Different Types Of Hypospadias Research Articles

Hypospadias: a review

Hypospadias is a common congenital anomaly, characterized by an alteration in the fusion of the ureteral meatus on the ventral aspect of the penis during embryogenesis. It presents with a classic triad of abnormal foreskin, penile curvature, and ureteral meatus in an ectopic position. Different types of hypospadias have been recorded, which will vary according to their severity and anatomical characteristics. Although its etiology has not been completely determined, it is known that it has a multifactorial origin, among which is genetic predisposition and has been associated with alterations in hormonal influence during pregnancy. An incidence of 1 in 200-300 male newborns has been reported. It has been associated with risk factors such as prenatal exposure to estrogens. It has been described concomitantly with other congenital anomalies such as Wilms tumor or aniridia. The initial management is surgical, which seeks penile anatomical correction and obtaining functional and aesthetic results. Currently, the surgical technique is recommended in a single surgical moment, which favors lower risks of complications. Prenatal diagnosis is of great importance with a post-birth evaluation to determine the type of hypospadias presenting and evaluate the most appropriate surgical approach. Surgical management must be accompanied by multidisciplinary management along with pediatrics and psychology, which resulted in a better physical and psychological outcome for the patient.

Comparison of hypospadias phenotype pixel segmentation to GMS score

Hypospadias phenotype assessment determines if the anatomy is favorable for reconstruction. Glans-Urethral Meatus-Shaft (GMS) has been adopted in an effort to standardize hypospadias classification. While extremely subjective, GMS has been widely used to classify the severity of the phenotype to predict surgical outcomes. The use of digital image analysis has proven to be feasible and prior efforts by our team have demonstrated that machine learning algorithms can emulate an expert's assessment of the phenotype. Nonetheless, the creation of these image recognition algorithms is highly subjective. In order to reduce a subjective input in the evaluation of the phenotype, we propose a novel approach to analyze the anatomy using digital image pixel analysis and to compare the results using the GMS score. Our hypothesis is that pixel cluster segmentation can discriminate between favorable and unfavorable anatomy. To evaluate whether image segmentation and digital pixel analysis are able to analyze favorable vs unfavorable hypospadias anatomy in a less subjective manner than GMS score. A total of 148 patients with different types of hypospadias were classified by 1 of 5 independent experts following the GMS score into "favorable" (GG), "moderately favorable" (GM) and "unfavorable" (GP) glans. From there, 592 images were generated using digital image segmentation. 584 were included for final analysis due to certain images being excluded for poor image quality or inadequate capture of target anatomy. For each image, the region of interest was segmented separately by two evaluators into "glans," "urethral plate," "foreskin" and "periurethral plate". The values obtained for each segmented region using machine-learning statistical pixel k-means cluster analysis were analyzed and compared to the GMS score given to that image using an ANOVA analysis. Analysis of image segmentation demonstrated that k-means pixel cluster analysis discriminated "favorable" vs "unfavorable" urethral plates. There was a significant difference between scores when comparing the GG and GM groups (p=0.03) and GG and GP groups (p=0.05). Pixel cluster analysis could not discriminate between "moderately favorable" and "unfavorable" urethral plates. Through our analysis, we found significant pairwise difference for different tissue qualities. Digital image segmentation and statistical k-means cluster analysis can discriminate anatomical features in a similar way to the GMS score. Future research can target discerning between different tissue qualities in an effort to predict surgical outcomes for hypospadias repair.

Urethral advancement and glanuloplasty versus tubularized incised plate urethroplasty for distal hypospadias repair: a prospective randomized study

