Hypospadias Repair In Children Research Articles

Safety and Effectiveness of Meatal Mobilization (MEMO) Technique for Glandular, Coronal, and Subcoronal Hypospadias Repair in Children: A 5-Year Single-Center Study with 105 Hypospadias.

This study aims to compare outcomes of treatment, in terms of early and late complications, between the Snodgrass and meatal mobilization (MEMO) techniques in children operated on because of distal hypospadias. The medical records of 127 children who underwent glandular, coronal, or subcoronal hypospadias repair between 1 January 2019 and 31 December 2023 were retrospectively reviewed. A total of 105 children met the inclusion criteria and were included in further analysis. The inclusion criteria were pediatric patients who underwent glandular, coronal, or subcoronal hypospadias repair using MEMO (n = 49) or the Snodgrass technique (n = 56) as a comparative group. The primary outcome of this study was the incidence of early and late complications with two different surgical techniques. Secondary outcomes were the duration of surgery, the length of hospital stay, the number of readmissions or unplanned returns to the operating room, and repeat surgeries between groups. The median age of all patients was 17 (interquartile range, IQR 13, 29) months, with a median follow-up of 26 (IQR 17, 34) months. Regarding the type of hypospadias, the majority of patients in both groups were categorized as coronal and subroronal hypospadias. Regarding the incidence of postoperative complications, a significantly lower incidence of postoperative complications was found in the MEMO group compared to the Snodgrass group (n = 4; 8.2% vs. n = 14; 25%; p = 0.037). An urethrocutaneous fistula was the most common complication in the Snodgrass group (n = 8; 14.3%), while in the MEMO group, only one patient (2%) developed a fistula (p = 0.034). The incidence of meatal stenosis (p = 0.621) and wound infections (p > 0.999) was low in both groups. No further complications were recorded during the follow-up period. Duration of surgery (41 min (IQR 38, 47) vs. 51 min (IQR 45.5, 61); p < 0.001), duration of hospitalization (1 day (IQR 1, 2) vs. 3 days (IQR 2, 6); p < 0.001), and time to catheter removal (3 days (IQR 2.5, 5) vs. 6 days (IQR 6, 8); p < 0.001) were significantly lower in patients operated on with MEMO compared to the Snodgrass technique. Only one case of readmission due to severe wound infection which led to suturing line dehiscence was recorded in the Snodgrass group. The incidence of redo surgery was significantly lower in the MEMO group than in the Snodgrass group (n = 3; 6.1% vs. n = 11; 19.6%; p = 0.048). MEMO is a safe and effective technique that can be used for the treatment of distal hypospadias. It showed excellent outcomes, cosmetic results, and a low incidence of complications as well as a significantly shorter duration of surgery compared to the Snodgrass technique.

Safety and Effectiveness of Triclosan-Coated Polydioxanone (PDS Plus) versus Uncoated Polydioxanone (PDS II) Sutures for Prevention of Surgical Site Infection after Hypospadias Repair in Children: A 10-Year Single Center Experience with 550 Hypospadias.

Triclosan is an antiseptic substance that has been shown in preclinical studies to reduce bacterial load in the wound and slow bacterial growth by inhibiting fatty acid synthesis. It is claimed that the coating protects against colonization of the tissue around the suture. This study aimed to compare the safety and efficacy of triclosan-coated polydioxanone versus uncoated polydioxanone sutures for the prevention of surgical site infections (SSIs) following hypospadias repair in children. The medical records of 550 children who underwent hypospadias repair between 1 January 2014 and 31 December 2023 were retrospectively analyzed. The patients included in the study were divided into two groups. The first group consisted of the patients in whom polydioxanone (PDS II) was used (n = 262), while in the patients of the second group (n = 288), triclosan-coated polydioxanone (PDS Plus) was used for hypospadias repair. Secondary outcomes were defined as the occurrence of early and late complications, the number of readmissions within 30 days after surgery (ReAd), unplanned return to the operating room (uROR), and repeat operations. The median age of all children enrolled in the study was 16 (IQR 14, 20) months. The patients in whom PDS Plus was used for hypospadias repair had a significantly lower number of SSIs than the patients in whom PDS II was used (n = 18 (6.9%) vs. n = 4 (1.4%), p < 0.001). Wound infection led to wound dehiscence in 10 of 18 patients from the PDS II group, while all four wound infections from the PDS Plus group led to wound dehiscence (p = 0.07). The number of postoperative urethrocutaneous fistulas was significantly lower in the patients in whom PDS Plus was used (13.7% vs. 8.3%, p = 0.042). The incidence of late complications did not differ between the study groups: meatal stenosis (p = 0.944), residual chordee (p = 0.107), urethral stricture (p = 0.196), scarring (p = 0.351) and urinary discomfort (p = 0.713). There were no cases of uROR in either group. The ReAd rate was low in both groups (n = 5 (1.9%) vs. n = 2 (0.6%), p = 0.266). The frequency of reoperations was lower in the group of patients treated with PDS Plus than in the group of patients treated with PDS II (11.1% vs. 20.6%; p = 0.03). The use of PDS Plus in hypospadias surgery significantly reduces the incidence of SSI, postoperative fistulas, and reoperation rates compared to PDS II.

