Distal Hypospadias Research Articles

Does grafted tubularized incided plate improve the outcome after repair of primary distal hypospadias: A prospective randomized study?

ObjectiveTo detect whether grafting the incised plate during Snodgrass repair would improve outcome. Materials and methodsSixty patients with primary distal hypospadias were included. Patients were equally randomized using closed envelop method to either Snodgrass or grafted tubularized incised plate repair (GTIP). All operations were performed by a single surgeon. All intaroperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meatus at the tip of the glans with no stenosis, fistula or diverticulum. ResultsAll 60 patients were evaluated at 1 year of follow-up. Mean age at surgery was 40±15months. Both groups were comparable as regard to patients' age, meatus location, length and width and depth of urethral plate and glans width. Success was documented in 29/30 patients (96.7%) in the Snodgrass group. The only complication was meatal stenosis in one patient, whereas success was documented in 28/30 patients (93.3%) in the GTIP group. The two failures were secondary to partial glans dehiscence. Success rate was not statistically different. Flow rate data at 1 year showed insignificant difference between both groups as regards Q-max and voiding time. The only statistically significant difference between both groups was a longer operative time 106±12min in the GTIP group compared to only 77±9 for the Snodgrass group (p = 0.005). ConclusionsSnodgrass and GTIP techniques for primary distal hypospadias repair have similar outcome. With a significantly shorter operative time, Snodgrass repair remains the first choice for primary distal hypospadias repair. Type of the studyProspective randomized study. Level of evidenceLevel I.

Commentary to: ‘Non-stented versus stented urethroplasty for distal hypospadias repair: A systematic review and meta-analysis'

Commentary to: ‘Non-stented versus stented urethroplasty for distal hypospadias repair: A systematic review and meta-analysis'

690 - Preputial dartos fascia flap as a secure layer in tubularized incised plate urethroplasty for repair of uncircumcised patients with distal hypospadias

690 - Preputial dartos fascia flap as a secure layer in tubularized incised plate urethroplasty for repair of uncircumcised patients with distal hypospadias

PT020 - Functional and cosmetic outcomes in adult life of distal and penile hypospadias repaired in childhood

PT020 - Functional and cosmetic outcomes in adult life of distal and penile hypospadias repaired in childhood

689 - Inlay internal preputial graft urethraoplasty vs tubularized incised plate urethroplasty for primary distal hypospadias

689 - Inlay internal preputial graft urethraoplasty vs tubularized incised plate urethroplasty for primary distal hypospadias

A TREATMENT OPTION FOR THE DISTAL FORM OF HYPOSPADIA WITH THE USE OF F-II TECHNIQUES (HODGSON-II MODIFICATION)

Introduction. At the moment present, the problem of choosing the method of correction of distal hypospadias due to persistent numerous postoperative complications has not been completely solved. The most frequent complications are fistulas, stenoses and lysis of neo-urethra. Distal hypospadias is divided into distal stem, coronary and capitate. Features of the anatomical structure of the head, prep and meatus in children with hypospadia are often explained by a deficit of plastic material, which can lead to mistakes in the choice of the method of urethroplasty. The current principles of plastic surgery still do not completely eliminate postoperative complications. Material and methods. Since 2004, due to using the F-II procedure 208 operations have been performed without complications mentioned above. At the moment, the long-term results are being investigated. Results. Prolonged search for the optimal approach for the correction of distal forms of hypospadias suggests the need to modify the Hodgson-II technique and introduce it into clinical practice. In this article, the advantages and principal differences of the operation of F-II in comparison with Hodgson-II modification, a brief literary reference about the current world studies of the complications of distal urethroplasty are presented. Conclusion. When using the urethroplasty with a displaced prepuce flap according to the F-II procedure, we get an advantage over the stock of plastic material in comparison with urethroplasty by local tissues. Compared with the Hodgson technique, we get the best cosmetic and functional result.

