Meatal Retraction Research Articles

Re-do hypospadias surgery following failed previous repair: lessons learned over two decades of experience.

To evaluate our experience with different surgical techniques and to find clinical factors that affect the outcome of treatment in cases of redo-hypospadias. We have retrospectively evaluated demographic and clinical data of children who underwent redo or cripple-hypospadias repair. Between 2004 and 2021, 76 patients met the inclusion and exclusion criteria. The median age of the first cripple-hypospadias surgery was 64.8 ± 62.9 months. Upon primary surgery 5(6.6%) patients presented with distal-hypospadias, 13(17.1%) midshaft-hypospadias, 37(48.7%) proximal-hypospadias and 21(27.6%)with an unknown initial meatal status. To correct cripple-hypospadias 3(3.9%) patients underwent meatal-advancement and meatoplasty 32(42.1%) different tubularization techniques, 25(32.9%) required flap/graft, 13(17.1%) staged procedure and in 3(3.9%) surgical technique was undefined. Fifty-four (71%) children presented with post-surgery complications: 25(32.9%) meatal retraction, 19(25.3%) meatal stenosis and 17(22.3%) developed urethro-cutaneous fistula. Thirty-six (47.4%) patients underwent additional surgeries. There was no association between surgical technique or age and the need for additional surgeries (P = 0.831, P = 0.425 respectively). There was no association between surgical technique or age and surgical complications (P = 0.514, P = 0.425 respectively). All surgical techniques except meatal-advancement might lead to urethral stricture on long term follow-up (P = 0.028). Our data show that treatment of cripple-hypospadias is challenging for both surgeon and patients alike. There is a need to tailor a surgical technique to each patient and there is no one technique which is appropriate for all patients.

Evaluation of preputial graft urethroplasty in primary repair of narrow plate hypospadias

Background There is yet no perfect Procedure for repairing hypospadias. In certain cases, a graft is required to reinforce the poor urethral plate (UP). The study aims to assess the efficacy of dorsal inlay preputial graft urethroplasty (DIGU) as a primary repair for narrow urethral plate distal and mid-penile hypospadias. Patients and methods A 40- child who underwent dorsal inlay preputial graft urethroplasty Repair for primary distal or mid-penile hypospadias at least 6 months old, as well as a UP less than 8 mm in a noncircumcised penis, were included in the research. Results The success rate was 75% (30 patients) and the Complications rate was 25% (10 patients). Six (60%) of the ten complicated patients had UP widths of 2.5–4 mm (total of 8 patients), implying that 75% of these patients had complications. There were four patients with fistula, two patients with meatal stenosis, two patients with meatal retraction, and two patients with failure. Conclusion One of the main factors influencing the surgical result of the hypospadias correction is the width and configuration of the UP.

Separation of the glanular part of the urethral plate, mobilization of the distal part of the neourethra, and creation of the glanular groove: a new modification of second-stage Thiersch-Duplay urethroplasty in proximal hypospadias repair.

To evaluate the effect of separation of the glanular part of the urethral plate from the underlying glans penis with creation of a glanular groove for free accommodation of the neourethra as a new modification of Thiersch-Duplay urethroplasty in proximal hypospadias repair. Between January 2016 and January 2022, 35 patients with proximal hypospadias underwent a modified Thiersch-Duplay two-stage procedure. The glanular portion of the urethral plate was either separated from the underlying glanular tissue or discarded if found scared with mobilization of the distal portion of the neourethra to reach the tip of the glans penis. In all patients, a few millimeter of glanular tissue is excised to create a glanular groove in which the neourethra is embedded freely. 35 patients were involved in this study. The patient's age at the time of operation ranged from 18months to 10years (median 3.7years). The mean follow-up period was 15.7months (ranging from 12 to 18months). Two patients developed urethrocutaneous fistula; while, none of the patients had meatal stenosis, urethral stricture, or meatal retraction. All patients have a slit-like meatus at the tip of the penis and a good cosmetic conical shape glans appearance. We believe that in Thiersch-Duplay urethroplasty, separation of the urethral plat from the underlying glanular tissue and creation of good glandular groove to accommodate the neourethra is associated with adequate glanular closure and minimization of post-operative meatal stenosis, glanular dehiscence, and meatal retraction.

