Meatal Retraction Research Articles

Y-TO-I WRAP: USE OF THE DISTAL SPONGIOSUM FOR HYPOSPADIAS REPAIR

Rather than resecting the distal spongiosum lateral to the open urethra for hypospadias, we mobilized this tissue with the urethral plate away from the corpora cavernosa, subsequently wrapping it around various types of urethroplasty to prevent fistula formation. The distal spongiosum was preserved and used for coverage in 25 hypospadias repairs in 1 year. We initially applied it in this manner when the distal spongiosum persisted as a pillar of healthy erectile tissue but later when the distal tissue appeared more fibrous in nature. The wrap was used to cover various types of urethroplasty, including advancement in 6 cases, tubularization in 10, flip-flap repair in 6 and an island onlay pedicle graft in 3. All patients have at least 1 year of followup. There has been no fistula formation or residual chordee. In 1 patient minor meatal retraction did not require a secondary procedure. Cosmetic results have been good. A distal wrap of corpus spongiosum may be used to avoid fistula formation without causing residual or recurrent curvature. It re-creates a nearly normal urethra in some cases.

MATHIEU HYPOSPADIAS REPAIR: EXPERIENCE IN 202 PATIENTS

The complication rate after Mathieu hypospadias repair was recently reported to be 3.6% in unstented cases. We reviewed our experience and results of the Mathieu repair performed at our institution during the last 5 years. We performed 197 primary and 5 secondary repairs in 202 patients. Reconstruction of the neourethra was done with a 2-layer anastomosis using optical magnification. Urethral stents were placed for postoperative drainage in all but 1 patient. Followup was up to 54 months. There were no incidences of stent migration or symptomatic urinary tract infection while the stent was in place and all patients voided spontaneously after stent removal. Excellent cosmetic results were obtained in 201 cases. In 1 patient meatal retraction required subsequent meatoplasty with meatal advancement. In 2 patients pinpoint urethrocutaneous fistulas were successfully repaired. The total rate of reoperation was 1.5% in our series. There was no report of urethral stricture during followup. The well established Mathieu repair provides excellent cosmetic and functional results. The overall complication rate is minimal and compares favorably with stentless repair. A 2-layer neourethral anastomosis performed under sufficient optical magnification produces a watertight closure with minimal risk of fistula formation. Postoperative urethral stenting decreases this risk even further, while adding only minimal morbidity. We believe that in the era of newly reported techniques the well established Mathieu procedure should be the standard by which distal repair is judged.

Repair of hypospadias complications using the tubularized, incised plate urethroplasty

Background/Purpose : Secondary procedures to correct complications after hypospadias repair remain challenging especially for “hypospadias cripples”. The tubularized, incised plate urethroplasty was first introduced by Snodgrass for the repair of primary hypospadias in 1993. The authors used this procedure to correct the complications after hypospadias repair in patients who had no abundant local skin flaps to be used for a neourethra. Methods : Six patients underwent tubularized, incised plate urethroplasty for the correction of complications of hypospadias repair performed the previous year, including a large urethrocutaneous fistula (n = 1) and disruption of the neourethra (n = 5). Prior surgical procedures included transverse island tube urethroplasty in 4 cases and 2-stage urethroplasty in 2 cases. The average patient age at the time of secondary procedure was 4.6 years (range, 1 to 12 years). Results : The mean follow-up period was 6 months (range, 2 months to 1 year). All the patients obtained a functional neourethra with a vertical, slitlike meatus. A small fistula developed in one child and mild meatal retraction in another. Conclusions : The tubularized, incised plate urethroplasty offers few complications and good cosmetic results. The authors recommend its use for patients who have had repeated surgeries for hypospadias repair, especially those in whom only limited local skin flaps can be utilized for a neourethra.

An axially vascularized meatal-based flap for the repair of hypospadias.

To report the initial experience of hypospadias repair using an axially vascularized meatal-based skin flap. Twenty-six children aged 2-5.5 years with subcoronal hypospadias underwent the procedure: three were circumcised and three had recurrent hypospadias. The neourethra was constructed using a meatal-based flap extending obliquely from the hypospadiac orifice towards the prepuce or its remnants. The flap was supplied axially by the ventrolateral branch of the superficial external pudendal artery. The vascular pedicle was dissected and mobilized to allow tensionless reflection of the flap ventrally to be sutured to the urethral plate. Functional and cosmetic success was achieved in 25 of the patients (96%). Haematoma and disruption of the flap occurred in one patient, who underwent re-operation, and slight and insignificant meatal retraction occurred in another child. The procedure confirmed the technical feasibility of creating an axially vascularized meatal-based flap. The oblique orientation of the flap permits it to be obtained from well-developed skin. Continuity of the oblique flap with the urethral plate reduces the total length of suture lines and minimizes the possibility of fistula formation.

