Neourethral Stenosis Research Articles

History and Determinant of Adult Neourethral Stricture After Hypospadias Repair in Childhood: A Single Center Study Derived From a Single Procedure by a Single Surgeon

ObjectiveTo elucidate the incidence, presentation timing, and determinants of adulthood neourethral strictures after childhood hypospadias repair, using data from a database derived from a single procedure performed by a single surgeon. MethodsPediatric patients with hypospadias who underwent staged surgery using a foreskin-derived neourethra served as the Denominator population. Clinical data from adult neourethral stricture patients who re-visited us were analyzed. ResultsFourteen of 723 Denominator population (1.9%) revisited for adult neourethral stricture. The median age at completion of the initial hypospadias repair was 6 years (IQR 4–7). Seven patients (50.0%) underwent surgical interventions in childhood, and six (42.9%) had a history of childhood stricture surgery at the age of 4–17 years (median, 5.5). Strictures sites were meatal in 3 (21.4%), entire neourethra in 2 (14.3%), and junctional in 9 (64.3%), with a median length of 17.5 mm (IQR 15–25). Urethral self-dilation was initiated in nine patients. Eleven patients, including six initially treated with self-dilation, required open urethral repair. Time from childhood repair to stricture symptoms ranged from 18 to 34 years (median, 26.5). Median ages at urethral stricture symptoms, re-visit, and open urethral repair were 34 (IQR 25–38), 38.5 (IQR 32–45) and 45 years (IQR 37–53), respectively. Multivariate Cox hazard analysis identified childhood surgical intervention post-initial repair as the only significant risk factor for neourethral stricture (p<0.05). ConclusionsThese results highlight the importance of educating patients about the risk of late strictures following childhood hypospadias repair.

Outcome of Snodgraft (G-TIP) Urethroplasty for the Treatment of Primary Distal Hypospadias

Background: One of the most prevalent congenital abnormalities of the external genitalia in boys is hypospadias. One common method of treating distal penile hypospadias is tubularized incised plate urethroplasty. However, there are a few side effects of this procedure, such as neourethral stenosis, meatal stenosis, and uretho-cutaneous fistula. In distal hypospadias, snodgraft modification has been suggested as a way to lower the risk of meatal and/or neourethral stenosis. Objective: To find out the outcome of Snodgraft urethroplasty technique in distal penile hypospadias. Materials and Methods: This prospective observational study was carried out in the Division of Pediatric Surgery, Bangladesh Shishu Hospital &amp; Institute from January 2020 to March 2022. Total 40 patients having distal variety of primary hypospadias were included by selection criteria. All patients with single stage urethroplasty using inner prepucial skin graft has been done. Statistical analysis was carried out using the Statistical Package for Social Sciences version 26.0 for Windows. Results: Majority of the patients had subcoronal variety 27(67.50%) followed by coronal 10(25.0%) and glanular hypospadias 3(7.50%). More than three fourth (77.5%) patients had urethral plate width 4-8 mm. Wound infection was developed in two patients out of 40, one coronal and one subcoronal. Four patients had developed urethro-cutaneous fistula among them one was coronal three was subcoronal. No meatal stenosis and urethral stricture was found in follow up period. Conclusion: The patient with Snodgraft (G-TIP) modification in repair of primary distal hypospadias leads to reduce the complication.

Effect of preoperative estrogen on complications after proximal hypospadias repair: A randomized controlled trial.

Proximal hypospadias repair has many postoperative complications such as urethrocutaneous fistulae, wound dehiscence, and urethral stricture. The beneficial effect of estrogen to promote wound healing has been known. We designed a study to determine whether preoperative stimulation of tissue with estrogen can reduce the postoperative complications associated with wound healing in patients undergoing hypospadias repair. Patients with proximal hypospadias requiring two-stage repairs (chordee correction followed by urethral tubularization) were randomized to estrogen and control groups before the second stage of surgery. In the former, topical estrogen cream (0.5 mg of estriol) was applied to the ventral penis for a month, whereas normal saline gel was applied to the latter; the urethroplasty was carried out thereafter. Patients were followed up for complications. There were 29 patients in the estrogen group and 31 in the placebo group after the exclusion criteria were met. There was no significant difference in the overall postoperative complications between the estrogen group (44.8%) and the placebo group (51.6%). The occurrence of urethrocutaneous fistula (37.9% vs. 51.6%) and dehiscence (41.4% vs. 45.2%) was not significantly different between the estrogen and placebo groups. Neourethral stricture occurred in four patients in the estrogen group, while none of the patients in the placebo group developed stricture. The preoperative application of topical estrogen cream to the ventral penis failed to demonstrate any significant effect on wound healing and complications.