Urethral advancement and glanuloplasty versus tubularized incised plate urethroplasty for distal hypospadias repair: a prospective randomized study

BackgroundAbout one in 200 to one in 300 male births has hypospadias. The prevalence of this congenital anomaly varies worldwide. The meatus is located distally in approximately 70% of cases. Several surgical techniques were described for distal hypospadias repair; despite this, there is no ideal approach. This study compares urethral advancement &glanuloplasty, and TIP techniques in terms of feasibility, duration of operation, and complications. Patients and.MethodsThis prospective randomized comparative study was conducted at Al-Azhar University Hospitals from April 2022 to October 2022. Fifty-seven cases with different types of hypospadias were assessed for eligibility. Among them, seven cases were excluded due to the presence of severe chordee (n = 3), proximal variant (n = 2), and recurrent cases of hypospadias (n = 2). Fifty cases were randomly divided into two groups using a 1:1 ratio (computer-generated randomization). Twenty-five cases were subjected to urethral advancement and glanuloplasty, and the rest were subjected to tubularized incised plate (TIP) urethroplasty.ResultsThe mean age of all studied cases was 4.2 years. Approximately 52% had coronal or sub-coronal meatus, whereas 48% had glandular meatus. Both groups were matched according to age and meatus location (p > 0.05). No statistically significant difference was observed between the two groups regarding duration of operation, postoperative pain, and postoperative hospital stay. In addition, both groups did not differ significantly in late complications (meatal stenosis, meatal retraction, fistula, and glans dehiscence).ConclusionsBoth urethral advancement &glanuloplasty, and TIP urethroplasty have comparable short-term outcomes. Urethral advancement and glanuloplasty is preferred in certain conditions, especially in circumcised children or those with a narrow urethral plate.Trial registrationThe study protocol was approved by the Pan African Clinical Trials Registry (number for the registry is: PACTR202211757905870) on (29/11/2022). All procedures were performed per the Helsinki Declaration.

LIMITED URETHERAL MOBILIZATION PROCEDURE (LUMP) FOR DISTAL PENILE HYPOSPADIAS REPAIR, A SINGLE CENTRE RETROSPECTIVE ANALYSIS

Background: Distal penile hypospadias is one of the commonest varieties of hypospadias. Different techniques have been mentioned in literature. The success rate is usually assessed by rate of fistula formation and over all cosmetic appearance and functional outcome. Limited Uretheral Mobilization Procedure (LUMP) for distal penile hypospadias is considered a good technique with almost zero fistula rate in some series. As no new urethral tube is constructed there is no risk of fistula. Objective: To evaluate the results of the Limited Urethral Mobilization Procedure (LUMP) for distal hypospadias repair. Methods.It is retrospective analysis of 32 patients aged up to 12 years who were treated with Limited urethral mobilization procedure for distal penile hypospadias in the Department of Paediatric Surgery Jinnah Hospital Lahore from December 2018 to November 2019. All patients were operated under general anesthesia. The urethra proximal to the meatus was mobilized adequately in such a way that it should reach the tip of glans easily without any ventral bending of penis.Then the urethra was placed in the glandular wings and reconstruction of glans was carried out. Dartos flap was also placed to cover the urethra as a safety measure to avoid urethrocutaneous fistula formation. Follow up was done for a period of 3 months with respect to fistula formation, meatal stenosis, retraction , chordee and over all cosmetic appearance. Results: Age range of children was 9 months to 12 years. Operation time ranged from 60-80 minutes. Seven of 32 cases were previously operated for distal penile hypospadias but after disruption of repair meatus was lying at coronal or subcoronal level. They also underwent LUMP. Five cases had minor chordee, it was corrected at the time of uretheral mobilization by simple excision of fiberous tisse in 4 patients while modified Nesbit dorsal placation was done in one. Cosmetically normal looking circumcised penis with slit like meatus was achieved in all.Two cases got superficial wound infection, two had meatal stenosis, one meatal retraction, one ventral chordee and one urethrocutaneous fistula. Conclusion: LUMP for distal penile hypospadias is a simple and effective procedure with minimum complications.There is no chance for development of urethrocutaneous fistula, a major postoperative complication of other surgical techniques for uretheroplasty. Postoperative management is simple and hospital stay is short.

