Primary Distal Hypospadias Research Articles

An evaluation study examining penile bacterial flora in boys undergoing hypospadias surgery with foreskin reconstruction

ABSTRACTHypospadias surgery with foreskin reconstruction is an increasingly preferred option for the management of this common condition. The objective of this study was to identify the bacterial flora present before and after cleansing of the prepuce as well as 7 d after surgery. Sixty‐three boys aged between 12–14 months, with primary distal hypospadias undergoing tubularized incised plate repair, were recruited between October 2013 and April 2014. Microbiological swabs were taken pre‐ and post‐operatively to identify organisms present under their foreskin at the time of surgery and compared with organisms present 7 d post‐operatively at the time of dressing removal. A parent reported wound infection tool was used to explore parents' perception and management of their son's wound 4 weeks following surgery. Bacterial colonization of the penis was common. Routine cleansing with an alcoholic chlorhexidine solution reduced bacterial flora in 82% of boys with a positive preoperative swab result. Post‐operative colonization of the penis was found in 93% of patients, wound dressing colonization was common. Two parents' reported concerns regarding their son's wound healing. Topical cleansing at the time of surgery is effective in reducing the number of organisms present under the foreskin. Despite recolonization 7 d after surgery, clinical infection remains uncommon. Complication rate 12 months after surgery was very low <2%.

Selecting the right method for hypospadias repair to achieve optimal results for the primary situation.

Background Over the past two decades, Snodgrass tubularized incised plate (TIP) urethroplasty has become one of the dominant surgical techniques with wide applications and excellent cosmetic results. However, TIP has many limitations. We performed a retrospective study at our department and assessed the outcome of the inlay internal preputial graft for extending the applications of TIP.MethodsBetween January 2009 and December 2013, we performed a retrospective study consisting of approximately 508 primary distal and moderate cases. Patients with primary distal hypospadias who had mild or no chordee and good penile development were divided into the following 3 groups based on their procedures: (1) classic TIP hypospadias repair group (n = 198); (2) inlay buccal mucosa graft group (n = 150); and (3) inlay internal preputial graft group (n = 160). The median age was 1.6 years (range 1–4 years). Our data were analyzed statistically by the Chi square test with P < 0.05 indicating significant differences. ResultsThe mean follow-up period was 18 months (range 6‒24 months). In the classic TIP group, the incidence of urinary fistula and meatal stenosis were both 3.0 % (6/198); in the inlay buccal mucosal graft group, the incidence of urinary fistula was 3.3 % (5/150), and the incidence of stenosis was 2.7 % (4/150); and in the inlay internal preputial graft group, the incidence of urinary fistula was 3.1 % (5/160), and the incidence of meatal stenosis was 4.4 % (7/160). The success rates of each group were as follows: the classic TIP group has a success rate of 93.9 % (186/198); the inlay buccal mucosa graft group had a success rate of 94.0 % (141/150); and the inlay internal preputial graft group had a success rate of 92.5 % (148/160). There were no statistically significant differences between the 3 groups with respect to complication rates.ConclusionsAs the inner foreskin Snodgraft does not appear to be worse than the buccal mucosa graft, it is a good method for hypospadias repair, and this method is not inferior to TIP.

Vascularized dorsal dartos flap to prevent fistula in tubularized incised plate urethroplasty for primary distal and mid shaft hypospadias

The aim of the present study was to evaluate the importance of neourethral covering using vascularized dorsal flap for preventing fistula in Tabularized incised plate (TIP) urethroplasty. The study included 52 children (aged 2-10 years) who had hypospadias repaired including 44 with distal and 8 with mid shaft hypospadias. In all children, a standard tabularized incised plate urethroplasty was followed by reconstruction of new surrounding urethral tissue. A longitudinal dartos flap was harvested from excessive dorsal preputial and penile hypospadiac skin and transposed to ventral side by a buttonhole maneuver. It was sutured to the glans wings and the neomeatus and to the corpora covernosa over the neo-urethra. Thus the new urethra was completely covered with well-vascularzed subcutaneous tissue. At a mean follow-up of 18 months, the result was successful with no fistula or urethral stenosis, except 2 of the mid penile hypospadias. All patients had good functional and cosmetic results with straight penis and vertical slit shaped meatus at the tip of the penis. The 2 patients developed tiny fistula, which were closed spontaneously after meatal dilatation. In conclusion, urethral covering should be part of TIP urethroplasty. A dorsal well-vascularized dartos flap, button holed ventrally is a good choice for preventing fistula for distal and mid shaft hypospadias.

