Hypospadias Repair Research Articles

Clinical outcomes of circumcisions and prevalence of complications of male circumcisions: A five-year retrospective analysis at a teaching hospital in Ghana.

Male circumcision is increasing in popularity due to its medical benefits, including reducing HIV prevalence. It is commonly performed by both health and non-health professionals, with most circumcisions occurring during the neonatal period. Studies suggest the benefits outweigh the risks, though complications can occur. This study aimed to determine the clinical outcomes of circumcisions and the prevalence of adverse events of circumcision in the Volta region of Ghana. A five-year retrospective descriptive and analytic study was conducted at Ho Teaching Hospital, using a structured data extraction sheet to collect demographic, clinical, and circumcision-related data from 186 cases. Among 186 circumcision cases, 23 (12.37%) experienced complications, with the most common being partial circumcision (43.48%), post-circumcision bleeding (21.74%), and urethrocutaneous fistula and/or wrongfully circumcised congenital hypospadias (13.04%). Low heamoglobin levels and infections were also noted. A significant relationship was found between the circumcision provider and complication rates (Chi-square = 16.975, p = 0.00). Doctors conducting circumcision had the lowest complication rates (4.3%), while nurses and traditional circumcisers had higher complication rates (39.1% and 34.8%, respectively). Circumcision-Revision surgery was the most common salvage surgery for circumcision mishaps (31.82%), with urethroplasty and hypospadias repair (for wrongful circumcised neonates born with hypospadias) accounting for 15.91%. Meatoplasties, glansplasties, fistulectomy plus primary repair and chordae-release surgeries were also performed. The success rate for salvage surgeries (first attempt) was 70%. Prompt initial management strategies were significantly associated with good outcomes. Under less-trained hands, circumcision could be catastrophic. Salvage surgeries for circumcision mishaps are associated with less favourable outcomes in about one-third of the cases, suggesting that circumcision mishaps are better prevented than salvaged. Training, guidance, and policy interventions are needed to reduce the incidence of circumcision-related mishaps. Public health campaigns to dissuade non-surgeon circumcisers to refrain from circumcising children with hypospadias but refer them, are urgently needed.

Microscopic and molecular analysis of the Urethral Plate: A Step Towards Improved Hypospadias Surgery Outcomes.

To investigate the microscopic and molecular structure of the urethral plate in hypospadias patients compared to normal urethral tissue, focusing on epithelial characteristics, cytokeratin expression, vascular patterns, and extracellular matrix components, including elastin fibers. We analyzed 8 full-thickness mid urethral plate samples from pediatric hypospadias patients using immunohistochemistry to evaluate epithelial structure, cytokeratin expression (PanCK, CK7, CK10, CK13, CK14), vascular patterns (vWF, CD31), and extracellular matrix components (elastin). Control tissues included fetal urethras and penile urethras from gender confirmation surgery. The hypospadias urethral plate exhibited a multi-layered epithelium, contrasting with the single-layered normal urethral epithelium. Cytokeratin expression differed significantly: CK7 was predominantly negative in hypospadias samples but strongly positive in controls; CK10 showed variable expression; CK13 and CK14 were consistently positive in hypospadias samples, with CK14 exhibiting strong expression in the basal layer. Vascular analysis revealed fewer subepithelial capillaries and smaller vascular spaces in hypospadias tissue. Elastin expression was positive in hypospadias samples, while fetal urethra showed lower expression and adult urethra displayed distinct elastin fiber bundles. Minimal smooth muscle tissue was observed in hypospadias and fetal samples compared to adult controls. The urethral plate in hypospadias patients demonstrates significant structural and molecular differences from normal urethral tissue, suggesting a developmental delay or arrest. These differences may contribute to surgical challenges and post-operative complications. Understanding these unique tissue characteristics could inform the development of novel surgical techniques or tissue engineering approaches to improve hypospadias repair outcomes.

