Midshaft Hypospadias Research Articles

Surgical Repair of Mid-shaft Hypospadias Using a Transverse Preputial Island Flap and Pedicled Dartos Flap Around Urethral Orifice.

To evaluate the effects, particularly the incidence of anastomotic fistula, of a pedicled dartos flap around the urethral orifice in the treatment of urethroplasty of mid-shaft hypospadias. A total of 46 cases of congenital mid-shaft hypospadias were included in this study. The patients ranged in age from 0.7 to 25.4years and the average was 5.8years. The patients received penis chordee correction. A transverse preputial island flap was developed for urethral reconstruction. The proximal dartos of the urethral orifice was used to develop a pedicled dartos flap, which was transposed to cover and strengthen neourethral anastomosis. The ventral penile skin defect was repaired by another flap. The 46 patients were examined during follow-up visits for 6months to 3years. An anastomotic fistula was observed in one case (2.2%). Scar healing without fistula was observed in another patient due to poor blood supply to part of the ventral penile skin. No other incidences of fistula, urethral rupture, flap necrosis, wound infections, urinary tract (meatal) stenosis, or urethral diverticulum were observed in the patients. A pedicled dartos flap around the urethral orifice can take advantage of well-vascularized local tissue to add a protective layer to the proximal aspect of the neourethral anastomosis for reducing the incidence of anastomotic fistula in mid-shaft hypospadias repair using a transverse preputial island flap. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Snodgross and para-meatal based flap technique for hypospadiasis

Objective: To compare the two surgical procedures Snod gross & parameatal based flap technique for mid & distal penile hypospadias including cosmosis. Study design: Randomized Clinical interventional trail. Place of study: This study was conducted in the Urology Department of Assir Central University Hospital ABHA, KSA and Department of Urology & Renal transplantation, Jinnah Hospital, Lahore from June 2002 to Dec 2004. Material & Methods: Thirty-two patients were selected for this randomized clinical intervention study with mid shaft & distal hypospadias fulfilling the inclusion criteria. Snod Gross and parameatal based flap technique was assigned randomly to patients comprising of two groups of sixteen each. Watertight closure was made with 6/0 vicryl. Tourniquet or 1:10000 epinephrine were used. Follow up at 2 weeks, three months; 6 months post catheter or stent removal and the patient were assessed on criteria of cosmosis, time for surgery and complications associated with the procedure. Results: Th irty-two patients who underwent procedure of Snodgross & parameatal-based flap in the management of mid shaft & distal penile Hypospadias. Age ranged from 2-12 years. The mean age was 5.23+4 years. The presentation of patients was dystocia of external meatus with misdirected stream in sixteen (50%) patients, spraying of urine in six (25%) and narrow stream in 4(13%) patients. Eighteen patients were having distal penile and fourteen were having mid shaft hypospadias. Following Snod grass technique all patients had good cosmetic results without any complication. Following parameatal based flap, one patients (6.3%) develop wound dehiscence, three patients (18.8%) develop urethral fistula, two patients (12.5%) showed metal retrieval and twenty patients showed good cosmosis. In our study, comparison between Snodgross & parameatal-based flap, the success rate was 100% and 62.4% respectively. Conclusions: Success with Snod gross procedure is better with no complications and good cosmosis. Complications rate was 37.6 % in-patient with para-meatal technique.

Normalized Urinary Flow at Puberty after Tubularized Incised Plate Urethroplasty for Hypospadias in Childhood