Tubularised incised-plate versus tubularisation of an intact and laterally augmented plate for hypospadias repair: A prospective randomised study

ObjectivesTo compare the outcome of hypospadias repair using tubularised incised-plate (TIP) urethroplasty and tubularisation of an intact and laterally augmented urethral plate. Patients and methodsThis prospective randomised study included 370 patients with primary distal hypospadias. All had urethral plate widths of 8–10mm and a glans of ⩾15mm. Exclusion criteria were previous repair, circumcision, a wide urethral plate of >10mm or a narrow plate of <8mm in diameter, a small glans of <15mm in diameter, chordee of >30°, and hormonal stimulation. Patients were randomised into two groups: Group 1 (185 patients) underwent TIP urethroplasty and Group 2 (185 patients) underwent tubularisation of the intact plate with lateral augmentation of the urethral plate using penile skin. The follow-up period was 12–28months. ResultsThere were 172 evaluable patients in Group 1 and 177 in Group 2. The urethroplasty was successful in 83.2% and 94.4% in Groups 1 and 2, respectively. Complications occurred in 16.8% in Group 1 and 5.6% in Group 2 (P=0.001). Meatal stenosis occurred in 7% and 3.4% in Groups 1 and 2, respectively (P=0.130). There were statistically significant differences in the wound dehiscence, fistula, and re-operation rates of Group 1 versus Group 2, at 6% versus 0%, 9.8% versus 2.8%, and 13.4% versus 5.6%, respectively. The presence of mild chordee did not affect the complication rate (P=0.242). The mean (SD) operative time was 56.7 (8.9) min in Group 1 and 93.7 (8.3) min in Group 2 (P<0.001). ConclusionThe outcome of tubularised intact and laterally augmented plate is better than classical TIP urethroplasty of hypospadias. Further trials are mandatory to extend the indications of the technique.

Parental Decisional Regret after Primary Distal Hypospadias Repair: Family and Surgery Variables, and Repair Outcomes

Decisional regret is defined as distress after making a health care choice and can be an issue for parents electing distal hypospadias repair for their sons. We assessed the influence on decisional regret of variables related to the family, surgery and outcomes. Charts for 372 patients undergoing primary distal hypospadias repair between 2005 and 2012 were reviewed, and validated questionnaires, including the Decisional Regret Scale, Pediatric Penile Perception Score and Dysfunctional Voiding and Incontinence Scoring System, were administered to parents. Data were available for 172 of 372 families (response rate 46.2%). Of 323 parents 128 (39.6%) presented with moderately strong decisional regret, with good agreement within couples. Predictors of decisional regret included intermediate parental educational level (OR 3.19, 95% CI 1.52-6.69), patient not being the first born (OR 2.01, 95% CI 1.07-3.78), family history of hypospadias (OR 4.42, 95% CI 1.96-9.97), initial desire to avoid surgery (OR 2.07, 95% CI1.04-4.12), younger age at followup (OR 0.81, 95% CI 0.72-0.91), presence of lower urinary tract symptoms (OR 4.92, 95% CI 1.53-15.81) and lower Pediatric Penile Perception Score (OR 0.86, 95% CI 0.75-0.99). Decisional regret was unrelated to parental desire to avoid circumcision, surgical variables, development of complications and duration of followup. Decisional regret is a problem in a significant proportion of parents electing distal hypospadias repair for their sons. In our experience family variables seemed to be predictors of decisional regret, while surgical variables did not. Predictors of decisional regret included worse parental perception of penile appearance and the presence of lower urinary tract symptoms. However, the latter could be unrelated to surgery. Irrespective of the duration of followup, decisional regret seems decreased in parents of older patients.