Molecular genetic diagnosis and surgical management in a cohort of children with 46,XY disorders/differences of sex development

ObjectiveA firm diagnosis revealing the etiology of disorders/differences of sex development (DSD) is most helpful in guiding clinical management. The aim of this study is to investigate molecular genetic diagnoses and surgical treatment in a cohort of children with 46,XY DSD.MethodsA retrospective study was conducted on children with 46,XY DSD. They were referred to a tertiary surgical center during the period between 2011 and 2022 and were found to have genetic alterations, which were considered etiologies for their DSD. Data on clinical presentations, sex of rearing, genetic findings, surgical treatment, and comorbidities were collected and reviewed.ResultsA total of 21 patients were included in the study: 11 and 10 were reared as male and female, respectively. Genetic alterations were found as the causes for androgen insensitivity syndrome (n = 4), 5-alpha reductase type II deficiency (n = 5), 17-beta hydroxysteroid dehydrogenase III deficiency (n = 1), 17-alpha hydroxylase deficiency (n = 1), and gonadal dysgenesis (n = 10). Of those with gonadal dysgenesis, the genetic alterations were NR5A1 mutation/deletion (n = 3), DMRT1 deletion (n = 4), WT1 mutation (n = 2), and DAX1 duplication (n = 1). A total of 20/21 patients underwent one or more surgical procedures including hypospadias repair (n = 10), gonadectomy (n = 11), gonadal biopsy (n = 4), hernia repair (n = 4), orchidopexy (n = 1), and feminizing genitoplasty (n = 1). A total of 5/21 had germ cell neoplasms in one or both gonads. A total of 8/10 patients with gonadal dysgenesis had comorbidities involving other systems. Of the whole group, seven patients were found to inherit genetic alterations from their parents.ConclusionsMolecular genetic diagnosis enhances the understanding of etiology, improves diagnostic accuracy, and provides precise guidance in the counseling and surgical management of children with 46,XY DSD.

Commentary regarding JPUROL-D-24-00367R2 Adherence to follow-up ten years after hypospadias repair.

Commentary regarding JPUROL-D-24-00367R2 Adherence to follow-up ten years after hypospadias repair.

Self-reported outcomes in adults with hypospadias: A meta-analysis of patient satisfaction and quality-of-life metrics.

Hypospadias reconstruction seeks to correct structural problems associated with this congenital condition to improve patient quality-of-life (QoL) and overall well-being. While corrective surgery can lead to major functional and psychosocial improvements, some patients experience continuing problems that require additional procedures. This study evaluates patient-reported outcomes (PROs) in hypospadias care, particularly penile satisfaction and QoL after surgery, to fill this essential gap in the literature. Computerized bibliographic searches were performed in PubMed, ScienceDirect, Cochrane Library, and ClinicalTrials. Up to July 30th, 2024. Funnel plots and ROBINS-I questioners were used to assess publication and overall risk of bias. The random effect model was applied to determine the pooled parameters when I2 was more than 50%. The fixed effect model was applied to the contrary. Confidence intervals (CIs) of 95% were calculated. Eight studies were selected which included a total of 726 patients who self-evaluated satisfaction levels following hypospadias repair procedures the earliest of which was published on 2008. Three studies involving 144 people also examined QoL metrics among patients underwent hypospadias repair, with low publication bias and low-to-moderate overall risk of bias across the included studies. The pooled results indicated that subjects without hypospadias (control group) reported significantly higher satisfaction with penile appearance in 4 studies with continuous data (mean difference -1.43, 95% CI -2.79-0.07, p<0.05, high heterogeneity I2=90%, p<0.05) and 4 studies with dichotomous data (odds ratio 0.1, 95% CI 0.07-0.15, p<0.05, low heterogeneity I2=0%, p=0.48). There is no significant difference of QoL between two groups (mean difference 0.62, 95% CI -2.05-3.28, p<0.65, moderate level of heterogeneity I2=69%, p<0.05). Our research shows that post-hypospadias repair surgery patient satisfaction is inadequate, but their quality of life is equivalent to those without hypospadias. This study enhances understanding of hypospadias patients' key issues and suggests ways to improve quality of life after corrective surgery.