Outcome of anterior hypospadias repair: A single center experience

Background: Hypospadias is a common congenital condition affecting the male phallus. It is characterized by abnormal opening of the urethra on the ventral aspect of the penis with ventral curvature of the phallus (chordee). Various surgical techniques have been described in the treatment of hypospadias. Evaluate the surgical outcome of anterior hypospadias repair including different procedures used to repair distal hypospadias. A retrospective observational study conducted by the Department of Pediatric Surgery, Kempegowda institute of medical sciences hospital, Bangalore from January 2014 to January 2018 over a period of 4 years. Patients and Methods: All children with anterior hypospadias were included in the study. Children underwent either meatal advancement and glanuloplasty (MAGPI) or Snodgrass urethroplasty depending on the type of hypospadias. On follow–up, children were evaluated for complications. Chi square test was used to test for relationships between categorical variables. Results: Fifty children were included in the study. Age ranges of children were between 9 months to 14 years. Coronal hypospadias was the most common variety (32%). Chordee, undescended testis, inguinal hernia, and penile torsion were observed in 44%, 4%, 6%, and 4%, respectively. On preoperative ultrasonography, renal anomalies were observed in 4 (8%) children. Out of 50 children, 25 underwent MAGPI and remaining 25 underwent Snodgrass repair. Postoperative complication was seen in nine children (18%). Most common complication was urethral fistula seen in five (10%) children followed-by meatal stenosis. Of these nine children with complication, only three children required resurgery. Conclusion: Distal hypospadias is uncommonly associated with renal anomaly, which was once again reiterated in our study. Undescended testis and inguinal hernia were the most common associated anomalies with distal hypospadias. MAGPI is choice in case of glanular and coronal hypospadias with minimal chordee. Snodgrass technique is excellent choice in subcoronal and distal penile hypospadias with chordee.

The Modified Multilayer Coverage of Urethroplasty for Distal Hypospadias.

Purpose:Our purpose is to present the modified multilayer coverage to prevent fistula and to present also the glans dissection respecting the continuity between glans and corpus spongiosum. We think an important factor for glans vascularization that prevents glans disruption for patients with distal hypospadias and report the follow-up.Introduction:Fistula and glans disruption are still the most frequent complications of hypospadias surgery. Neourethral coverage is a mandatory step in this challenging surgery; it reduces the rate of fistula.Materials and Methods:Between September 2013 and December 2015, the modified multilayer coverage using two or three intermediate layers was performed in 110 patients with distal and midshaft hypospadias. Follow-up based on local examination, visual assessment of urine stream, and parent satisfaction was recorded at 1, 3, 6 months, 1 year, and yearly thereafter. Patients lost for the follow-up and the circumcised patients with a bad quality remaining dorsal dartos are excluded from the study.Results:Intraoperatively, the decision whether two or three intermediate layers should be performed depending on the type of the hypospadias and the presence of hypoplastic urethra. Among the 88 patients retained for the study, 86 patients presented satisfactory results, but one patient had a fistula that healed spontaneously and the second patient had a glans disruption.Conclusions:The modified multilayer coverage with a wings glans dissection respecting the continuity of spongiosum and glans is a reliable procedure to reduce the rate of fistula and glans disruption in anterior and midshaft hypospadias.

The Penile Perception Score after distal hypospadias repair with tubularized incised plate and Mathieu

Objective: The aim of this study was to evaluate the Penile Perception Score (PPS) after repair of distal penile hypospadias using tabularized incised plate (TIP) and Mathieu procedures. Methods: A randomized controlled study was conducted at urology department from October 2013 to May 2014. It included 60 children who were divided into three groups: group A included 20 patients with distal hypospadias corrected using TIP; group B included 20 patients with distal hypospadias corrected using Mathieu; and group C included 20 children with normal male genitalia who were circumcised and considered as a control group. Results: There were no statistically significant differences between group A and group B in urologists’ and parents’ average sum of PPS evaluation, but urologists’ satisfaction was more than parents’ satisfaction. The PPS for TIP was 8.43 and 7.80 for urologists and parents, respectively. The difference was significant. The PPS for Mathieu were 8.04 and 7.89 for urologists and parents, respectively, with no significance. There were no statistically significant differences between group A and group B in the postoperative evaluation by urologists and by parents in meatus, glans, shaft skin, and general appearance. There were complications in 10% of cases from group A in the form of fistula, in 30% of cases from group B in the form of fistula in 25% and meatal stenosis in 5%, and no complication in group C. Conclusion: TIP showed better PPS score compared with Mathieu in hypospadias repair. However, the results of this study were not statistically significant. PPS was a good scale to evaluate hypospadias repair after surgery. Keywords: hypospadias, parents and urology, Penile Perception Score

Management of hypospadias in Saudi Arabia: A national survey.