BackgroundAbout one in 200 to one in 300 male births has hypospadias. The prevalence of this congenital anomaly varies worldwide. The meatus is located distally in approximately 70% of cases. Several surgical techniques were described for distal hypospadias repair; despite this, there is no ideal approach. This study compares urethral advancement &glanuloplasty, and TIP techniques in terms of feasibility, duration of operation, and complications. Patients and.MethodsThis prospective randomized comparative study was conducted at Al-Azhar University Hospitals from April 2022 to October 2022. Fifty-seven cases with different types of hypospadias were assessed for eligibility. Among them, seven cases were excluded due to the presence of severe chordee (n = 3), proximal variant (n = 2), and recurrent cases of hypospadias (n = 2). Fifty cases were randomly divided into two groups using a 1:1 ratio (computer-generated randomization). Twenty-five cases were subjected to urethral advancement and glanuloplasty, and the rest were subjected to tubularized incised plate (TIP) urethroplasty.ResultsThe mean age of all studied cases was 4.2 years. Approximately 52% had coronal or sub-coronal meatus, whereas 48% had glandular meatus. Both groups were matched according to age and meatus location (p > 0.05). No statistically significant difference was observed between the two groups regarding duration of operation, postoperative pain, and postoperative hospital stay. In addition, both groups did not differ significantly in late complications (meatal stenosis, meatal retraction, fistula, and glans dehiscence).ConclusionsBoth urethral advancement &glanuloplasty, and TIP urethroplasty have comparable short-term outcomes. Urethral advancement and glanuloplasty is preferred in certain conditions, especially in circumcised children or those with a narrow urethral plate.Trial registrationThe study protocol was approved by the Pan African Clinical Trials Registry (number for the registry is: PACTR202211757905870) on (29/11/2022). All procedures were performed per the Helsinki Declaration.

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

BackgroundHypospadias 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.MethodsRetrospective 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.ResultsIn 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).ConclusionSeveral 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.

Is the Snodgrass technique suitable for different types of hypospadias? Single-center experience

Background: Hypospadias is a congenital penile defect and Tubularized Incised Plate (TIP) urethroplasty is a widely accepted option to repair this defect. Our experience about the outcome of hypospadias repair by this technique is discussed. Methods: This is a retrospective analytical study consisting of 80 cases, conducted between May 2017 to December 2019 at the Department of Pediatric Surgery, Maternity, and Children’s Hospital Dammam. All the cases with anterior, middle, and posterior hypospadias, who underwent Snodgrass TIP urethroplasty, were included in the study. The same surgeon performed all the operations. The follow-up period lasted for 2 years, after surgery and the final outcome of the procedure was recorded, based on the observations. Results: The age range of the patients varied between 1 to 9 years. Anterior hypospadias constituted 64 (80%) cases followed by middle hypospadias 13 (16.25%), and posterior hypospadias 3 (3.75%). By type, glanular hypospadias was the most common 30 (37.5%), followed by sub-coronal 19 (23.75%), coronal 15 (18.75%), mid-penile 11 (13.75%), proximal penile 2 (2.5%) and penoscrotal hypospadias 2(2.5%). Scrotal hypospadias was the least common type, 1 (1.25%). Overall complications that required re-intervention occurred in 16 (20%) cases. Urethrocutaneous fistula (UCF) which occurred in 7 (8.75) cases was the most common complication, followed by meatal stenosis in 4 (5%) and glans dehiscence and urethral stricture 2 in each (2.5% each). Total repair disruption was the least common complication that was noticed in 1 (1.25%) case. Functional and cosmetic results were judged as satisfactory. Conclusion: For hypospadias repair, TIP urethroplasty is the procedure of choice for anterior hypospadias with excellent results. It is also quite suitable with middle hypospadias and acceptable for posterior hypospadias for selected cases. The overall complication rate is low and also offers very good functional and cosmetic results.

Does the suturing technique (continuous versus interrupted) have an impact on the outcome of tubularized incised plate in hypospadias repair with adequate urethral plate? A prospective randomized study

Hypospadias is one of the most common anomalies of male external genitalia. The aim of hypospadias repair is to achieve a normal phallus with a satisfactory functional and cosmetic result and to develop a single and consistent urinary stream while in standing position. The introduction of tubularized incised plate (TIP) urethroplasty by Snodgrass in 1994 resulted in revolutionizing management of different types of hypospadias. While there is consensus on the use of absorbable sutures in hypospadias repair, there are no specific guidelines for the suturing technique and the technique itself remains debatable. To compare the outcome of interrupted- and continuous-suture in hypospadias repair using TIP technique. This was a prospective randomized study. It comprised 260 uncircumcised hypospadiac boys with adequate urethral plate who underwent TIP repair. Boys with glanular, recurrent, proximal hypospadias and inadequate urethral plate were excluded from the study. The boys were randomized into two groups: Group A consisted of 130 boys who underwent TIP repair using continuous subcuticular suture urethroplasty and Group B of 130 boys who underwent TIP repair using interrupted subcuticular suture urethroplasty. The operative time was of lower statistical significance in group A (P=0.006) while the rate of complications were of higher statistical significance in group A (P=0.027). Urethrocutaneous fistulae occurred in 20 patients (14 in Group A and six in Group B), which is a statistically significant difference (P=0.048). On the other hand, superficial wound infection, partial glans dehiscence, meatal stenosis, urethral stricture, and aesthetic appearance were statistically insignificant. The effect of suturing techniques in bowel anastomosis has been studied and it has been found that the use of an interrupted-suturing technique results in a decreased complication rate compared to continuous suturing. This agrees with our study where the running sutures groups was associated with a higher complication rate compared to interrupted sutures.

