Primary Distal Hypospadias Repair Research Articles

Snodgrass (tubularized incised plate) versus Mathieu repair of distal hypospadias: A systematic review and meta-analysis of randomized controlled trials.

Distal hypospadias accounts for the majority of hypospadias. Mathieu and Snodgrass techniques are widely used for repair of distal hypospadias but their comparative efficacy and reported outcomes are still debated. We conducted a systematic review and meta-analysis to compare the outcomes of these two techniques. Electronic databases and trial registries were searched for randomized controlled trials (RCTs) comparing Mathieu and Snodgrass techniques for primary distal hypospadias repair. Outcome measures included complication rates and cosmetic outcomes. Risk of bias assessment was performed using the ROB2. Data was analyzed using Review Manager 5.4; Trial Sequential Analysis (TSA) also was conducted for important outcomes. Twelve RCTs were eligible for inclusion. The Snodgrass technique showed a significantly lower incidence of urethrocutaneous fistula (UCF) (RR 0.48, 95% CI [0.30-0.77]). However, there was no significant difference in the incidence of meatal stenosis (MS) between the two (RR 1.64, 95% CI [0.85-3.15]). TSA supports the findings for outcome UCF but not for MS. Operative time was shorter with the Snodgrass technique. This SRMA indicates a lower incidence of UCF with Snodgrass technique compared to the Mathieu technique in distal hypospadias repair. However, there was no significant difference in the risk of MS.

Comparison of the efficacy and safety of dorsal inlay graft urethroplasty (DIGU) method with tubularized incised plate urethroplasty (TIPU) method in primary distal hypospadias repair: a systematic review and meta-analysis

Link of Video Abstract: https://youtu.be/r399GEt3guoIntroduction: Tubularized Incised Plate Urethroplasty (TIPU) is a technique that is widely used in distal hypospadias repair. The advantages possessed by this technique are better cosmetics, the meatus is at the tip of the penis, and the phallus is straight. Some researchers believe that a urethral plate with a size of less than 8 mm is unsuitable for the TIPU technique so augmentation with a graft using the dorsal inlay graft urethroplasty (DIGU) technique is needed. To date, there have been no systematic reviews and meta-analyses that have directly compared the efficacy and complications of DIGU and TIPU. Therefore, this study aimed to compare the effectiveness and complications of these two modalities for repair in primary distal hypospadias patients. Methods: This study is a systematic review study and meta-analysis. The protocol for conducting and compiling this study was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was performed on six databases: PubMed, Scopus, Web of Science, ProQuest, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov. The risk of bias in the study will be analyzed using the Cochrane Risk of Bias Tools for Randomized Trials version 2 (RoB 2). Results: Six studies that met the inclusion criteria were included in the meta-analysis with a total of 381 samples. The success rates (OR 1.46, 95% CI 0.74-2.87, p = 0.28) and urine output (OR 2.54, 95% CI 0.63-10.20, p = 0.19) were not significantly different, while the mean operating time (MOT) (SMD 1.96, 95% CI 1.10-2.82, p < 0.0001) was significantly shorter in TIPU (P < 0.05). The incidence of meatal stenosis was significantly more in TIPU than DIGU significantly (OR 5.11, 95% CI 1.46-17.92, p = 0.01), while fistula (OR 2.93, 95% CI 0.92-9.35, p = 0.07) and dehiscence (OR 3.05, 95% CI 0.81-11.45, p = 0.10) was not significantly different between the two techniques. Conclusion: TIPU has the advantage of shorter operating time but a higher incidence of meatal stenosis than DIGU.

The Use of Preputial Dartos Flap in the Primary Repair of Distal Hypospadias: A Single-centre Experience.