Long-term functional outcomes of distal hypospadias repair: A single center retrospective comparative study of TIPs, Mathieu and MAGPI

Tubularized Incised-Plate (TIP) urethroplasty is currently the preferred technique for distal hypospadias repair. Nevertheless, concerns have been raised on the long-term functionality of the reconstructed neourethra. The aim of this study is to evaluate long-term uroflowmetry parameters' evolution after TIP surgery over a long-term follow-up including the adolescent period. TIP patients were compared to normal children using established Miskolc nomograms, as well as to patients who underwent Mathieu and Meatal Advancement and Glanuloplasty (MAGPI) surgery repairs for distal hypospadias. Files from patients who underwent primary distal hypospadias repair at our institution between January 1, 1997 and January 31, 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (TIP vs. Mathieu vs. MAGPI) was performed according to the following postoperative time interval endpoints: 0-6 months, 6-12 months, 12-24 months, 24-48 months, 4-6 years, 6-10 years and >10 years. Maximal urinary flow rate (Qmax) in relation to Voiding Volume (VV) adjusted for Age or Body Surface Area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques. 153 patients met the inclusion criteria: 70 (43%) TIP, 24 (17%) Mathieu and 59 (35%) MAGPI. Overall, Qmax increases progressively according to time and age and in particular during the period covering adolescence with a similar trend regardless of the type of surgery. Uroflowmetry profiles in terms of Qmax, VV and PVR were equivalent between surgeries at each examined time point. At 10 years of follow-up postopertively, mean Qmax were 17.2 ml/s, 18.8 ml/s and 21.6 ml/s respectively with no significant difference detected between groups (p = 0.344). Compared to normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax< 5th percentile of nomograms was more prevalent in patients aged 2-7 years old at 60% but decreased to less than 10%in patients aged >13 years for all procedures combined (see abstract figure) but without detected differences between surgery types (p = 0.276). After sub-optimal obstructive maximal urinary flows in the early postoperative period, hypospadias patients treated with TIP exhibit favourable long-term evolution with age and during adolescence in particular compared to normal children. In addition, a similar trend was found for patients treated with Mathieu and MAGPI with no significant differences detected between procedures. Nevertheless, because of the relatively small sample size we cannot exclude that a statistical difference between surgeries would have been detected if the study was adequately powered on every endpoint. Nevertheless and also as suggested by the values obtained, this potential difference may be quite small and not clinically relevant. These results suggest that the obstructive urinary flow pattern observed in patients early on is possibly an intrinsic feature associated to the malformation itself and may be less of a consequence of the surgical technique.

Role of the urethral plate characters in the success of tubularized incised plate urethroplasty.

Background:Today, tubularized incised plate (TIP) urethroplasty is the most commonly performed operation for distal and mid-penile hypospadias. Reports from different centers worldwide confirm its nearly universal applicability and low complications rate.Aim:Evaluation of the urethral plate characters and its effect on the outcome of TIP urethroplasty.Materials and Methods:Between 2010 and 2013, 100 children with primary distal penile hypospadias underwent TIP urethroplasty. Urethral plates were categorized as flat, cleft, and deeply grooved. Postoperatively, patients were followed-up for evaluation of meatal stenosis, fistula formation, and glandular dehiscence at 1st, 3rd and 6th months. Patients were followed-up for urethral calibration by urethral sound 8 Fr at 3rd and 6 months follow-up. Data were statistically analysed using Epi info program to correlate between the width, plate shape, and complications.Results:Mean age at surgery was 4.3 years. Patients were followed-up for an average period of 6.4 months. Pre-operative location of the meatus was reported as coronal in 46, subcoronal in 50 and anterior penile in 4 cases. Urethral plate characters were flat in 26 cases, cleft in 52, and deeply grooved in 22. Urethral plate width was >8 mm in 74 cases and <8 mm in 26. Patients with urethral plate <8 mm had a statistically significant higher fistula rate (P = 0.004) and failed 8 Fr calibrations in 26.9% (P = 0.01) compared with the patients with urethral plate >8 mm. In addition, we also founds higher fistula rate and failed 8 Fr calibrations in flat urethral plate.Conclusions:An adequate urethral plate width (>8 mm) is essential for successful TIP repair. Lower success rates with flat plates may need buccal mucosal augmentation to improve the results.

Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes

ObjectivesTo objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score. Patients and methodsIn a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3months after surgery, the flow pattern, maximum (Qmax), and mean urinary flow rate (Qave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system. ResultsThe native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5–14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3–24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3–14) years showed an abnormal Qmax below the fifth percentile in four (15%), with the Qave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13–16). Two patients had a small, single subcoronal fistula. ConclusionExtending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.