Comparison of Single-Staged and Staged Repair of Proximal Hypospadias among Children Attending a Tertiary Care Center of Northern India: A Retro-prospective Analysis

Introduction: Hypospadias is a common congenital malformation, with proximal hypospadias occurring in 20% of cases and having a higher incidence of complications than distal hypospadias. Surgical reconstruction varies between single-stage and multi-stage procedures, with no consensus on the optimal approach. Objectives: This study aimed to compare the outcomes of single-stage and staged repairs for proximal hypospadias in a lower middle-income country, focusing on complications, operative time, patient satisfaction, and overall surgical success. Materials and Methods: An ambispective observational study was conducted at King George’s Medical University, Lucknow, from May 2014 to February 2020. Sixty patients with proximal penile hypospadias and chordee were selected (29 from previous medical records and 31 were enrolled prospectively) and divided into two groups of 30 each: single-stage reconstruction and staged repair. Data on demographics, follow-up duration, complications, reoperations, and satisfaction were collected. The Hypospadias Objective Scoring Evaluation (HOSE) system as well as cosmesis was used to assess outcomes at 6-week follow-up. Results: The mean age was 3.8 years for single-stage and 4.5 years for staged repair, with no significant age difference (P = 0.725). The mean operating time was 90 min for single-stage and 210 min for staged repair. Complication rates, including meatal stenosis and urethral stricture, showed no significant differences. However, graft rejection occurred in four staged repair cases (P = 0.112). The staged repair group had higher reoperation rates (26.67% vs. 13.33%, P = 0.062) and longer hospital stays (26.47 vs. 13.87 days, P = 0.0001). Staged repair achieved better slit-like meatus shapes (83.3% vs. 60%, P = 0.021) and higher satisfaction with residual skin (P = 0.004). HOSE scores showed significant advantages for staged repair in the urinary stream (P = 0.048) and erection outcomes (P = 0.001). Conclusion: Staged repair showed better cosmetic outcomes and satisfaction in specific areas but required more operative time and hospital stay. Single-stage reconstruction was more cost-effective and had fewer reoperations. The choice of procedure should consider patient-specific factors and resource availability.

Successful Surgical Repair of Sub-Coronal Hypospadias in a 10-Year-Old Male: A Case of Delayed Presentation and Effective Intervention

Successful Surgical Repair of Sub-Coronal Hypospadias in a 10-Year-Old Male: A Case of Delayed Presentation and Effective Intervention

Usefulness topical di-hydro testosterone prior to proximal hypospadias repair in testosterone non-responders

Usefulness topical di-hydro testosterone prior to proximal hypospadias repair in testosterone non-responders

Effect of Intravenous Paracetamol on Postoperative Recovery in Children Undergoing Hypospadias Repair under General Anaesthesia with Caudal Block: A Randomised Controlled Trial.

To explore the impact of perioperative intravenous (IV) paracetamol, administered with caudal ropivacaine on the quality of postoperative recovery in children undergoing hypospadias repair. Double-blinded randomised controlled trial. Place and Duration of the Study: The operating room, post-anaesthesia care unit (PACU), and paediatric surgical ward at the Aga Khan University Hospital, from 31st January 2019 to 1st May 2022. Children aged 3-10 years undergoing hypospadias repair were randomly divided into two groups. Group P was administered IV paracetamol 15 mg/kg an hour before the completion of the repair procedure. Group C received a placebo instead of paracetamol. Modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) was measured at 15 and 30 minutes, and at 1, 2, 4, and 6 hours postoperatively. The sedation score was documented for four hours postoperatively. Out of total 59 children included in the analysis, 55% (n = 16) in the Group P and 45% (n = 13) in the Group C needed additional analgesia within the first six hours post-procedure. No significant variations were observed between the groups' CHEOPS scores and sedation levels. The addition of perioperative intravenous paracetamol 15 mg/kg in combination with 0.25% ropivacaine through the caudal route, along with general anaesthesia, did not significantly affect the quality of postoperative recovery in children measured by pain score and sedation. Intravenous paracetamol, Caudal analgesia, Ropivacaine, Paediatric patients.

Comparison of Interrupted Vs Continuous Suture Urethroplasty in Tabularised Incised Plate Hypospadias Repair. A Prospective Study

Comparison of Interrupted Vs Continuous Suture Urethroplasty in Tabularised Incised Plate Hypospadias Repair. A Prospective Study

Correlation between histopathology properties of dartos tissue and the severity of penile curvature in hypospadias.