An additional flap during the tubularization of incised urethral plate urethroplasty (TIPU) is believed to minimize the postoperative complications. It is still debatable whether using an additional flap is worth the risk given the hazards associated with doing so. This study aims to re-evaluate the benefits and drawbacks of TIPU with or without a preputial dartos (PD) flap. We assessed the results of patients with distal hypospadias who underwent surgery in our institute over the past 2 years. The urethral plate's width, thickness, and depth, the periurethral tissue's quality, and the width of the glans at the mid-glans level determined whether the neourethra was covered with a PD flap or left uncovered. Data on intra-operative blood loss, operating time, length of hospital stay, postoperative complications, and outcome were analysed. There were 96 patients: 58 received an extra PD flap, whereas the other 38 did not. In the flap group, ventral skin necrosis was a prevalent problem, whereas meatal stenosis predominated in the no-flap group. Both the flap group (25.66%) and the no-flap group (23.86%) experienced comparable postoperative complications (P = 0.503). In comparison to the no-flap group, the flap group showed statistically significant differences (P<0.001) in intra-operative blood loss (22.10 ± 6.96 vs. 10.34 ± 3.02 mL), operating time (96.34 ± 6.661 vs. 71.39 ± 9.76 min), and hospital stay (10.04 ± 0.87 vs. 8.47 ± 1.64 days). The additional PD flap does not always affect the result of TIPU in terms of complications.

Distal hypospadias repair: Comparative study between snodgrass and transverse preputial onlay flap

Distal hypospadias repair has several operative strategies such as tubularized incised plate (TIP); Transverse preputial onlay flap (TPOF) and Modified Mathieu Procedure. The aim of our work is to compare between TIP and TPOF techniques in the outcome. We conducted this comparative study on 66 patients with different types of distal hypospadias divided in two groups A and B for TIP and TPOF respectively. We reported outcome and complications for both TIP and TPOF repair. Our results revealed mean operative time was significantly higher in group B (123.1±6.8min) than in group A (93.73±3.9min, P value<0.001). Postoperative urinary fistula was reported in group A (15.2%) while no fistula in group B (p value=0.05). The vertical slit appearance of meatus was better in group A (54.5%) than in group B (24.2%, P value 0.023). As regard to hypospadias objective scoring evaluation (HOSE) (Summary Figure) the meatal shape score was higher in group A (1.55±0.51) than in group B (1.24±0.44, p value=0.0l), the urinary stream score was significantly higher in group A (1.82±0.39) than in group B (1.97±0.17, p value=0.04) and the urinary fistula score was significantly higher in group A (3.79±0.60) than in group B (4±0, p value=0.04). Complications are more common after TIP than in TPOF. As regard the meatus shape, the naturally looking vertical slit like meatus was achieved more in the TIP than in TPOF. We advocate further studies with a large number of patients with a long follow up period. TPOF is a great option to consider in cases of distal hypospadias because it is an effective technique for primary distal hypospadias repair with a good cosmetic outcome and a low associated complication.

THE OUTCOME OF DOUBLE DARTOS VERSUS SINGLE LAYER FLAP IN SNODGRASS URETHROPLASTY FOR DISTAL HYPOSPADIAS REPAIR IN BASRA TRAINING CENTER OF UROLOGY