Urethral Extensibility Applied to Urethral Advancement

BACKGROUND: The male urethra in humans has a large capacity to extend under traction. This property is the main principle of the urethral advancement technique.
 AIM: We aimed to determine the safe limits of urethral mobilization and extensibility for reconstructive surgery of distal to midshaft hypospadias by applying urethral extensibility on the urethral advancement technique. Also, we wanted to evaluate the variable application of the gap-to-urethra (G:U) ratio from a cadaver to a live human body.
 METHODS: From November 2004 to February 2006, 20 boys aged from 2 to 16 years old underwent repair of midshaft to glanular hypospadias by urethral advancement technique. The ratio of G:U proposed for a safe limit of urethral extensibility (measured from normal, fresh human cadaveric urethras) applied to know if its application can help in decreasing the rate of late complications. The mean follow-up period was 10 months, which ranged from 4 to 16 months.
 RESULTS: Late complications were as follows: 25% meatal retraction (MR), 15% meatal stenosis (MS), and 5% fistula. Besides, MR and MS late complications associated with urethral mobilization of G:U ratio of less than 73%.
 CONCLUSION: The more the approximation in the application of the G:U ratio, the less the rate of MS and MR. Besides, urethral mobilization to the base of the penis helps to decrease the frequency of MS and MR. Furthermore, the type of complication, MR or MS, in urethral advancement correlates with the extent of urethral mobilization.

Evaluation of double-folded meatal-based flap (modified Mathieu) in redo circumcised distal penile hypospadias: a prospective multicenter study

BackgroundSometimes it becomes a dilemma to repair a failed circumcised distal penile hypospadias with partial or complete wound dehiscence. In many of these cases, redo operations need a graft or a flap. The aim of this study is to evaluate the double-folded meatal-based flap in redo circumcised hypospadias with shallow urethral plate and a small glans penis.ResultsFrom September 2015 to August 2018, we prospectively studied the double-folded meatal-based flap in 56 failed circumcised distal hypospadias without penile curvature with shallow urethral plate and a small glans penis. Distally folded Mathieu flap was done. Forty-seven cases only had completed the study. We had 19 patients with distal penile hypospadias, 19 with sub-coronal hypospadias, and 9 with coronal hypospadias. Median operative time was 50 (range 40–80 min). The median length of the double-folded flap was 14 (range 10–18 mm). The median follow-up was 12 (range 1–33 months). The success of the operation means that there is an absence of any complications. Our success rate was 73%. We had 8 patients with meatal retraction, one fistula, and one patient with wound disruption. Only 3 patients (6.4%) needed re-operation: one case with meatal retraction, another with fistula, and a third with complete wound disruption.ConclusionDistally folded meatal-based flap is an additional option in redo circumcised hypospadias with shallow urethral plate, small glans penis, and pliable anterior penile skin with a considerable high percent of meatal recession.

The outcome of limited urethral mobilization urethroplasty for anterior hypospadias.

Objectives: Hypospadias, one of the most common genital anomalies, is characterized by an abnormal meatal opening on the ventral aspect of penis. Anterior hypospadias are the most common. Most of the surgical techniques involves the construction of neourethra with significant risk of urethrocutaneous fistula. Limited urethral mobilization technique involves the advancement of native urethra. Study Design: The objective of this study was to evaluate the outcome of Limited Urethral Mobilization Urethroplasty for Anterior Hypospadias. Setting: The study was conducted in the Department of Paediatric Surgery, DHQ teaching Hospital Sahiwal. Period: From January 2016 to December 2018. Material & Methods: A total number of 187 patients were included in this study. Limited urethral mobilization technique was used in all patients. Minimum age was 2.5 Years and maximum age was 12 years. Cosmetic appearance, functional outcome and complication rate were assessed. Results: Wound infection developed in 3.20 %( n=6) patients. Complete glanular disruption was seen in 2.13 %( n=4) patients. Partial disruption of glans with meatal retraction was observed in 1.60 %( n=3) patients. Post-operative haematoma was seen in 1.60 %( n=3) patients. Meatal stenosis in 1.06 %( n=2) patients. Post-operative bleeding and diverticula was observed in 0.5 %( n=1) patients each. Vertical oriented, slit like meatus at the tip of glans was achieved in 95.72 %( n=179) patients. Conclusion: Limited urethral mobilization urethroplasty is a technique with proven benefits and effectiveness in the terms of cosmesis and functional outcome with a minimal number of complications because of the usage of native elastic urethra.