Do New Complications Develop during Puberty after Childhood Hypospadias Repair?

We sought to determine if penile growth at puberty causes new complications after childhood hypospadias repair. Consecutive Tanner 2-5 patients presenting with complications after childhood hypospadias repair were queried to determine if those problems occurred before, during or after puberty. There was a total of 82 patients, 15 Tanner 2-4, evaluated at a mean age of 28 years (range 12-66). These underwent an average of 3 (range 1-20) childhood operations, mostly using skin flaps. Two-thirds had nondistal hypospadias. The most common complication was dehiscence in 73%, with ventral curvature in 39%, neourethral strictures or meatal stenoses in 29% and fistulas in 15%. Many patients had more than 1 problem. Of these complications 80% were reported to have occurred before puberty, including all dehiscences and recurrent ventral curvature, while 15% were diagnosed in men at an average age of 47 years who developed neourethral strictures or meatal stenosis. Only 5% of complications were reported to have occurred during puberty. There is a bimodal presentation of complications after childhood hypospadias repair. Most occur before puberty, while a smaller number of obstructive lesions develop in middle age. We found few new complications occurring during penile growth at puberty. These data potentially impact discussions regarding optimal duration of followup after childhood hypospadias repair, and also can reassure caregivers considering repair in boys that the risk for new complications developing during puberty appears to be small.

Total Urethra and Penile Shaft Reconstruction with Combined Pedicled Anterolateral Thigh Flap and Radial Forearm Free Flap after Total Penectomy.

Total reconstruction of the penis (TPR) represents a challenge for urologists and plastic surgeons, especially when urethral length is severely reduced. We here describe, for the first time in an oncologic scenario, a double flap phalloplasty using a pedicled anterolateral thigh (ALT) flap for penile reconstruction and a radial forearm free flap (RFFF) for complete neourethra and glans reconstruction following penile amputation. A 48-year-old patient came to our department following a total penectomy with inferior urethral derivation. The indication for a double flap phalloplasty was posed as only way to fully reconstruct the urethra on its length avoiding possible complications of single flap reconstruction using tube-into-tube technique. Both flaps healed uneventfully with no neourethral strictures or fistulas described. At 18 months follow-up, the patient was extremely satisfied with the aesthetic result and was able to void in standing position. We think that a double free tissue transfer for TPR should be considered, particularly when a urethral length > 14 cm needs to be reconstructed. While the pedicled ALT can be used to reconstruct a proper penile shaft with an easily concealed scar, the RFFF can provide adequate neourethra length with satisfactory sensory recovery at the neoglans.

Meta Analysis Study of Complications Following Repair of Mid Penile Hypospadius using Different Surgical Techniques

Abstract Background Hypospadias is one of the most common congenital defects affecting the external male genitalia. The incidence is 1 in 250 male newborns, although its incidence seems to be increasing. Hypospadias is defined as an insufficient development of the urethral fold and the ventral foreskin, with or without penile curvature. The urethral opening is located more proximally anywhere between the tip of the penis and the perineum. Aim of the Work The aim of this study is to determine the best surgical technique with the least complications for repair of mid-penile hypospadias. Materials and Methods This systematic review and meta-analysis was performed in accordance to the recommendations of the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. MOOSE is a reporting checklist for Authors, Editors, and Reviewers of Meta-analysis of interventional and observational studies. According to International committee of medical journal association (ICJME), reviewers must report their findings according to each of the items listed in those checklists. Results Fistula is less common after Preputial island flap technique. Fistula is more common with Modified koyanagi technique. Meatal stenosis is less common after Mathieu and Preputial island flap techniques. Meatal stenosis is more common after TIP technique. Wound Dehiscence is not common after lateral based flap and modified koyanagi and Onlay island flap techniques. Neourethral Stricture is not common after lateral based flap and Mathieu and Onlay island flap techniques. Conclusion The Mathieu and Preputial island flap techniques for mid-penile hypospadias reconstruction are associated with a significantly lower risk for postoperative urethral stricture and may be the preferred method for hypospadias. However, the clinical implications of the results can be discussed because the risk of stricture in all procedures was low. The implications for research are obvious because there had been no studies that provided firm guidelines on the best method for the operative intervention for hypospadias. Further trials are still needed to confirm our findings.