An obstructive urinary flow pattern is frequently seen after tubularized incised plate urethroplasty for hypospadias. However, the significance of this finding has not been determined and long-term results are few. We describe postoperative long-term uroflowmetry results after puberty in males who underwent tubularized incised plate urethroplasty in childhood. A total of 126 boys underwent tubularized incised plate urethroplasty for distal penile to mid shaft hypospadias at Queen Silvia Children's Hospital in Gothenburg between 1999 and 2003. Of the patients 48 were toilet trained at surgery. We report on 40 patients who had data available at 2and 12 months postoperatively, 7 years postoperatively and at puberty (median age 15.0 years, range 13.7 to 17.1). Of the patients 31 had distal and 9 had mid penile hypospadias. Clinical examination, urinary medical history, uroflowmetry and ultrasound measuring residual urine were performed. Maximum urinary flow was correlated to age and voided volume, using Miskolc nomograms for comparison of percentiles. At 1 year postoperatively 15 boys (37.5%) had normal urinary flow (above 25th percentile), compared to 16 (40%) at 7 years and 38 (95%) at puberty (p <0.0001). Improvement was significant in patients with distal (p <0.0001) and mid penile hypospadias (p = 0.008), as well as in patients who did (p = 0.0078) and did not undergo intervention (p <0.0001). During followup 5 patients underwent meatotomy due to obstructive symptoms and 4 underwent dilation. Three of these 9 patients had lichen sclerosus. There is great potential for normalization of urinary flow at puberty for boys with hypospadias treated with tubularized incised plate urethroplasty. Unless symptoms occur, a conservative approach seems preferable.

Impact of penile degloving and proximal ventral dissection on curvature correction in children with proximal hypospadias.

Penile degloving is an important step in orthoplasty. Although its role in correcting mild curvature in distal and midshaft hypospadias has been previously reported, its impact on ventral curvature (VC) correction in proximal defects warrants further investigation. Therefore, we sought to document the effect of degloving and proximal urethral dissection on VC correction in children with proximal hypospadias. We retrospectively reviewed the records of 137 patients who underwent proximal hypospadias repair between 1998 and 2006. VC, defined as mild (<30%), moderate (30%-45%), and severe (>45%), was recorded before penile degloving and after erection test. Percent improvement in VC and need for further treatment (beyond degloving and proximal dissection) based on preoperative degree of curvature were assessed. ANOVA test was used to compare improvement among the 3 groups. Mean age at repair was 14 months (range: 6-24). Penile degloving associated with proximal urethral dissection when necessary was responsible for the improvement in the degree of curvature in 7 of 9 (77%) patients with mild VC, 23 of 44 (52%) with moderate and 35 of 84 (40%) with severe VC. Additionally, degloving alone was sufficient for VC correction in 7 of 9 (77%) mild cases, 14 of 44 (30%) moderate and only 2 of 84 (2%) severe cases. The difference among these 3 groups was statistically significant (p < 0.001). Penile degloving alone can correct VC. The percentage of improvement depends on the preoperative degree of curvature, with severe VC cases showing the least improvement.

A modification of the TIP procedure for distal hypospadias: The burrowing technique.

The tubularized incised plate urethroplasty (TIP) hypospadias repair is a commonly performed procedure for hypospadias. Multiple series document excellent cosmetic outcome in conjunction with low complication rates. We describe a modification that we have named the "burrowing technique." We believe that this technique facilitates dissection of the glans, which improves mobility, decreases tension with closure, and potentially improves outcomes. A retrospective review was performed of 193 coronal or mid-shaft hypospadias repairs by a single surgeon. The first 98 were performed using the TIP procedure, then the burrowing technique was developed and a subsequent 95 were analyzed for outcomes using this modification. Urethral plate characteristics and glandular size did not influence the choice of surgical technique. Cases were selected to allow for a "learning curve," and were consecutively accrued. None of the boys had undergone prior hypospadias surgery. Proximal 2 stage repairs and distal (glanular) repairs were excluded. A total of 193 boys underwent repair, 98 with the traditional TIP procedure and 95 using the burrowing modification. In total, 37 (19.2%) patients required re-operation for either fistulas or dehiscence; 23 (23.5%) in the non-burrowing group and 14 (14.7%) in the burrowing group, odds ratio 0.54 (p = 0.10). The TIP procedure has revolutionized the management of distal hypospadias. The burrowing modification increases glandular mobility simplifying the procedure and demonstrates a non-statistically significant trend in reducing reoperation rates.

Urethral Mobilization for Distal and Mid Shaft Hypospadias with Chordee

Urethral Mobilization for Distal and Mid Shaft Hypospadias with Chordee

Hypospadias in Three Generations: Is There a Dominant Responsible Gene for Hypospadias?

