates were 61.3% and 95.8% in Group A and Group B, respectively (P < 0.001).

CONCLUSIONS

Compared with one-stage TPIF urethroplasty, staged TPIF urethroplasty in the treatment of certain cases of primary proximal hypospadias with moderate-to-severe chordee resulted in fewer postoperative fistulas, urethral strictures and urethral diverticula. The staged TPIF urethroplasty procedure was effective in reducing the operation difficulty and complication rate of hypospadias, improving the curative effect of complex hypospadias and having good clinical application value.

Acellular dermal matrix graft for ventral corporal lengthening orthoplasty in 2-stage proximal hypospadias repair

BACKGROUND

Correcting ventral curvature (VC) by lengthening the ventral corpora using a graft has been verified feasible, but still has been associated with the recurrence. The use of acellular dermal matrix (ADM) in the setting of tissue reconstruction has captured the attention of many surgeons. There are few reports on the use of ADM exclusively as correction of VC. Thus, we evaluate the safety and effectiveness of repairing the defect with ADM for straightening the VC in proximal hypospadias repair.

METHODS

We retrospectively analyzed the records of patients with proximal hypospadias who underwent ventral corporal lengthening with graft in staged repair from January 2013 to December 2019. Those with curvature greater than 30° after urethral plate transection were enrolled. ADM was used for repairing the defect left by transversely transection of tunica albuginea. Patient outcomes were compared with the non-matched control group who underwent the same procedure with tunica vaginalis (TV) repair. Patient demographics, operative techniques, complications, reoperations were summarized and compared between 2 groups.

RESULTS

Forty-three patients underwent ventral lengthening with ADM repair after transverse urethral plate transection and 35 patients with TV patching respectively. At a mean follow-up of 10 months in those with the first-stage ventral lengthening, 5 of 43 (11.6%) in ADM group was detected with recurrent VC, while 2 of 35 (5.7%) in TV group were observed with recurrent curvature contemporarily (P=0.363). At a mean follow-up of 46.8 and 45.3 months, persistent curvature in ADM group was not significantly different comparing to TV group (1/43, 2.3% vs. 1/35, 2.9%; P=0.883).

CONCLUSIONS

Ventral corporal lengthening using ADM graft may facilitate correction of VC without increasing the risk of urethroplasty complications. It offers a promising material that can be safe, effective and simple to use and provides psychological and aesthetic benefits. Additional series assessment and further randomized controlled trials will elucidate the clinical impact of using ADM with ventral lengthening.

Results of the one-stage proximal hypospadias repair with modified Koyanagi technique: A prospective cohort study in a single Vietnam centre

Introduction

Proximal hypospadias is the most severe type of hypospadias. Our approach to Koyanagi technique for proximal hypospadias aims to improve the blood supply to the neourethral flaps and reduce meatal complications.

Methods

Our prospective study included 75 patients who were operated for proximal hypospadias by our Koyanagi technique at Viet Duc hospital between January 2019 and December 2020. The clinical information obtained included a detailed medical history; preoperative, intraoperative, and postoperative data; short-term outcomes by the HOSE score were evaluated by a different physician.

Results

The mean (range) age was 3.59 ± 2.41 years (1.5–14), 86.7% under 5 years old. There are 31 penoscrotal, 31 scrotal, and 13 perineal hypospadias. The length of the neourethra ranged from 3.5 to 8 cm, mean 5.02 ± 0.88 cm. Evaluation of the surgeon at 6 months after surgery: primary success 81.3%. Complications occurred in 14 cases (18.7%), included 10 urethrocutaneous fistula and 4 dehiscence of the urethra. No cases of meatal stenosis or recession, urethral stricture, urethral diverticula. The mean HOSE score was found to be 14.47 ± 1.35, ranged 11 to 16. 57 patients (76%) had a total HOSE 14 and above and 18 patients had score below 14 (24%)

Conclusion

Our modified Koyanagi technique give us a good result for one-stage reconstruction of proximal hypospadias. Applying the HOSE score makes postoperative evaluation of hypospadias more objective and reliable.

•

Proximal hypospadias is one of the most challenging conditions.

•

Modified Koyanagi techniques improve the blood supply to the neourethral flaps.

•

The HOSE score is an objective appraisal of the outcome of hypospadias repair.

Koyanagi urethroplasty for proximal hypospadias: A stage procedure?

OBJECTIVE

To report experience and technical refinements with the Koyanagi urethroplasty for proximal hypospadias.

METHODS

A retrospective study was conducted between 2004 and 2017. Medical records of patients treated by the Koyanagi technique were investigated. The penile ventral skin was closed either with a Byars flap or using an "Ombredanne's chasuble" (OC). The cohort was divided chronologically into two groups of the same number of patients (early -E- and late experience group-LEG-). Demographics, anatomical findings and surgical outcomes were compared between groups using univariate analysis. A logistic regression was performed to assess factors associated with the occurrence of a postoperative urethrocutaneous fistula or urethroplasty dehiscence (UD).

