Reoperative Hypospadias Research Articles

Tubularized incised plate urethroplasty for hypospadias reoperation: a review and meta-analysis.

Tubularized Incised Plate (TIP) urethroplasty is a technique for urethral reconstruction of hypospadias although there are some controversies for its use in recurrent cases. The aim of this study was to review the results of TIP technique in various studies and the usage of different flaps for covering the repair site. Extensive Search was performed for articles published between 1994 and 2013 in common electronic databases. The overall TIP complication rates were estimated by a fixed effects model meta-analysis. 17 articles of hypospadia repair using the TIP method were reviewed. All studies performed surgery and repair on the basis of the Snodgrass's method; however, some introduced modifications to the method. The prevalence of complications in repeated TIP surgery was 11.1 to 33.3% and the most prevalent complication in different studies was fistula. Based on the meta-analysis, the overall estimation of complications was 21.8% (95% CI: 18.3 to 25.5). Most studies performed the incision of the urethral plate to create a supportive coverage upon neourethra, and confirmed its success. We recommend further investigation on using different flaps in well-designed randomized controlled trials to choose the best surgical method for repairing recurrent hypospadias.

Primary and Reoperative Hypospadias Repair in Adults—Are Results Different than in Children?

There is widespread belief that hypospadias surgery in adults has a greaterurethroplasty complication rate than similar repair in children. We compared outcomes of primary and reoperative hypospadias repair in adults vs children. We evaluated prospectively maintained databases of consecutive boys and adults, defined as Tanner 4 or greater, treated with primary or reoperative hypospadias repair from 2000 to 2013. We searched for urethroplasty complications, including fistula, glans dehiscence, stricture/stenosis and diverticulum. All operations were done with the goal of creating a neomeatus at the normal location at the tip of the glans. Univariate and multivariate analyses were done to determine whether pubertal status impacted urethroplasty complications. A total of 1,140 patients were operated on by a single surgeon, including 69 adults with a mean age of 23 years. Complications developed in 209 cases (18%), including 124 of 883 primary repairs (14%) and 85 of 257 reoperations (33%). There was no difference in outcomes between adults and children. Complications were noted in 1 of 8 men (12.5%) vs 123 of 871 children (14%) with primary repair (p = 0.9) and in 16 of 61 (26%) vs 69 of 196 (35%) with reoperation (p = 0.2). Multivariate analysis showed that a proximal meatus and reoperation were risk factors for complications but not pubertal status. In contrast to popular belief, our data do not indicate a greater risk for urethroplasty complications after hypospadias surgery performed in adulthood. Repair in adults can be done using the same techniques as in children with the same goal of a neomeatus at the tip of the glans.

Tunica Vaginalis Flap as a second layer for Tubularized incised plate urethroplasty (Snodgrass method) in reoperation for hypospadias

Purpose: Reoperation for failed hypospadias has been considered to be seriously bothersome because abundant penile skin doesn’t tend to remain for urethroplasty or for penile shaft skin coverage. In this study, the tubularization of incised urethral platewrapped by tunica vaginalis flap as the second layer to increase the success rate of operation and decrease the incidence of urethrocutaneous fistula.

Tunica Vaginalis Flap as a second layer for Tubularized incised plate urethroplasty (Snodgrass method) in reoperation for hypospadias

Tunica Vaginalis Flap as a second layer for Tubularized incised plate urethroplasty (Snodgrass method) in reoperation for hypospadias

Regenerative urethroplasty in reoperative hypospadias: Buried strip principle revisited

Aim:Reporting the feasibility of the Denis Browne (buried strip) principle along with tunica vaginalis (TV) pedicled wrapping of the strip in reoperative urethroplasty in hypospadias.Materials and Methods:Over a period of 5 years, 32 patients presented with failure of previous urethroplasty and the range of failure was between 2 and 6 times; mean 2.5 times. Mean age was 12.9 (range 2 to 26 years) years. “Buried strip” urethroplasty (i.e., without tubularization of urethral plate) and wrapping with TV were done along with supra pubic cystostomy (SPC) for diversion of urine. Mean follow-up was 29.8 (range 12 to 56 months) months.Results:One patient had fistula and vertical slit meatus was possible in 26 patients. The flow of urine was satisfactory in 31 patients and one patient developed pouch in penile urethra.Conclusions:The buried strip along with the additional coverage with TV was found to be simple and effective in salvaging the failed urethroplasty.