Hypospadias, one of the congenital anomalies commonly associated with some degrees of ventral penile curvature that may arise from malformation of dartos fascia, the chordee. Our study aims to determine the correlation between the histopathology properties of dartos fascia and the severity of ventral penile curvature in hypospadias. One hundred hypospadias patients with various degrees of ventral penile curvature were included in this cross-sectional analytical study from 2020 to 2022. During hypospadias repair, ventral dartos fascia was excised and analyzed for the degree of collagen thickness and the severity of the fibrotic condition. Out of 100 patients, the mean age was 6.58 + 4.28 years, who were classified as mild to moderate (66%) and severe (34%) ventral curvature cases. The analyses showed significant differences in the severity of fibrotic condition and collagen thickness of dartos fascia to the severity of penile ventral curvature with p-values of 0.002 and 0.017, respectively. The difference in histopathology properties of dartos fascia may affect the severity of penile curvature in hypospadias patients.

Etiology of panurethral strictures in a low socioeconomic status population.

Panurethral strictures represent the most severe form within the anterior urethral stricture spectrum, requiring more technically complex repairs and resulting in poorer outcomes compared to localized anterior urethral strictures (penile or bulbar). This abstract aims to describe the distinct characteristics of patients with panurethral strictures in a low socioeconomic status population. Patients presenting with localized anterior (penile or bulbar) or panurethral strictures at University Hospital in Newark, NJ, between 2021 and 2023 were retrospectively identified. Data were extracted from electronic medical records and analyzed statistically using IBM SPSS Software. Among the patients, 33 had localized anterior urethral strictures, and 22 had panurethral stricture disease. Hispanic and African American patients accounted for the majority of stricture cases (63.6%), including 59% of the panurethral stricture cohort. The only statistically significant factor contributing to panurethral disease was lichen sclerosis (p < 0.05). Patients with panurethral strictures had a higher incidence of inflammatory and systemic diseases such as STDs, recurrent UTIs, diabetes, and hypertension, while those with localized anterior urethral strictures showed a higher incidence of iatrogenic factors, including prior catheterizations and transurethral surgeries. However, these factors did not reach a statistical significance. Hypospadias repair was observed in 6% of localized anterior urethral stricture cases, compared to 13.6% of panurethral stricture cases. While iatrogenic causes remain the predominant contributors, inflammatory and systemic conditions, particularly lichen sclerosis, significantly influence the development of panurethral strictures. Early surgical intervention and better management of systemic diseases may prevent the progression of localized anterior urethral strictures to panurethral disease, but further studies utilizing larger number of patients may shed light on the significance of these systemic factors.

Incidence of urethrocutaneous fistula after distal and midshaft hypospadias repair does not differ among patients treated with or without a protective second-layer: single tertiary centre experience.

Urethrocutaneous fistula (UCF) is the most common complication after hypospadias repair, with an variable incidence of 2-35%, depending on defect type. The interposition of tissue between the neourethra and the skin or glans is considered an important factor to reduce the risk of UCF. Literature has focused on the comparison of different types of second layers, but there is still no consensus regarding the best tissue to adopt. By contrast, literature regarding not-covered urethroplasty is lacking. Our aim is to investigate the value of hypospadias repair without a second-layer and to compare the results with hypospadias repaired with the use of an alternative, easily available second layer of periurethral tissue. All distal and mid-penile hypospadias treated with single-stage urethroplasty at our centre between 2016 and 2020 were reviewed. Cases were divided according to the surgical technique: Group-A (urethroplasty with a second layer of periurethral tissue) and Group-B (single-layer urethroplasty). Anagraphic data and complications such as UCF and meatal stenosis were analysed. 425 single-stage urethroplasties were collected. 30 cases of UCF were observed (7%), 11/164 for Group A (6,7%) and 19/261 for Group B (7,3%) at a mean follow-up of 3years. The difference was not statistically significant (p = 0.8). In 11/30 patients (37%) the UCF was associated with meatal stenosis. A well-performed urethral suture, more than a second layer, is fundamental to prevent UCFs. Periurethral tissue is a valid second layer, providing good coverage with minimal tissue manipulation. Larger, prospective and randomised studies could be encouraged to confirm our data.