Histological Evaluation of Vaginal Cavity Remnants Excised During Neourethral Stricture Repair in Transgender Men

ObjectiveTo determine the prevalence of patients who require vaginal cavity remnant excision and obliteration during neourethral stricture repair and to characterize the histological composition of the excised tissue. MethodsA retrospective review was performed of all transgender men who underwent neourethral stricture repair. Preoperative imaging and operative reports were reviewed to determine the presence of a vaginal cavity remnant that was excised and obliterated during neourethral reconstruction. Pathology slides were reviewed by 2 pathologists to determine if there was presence of stratified squamous epithelium consistent with vaginal tissue within the vaginal cavity remnant. ResultsA total of 47 consecutive transgender men underwent neourethral stricture repair between January 2014 and December 2020. Of these, 18 patients (38%) with a mean age of 37 years (23-59) underwent excision and obliteration of a vaginal cavity remnant. Seventy eight percent (14/18) had a prior phalloplasty and 22% (4/18) had a prior metoidioplasty. Primary vaginectomy type was not associated with whether or not a patient had a vaginal cavity remnant (P = .12). Histological evaluation demonstrated the presence of vaginal epithelium in all vaginal cavity remnant specimens. ConclusionA high percentage of transgender men with neourethral strictures present with vaginal cavity remnants despite prior vaginectomy. Pathological evaluation confirms that all vaginal cavity remnant specimens contain vaginal epithelium that was either incompletely excised or regenerated. While the implications of this residual vaginal epithelium require further investigation, total removal of vaginal tissue primarily or during reconstruction is important given the risk of associated symptoms.

Tubularized incised plate urethroplasty with or without dilatation in hypospadias repair: a comparative study

Background. After tubularized incised plate (TIP) urethroplasty meatal and urethral dilatation is a common practice. There are some complication of uretheral dilatation like urethral bleeding,urethral perforation and creating a false passage. Moreover dilating the urethra regularly is physically or psychologically painful both for the child and the parents. The aim of this study was to justify the necessity of uretheral dilatation after TIP urethroplasty.Material and Methods. This study was a prospective, comparative study performed in Dhaka Shishu (Children) Hospital from July 2017 to June 2020. Total 60 respondents were participated in this study with maintain inclusion criteria. Respondents with primary distal and mid-shaft hypospadias where TIP urethroplasty was indicated, admitted in Dhaka Shishu Hospital during study period were included. Group 1 was assigned non dilatation group and Group 2 was assigned to regular urethral ditatation group after TIP urethro- plasty. Fistula formation, meatal stenosis and neourethral stricture were compaired between two groups. Informed written consents were taken from legal guardians. Data ware analyzed by SPSS Program.Results. In this study there was no significant difference of ages between two groups. In Group 2 10 %( 3)respondents developed urethrocutaneous fistula, 10% (3) respondents developed meatal stenosis and 3.33% (1)respondents developed neourethral stricture. On the other hand. In Group 1 10% (3) respondents developed urethrocutaneous fistula, 6.66% (2) respondents developed meatal stenosis. None of patient in Group 1 developed neourethral stricture.Conclusion. There was no significant difference in fistula formation, meatal stenosis and neourethral stricture in between regular urethral dilatation group and non-dilatation group after TIP urethroplasty.

