Dorsal Inlay Graft Research Articles

Outcomes of Dorsal Inlay Graft Urethroplasty

Outcomes of Dorsal Inlay Graft Urethroplasty

Hypospadias Reconstruction Training: Development of an Ex-Vivo Model for Objective Evaluation of Surgical Skills

To objectively evaluate technical skill acquisition in hypospadias repair procedures during surgical training using noninvasive wearable sensor technology. We combined subjective video evaluations with objective electromyography (EMG) measurements in a hands-on hypospadias training course. Surgeons wore wireless EMG and accelerometer sensors on their dominant hand while performing tasks on ex-vivo cadaveric calf penises. The study focused on 4 skills as follows: urethral mobilization, dorsal inlay graft harvest/implantation, meatal-based flap urethroplasty, and dorsal plication. Machine learning techniques analyzed muscle activation patterns and attributes for assessing surgical precision. The course included 18 participants (10 female, 8 males; average age 40.18±8.46 years) categorized as novice (n=10, <3 years' experience), intermediate (n=5, 3-5 years), and expert (n=3, >5 years). Video evaluations did not reveal significant differences due to short-term training. However, EMG measurements showed significant reductions in average EMG power, total time, dominant frequency, and cumulative muscle workload after training. Additionally, the mean power spectral density of the EMG signal decreased notably post-training. This study presents a structured approach for hypospadias training and highlights the effectiveness of wearable sensor technology for objective skill assessment. While video evaluations did not detect significant changes, EMG data provided measurable differences in skill acquisition, suggesting that wearable sensors could enhance objective evaluations of surgical proficiency in residency programs.

Glans cap-preserving dorsal inlay-free graft augmentation technique for reconstruction of meatal stenosis and fossa navicularis strictures: Analysis of short-term functional outcomes.

Meatal stenosis and fossa navicularis strictures (FNSs) are commonly caused by lichen sclerosus and instrumentation. We present the technique and short-term functional outcomes of glans cap-preserving dorsal inlay-free graft augmentation for the reconstruction of meatal stenosis and FNS. This retrospective study analyzed patients with meatal stenosis and FNS who underwent glans cap-preserving dorsal inlay-free graft augmentation at our institute since 2019. The surgical technique included a ventral subcoronal approach, preservation and mobilization of the glans cap, a ventral midline urethrotomy incision over the stricture, and a dorsal midline meatotomy incision extending to the proximal normal urethral mucosa at the fossa navicularis, followed by dorsal inlay graft augmentation. During the follow-up, patients were periodically assessed for symptom scores, urinary flow rates (UFRs), and patient-reported outcomes. A total of 26 patients with a mean age of 45 ± 15 years were assessed. The predominant cause of stricture was lichen sclerosus (n = 15; 58%). The mean stricture length was 3.8 ± 0.5 cm, 73% had a circumcised phallus, and an oral mucosa graft augmentation was performed in 22 (85%) patients. Notable postoperative complications included intractable meatal hemorrhage (n = 1) and glans suture granuloma (n = 1), which required intervention. At a mean follow-up of 40 months, there were four failures, of which one patient required redo-urethroplasty. The remaining patients (n = 22; 85%) showed improved symptom scores (P < 0.05), UFRs (P < 0.05), and satisfactory patient-reported outcomes. Glans cap-preserving dorsal inlay-free graft augmentation is a safe and feasible technique with satisfactory short-term functional outcomes for the management of meatal stenosis and FNS in carefully selected patients.

Editorial comment for “Surgical and functional outcomes of dorsal inlay graft urethroplasty in revision vs primary hypospadias repair in the pediatric age”

Editorial comment for “Surgical and functional outcomes of dorsal inlay graft urethroplasty in revision vs primary hypospadias repair in the pediatric age”