Hypospadias, a nomination of medical term which was derived from the Greek terms: hypo (under) and spadon (rent, fissure). It is one of the congenital abnormalities of the genitourinary tract. There are about 400 different procedures described for correction of this type of anomaly, but Tubularized Incised Plate (TIP) Urethroplasty is considered the most popular one, and there are multiple variations in this procedure to get high success rate and decrease the complications. In this study, we compare between single layer dartos flap versus double layer dorsal flaps in TIP urethroplasty. This is to assess the outcomes of double dartos flaps versus single layer flap in TIP urethroplasty for primary distal hypospadias repair in Basrah Teaching Center regarding the success rate, and to investigate the importance of double flaps in preventing possible complications in particular, urethral fistula. A cross sectional prospective study was done in Basra Teaching Hospital, between January 2018 to March 2020. A total of 50 boys, 2 to 10 year- old with coronal and sub coronal primary Hypospadias were treated with TIP urethroplasty (Snodgrass procedure) by one surgical team, who were referred to Basrah Teaching Hospital from private and outpatient clinics. Patients were divided into 2 groups: (group I: 25 patients) single layer Dartos flap & (group II: 25 patients) double layers of Dartos flaps. Six patients were missing during follow up, coincidentally 3 patients in each group. The mean age was 4.55 and 4.86 year for groups I, II respectively, the mean operative time was 88.81 and 91.86 minutes for group I & group II respectively. The success rate was (81%) and (86%) for group I, II respectively, with exception of complications which need re-do surgery. Urethrocutaneous fistula (UF) was developed in (22.7%) in group I, and in (4.5%) in group II. Bleeding was happened in 2 cases (9.1%) in group I and 3 cases (13.6%) in group II. Meatal stenosis was diagnosed in (9.1%) in group I and (13.6%) in group II. Glans dehiscence was seen in 1 case (4.5%) for each group. There was a significant difference between the two groups in the occurrence of UF (P = 0.001). According to our evidence in this study, double dartos flaps is easy to be harvested, safe procedure, and represents very good choice for UF prevention. Although the number of complicated patients regarding bleeding and meatal stenosis are higher in group II than group I but they were statistically insignificant. Keywords: Hypospadias, Urethroplasty, Tubularized Incised Plate (TIP), urethral fistula, dartos flaps.

Predictors of successful outcome of tubularized incised plate for primary distal hypospadias repair

BackgroundSeveral preoperative factors affect the outcome of Tabularized Incised Plate (TIP) repair. Our aim was to collect and analyze all these factors to define what the most important predictive factors are.MethodsHundred patients (1–5 years old) with primary distal hypospadias were included. Exclusion criteria included previous penile operations and hormonal treatment or associated congenital anomalies. Anogenital distance (AGD), stretched penile length (SPL), meatal site, glanular shape, chordee and torsion degree, plate width and glans meatus shaft (GMS) score were assessed. TIP repair was done to all patients and followed up for one year. The outcome was correlated with the above parameters.ResultsMean ± SD of age of patients was 3.5 ± 1.5 years, while weight was 14.1 ± 3.0 kg. Complication rate was 18% including urethrocutaneous fistula (UCF) and meatal stenosis 14%, repair breakdown 1% and urethral stricture 3%. Patients with chordee degree < 30° and distal penile meatal location were associated with increased risk for complications by 11.6 and 8.2 times; 95% CI was (1.46–91.75) and (1.02–66.52), respectively (p < 0.05 for each). Plate width ≥ 9 mm, AGD > 5 cm, GMS score ≤ 7 (p < 0.001 for each), age of patient ≤ 2 years old, and SPL > 3.5 cm (p < 0.01 for each) were associated with successful outcome of repair.ConclusionThe proposed successful criteria of TIP repair were absent chordee, coronal/subcoronal penile meatal location, plate width ≥ 9 mm, AGD > 5 cm, age of patient ≤ 2 years old, GMS score ≤ 7, SPL > 3.5 cm and grooved glanular shape.

Extended TIP vs. Standard TIP for primary distal hypospadias repair: randomized study for comparing functional and cosmetic outcomes