Hypospadias can be defined as a incomplete development of the urethra. Most hypospadias cases show spontaneous occurrence and have no clear cause because the genetic pathways of external genitalia formation are poorly understood. Familial tendency is associated with hypospadias. The brother of an affected boy may also have hypospadias, and this rate is approximately 9-17%. In this case report, we present three hypospadias cases with the same localization that have prolonged to three generations including grandfather, father and three sons. They were applied by their father for circumcision. The socio-economic status of the father was the main reason for the delay of elder brothers’ circumcision. We revealed midshaft hypospadias without chordee in three brothers at physical examination. The father also told us he had the same disorder and our physical examination of the father supported hypospadias. Also according to the history taken from father, the grandfather had also hypospadias probably at the same localization. We performed tubularized incised urethral plate to these cases. In the light of these cases, we have thought that there should be a dominant gene responsible for formation of hypospadias. J Med Cases. 2014;5(3):152-154 doi: https://doi.org/10.14740/jmc1670w

Advantages of the anterior and mid-shaft hypospadias repair in the first year of life

Only a few studies have been performed on the evaluation of complications strictly related to the age at operation of hypospadias repair. The aim of our study was to evaluate the incidence of complications of surgical treatment of anterior and midshaft hypospadias in relation to the age at operation. 108 patients from 2005 to 2011 were operated on by the same surgeon (AM) for anterior and mid-shaft hypospadias. The patients were divided into two groups according to their age: group A consisted of 48 patients who had undergone surgery before 12 months, group B consisted of 60 patients in whom surgery was performed after 12 months of age (2months -12 yrs). All patients were corrected with TIPU (Snodgrass technique). For the two groups was evaluated the rate ofperioperative complications (hematoma, edema, hemorrhage), suture dehiscence, fistula, stenosis. For the statistical analysis of complications was used the exact test of chi-square Fischer. At a mean follow-up of 36 months. Group A: 2/48 patients presented fistula after 2-6 weeks. Group B: 15/60 patients presented the following complications: 2 hematomas, 1 postoperative bleeding; 5 fistulas arising after 2-6 weeks, 3 minimal meatal regression; 4 thinning flow. The Fisher test was significant. The results of our study confirm that patients with hypospadias, operated within the first years of life, have a statistically lower rate of complications than patients treated at later dates. Therefore, the age is believed to be a pivotal prognostic factor for the functional and aesthetic results.

Regular Dilatation in Tubularized-Incised Urethral Plate Urethroplasty for Prevention of Fistula Formation

Dear Editor, Tubularization of an entirely incised urethral plate is reported to have satisfactory functional and cosmetic results even in proximal hypospadias (1). In this technique, the urethral plate is divided into two epithelial strips that are approximated in the midline ventrally however; the roof and the side-walls are formed by raw surface that will eventually be covered by epithelium of plate regenerating (2). The stenosis of the neomeatus was associated with post-operative fistula (1). In our experience, thirty five patients (mean age 2.5 years, range 2–10 years old), whose hypospadias were corrected using the tubularized-incised urethral plate technique, were followed-up. Ten had coronal, and twenty five had mid shaft hypospadias. The urethral plate was incised in the midline and tubularized over a proper stent. A local anaesthetic gel containing lidocaine hydrochloride was applied and the neourethra gently dilated using a Nelaton catheter of the same size as the intra-operative stent. This manoeuvre prevented adhesions between the raw surfaces of the incised urethral plate. Of total 35 patients, ten patients had a small fistula associated with meatal stenosis. By regular dilatation of the urethra, six fistulae resolved spontaneously and the remaining patients cured surgically. Other complications included hematoma formation in five patients and urinary tract infection in two patients. Jordan and Schlossberg (3) explained the cause of post-operative meatal stenosis as epithelial apposition is prevented by separating both sides of the wound, healing occurs by secondary intention and the epithelium progresses slowly from the edges of the wound to cover the raw surface. The natural tendency of wounds to contract will aid epithelial apposition; limits the size of the area requiring epithelialization and promotes stenosis that make the urethroplasty developed fistula. The most reliable method to counteract the process of urethral wound contraction is long-term and regular dilatation of the urethra (4-6). Neourethral dilatation is easy, relatively painless and can be administered at home by parents for 1–2 weeks. Older children, adolescents and young adults were able to perform daily dilatation themselves with no problems. Regular urethral dilatation is important in preventing adhesions between both sides of the incised plate, which can result in meatal stenosis and fistula.