Introduction:Hypospadias is one of the most common congenital anomalies of the penis. Different methods of hypospadias management are described in the literature. We try in this study to evaluate the national trends and to compare them with international practices.Materials and Methods:A multiple choice survey was distributed among a sample of national practitioners using a weblink between September and December 2017. It included questions about participants demographics, number of cases operated on per year, perioperative care and preferences, long-term follow-up, and complications. Data were analyzed and compared with international practices.Results:Results of 47 practitioners were evaluated and analyzed in this study. The majority of the participants were pediatric urologists (48.9%) and from the central province (44.7%). Most of the participants prefer to operate on patients between the ages of 1 and 2 years (48.9%) and operate at ≥20 cases per year (76.6%). Tubularized incised plate (TIP) is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for proximal cases. All participants use a form of a second layer and a stent for their repairs. The majority reported an overall complication rate of ≤10% for distal penile hypospadias (76.1%) and >10% for proximal penile cases (59.6%).Conclusion:This study helped us identify national trends in hypospadias management, which were comparable to the international trends. TIP repair is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for more complex proximal variants. Although data in this study come from reports of personal experience, it can serve as a backbone for the future prospective studies on this topic.

Comparative study between tubularized incised plate urethroplasty with and without dorsal inlay graft

Objectives The aim of this study was to compare the results of two single-stage hypospadias repairs, namely, tubularized incised plate (TIP) repair with and without dorsal inlay preputial skin graft urethroplasty as regards meatal stenosis, urethral stricture, and cosmetic outcome. Background The most commonly performed operation to repair distal hypospadias is the TIP repair. The key step is midline incision of the urethral plate, which widens a narrow plate and converts a flat groove into a deep plate groove, ensuring a vertical, slit neomeatus and a normal-caliber neourethra. At times in cases of distal hypospadias, the urethral plate is very narrow and needs to be augmented or substituted for further tubularization. We report our experience with primary single-stage dorsal inlay urethroplasty using inner preputial skin grafts. Patients and methods This study included 30 patients less than 10 years old who presented with primary distal types of hypospadias with narrow urethral plate at the Department of Plastic Surgery, Menoufia University Hospital and were divided into two groups: group A included 14 patients operated by TIP without dorsal inlay graft and group B included 16 patients operated by TIP with dorsal inlay graft. Patients who had undergone circumcision, previous hypospadias repair, or who had a deeply grooved urethral plate were excluded. Results A total of 16 children underwent primary dorsal inlay preputial graft urethroplasty, of whom one (6.2%) child had partial wound dehiscence, two (12.5%) of the children had meatal stenosis, and one (6.2%) of these children developed urethral stricture; 14 children underwent TIP urethroplasty, of whom two (14.3%) children had wound dehiscence, four (28.6%) of the children had meatal stenosis, and four (28.6%) of these children developed urethral stricture. Conclusion Primary dorsal inlay inner preputial graft urethroplasty successfully fulfills all traditional hypospadias repair criteria. It offers a viable, safe, rapid, and easy option in the management of proximal hypospadias with a narrow urethral plate.

Prophylactic Antibiotics After Stented, Distal Hypospadias Repair: Randomized Pilot Study.

The usage of prophylactic oral antibiotics following distal hypospadias repair with stenting has been recently challenged. This study evaluated the incidence of symptomatic urinary tract infections (UTIs) following stented, distal hypospadias repair and the impact of prophylactic antibiotic therapy. Subjects 0 to 5 years of age with distal hypospadias were randomized to either Group 1 (antibiotics) or Group 2 (no prophylactic therapy). Urinalysis/urine culture was obtained intraoperatively with no preoperative antibiotics given. Phone interviews at 1 month and 3 months after surgery were done. Forty-eight patients were successfully randomized to either Group 1 (24) or Group 2 (24). The incidence of symptomatic UTI in this pilot study is low, and prophylactic antibiotic therapy does not appear to lower the incidence of symptomatic UTI. A larger, randomized, multicenter trial is needed to determine whether antibiotic prophylaxis reduces the risk of symptomatic UTIs following stented, distal hypospadias repair.