RESULTS

The Koyanagi urethroplasty was performed in 67 patients, 33 in the EEG and 34 in the LEG. The overall surgical complication rate was 64.2% (n=43), including 42 fistula or UD, higher in the EEG (81.8%) than in the LEG (44.1%, P<0.01). However, in the LEG, patients underwent the surgery older and the use of OC more frequent. After multivariate analyses, factors associated with a postoperative fistula or UD were the year of surgery (OR=0.71 [0.53-0.96] P=0.02), the age at surgery (OR=1.11 [1.01-1.22], P=0.03); contrary to the skin coverage method or the stenting duration (P>0.05). An urethral stenosis occurred in 1 patient (1.5%). At last follow-up, 64.2% of patients required a further procedure and 80.6% of urethral meatus were glandular.

CONCLUSION

In this study the complication rate, particularly the urethrocutaneous fistula, remained high. Urethral stenosis, were rare but the follow-up was too short to clearly identified them. Considering as a 2 stage procedure koyanagi uretroplasty allows to obtain finally good results.

LEVEL OF EVIDENCE

III.

Recurrent ventral curvature after proximal TIP hypospadias repair

EXTENDED SUMMARY

Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened while preserving the urethral plate to use TIP repair. That is usually done by dorsal plication (DP). However, we reported recurrent VC was commonly found after DP in boys with proximal urethroplasty complications, and have diagnosed VC in patients similarly straightened by WS. We reviewed our proximal TIP patients and now report their recurrent VC.

METHODS

We used a prospectively-maintained database to identify all patients with proximal TIP by WS and document recurrent VC. Penile straightening was primarily done by midline DP using 5-0 or 6-0 polypropylene, and/or other maneuvers including combinations of urethral plate elevation off the corpora, mobilization of the urethra to the external sphincter, and ventral corporotomies. Recurrent VC was suspected by a characteristic 'hunched-over' appearance and resistance to lifting the glans cephalad (Figure), and confirmed in all cases by artificial erection intraoperatively.

RESULTS

58 of the 77 patients with follow up had VC straightened. Recurrent VC was diagnosed in 26%. It was suspected during this review in another 10% who had recurrent urethroplasty complications which we now know often indicate VC, or urethral plate elevation with no treatment for corporal disproportion. This recurrent VC was objectively measured in nearly half those diagnosed, averaging 52 (30-75). It was diagnosed before puberty in all cases. There was no difference in recurrent VC in those managed with DP alone versus those straightened by DP and/or other maneuvers.

DISCUSSION

The finding that 1 of every 4 patients had recurrent VC after proximal TIP, and that as many as 1 of every 3 might have had that complication, is concerning. During most the study the extent of VC was visually estimated, and most patients were thought to have <45° with no tension on the UP after straightening. We reported 70% of patients operated elsewhere for proximal hypospadias and presenting with urethroplasty complications had recurrent VC ≥ 30° following earlier DP. In that series, in the current patients, and in an earlier report by Braga et al., an intact urethral plate correlated with increased risk for recurrent VC. Despite our improved ability to diagnose recurrent VC, we have not found it in boys who underwent STAG repair with urethral plate transection.

CONCLUSIONS

Recurrent VC after proximal TIP repair occurred in at least 1 of every 4 patients despite DP and/or additional maneuvers to straighten the penis while preserving the urethral plate. Accordingly, we now only perform proximal TIP when there is little (<30°) or no VC.

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.

Clinical efficacy of transverse preputial island flap urethroplasty for single-stage correction of proximal hypospadias: a single-centre experience in Chinese patients

Background

This study was designed to summarize the clinical outcomes of transverse preputial island flap urethroplasty for single-stage correction of proximal hypospadias in our hospital.

Method

This study retrospectively analysed the clinical data, including the preoperative general information, intraoperative and postoperative data, and follow-up data, of 155 children with proximal hypospadias who were admitted to our hospital from January 2009 to January 2019.

Results

During follow-up, a total of 92 postoperative complications occurred, and 41 patients underwent reoperation. There were 49 patients with urinary fistula, 26 patients with urethral stricture, 9 patients with urethral diverticulum and 8 patients with urinary tract infection. Regarding the family members’ satisfaction with the cosmetic appearance of the penis, the satisfaction rate with the urinary meatus was 85.2%, the satisfaction rate with the glans appearance was 87.7%, the satisfaction rate with the the appearance of the foreskin of the penis was 92.3%, and the satisfaction rate with the overall penis shape was 89.0%.

Conclusion

Proximal hypospadias is a serious condition that is often combined with severe chordee, and transverse preputial island flap urethroplasty for single-stage correction is an effective surgical procedure for treating this condition.

Urethral fistulae following surgery for scrotal or perineal hypospadias: A 20-year review

INTRODUCTION

Urethral fistulae (UF) following hypospadias surgery can be a frustrating complication with reports of even 15 attempts to close a difficult fistula (Richter 2003). UF occurring in scrotal or perineal hypospadias (SPH) pose a further challenge because of the under-virilised penis.

OBJECTIVE

To review the outcomes of a single surgeon's experience over 20 years of managing UF in SPH. To analyse the traditional approach of fistula closure and three alternative techniques.