The long-term consequences of the hypospadias salvage repair issue

PurposeTo present the long-term results of redo-hypospadias at our tertiary referral center following a failed prior repair.MethodsOne hundred sixty-four individuals with a history of unsuccessful repairs qualified for our retrospective cohort study. Our inclusion criteria were as follows: pre-operative data that was accessible, redo-hypospadias that was successfully repaired, and at least three years of follow-up at the last hospital visit.ResultsThe mean patient age was 91.3 ± 21.1 months. The mean follow-up after successful repair was 41.3 ± 3.1 months. Ninety-two (group A) had one prior repair, and 72 (group B) had 2 or 3 repairs. Group A underwent six primary techniques: 32 underwent Onlay Island Flap (OIF), 10 underwent Mathieu, 12 underwent Tubularized Incised Plate Urethroplasty (TIPU), 8 underwent Urethral Mobilization (UM), and 34 underwent Buccal Mucosal Graft (BMG) { dorsal inlay Graft Urethroplasty (DIGU) in 4 and staged BMG in 30 patients}. In group B, four procedures were used: TIPU in 4, UM in 6, and BMG in 62 (staged BMG in 50 cases and DIGU in 12).ConclusionsThe selected type of repair will depend on many factors, like residual healthy local skin and expertise. Safe techniques for repair of redo hypospadias after its 1st failure include TIPU, Mathieu, UM, OIF, and DIGU for distal varieties. After 2nd or 3rd repair DIGU, UM, and TIPU can be performed in distal types, while staged BMG can be applied for proximal ones.

Surgical and functional outcomes of Dorsal Inlay Graft urethroplasty in revision vs primary hypospadias repair in the pediatric age

Over the years, Dorsal Inlay Graft (DIG) urethroplasty has gained worldwide acceptance for primary hypospadias repair. However, its safety and effectiveness for revision surgery are yet to be proven. The aim of the study is to assess and compare complication rates and functional outcomes of DIG surgery in revision versus primary hypospadias repair. We carried out a retrospective analysis of data collected from 53 consecutive DIG urethroplasties performed by a single surgeon at our institution. Patients were stratified in two groups - primary repair and redo-urethroplasty. For each group, we recorded standard pre-operative characteristics, surgical technicalities, complication rates and uroflowmetry parameters. Out of 53 DIG urethroplasties, 21 (39.6%) where primary and 32 (60.4%) were re-do. As expected, the two groups differed for median age at surgery: 20 months for primary and 68.5 months for revision surgery (p<0.001). Additionally, all 21 (100%) primary interventions were performed with a preputial graft, whereas among revision DIG urethroplasties only 2 (6.3%) where preputial and 30 (93.8%) were buccal (p<0.001). Catheterization time (7 vs 8 days, p=0.155) and postoperative complication rates (14.3% vs 9.4%, p=0.581) were comparable between the primary and revision surgery group, respectively (all p>.05). Forty-two of the 53 patients underwent uroflowmetry during follow-up. Of these, 19 (63%) patients presented with abnormal uroflowmetry and 11 (37%) had equivocal parameters with no difference between the two groups. Dorsal Inlay Graft urethroplasty has long been known to be safe and effective for primary hypospadias repair. On the other hand, data on dorsal inlay graft urethroplasty as a salvage surgery after primary hypospadias repair failure is scarce. Surprisingly, according to our findings, surgical outcomes and complication rates are comparable between primary and revision hypospadias cases. Additionally, our results in the redo group are absolutely encouraging if compared to those reported in the literature for the same subset of patients. According to our findings, DIG urethroplasty is a safe and effective option to treat revision hypospadias repair.

Comparison of the efficacy and safety of dorsal inlay graft urethroplasty (DIGU) method with tubularized incised plate urethroplasty (TIPU) method in primary distal hypospadias repair: a systematic review and meta-analysis

Link of Video Abstract: https://youtu.be/r399GEt3guoIntroduction: Tubularized Incised Plate Urethroplasty (TIPU) is a technique that is widely used in distal hypospadias repair. The advantages possessed by this technique are better cosmetics, the meatus is at the tip of the penis, and the phallus is straight. Some researchers believe that a urethral plate with a size of less than 8 mm is unsuitable for the TIPU technique so augmentation with a graft using the dorsal inlay graft urethroplasty (DIGU) technique is needed. To date, there have been no systematic reviews and meta-analyses that have directly compared the efficacy and complications of DIGU and TIPU. Therefore, this study aimed to compare the effectiveness and complications of these two modalities for repair in primary distal hypospadias patients. Methods: This study is a systematic review study and meta-analysis. The protocol for conducting and compiling this study was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was performed on six databases: PubMed, Scopus, Web of Science, ProQuest, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov. The risk of bias in the study will be analyzed using the Cochrane Risk of Bias Tools for Randomized Trials version 2 (RoB 2). Results: Six studies that met the inclusion criteria were included in the meta-analysis with a total of 381 samples. The success rates (OR 1.46, 95% CI 0.74-2.87, p = 0.28) and urine output (OR 2.54, 95% CI 0.63-10.20, p = 0.19) were not significantly different, while the mean operating time (MOT) (SMD 1.96, 95% CI 1.10-2.82, p &lt; 0.0001) was significantly shorter in TIPU (P &lt; 0.05). The incidence of meatal stenosis was significantly more in TIPU than DIGU significantly (OR 5.11, 95% CI 1.46-17.92, p = 0.01), while fistula (OR 2.93, 95% CI 0.92-9.35, p = 0.07) and dehiscence (OR 3.05, 95% CI 0.81-11.45, p = 0.10) was not significantly different between the two techniques. Conclusion: TIPU has the advantage of shorter operating time but a higher incidence of meatal stenosis than DIGU.

Spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty for primary hypospadias repair

Neourethral covering is an essential technique for preventing complications such as fistula and glans dehiscence in hypospadias repairs. The spongioplasty has been reported for neourethral coverage about 20 years ago. However, reports of the outcome are limited. This study aimed to retrospectively evaluate the short-term outcome of spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty (DIGU). From December 2019 to December 2020, 50 patients with primary hypospadias (median age at surgery, 37 months; range, 10 months-12 years) were treated by a single pediatric urologist. The patients underwent spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty in single stage. The penile length, glans width, urethral plate width and length, and the location of the meatus of the patients were recorded preoperatively. The patients were followed up,complications noted, and postoperative uroflowmetries at the one-year follow-up time were evaluated. The average width of glans was 12.92±1.86mm. A minor penile curvature was observed in all patients (≤30°). The patients were followed up for 12-24 months, and 47 patients (94%) were free from complications. A neourethra formed with a slit-like meatus at the tip of the glans, and the urinary stream was straight. Three patients had coronal fistulae (3/50) and no glans dehiscence, and the mean±SD Qmax of postoperative uroflowmetry was 8.13±3.8ml/s. This study estimated the short-term outcome of the DIGU covered using spongioplasty with Buck's fascia as the second layer in patients diagnosed with primary hypospadias with a relatively small glans (average width <14mm). However, only a few reports emphasize spongioplasty with Buck's fascia as the second layer and the DIGU procedure performed on a relatively small glans. The major limitations of this study were its short follow-up time and the retrospective data collection. Dorsal inlay graft urethroplasty combined with spongioplasty with Buck's fascia as coverage is an effective procedure. In our study, this combination had good short-term outcomes for primary hypospadias repair.

Is dorsal inlay graft urethroplasty safe and effective for revisional hypospadias repair in the pediatric age?

Is dorsal inlay graft urethroplasty safe and effective for revisional hypospadias repair in the pediatric age?

Glans Preserving Buccal Mucosa Urethroplasty for Glandular and Distal Urethral Strictures.

To describe a step-by-step approach for glans preserving urethroplasty with a dorsal inlay graft used for distal urethral strictures. Description of the Technique: The reconstruction was performed through a keyhole incision in the urethra. In this way, we achieve maximal exposure by a minimal incision and saving of the glans. After incision of the diseased dorsal urethral mucosa through the keyhole and the meatus, a buccal mucosa graft pull-through resulting in a dorsal inlay is done. Patient(s) and Methods: We treated 10 patients in different clinical settings with success by using the newly described technique below. We highlight and illustrate 1 case of a 34-year-circumcised male. Antegrade urethrogram showed a distal penile and fossa navicularis stricture with a total estimated length of 3.5 cm. In this specific case the glans sparing approach had a surgical duration of 115 minutes. After 3 weeks the urinary catheter was removed. At 12 months, the patient reported no remaining urinary tract symptoms. Examination showed a fully healed lesion and an adequate uroflowmetry with a Qmax of 24 mL/s coming from 4 mL/s pre-operatively. In our 10-patient case series, all treated patients had complete resolution of their complaints, significant improvement in flow rates and excellent cosmetic results without complications. In selected cases, the described technique is feasible, safe, and effective with excellent functional outcomes and better cosmetic results especially due to the glans preservation.

SC123 - Tubularized incised plate urethroplasty with dorsal inlay graft for hypospadias repair in pediatric age: long-term outcomes

SC123 - Tubularized incised plate urethroplasty with dorsal inlay graft for hypospadias repair in pediatric age: long-term outcomes

Lichen sclerosis-induced long segment anterior urethral stricture: The early outcome of one-stage repair using dorsolateral onlay buccal mucosa graft.