Indocyanine Green (ICG)-Guided Onlay Preputial Island Flap Urethroplasty for the Single-Stage Repair of Hypospadias in Children: A Case Report

First described by Duckett in 1981, and initially employed for the surgical correction of mid-penile hypospadias, the onlay preputial island flap urethroplasty has progressively gained increasing popularity, extending its indication to proximal forms. However, with the complexity of the penile anomaly, the rate of postoperative complications related to poor tissue perfusion (including skin and glans dehiscence, urethral stenoses, and fistulas) has also increased. Conventionally, the visual assessment of the onlay preputial island flap is the only option available to establish the appropriate tissue vascularization during surgery. To this end, we have first introduced the EleVision IR system (Medtronic Ltd., Hong Kong, China) to assess the vascular perfusion of the preputial island flap in a 13-month-old boy undergoing the onlay urethroplasty for the surgical correction of a mid-shaft hypospadias. This was possible 80 s after the intravenous injection of indocyanine green (ICG, 0.15 mg/kg, Diagnostic Green GmbH, Munich, Germany). ICG-based laser angiography helped define the proximal resection margin of the preputial flap, and proved to be safe, effective, and easy to employ. This innovative intraoperative imaging modality can be considered a useful adjunct for tissue perfusion evaluation and intraoperative decision-making during the onlay preputial island flap urethroplasty in children.

Comparing Postoperative Analgesia of Caudal and Penile Blockade using Bupivacaine in Children Undergoing Hypospadias Repair

Background &amp; Objectives: Caudal epidural and dorsal nerve penile blockade are commonly used for analgesia during and after hypospadias repair in children. Comparative studies to recommend the most effective block are in dearth. This study aims to compare penile block versus caudal block with bupivacaine for hypospadias repair in children in terms of post-operative effectiveness, pain management, and complications. Methodology: The study was conducted on 60 male children, aged 1-9 years, undergoing hypospadias surgery under general anesthesia. The subjects were randomly divided into two groups: (A: caudal block, n=30, and B: penile block, n=30). A postoperative pain assessment was conducted using FLACC scale until 24 hours post-surgery. Results: The patients from the A and B groups were comparable in age, weight, and ASA classification. All patients in the 2 groups did not feel pain post-operatively throughout the first 6 hours. One patient (3.4%) from each of the A and B groups started to feel pain 6 hours, and 9 hours, respectively after surgery. Eight patients (26.7%) in group A and 6 patients (20%) in group B felt pain throughout 6 to 24 hours after surgery. Four patients from group A and 1 patient from group B developed nausea and vomiting during the first 24 hours post-surgery. Conclusion: The penile blockade proved to be more effective in lowering postoperative pain scores, with fewer side effects, thereby decreasing the need for rescue analgesia.

Complications of Hypospadias Repair in Children: A Single Center Experience

Complications of Hypospadias Repair in Children: A Single Center Experience

Do preoperative leukocyte and neutrophil levels have a predictive value on the complications of hypospadias repair in children?

Surgeons observed that the outcomes after the same repair technique in the same type of hypospadias performed by the same surgeon may be different. There may be some indeterminate factors that influence the results such as subclinical inflammation. Our study evaluated the predictor values of inflammatory hematologic parameters on the complications after hypospadias repair. We retrospectively reviewed the data of patients who underwent hypospadias repair between January 2016 and January 2019 in our clinic. Age at surgery, hypospadias type, repair technique, complications were recorded. Patients who underwent Snodgrass repair by a single surgeon were included in the study while patients who underwent different techniques or procedures that were performed by other surgeons were excluded. The levels of white blood cell, neutrophil, lymphocyte, platelet and monocyte, the mean platelet volumes were recorded from blood test that were performed one day before surgery. Neutrophil-lymphocyte ratio (NLR), plateletlymphocyte ratio (PLR), and other parameters were analyzed to determine their relationship with complications after hypospadias surgery. WBC and neutrophil levels were statistically higher in patients with complications (p = 0.006 and 0.017 respectively). Other hematological parameters were not different between patients with or without complications. To predict the complications, the WBC cutoff was 9500/mm3, the neutrophil cutoff was 3000/mm3. WBC and neutrophil values were statistically significant in predicting the complications after Snodgrass repair in patients with hypospadias. Our result determined no relation between complications and NLR, PLR.