Feasibility of a tubularised incised-plate urethroplasty with double de-epithelised dartos flaps in a failed hypospadias repair: A preliminary report

Reoperation for failed hypospadias has been considered to be seriously problematic. The dense fibrotic tissue causes difficulties in wound healing and increases the rate of complications. The tubularised incised-plate urethroplasty (TIPU) method has become a preferred method for all varieties of hypospadias in the past decade. However, fistulas are still one of the most common complications of this technique. The aim of this paper was to present the preliminary results of TIPU procedure with double de-epithelised dartos flaps in failed hypospadias repair. All patients were treated between January 2009 and August 2010 by the same procedure, utilising TIPU with double de-epithelised dartos flaps. Vascularised ventral dartos flaps harvested from each side of the penis with their vascular supply were transposed to cover the suture line by wrapping them from either side of the penis. There were 21 boys with failed hypospadias: 20 had previously undergone TIPU, and one Koyanagi repair. Patients presented with very large fistulas in four and dehiscence in 17. Repair of the failed hypospadias using TIPU with double de-epithelised dartos flaps was quite successful, with no fistula recurrence or dehiscence observed. The preliminary results showed that TIPU with double de-epithelised dartos flaps is a useful method of successfully repairing failed hypospadias.

Complications in Hypospadias Surgery and Reoperation in Failed Hypospadias Repair

Complications in Hypospadias Surgery and Reoperation in Failed Hypospadias Repair

Staged buccal mucosa urethroplasty in reoperative hypospadias

Introduction:Repeated attempts at surgical repair of serious complications involving either the partial or complete breakdown of the hypospadias repair are less likely to succeed because the penis is densely scarred, or significantly shortened, and the skin over the penis is immobile and hypovascular. Buccal mucosa (BM) has become the preferred material for reconstruction, whenever a child with skin-deficient hypospadias needs reoperation. We report the results of our surgical experience with staged reoperation using BM, in the repair of hypospadias in children with complications after multiple failed repairs.Materials and Methods:Children needing reoperation for hypospadias underwent a staged repair using buccal mucosa. The complications were noted.Results:Twenty-one children aged 3 – 16 years underwent this staged repair during the period May 2000 – April 2010. Two of these 21 children had a failed first stage. One child developed a urethro-cutaneous fistula following the second stage, which was corrected in an additional stage.Conclusions:The use of the buccal mucosa graft for urethral reconstruction in a child with hypospadias, needing a reoperation, is a successful method, with a low incidence of complications.

Management of recurrent urethral strictures after hypospadias repair: Is there a role for repeat dilation or endoscopic incision?

Urethral strictures are among the most common complications after hypospadias repair. We report our 10-year experience with endoscopic incision or dilation of urethral strictures after hypospadias repair, to determine the best management technique. All cases of urethral strictures after hypospadias repair treated with direct vision internal urethrotomy (DVIU), dilation or urethroplasty at our institution from 1997 to 2007 were included. Records were reviewed and clinical parameters analyzed. Data were statistically analyzed to identify risk factors for stricture recurrence after initial or subsequent treatment(s). Of 2273 patients, 73 were treated for a postoperative urethral stricture and 15 others were referred for stricture treatment. Of these 88 patients, 39 were treated with initial dilation or DVIU and 49 underwent urethroplasty or reoperative hypospadias repair. Fifteen (38%) of the patients treated with initial DVIU or dilation showed no recurrence. Of the patients that did have a recurrence, a repeat DVIU or dilation had a success rate of 17% with no difference in success between these two groups. Choice of therapy between repeat dilation/DVIU and urethroplasty at the second procedure showed a statistically significant higher success rate in the urethroplasty group (67% vs 17%, P=0.03). Although numbers are small, our data suggest that if there is recurrent stricture after initial DVIU/dilation then a formal urethroplasty has a significantly higher success rate than repeat DVIU/dilation.

Dartos flap coverage of the neourethra following repair for primary hypospadias, reoperative hypospadias and urethrocutaneous fistulas: it is a safe approach