MERCEDES BENZ INCISION: A MODIFICATION OF THE MAGPI PROCEDURE FOR DISTAL HYPOSPADIAS REPAIR

Background: Hypospadias is one of the most common congenital abnormalities of the male genito-urinary system. The main goal in surgery is to attain cosmetic and functional correction. Hypospadias repair should be done with minimal complications. Duckett innovated meatal advancement and glanuloplasty (MAGPI) procedure and was applied for correction of this lesion. Objectives: Evaluation of Mercedes Benz incision as a modification of the MAGPI procedure for repair of distal hypospadias with mobile meatus. Paitents and Methods: Forty five children with distal hypospadias and mobile meatus were operated on using this technique. Mean age of patients was 2 ± 4.2 year (1-10) years. Results: Patients were discharged home after 3 days. The operation resulted in a slit-like urethral meatus. Follow-up was done for 6 months. Good cosmetic and functional results were obtained in 44 patients (97.78%). One patient (2.22%) had mild meatal stenosis that corrected by frequent dilation. Complication occurred in one patient (2.22%) who suffered from dehiscence of the wound and retraction of the meatus. The meatal retraction was corrected using circum-meatal urethral advancement technique. Conclusion: Mercedes Benz incision as a modification of the MAGPI procedure was feasible and suitable for appropriately selected cases with distal hypospadias and mobile meatus. It provides a cosmetically natural vertical slit-like urethral meatus at the tip of the glans.

Evaluation of Urethral advancement and Glanuloplasty in Hypospadias repair

Background:There has been great progress in reconstructive surgery of the male urethra in the last decades. Several complex techniques were developed to correct urethral defects with great variations in the success rate. However, there is no an ideal substitute for the male urethra as good as the urethra to our knowledge at this time .Human male urethra has a large capacity to extend under traction. This extensibility is the principle of urethral advancement technique used to correct urethral defect in hypospadias by using the urethra itself.The objective of this study was to evaluate the urethral advancement and glanuloplasty (UGPI) procedure in hypospadias repair.During a period of 1 year, 20 boys ranging between 2-16 years old underwent repair of glanular to midshaft hypospadias by UGPI procedure. At or near the tip meatus was accomplished in 75% of the patients, with 85% adequate meatal size, 85% straight penis and 70% of conical glans shape. While the complications were 15% meatal stenosis (MS), 25% meatal retraction (MR), 5% fistula , 35% bleeding and haematoma, 10% for cellulites and UTI (infection), 20% wound dehiscence, and 10% abnormal urine stream.Adequate mobilization of the urethra for advancement decreases the incidences of complications of MR and MS.The lower incidence of fistula in UGPI procedure support the sentence of "There is no an ideal substitute for the male urethra as good as the urethra".

Hypospadias repair with the glanular-frenular collar (GFC) technique

In the normal human penis, the glans wings merge in the midline ventrally, but are separated by the 'septum glandis' in conjunction with the frenulum. The frenulum is also included in the formation of the distal (glanular and subcoronal) urethra, which has a special part known as the 'fossa navicularis'. This has inspired a hypospadias repair technique that simulates the development of the glanular and subcoronal urethra, which can be incorporated into the repair of all cases of hypospadias. A total of 121 patients with varying degrees of hypospadias underwent surgery with the described technique: a Y-V plasty was used to dissect the inner foreskin, in a fashion that allowed for its ventral mobilization as a frenular mucosal collar. After tubularization of the proximal urethra, a partial spongioplasty was performed that extended up to the subcoronal level. The glans wings were approximated only at their outermost convexities, with a couple of subepithelial sutures, leaving a slit for the meatus. The cleft-like area between the split wings of the glans penis was filled with the terminal ends of the spongiosum and the dartos of the mucosal collar, which converged to form a septum and a neo-frenulum (glanular-frenular collar, GFC). The midline skin closure of the ventral collar and the circumferential foreskin closure was completed as usual. At a mean follow-up of 10 months, two patients developed urethral fistula (2%), six had meatal stenosis (5%), and two had glans dehiscence (2%) that resulted in meatal retraction. Overall, patients had a cosmetically satisfying appearance (Figure). Forty-one received secondary circumcision; the parents of 80 (66%) patients were satisfied with the final foreskin appearance obtained with this method. The split wings of the glans penis or so-called ventral cleft between the glans wings that accommodate the frenulum is part of normal anatomy. Hence, in hypospadias surgery, the approximated glans wings should allow for ventral support of the glanular and subcoronal urethra through a reconstructed neo-frenulum. Neither glanular surface enhancement nor extensive dissection of the glans wings and their full-length approximation are necessary, and may in fact be counter-productive. The employment of a GFC provided: 1) an anatomical restoration of the distal (glanular and subcoronal) urethra, supported by a frenulum; 2) a protective (undissected) dartos layer over the distal part of the tubularized neourethra; and 3) a space for the re-formation of the fossa navicularis.

A novel technique for repair of mid-penile hypospadias using a preputial skin flap: results of 110 patients.