THE SPLIT PREPUCE IN SITU ONLAY HYPOSPADIAS REPAIR

Purpose We describe the surgical technique and report the results of the first 100 patients who underwent a modification of the onlay hypospadias repair, which we refer to as split prepuce in situ onlay repair. Materials and Methods We treated 100 boys with a mean age of 11 months at surgery who had coronal to mid shaft hypospadias with split prepuce in situ onlay hypospadias repair. The operative technique varies from that of the standard onlay procedure by preserving the whole blood supply of the half of the prepuce used for the island onlay flap, and using its abundant subcutaneous tissue to cover completely the suture lines used to create the neourethra. Results Only 5 complications required reoperation, including 1 hematoma evacuation and 4 urethrocutaneous fistulas. No patient had meatal stenosis, urethral stricture, meatal retraction or acquired urethral diverticulum necessitating reoperation. A good cosmetic result was obtained in all cases. Conclusions Split prepuce in situ onlay hypospadias repair is applicable in virtually all cases of coronal to mid shaft hypospadias. It optimizes the blood supply to the island flap and provides well vascularized coverage of the neourethra, resulting in a decreased complication rate.

Urethral advancement and glanuloplasty (UGPI): a modification of the MAGPI precedure for distal hypospadias

A modification of the meatal advancement and glanuloplasty technique (MAGPI), the urethral advancement and glanuloplasty (UGPI), is described. Forty-seven patients, who had this operation from 1985 to 1994, have been reviewed. The overall complication rate was low with a 2.1% fistula rate and a 6.4% incidence of meatal retraction. Only one patient required secondary surgery.

Repair of Hypospadias Complications Using the Meatal Based Flap Urethroplasty

While long used for primary hypospadias repair, meatal based flap urethroplasty has not been widely considered a viable alternative for a secondary procedure. We reviewed 200 patients who underwent meatal based flap urethroplasty and identified 9 (4.5%) who underwent the procedure for correction of complications of previous hypospadias repair, including urethrocutaneous fistula, severe meatal retraction, persistent chordee and hair in the urethra. The complication was corrected with a single operation in 8 of the 9 patients (89%). A single small fistula developed in 3 patients, which closed spontaneously in 2 and required another procedure in 1. Meatal based flap urethroplasty should be considered for correction of distal complications of hypospadias repair.

Results of one-stage hypospadias repair

We reviewed 17 patients who had first undergone one-stage hypospadias repair. According to the criteria proposed by Keating and Duckett, the operative procedure performed was the MAGPI procedure in 2 patients, the pyramid procedure in 2, the Mathieu procedure in 1, the onlay island flap procedure in 6, the transverse preputial island flap and glans channel procedure (Duckett) in 4 and a combined method using the buccal and bladder mucosa graft in 2. The age of the patients ranged from 11 months to 22 years (median age 3.2 years). Postoperative follow-up ranged from 3 to 30 months (mean 7 months). Postoperative complications requiring revision occurred in 4 patients; urethrocutaneous fistula developed in 1 patient with the onlay island flap, urethral sticuture at the anastomosis and meatus in 1 patient with the transverse preputial island flap, meatal retraction in 1 patient with the mucosal graft, and urethral stricture at the distal anastomosis and bladder stone in the other patient with the mucosal graft. These complications were successfully revised by simple operations. Ventral skin tethering caused by scar contracture developed in 2 patients with the preputial island flap, and spontaneously improved with time in 1 patient. These results indicate that the criteria proposed by Keating and Duckett is proper to select an operative procedure for hypospadias.

M Inverted V Glansplasty: A Procedure for Distal Hypospadias

Minimal hypospadias is a commonly encountered anomaly. Duckett’s innovative meatoplasty and glanuloplasty (MAGPI) procedure has become a standard operation for the correction of these lesions. Although usually successful, the complication of meatal retraction has been recognized at times after a MAGPI. The M inverted V glansplasty was designed to address the factors leading to meatal retraction and the abnormal glans shape sometimes seen after the MAGPI. The M inverted V glansplasty derives its name from the initial M-shaped incision that reconfigures during the course of the procedure into an inverted V. Of 16 boys followed for more than 2 months after an M inverted V glansplasty 14 have achieved good results. The remaining 2 cases had a definite degree of meatal retraction but because of the meatal and glanular relationships they have a good cosmetic result. The technique, its indications and its limitations are described.

One‐stage Hypospadias Repair: Experience of 367 Cases

Over a 6 1/2-year period we performed 374 primary hypospadias repairs, all but 7 as single-stage procedures. We usually employed the MAGPI, tubed preputial island flap and Mathieu reconstructions. Complications were comparatively few, with an overall incidence of 5% fistulae, 3% anastomotic strictures and 7% meatal retraction or stenosis. The cosmetic results were superior to those of staged procedures in that it was almost always possible to obtain a glanular meatus which was both terminal and realistic.

Sleeve Advancement Distal Hypospadias Repair

We report the technique and late results of a procedure for selected cases of distal hypospadias called sleeve advancement urethroplasty. This procedure incorporates correction of chordee, distal urethral mobilization and glans plasty in patients with coronal or distal subcoronal hypospadias. A total of 69 boys underwent this procedure at our institution: 59 as a primary repair and 10 for correction of meatal retraction after a previous failed reconstruction. Cosmetic results were excellent in most patients. Complications included meatal retraction in 2 patients and mild meatal stenosis in 2 in the primary repair group, and meatal stenosis in 3 (with associated fistula in 1) in the secondary repair group. Although not a replacement for meatal-based flap procedures, and more tedious to perform than the meatal advancement and glanuloplasty procedure, we have been impressed with the superior cosmetic results and minimal morbidity of the sleeve advancement urethroplasty.

Partial penectomy Technique to eliminate meatal stricture

A surgical technique for partial penile amputation is described which prevents meatal retraction and stenosis, and results in a functionally and cosmetically acceptable phallus.