Objectives The aim of this study was to critically evaluate distal extension of the midline urethral plate incision, extended tubularized incised plate (e-TIP) technique, with the standard TIP and investigating predictors of functional and cosmetic success. Methods In a prospective study, consecutive patients with primary distal hypospadias presented for repair were randomized to undergo either extended TIP (e-TIP) or standard TIP (s-TIP) technique. Cosmetic outcome was evaluated postoperatively using Hypospadias-Objective-Penile-Evaluation (HOPE) score and measurement of ventral-glans-closure-length (VGCL) and meatal length (ML). Functional outcome was evaluated by maximal flow rate (Qmax), average flow rate (Qave), and postvoid residual urine (PVR). The effect of preoperative parameters on the outcome was assessed with regression analysis. Results In all 94 cases, out of 110 randomized, were available for analysis. Forty-six in e-TIP group and 48 cases in s-TIP group with comparable preoperative demographics. Median (inter-quartile range) of postoperative total HOPE-score was 57(45–60) vs. 55(44–60) for e-TIP and s-TIP (p < 0.001), respectively. The mean (SD) ratio of VGCL/ML was 87% (26) versus 46% (12) for e-TIP vs. s-TIP, respectively (p < 0.001). Both complications and functional outcomes were comparable. Urethral plate (UP) width and the use of e-TIP technique were significant predictors of successful cosmetic outcome in regression analysis (p = 0.019 and p = 0.001), respectively. Conclusion Extension of midline urethral plate can potentially create a vertical slit-like meatus located at the glans tip without compromising the functional outcome, thus providing better cosmetic outcome compared with the standard technique. The UP width was a significant predictor of superior cosmetic outcome.

Self-reported outcomes after the onset of puberty in patients undergoing primary distal hypospadias repair by the tubularized incised plate technique combined with preputial reconstruction vs. circumcision: A norm related study

PurposeWe assessed self-reported outcomes after the onset of puberty in patients undergoing tubularized incised plate (TIP) repair in combination with preputial reconstruction (PR) or circumcision for primary distal hypospadias, in comparison to normal controls. Material and methodsOut of 498 patients undergoing primary distal hypospadias repairs between 2001 and 2012, 83 underwent TIP repair associated with PR or circumcision before age 10-year, and had a Tanner stage ≥2 at study. Outcomes were assessed by online self-administration of validated questionnaires and additional non-validated questions. Results were compared between patients undergoing TIP repair vs. normal age-matched controls (healthy volunteers), and, between patients undergoing PR vs. circumcision. ResultsForty-one of the 83 eligible patients completed the study (response rate 49.3%). Of these, 26 had undergone PR. Median post-operative follow-up was 11.8 (range 6.5–16.2) years. The control group included 45 healthy boys. Comparing groups, there were no statistically significant differences in the cosmetic aspect of the penis, patient perception of penile appearance, and quality of life. Irrespective of preputial management, patients reported fear of being teased for the appearance of their genitalia much more commonly than controls (p = 0.02), but this did not affect their relationship patterns and quality of life. ConclusionSelf-reported outcomes after the onset of puberty were not significantly different between patients undergoing primary TIP repair of distal hypospadias in childhood and normal controls. Patients were significantly more commonly feared of being teased for their genital appearance, but this did not interfere with their social skills. Preputial management, namely PR vs. circumcision, did not affect the outcome.

Penile nerve block predicts higher revision surgery rate following distal hypospadias repair when compared with caudal epidural block: A consecutive cohort study

Recent literature has suggested caudal epidural blocks (CEB) may increase revision surgery rates following hypospadias repair. We sought to investigate this using a large, multi-surgeon series. The primary objective of this study was to identify the impact of CEB or penile nerve blocks (PNB) on revision surgery rates following distal hypospadias repair at our centre. A prospectively maintained database of consecutive patients undergoing primary hypospadias repairs under the supervision of 8 different paediatric surgeons at our centre between January 2015 and December 2018 was queried for the following potential risk factors: Age at surgery, American Society of Anaesthesiologist's (ASA) grade, hypospadias type, type of surgery, CEB or PNB, and training level of primary surgeon. Revision surgery was defined as reoperation for fistulas, dehiscence, strictures or meatal stenosis. Univariate and Multivariate analysis was performed using logistic regression. 188 patients underwent primary distal hypospadias repair over the study time period. Patients were aged between 7 months and 15 years of age. Median age at surgery was 14 months. Revision surgery was performed for 31 patients (16.5%). Indications were urethrocutaneous fistula (n=17, 9.0%), meatal stenosis or stricture (n=9, 4.8%) and glans dehiscence (n=5, 2.7%). 114 (60.6%) received a penile block and 74 (39.4%) a caudal block. On univariate analysis, PNB (HR 2.55 95% CI 1.04-6.27, p=0.04) was statistically significant for revision surgery. This association remained significant on multivariate analysis (HR 2.74 95% CI 1.09-6.92, p=0.03). All other prognostic factors examined were not statistically significant for revision surgery. Our findings suggest PNB are associated with higher revision surgery rates following distal hypospadias repair. This contrasts with the findings of other authors. Our study is the first to demonstrate an association between PNB and higher revision surgery rates following distal hypospadias repair.