Work relative value units do not account for complexity and operative time in hypospadias surgery

Relative value units (RVU) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determine physician work RVU (wRVU) based on operative time, technical skill and effort, mental effort and judgement, and stress. In theory, wRVU should account for the complexity and operative time involved in a procedure. The primary aim of this study is to assess if operative time and complexity of hypospadias surgery is adequately accounted for by the current wRVU assignments. The American College of Surgeons National Surgical Quality Improvement Program Participant User File (ACS-NSQIP PUF) database was utilized from 2012 to 2017. Single stage hypospadias current procedural terminology (CPT) codes (including acceptable secondary CPT codes) were extracted. Using total wRVU and total operative time, the primary variable of wRVU per hour was calculated (wRVU/hr). Multivariable linear regression analysis was used to assess the relative influence that wRVU and operative time had on the wRVU/hr variable. 9810 cases were included in the final study population divided into four categories: simple distal (eg. MAGPI, V-Flap), single stage distal, single stage mid, single stage proximal. On analysis of variance, there was statistically significant different wRVU/hr for the four different types of hypospadias repairs with simple distal having the highest mean wRVU/hr of 19.5 and the lowest being proximal hypospadias repairs at 13.2. Simple distal, distal and midshaft hypospadias had statistically significantly higher wRVU/hr compared to proximal hypospadias (16.2, 95% CI: 15.8-16.5 vs. 13.2, 95% CI 10.9-15.5; p<0.001). Multivariable linear regression revealed that each additional hour of operative time was expected to decrease wRVU/hr by 10.5 (-10.5, 95% CI: -11.0 to -10.1, p<0.001); total work wRVU had a statistically significant independent association with wRVU/hr (0.6, 95%CI: 0.5-0.7, p <0.001). This the first objective assessment of the current wRVU assignments with regards to one stage hypospadias repairs. More complex and longer hypospadias procedures are not adequately compensated by wRVU. Most notably, simple distal procedures are reimbursed at a mean of 19.5 wRVU/hr compared to 13.2 wRVU/hr for one stage proximal repairs. This analysis of national-level data suggests that the current wRVU assignments significantly favor shorter and simpler procedures in hypospadias surgery.

Psychosexual Functioning Outcome Testing after Hypospadias Repair.

Self-confidence plays an important role in both genders’ sexual functioning. Lack of genital self-esteem may have negative effects on psychosexual development, especially in males, where deviations from a standardized normal penile appearance can lead to inhibitions in entering into sexual relationships. The aim of our study was to evaluate the informativeness of studied domains of the Global Sexual Functioning (GSF) questionnaire and sexual functioning of patients surgically treated in childhood for different types of hypospadias. We evaluated 63 males with hypospadias and 60 healthy age- and gender-matched controls. The GSF questionnaire was used to estimate psychosexual function as a long-term follow-up after the surgical correction of hypospadias in the patient and control groups. Sexual activity (p = 0.017), arousal (p = 0.033) and orgasmic abilities (p = 0.002) values were significantly increased in patients. Strong correlation was noticed between sexual activity and sexual desire (R = 0.872); arousal and sexual desire (R = 0.753), as well as orgasmic and erectile abilities (R = 0.769). Different domains of psychosexual functioning in the patient group correlated with each other to various degrees, resulting in a heterogeneous expression of psychosexual dysfunctions, implicating the necessity of a personalized treatment approach.