Substitution urethroplasty using buccal mucosal grafts can be performed by several approaches including ventral onlay graft, dorsal onlay graft, or ventral urethrotomy with dorsal inlay graft. Our study aims to evaluate the surgical outcome of dorsolateral buccal mucosal graft for long segment anterior urethral stricture >6 cm in patients with Lichen sclerosus (LS). A retrospective study included patients who underwent repair for long segment anterior urethral stricture >6 cm due to LS between January 2013 and April 2019. All patients were followed-up at 3, 6, 9, and 12 months postoperatively and then yearly by clinical symptoms, uroflowmetry, and calculation of post-void residual urine volume. Retrograde urethrogram was requested for patients with voiding symptoms or decreased maximum flow rate. Stricture recurrence that required subsequent urethrotomy or urethroplasty was considered failure. The success rate and surgical complications were collected and analyzed. Thirty patients were identified. The median age (range) was 39 (25-61) years and a median (range) stricture length was 8 (6-14) cm. Most of postoperative complications were of minor degree. The success rate at median follow-up of 15 (12-24) months was 86.5%. The median maximum flow rate increased significantly from 6 (2-11) ml/s preoperatively to 18 (range: 6-23) ml/s at the 6th month (p value < 0.001). Dorsolateral buccal mucosal grafts urethroplasty for long anterior urethral stricture caused by LS has a high success rate and low risk of complications including stricture recurrence.

Narrow urethral plate augmentation in anterior and middle hypospadias repair: Onlay flap VS. Inlay graft. A prospective randomized comparative study

The measurement of the urethral plate width (as an objective parameter) and its effect of this width on the results of tubularized incised plate urethroplasty (TIPU) have been reported in two series and both authors reported that a urethral plate width<8mm is associated with higher complication rates. The augmentation of the urethral plate either by dorsal inlay graft urethroplasty (DIGU) or Onlay flap has been compared with the original TIPU in different degrees of hypospadias with better surgical results in augmented cases. To evaluate the surgical results of longitudinal Onlay preputial flap (LOF) vs (DIGU) techniques in augmentation of the narrow urethral plate. Primary anterior and middle hypospadias cases with narrow urethral plates were randomly allocated into two groups; group one operated by DIGU and group two operated by (LOF). The Success rate, individual complication rate, and operative times were compared. 39 cases completed the study. No significant differences in patients' characteristics were detected. In the DIGU group, one case (5.3%) complicated with fistula and glandular dehiscence wherein in the LOF group, 7 cases (35%) Complicated with 5 fistulae, 2 glanular dehiscences, one flap loss, one diverticulum (p= .02). No significant differences in the rates of individual complications. Variables affecting the success of hypospadias repairs are many. Urethral plate quality is an important variable among these variables. The definition of urethral plate quality is usually subjective. In the DIGU group, only 1/19 (5.3%) case had two complications, fistula and glandular dehiscence. Mouravas etal., in their comparative study between TIPU and G-TIP without mention of urethral plate width reported a significant reduction of the overall complications and urethral stenosis without significant reduction in fistula rate. In their G-TIP group, only 2 cases out of 24 (8.3%) were complicated with one fistula and one glandular dehiscence where in the TIPU group, 7 cases (30.4%) were complicated with one glandular dehiscence and 6 cases with urethral stenosis. In the LOF group, fistula in 5/20 cases (25%) was the commonest complication followed by glandular dehiscence in 2 cases (10%). Diverticulum and flap loss occurred in one case for each (5%). In the multivariate analysis of 474 patients' cohort by Spinoit etal., there were no significant differences between the risk of re-intervention after TIP and Onlay flap in anterior and middle hypospadias (25.8% vs. 18.8%), and (22.2% vs. 20%) respectively. Our data suggest that augmentation of the narrow urethral plate with DIGU has a better surgical outcome than with LOF. No significant difference in cosmetic outcomes detected.

&lt;p&gt;Comparison of Outcome and Success Rate of Onlay Island Flap and Dorsal Inlay Graft in Hypospadias Reconstruction: A Prospective Study&lt;/p&gt;