Paediatric penile perception score (PPPS) in hypospadias repairde34.

The present cross-sectional study sought to evaluate the Paediatric Penile Perception Score (PPPS) as a tool to assess parental perception of hypospadias repair in children. In all, 60 patients were enrolled in the study with median age of 3.9 years; of these 24 (40%) had proximal hypospadias and 36 (60%) had distal hypospadias. After hypospadias repair, parents/guardians were interviewed about meatus, glans, skin, and general appearance using a standardised questionnaire to report penile appearance and penile perception. Overall, the median PPPS score was 17 (IQR: 16-18) with no significant difference in the penile perception score between the type of hypospadias, relationship of the person interviewed with the child (mother, father or other), nor the children's age. The study revealed that penile perception score (PPPS) is a valuable tool that can be used to assess parental penile perception regarding the child's penile appearance and noted overall high satisfaction after hypospadias repair.

Snodgrass procedure for distal penile and mid-shaft hypospadias repair in children

Introduction. Hypospadias is one of the most frequent penile malformations in newborn boys. Warren Snodgrass developed the «tubularized incised plate» (TIP) urethroplasty that is the most often procedure used in the surgical treatment of distal hypospadias for the last 20 years. Despite the great popularity of the technique, its no less famous Grafted TIP (GTIP) modification appeared. The technique is aimed at filling the defect in the urethral site with a foreskin free flap followed by tubularized urethroplasty.Purpose of the study. To compare the outcomes of TIP and GTIP procedures in our clinic which have been performed in the last 10 years.Materials and methods. One hundred-fourteen boys with hypospadias (aged 6 mo – 15 years) were operated on using the TIP technique and its modification GTIP during 2010 – 2020 (Sochi Center of Motherhood and Childhood Protection). The patients were: boys up to 1 year – 27 (23.7%), from 1 to 3 years – 57 (50%), 4 – 7 years – 19 (16.7%), from 8 to 14 years – 14 (12.3%). Primary repair was done in 112 cases (98.2%), the second procedure was done in 2 (1.8%) cases. There were 94 (82.5%) boys with distal hypospadias and 20 (17.5%) children with mid-shaft hypospadias. All patients were examined 3 and 12 months after surgery. We assessed the degree of skin scar process on the penile shaft, the location of the meatus and the quality of urination during the examination.Results. We observed 27 (23.7%) complications after urethroplasty out of 114 treated boys. There were 13 (11.4%) cases of urethral fistula, which were secondary repaired 6 months later. Meatal stenosis was observed in 2 (1.8%) cases, which required secondary meatoplasty. Repeat urethroplasty was done in 10 (8.7%) cases due to neourethral suture failure. There were also 2 (1.8%) cases of secondary penile curvature that required repeat surgery. The good cosmetical and functional results were achieved finally in all children.Conclusion. The analysis of our ten-year experience of using TIP-urethroplasty and its GTIP modification did not reveal significant differences in the overall incidence of postoperative complications. Yet, using the TIP procedure is associated with more fistulas. There were more cases of urethral suture failure in children whom the GTIP technique was performed. Our data suggest the need for a selective approach in the formation of indications for using TIP and GTIP procedures, along with research aimed at finding criteria for patient selection.

Outcome of Proximal Hypospadias Repair in Children using Standard Surgical Technique with Intermediate Vascularised Flap- ARetrospective Cohort Study