Tubularized incised plate urethroplasty with or without dilatation in hypospadias repair: a comparative study

Background. After tubularized incised plate (TIP) urethroplasty meatal and urethral dilatation is a common practice. There are some complication of uretheral dilatation like urethral bleeding,urethral perforation and creating a false passage. Moreover dilating the urethra regularly is physically or psychologically painful both for the child and the parents.The aim of this study was to justify the necessity of uretheral dilatation after TIP urethroplasty.Materials and Methods. This study was a prospective, comparative study performed in Dhaka Shishu (Children) Hospital from July 2017 to June 2020. Total 60 respondents were participated in this study with maintain inclusion criteria. Respondents with primary distal and mid-shaft hypospadias where TIP urethroplasty was indicated, admitted in Dhaka Shishu Hospital during study period were included. Group A was assigned non dilatation group and Group B was assigned to regular urethral ditatation group after TIP urethro- plasty. Fistula formation, meatal stenosis and neourethral stricture were compaired between two groups. Informed written consents were taken from legal guardians. Data ware analyzed by SPSS Program.Results. In this study there was no significant difference of ages between two groups. In Group B 10% (3)respondents developed urethrocutaneous fistula, 10% (3) respondents developed meatal stenosis and 3.33% (1)respondents developed neourethral stricture. On the other hand In Group A 10% (3) respondents developed urethrocutaneous fistula, 6.66% (2) respondents developed meatal stenosis. None of patient in Group A developed neourethral stricture.Conclusion. There was no significant difference in fistula formation, meatal stenosis and neourethral stricture in between regular urethral dilatation group and non-dilatation group after TIP urethroplasty.

Using prepucial mucous to cover neourethra in TIP urethroplasty: 4 years experience in a tertiary paediatric hospital of Bangladesh

Background. Hypospadias has a wide spectrum of penile abnormality requiring surgical correction. Most of the cases are of anterior variety and the surgical technique depends on constructing a neo urethra. Snodgrass or Tubularized Incised Plate (TIP) urethroplasty is one of the most popular techniques of urethroplasty which depends on the existing healthy, adequate and intact urethral plate. Different tissues have been described to cover the neourethra as second layer in literature. In this study we modified the TIP urethroplasty by covering the neourethra with 2 layers of pedicled prepucial mucosa or Dartos flap. Objective. To see the outcome of modified Snodgrass or TIP urethroplasty in anterior mid and proximal penile hypospadias. Materials and method. Total 88 patients were operated by modified Snodgrass technique or modified TIP urethroplasty from January 2012 to July 2016. Coronal, subcoronal, distal penile, mid penile and proximal penile hypospadias were included in the study. Every patient underwent modified TIP urethroplasty and outcomes were assessed. Results. The mean age of the patients were 28.34±14.98 months, ranges from 6.5 to 65 months. 9 (10.2%) patients of our series develop urethrocutaneous fistula, 5 (5.68%) patients develop meatal stenosis and 1 (1.1%) patient developed neourethral stricture. Conclusion. TIP urethroplasty is a versatile method to correct penile hypospadias. Covering of the neourethra with prepucial mucosa secure the neourethral anastomosis. The author declares that there is no conflict of interest. Key words: Hypospadias, TIP urethroplasty, Prepucial mucosa.

MP29-18 VAGINAL CAVITY REMNANT RE-EXCISION AND RE-OBLITERATION IN TRANSGENDER MEN UNDERGOING NEOURETHRAL STRICTURE REPAIR