Medium to long term results following single stage Snodgrass hypospadias repair

The Snodgrass technique for primary hypospadias repair was described in 1994 and involves dorsal incision and tubularisation of the urethral plate distal to the meatus. While the advantages of good short-term outcome and good cosmesis have been reported, there is little data on long-term results in patients who have undergone a Snodgrass repair as a primary procedure for hypospadias. Our aim is to retrospectively review our medium to long-term results of primary tubularised incised-plate urethroplasty for hypospadias repair over a two-year period with up to eight-year follow-up. We conducted a case note review of 74 patients who had undergone single-stage Snodgrass hypospadias repair, performed by a single surgeon (AB), from April 2000 to January 2003. The mean documented follow up was 56 months (3-103 months). The mean age of patients at time of surgery was three and a half years. 95% (70) of patients had a distal (glanular, coronal, sub-coronal, distal shaft) meatus and 5% (4) had a proximal (mid-shaft) meatus. The overall complication rate was 7% (5). Two patients developed fistulae, which was noted and repaired at six months post-op with no further surgical intervention required. One patient underwent an EUA and meatal advancement glansplasty at 6 months for mild glanular dehiscence. Two further patients required EUA and dilatation procedures at two and three years respectively, both for mild meatal stenosis. Again, no further intervention was required. From a cosmetic perspective, two patients were noted to have some residual bulkiness of the skin around the corona and a further two patients were noted to have a small meatus, but with no functional symptoms. Our study has shown a low long-term complication rate in patients undergoing Snodgrass repair as a primary procedure for distal and midshaft hypospadias repair. This supports the results of earlier studies that have shown good functional and cosmetic outcome in the short-term for this procedure which persists into the medium/long term.

Outcome Analysis of Tubularized Incised Plate Repair in Hypospadias: Is a Catheter Necessary?

Objective: Tubularized incised plate (TIP) urethroplasty is performed by many pediatric urologists and has been widely accepted for repair of distal and mid-shaft hypospadias. However, the role of urethral catheter placement in TIP repair remains controversial. In this study, the surgical outcomes of indwelling urethral catheter and non-catheter TIP repairs in boys with hypospadias were compared. Methods: A total of 254 patients with primary distal and mid-shaft hypospadias underwent TIP repair and were evaluated retrospectively. A urethral catheter was placed in 103 patients (group A) and non-catheter repair was performed in 151 patients (group B). Information obtained included age, toilet training, chordee, type of hypospadias, presence or absence of a catheter, and postoperative complications. The complications recorded included wound infection, urinary tract infection, bladder spasm, urinary retention, urinary extravasation, meatal stenosis, urethral stricture, and urethrocutaneous fistula. Results: There was no statistical difference in age, toilet training, chordee, hypospadias site, or performing surgeon between the two groups. The median follow-up time was 22 and 24 months for groups A and B, respectively. The rate of bladder spasms (10.7 vs. 0%, p < 0.001) and urinary tract infection (9.7 vs. 3.3%, p = 0.034) was significantly higher for group A than group B. Although the rate of urinary retention was higher in group B than in group A (4.0 vs. 0%), there was no statistically significant difference between the two groups (p = 0.084). Likewise, the incidence of urethrocutaneous fistula and meatal stenosis was not significantly different. Conclusion: Non-catheter TIP repair is feasible and positive outcomes can be achieved with minimal complications and less patient discomfort.

Urethral Mobilization for Distal and Mid Shaft Hypospadias with Chordee

Many options are available for repairing mid shaft to distal hypospadias. Reported complications include poor cosmesis, persistent chordee, meatal stenosis and fistula. We hypothesized that advancing the intact native urethra would facilitate chordee correction and minimize complications. We retrospectively reviewed our records of all 248 hypospadias repairs done from July 2003 to May 2009 and identified patients younger than 18 years with distal or mid shaft hypospadias who underwent repair by urethral mobilization. The outcomes recorded were patient satisfaction, bladder scan volume, and the rate of fistula, meatal stenosis or other complications. Of the patients 83 met study inclusion criteria, including 5 (6%) treated with previous failed hypospadias operations. The hypospadias site was the distal, mid shaft and megameatal intact prepuce variant in 69 (83.1%), 11 (13.3%) and 3 patients (3.6%), respectively. Chordee was present in 80 patients (96.4%). The mean degree of chordee was 61.5 degrees, mean age at operation was 35.7 months and mean followup was 18 months (range 0.25 to 79). Of parental responses 94% were pleased or very pleased. Mean bladder volume on bladder scan was 9.7 ml (range 0 to 81). Fistula developed in 1 patient (1.2%). There were no meatal stenosis cases. Urethral mobilization results in excellent cosmesis and a low complication rate. This technique is especially well suited to patients with prior operations or deficient preputial skin. Using the native urethra with its blood supply is our preferred method of repairing distal and mid shaft hypospadias with chordee.