Several techniques have been used to repair mid-penile hypospadias; however, high failure rates and major complications have been reported. In this study, we describe a novel technique using a well-vascularized flap of the inner and outer preputial skin. A total of 110 male children with hypospadias underwent repair by our technique between 2008 and 2015. The inclusion criteria were children with mid-penile or slightly more proximal hypospadias, with or without ventral chordae, and an intact prepuce of the cobra eyes variety. Recurrent cases, patients with other preputial types, and circumcised children were excluded from this study. The prepared flap was sutured in its natural longitudinal orientation to the created urethral plate strip to form a neo-urethra over a urethral catheter. Outcome measures included surgical success without the formation of a urethra-cutaneous fistula, no ischaemia of the flaps, glans dehiscence or infection and functional outcome and cosmetic appearance. The median follow-up duration was 3.3years. There were 63 cases of mid-penile hypospadias (57.3%), and in 47 cases (42.7%), the meatus was slightly more proximal. The age of the patients ranged from 1.1 to 8.0years, with a mean age of 4.6±1.2years. Surgery was successful in 106 (96.4%) cases. Minor complications occurred in 11 patients (10%) and included oedema of glans in ten patients and bluish discoloration on the ventral aspect of the glans close to the suture line in three patients. All patients improved within 2weeks after surgery. Long-term follow-up revealed a properly functioning urethra with a forward, projectile, single, compact, and rifled urinary stream of adequate calibre and cosmetically acceptable repair. No cases of meatal retraction, meatal stenosis, urethral stricture, or acquired urethral diverticulum occurred. Our technique is different from the split prepuce in situ technique. We create a narrow strip of the urethral plate that facilitates glanular closure, and we use the inner and adjacent outer skin in a vertical manner to preserve excess skin for penile coverage. Prepuce is split at midline to preserve more preputial skin with favourable dartos tissue for penile skin coverage. The glans is closed using a stitch-by-stitch method that has not been described previously. This study presents a novel technique for mid-penile hypospadias repair using a preputial skin flap with excellent results in terms of short- and long-term outcomes.

Urethral mobilization and advancement for distal hypospadias

Background/purpose Despite the existence of numerous techniques for the repair of distal penile hypospadias, none of them is completely satisfactory. Advancing the urethra without mobilization for repair of glanular hypospadias has the advantage of avoiding a common problem occurring with other techniques: urethrocutaneous fistula. This study aims at evaluation of our experience with this technique for repair of distal hypospadias. Materials and methods A prospective study was conducted on patients with glanular, coronal and subcoronal hypospadias during the period from December 2012 to December 2014. Recurrent cases were excluded. Feasibility of the technique and postoperative complications were recorded. Results A total of 30 boys between 9 months and 7 yearsof age were included in the study. They underwent repair of glanular (five), coronal (10), and subcoronal (15) hypospadias. The urethra was mobilized to the proximal shaft in almost all cases. Three cases developed postoperative hematoma, which were managed conservatively and resolved spontaneously. Two cases developed wound infection and were managed with antibiotics and daily dressing until infection resolved. None of the patients had major complications such as dehiscence, urethral stricture, or fistula. Three patients developed meatal stenosis; two of them responded to repeated dilatation twice weekly for 2 weeks; and one needed meatoplasty. In one patient, the most distal of the glans approximation sutures disrupted, leading to a minor detachment in the glans. There was no recurrent chordee. Two patients underwent meatal retraction, wherein the urethra migrated proximally but still within the glans; only one of these patients required a second procedure. Conclusion The urethral mobilization technique seems tobe a good method for the repair of distal hypospadias with or without chordee with satisfactory cosmetic and functional results. The procedure has the advantage of avoiding the need for a second layer of tissue covering during repair. Moreover, there is no chance for the development of urethrocutaneous fistula, a major postoperative complication of other surgical techniques creating a neourethra. Postoperative management is simple and a brief hospital stay is sufficient. Keywords : distal hypospadias, hypospadias repair, urethral mobilization

Double Y glanuloplasty for glanular hypospadias

Purpose A double Y glanuloplasty technique is described for the repair of glanular hypospadias with mobile meatus. Materials Ninety-seven children with glanular hypospadias and mobile meatus were operated on using this technique in the period from January 2003 to January 2009. Mean age of patients was 12 (range, 4-60) months. Results Patients were discharged home within 3 days. The operation resulted in a slit-like meatus. Follow-up ranged from 8 months to 6 years (mean, 45 months). Good cosmetic and functional results were obtained in 94 patients. Complications occurred in 3 patients (3%). Two patients experienced meatal stenosis. This was corrected using ventral meatotomy. One patient suffered from dehiscence of the wound and retraction of the meatus. The meatal retraction was corrected using a modified inverted Y Mathieu technique. Conclusions The double Y glanuloplasty technique is suitable for appropriately selected patients with glanular hypospadias and mobile meatus. It provides a cosmetically natural vertical slit at the tip of the glans.