565 - Real prevalence and severity of penile curvature in different types of hypospadias

565 - Real prevalence and severity of penile curvature in different types of hypospadias

Case series: long term experience with different types of hypospadias and its correction by single stage procedure

Background: Hypospadias is a relatively common congenital defect of the male external genitalia. It is present in approximately 1 in 250 male newborns. Hypospadias, in boys, is defined as an association of three anomalies of the penis: an abnormal ventral opening of the urethral meatus that may be located anywhere from the ventral aspect of the glans penis to the perineum, an abnormal ventral curvature of the penis (chordee), and an abnormal distribution of foreskin with a “hood” present dorsally and deficient foreskin ventrally.Methods: In this study author operated 250 cases of Hypospadias of different types in different age groups during (1992-2017) using MAGPI for glandular, TIP and Flip-flap procedure for distal penile and Ducket Onlay Flap technique for Proximal penile, penoscrotal and perineal Hypospadias. Complicated / Failed Hypospadias was repaired by Trap door technique or Byer’s double tube technique.Results: After the primary repair of Hypospadias fistula was found in 4.5% of patients. Post-operative haemorrhage was seen in 3.2% of patients. Flap Necrosis was found in 8% of patients after Mathieu’s Flip- Flap technique. The success rate of Complicated Hypospadias was quite satisfactory and Meatal Stenosis was seen in 10% of the cases. Over All study has shown superior cosmetic results and one stage repair is cost effective, satisfactory and less psychologically affecting the parents and the patients.Conclusions: MAGPI and its different modifications in the repair for Glandular and Flip-flap or TIP for distal penile in cases of mild or no chordee. Proximal Penile has sufficient Chordee and can be corrected by dorsal plication and urethroplasty by Ducket’s Onlay flap technique. The cost-effectiveness due to single stage repair and its cosmetic results and there least complications prove the efficacy of this protocol. Single stage repair is also beneficial for developing countries like India where the follow-up compliance in the rural patients is extremely poor.

Expression of androgen, estrogen, and progesterone hormone receptors in the penile tissues of children with different types of hypospadias.

OBJECTIVE:Androgen (AR), Estrogen (ER) and Progesterone (PR) hormones play an important role in the prenatal and postnatal development of urogenital tract and especially the penis. The expressions of AR, ER and PR receptors in penile tissues in children with hypospadiases had also been shown previously. In this leading study, to demonstrate of the sex hormone receptor expression in cases with different types of hypospadias were aimed.METHODS:This study was designed in children operated due to hypospadiases without DSD. Biopsy samples of 3 mm’s were obtained from three different sytes as the lateral parameatal tissue and the anterior corner of the prepuce, and inner layer of posterior prepuce. The presence of AR, ER and PR receptors was investigated immunehistochemically.RESULTS:Mean age was 5.4 years in 18 children with hypospadiases; in totally 33 specimens were taken in 5 subcoronal as 5 specimens, and 7 penile as 15 specimens, and 6 penoscrotal as 13 specimens. According to sytes of samples; 13 samples were from lateral para-meatal tissues, and 13 were from anterior corners of prepuces, and 7 were from inner layers of posterior prepuces. In regard to receptor expression; ER and AR receptors were positive in 29 (87.8%) and 12 (36.4%) respectively; PR receptors were negative.CONCLUSION:This study emphasized the dominant expression of estrogen receptors in penile tissues of children with hypospadias. Although there was not a manifest correlation of androgen receptors absence in regard to the severity of hypospadias patients, there was a marked estrogen receptors presence in penile tissues. These findings suggest that the disrupted androgen and estrogen receptor interaction and/or balance could play a role during the development of external genitalia in hypospadias patients. Progesterone receptor was not present and therefore the active role in the postnatal development of hypospadias is still debatable.