INTRODUCTION AND OBJECTIVE: Transmasculine genital affirmation surgery usually involves vaginectomy and construction of a neophallus. Common urinary complications after phalloplasty include neourethral strictures and fistulae. Distal obstruction forces pressurized urine to fistulize between the neourethra and the previously obliterated vaginal cavity leading to formation of a urine-filled cavity. Patients present with post-void dribbling, pelvic pressure, pain or recurrent infections. Our objective is to determine a proportion of patients requiring cavity re-excision and re-obliteration during neourethral stricture repair as well as the histological composition of the excised tissue. METHODS: A retrospective review was performed of all transgender male patients who underwent neourethral stricture repair. Operative reports were reviewed to determine the presence of a vaginal cavity remnant that required re-excision and re-obliteration at the time of the neourethral reconstruction. Pathological H&E slides of the excised specimens were evaluated by a pathologist. RESULTS: A total of 39 consecutive transgender male patients underwent neourethral stricture repair between January 2014 and October 2019. The mean age was 38 years (23-61 years). Of those patients, 31/39 (79%) had prior phalloplasty and 8/39 (21%) had prior metoidioplasty. All patients had documented history of prior vaginectomy at the time of their initial genital affirmation surgery at other institutions. During neourethral stricture repair, a total of 15/39 (38%) were found to have a vaginal cavity remnant requiring re-excision and re-obliteration. These cavities were found in 12/31 (39%) of phalloplasty patients and 4/8 (50%) of metoidioplasty patients. Pathological evaluation of all 15 vaginal cavity remnants demonstrated the presence of vaginal epithelium. Additional findings included chronic inflammation (11), fibrosis (8), granulation tissue (2), microabscesses (1), calcification (1) and multinucleated giant cells (1). CONCLUSIONS: A high percentage of transgender men with neourethral strictures present with vaginal cavity remnants despite prior reports of vaginectomy. Pathological evaluation confirms that all vaginal cavity remnant specimens contain vaginal epithelium that was either not completely excised or regenerated. While the implications of this residual vaginal epithelium requires further investigation, total removal of vaginal tissue primarily or during reconstruction is important to possibly avoid a vaginal cavity remnant. Source of Funding: None

Stented versus Non-Stented Snodgrass Urethroplasty for Distal Hypospadia Repair

Background: Hypospadia is one of the most common congenital anomalies in children. Patients with distal hypospadias can be treated successfully with a tubularized incised plate (TIP) urethroplasty, usually with a postoperative urethral stent to divert urine into the diaper or a urine bag for approximately 1 week. However, these stents have their own morbidity and complications. We therefore tried to determine the safety of distal penile hypospadias repair without the use of a postoperative stent. Patients and Method: Fifty patients with distal penile hypospadias were prospectively assessed from May 2016 to August 2018. All patients underwent Snodgrass urethroplasty by the same surgeon. Half of the patients had a postoperative stent for 1 week. The other half had no stent. Clinical follow-up was over 6 months with an emphasis on possible stent-related complications. Results: Fifty children underwent TIP urethroplasty for distal hypospadia repair. The mean age was 5.9 years (range 2–12). In 25 cases, a stent was removed within 1 week. In the other 25 cases, no postoperative stent was placed. The overall complication rate for the stented group was 48% (n = 12) and for the non-stented group 68% (n = 17), respectively. In the stented group, 1 patient (4%) developed a fistula, whilst there were 2 (8%) in the non-stented group. All fistulas were repaired after 6 months postoperatively. Neourethral stenosis and glans dehiscence occurred in each 1 case (4%) in both groups. Differences were not statistically significant. However, there were significantly more wound infections in the stented group. On the other hand, stents prevented temporary urinary retention which occurred in 2 patients in the non-stented group. Conclusion: Despite the limited number of cases, our study suggests that, all in all, there is no significant difference in severe complication rates regardless whether a postoperative stent is used or not.

Comprehensive evaluation of grafting the preservable narrow plates with consideration of native plate width at primary hypospadias surgery

Dorsal inlay graft urethroplasty using inner-face preputial graft was described as an adjunct method to the classic tubularized incised plate (TIP) urethroplasty, aiming at reducing the risk of neourethral stenosis. To evaluate the impact of dorsal inlay grafting of preservable narrow plates, in relation to native plate width. Consecutive children with penile hypospadias with narrow plate (width<8mm) were evaluated prospectively between Jan 2014 and Jun 2018. Included cases were stratified into two groups: group A (plate width: 4 to <8mm) and group B (plate width: < 4mm). All cases were approached by TIPurethroplasty, with dorsal inlay grafting (inner-face prepuce). Cases with significant chordee (non-preservable plates), circumcised cases, and redo cases were excluded. A total of 104 hypospadias cases with narrow plates were included in this study. Among group A (n=81), the need for postrepair urethral dilations was reported in two cases (2.5%) vs seven cases (30%) in group B (n=23) (P-value<0.001). Another two cases (2.5%) in group A developed urethrocutaneous fistulae vs three cases (13%) in group B (P-value=0.0624). Surgical repair of the reported five cases with fistulae, revealed an ample neourethral wall; disclosing well-taken grafts in both groups. Few published studies evaluated grafting the incised plate in penile hypospadias. To the authors knowledge, this is the first study that selectively evaluated the impact of grafting narrow plates in relation to its native pre-incision width. According to the presented authors' experience, 4mm width is the border line of clinical relevance that defines poor urethral plate. Grafting that plate failed to compensate for its native poor characteristics; however, it offered a valuable neourethral wall that proved indispensable when redo surgery deemed necessary, without adding grafting-related problems. Nevertheless, further extended comparative studies came across as a necessity to verify the long-term outcomes of grafting the incised poor plates.