Two different suturing techniques in distal hypospadias repair using tubularized incised plate urethroplasty

Background: Hypospadias is one of the most common congenital anomalies, occurring in Bone of 200 to one of 300 live births. Tubularized incised plate (TIP) urethroplasty or the Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair because of its low complication rate and technical simplicity. Objective: We compared two refinements in TIP repair for primary distal hypospadias, namely, a subcuticular uninterrupted suturing technique and full-thickness interrupted sutures. In addition, we compared the impact of these surgical modifications on the complication rate and surgical outcome of the Snodgrass procedure. Patients and methods: Eighty boys with primary distal hypospadias were treated using the TIP procedure between January 2009 and December 2011. Patients were prospectively randomized into two equal groups on the basis of the suturing technique. A neourethra was constructed using a subcuticular uninterrupted suturing technique (group A) or using full-thickness interrupted sutures (group B). All patients were subjected to the same preoperative, operative, and follow-up protocols. Both groups were compared as regards the complication rate. Results: The age ranged between 8 and 48 months, with a mean age of 13.6 ± 6.9 months at the time of repair. The overall success rate was 90% (97.5% for group A and 82.5% for group B). Late complications in the form of a urethrocutaneous fistula, meatal stenosis, and wound dehiscence or infection developed in eight (10%) patients (one patient of group A and seven of group B). The mean follow-up duration was 8.1 ± 2.4 months (range 4–13 months). Conclusion: The subcuticular uninterrupted suturing technique seems to have a lower complication rate when compared with the use of full-thickness interrupted sutures in the repair of distal hypospadias by TIP urethroplasty. Keywords: Hypospadias, Tubularized Incised Plate, Urethroplasty

Combined use of Mathieu and incised plate technique (Snodgrass technique) for repair of distal hypospadias in older children

ObjectivesTo evaluate the results and complications after combined use of Mathieu and incised plate technique for management of distal hypospadias in older children. Patients and methodsA total of 33 patients with primary distal penile hypospadias were operated upon using the Mathieu technique combined with deep urethral plate incision (Snodgrass technique). Each patient was evaluated according to the site of original urethral opening, original urethral stenosis, the presence and degree of chordee. The operative and postoperative results and complications were reported. Follow up of the patients was done weekly for 3 weeks postoperatively and then every month for at least 1 year. ResultsThe mean age was 6.5±2.5 years (range 6–9 years). Bleeding was reported in one case. Wound infection was reported in two cases. Forcible slippage of stent occurred in one case. Meatal stenosis occurred in two cases and urethrocutaneous fistula occurred in one case. No urethral stenosis was reported in any of the patients. ConclusionCombined use of Mathieu and incised plate technique is suitable for primary distal hypospadias in older children with original meatal stenosis.

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.

One-step techniques for primary distal hypospadias in children and adolescents

One-step techniques for primary distal hypospadias in children and adolescents

Predictors of Secondary Surgery After Hypospadias Repair: A Population Based Analysis of 5,000 Patients

The literature on secondary surgery after hypospadias repair is limited. We determined risk factors for secondary surgery via a population based approach. We used a hospital consortium database to identify a population that underwent hypospadias repair in 2009 and 2010. Specifically meatal advancement and glanuloplasty, distal, proximal and perineal hypospadias repairs were evaluated. Secondary surgeries performed between 2009 and 2011 were captured and the variables of age at primary surgery, insurance, region and surgeon volume were measured. Mixed effects logistic regression analysis was used to analyze independent variables associated with secondary surgery. We identified 5,326 subjects who underwent primary hypospadias repair by 114 surgeons at 47 hospitals in 2009 and 2010. Distal hypospadias repair is associated with a 9% secondary surgery rate. After adjusting for other factors every additional 10 distal repairs that a surgeon performed yearly was associated with a 29% decreased risk of requiring fistula, stricture or diverticulum repair. There were regional differences for secondary surgery following meatal advancement and glanuloplasty and distal repairs. Finally, each additional year of patient age at distal repair was associated with a 15% increased risk of requiring secondary cystoscopy and a 21% increased risk of requiring urethral dilation/incision. This population based study produced significantly different results than small studies of select patients and techniques. Distal hypospadias repair is associated with a 9% secondary surgery rate. Low surgeon volume independently increases the risk of fistula, stricture or diverticulum repair. Increased patient age at primary distal hypospadias repair increases the risk of cystoscopy and urethral dilation/incision.