Experience with tubularized incised plate urethroplasty in distal and mid penile hypospadias

Background: Whilst hypospadias is a common congenital defect in boys its aetiology largely remains unknown. The objective of this study was to evaluate the results of tubularized incised plate (TIP) urethroplasty in distal and mid-penile hypospadias repair. Patients and Methods: This was a prospective clinical study conducted in the Department of Pediatric Surgery over a period of 42 months (January 2012 to June 2015). All patients with distal and mid shaft hypospadias who underwent TIP urethroplasty in our department were studied. The patients were followed up for a period of 1 year after surgery. Results: Fifty eight patients (N = 58) with hypospadias (29 distal and 29 mid penile) were included in the study. The mean age at presentation was 4.5 years (range 3–7 years). The mean operative time was 70 min (range 55–90 min). The mean duration of postoperative stay was 11 days (range: 10–14 days). Overall 15 patients (25.86%) developed complications. Urethrocutaneous fistula (UCF) developed in 10 (17.24%) patients. Meatal stenosis occurred in six (10.34%) patients. Five patients (8.62%) developed flap necrosis and dehiscence of glans occurred in two patients (3.44%). The difference in complication rate between different types of hypospadias was not statistically significant (P > 0.05). There was no statistically significant difference in cosmetic and functional outcome between two groups operated by TIP urethroplasty. Conclusion: TIP urethroplasty is a simple and effective technique of repair for distal and mid-penile hypospadias in properly selected patients. It offers good functional and cosmetic results.

Effect of epidermal growth factor and testosterone on androgen receptor activation in urethral plate fibroblasts in hypospadias

To investigate androgen receptor (AR) expression and the effect of epidermal growth factor (EGF) and testosterone on AR expression level. EGF or different concentrations of testosterone were incubated with the primary urethral plate fibroblasts from patients with hypospadias. The levels of AR expression in the fibroblasts were detected by immunocytochemical assays and graphical analysis. There was no significant difference in AR activation under physiological concentrations (3×10(-8) mol/L) of testosterone between the control and the distal hypospadias group (P>0.05). However, there was a significant decrease in AR activation in the proximal hypospadias group compared to that in the control group (P<0.001). Under the concentration of 3×10(-6) mol/L, the effects of testosterone on AR activation were dramatically different in the three groups (control group>distal hypospadias group>proximal hypospadias group, P<0.001). AR activation level in the group of proximal hypospadias was improved most obviously when EGF and physiological concentration of testosterone were employed in the urethral plate fibroblasts from hypospadias patients (P<0.001), and it was improved more in the distal hypospadias group than that in the control group (P=0.02). AR expression and activation in the urethral plate fibroblasts from hypospadias patients are abnormal. EGF can be used to improve AR activation in fibroblasts from different types of hypospadias, especially in the proximal type.

Testicular disorder of sex development in four cats with a male karyotype (38,XY; SRY-positive)

The molecular background of disorders of sex development (DSD) in cats is poorly recognized. In this study we present cytogenetic, molecular and histological analyses of four cats subjected for the analysis due to ambiguous external genitalia. Three cases, with rudimentary penises and an abnormal position of the urethral orifice, represented different types of hypospadias. The fourth case had a normal penis, a blind vulva and spermatogenetically active testes. Histological studies showed structures typical of testes, but spermatogenic activity was observed in two cats only. All the cats had a normal male chromosome complement (38,XY) and the Y-chromosome linked genes (SRY and ZFY) were also detected. Fluorescent in situ hybridization (FISH), with the use of the feline BAC probe harboring the SRY gene, excluded the possibility of chromosome translocation of the Y chromosome fragment carrying the SRY gene onto another chromosome. Sequencing of four candidate genes (SRY—sex determining region Y; AR—androgen receptor; SRD5A2—steroid-5-alfa reductase 2 and MAMLD1—mastermind-like domain containing (1) revealed one SNP in the SRY gene, one common polymorphism in exon 1 of the AR gene (tandem repeat of a tri-nucleotide motif—CAG), six polymorphisms (5 SNPs and 1 indel) in the SRD5A2 gene and one SNP in the MAMLD1 gene. Molecular studies of the candidate genes showed no association with the identified polymorphisms, thus molecular background of the studied DSD phenotypes remains unknown.

A modified tubularised incised plate urethroplasty technique and a revised hypospadias algorithm.