Применение никелид титановых стентов у детей со стриктурами уретры после первичных уретропластик

Gipospadia is one of the most common genital malformation in male children, that cause amount of urethroplasty. Urethral stricture is one of the most frequent complications after urethroplasty. The objective of the study was to compare two methods of management of neourethral strictures: internal optical urethrotomy (IOU) and IOU + urethral stenting. Patients and methods. 28 patients with urethral strictures were included in the prospective randomized study. All patients had a special urological investigation, consisted of uroflowmetry, urethrography and urethroscopy. Most of strictures were located in penile urethra. The length of stricture was from 1 mm to 5 mm in different patients. All patients had only single stricture. After randomizing, for one half of patients internal visual urethrotomy was performed and for another half of patients internal visual urethrotomy was performed with one-time stenting using individual prepared titanium nickelide stent. Stent was in urethra for 14–21 days. After it had been evacuated from urethra and uroflowmetry and urethrography were performed. Results. All patients in research group have good results of uroflowmetry after treatment. The results of urethrography and urethroscopy have also showed that there were no urethral strictures. The longest follow-up has lasted for 3 years. The efficiency of treatment is 93%. In one case repeated procedure was required. Conclusion. All things considered, it is reasonable to assume that stenting of urethra after internal visual urethrotomy has good outcomes, and seems like a very perspective minimally invasive way of treatment of urethral stricture. Key words: children, internal visual urethrotomy, titanium nickelide stent, urethral stricture

Cystoscopic-assisted laparoscopic excision of prostatic utricle

We present a video of our technique for resection of a large prostatic utricle (PU) in a patient who presented initially with disordered sexual development. His karyotype was 46XY, and phenotypically had penoscrotal hypospadias, bifid scrotum, and retractile right testis. An initial micturating cystourethrogram (MCUG) demonstrated the utricle but failed to cannulate the bladder. Being asymptomatic, we carried out staged repair of his hypospadias. Later, he started to have recurrent epididymo-orchitis with resistance to multiple antibiotics. Examination under anaesthesia was done and ruled out meatal or neo-urethral strictures. A subsequent MCUG demonstrated the large utricle and its relation to the bladder. We carried out a cystoscopic-assisted laparoscopic excision. There has been no consensus about the best surgical approach to resect a PU and most known procedures involved extensive pelvic dissection and carried a significant risk of damage to the pelvic nerves. The laparoscopic approach seems to be promising in this field as it provides proper view of the deep pelvis with reasonable magnification, less dissection and shorter postoperative pain and scarring. Cystoscopic assistance in this technique was a great addition to provide counter-traction movement and facilitate proper dissection.

Tubularized incised plate urethroplasty for distal and midpenile hypospadias reoperation: A single institute experience

Objective: Our study aimed to evaluate our experience in tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Patients and methods: This was a retrospective study in which we reviewed the medical records of 56 patients who underwent tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Tubularized incised plate urethroplasty was performed using a surgical technique like the primary tubularized incised plate repair based on the Snodgrass’s method. We recorded complications and functional outcomes of redo procedures. Results: We reviewed 56 patients who ranged in age from 2–16 years (mean 7.02±3.8 years). The overall complication rate was 33.9% ( n=19). Eight patients (14.3%) had fistula, six had meatal stenosis (10.7%), four had dehiscence (7.1%), and one had neourethral stenosis (1.8%). The complications occurred in 13 of mid-penile cases representing 50% of mid-penile cases but occurred in six cases of distal-penile cases (20%). The success rate of tubularized incised plate urethroplasty reoperation was 94.6% after repair of fistula and meatal stenosis by simple closure of fistula and meatoplasty. Conclusion: Tubularized incised plate urethroplasty is a safe and effective alternative procedure for hypospadias reoperations. The outcome is favorable if the urethral plate has no scars and with distal meatal location. The complication rate increases if the third redo is done and with midpenile meatal location.