Introduction: Hypospadias is a very common congenital anomaly noted in children with reported incidence of 0.4-8.2% in 1000 live birth. Treatment of hypospadias is urethroplasty, but is a difficult procedure due to complex anatomy, nonavailability of adequate tissue for repair, prolonged postoperative course and increased incidence of complications even in experienced hands. Aim: To highlight the complications and functional outcome of various types of proximal hypospadias using standard surgical technique with intermediate vascularised flap. Materials and Methods: This was a retrospective cohort study conducted from on 31 children, between the age of 2-13 years from June 2020 to August 2020. The children had proximal hypospadias with or without chordee were operated using primary procedure Tubularised Incised Plate (TIP) and staged procedure with cover of intermediate vascularised flap. These children had peno-scrotal, proximal, mid and distal penile hypospadias with meatus placed 1.5 cm proximal from the glans tip. In all cases, an intermediate layer of vascularised flap was put to cover the neourethra. Tunica vaginalis flap was used in 27 cases and dartos flap in 4 cases. The outcomes of surgical procedure, early and late complications with follow-up results were analysed using descriptive statistics of frequency and percentage. Final functional results of the procedures and cosmesis were observed during a two-year follow-up period. Results: Out of the 31 patients, 27 patients had urethroplasty (20 staged procedures and seven TIP) with tunica vaginalis as intermediate layer. Another four patients had TIP urethroplasty with dartos as intermediate layer. Four patients of tunica vaginalis as intermediate layer had early urethrocutaneous fistula (14.8%), one patient (3.7%) required closure of fistula and another three closed spontaneously. Two patients had meatal stenosis (7.4%) and four had slight pulled up ipsilateral testis (14.8%). One patient of TIP urethroplasty with dartos as intermediate layer was reoperated for late urethrocutaneos fistula at corona glandis (25%). Conclusion: The outcome of pediatric urethroplasty was favourable with routine use of intermediate vascularised flap in proximal hypospadias repair.

Staged Buccal Mucosa Graft Urethroplasty for Proximal Hypospadias in Children: A Short- to Mid-Term Follow-Up Retrospective Study.

The aim of this study is to report our experience with modified staged buccal mucosa graft urethroplasty for the repair of proximal hypospadias in children and adolescents. A total of 183 patients were treated at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between 2010 and 2019. The patients were grouped according to age: (1) within 1.5-year-old group, (2) prepuberty group (Tanner stage 1), and (3) puberty group. In total, 153 patients were included in this study. Thirty-six patients had complications: seven after stage one; 29 after stage two; one patient had two complications. Maximum flow rates were 11.80 ± 1.46 mL/s in the 1.5-year-old group, 13.24 ± 2.61 mL/s in the prepuberty group, and 13.60 ± 2.20 mL/s in the puberty group (p = 0.199). Average flow rates were 6.86 ± 1.37, 7.94 ± 1.74, and 7.88 ± 1.22 mL/s, respectively (p = 0.203). The optimal hypospadias objective scoring evaluation score of 16 was seen in 117 patients (76%), the score of 15 in 23 patients (15%), 14 in 10 (7%), and 13 in 3 patients (2%). Patients with an uncomplicated treatment (no complication) had a higher clinical outcome than patients with a complication (15.8 ± 0.53 vs. 15.3 ± 0.97, with or without complication, p = 0.000). Multivariable analyses showed that previous treatment was closely related to the complication rate (p = 0.016). The modified procedure allows for two-stage repair of proximal hypospadias with good results with a low complication rate and good functional results. Delaying operation did not increase complication rates in our research.

Hypospadias Repair in Children: A 5-Year Experience from a Pediatric Surgery Department of Chittagong Medical College

Background: Hypospadias a very common condition in the children and the incidence is increasing. Here we present our experience of managing hypospadias patients over the last five years. &#x0D; Materials and methods: It was a retrospective study from 2014 to 2018 in the Department of Pediatric Surgery, Chattogram Medical College Hospital. Records of all hypospadias patients were analyzed and type of hypospadias, age at repair, type of repair and admission with complication of hypospadias were recorded. &#x0D; Results: A total of 492 boys were admitted with the diagnosis of hypospadias and 272 boys underwent hypospadias surgery. Distal penile hypospadias (148 patients, 30%) was the commonest variety followed by coronal hypospadias (144 patients, 29%). Age at surgery ranged from 6 months to 19 years with a mean age of 7±4 years. General anesthesia was given in 133 patients (64.7%) spinal anesthesia in 93 patients (31.8%) local anesthesia in 7 patients (2.4%) and caudal block in 3 patients (1%). Urethro-cutaneous fistula, failed urethroplasty and meatal stenosis are the admissions with hypospadias complications. &#x0D; Conclusion: Hypospadias is still common with substantial number of complications. Health education is necessary to reduce age at surgery.&#x0D; JCMCTA 2020 ; 31 (1) : 38-41

Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis.