Comparison of Anatomical Landmarks and Dimensions in a Hypospadiac Glans with Those of a Normal Glans.

Aim of the Study:The aim of this study is to establish ventral glans length (VGL), meatus (M) size, and their ratio VGL/M (R) in normal Indian boys and to compare these with the respective equivalent dimensions in boys with distal and mid-penile hypospadias using anatomic landmarks.Methods:Normal boys were designated as Group A (n = 108), and the boys with hypospadias were designated as Group B (n = 81). The anatomical landmarks marked on the glans were measured using a digital camera and appropriate software.Results:The mean age of the boys in Groups A and B was 4.26 ± 3.59 (range 0.5–12) and 3.82 ± 2.85 (0.7–11) years, respectively. The observed mean values in Group A for VGL-A, M-A, and R-A were 3.05 ± 1.27 (range 1.19–8.09), 4.3 ± 1.23 (range 1.61–7.04), and 0.8 ± 0.45 (range 0.27–2.1) mm, respectively. The observed mean values in Group B for VGL-B, M-B, and R-B were 3.77 ± 0.81 (range 12.41–5.2), 3.27 ± 0.71 (range 2.25–5.34), and 1.17 ± 0.26 (range 0.84–1.86) mm, respectively. Comparison of R-A and R-B showed a statistically significant difference (P < 0.0001).Conclusions:The dimensions and the studied ratio between a hypospadiac glans and a normal glans differed significantly. The ratio between VGL and M was 0.8 in normal boys. In comparison, the ratio between the equivalent VGL and M in the hypospadiac boys was 1.17. During glansplasty in surgery for hypospadias, this factor should be taken into consideration to avoid the creation of long and tight ventral glans closure.

A New Management Protocol for Lowering the Rate of Distal Penile Hypospadias Fistula

A New Management Protocol for Lowering the Rate of Distal Penile Hypospadias Fistula

Antibiotic Prophylaxis with Trimethoprim-Sulfamethoxazole versus No Treatment after Mid-to-Distal Hypospadias Repair: A Prospective, Randomized Study.

Purpose To evaluate the impact of prophylactic antibiotics after distal hypospadias repair on postoperative bacteriuria, symptomatic urinary tract infection, and postoperative complications in a prospective, randomized trial. Materials and Methods Consecutive patients aged 6 months to 2 years were enrolled at our institution between June 2013 and May 2017. Consenting patients were randomized to antibiotic prophylaxis with trimethoprim-sulfamethoxazole versus no antibiotic. Patients had catheterized urine samples obtained at surgery and 6–10 days postoperatively. The primary outcome was bacteriuria and pyuria at postoperative urine collection. Secondary outcomes included symptomatic urinary tract infection and postoperative complications. Results 70 patients consented to the study, of which 35 were randomized to receive antibiotics compared to 32 who did not. Demographics, severity of hypospadias, and type of repair were similar between the groups. Patients in the treatment group had significantly less pyuria (18%) and bacteriuria (11%) present at stent removal compared to the nontreatment group (55% and 63%; p=0.01 and p < 0.001, resp.). No patient had a symptomatic urinary tract infection. There were 11 postoperative complications. Conclusions Routine antibiotic prophylaxis appears to significantly decrease bacteriuria and pyuria in the immediate postoperative period; however, no difference was observed in symptomatic urinary tract infection or postoperative complications. Clinical Trial Registration Number NCT02593903.