Repair of stenosed neourethra using the proximal neourethral diverticulum – A technique in redo hypospadias surgery

Neourethral diverticulum secondary to distal neourethral stenosis is not uncommon after proximal hypospadias repair. We describe a technique using the neo urethral diverticular roof and overlying skin as a composite flap to reconstruct the urethral stenosis distal to the diverticulum. The composite flap is advanced distally for reconstruction of the stenosed urethra either as a tube or as an onlay. Urethra at the diverticular bed is tubularized to reduce its caliber. This technique has yielded excellent results in three children. The tissue expansion caused by the obstructed urinary stream has been utilized to correct both neourethral diverticulum and stenosis.

Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias.

To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique. We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra. There were 52 patients each in Cohort One (DD, n=52) and Cohort Two (DESP, n=38; TV, n=14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28months, 36 patients (34.6%) developed 47 complications including fistula (n=19; 18.3%) and neourethral dehiscence (n=4; 3.8%). Cohort One patients had significantly more fistula (28.8 vs 7.7%; p=0.005) and neourethral dehiscence (7.7 vs 0%; p=0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture. Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.

The success of tubularized-incised plate urethroplasty in adults and children.

PurposeHypospadias repair is rarely performed in adults. It is believed that the success rate is lower in adulthood. We aimed to compare the success rate of primary hypospadias repair with tubularized-incised plate (TIP) urethroplasty in adults and children.Patients and methodsThe databases of consecutive boys and adults who were treated with TIP urethroplasty for primary hypospadias between 2012 and 2015 were evaluated. All operations in the boys and adult patients were performed by a single surgeon. We considered urethroplasty complications to include a urethrocutaneous fistula, neourethral stricture, meatal stenosis, diverticulum, and glans dehiscence. Urine flow was also evaluated using uroflowmetry.ResultsSeventy-seven consecutive patients underwent surgery by a single surgeon in the last 3 years for hypospadias repair. Nineteen of these patients were adults. Urethrocutaneous fistulae developed in 2 of the 19 (10.5 %) adults, and 3 of the 58 (5.2 %) boys. In addition, there were urinary tract infections in 2 (3.4 %) children, meatal stenosis in 1 (1.7 %) child, and glans dehiscence in 1 (5.3 %) adult. Uroflowmetry was normal in all patients. There was no difference in outcomes between boys and adults.ConclusionOur data showed that the success rate of hypospadias repair with TIP urethroplasty is similar in adults and children. TIP urethroplasty is associated with good results in adults and boys.

Our experience of proximal hypospadias repair using the Cloutier-Bracka technique at the Gynaeco-Obstetric and Paediatric Hospital, Yaounde-Cameroon.

Background:In parts of Africa, routine circumcision is practised and sometimes even on children with hypospadias. The lack of preputial foreskin renders urethroplasty more difficult and often requires to use of a mucosal graft as described by Bracka.Objective:The authors describe their experience of hypospadias repair using Bracka's technique.Materials and Methods:Over a period of 5 years, 100 cases of proximal hypospadias were operated in our institution. All patients aged 0–18 years who had already been circumcised were included in this study.Results:The outcome of the 12 cases operated according to Bracka's technique was analysed. The mean age was 11.5 years. The ectopic meatus was penoscrotal in three cases, scrotal in one case and perineal in eight cases. After reconstruction, the new meatus was sutured at the top of the glans in one case, at the prepuce in seven cases and at the penile midshaft in one case. The main complications noted were surgical site infection, wound dehiscence, residual chordee and urethrocutaneous fistula. No neourethral stenosis nor uretrocele was recorded.Discussion:The buccal mucosal graft urethroplasty as described by Bracka is associated with a lower risk of meatal strictures compared to other free mucosal grafts. The buccal mucosa is easier to harvest and causes less scarring than bladder mucosa.Conclusion:Repair of severe hypospadias remains a challenge for paediatric surgeons. The functional and cosmetic outcomes depend on the choice of the donor site for the graft and objective assessment of successful reconstruction criteria during follow-up.