is commonly used for children undergoing hypospadias repair. However, the safety of caudal block for hypospadias repair in children is controversial in terms of surgical complications such as urethrocutaneous fistula and glans dehiscence. We sought to perform a meta-analysis to estimate the analgesic efficacy and relative complications of caudal block for hypospadias repair in children. We identified comparative studies of caudal block versus peripheral nerve block or no caudal block; studies were published or presented through 1 January 2018, and reports of analgesic efficacy or surgical complications of hypospadias repair in children were identified. Peripheral nerve block includes dorsal nerve penile block and pudendal nerve block. Data were abstracted from studies comparing caudal block with peripheral nerve block or no caudal block; original source data were used when available. We prespecified separate assessments of randomized controlled trials (RCTs) and observational studies given the inherent differences between types of study designs. Data from 298 patients in four RCTs and from 1726 patients in seven observational studies were included. RCT and observational data were analyzed separately. In RCTs, caudal blocks (compared with peripheral nerve blocks) showed no detectable differences in terms of need for additional analgesia within 24 hours after the surgery (OR 10.49; 95% CI 0.32 to 343.24; p=0.19), but limited data showed lower pain scores 24 hours after the surgery (standardized mean difference (SMD) 1.57; 95% CI 0.29 to 2.84; p=0.02), a significantly shorter duration of analgesia (SMD -3.33; 95% CI -4.18 to -2.48; p<0.0001) and analgesics consumption. No significant differences were observed in terms of postoperative nausea and vomiting (OR 3.08; 95% CI 0.12 to 77.80; p=0.50) or motor weakness (OR 0.01; 95% CI -0.03 to 0.05; p=0.56). Only one randomized study showed that caudal blocks (compared with peripheral nerve blocks) were associated with detectable differences in urethrocutaneous fistula rate (OR 25.27; 95% CI 1.37 to 465.01; p=0.03) and parental satisfaction rate (OR 0.07; 95% CI 0.02 to 0.21; p<0.00001). In observational studies, caudal block was not associated with surgical complications in all types of primary hypospadias repair (OR 1.83; 95% CI 0.80 to 4.16; p=0.15). To adjust for confounding factors and to eliminate potential selection bias involving caudal block indication, we performed subgroup analysis including only patients with distal hypospadias. This analysis revealed similar complication rates in children who received a caudal block and in children not receiving caudal block (OR 1.02; 95% CI, 0.39 to 2.65; p=0.96). This result further confirmed that caudal block was not a risk factor for surgical complications in hypospadias repair. The direction of outcomes in all the other subgroup analyses did not change, suggesting stability of our results. In RCTs, only limited data showed peripheral nerve blocks providing better analgesic quality compared with caudal blocks. In real-world non-randomized observational studies with greater number of patients (but with admitted the potential for a presence of selection bias and residual confounders), caudal blocks were not associated with postoperative complications including urethrocutaneous fistula and glans dehiscence.

The use of postoperative prophylactic antibiotics in stented distal hypospadias repair: a systematic review and meta-analysis

The current literature on the use of antibiotics perioperatively for many pediatric procedures, including hypospadias, is inconsistent. There is currently no clear evidence for the use of postoperative antibiotic prophylaxis for stented distal hypospadias repair. This study aims to synthesize and assess the available literature on the use versus non-use of postoperative antibiotic prophylaxis for stented distal hypospadias repair. Systematic literature search was performed on March 2018 for evaluation of trials that assessed the use and non-use of postoperative prophylactic antibiotics among stented distal hypospadias repair in children. Methodological quality of the studies was assessed according to the study design as recommended by the Cochrane Collaboration. The outcome assessed includes composite overall posthypospadias repair complications of infection and wound healing complications. The event rate for each treatment group was extracted to extrapolate intervention relative risk (RR) and corresponding 95% confidence interval (CI). Mantel-Haenszel method with random effect model was used in pooling of effect estimates from the included studies. Heterogeneity was assessed with subgroup analysis performed according to the study design. Publication bias was likewise determined. The protocol of this review was registered in PROSPERO (CRD42018087301) and reported in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A total of seven studies (four cohorts, three randomized controlled trials) with 986 stented distal hypospadias repairs (408 with no post-operative prophylactic antibiotics and 578 given postoperative prophylactic antibiotics) were included for the meta-analysis. Moderate to serious risk of bias was noted among the cohort studies, while the included randomized controlled trials (RCT) were of high risk of bias. Inconsistencies of effect estimates between subgroups and publication bias with small study effect were likely present. The overall pooled effect estimates comparing treatment groups showed no significant difference for outcomes of overall composite postoperative complication (RR 0.93, 95% CI 0.45, 1.93). Assessment of composite infection related complications and wound healing complications likewise did not show any significant between-group differences (RR 1.28, 95% CI 0.49, 3.35 and RR 1.01, 95% CI 0.48, 2.12; respectively) (Table). Asymptomatic bacteriuria was noted to be significantly higher among the intervention group with no postoperative prophylactic antibiotics (RR 4.01, 95% CI 1.11, 14.54). The available evidence to date was assessed to be of high risk. The low level of evidence generated suggests that there is limited utility in the use of postoperative prophylactic antibiotics to prevent clinically significant posthypospadias repair complications.