Urethrocutaneous fistula and neourethral dehiscence are frequently seen complications of hypospadias surgery requiring reoperation. In this study we report the experience of one surgeon with dartos flap coverage in primary hypospadias, reoperative hypospadias and urethrocutaneous fistulas repair. A total of 23 patients underwent hypospadias and urethrocutaneous fistulas repair from January 2006 to May 2009. Fourteen patients were operated on for primary hypospadias repair at our institution and 9 patients were admitted for hypospadias complications such as failed hypospadias repair and urethrocutaneous fistula. In all the patients, the dartos flap was dissected and transposed to cover the neourethra. Operative results were recorded. The primary surgical procedure was a one-stage repair in 61% (n = 14); tubularised incised plate (TIP) urethroplasty in 43% (n = 6) and a Mathieu procedure in 57% (n = 8). Urethrocutaneous fistulas complicating the previous initial hypospadias repair were anterior in 33% (n = 2), middle in 33% (n = 2) and proximal in 33% (n = 2). Repair of the fistula was successful on the first attempt in all patients. The reason for redo surgery in 3 patients was complete dehiscence and the patients had distal shaft hypospadias. Dartos flap coverage of the neourethra seems to be an effective method of reducing the fistulous complication rate following primary and secondary hypospadias repair.

Single-stage dorsal inlay full-thickness genital skin grafts for hypospadias reoperations: Extended follow up

To report our extended experience with single-stage genital skin graft urethroplasty for complex hypospadias reoperations. Thirty-one patients with failed hypospadias surgery were included. The urethral plate had been removed or was scarred in all. After excision of fibrotic tissue a free full-thickness skin graft was quilted to the corpora cavernosa. The neourethra was then tubularized followed by glanuloplasty. Voiding cystograms, urethral ultrasound and flow measurements were performed in all. Outcome was considered a failure when postoperative instrumentation was needed. Follow up was 78.45 +/- 18.18 months. Shaft skin was used in 13 and internal prepuce in 18. Average graft length was 3.66 +/-1.56cm. Eighteen patients required glanuloplasty. Initial graft healing was successful in all. There was no postoperative infection involving the inlay. We did not note complications from the graft donor sites. Four patients underwent redo surgery yielding a complication rate of 12.9%. Urethral stricture of the proximal anastomosis was most frequent. This single-stage approach using dorsal inlay skin grafts is reliable, creating a substitute urethral plate in the long term. Complication rates are equivalent to those of staged strategies. This is a safe option for hypospadias reoperations if the urethral plate is compromised.

Algorithm for Comprehensive Approach to Hypospadias Reoperation Using 3 Techniques

Algorithm for Comprehensive Approach to Hypospadias Reoperation Using 3 Techniques

Algorithm for Comprehensive Approach to Hypospadias Reoperation Using 3 Techniques

We describe comprehensive hypospadias reoperation based on presence or absence of a supple urethral plate using the 3 surgical techniques of transurethral incised plate, 1-stage inlay graft and 2-stage buccal graft. We reviewed prospective data from all reoperative hypospadias urethroplasties performed by one of us (WTS) between 2000 and 2008. Patient age, number of operations, indications for additional surgery, meatal location, reoperative surgical technique and outcomes were extracted. A total of 133 patients underwent reoperation by transurethral incised plate (69), 1-stage inlay graft (16) or 2-stage buccal graft (48) urethroplasty. Mean number of prior failed repairs was 1.1, 1.9 and 4.3, respectively. Followup was available in 121 patients (91%), with 90 (74%) undergoing 1 successful reoperative urethroplasty. Complications occurred in 19%, 15% and 38% of patients, respectively, and most often consisted of fistulas or glans dehiscence. Hypospadias reoperation can be accomplished using these 3 techniques without skin flaps, a potential advantage given the relative paucity of skin after failed repair. Fistulas after transurethral incised plate urethroplasty correlate with barrier layers used, while glans dehiscence is more likely in 2-stage buccal graft repairs when cheek rather than lip is used within the glans.

Double-Cross Flap Protection: New Technique for Coverage of Neourethra in Hypospadias Repair

We analyzed a new urethra preserving approach, double-cross flap protection, during tubularized incised plate urethroplasty. We compared the results of 57 patients treated with this new procedure and 80 patients treated with 2 different techniques. We studied 137 patients with hypospadias between October 2002 and March 2008. Patients were divided into 3 groups. Group 1 consisted of 40 patients (mean age 50 months) undergoing tubularized incised plate urethroplasty. Group 2 included 40 patients (mean age 48 months) undergoing tubularized incised plate urethroplasty with dorsal subcutaneous flap. Group 3 consisted of 57 patients (mean age 39 months) undergoing tubularized incised plate urethroplasty with 2 de-epithelialized preputial flaps twisted ventrally and sutured individually over the neourethra. All patients were operated on by the same surgeons. Statistical analysis of postoperative complications was performed by ANOVA and chi-square test. In Group 1 fistula developed in 6 patients (15%) and was associated with stenosis of the neourethra in 4 (10%). In Group 2 fistula developed in 4 patients (10%). In Group 3 no fistula was observed, but mild stenosis of the neomeatus developed in 3 patients (5.3%), which was treated with dilation. Thus, the incidence of fistula in group 3 was significantly less (p = 0.015). Double-cross flap protection is safe and significantly reduces the incidence of postoperative fistula.