To simplify and standardize surgical management of hypospadias, a modified tubularised incised plate (TIP) urethroplasty (Snodgrass) technique has been described and a revised hypospadias management algorithm has been formulated. The study aims to evaluate the viability of the described procedure in different types of hypospadias and tests the validity of the algorithm. The modification described is recruitment of penile and glandular skin lateral to the urethral plate to facilitate tubularisation. The algorithm starts with penile degloving with preservation of urethral plate. Snodgrass repair was done in cases with no chordee and where skin chordee resolved by skin take down. Modified Snodgrass repair was done in cases where urethral plate was narrow. Another modification proposed by us is single layer penile skin closure instead of an added dartos flap, which was done in both classical and modified Snodgrass repair. Cases of severe chordee not resolved by skin take down were repaired by transverse preputial island flap (TPIF) and Bracka's technique. Dorsal plication was not used as an orthoplasty modality. It was possible to repair 68.89% of the cases by Snodgrass repair. These patients either had no chordee or had superficial skin tethering (skin chordee) which resolved on degolving. All these cases were coronal, distal and mid penile hypospadias. Remaining cases were mid, proximal and penoscrotal with true fibrous chordee and were repaired by TPIF or Bracka's technique. The Snodgrass technique had a fistula rate of 9.67%. Acceptably, low fistula rate and simple execution make the proposed modification of classical Snodgrass repair a viable option. The proposed algorithm proves to be a useful tool for standardised and logical preoperative decision making. It also defines indications of the three techniques vis-à-vis the type of hypospadias.

Long-Term Results of Preputial Reconstruction in Selected Cases of Hypospadias

Purpose To evaluate the long-term results of preputial reconstruction (PR) (instead of circumcision) in selected cases of hypospadias repairs. Material and Methods 216 consecutive primary hypospadias repairs performed before 01/01/2000 by 2 pediatric urologists in 1 institution were identified; 9 were lost for FU, the remainder had a mean FU of 93 (minimum: 60) months. PR was performed in all cases where this was both technically feasible and the parent's preference. Types of hypospadias repair were MAGPI in 98, Mathieu in 32, TIP in 26, onlay in 49 and 2-stage in 2 cases. PR was performed in 128 of 207 cases (62%); This was after MAGPI, Mathieu, TIP, Onlay and 2-stage type repairs in 85(87%), 21(66%), 20(77%), 2(4%) and 0(0%) repectively. Results Three specific types of complications can occur after PR which are avoided by primary circumcision: dehiscence of the PR, formation of a preputial fistula ( = minor partial dehiscence, not communicating with the urethra) or syptomatic / fibrotic phimosis. In this series, 16 boys (8%) had a specific PR-related complication leading to re-operation in 11(5%): 8 preputial fistulae (1 circumcision; 5 fistula-repairs; 2 no intervention) and 8 symptomatic and/or fibrotic phimosis (3 circumcisions; 2 preputioplasties; 3 conservative management). No preputial dehiscence occurred. No significant differences in PR-related complications were seen after different types of hypospadias repairs. The majority of PR-related complications occured during the first year after hypospadias repair. In the remaining 112 boys, the prepuce was fully retractible in 110 and partially retractible in 2 (without fibrosis or symptoms) at the last FU visit. Our results are comparable to the very scarce previous literature on this subject which has upuntill now only presented short-term results. Conclusions Preputial reconstruction is feasible in over 60% of hypospadias repairs (if this is the patient's/parent's preference) at the cost of a limited number of additional complications (8%) and re-operation rate (5%).

Versatility of tubularized incised plate urethroplasty in the management of different types of hypospadias: 5-year experience

The outcomes of urethroplasty in the management of different types of hypospadias have continued to improve since the introduction of the tubularized incised plate (TIP) urethroplasty (Snodgrass method). The aim of this study was to evaluate the feasibility and applicability of TIP urethroplasty in the management of different types of hypospadias. This work was carried out at Al-Azhar University Hospital, Cairo, Egypt in the period from January 2002 to December 2002 and King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia; in the period from January 2003 to January 2007 by the same authors. The medical records of 175 boys with different types of hypospadias, who underwent TIP urethroplasty, were critically reviewed. Their age ranged from 9 to 36 months (mean age; 22.72 +/- 7.75 months).The period of follow-up was ranged from 7 to 60 months (mean 34.42 +/- 15.41). All families were happy with penile aesthetic appearance. The total number of boys with different types of hypospadias was 175 (145 1ry and 30 2ry). Out of 175 cases, the overall urethrocutaneous fistula rate was 11 (6.29%), and the overall rates for glanular dehiscence, urethral stricture, meatal stenosis and meatal regression were 4 (2.29%), 5 (2.86%), 17 (9.71%), and 10 (5.71%), respectively. All cases of urethral stricture and most cases of meatal stenosis 12 (6.86%) responded well to regular urethral dilatation. Meatoplasty was performed in only 5 (2.85%) cases (1 of 1ry and 4 of 2ry cases). Secondary surgery for fistula repair and glans closure was successful in all patients. All children void with a single straight urinary stream in a forward direction, and have a rounded glans with vertical slit- like terminal glanular meatus. The mean hospital stay was 4.6 days. TIP urethroplasty with neourethral coverage using a vascularized pedicle of dartos flap is versatile and simple operation in management of different types of hypospadias. It has a good functional and cosmetic outcome.