Tunica vaginalis flap is superior to inner preputial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias

AimsThe aims of this study are 1. to compare outcome of standard tubularised incised plate urethroplasty (TIP) repair using dartos flap in distal vs. midshaft hypospadias and 2. to determine whether tunica vaginalis flap (TVF) is superior to dartos flap in midshaft hypospadias in reducing early complications. MethodsAll patients who underwent TIP repair between 2004 and 2011 by the same surgeon were divided into three groups based on type of hypospadias and choice of waterproofing layer: Group A: Distal hypospadias; inner prepucial dartos flap (n = 36); Group B: Midshaft hypospadias; inner prepucial dartos flap (n = 26); Group C: Midshaft hypospadias; TVF (n = 21). Early outcomes were compared between the groups using Fisher's exact test. ResultsThere was no significant difference in the age distribution or duration of follow up between the groups. There was no significant difference in terms of, glans dehiscence or meatal stenosis between the groups. In Group A, 0/36 had ventral skin necrosis and 3/36 (8.3%) developed urethrocutaneous fistula. In Group B, there was significantly higher ventral skin necrosis (6/26; 23%) and urethrocutaneous fistula (8/26; 30.7%) compared to Group A (p = 0.04). In Group C, there was significantly less ventral skin necrosis (0/21) and urethrocutaneous fistula (1/21; 4.7%) compared to group B (p = 0.03). There was no significant difference in outcomes between Group A and Group C. Conclusion1. TIP repair using inner prepucial dartos flap has significantly higher complications when used for midshaft hypospadias compared to distal hypospadias. 2. Tunica vaginalis flap reduces the fistula rate and is superior to inner prepucial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias.

Para-meatus Skin Incision With Long Channel Technique for Midshaft Hypospadias Repair Without Penile Curvature

To report a new surgical technique for midshaft hypospadias repair without penile curvature. From September 2007 to October 2010, 21 patients, aged 13 months to 8.9 years, underwent single-stage hypospadias repair by 1 surgeon. The skin incision was created around the meatus, and a long channel beneath the urethral plate was created through the incision to the apex of the glans. The inner preputial flaps were tubularized into a neourethra, which was then transposed to the ventral channel through a ventrolateral tunnel beneath Buck's fascia. Most of the neourethra was covered by the intact soft tissue of the distal ventral penis. The proximal portion of the neourethra was covered by Buck's and dartos fascia around the skin incision, and the skin incision was closed longitudinally. The length of the urethral defect and channel and the postoperative complications were collected and analyzed. A total of 21 patients underwent single-staged hypospadias repair. The average length of the channel was 30 mm (range 25-35). The average length of the neourethra was 35 mm (range 30 to 40). The mean operative time was 60 minutes (range 50-70). The mean hospital stay was 12 days (range 10-14). With an average follow-up of 20 months (range 6-37), no postoperative complication was detected. This technique provides excellent short-term results for midshaft hypospadias without penile curvature and is a safe and simple solution.

Préparation à l’érythropoïétine avant chirurgie de l’hypospade : de meilleurs résultats ?