Limited Urethral Mobilization Technique in Distal Hypospadias Repair : An Overview

Background: Fistula formation is the most common complication with various rates among different techniques of hypospadias repair. The urethral advancement as an one stage technique for repair of hypospadias is considered a good technique. As no new urethral tube is constructed there is no risk of fistula. We assess the outcomes of the Limited Urethral Mobilization (LUM) technique in distal hypospadias repair.Methods: Our study included 20 patients aged upto 12 years who were treated with Limited urethral mobilization technique for distal hypospadias in Shaheed Suhrawardy Medical College Hospital from December 2014 to December 2015. The urethra proximal to the meatus was mobilized for a distance sufficient to allow it to reach the glans tip without tension. Then the urethra was placed in the glanular bed and glanular reconstruction was performed.Results: Three-fold urethral mobilization was sufficient for construction of tension-free urethra-glanular anastomosis. Cosmetically normal looking circumcised penis with ventrally slit meatus achieved in all but one subcoronal case where the most distal of the glans approximation sutures disrupted leading to a minor detachment in the glans. The minor complications includes preputial edema in one patient, two patients had wound infection, one had meatal stenosis which was treated with gentle dilatations. Postoperative urethro cutaneous fistula, retraction of the urethral meatus or recurrent chordee were not observed.Conclusion: Distal hypospadias repair with the LUM technique can be effective with satisfactory cosmetic and functional results. There is no chance for development of urethro cutaneous fistula, a major postoperative complication of other surgical techniques of creating a neourethra. Postoperative management is simple and a brief hospital stay is sufficient.Chatt Maa Shi Hosp Med Coll J; Vol.16 (1); Jan 2017; Page 37-41

Utilization of Postpenile Surgery Illustrated Healing Atlas: A Comparative Study

To determine the effect of the postpenile surgery illustrated healing atlas on caregivers' anxiety levels pre- and postoperatively, the frequency of family's postoperative communication with the urology care team, and the number of unplanned emergency room (ER) return for wound checks. A prospective cohort enrolled children who underwent penile surgeries (distal hypospadias repair and phalloplasty) with no concomitant procedures from December 2016 to June 2017. A 6-item short-form Spielberger State-Trait Anxiety Inventory (STAI) was used to determine baseline and postoperative anxiety levels of the caregivers. Two groups were created: caregivers who did not view the illustrated atlas vs caregivers who were shown the atlas. Baseline characteristics and demographics were compared, along with caregiver's pre- to postoperative anxiety level difference, frequency of postoperative communication, and number of unplanned ER return for wound checks. Fifty-four patients were enrolled with 27 families in each group. Baseline characteristics and demographics were comparable with no significant differences. The assessment of the pre- to postoperative anxiety levels in both groups showed no significant differences (median difference -5 [interquartile range -8 to -5] vs -5 [interquartile range -8 to -4], P = .94). Although no differences were noted for ER-return rates between the groups (18% vs 11.1%, P = .704), significantly less postoperative calls and e-mails were noted among families who received or viewed the postpenile surgery illustrated healing atlas (51.9% vs 11.1%, P = .003). The utilization of a postpenile surgery illustrated healing atlas as part of the postoperative support provided to families was able to decrease postoperative calls and e-mails.

Role of urethral plate and fossa navicularis biopsies in the detection of balanitis xerotica obliterans in boys undergoing redo hypospadias repair

ObjectivesTo evaluate the presence of balanitis xerotica obliterans (BXO), clinically and pathologically, in the urethra of boys with failed previous hypospadias repair and where surgical management was planned. Patients and methodsBetween February 2010 and March 2015, boys with failed distal penile hypospadias repair who were planned for surgical management were evaluated for the presence of clinical and pathological evidence of BXO. Samples were obtained from the urethral plate and fossa navicularis, after obtaining informed consent and ethical approval. The samples were fixed, sectioned, and haematoxylin and eosin stained for light microscopic examination. ResultsIn all, 157 boys were enrolled in our study, with a mean (SD) age of 6.4 (2.8)years. All the boys had a history of failed hypospadias repair surgeries (once or more). The presentation was fistula in 34 boys (21.7%), meatal stenosis in 45 (28.7%), urethral stricture in 28 (17.8%), and total dehiscence in 50 (31.8%). BXO was detected clinically in 46 boys (29.3%). The total number of biopsies taken was 314, of which 124 (39.5%) were pathologically BXO-positive samples. Of the 157 boys, BXO-positive cases were clinically associated with fistula in seven boys (4.5%), meatal stenosis in 18 (10.8%), urethral stricture in seven (4.5%), and total dehiscence in 15 (9.6%). Of the 314 pathological samples, pathologically BXO-positive samples were associated with fistula in 20 samples (6.4%), meatal stenosis in 40 (12.7%), urethral stricture in 22 (7%), and total dehiscence in 42 (13.4%). ConclusionsIn failed hypospadias cases BXO should be considered, especially for cases with multiple failures, meatal stenosis, and total dehiscence. Urethral plate and fossa navicularis biopsies are important in planning a proper approach for subsequent repair.