New concept in urethral advancement for anterior hypospadias

Objective We report on our experience with urethral mobilization and advancement as a treatment for anterior hypospadias. Patients and methods From January 2004 to March 2007, 55 out of 160 children with anterior hypospadias were managed by urethral mobilization and advancement; 46 had a mean follow-up period of 25 months (range 6–38) and are the subjects of this report. Their ages ranged from 2.5 to 12 years with mean age 4.5 years. The dissection began proximally in the avascular plane above the tunica albuginea covering each corpus cavernosum medially until reaching beneath the corpus spongiosum up to the hypospadiac meatus. Tension-free urethral anastomosis was achieved. The ventral glans was incised deeply at the interballanitic groove. The two glans wings and ventral glanular mucosal flaps were mobilized laterally. Interrupted sutures were placed through the tunica albuginea of corpus spongiosum to the corpora cavernosa. The mobilized urethra was wrapped by dartos fascia. The urethral stent was removed 24 h postoperatively. Results Three-fold urethral mobilization was sufficient to achieve tension-free urethral anastomosis. A slit-like orthotopic meatus, with conically shaped glans and straight penis, was achieved in all but one subcoronal case with mid-glans meatal retraction during our early experience. Postoperative urethral fistula was not recorded in any patient. Satisfactory urinary stream for parents and child was reported in 42/46. Peak flow rate was within normal range (upper 50% percentile) in all. Conclusion Urethral mobilization should begin proximally. Three-fold penile urethral mobilization, deep interballanitic incision and wide dissection of the glans can provide a slit-like orthotopic meatus with conical glans and straight penis in cases of anterior hypospadias without hypoplastic distal urethra and persistent ventral curvature after penile skin degloving, regardless of the presence of unhealthy, narrow urethral plate, shallow glanular groove, and flat or small glans.

Urethral mobilization and advancement for midshaft to distal hypospadias.

A urethral mobilization and advancement technique for repairing glanular, subglanular and midshaft hypospadias with or without chordee was developed, and has been used for more than 6 years. A brief description of the procedure and the results are presented. From 1995 to 2001, 73 boys 4 months to 12 years old underwent repair of glanular (14), subglanular (38) and midshaft (20) hypospadias. Chordee was present in 37 boys. Upon initiating the surgery, a circumcising incision was made proximal to the urethral orifice. The ventral glanular mucosa was preserved. The penile skin was degloved and any chordee was corrected. The meatus was circumscribed and the urethra was mobilized proximally until a 4 to 5:1 ratio was achieved between the length of the mobilized urethra and the initial distance measured from the meatus to the distal margin of the glanular groove. The ventral glans was incised deeply to the corpora cavernosa and the glans wings were mobilized laterally. The urethral meatus was advanced and sutured to the distal glans. The glans wings were approximated over the urethra. The glanular mucosal wings were approximated ventrally, and the skin was resected and closed in the usual fashion. A urethral catheter was left overnight. Followup ranged from 6 months to more than 6 years. None of the patients had a urethrocutaneous fistula or meatal stenosis. There were no episodes of new, persistent or recurrent chordee. Two patients had meatal retraction wherein the urethra migrated proximally but still within the glans. Only 1 of these patients required a second procedure. One patient had a hematoma that resolved spontaneously. The hypospadias technique described, which uses wide urethral and glanular mobilization and advancement, can be useful for repair of midshaft to distal hypospadias with or without chordee with minimal complications and excellent cosmetic results.

Comprehensive analysis of tubularized incised‐plate urethroplasty in primary and re‐operative hypospadias