“Snodgraft” Technique for the Treatment of Primary Distal Hypospadias: Pushing the Envelope

“Snodgraft” Technique for the Treatment of Primary Distal Hypospadias: Pushing the Envelope

Primary Severe Hypospadias: Comparison of Reoperation Rates and Parental Perception of Urinary Symptoms and Cosmetic Outcomes Among 4 Repairs

We compared complication rates, urinary symptoms and cosmetic outcomes as perceived by parents of patients undergoing 1 of 4 repairs for proximal hypospadias associated with ventral curvature. A total of 93 patients underwent hypospadias repair between 2004 and 2010. In patients requiring no urethral plate transection the repair consisted of tubularized incised plate urethroplasty (26 patients) or onlay island flap urethroplasty (31). In patients requiring urethral plate transection the repair consisted of onlay island flap on albuginea (18 patients) or 2-stage repair (18). Complications were assessed by chart review. A customized questionnaire and the Pediatric Penile Perception Score were administered to parents to evaluate their perception of urinary symptoms and cosmetic outcomes, respectively. After a median followup of 4.5 years (range 2.2 to 8.4) complications developed in 21 patients (23%) without any difference among procedures or between patients who did and did not require urethral plate transection. Parents of 75 patients (80%) participated in the survey without differences among repairs (p = 0.35). Reported urinary symptoms were not different among repairs. For Pediatric Penile Perception Score the only difference concerned the question about penile length (p = 0.03), with the score being significantly better for the techniques requiring urethral plate transection (p = 0.05). The 2-stage repair had a significantly better score for the question about penile length and overall Pediatric Penile Perception Score than all other techniques. Overall complication rates were comparable among repairs and did not increase after urethral plate transection. Urinary symptoms as reported by parents were comparable among the procedures. Perceived penile length was significantly better after urethral plate transection. The 2-stage repair yielded the best cosmetic results.

Single vs. double dartos layers for preventing fistula in a tubularised incised-plate repair of distal hypospadias

ObjectiveTo compare the outcome of a single vs. a double-layer dartos interposition for preventing a fistula after tubularised incised-plate (TIP) distal hypospadias repair. Patients and methodsWe retrospectively reviewed the records of patients with primary distal hypospadias who had the hypospadias repaired between February 2009 and June 2011, operated by one surgeon (S.A.K.). In all of the children a standard TIP urethroplasty was performed, which was covered by a dartos fascial flap fashioned using one of two techniques, i.e. in Group I (48 patients) double dartos preputial flaps were used, and in Group II (52 patients) a single dorsal dartos flap was used and transposed ventrally via a ‘buttonhole’. The fistula rate and other complications related to each group were recorded. ResultsThe mean (range) follow-up was 12 (6–22) months for Group I and 14 (6–24) months for Group II. The result was considered a success in 96% of Group I and 92% of Group II. In Group I there were no fistulae, while in Group II there were four fistulae (8%) detected; this difference was statistically insignificant (P=0.1). Meatal stenosis was associated with a fistula in one patient in Group II but not in the other three. In Group I a meatal stenosis developed late after complete healing of the urethroplasty, with no associated fistula. The repair broke down in one patient in Group I (2%). ConclusionA double-dartos neourethral cover in TIP hypospadias repair seems to be more effective than a single layer for preventing a fistula, despite there being no statistically significant difference between the groups. However, the protective effect of double-dartos flaps must be appropriately evaluated in a prospective, randomised and controlled study in more patients.

“Snodgraft” Technique for the Treatment of Primary Distal Hypospadias: Pushing the Envelope

"Snodgraft" modification has been proposed to reduce the risk of meatal/neourethral stenosis in distal hypospadias. We applied the Snodgraft technique by using inner preputial graft in primary distal hypospadias repair. A total of 102 consecutive patients undergoing the Snodgraft procedure were prospectively studied between 2006 and 2011. Mean patient age was 7.2 years. Localization of the meatus was glanular in 5 patients, coronal in 49, subcoronal in 45 and mid penile in 3. In all patients the posterior urethral plate was incised, and the graft harvested from the inner prepuce was sutured from the old meatus to the tip of the glans. A neourethra was created over a urethral catheter using 6-zero polyglactin suture. An interpositional flap was laid over the urethra as a second barrier. All patients were followed at 3 to 6-month intervals for cosmetic and functional results. At a mean of 2.4 years of followup no patient had meatal stenosis or diverticulum at the inlay graft site. However, urethrocutaneous fistula was observed in 10 patients (9.8%). A slit-like appearance of neomeatus was achieved in all patients. During followup no obstructive urinary flow pattern was detected, and early and long-term maximum urine flow rates were comparable. No meatal/neourethral stenosis was observed in any patient undergoing a Snodgraft procedure. A randomized trial will be needed to prove that the incidence of meatal/neourethral stenosis is lower after Snodgraft repair compared to routine tubularized incised plate repair.