BackgroundChordee correction, urethroplasty, and tissue reconstruction are performed to correct and retain standard functionality of the penis in hypospadias. Conventional reconstruction techniques, such as onlay island flap and the dorsal inlay graft, can be performed based on the classification of hypospadias. However, the outcomes and complication rates have not been widely studied. Thus, we aimed to provide preliminary evidence regarding the efficacy and safety of both approaches in hypospadias reconstruction.Patients and MethodsA prospective study with two time evaluations of 14 and 180 days post-operatively was performed at the Urology outpatient clinic from October 2014 to September 2019. A proportion comparison of success rate, time to the complication, operation time, catheterization duration, uroflowmetry parameter post-surgery, and mean scores comparison of PPPS were measured as the intended outcomes.ResultsIn a total of 59 pediatric hypospadias, patients who had undergone reconstruction are included in this study. Higher subjects’ age and severe chordee severity were more common in the dorsal inlay graft group (age=7.50 [1–26] months; severe chordee 45.8%) compared to the onlay island flap group (age=4.0 [1–67] months; severe chordee 31.4%), both groups showed similar satisfaction regarding meatal shape and position (P=0.618), glands shape (P=0.324), penile skin shape (P=0.489), and general cosmetic appearance (P=0.526). Complication occurrence and time to complication duration of both groups were also not statistically significant (P=0.464 and P=0.413). There are no significant differences in Qmax, Qmean, voided volume, and PVR of both groups (P=0.125, 0.136, 0.076, 0.260, respectively). Significant differences in operation times and catheterization duration are found in this study (P<0001).ConclusionOutcome evaluation regarding functional, complication and patient satisfaction comparing onlay flap and dorsal inlay graft for hypospadias patients is scarce. This study found that both procedures can be considered safe with comparable incidence of complications.

Ingrafts in hypospadias surgery: Longer-term outcomes

The technique of hypospadias repair with a dorsal inlay graft (ingraft) was initially reserved for boys with an unfavorable glans configuration or in previously failed repairs. Although the ingraft technique has been used for some time, there is scarce literature describing its longer term outcomes. Additionally, there is minimal data comparing inner preputial skin and buccal mucosal graft outcomes in primary and reoperative surgery. To describe longer-term outcomes in the use of buccal mucosa and inner preputial skin ingrafts for primary and revisional hypospadias repairs. We conducted a single-center retrospective review of our hypospadias repairs employing ingrafts along with a review of the literature. A total of 47 patients met inclusion criteria. Primary repair was performed in 38 patients, all with unfavorable glans characteristics at a mean age of 16 months and redo repairs in 9 boys at a mean age of 110 months. We used a buccal mucosal graft (BMG) in 19 boys and the remaining 28 were grafted with inner preputial skin. The complication rate was 32% in primary repairs and amongst those, 6 of 28 patients (21%) with skin grafts and 6 of 10 patients (60%) with BMGs suffered a complication. Only BMGs were used in reoperative situations and complications occurred in 2 of 9 cases (22%) of those cases. Overall, 8 patients (42%) with BMG and 6 patients (21%) with preputial skin ingrafts experienced a complication, at an average time of 17 months (range: 0.4-66 months) and 24 months (range: 1.1-113 months), respectively. Surgical correction of the complications resulted in resolution of symptoms in a majority of patients. In our experience, BMGs used as salvage therapy in revisional hypospadias surgery, had lower observed complication rates when compared to its use in primary repair. Inner preputial skin ingrafts for primary repair yielded an acceptable complication rate. Our study describes some of the longest follow-up times in the literature with complications observed even up to 10 years postoperatively. This reinforces the need for active long-term follow-up in reporting outcomes in hypospadias surgery.

Comprehensive evaluation of grafting the preservable narrow plates with consideration of native plate width at primary hypospadias surgery

Dorsal inlay graft urethroplasty using inner-face preputial graft was described as an adjunct method to the classic tubularized incised plate (TIP) urethroplasty, aiming at reducing the risk of neourethral stenosis. To evaluate the impact of dorsal inlay grafting of preservable narrow plates, in relation to native plate width. Consecutive children with penile hypospadias with narrow plate (width<8mm) were evaluated prospectively between Jan 2014 and Jun 2018. Included cases were stratified into two groups: group A (plate width: 4 to <8mm) and group B (plate width: < 4mm). All cases were approached by TIPurethroplasty, with dorsal inlay grafting (inner-face prepuce). Cases with significant chordee (non-preservable plates), circumcised cases, and redo cases were excluded. A total of 104 hypospadias cases with narrow plates were included in this study. Among group A (n=81), the need for postrepair urethral dilations was reported in two cases (2.5%) vs seven cases (30%) in group B (n=23) (P-value<0.001). Another two cases (2.5%) in group A developed urethrocutaneous fistulae vs three cases (13%) in group B (P-value=0.0624). Surgical repair of the reported five cases with fistulae, revealed an ample neourethral wall; disclosing well-taken grafts in both groups. Few published studies evaluated grafting the incised plate in penile hypospadias. To the authors knowledge, this is the first study that selectively evaluated the impact of grafting narrow plates in relation to its native pre-incision width. According to the presented authors' experience, 4mm width is the border line of clinical relevance that defines poor urethral plate. Grafting that plate failed to compensate for its native poor characteristics; however, it offered a valuable neourethral wall that proved indispensable when redo surgery deemed necessary, without adding grafting-related problems. Nevertheless, further extended comparative studies came across as a necessity to verify the long-term outcomes of grafting the incised poor plates.