The Concept of Tubularized Incised Plate Hypospadias Repair for Different Types of Hypospadias

Using the concept of tubularized incised plate (TIP) urethroplasty technique for proximal, distal, primary, secondary and complicated cases of hypospadias. From June 2002 to December 2003 TIP urethroplasty was performed in 15 patients between the age of 1-18-year-old with penosecrotal, mid shaft and subcoronal hypospadias. In 13 of them TIP urethroplasty used as the primary repair while in two of them as secondary repair. No clinically important complications were observed in those boys who underwent primary reconstruction. One of them had meatal stenosis at the early postoperative period which was corrected by dilatation of the external meatus by feeding catheter at intervals up to 2 months postoperatively. Three boys had very narrow fistula which just allow leak of few drops of urine through urination. One boy with penoscrotal hypospadias who underwent two-stage repair had fistula. The concept of TIP urethroplasty is the procedure of choice for the treatment of proximal hypospadias and, it seems to be suitable for distal, secondary and even complicated hypospadias reconstruction. The advantages of this procedure include its simplicity, low complication rates and very good appearance of the glance with normal meatus.

Hypospadias and the androgen receptor gene: mutation screening and CAG repeat length analysis.

We report on mutation screening and CAG repeat length analysis of the androgen receptor (AR) gene in 21 patients with hypospadias. The urethral meatus was located at the glandular region in six patients (glandular type), at the penile shaft in seven patients (penile type), and at the scrotal/perineal region in eight patients (scrotal/perineal type). Mutation screening was performed for exons 1-8 and their flanking introns (except for the CAG and GGC repeat regions at exon 1) by the heteroduplex detection method and showed no abnormal chromatograms. The CAG repeat length analysis was carried out using 50 normal boys and 50 fertile males as controls, and demonstrated no statistically significant difference in the median of CAG repeat lengths or in the frequency of long CAG repeats (> or = 26 or > or = 28) between the controls and the patients with the three different types of hypospadias. The results suggest that AR gene abnormalities do not constitute a major factor in the development of hypospadias.

Hypospadias: 10 year review of outcome of treatment in pediatric urological practice

Introduction: Hypospadias and its surgical correction is a challenging urologic discipline. Various surgical procedures for correction of this anomaly have evolved, in order to reduce complication rate and improve cosmetic outcome. The aim of this study is to review the complication rate and cosmetic outcome in patients who had hypospadias surgery at Ahmadu Bello University Teaching Hospital, Zaria. Patients and Methods: The case records and clinical appearance of 54 patients with hypospadias who had surgery between June1998 and June 2008 were reviewed. The effect of different variables on the overall complication rates were evaluated, including: the degree of chordee; the urethral meatal site after correction of any penile curvature; the age of the patient at surgery; the source of the neourethra; and tubularization of the flap. Result: The mean age of the patients was 1.97 (0.5-12) years. Most patients had their repair at 2 years of age. Twenty-six had distal hypospadias while twenty-eight were mid penile or proximal hypospadias. Distal hypospadias have a better outcome than proximal hypospadias. Onlay flaps have lower stricture and fistula compared with tubularized flaps. Repairs are done recently at earlier age with equal or better outcome. Conclusion: Skin flap procedures have had sufficiently extensive use to support the feasibility of a one-stage repair of different types of hypospadias. Snodgrass is gaining popularity in recent times, and more procedures are likely to evolve in order to improve cosmetic outcome.