MATERIALS AND METHODS

A prospectively maintained database of patients who underwent hypospadias surgery for SPH from January 1997 to September 2018 was reviewed. Patients with UF were identified and their data recorded. The techniques of fistula closure were: a-Traditional approach. b Purse-string closure. c. Right angle intersection technique where the skin and urethra are closed at right angles to each other. d Anchoring skin to corpora away from the fistula closure.

RESULTS

32 patients with 41 fistulae were identified. Follow-up ranged from 1 to 18 years. 10/32 (31%) had concomitant meatal stenosis or urethral strictures. The sites of UF were: penoscrotal 19/41 (46%), midpenile 14/41 (34%), coronal or subcoronal in 8/41 (20%). One fistula resolved spontaneously after a single urethral dilatation. 4 patients with a coronal fistula were laid open to the glandular meatus creating a coronal hypospadias, with redo-urethroplasty later (in 2 a buccal graft was used). Of the rest, 29 fistulae were cured after one surgery, while 7 needed two attempts. No patient needed more than two surgeries to close the fistula. The recurrence rates were as follows- Purse-string suture: 10%, Right angle intersection technique: 14.3%, Anchoring skin to corpora: 16.7%, Traditional approach: 21.7%. Although the purse-string suture technique had the lowest recurrence rate, the figures did not reach statistical significance (P-0.95).

CONCLUSION

Urethral fistulae occurring in SPH pose challenges because of the under-virilised penis. A third of patients may have meatal stenosis or urethral strictures which must be identified and dealt with. The three novel techniques we employed helped drive down our recurrence rate. Purse string sutures reduce the weak area to a dot and are an excellent way to deal with small fistulae (<5 mm). Other innovations include offsetting the skin suture line by anchoring it to the penile shaft well away from the fistula repair or closing the fistula and skin at right angle to each other. The fact that no patient needed more than two operations to lose the UF, was gratifying.

Bracka verses Byar's two-stage repair in proximal hypospadias associated with severe chordee: a randomized comparative study

INTRODUCTION

Proximal hypospadias associated with severe chordee represents a major surgical challenge and the debate over its optimal treatment is ongoing. The objective of this study is to compare the outcome of two-stage Bracka and Byar's repair in proximal hypospadias.

MATERIALS AND METHODS

This study was conducted from January 2013 to February 2018 in a tertiary care centre. Patients of hypospadias with severe chordee who required urethral plate transection were included in the study. Patients were randomly divided into two groups by simple randomization method. Bracka staged repair was done in Group A and Byar's staged repair in Group B. Postoperatively complications including graft loss, flap necrosis, fistula formation, meatal stenosis, stricture, diverticula formation, residual chordee were noted in both the groups and compared. p value of < 0.05 was considered statistically significant.

RESULTS

Over a period of 5 years, 74 patients in group A and 68 patients in group B were operated. Fistula occurred in 6.8% and 10.2% in group A and group B, respectively (p value 0.629). Meatal stenosis was seen in 4% in group A and 3% in group B (p value 0.731). Stricture was seen in 1% in each group (p value 0.339). Diverticula formation was seen in 2% in group B and none of the patient in group A (p value 0.960). None of the patient had recurrence of chordee in either group.

CONCLUSION

Bracka and Byar's two-stage repair have similar postoperative outcome and the choice between the two depends up on the surgeon's choice and experience rather than scientific evidence.

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.

Double-face preputial island flap revisited: is it a reliable one-stage repair for severe hypospadias?

PURPOSE

We have studied outcome of double-face preputial island flap (DFPIF) technique in severe types of hypospadias: penoscrotal, scrotal and perineal.

METHODS

We have used DFPIF in 75 boys at a median age of 1.1 years (1.0-1.5). The meatus was penoscrotal, scrotal or perineal after de-gloving the penis. The inner face of the foreskin was used for urethroplasty and the outer face for ventral skin covering. Modifications were added: proximal anastomosis was protected by a spongioplasty; in case of urethral plate transection, we anastomosed on onlay proximal and distal segments of the flap (onlay-tube-onlay) and the tubularized part was sutured to corpus cavernosa. FU was scheduled at one month then every 3 months for a year then annually. At each consultation, the surgeon filled out a detailed cosmetic and functional sheet including flowmeter.

RESULTS

Thirty-four patients had onlay preputial flap repair with urethral plate preservation. Forty-one had the onlay-tube-onlay technique. All children had a curvature, 19 had a significant residual curvature after dissection, corrected by dorsal plication (n = 9) and ventral lengthening (n = 10). Median FU was 4.2 years (2.7-6.5). 36 children (48%) had complications and needed redo surgery: 12 fistulas, 11 diverticula, 7 meatal stenosis, 3 strictures and 2 residual curvatures. All children but three voided within the normal limits for their age.

CONCLUSION

DFPIF remains a good option for a one-stage repair of severe hypospadias. After a median of 1.8 procedures, the final success rate was 96%. The healthy well-vascularized ventral skin allows safe redo surgery when needed.

Use of Acellular Dermal Matrix for Urethroplasty Coverage in Proximal Hypospadias Repair: a Pilot Study

Introduction

The complication rates of proximal hypospadias, especially fistula, are much higher than those of distal hypospadias. Urethral coverage is an effective method for reducing fistulas. Acellular dermal matrix (ADM) has been shown to exhibit structural compatibility and biocompatibility, both of which promote tissue healing.