Age-related changes in urinary flow following dorsal inlay graft urethroplasty for hypospadias in early childhood: Potential improvement over 11 years of age

One of the goals of hypospadias repair is to create a neourethra with normal urinary stream and normal growth. Several studies have reported that dorsal inlay graft urethroplasty (DIG) has wide indications for various clinical phenotypes of hypospadias, with good short-term outcomes and few complications. However, there have been no reports that evaluated both short-term and long-term functional outcomes using uroflowmetry in patients with DIG. The aim was to investigate whether uroflowmetry parameters change with time following DIG for hypospadias in early childhood. Uroflowmetry parameters after DIG for hypospadias in childhood were retrospectively evaluated and compared between two defined ages at follow-up: 4-6 years and 11-13 years. Maximum urinary flow (Qmax) under the 25th percentile on the Miskolc nomogram was defined as obstruction. To evaluate the shapes of uroflow quantitatively, the flow index (FI) was used. The FI cut-offs for the flow shapes were defined as tower >1.253, plateaus <0.659; bells were between these two values. Thirty-four patients met the inclusion criteria. The median operative age was 1.8 years (range 1.0-4.9 years). The median follow-up time was 10.3 years (range 7.2-12.3 years). The mean±SD Qmax at the two follow-up times increased with time, from 9.2±3.7 to 18.8±7.8. The mean±SD FI changed from 0.53±0.19 to 0.85±0.31. Both Qmax and the FI were significantly improved (p<0.001, p<0.001, respectively). There were significantly fewer patients with obstruction evaluated by the Miskolc nomogram at 11-13 years of age (n=11, 32.4%) than at 4-6 years (n=31, 91.2%) (p<0.001). Plateau shapes assessed by the FI were seen in 24 (70.6%) patients at 4-6 years and 10 (29.4%) patients at 11-13 years (Table). The number of patients with plateau shapes was significantly decreased (p=0.001). Only one report noted long-term outcomes and spontaneous uroflowmetry resolution after tubularized incised plate urethroplasty. The current report is the first to present the short-term and long-term uroflowmetry outcomes after DIG. In addition, the FI was used for the first time to evaluate uroflowmetry after hypospadias repair. It was found that the uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood. Uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood.

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.

Single-stage urethroplasty with buccal mucosal inlay graft for stricture caused by balanitis xerotica obliterans in boys: Outcomes in the medium term

Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to stricture. Numerous procedures have been suggested to treat urethral stricture secondary to BXO but these have had variable results. We describe the first prospective study of a single stage buccal mucosal inlay grafting in children with urethral strictures resistant to existing remedies. We treated five boys with resistant urethral strictures secondary to BXO with a single stage buccal mucosal inlay graft (BMIG, Figure). Uroflowmetry was performed both pre- and post-operatively. Functional outcome was the prime measure determining success. All the boys had a successful functional outcome and all expressed satisfaction with cosmetic outcome as well. Uroflow parameters improved remarkably, with maximum and mean urinary flow rates significantly improved from 4.2mL/s to 26mL/s (p=0.0002) and from 1.6mL/s to 12.2mL/s (p=0.003), respectively. Median follow-up was 34 months (range 30-42 months). This paper is the first to describe the successful use of buccal mucosal inlay grafts to treat refractory BXO stricture in children. Various surgical techniques have been proposed particularly in adults including single vs. staged procedures, preputial and post auricular grafts, circular mucosal buccal grafts, as well as double mucosal grafts placed both ventrally and dorsally. All of these procedures are not without problems, and had variable results and outcome. Most of the procedures have been described in adult urethra and are not suitable for paediatric small calibre urethra. Our technique of dorsal inlay graft gives a robust structure to the distal urethra avoiding diverticula, pooling or urine spraying and can be placed onto proximal urethra as well. We have not seen recurrence of BXO in our buccal grafts, which is reported in other grafts from prepuce and post auricular grafts. The number of patients presented in our study is limited, nonetheless an excellent result in all our cases makes this a compelling approach to manage BXO urethral strictures. An early intervention in such cases is paramount to convert a salvage operation to a pre-emptive procedure. A single stage buccal mucosal inlay grafting in children with BXO stricture can offer an excellent outcome.

Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period

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