To study the effect of a preparation by erythropoietin before Onlay's intervention on postoperative hematocrits and medium-term results of the surgery. Twenty-one patients were operated on by Onlay's technique between 2001 January and 2008 September, after being treated by erythropoietin. Seven had a midshaft hypospadias, two a posterior hypospadias and 12 a penoscrotal hypospadias. All children were examinated four months after surgery to evaluate the surgical results. After the surgery, 18 children had an apical meatus (85.7%). Three had a balanopreputial meatus, two a stenosis of the meatus. Two children were reoperated on, one with the Duplay's technique, the other for a meatostomy. No fistula, no necrosis of the preputial flap was observed. The preoperative hematocrit was measured at 41%, with an increase of 3.8% because of the preparation. Peroperative blood loss was evaluated at 6.6%. After surgery, 12 children had an hematocrit inferior than 35%, four an hematocrit inferior than 30%. No transfusion was needed. Preparation by erythropoietin before severe hypospadias surgery seemed to have several advantages: a more elevated hematocrit after surgery than with an iron preparation alone, and a lower rate of postoperative complications, including fistulas and necrosis of the preputial flap.

Mathieu repair of distal and midshaft hypospadias: risks and benefits of foreskin reconstruction versus circumcision.

BackgroundThe purpose of this study was to compare the risks and benefits of Mathieu repair of hypospadias with or without circumcision in consecutive operated cases.MethodsEighty-six children with midshaft or distal hypospadias were randomly divided into two groups and underwent circumcision (Group A) or preputial reconstruction (Group B) during hypospadias repair. Postoperative complications, outcomes, and parental satisfaction were assessed for circumcised and uncircumcised patients. All patients with midshaft or distal hypospadias with or without minimal chordee were included.ResultsNo statistically significant differences in urethral complications were found between the two groups. Meatal stenosis occurred in one case in Group A and one case in Group B. Fistulae occurred in five cases in Group A and six cases in Group B. Urethral dehiscence occurred in no case in either group. No case of phimosis was seen in Group B. After a mean follow-up of 6 months, all parents of Group A cases stated that they were satisfied with the circumcision for religious and/or social reasons, but no parents of Group B cases were satisfied with preputioplasty (P ≤ 0.05). No case of hypospadias repair failure was seen in our operated cases. Finally, no cases in Group B required redo hypospadias surgery.ConclusionMathieu repair with synchronous circumcision is feasible in all patients with distal or midshaft hypospadias with or without minimal chordee, and should be considered in accordance with surgeon preference. In the case of prepuce preservation, parents should be informed that there is a benefit of tissue banking for probable redo hypospadias repair but with an increased risk of complications and a need for another procedure, ie, circumcision.

Mathieu repair of distal and midshaft hypospadias: risks and benefits of foreskin reconstruction versus circumcision

Mathieu repair of distal and midshaft hypospadias: risks and benefits of foreskin reconstruction versus circumcision Mohammad Kazem Moslemi1, Mohammad Ali Sadighi Gilani2, Hossein Shahrokh31Department of Urology, Kamkar Hospital, School of Medicine, Qom, University of Medical Science, Qom, Iran; 2Department of Urology, Shariati Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; 3Department of Urology, Hasheminejad Kidney Research Center, School of Medicine, Tehran University of Medical Sciences, Tehran, IranBackground: The purpose of this study was to compare the risks and benefits of Mathieu repair of hypospadias with or without circumcision in consecutive operated cases.Methods: Eighty-six children with midshaft or distal hypospadias were randomly divided into two groups and underwent circumcision (Group A) or preputial reconstruction (Group B) during hypospadias repair. Postoperative complications, outcomes, and parental satisfaction were assessed for circumcised and uncircumcised patients. All patients with midshaft or distal hypospadias with or without minimal chordee were included.Results: No statistically significant differences in urethral complications were found between the two groups. Meatal stenosis occurred in one case in Group A and one case in Group B. Fistulae occurred in five cases in Group A and six cases in Group B. Urethral dehiscence occurred in no case in either group. No case of phimosis was seen in Group B. After a mean follow-up of 6 months, all parents of Group A cases stated that they were satisfied with the circumcision for religious and/or social reasons, but no parents of Group B cases were satisfied with preputioplasty (P &le; 0.05). No case of hypospadias repair failure was seen in our operated cases. Finally, no cases in Group B required redo hypospadias surgery.Conclusion: Mathieu repair with synchronous circumcision is feasible in all patients with distal or midshaft hypospadias with or without minimal chordee, and should be considered in accordance with surgeon preference. In the case of prepuce preservation, parents should be informed that there is a benefit of tissue banking for probable redo hypospadias repair but with an increased risk of complications and a need for another procedure, ie, circumcision.Keywords: hypospadias, circumcision, preputioplasty, distal, midshaft, Mathieu repair