Methods

The present non-randomized study evaluated the efficiency, feasibility, and safety of using ADM for urethroplasty coverage in patients with proximal hypospadias. This prospective study enrolled 35 patients (age range 15–60 months) with proximal hypospadias who underwent operation between September 2018 and March 2019 at Beijing Children’s Hospital (Beijing, China). Urethroplasties were performed by the transverse preputial island flap (TPIF) technique. ADM was applied and sutured over the urethroplasty as an additional covering layer. Patient outcomes were compared with those of 80 non-matched control patients with proximal hypospadias who underwent the same procedure, with dartos as a covering layer.

Results

During a median follow-up of 11.56 months (range 9–15 months), urethral fistula occurred in six patients (17.1%) in the ADM group and 28 patients (35%) in the dartos group. Superficial wound infection was observed in six patients (17.1%) in the ADM group and 10 patients (12.5%) in the dartos group. One patient in the ADM group had diverticulum, compared with five patients (6.25%) in the dartos group. Meatal stenosis and urethral stricture were observed in four patients (11.4%) in the ADM group and six patients (7.5%) in the dartos group; all of these complications were treated conservatively. No glans dehiscence was observed in either group.

Conclusion

Use of ADM may be a safe and efficient covering technique to provide an additional coverage layer for proximal hypospadias repair, thereby reducing the incidence of fistula formation, especially among patients who have poor-quality covering materials.

Yield of modern genetic evaluation for patients with proximal hypospadias and descended gonads

INTRODUCTION AND BACKGROUND

Although the pediatric urologic community has embraced a multidisciplinary genetic and endocrine evaluation for newborns with ambiguous genitalia, this approach has been reserved for the most severe cases of undervirilized 46,XY individuals despite growing evidence that genetic differences are found even in patients whose only genitourinary anomaly appears to be proximal hypospadias. Identifying these genetic differences is vital for counseling patients as they move through puberty to parenthood as well as parents on future pregnancies.

OBJECTIVE

The primary objective was to evaluate genetic diagnosis in patients with proximal hypospadias. The authors hypothesized the more sensitive genetic evaluation available in the modern era will reveal a high rate of patients with proximal hypospadias and descended testicles who are found to have a genetic difference, supporting a thorough genetic evaluation in these patients.

STUDY DESIGN

A retrospective review was performed of all patients who underwent surgical correction for proximal hypospadias at a single institution from January 1, 2010, to December 31, 2016. Those with midshaft hypospadias were excluded as were patients whose primary surgery was performed at an outside institution. Patient characteristics, including demographics, clinical presentation, genetic evaluation, and referral to a multidisciplinary difference of sex development (DSD) clinic, were collected. The chi-squared test and t-test were used for analysis.

RESULTS

There were 112 patients with proximal hypospadias who met the inclusion criteria. Of these, 91 had bilaterally descended testicles, whereas 21 had one or more undescended testicles. Thirty-three percent of patients with isolated proximal hypospadias received genetic testing of some kind, with 24% seen in the multidisciplinary DSD clinic. Four patients had an associated genetic syndrome identified, and 5 had a genetic difference of unknown clinical significance. Overall, 10% of patients with proximal hypospadias and descended testicles had an identifiable genetic difference vs 33% with associated cryptorchidism. Of these, one patient with proximal hypospadias and descended testicles had a genetic difference of known clinical significance that was likely to have been missed in the absence of an evaluation by a geneticist.

DISCUSSION AND CONCLUSION

There was a high rate of identifiable genetic differences in patients whose only genitourinary abnormality was proximal hypospadias, especially with the 1% risk of a likely missed diagnosis. These findings support the discussion of a genetic evaluation for all patients with proximal hypospadias, regardless of the testicular location.

Incidence and diagnoses of disorders of sex development in proximal hypospadias

BACKGROUND

Evidence-based guidelines on evaluation of boys with proximal hypospadias for the possibility of a disorder of sex development (DSD) have yet to be developed. We aimed to investigate the incidence and diagnoses of DSD in patients with proximal hypospadias.

METHODS

We retrospectively reviewed the records of consecutive boys who underwent proximal hypospadias repairs from 2006 to Sept 2017. Data collected included scrotal anomaly, testes position/palpability, micropenis, DSD investigations, and surgical techniques.

RESULTS

165 patients were eligible for the study. 14 (8.5%) were diagnosed to have DSD. The diagnoses were 46,XX testicular DSD [n = 1], 46,XY DSD [n = 7; partial gonadal dysgenesis (PGD) = 3; 5α-reductase type 2 deficiency = 3; 17α-hydroxylase deficiency = 1], Sex Chromosome DSD [n = 6; 45,X/46,XY PGD = 4; Klinefelter = 2]. 3/7 (43%) patients with PGD had gonadal germ cell neoplasms. Of the DSD patients, 6/14 (43%), 11/14 (79%) and 11/14 (79%) had undescended/impalpable testes, micropenis and penoscrotal transposition/bifid scrotum, respectively, significantly higher prevalence rates than those without DSD diagnosis (p-values <0.05). 10/14 (71.4%) DSD patients underwent 2-stage repair compared with 57/151 (37.7%) of others without DSD diagnosis (p = 0.01).