Classic Snodgrass Versus Inner Preputial Inlay Grafted Snodgrass in Distal Penile Hypospadias Repair

Assessment of the outcome of G-TIP technique in primary distal hypospadias repair in comparison to TIP repair using HOSE score This study had been performed between June 2018 and June 2019 which included 50 patients all presented to urological outpatient clinic of Benha university hospital -Egypt- with different types of primary distal hypospadias. They were divided into two groups (Group A operated upon using classic Snodgrass TIP urethroplasty and Group B operated upon using G-TIP urethroplasty technique), each group included 25 patients. Circumcised cases or cases with penile chordea more than 30 degree were excluded from the study. Urethral catheter might have been exited set up for particular case week on 10 times. Catch up might have been consistently during 1st, 3rd Also 6th months (3 patients didn't go to the 6th month catch up 2 from one assembly An tip Also particular case starting with the G-TIP assembly B). Mean hose score a t 6th month might have been 15. 7 out about 16 Previously, tip and 15. 5 Previously, G-TIP (P 0. 52 (NS)). In the tip aggregation those score might have been because of difficulties which incorporated an instance for urethrocutaneous fistula and an instance about meatal stenosis with urethrocutaneous fistula same time in the G-tip an instance from claiming glans dehiscence What's more an instance about gentle remaining chordea. Constantly on effects demonstrated no noteworthy measurable distinction between the two bunches but more agent chance 91. 4±6. 2 minutes in the G-TIP assembly contrasted with main 85. 2±6. 3 to tip gathering (P 0. 002 (S)), those time used for harvesting, get ready Also inlaying those graft. We finished up that G-TIP urethroplasty is a great elective procedure of the excellent tip repair shed for tantamount comes about Furthermore Despite there were no noteworthy measurable distinction the middle of those 2 gatherings in regards complications, G-TIP gatherings demonstrated preferred outcomes Concerning illustration view meatal stenosis Also urethrocutaneous fistula yet all the for longer agent run through.

Does grafted tubularized incided plate improve the outcome after repair of primary distal hypospadias: A prospective randomized study?

ObjectiveTo detect whether grafting the incised plate during Snodgrass repair would improve outcome. Materials and methodsSixty patients with primary distal hypospadias were included. Patients were equally randomized using closed envelop method to either Snodgrass or grafted tubularized incised plate repair (GTIP). All operations were performed by a single surgeon. All intaroperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meatus at the tip of the glans with no stenosis, fistula or diverticulum. ResultsAll 60 patients were evaluated at 1 year of follow-up. Mean age at surgery was 40±15months. Both groups were comparable as regard to patients' age, meatus location, length and width and depth of urethral plate and glans width. Success was documented in 29/30 patients (96.7%) in the Snodgrass group. The only complication was meatal stenosis in one patient, whereas success was documented in 28/30 patients (93.3%) in the GTIP group. The two failures were secondary to partial glans dehiscence. Success rate was not statistically different. Flow rate data at 1 year showed insignificant difference between both groups as regards Q-max and voiding time. The only statistically significant difference between both groups was a longer operative time 106±12min in the GTIP group compared to only 77±9 for the Snodgrass group (p = 0.005). ConclusionsSnodgrass and GTIP techniques for primary distal hypospadias repair have similar outcome. With a significantly shorter operative time, Snodgrass repair remains the first choice for primary distal hypospadias repair. Type of the studyProspective randomized study. Level of evidenceLevel I.