To retrospectively review our experience of the tubularized incised-plate (TIP) urethroplasty over the last 4 years. From 1998 to December 2001, 133 patients (mean age 7 years, sd 4, range 1-22), had a TIP urethroplasty by one surgeon for primary (103) and re-operative (30) hypospadias; the defects included 106 (79%) distal and mid-shaft, and 27 (21%) posterior shaft. The neourethra was covered by a subcutaneous flap in 66 (50%) patients or by corpus spongiosa (spongioplasty) in 31 (23%), with no cover in the remaining 36 (27%). In the last 20 patients (15%) a modified meatoplasty was used; the site and size of the new meatus was predetermined on the glans around a suitable catheter before any incision. Urethral stents were not used after repair in 39 (29%) patients, and regular meatal dilation was used only in patients with voiding difficulty and obvious tendency to stenosis. The presence of complications requiring re-operation and overall general appearance were recorded. The mean (sd) follow-up was 10 (5) months; there were 24 complications in 20 patients (15%), including a small fistula in 12 (9%), complete disruption of the repair in 4 (3%), meatal stenosis in seven (5%) and neourethral stricture in one (0.8%). Complications were not significantly different between primary and re-operative cases, and unaffected by the use of the stents. On univariate analysis complications were significantly higher with running than interrupted sutures, in repairs in the first 2 years of the study, in patients with posterior hypospadias, and in those with no neourethral coverage. However, the last two factors were the only significant independent risk factors in a multivariate analysis. Regular urethral dilatation was indicated in 43 patients (32%). Modified meatoplasty was associated with a significantly lower requirement for regular dilatation (P < 0.05) and no meatal stenosis. In the 113 complication-free patients the operation gave an excellent cosmetic appearance with a vertical slit meatus on the tip of conical glans in 110 (97%); there was slight meatal retraction in the remaining three patients. The TIP repair is a reliable method for treating both distal and proximal penile shaft hypospadias, is suitable for both primary and re-operative cases, and is more versatile than other repairs. Covering the neourethra with a flap or spongioplasty significantly improves the results. Regular urethral dilatation is required in a third of patients but modified meatoplasty obviates the need for regular dilatation and eliminates the risk of meatal stenosis.

Hypospadias surgery: a 10-year review.

Hypospadias surgery is one of the most difficult areas in pediatric urology and has been characterized by constant evolution. Some of the surgical techniques proposed in the past are now considered inadequate because of an unacceptable complication rate or poor functional and aesthetic results. The key for assessing a surgical technique (or a particular aspect of it) is continuous evaluation through long-term patient follow-up. We present the medical records of 693 patients over 10 years, all operated on by the same surgeon (the first author), with a minimum of 12 months of follow-up. The overall complication rate was 6.49% (45 cases). The most frequent complication was urethral fistula, occurring in 28 patients (62%). Other complications were redo for penile deformity or meatal retraction (eight cases, 17%), megalourethra (five cases, 11%), meatal stenosis (two cases, 4%), and urethral stenosis (two cases, 4%). We have noticed an increased rate of complications in patients older than 12 months (18.7% vs. 3.4% in patients younger than 12 months) and in patients operated on at puberty or later (15%). We have seen no difference in the complication rate related to the type of hospitalisation (day surgery vs. traditional hospitalisation). Regarding the relationship between the type of complication and the type of defect, except for the constant presence of fistulae, a high incidence of megalourethra was seen in proximal defects treated with preputial graft. The sexual outcomes of 32 subjects are presented. Multiple factors influence the final result, but the most important factor is the surgeon's own experience. Knowledge of different techniques and delicate tissue handling are essential. Our experience shows that the ideal age for surgery is 8-12 months. Owing to a minimal emotional impact on the child and to a reasonable use of economical resources, we consider day surgery the ideal way to treat these patients whenever possible. Even in the absence of complications, follow-up must be continued at least until the end of puberty and, when possible, up to the patient's sexual debut. Adequate interviews with the patients (principally teenagers and young adults) are the best way to evaluate their need for psychological support.