The role of preoperative intra muscular testosterone in improving functional and cosmetic outcomes following hypospadias repair: A prospective randomized study

There are very few well-designed studies on the role of preoperative testosterone in hypospadias repair. The aims of the current study are to ascertain the efficacy of intramuscular testosterone in increasing the glans width, reducing the complications and improving the functional and cosmetic outcomes. Between January 2013 and December 2016, a total of 200 patients with distal hypospadias were recruited to this prospective randomized study. Only patients with distal hypospadias eligible for a tubularized incised plate (TIP) repair were included. Group 1 did not receive any intervention, and group 2 received three doses of intramuscular testosterone enanthate 2mg/kg at the age of 9, 10, and 11 months. Glans width was measured in millimeters in all patients using calipers at the time of recruitment and at the time of surgery. Within group 2, those who failed to have more than a 2mm increase in size were considered non-responders (group 2a), and the remaining were taken to be responders (group 2b). TIP repair was performed by the same surgeon, and patients were followed up, looking for urethrocutaneous fistula, glans dehiscence, meatal stenosis, etc. Cosmetic evaluation was performed using the Parental Penile Perception Score (PPPS). A total of eight patients dropped out in group 1 (n=92), while six dropped out in group 2 (n=94). In group 2, 17% patients did not respond to testosterone (group 2a; n=16), whereas 83% showed significant increase in glans width (group 2b; n=78). The table compares the functional and cosmetic outcomes between groups. Total complications were significantly less in group 2b (17.9%) than in group 2a (50%). The reoperation rate was significantly less in group 2b (11.5%) than in group 1 (23.1%). A significantly higher number of parents (p=0.03) were satisfied with cosmesis of the glans/meatus in group 2b (71/78; 91%) compared with group 2a (11/16; 69%) or group 1 (72/92; 78%). The overall PPPS was significantly higher (p=0.003) in group 2b (8.88±2.20) than in group 1 (8.03±1.55). Two systematic reviews on the role of preoperative testosterone failed to reach any conclusion. One described a glans width <14mm as a risk factor for urethral complications after hypospadias repair but another did not support this. Our findings reveal that preoperative testosterone significantly increases the glans width thereby reducing the complications and requirement for reoperation. It also improves the cosmetic outcomes and parental satisfaction.

Comparative study between the usage of transurethral diversion and suprapubic cystostomy after distal hypospadias repair by tubulerized incised urethroplasty

Objective:-to compare the usage of transurethral urinary diversion and that of suprapubic cystostomy after distal shaft hypospadias repair by tubulerized incised urethroplasty.Method: - between December 2008 to October 2010 a 48 boys who had primary hypospaidais under went surgical repair by tubulerised incised urethroplasty, they divided into two groups according to the type of urinary diversion that used post operatively; group A with suprapubic diversion and group B with transurethral nasogasteric tube diversion.Result: - 48 boys aged between 3-21years with hypospadais had divided in to two equal groups according to type of post operative urinary diversion (suprapubic and transurethral), the distribution of hypospadais type similar in both groups. Urinary diversion was more effective , post operative complication were rare ,no trigon irritation and excellent cosmetic result (100%) were recorded following transurethral diversion with nasogasteric feeding tube ,conversely the creation of suprapubic cystostomy increased incidence of trigon irritation (12.5%) and fistula formation( 4.17 %).Conclusion: - transurethral urinary diversion was very effective and gave better result than suprapubic cystostomy in distal type hypospadias repair.