CONCLUSIONS

Patients presenting with proximal hypospadias and one or more of the coexisting anomalies of micropenis, undescended/impalpable testes, and penoscrotal transposition/bifid scrotum should warrant DSD evaluation. Presence of bilaterally descended testes in scrotum does not preclude the possibility of DSD.

LEVEL OF EVIDENCE

IV.

Posterior hypospadias: Evaluation of a paradigm shift from single to staged repair

INTRODUCTION

Repair of posterior hypospadias is a current dilemma. Single versus staged repair is the main question to answer. The answer is not easily reached due to lack of comparative studies. Hence such studies are not available, the reports of a change from one approach to the other one are important to point out the results of each procedure in the same hands and in the same center. Herein, we report our results of the repair of posterior hypospadias shifting from single stage to staged repair.

PATIENTS AND METHODS

65 children were operated in a single Centre in the period from 2011-2016 using single stage repair by dorsal island flap in the first 40 children and then a shift to staged repair involved 25 children repaired using Bracka procedure, children are evaluated for the outcome and for the development of complications during the period of follow up.

RESULTS

The mean age of children operated using single stage technique was 2.8 years (0.83-12.0), Onlay repair was performed in 29 cases (72.5%), while a tube was performed in 11 cases (27.5%). The success rate was 55% with 45% complication rate, in the form of infection in (2.5%), partial dehiscence in (10%), urethrocutaneous fistula in (15%), meatal stenosis in (12.5%), urethral diverticulum in (5%). 25 children were operated using staged repair according to Bracka using inner preputial graft in fresh cases and buccal graft in redo cases. Mean age of 4.5 years (7 months-18 years), 15 primary cases and 10 redo cases, 12 penoscrotal, 11 scrotal and 2 perineal cases, preputial graft in 17, buccal graft in 8, 25 children completed their second stage, tunica vaginalis cover was used in 23 children, localized penile skin dartos was used in 2 children, the overall success after second stage was 80%, complications were in the form of 4 fistulas (16%), hematoma and complete disruption in a redo case (4%). There is a significant statistical difference in the incidence of complications between both groups in favor of lower complication rate (20%) in the staged group versus the single stage group (45%) with a P = 0.0419.

CONCLUSION

Staged repair considerably improves complication rate of posterior hypospadias reconstruction compared to single stage repair using pedicled island flap. More follow up and continuous reporting of honest complication rate is needed to improve the outcome of a complex pathology and to help the choice of the best procedure.

Modified tubularized incised plate urethroplasty reduces the risk of fistula and meatal stenosis for proximal hypospadias: a report of 63 cases

PURPOSE

To report the feasibility of modified tubularized incised plate (TIP) urethroplasty technique for proximal hypospadias in 63 cases.

METHODS

From January 2004 to March 2010, 63 patients underwent one-stage TIP urethroplasty (modified Snodgrass technique repair) using 2-3 of three covering layers (corpus spongiosum, dartos, and tunica vaginalis). The primary meatus was proximal penile, penoscrotal, scrotal, and perineal in 38, 13, 10, and 2 patients, respectively. All patients had chordee that was corrected with dorsal plication. Glanuloplasty was performed in all cases. Complications and cosmetic results were documented after 6-72 months of follow-up.

RESULTS

A total of 63 boys with proximal hypospadias underwent Snodgrass hypospadias repair at a mean age of 8.5 months (range 6-54). Mean operative time was 210 ± 35 min. Patients were followed up with 6-month intervals for up to 6 years postoperatively. After 6 years of follow-up, nine urethrocutaneous fistulae, four bleeding, four meatal stenoses, and one urethral stricture were reported. Cosmetic result was satisfactory according to parent's opinion and another surgeon. No residual chordee was observed in any cases (without artificial correction).

CONCLUSION

In conclusion, this preliminary report can be estimated as an alternative technique with acceptable complication and cosmetic results for proximal hypospadias correction.

Two-stage flap repair of severe hypospadias: Usefulness of the tubularized incised plate urethroplasty

PURPOSE

The use of flaps in the two-stage repair of posterior hypospadias associated with severe chordee has been well established. Despite the almost certain guarantee of flap take, complications such as diverticuli are still relatively high. While different applications of the tubularized incised plate have been described, experience with the application of the technique to the two-stage flap repair is very limited. A previous local review of 15 cases performed at the present institution during the period 1998-2003, using the technique as described by Rekit, revealed fistulae and diverticulum rates of 20% and 27%, respectively. With the primary objective of improving surgical outcome, the midline incision was incorporated into the two-stage flap repair.

MATERIALS AND METHODS

Between 2004 and 2015, 35 boys (aged 2-15 years) with severe hypospadias that required excision of the urethral plate were operated using the two-stage flap technique. The first stage involved mobilization of preputeal or dorsal penile skin (if circumcised) to the ventral surface, as described by Retik. After a minimum interval of 6 months, the second-stage operation was performed in a way similar to the technique of tubularized incised plate urethroplasty, as popularized by Snodgrass, and involved a preliminary midline incision on the neo-urethral plate followed by tubularization and multilayered closure.