Mathieu technique with incision of the urethral plate versus standard tubularised incised-plate urethroplasty in primary repair of distal hypospadias: A prospective randomised study

ObjectiveTo compare outcomes of the Mathieu incised-plate (Mathieu-IP) technique vs the standard tubularised incised-plate (TIP) technique for primary management of distal hypospadias. Patients and methodsBetween April 2012 and August 2015, 66 patients (aged 15–60months) with primary distal hypospadias were randomly allocated to two groups. Group 1 included 34 patients who underwent Mathieu-IP repair and Group 2 included 32 patients managed using the TIP technique for primary management of distal hypospadias. Postoperatively, all patients were examined weekly up to 1month and then at 3 and 6months. Perioperative data, complications and outcomes of both procedures were statistically analysed and compared. ResultsThere were no statistically significant differences in patient demographics between the groups at baseline. There was no statistically significant difference in the mean (SD) operative time between Groups 1 and 2, at 95 (7.6) and 91.2 (8.1) min, respectively. There was no statistically significant difference in the shape of the urine stream at micturition or the neomeatus between the groups postoperatively. The rate of postoperative fistula was significantly higher in Group 2 (TIP) compared to Group 1 (Mathieu-IP), at 18.7% vs 2.9% (P=0.004). There was no postoperative meatal stenosis in Group 1, which did occur in five patients (15.6%) in Group 2 (P=0.002). ConclusionThe Mathieu-IP technique appeared to be better than the standard TIP technique with regard to postoperative fistula formation and meatal stenosis, and with acceptable cosmesis.

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.

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.

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.

A Population Based Study of 2,856 School-Age Children With Urinary Incontinence

We estimated the spectrum and risk factors for daytime urinary incontinence in school-age children. A validated, reproducible, parent administered daytime incontinence questionnaire was distributed to randomly selected school children. The questionnaire elicited information on demographic factors, prenatal and developmental factors, and bowel and urinary history. The spectrum of daytime urinary incontinence was measured by recording the frequency and amount of incontinence. Parents of 2,856 children (mean age 7.3 years) completed the questionnaire. Overall 16.9% reported any daytime urinary incontinence in the previous 6 months, with 64% of cases being very mild, 14.8% mild, 11.6% moderate and 9.6% severe. There was low agreement between frequency and amount of incontinence (weighted kappa 0.03) but risk factors were similar. Independent risk factors were nocturnal enuresis (OR 7.2, 95% CI 3.4 to 15.2), female gender (5.4, 2.6 to 11.1), social concerns (3.4, 1.4 to 8.3), urinary tract infection (5.6, 2.0 to 15.6) and encopresis (3.3, 1.4 to 7.7). Expressed as population attributable risk, 36% of moderate to severe daytime incontinence can be attributed to encopresis, nocturnal enuresis, social concerns, female gender or urinary tract infection. Urinary tract infection was a risk factor for boys but not for girls (interaction p <0.01). Daytime urinary incontinence in children is a common but heterogeneous disorder. Episodes may be frequent or major or both but appear to share the same causal pathway. Given the risk factors identified, interventions should target endogenous/physiological and environmental factors.

Salvage Mathieu urethroplasty: Reuse of local tissue in failed hypospadias repair