Urethral Mobilization and Advancement For Midshaft to Distal Hypospadias

No AccessJournal of UrologyHypospadias1 Oct 2002Urethral Mobilization and Advancement For Midshaft to Distal Hypospadias Anthony Atala Anthony AtalaAnthony Atala More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64402-3AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: A urethral mobilization and advancement technique for repairing glanular, subglanular and midshaft hypospadias with or without chordee was developed, and has been used for more than 6 years. A brief description of the procedure and the results are presented. Materials and Methods: From 1995 to 2001, 73 boys 4 months to 12 years old underwent repair of glanular (14), subglanular (38) and midshaft (20) hypospadias. Chordee was present in 37 boys. Upon initiating the surgery, a circumcising incision was made proximal to the urethral orifice. The ventral glanular mucosa was preserved. The penile skin was degloved and any chordee was corrected. The meatus was circumscribed and the urethra was mobilized proximally until a 4 to 5:1 ratio was achieved between the length of the mobilized urethra and the initial distance measured from the meatus to the distal margin of the glanular groove. The ventral glans was incised deeply to the corpora cavernosa and the glans wings were mobilized laterally. The urethral meatus was advanced and sutured to the distal glans. The glans wings were approximated over the urethra. The glanular mucosal wings were approximated ventrally, and the skin was resected and closed in the usual fashion. A urethral catheter was left overnight. Results: Followup ranged from 6 months to more than 6 years. None of the patients had a urethrocutaneous fistula or meatal stenosis. There were no episodes of new, persistent or recurrent chordee. Two patients had meatal retraction wherein the urethra migrated proximally but still within the glans. Only 1 of these patients required a second procedure. One patient had a hematoma that resolved spontaneously. Conclusions: The hypospadias technique described, which uses wide urethral and glanular mobilization and advancement, can be useful for repair of midshaft to distal hypospadias with or without chordee with minimal complications and excellent cosmetic results. References 1 : A new operation for balanic hypospadias. NY Med J1898; 67: 147. Google Scholar 2 Belman A.B. Urethroplasty. Society for Pediatric Urology Newsletter, December 28, 1977 Google Scholar 3 : Urethral advancement for distal hypospadias repair in circumcised patients. Plast Reconstr Surg1982; 70: 496. Google Scholar 4 : Distal hypospadias repair. J Urol1984; 131: 928. Link, Google Scholar 5 : Sleeve advancement distal hypospadias repair. J Urol1990; 144: 523. Link, Google Scholar 6 : Distal hypospadias repair by urethral sliding advancement and Y-V glanuloplasty. J Urol1991; 146: 644. 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Google Scholar From the Department of Urology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts© 2002 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byKoenig J, Kottwitz M and McKenna P (2013) Urethral Mobilization for Distal and Mid Shaft Hypospadias with ChordeeJournal of Urology, VOL. 190, NO. 4S, (1545-1549), Online publication date: 1-Oct-2013.Lalla M, Gregersen H, Olsen L and Jørgensen T (2010) In Vivo Biomechanical Assessment of Anterior Rabbit Urethra After Repair of Surgically Created HypospadiasJournal of Urology, VOL. 184, NO. 2, (675-682), Online publication date: 1-Aug-2010.Mollaeian M, Sheikh M, Tarlan S and Shojaei H (2008) Urethral Mobilization and Advancement With Distal Triangular Urethral Plate Flap for Distal and Select Cases of Mid Shaft Hypospadias: Experience With 251 CasesJournal of Urology, VOL. 180, NO. 1, (290-294), Online publication date: 1-Jul-2008.Lalla M, Danielsen C, Austevoll H, Olsen L and Jørgensen T (2018) Biomechanical and Biochemical Assessment of Properties of the Anterior Urethra After Hypospadias Repair in a Rabbit ModelJournal of Urology, VOL. 177, NO. 6, (2375-2380), Online publication date: 1-Jun-2007. Volume 168Issue 4 Part 2October 2002Page: 1738-1741 Advertisement Copyright & Permissions© 2002 by American Urological Association, Inc.Keywordsreconstructive surgical procedureshypospadiasurethra, penisMetricsAuthor Information Anthony Atala More articles by this author Expand All Advertisement PDF downloadLoading ...

T-incision technique in distal hypospadias: a modification of meatal advancement and glanuloplasty.

Hypospadias is among the most common of the congenital anomalies. Distal hypospadias refers to an orifice in the distal third of the penile shaft. Correction of distal hypospadias requires different techniques, depending on the location of the meatus. Simple advancement techniques can be used for most distal hypospadias, whereas hypospadias with chordee requires reconstruction of a urethra. The meatoplasty and glanuloplasty procedures developed by Duckett have become standard operations to correct these lesions. Complications such as meatal stenosis, meatal retraction, and fish mouth-like meatus can be seen after meatal advancement and glanuloplasty ("MAGPI"), though it usually yields good results. In an attempt to avoid the complications associated with the meatal advancement and glanuloplasty procedure, the authors added a modification to the procedure for those hypospadias cases located in the coronal sulcus or its distal part. As an addition to conventional meatal advancement and glanuloplasty, a transverse incision on top of the vertical incision was made so that the urethra was supported by lateral triangle flaps created on the glans. Lateral triangle flaps of the glans were sutured to the dorsal aspect of the urethra advanced from the previous position. Thus, stress on the urethra was lessened and meatal retraction was prevented. When closure was performed with a T incision, an M-shaped, zigzag incision line was placed instead of a circular incision line. Therefore, stenosis was prevented and a vertical meatus with good cosmetic appearance was obtained. Fifty-three boys aged 4 to 7 years were operated on with this technique and were followed for 2.4 years. Good functional and cosmetic results were achieved in most of the cases.