RESULTS

All but one flap took successfully. The outcome was satisfactory in 80% of patients, and there was a fistula rate of 14% ( Summary Table). One patient had a complete breakdown of the flap and was successfully treated about 12 months later by repeating the second stage of the operation. No case of diverticulum or stricture was recorded.

DISCUSSION

Even though there was a marginal improvement in the fistula rate, the most striking observation was the complete absence of diverticulum or stricture. With a reported incidence rate of 20-63%, different authors have reported diverticulum formation (despite the absence of distal obstruction) to be a major problem of the two-stage flap technique. Attempts by these authors at reducing the risk of diverticulum by reducing flap size have tended to increase the risk of strictures. This has been the main reason given by some authors for abandoning the technique. The main limitations of the present study included the wide age range of the patients and the small sample size.

CONCLUSION

The inclusion of a midline incision in a two-stage flap urethroplasty for proximal hypospadias appears to prevent the development of diverticulum.

A new modification of the Duckett technique for one-stage repairing urethral plate transected hypospadias: Another option for severe hypospadias?

OBJECTIVES

The study aimed to evaluate the new modification of the Duckett technique in decreasing the incidence of urethral strictures for urethral plate transected hypospadias and also explored its clinical application.

METHODS

Thirty-three patients (aged 7 months to 12 years, mean age 2.8 years) who underwent repair of primary hypospadias using the new one-stage urethroplasty were enrolled. Clinical data, including cosmetic and its complications, and uroflowmetry data were documented. Uroflowmetry data of 19 patients who underwent Duckett urethroplasty were used as a comparison.

RESULTS

The length of the urethral defect ranged from 2.5 to 5.0 cm. The postoperative follow-up was 14-30 months. Ten patients (30.3%) had fistulas; no patients had strictures or diverticula. All ten fistulas were small (<0.5 cm) and repaired with fistula repairing operation. The appearance of the penis remained satisfactory, and the meatus was located in the normal anatomic position. Among 17 patients who underwent uroflowmetry, all patients were bell-shaped or platforms, and Q _max was 7.37 ± 2.45 ml/s. Compared with 14 of 19 patients who underwent Duckett urethroplasty, the urethral function achieved with new one-stage urethroplasty was significantly better (p < 0.05).

CONCLUSIONS

The incidence of strictures was dramatically lowered in patients with proximal hypospadias. Small fistulas are common complications and can be repaired easily. Based on the uroflow pattern results, the quality of neourethra and function of it were better than Duckett urethroplasty. These preliminary results suggested that the modified procedure seems to be reliable and can be a suitable option for proximal hypospadias.

Neo-yoke repair for severe hypospadias: A simple modification for better outcome

BACKGROUND

Although staged repair for reconstructing severe hypospadias is more popular, various one-stage repairs have been attempted. Koyanagi repair (parameatal-based and fully extended circumferential foreskin flap urethroplasty) has enabled correction of severe hypospadias in one stage. However, its un-acceptably high incidence of complications has initiated a series of technical modifications, including the "yoke" repair.

OBJECTIVES

To retrospectively analyze the outcome of a proposed modification of the originally described yoke repair, for patients with severe hypospadias. This modification was developed to reduce complications.

STUDY DESIGN

Over 4 years (between Jan 2011 and Jan 2015), all cases of severe hypospadias were included in this study; except those with prior attempts at repair, circumcised cases, and cases with severe hypogonadism - because of partial androgen insensitivity - not responding to hormonal manipulations. The make-up of the neo-urethra in this modification is the urethral plate with its spongiosal tissue proximally, a circum-coronal preputial pedicled flap in the middle, and an incorporated part of the augmented preputial flap and the preserved V-shaped glanular urethra, distally. Close postoperative follow-up was conducted to investigate the outcome.

RESULTS

Thirty-one children with a median age of 32.48 months had repair of severe hypospadias using the neo-yoke technique. After a median follow-up of 26.7 months, the overall complication rate was 16.1%. Four children developed urethrocutaneous fistula (12.9%). Meatal drop-back occurred in one case (3.2%). No meatal stenosis or urethral sacculation was detected during follow-up of the studied group. Almost all cases had cosmetically appealing outlook. Single-staged repair of severe hypospadias using parameatal foreskin-based urethroplasty has passed through different modifications, all aimed at optimizing the outcome (Table).

CONCLUSION

Neo-yoke repair for severe hypospadias is a natural development of established one-stage techniques, which resulted in better mid-term outcomes. However, an extended study is needed to declare the long-term results.

Proximal hypospadias repair with bladder mucosal graft: Our 10 years experience

INTRODUCTION AND OBJECTIVE

A great variety of different surgical techniques has been described for proximal hypospadias repair and an ideal tissue has not been determined yet. We present our 10 years of surgical experience using a bladder mucosal graft for urethroplasty.