This Month in Pediatric Urology

No AccessJournal of UrologyThis Month in Pediatric Urology1 Sep 2012This Month in Pediatric Urology Laurence S. Baskin Laurence S. BaskinLaurence S. Baskin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.06.052AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Adult care of children from pediatric urology: part 2. J Urol2012; 188: 717. Link, Google Scholar 2 : Adult care of children from pediatric urology: part 1. J Urol2012; 187: 1164. Link, Google Scholar 3 : Preoperative assessment of neurovesical function in children with anorectal malformation: association with vertebral and spinal malformations. J Urol2012; 188: 943. Link, Google Scholar 4 : Long-term bladder function followup in boys with posterior urethral valves: comparison of noninvasive vs invasive urodynamic studies. J Urol2012; 188: 953. Link, Google Scholar 5 : Effect of extracorporeal shock wave lithotripsy on kidney growth in children. J Urol2012; 188: 928. Link, Google Scholar 6 : Usefulness of concomitant autologous blood and dextranomer/hyaluronic acid copolymer injection to correct vesicoureteral reflux. J Urol2012; 188: 948. Link, Google Scholar 7 : Robot-assisted laparoscopic reoperative repair for failed pyeloplasty in children: a safe and highly effective treatment option. J Urol2012; 188: 932. Link, Google Scholar 8 : “Snodgraft” technique for the treatment of primary distal hypospadias: pushing the envelope. J Urol2012; 188: 938. Link, Google Scholar © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 188Issue 3September 2012Page: 689-691 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laurence S. Baskin More articles by this author Expand All Advertisement PDF downloadLoading ...

The slit-like adjusted Mathieu technique for distal hypospadias

PurposeThe aims of this study were to describe the slit-like adjusted Mathieu technique (SLAM) for distal and midpenile hypospadias and report the midterm follow-up. Materials and MethodsBetween January 2005 and December 2009, the SLAM technique was performed in 923 patients. The key modification is the design of a converging incision and the technique of suturing. Patient age ranged between 4 months to 30 years (mean, 1.5 years). The records of 872 patients who maintained regular follow-up were reviewed. The technique was performed in all forms of distal hypospadias, regardless of the size of the glans or the degree of glans clefting. Cutaneous chordee was corrected by skin mobilization. Follow-up period ranged from 22 months to 6 years (mean, 38 months). A transurethral catheter was used for 1 to 3 days. Results and ComplicationsSatisfactory results were obtained in 848 patients (97%). Fourteen patients developed fistulae. Four patients developed meatal stenosis. Six patients had wound dehiscence. ConclusionsThe SLAM technique is a reliable technique for correction of distal and midpenile hypospadias with persistent good results. It avoids the drawbacks of the classic Mathieu (a transverse rounded meatus that is not terminal). Multiple-layer closure and careful attention to technical details contributed to a 3% complication rate in primary distal hypospadias.

Multicentric experience on double dartos flap protection in tubularized incised plate urethroplasty for distal and midpenile hypospadias

We report a multicenter experience using double dartos flap to protect the neourethra in TIP urethroplasty for distal and midpenile hypospadias. A total of 394 patients underwent tubularized incised plate urethroplasty for primary distal and midpenile hypospadias using double dartos flap protection by ten pediatric surgeons and urologists at five different institutions. Tubularized incised plate urethroplasty protected by a double dartos flap was simple to perform and flaps were easy to obtain. Complications occurred in 23 patients (5.83%): fistulas 1.01% (4 cases), stenosis 0.25% (1 case), mild stenosis 2.53% (10 cases), dehiscence of ventral cutis 0.50% (2 cases) and penile torsion 1.26% (5 cases). All fistulae had a spontaneous resolution. Double dartos flap to protect tubularized incised plate urethroplasty is safe with a low complication rate. The neourethra is covered entirely with a double layer of vascularized tissue and the double coverage appears a good choice for preventing urethrocutaneous fistula formation.