Outcome and Risk Factors of Tubularized Incised Plate Urethroplasty in Patients with Reoperative Hypospadias Repairs

Purpose: We retrospectively evaluated the outcome and risk factors of tubularized incised plate (TIP) urethroplasty in patients with reoperative hypospadias repairs. Materials and Methods: Thirty-nine patients with reoperative hypospadias repairs by the TIP method were evaluated. The meatal location, interval between prior urethroplasty and reoperation, length from meatus to penile tip, coexistence of chordee, type of prior urethroplasty, shape of glans, scarring on urethral plate, times of prior urethroplasty, and complications were reviewed. We also evaluated the outcome of reoperative hypospadias repairs and the relationships between these factors and outcomes. Results: The mean age of the patients was 47.7±77.9 months (range: 5-384 months) at prior urethroplasty and 92.7±115.6 months (12-480 months) at reoperative urethroplasty, and the mean follow-up duration was 54.2±90.5 months (6-443 months). Complications at prior urethroplasty included urethrocutaneous fistula in 18 patients, wound dehiscence in 9, meatal stenosis in 5, persistent chordee in 5, and urethral diverticulum in 3. Complications at TIP reoperation were urethrocutaneous fistula and wound dehiscence in 11 and 4 patients, respectively (complication rate: 38.5%). Older age at the time of the repeat urethroplasty, long urethral defect, and scarring in the urethral plate at reoperation were related with poor outcomes in reoperative urethroplasty. Conclusions: TIP urethroplasty for reoperative hypospadias repair can result in good cosmetic and functional outcomes. However, caution is necessary in patients of old age or with a long urethral defect and scarring at the urethral plate at reoperation. (Korean J Urol 2009;50:67-71)

Staged Reconstruction of Long Segment Urethral Strictures in Men With Previous Pediatric Hypospadias Repair

Reconstruction of long segment urethral stricture disease in adults with a history of pediatric hypospadias repair remains complex secondary to poor urethral blood supply, extensive penile scarring and the need for significant amounts of graft or flap tissue. We describe our experience with staged urethroplasty in this cohort of men. A total of 15 males underwent staged urethroplasty for urethral stricture disease following previous hypospadias repair in childhood. All men underwent 2-stage repair with a minimum of 6 months separating each operation. Bulbar urethral stricture disease due to previous dilation was seen in 2 of the 15 men (14%). Graft sources included buccal mucosa in 12 cases, full-thickness hairless abdominal wall skin in 2, penile skin in 1 and posterior auricular tissue in 1. Median patient followup was 22 months (range 5 to 62) after stage 2 closure. Median patient age at presentation was 31 years (range 19 to 57). Mean stricture length was 8 cm (range 5 to 14) and mean graft area was 22 cm(2) (range 10 to 38). There was no clinical evidence of stricture recurrence, fistula or wound dehiscence at last followup in 13 of the 15 men (86%). Two men with a congenital hypoplastic glans were left with distal hypospadias. Minor voiding symptoms were described in 3 of the 15 men (21%) with resolution in all by 6 months postoperatively. We describe outcomes after staged reconstruction for extensive urethral stricture disease in men after previous pediatric hypospadias repair in childhood. At intermediate followup staged urethroplasty provided acceptable outcomes.

Use of tubularized incised plate urethroplasty for secondary hypospadias repair or repair in circumcised patients

To retrospectively review our experience of the tubularized incised plate (TIP) urethroplasty in a series of re-operative hypospadias repairs or circumcised children. Between September 2001 and September 2007, 17 children (mean 4.6 years, range 7 months to 15 years), were referred for hypospadias re-operation. Some of these patients had previously undergone circumcision and missed hypospadias. In all cases, the TIP urethroplasty was covered with an additional layer of subcutaneous tissue or dartos flap. The original location, associated complications and results were recorded. There were 4 (30.7%), incidences of complications of TIP re-operation, 2 meatal stenosis, one stenosis with small fistula and one dehiscence. Re-operation was necessary in only one patient of our series (7.6%) and the others were cured by dilatation. No complications occurred in the circumcised patents. Using TIP urethroplasty as described by Snodgrass, is a suitable method for treating primary and re-operative cases. It can also be used successfully in patients, who do not have a healthy skin flap and in circumcised patients when there is a lack of foreskin.