STUDY DESIGN

Bladder mucosal graft urethroplasty was performed between 2005 and 2015 in 50 patients with severe proximal hypospadias. The mean age of patients was 45.1 months (range 24-164 months). Hypospadias were perineal in 18 patients, scrotal in 22, and penoscrotal in 10. In all cases a chordee correction was performed and median time between the first and the second stages was 12 months (mean 17 months, range 4-68 months). Both foley catheter and a suprapubic cystostomy were positioned and maintained for 2-4 weeks. Follow-up was performed at 1-3 and 6-12 months after surgery, and afterwards annually with clinical examination and flowmetry test.

RESULTS

Mean follow-up was 5.3 years (median 5, range 1-10 years). Mean graft length was 57.4 mm (median 55 mm, range 35-85 mm). Among all the only early complication registered was a postoperative infection in one patient (2%) at the site of anastomosis. The long-term complications observed were urethrocutaneous fistula in nine patients (18%), urethral stricture in 15 patients (30%), meatal stricture in four patients (8%), and prolapse of meatus in seven patients (14%). The mean time of complication occurrence was 15 months (median 15.5 months, range 1-96 months). The functional and cosmetic appearance after surgery was satisfactory in 42/50 patients (84%) during the follow-up period.

DISCUSSION

There is still an open debate regarding the optimal surgical approach for management of severe proximal hypospadias. Compared with other approaches, our technique showed acceptable results even though encumbered by slightly higher complication rates.

CONCLUSION

Our results show that bladder mucosal graft for primary severe proximal hypospadias in selected patients is a possible alternative to other commonly used techniques, with the aim of restoring recovery of the normal continuity of the distal urinary tract see figure below.

Correction of Residual Ventral Penile Curvature After Division of the Urethral Plate in the First Stage of a 2-Stage Proximal Hypospadias Repair

PURPOSE OF REVIEW

The first stage of a 2-stage proximal hypospadias repair involves division of the urethral plate and correction of any residual ventral penile curvature (VPC). Options to correct residual VPC include dorsal corporal shortening or ventral corporal lengthening techniques. This review discusses these options and suggests an approach to management.

RECENT FINDINGS

Recent reports of 2-stage proximal hypospadias repairs indicate low rates of recurrent VPC with either dorsal corporal shortening or ventral corporal lengthening. Dorsal corporal shortening with dorsal plication may be preferentially used for mild to moderate residual VPC after division of urethral plate and ventral corporal lengthening reserved for severe residual VPC. Ventral corporal lengthening with grafts has been associated with urethroplasty complications after the second stage hypospadias surgery. Ventral corporal lengthening with relaxing incisions of corpora has been reported, but concerns about adverse effects require longer term studies. Little guidance exists to choose the best technique for VPC correction during first stage hypospadias repair after division of urethral plate. Reported literature suggests good results with dorsal plication techniques and ventral corporal lengthening. A practical approach is to use dorsal plication techniques for mild to moderate residual VPC after division of urethral plate (<45°) and reserve ventral corporal lengthening for severe residual VPC (>45°).

Unexpected outcome of a modification of Bracka repair for proximal hypospadias: High incidence of diverticula with flaps

INTRODUCTION

Various graft and flap techniques have been proposed for urethral reconstruction in proximal hypospadias repair. The Bracka repair involving the transfer of inner prepuce like a Wolfe graft mostly results in satisfactory results besides a high fistula rate.

AIM

The aim was to decrease the high fistula rate with Bracka repair; we wanted to use the advantages of vascularized skin in the Bracka method. The aim of this study was to evaluate our results with this modification.

STUDY DESIGN

Our modification involves using a flap instead of a graft. In the first stage, chordee was corrected by transection of the urethral plate and dorsal midline plication when necessary. Instead of a graft as suggested by Bracka, inner preputial skin with ample blood supply was transferred and stitched to the denuded ventral penile surface. In the second stage after 6 months, this flap was tubularized in the Thiersch-Duplay fashion. Hospital records of patients who had undergone two stage modified Bracka repair between June 2007 and July 2012 were reviewed, including complaints, complications, and need for interventions.

RESULTS

Thirty-eight patients had undergone this operation. Four patients were lost to follow-up. The main complaint was obstructed urinary flow. Voiding symptoms were first attributed to urethral stenosis, but were, however, found to be due to diverticulum and vortex of the urine in the dilated urethra. Twenty-one patients (61%) had voiding problems and 10 patients (29%) had urinary tract infections. Fistula was observed in 23 and diverticula were observed in 24 patients. Of these, 16 patients had both fistula and diverticula. Only two patients (5%) were free of complications and totally satisfied with the operation, and 23 of the 34 patients had complications requiring intervention (Figure).

DISCUSSION

Inner preputial flaps used in proximal hypospadias repairs are prone to diverticula formation. They become redundant in time requiring reoperation, thus decreasing the success rate. Careful fixation of the flap to the corpora and allowing time for additional attachment of the urethral plate substitution through fibrotic activity could not overcome this complication.

CONCLUSION

Our modification of the Bracka technique using a flap for the plate resulted in a high rate of complications (in particular diverticulum formation) and was therefore abandoned. We recommend careful use of flaps in hypospadias surgery and long-term follow-up studies to evaluate actual functional and cosmetic results.

Hypospadias: Are we as good as we think when we correct proximal hypospadias?