Hypospadic Cripple: How To Avoid

The term hypospadic cripple is very apt to use for hypospadic patient who has underwent several unsuccessful reconstruction attempt. The meaning of the word cripple is uncapable to function properly. If it is used for condition after failure of several attempt of reconstructions in hypospadia repair, the meaning of severe damage should apply; a crippled penis with fistula, stricture, contracture and less healthy skin cover.

Additive outcome of platelet rich fibrin neourethral coverage of tubularized incised plate in primary distal hypospadias repair

BackgroundHealing complications are a significant concern after hypospadias repair, often attributed to deficient growth factors and reduced healing potential of hypospadiac tissue. Platelet-Rich Fibrin (PRF), a new generation of platelet concentrates rich in growth factors, has been successfully applied to provide a mechanical barrier and promote healing in different surgical fields. The objective of this study was to assess the role of a PRF membrane covering the neourethra, in addition to a Dartos flap, optimizing the outcomes of primary distal hypospadias repair.MethodsForty-four patients undergoing primary distal hypospadias repair were randomized and then assigned to two groups according to the covering layer(s) applied over the neourethra in Tubularized Incised Plate (TIP) repair. Each group included 22 cases with an average age of 38 ± 28 months for group A and 30 ± 21 months for group B. In group A, the classical technique of a single Dartos flap was used. In group B, an autologous PRF membrane -prepared during surgery using the patient’s own serum- was placed to the neourethra and subsequently covered with Dartos flap.Resultswith a mean follow up of 17.9 ± 7.2 months (range 6–30 months), group B had the lowest rate of complicated cases (9.1% compared to 31% for group A), Nevertheless, this finding was not statistically significant. The implementation of PRF in group B scaled down the rate of urethrocutaneous fistula (UCF) formation to 4.5% compared to 18.2% in group A. Furthermore, group B had no incidence of wound infection compared to 22.7% in group A (p < 0.05).ConclusionCombined neourethral coverage with a PRF membrane and a Dartos flap leads to a trend toward a significant decrease in rate of UCF and leads to a significant reduction in wound infection after TIP repair compared to a single Dartos flap after TIP repair compared to a single Dartos flap. The technique is technically simple, inexpensive and is also not time-consuming.

Effects of preoperative caudal epidural block on surgical outcomes in distal hypospadias surgery

Aims: Hypospadias is an anomaly of the urogenital system with an incidence of approximately 0.5% in children. Caudal epidural block (CEB) is one of the most preferred analgesia methods in hypospadias surgery. Recently, there have been reports in the literature about an increase in postoperative complications (especially fistula) due to CEB after hypospadias surgery. In this study, we aimed to retrospectively evaluate the effect of CEB analgesia on surgical outcomes in distal hypospadias surgery performed in our center. Methods: The study included 63 pediatric patients operated for distal hypospadias between 2020 and 2023. These patients were divided into two groups according to whether CEB was applied during surgery or not. Patients were evaluated in terms of surgical technique, age, and complications. Results: A total of 63 pediatric surgeries with a mean age of 45.12±26.76 months and ranging from 1 to 10 years were analyzed. 63 cases with subcoronal hypospadias were included in the study. 26 cases(41.3%) underwent CEB, while 37 cases(58.7%) received intravenous analgesia (IA).The surgical complication rate in our study was 34.9%(n=22). There was no significant difference in postoperative complications between CEB and IA groups. Conclusion: In this study, there was no statistically significant difference in the incidence of postoperative complications between CEB and IA in children operated for distal hypospadias. CEB can be used as a safe pain management method in hypospadias repair. However, we think that prospectively designed studies with a larger number of patients will be more useful in clarifying the issue.

Parameatal based flip flap urethroplasty as a salvage procedure for management of graft fibrosis following first stage of staged free graft hypospadias repair.