TUBULARIZED INCISED PLATE URETHROPLASTY FOR ONE-STAGE HYPOSPADIA REPAIR IN CHILDREN AT HASAN SADIKIN HOSPITAL BANDUNG

Objective: To determine the outcome of tubularized incised-plate (TIP) urethroplasty for one stage hypospadia repair in children. Material &amp; methods: A 7-year retrospective experience at Hasan General Sadikin Hospital Bandung on the outcome of tubularized incised plate for one-stage hypospadias repair in children during 2009-2015. Results: A total of 102 children was undergone one stage hypospadias repair with TIP urethroplasty. The mean age was 6.97 years old. As much as 65 (63.72%) children had distal, and 37 (36.28%) children had proximal hypospadia. The mean length of surgery was 112.56 minutes. Post operative complications was rarely found, consisting of 5 (6.32%) children had urethrocutaneus fistula formation and 11 (13.9%) children had haematoma. 4 (10.81%) children with proximal hypospdia and 1 (1.53%) children with distal hypospadia had urethrocutaneus fistula formation. 4 (6.15%) children with distal hypospadia and 7 (18.91%) children with proximal hypospadia had haematoma. Conclusion: Tubularized incised-plate (TIP) urethroplasty for one stage hypospadia repair in children was highly effective with rare complications comparable with recently published study.

Prevention and treatment of urethral stricture after hypospadias repair in children

Urethral stricture is one of the common complications after hypospadias repair, and it is related with the blood supply of materials used in urethra formation.The more severe and proximal hypospadias is, the higher possibility of stricture is.The patients with urethral stricture have the symptoms of stranguria and urinary retention, and they usually need re-surgery.The repair with well vascularized flap can decrease the occurrence of urethral stricture after hypospadias repair. Key words: Hypospadias; Urethral stricture; Child

Tubularized incised plate urethroplasty repair in adult hypospadias patients. Are results similar to those reported in the pediatric age group? A prospective study

ObjectiveMost studies published in the literature report on the results of tubularized incised plate urethroplasty (TIPU) for hypospadias repair in children. Hence, the objective of this study was to evaluate the results of TIPU repair in adults. Patients and methodsThe records of 60 adult patients with primary hypospadias treated with TIPU between April 2009 and May 2012 were reviewed. All the procedures were done by the same surgeon under similar conditions and using the same kind of instruments and suture material. On clinical examination, the meatal location, as well as the presence/absence of chordee and penile torsion was assessed. The quality of the spongiosum and the width of the urethral plate were evaluated intraoperatively. The postoperative complications and results were recorded and the data were analyzed. ResultsThe patients’ age ranged from 16 to 27 years with a mean of 21 years. Out of the 60 cases, 43 (72%) had distal penile, 7 (11%) mid-penile and 10 (17%) proximal hypospadias. Penile torsion was present in 10 (17%) cases with 80% having a torsion ≤45° and 20% having a torsion of 45–90°. Ventral chordee ranging from 30° to 90° was present in 14 (23%) cases. Chordee correction was possible by penile de-gloving in 4 (29%) patients (2 with distal and 2 with mid-penile hypospadias), by further mobilization of the urethral plate with the corpus spongiosum in 3 (21%) and by proximal urethral mobilization in another 6 (42%) patients with proximal hypospadias. One (7%) patient also required tunica albuginea plication. The urethral plate was wide in 22 (37%), average in 26 (43%) and narrow in 12 (20%) patients. Fifty percent of the patients with a narrow urethral plate developed complications, compared to 15% of the patients whose urethral plate had an average width and none of the patients with a wide urethral plate. The spongiosum was well developed in 38 (63%) patients, while in 11 (18%) patients each the spongiosum was moderately and poorly developed. The complication rates were significantly higher (55%) in patients with a poorly developed spongiosum as compared to those with a well-developed spongiosum. The overall complication rate was 17% including fistula in 10% of the patients (2 patients with mid-penile and 4 patients with proximal hypospadias). Meatal stenosis was found in 4 patients with distal hypospadias (7%) who responded well to meatal dilatation. The fistula cases required surgical repair with a success rate of 100%. Mean hospitalization and follow-up were 9 days and 6–24 (median 37) months, respectively. ConclusionsComplications encountered in the present study were urethral fistula and meatal stenosis with a higher incidence in patients with proximal hypospadias than reported in the literature. The important factors for the outcome of TIPU were the severity of hypospadias, the degree of curvature and the development of the spongiosum and urethral plate. Proximal hypospadias with a poor urethral plate and severe curvature in adults is not suitable for TIPU. In such cases, single-stage flap urethroplasty or two-stage buccal mucosal urethroplasty should be considered instead.