OBJECTIVE

Hypospadias surgery is a humbling art form. Although outcomes with distal hypospadias are favorable, recent publications have suggested that the complication rates are much higher than previously anticipated for proximal hypospadias. The present review examined the literature concerning proximal hypospadias, to explore some of the inadequacies and identify some of the reasons behind these shortfalls in the reported data.

METHODS

A systematic review of the published literature was conducted using keywords relevant to proximal hypospadias and long-term outcomes.

RESULTS

The literature for hypospadias was reviewed, and outcomes for distal vs proximal variants were compared. The quality of the literature for proximal hypospadias was examined, and the shortcomings that led to underreporting of the surgical outcomes were identified. Special focus was on the lack of standardized documentation, the subsequent inability to objectify the severity of the phenotype, and the underestimation of complications due to lack of long-term follow-up. There was also a great deal of variability in the utilized techniques, and the literature was filled with small case series from single institutions. To enable scientific assessment of outcomes, it is proposed that the following be implemented: acceptance and incorporation of standardized phenotype assessment scores in the pre-operative period, objective intraoperative hypospadias characterization, and postoperative score assessment.

CONCLUSIONS

Treatment of proximal hypospadias is much less successful than the distal variant. A specialty wide commitment to standardize the hypospadias language is required to make advancement in surgical outcomes. Boys need to be followed through puberty into adulthood, and honest reporting of outcomes must be discussed so that surgical techniques for this complicated disease process can be advanced.

Long-term functional outcomes after penoscrotal hypospadias repair: A retrospective comparative study of proximal TIP, Onlay, and Duckett

INTRODUCTION

A variety of techniques are available for proximal hypospadias repair. Onlay, proximal tubularized incised plate (TIP), and Duckett are among the popular choices because they can be performed as a one-step procedure. However, the decision to select a procedure often comes down to the surgeon's preference rather than that supported by evidence-based data. In particular, there is a paucity of literature on the long-term urinary outcomes after proximal hypospadias repair.

OBJECTIVE

The aim of this study was to evaluate the evolution of long-term uroflowmetry parameters after proximal hypospadias surgery over a long-term follow-up including the adolescent period.

STUDY DESIGN

Files from patients who underwent primary proximal hypospadias repair at our institution between 1997 and 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (pTIP vs. Onlay vs. Duckett) was performed according to the following postoperative time interval endpoints: 0-1 years, 1-2, >2-4, >4-6, >6-10, >10-12, and >12 years. Maximal urinary flow rate (Qmax) in relation to voiding volume (VV) adjusted for age or body surface area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques.

RESULTS

Fifty-two patients met the inclusion criteria with a median follow-up of 10 years: 25 (59.6%) TIP, 18 (34/6%) Onlay, and nine (17.3%) Duckett. Overall, Qmax increased progressively according to time and age in particular during the period covering adolescence. At follow-up 12 years postoperatively, median Qmax values were 18.5 mL/second, 13.8 mL/second and 16.6 mL/second for TIP, Onlay, and Duckett, respectively, with no significant differenced detected between groups (p = 0.5) see figure). Compared with normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax<25th percentile of nomograms was more prevalent in patients aged 3-7 years old at 83.8% but decreased to less than 21.2% in patients aged >13 years for all procedures (see figure).

DISCUSSION

These results are consistent with previous work showing frequently reduced Qmax after hypospadias surgery with great potential for improvement at puberty.

CONCLUSION

These results suggest that the obstructive urinary flow pattern observed in patients early on is a frequent finding after proximal hypospadias surgery. However, because of the remarkable improvement observed at puberty a watchful waiting approach is proposed in order to avoid unnecessary intervention.

Single institution outcome analysis of three surgical techniques over a 10-year period

INTRODUCTION

The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled.

OBJECTIVE

To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias.

METHODS

Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later.

RESULTS

A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR.

CONCLUSIONS

Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes.

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias

AIMS AND OBJECTIVES

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias.

MATERIALS AND METHODS

All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty.

RESULTS

Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52 %) children required a tunica albuginea plication for chordee correction. In total, 16 (17 %) patients developed 24 complications and 11 children (12 %) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus.

CONCLUSIONS

Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

Video presentation of the second stage of a two-stage repair for proximal hypospadias: a safe and reproducible technique

OBJECTIVE

The aims of proximal hypospadias repair are good cosmetic outcomes with low rates of complication, with a low number of operative exposures, before the age of genital difference realisation. Neo-urethral fistula and stenosis are well recognised complications; with international rates of 3.8-16% and 1.3-15.6% respectively. We present the key steps of the second of a two staged repair in video format.

METHOD

Video recording of the procedure performed on an 18-month-old with mid-penile hypospadias is presented. The steps are described; the importance of tension free tubularisation, layered urethral closure, suture technique, vascularised prepucal graft technique, optimal glanuloplasty, and penile shaft skin repair are highlighted.

RESULT

The child was brought back to the day ward for catheter removal at 7 days; follow-up in clinic showed good postoperative appearance. This technique has been performed on 31 boys with a fistula rate and stenosis rate favourable to the literature.

CONCLUSION

We demonstrate a two-stage technique by video format for proximal hypospadias which is reproducible and gives results comparable to the literature.