Graft fibrosis following the first stage of a free graft staged hypospadias repair is a difficult scenario where the management has traditionally been to excise the graft and replace it with a new graft. However, still the risk of recurrent fibrosis remains making it difficult to proceed to the second stage and tubularising a fibrosed graft practically ensures a breakdown. Herein, we present our way of using parameatal based flip flap urethroplasty as a salvage procedure in this situation. This video is a step by step description of the parameatal based flip flap urethroplasty technique used in our center in patients who returned with graft fibrosis following first stage repair with a graft. Operative details and post-operative management in an index case are described. We have utilized this technique in 5 patients who had developed graft fibrosis after the first stage of a free graft staged repair. One patient had a small urethrocutaneous fistula which was subsequently closed. At a median follow-up of 34 months, all patients are voiding well from the glanular tip. Our experiences demonstrates that Parameatal based flip flap urethroplasty can be an effective salvage technique for managing graft fibrosis following the first stage of a free graft staged hypospadias repair. This technique leverages available local tissue, even in complex scenarios where previous repairs and grafting have failed. The satisfactory outcomes in these complex cases highlight its potential as a valuable tool for pediatric urologists.

Dual Urethral plate substitution in staged hypospadias repair: flap for the shaft and graft for the glans

Dual Urethral plate substitution in staged hypospadias repair: flap for the shaft and graft for the glans

Comparative study in distal hypospadias repair: a meatal-based flaps technic vs. tubularized incised plate urethroplasty

ObjectivesHypospadias is the most common anomaly of the male genital system after undescended testis. More than 200 surgical repair techniques have been described for the treatment of hypospadias due to many different meatus localisations and other accompanying anomalies. Kutlay defined a new technique in 2010 with 10 patients with distal hypospadias patients. We compared this new technique with tubularized incised plate urethroplasty (TIP) which is one of the most frequently performed methods.Methods148 patients with hypospadias who underwent surgery at the Urology and Pediatric Surgery Clinic during the period of January 2010 to December 2022 in the first and 2nd clinic, were retrospectively analyzed. The study focused on the remaining 83 patients with distal hypospadias for the purpose of comparison.ResultsThe mean age of group one was 10.0 (± 6.9, range 2–27), while for group two it was 10.8 (± 5.9, range 3–23). There was no statistically significant difference between the two groups in terms of anatomical position of the meatus, stricture and fistula complications (p > 0.5).ConclusionThe Kutlay technique has been described as an easy-to-learn and feasible method with reliable results. No significant difference in complications was observed in this study compared with TIP, which is known as the standard technique worldwide. We would like to suggest that the method be considered for further evaluation with larger patient groups and different techniques.

Hydromorphone Combined with Ropivacaine for Caudal Block Reduce Early Postoperative Pain in Children: A Randomized Clinical Trial

Purpose: This prospective, randomized, double-blinded study aimed to evaluate the effectiveness and safety of hydromorphone combined with ropivacaine for caudal block in children. Patients and Methods: One hundred children scheduled to undergo hypospadias repair or congenital hip arthroplasty at West China Hospital were included. The patients were randomly allocated into the HR group (hydromorphone combined with ropivacaine) or the R group (ropivacaine only). In the HR group, patients received a single-shot caudal block with hydromorphone 10 μg/kg combined with 0.2% ropivacaine 1 ml/kg. In the R group, only 0.2% ropivacaine 1 ml/kg was administered for the single-shot caudal block. The primary outcome was the postoperative pain score for the first 72 hours in both groups. Results: A total of 106 eligible children were screened, and 100 were included in this trial, with 50 in the HR group and 50 in the R group. The average postoperative FLACC pain score within 12 hours after surgery was significantly lower in the HR group compared to the R group (P &lt; 0.05). The pain scores at 1 h, 6 h, and 12 h post-surgery in the HR group were significantly lower than those in the R group (P &lt; 0.05). The incidence of moderate-to-severe pain in the HR group was markedly lower than that in the R group (P &lt; 0.05). Conclusion: The use of hydromorphone 10 μg/kg combined with 0.2% ropivacaine for single-shot caudal block in children can effectively reduce early postoperative pain scores and the incidence of moderate-to-severe pain. No adverse reactions were noted from hydromorphone, except pruritus.