545 USE OF FIBRIN GLUE AS AN ADJUNCT IN HYPOSPADIAS REPAIR

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Lower Urinary Tract & Genitalia1 Apr 2011545 USE OF FIBRIN GLUE AS AN ADJUNCT IN HYPOSPADIAS REPAIR Ayme Schmeeckle, Dennis Venable, and John Mata Ayme SchmeeckleAyme Schmeeckle Shreveport, LA More articles by this author , Dennis VenableDennis Venable Shreveport, LA More articles by this author , and John MataJohn Mata Shreveport, LA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1270AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previously, we reported a positive experience with fibrin glue (Tisseel TM) in securing skin grafts during genital reconstruction. It has been suggested that fibrin glue may decrease incidence of urethrocutaneous fistulae and postoperative bleeding when used during hypospadias surgery. Herein, we report our results of a retrospective review comparing a cohort of patients with mid to distal shaft hypospadias undergoing primary tubularized incised plate (TIP)reconstruction with and without fibrin glue. METHODS We reviewed a group of 39 patients, ages 7 months to 14 years, who underwent a TIP hypospadias repair from 2008 to 2010. 13 patients had a thin layer of fibrin glue applied over the neourethra and 26 patients did not. Averages ages were 27 months in the fibrin group and 10 months in the non-fibrin group. Two patients in the fibrin group had midshaft hypospadias compared to seven in the non-fibrin group. All patients had urethral catheters for 5 to 7 days postoperatively and Tegaderm dressings. We compared the complication rates of the two groups at a mean follow-up of 15 months. RESULTS Although there was a subjective assessment that minor bleeding stopped more readily in the fibrin group intraoperatively, estimated blood loss in all patients was negligible since all repairs were done with tourniquet control. No patient in either group developed significant hematoma or required return to the operating room for postoperative bleeding. In the fibrin group, 6 of the 13 (46.15%) patients developed a urethrocutaneous fistula compared to 2 of 26 (7.69%) in the non-fibrin group. One patient in each group had a partial glans dehiscence associated with the fistula. All patients who elected for fistula repair received successful surgical correction in the standard fashion without fibrin glue at 6 months postoperatively. CONCLUSIONS Patients receiving fibrin glue had a greater than six fold increased incidence of fistula formation. These findings suggest that fibrin glue may disrupt normal tissue incorporation in the postoperative healing phase. Although fibrin glue helped stop bleeding from glansplasty, it made no difference in the overall estimated blood loss. Further basic science studies on wound healing with fibrin glue as well as larger clinical prospective, randomized trials are needed to help define the role of fibrin glue in hypospadias surgery. Until the results of such trials are known, fibrin glue should be used with caution in patients undergoing hypospadias repair. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e221 Peer Review Report Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ayme Schmeeckle Shreveport, LA More articles by this author Dennis Venable Shreveport, LA More articles by this author John Mata Shreveport, LA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Stent-Free Tubularized Incised Plate (TIP) Repair of Distal and Mid-Shaft Hypospadias Irrespective of Age

Aim of this study was to report our experiences with tubularized incised plate (TIP) repair without placement of a postoperative urethral stent in 41 cases. Since October 2005, we have performed TIP repair for distal penile hypospadias without using a postoperative urethral stent. A urethral stent is used intraoperatively for the tubularization of the neourethra and is removed at the end of the procedure. Follow-up included clinical examination and a structured telephone interview on parental satisfaction. The group included 41 boys, 60% with coronal or distal hypospadias and 40% with mid-shaft hypospadias (aged 6 months to 16 years, median: 3 years). In 7 cases, the prepuce was also reconstructed. There were 2 cases with fistula and one case of meatal stenosis. No glans dehiscence, severe bleeding, or wound infection was observed. No urinary retention requiring catheterization was observed, irrespective of age. All but one patient was discharged the day after surgery. Follow-up ranged from 8 to 48 months (average: 22 months). Most parents (87.5%) were satisfied or very satisfied. Based on our preliminary experiences, patient comfort and safety, parental satisfaction and the rate of complications seem to be promising with this technique.

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

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