RETRACTED: The effect of parenteral testosterone administration prior to hypospadias surgery: A prospective, randomized and controlled study

The goal of hypospadias surgery is to provide a functionally and cosmetically normal penis. Whether this goal will be to the patient's satisfaction depends largely on the original anatomy, surgical technique and surgeon's experience. It has been suggested that androgen administration is associated with better outcomes in hypospadias repair; however, few studies have included control groups and the issue is still controversial. To evaluate the effects of parenteral testosterone administration on the results of hypospadias repair in children with untreated hypospadias. A total of 182 children with midshaft or distal hypospadias and a mean age of 30 months (range 18-52 months) were enrolled in this study. Consecutive children were randomly allocated to the study group (testosterone administration) (Group 1, n = 91) or control group (Group 2, n = 91). Only children with a flat urethral plate were included in this study. The control group did not receive any pre-operative treatment. Children with a previous history of hypospadias repair and any proven endocrine disorder were excluded. The study children received 2 mg/kg testosterone enanthate monthly for two months before surgery. Tubularized incised plate (TIP) urethroplasty, with or without chordee correction, was performed for all children in both groups by the same urologist. Hypospadias repair was performed 4 weeks after the second dose of testosterone administration. Postoperative complications were recorded, including: urethrocutaneous fistulas, urethral diverticula, meatal stenosis, and glanular dehiscence. The mean stretched penile length and circumference were measured at baseline and at 1 month and 2 months post operation. All children were examined every month for any adverse affects to testosterone treatment, like pubic and axillary hair, and height acceleration, up to 3 months post operation. An increase in penile length (from 28.1 ± 2.2 mm to 38.5 ± 2.6 mm) (P = 0.001) and penile circumference (from 35.1 ± 1.6 mm to 45.5 ± 2.2 mm) (P = 0.001) were noticed in all but four children in Group 1. The actual values for increase in penile length in the study group were, 22.0%, 35.0% and 36.0%, at postinjection months 1, 2 and 3, respectively (P = 0.01, P = 0.001 and P = 0.001, respectively) (Figure). The actual values for increase in penile circumference in the study group were, 16.0%, 27.0% and 29.0%, at postinjection months 1, 2 and 3, respectively (P=0.01, P=0.001 and P =0.001, respectively). The overall complication rates were significantly higher in Group 2 [12 children, 13.18%) compared to Group 1 (five children, 5.45%) (P=0.03). Urethrocutaneous fistula was the most common complication in both groups (four children [4.39%] in Group 1 and seven children [7.69%] in Group 2) (P=0.02), followed by meatal stenosis (one child [1.09%] in Group 1 and three children [3.29%] in Group 2) (P=0.03). All children in Group 1 developed pigmentation of the genitalia, and scant pubic hair appeared in 14 of them. These side effects disappeared by the 3 months postoperation follow-up visit. Tubularized incised plate urethroplasty is a popular reconstructive method for hypospadias repair and is widely accepted by pediatric urologists. It is a reliable and simple technique with low complication rates. Testosterone administration before hypospadias repair decreases complication rates, reduces the need for reoperation and results in better cosmetic outcomes. Some studies have demonstrated temporary side effects like pubic hair growth and aggressive behavior, which gradually became normalized after treatment cessation. Nowadays, many pediatric urologists administer testosterone prior to hypospadias surgery; however, this can be variable. Parenteral testosterone administration before hypospadias repair is beneficial in decreasing complication rates.