Objectives To report our experience with Mathieu urethroplasty for revision of hypospadias repairs. Mathieu perimeatal-based flap urethroplasty remains a popular technique more than seven decades after its description for single-stage hypospadias repair. The excellent results of primary distal hypospadias repair are well documented, but reports of the results using the technique as a salvage procedure are sparse. The reuse of local tissue may be hampered by the presence of scar tissue and reduced vascularity. Methods A total of 40 patients underwent salvage urethral reconstruction. Of the 40 patients, 34 (mean age 70 months, range 11 to 216) underwent salvage Mathieu urethroplasty. All patients underwent surgery at least 6 months after the previous surgery. One, two, and three or more prior procedures had been performed in 22, 6, and 6 patients, respectively. The mean follow-up period was 29 months (range 1 to 84). In 6 patients, local tissue was scarred and immobile, and they underwent the procedure using buccal mucosal grafts. Results Satisfactory functional and cosmetic results after the initial procedure were achieved in 25 patients (74%). Two patients underwent reoperation for repair of meatal stenosis, and 5 (15%) underwent simple repair of fistula without the need for urethral reconstruction. Two patients underwent reoperation at other medical centers and were lost to follow-up. Overall, cure was achieved in 32 (94%) of the 34 patients. Conclusions Mathieu urethroplasty is an efficient technique for salvage hypospadias repair. Patient selection is the key to successful repair. Despite the effects of previous surgery, local tissue of adequate quality to facilitate repair exists in most patients.

Clinical review of the 'Snodgrass' hypospadias repair.

Snodgrass first described the tubularized, incised plate (TIP) urethroplasty for distal hypospadias repair in 1994 based on the concept of hingeing the incised urethral plate. The use of this technique allows a vertically orientated glanular meatus to be produced. A retrospective review of patients who had this procedure for the primary repair of distal hypospadias at New Children's Hospital was performed to objectively assess the cosmetic and functional outcomes of this technique. All patients having a TIP urethroplasty for the primary repair of distal hypospadias between 1996 and 1998 were requested to attend for review in an independent clinic. The parents were interviewed and the patient was examined to determine meatal location, meatal size, glanular configuration, urinary stream, straightness of erections, cosmesis, and the presence or absence of cutaneous sinus tracts or a urethral fistula. Sixty patients were identified. Forty-nine were reviewed in person, 10 were reviewed by telephone and one could not be traced. The median age at surgery was 13 months (range: 6-144 months), with a median follow up of 27 months (range: 2-33 months). A glanular meatus was achieved in 57 patients (97%) and a conical glanular configuration was achieved in 58 patients (98%). The urinary stream and erections were straight in 54 (89%) and 58 patients (98%), respectively. Suture sinus tracts were present in 14 (24%) patients. Six patients (10%) developed a urethral fistula and three (5%) developed meatal stenosis. A good or satisfactory final cosmetic and functional result was achieved in 58 patients (98%). The results of TIP urethroplasty are satisfactory at New Children's Hospital with the benefit of a cosmetic final outcome similar to a circumcised penis.

Tubularized-incised urethral plate urethroplasty: is regular dilatation necessary for success?

To report the results of the tubularized-incised urethral plate repair of hypospadias. Twenty-seven patients (mean age 8 years, range 6-18) had their hypospadias corrected using the tubularized-incised urethral plate technique. Five patients had glanular, 16 had coronal, and two had recurrent hypospadias after a failed Mathieu repair, and four patients required a second-stage repair. The urethral plate was incised in the midline and tubularized over a suitably sized stent. In patients who required second-stage repair a Thiersch-Duplay neourethra was constructed from the hypospadiac orifice to the corona and the glanular urethra was constructed by tubularization of the incised urethral plate. The functional and cosmetic results were excellent. Of the first seven patients, four had a small fistula associated with meatal stenosis. By regular dilatation of the glanular urethra, all fistulae resolved spontaneously. Dilatation was instituted in all the remaining patients and no fistula or meatal stenosis occurred. Other complications included haematoma formation in one patient, urinary tract infection in another and frequent bladder spasm in two. The tubularized-incised urethral plate urethroplasty is a simple and versatile technique that provides an excellent cosmetic appearance of the glans. It can be applied not only for the primary repair of distal hypospadias, but also for re-operation of recurrent hypospadias. The technique is ideal for constructing a glanular urethra when the Thiersch-Duplay operation is used to repair posterior hypospadias. Regular urethral dilatation is important in preventing adhesions between both sides of the incised plate, which can result in meatal stenosis and fistula.