Single stage dorsal inlay buccal mucosal graft with tubularized incised urethral plate technique for hypospadias reoperations

To report the experience with single stage dorsal inlay buccal mucosal grafts using the Snodgrass technique for complex redo cases. From May 2004 to December 2005, a total of 53 patients aged from 3 to 34 years old (average 11.62 +/- 7.18 years) with failed previous hypospadias surgery were included in the present study. Indications included urethral strictures and repair breakdown. The unhealthy urethra was unroofed from the meatus in the ventral midline, a buccal mucosal graft was inlayed between the incised urethral plate and fixed to the corpora cavernosa. The neourethra was tubularized, and covered with subcutaneous (dartos) tissue and penile skin. Glanuloplasty was also performed in all cases. Outcome analysis included clinical follow-up, and endoscopy in 2 selected cases. The buccal mucosal graft was 3.0-7.5 cm in length and 0.7-2.0 cm in width. All patients required glanuloplasty, with buccal mucosal grafts extended to the tip of the glans. After a follow-up of 14-30 months (mean 22.6 months), the total complication rate was 15.1%, with five cases of fistula and three cases of stricture. Inlaying dorsal buccal mucosal grafts applying the Snodgrass technique is a reliable method for creating a substitute urethral plate for tubularization. The recurrent rate of urethral stricture and fistula is at an acceptable level for redo cases. This approach represents an effective, simple and safe option for reoperations.

The Single Stage Dorsal Inlay Skin Graft for Hypospadias Reoperations: Long-Term Follow-Up

PURPOSE Despite high success rates for primary hypospadias repair, some patients still require multiple sessions for ultimate functional reconstruction. We report our long-term experience with single stage dorsal inlay urethroplasty using skin grafts for complex hypospadias reoperations. MATERIAL AND METHODS 35 patients (mean 13.8 years) with failed hypospadias surgery (mean 4.2 times) were included. Indications comprised fistulas, strictures, diverticula, and repair breakdown. The urethral plate had been removed or was scarred in all patients. After excision of fibrotic tissue a free penile or groin skin graft was sutured and quilted to the corpora cavernosa. The neourethra was tubularized followed by glanuloplasty in a single stage. Clinical outcome was considered a failure when any postoperative instrumentation was needed. RESULTS Penile skin was used in 31 and inguinal skin in 4 cases.The average graft length was 4.87 cm. Initial graft healing was successful in all cases. We did not note complications from the graft donor sites. After a mean follow up of 55.73 +/- 18.26 months 5 patients underwent redo surgery leaving a complication rate of 14.3 %. Urethral stricture of the proximal anastomosis was the most frequent finding. Single internal urethrotomy was sufficient for 2 boys whereas 2 finally required another urethroplasty using the same technique. CONCLUSIONS This single stage approach using dorsal inlay skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged strategies with the advantage of only one hospital stay. Residual penile skin should be used as a graft donor site to optimize the outcome if available. Given the excellent long term follow-up, this approach represents a safe option for hypospadias re-operations even if the urethral plate or midline penile skin is grossly scarred.

THE SINGLE STAGE DORSAL INLAY SKIN GRAFT FOR HYPOSPADIAS REOPERATIONS: LONG-TERM FOLLOW-UP

You have accessJournal of Urology1 Apr 2008THE SINGLE STAGE DORSAL INLAY SKIN GRAFT FOR HYPOSPADIAS REOPERATIONS: LONG-TERM FOLLOW-UP Christian Schwentner, Alexandre E Pelzer, Josef Oswald, Georg Bartsch, and Christian Radmayr Christian SchwentnerChristian Schwentner More articles by this author , Alexandre E PelzerAlexandre E Pelzer More articles by this author , Josef OswaldJosef Oswald More articles by this author , Georg BartschGeorg Bartsch More articles by this author , and Christian RadmayrChristian Radmayr More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)61198-2AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "THE SINGLE STAGE DORSAL INLAY SKIN GRAFT FOR HYPOSPADIAS REOPERATIONS: LONG-TERM FOLLOW-UP." The Journal of Urology, 179(4S), p. 409 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 409 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Christian Schwentner More articles by this author Alexandre E Pelzer More articles by this author Josef Oswald More articles by this author Georg Bartsch More articles by this author Christian Radmayr More articles by this author Expand All Advertisement PDF downloadLoading ...