Caudal Additives Do Not Improve the Analgesia Afforded by Levobupivacaine After Hypospadias Repair

Background: Caudal analgesia is commonly employed to provide excellent intra- and postoperative analgesia for primary hypospadias repair in children. Several additives to local anesthetics are commonly employed to increase the block duration, although these have uncertain benefits. Objectives: This study investigated whether, in caudal analgesia with levobupivacaine 0.25%, the addition of S (+)-ketamine, clonidine, or both agents combined, would prolong postoperative analgesia in patients undergoing primary hypospadias repair. Patients and Methods: We conducted a retrospective chart analysis for all patients who underwent hypospadias repair with caudal analgesia over a consecutive 3-period at this institution. The study examined four patient groups, classified according to the analgesia used:\r\n1) No additive, levobupivacaine alone\r\n2) Levobupivacaine and S (+)-ketamine\r\n3) Levobupivacaine and clonidine\r\n4) Levobupivacaine, S (+)-ketamine, and clonidine\r\nPrimary outcome measures were as follows: time to the first postoperative request for analgesia, total first 24-hour postoperative analgesia, and time to hospital discharge.\r\n Results: The 87 patients included had a mean ± SD age of 21.4 ± 13.5 months and weight of 11.9 ± 2.4 kg. The median doses of levobupivacaine, S (+)-ketamine, and clonidine were 0.7 mg/kg (range, 0.4–1.3), 0.5 mg/kg (0.2–1.1), and 1.8 μg/kg (0.8–2.3), respectively. The addition of S(+)-ketamine, clonidine, or both did not increase the time to first oral analgesia request. Neither did it reduce the total first 24-hour postoperative analgesia requirements or alter hospital discharge time. However, the additive drugs in combination did increase postoperative sedation. Conclusions: The addition of S (+)-ketamine or clonidine to levobupivacaine 0.25% in caudal analgesia for hypospadias repair appears to be of no benefit. However, use of the additives in combination increased postoperative sedation.

Caudal additives do not improve the analgesia afforded by levobupivacaine after hypospadias repair.

Background:Caudal analgesia is commonly employed to provide excellent intra- and postoperative analgesia for primary hypospadias repair in children. Several additives to local anesthetics are commonly employed to increase the block duration, although these have uncertain benefits.Objectives:This study investigated whether, in caudal analgesia with levobupivacaine 0.25%, the addition of S (+)-ketamine, clonidine, or both agents combined, would prolong postoperative analgesia in patients undergoing primary hypospadias repair.Patients and Methods:We conducted a retrospective chart analysis for all patients who underwent hypospadias repair with caudal analgesia over a consecutive 3-period at this institution. The study examined four patient groups, classified according to the analgesia used:No additive, levobupivacaine aloneLevobupivacaine and S (+)-ketamineLevobupivacaine and clonidineLevobupivacaine, S (+)-ketamine, and clonidinePrimary outcome measures were as follows: time to the first postoperative request for analgesia, total first 24-hour postoperative analgesia, and time to hospital discharge.Results:The 87 patients included had a mean ± SD age of 21.4 ± 13.5 months and weight of 11.9 ± 2.4 kg. The median doses of levobupivacaine, S (+)-ketamine, and clonidine were 0.7 mg/kg (range, 0.4–1.3), 0.5 mg/kg (0.2–1.1), and 1.8 μg/kg (0.8–2.3), respectively. The addition of S(+)-ketamine, clonidine, or both did not increase the time to first oral analgesia request. Neither did it reduce the total first 24-hour postoperative analgesia requirements or alter hospital discharge time. However, the additive drugs in combination did increase postoperative sedation.Conclusions:The addition of S (+)-ketamine or clonidine to levobupivacaine 0.25% in caudal analgesia for hypospadias repair appears to be of no benefit. However, use of the additives in combination increased postoperative sedation.

Outcomes of Hypospadias Repair in Older Children: A Prospective Study

The American Academy of Pediatrics recommendation is to perform hypospadias repair at age 6 to 12 months. However, our patient population included a significant proportion of patients in adolescence and beyond undergoing primary repair. We report a comparison of outcomes in patients in different age groups. We prospectively report on patients with distal hypospadias who underwent primary repair at our institution during 7 months. Study parameters included age, degree of hypospadias, surgical technique and the complications rate. A total of 61 patients were included in analysis. All cases underwent repair using the tubularized incised plate technique. More proximal hypospadias and different repair techniques were excluded from study. Patients were classified by age, including group 1-25 (40%) 6 months to 2 years old, group 2-17 (28%) 2.2 to 3.7 years old and group 3-19 (32%) 4 years old or older. Only 6 patients (9.8%) had postoperative complications and all were in groups 2 and 3. In group 2 there were 3 complications (17.6%), including loss of repair, meatal stenosis and hematoma in 1 case each. In group 3 there were 3 cases (15.8%) of postoperative fistula. The fistula incidence was higher in group 3 (p = 0.032). Despite previous reports suggesting a much higher incidence of complications in older children the complication rate is within the acceptable range for infant hypospadias repair in some series. However, these complications were statistically significantly different between the older groups when compared with the recommended age group under American Academy of Pediatrics guidelines.