Distal Hypospadias Repair Research Articles

Comparative study in distal hypospadias repair: a meatal-based flaps technic vs. tubularized incised plate urethroplasty

ObjectivesHypospadias is the most common anomaly of the male genital system after undescended testis. More than 200 surgical repair techniques have been described for the treatment of hypospadias due to many different meatus localisations and other accompanying anomalies. Kutlay defined a new technique in 2010 with 10 patients with distal hypospadias patients. We compared this new technique with tubularized incised plate urethroplasty (TIP) which is one of the most frequently performed methods.Methods148 patients with hypospadias who underwent surgery at the Urology and Pediatric Surgery Clinic during the period of January 2010 to December 2022 in the first and 2nd clinic, were retrospectively analyzed. The study focused on the remaining 83 patients with distal hypospadias for the purpose of comparison.ResultsThe mean age of group one was 10.0 (± 6.9, range 2–27), while for group two it was 10.8 (± 5.9, range 3–23). There was no statistically significant difference between the two groups in terms of anatomical position of the meatus, stricture and fistula complications (p > 0.5).ConclusionThe Kutlay technique has been described as an easy-to-learn and feasible method with reliable results. No significant difference in complications was observed in this study compared with TIP, which is known as the standard technique worldwide. We would like to suggest that the method be considered for further evaluation with larger patient groups and different techniques.

Editorial Comment on "The effectiveness of double dorsal dartos flap for urethroplasty coverage in distal hypospadias repair: A single surgeon approach to preventing urethrocutaneous fistula".

Editorial Comment on "The effectiveness of double dorsal dartos flap for urethroplasty coverage in distal hypospadias repair: A single surgeon approach to preventing urethrocutaneous fistula".

Comparison of the of tubularised incised plate uretheroplasty versus grafted tubularised incised plate uretheroplasty in distal hypospadias repair with narrow uretheral plate.

Comparison of the of tubularised incised plate uretheroplasty versus grafted tubularised incised plate uretheroplasty in distal hypospadias repair with narrow uretheral plate.

Parental regret following decision for sons to undergo elective post-neonatal circumcision

The reasons for performing a circumcision among males after the neonatal period are usually cultural or medical. We aimed to evaluate parental regret for providing consent and to identify factors associated with such regret. Included were the parents of males aged 6 months to 18 years who underwent circumcision under general anesthesia at a single center between 2/2017 and 01/2023. Those who underwent additional surgical procedures during the same session were excluded. Parents responded telephonically to the Decision Regret Scale (DRS) questionnaire. Regret was classified as none (0 points), mild (1-25) or moderate-to-strong (26-100). Surgical and demographic data were retrieved for comparison to DRS scores and identification of predictors of parental regret. In total, 201 of the 265 suitable patients met the inclusion criteria. Parents of 130 patients (65% response rate) whose average age was 5.06 (IQR 1.58,7.53) years completed the DRS questionnaire (study group). The average time since surgery was 41.8 (IQR 25.4,59.3) months. Forty surgeries were undertaken for cultural reasons and 90 for medical considerations. Eighteen parents reported regret (15 mild and 3 moderate-to-strong) for their decision to consent to their son's circumcision. The time from responding since surgery was the only significant variable in the DRS scores, with a 33-month gap predicting no regret (p=0.02 compared to shorter gaps). The reasons for circumcision did not significantly differ between the "regret" and "no-regret" groups (p=0.23). Our current investigation revealed a lower incidence of parental regret when compared to previous reports following distal hypospadias repair, likely attributable to the lower complication rate associated with circumcision. Our data reflect the experience of a single center in a country where neonatal male circumcision is routinely performed for cultural and religious reasons, thus precluding the generalization of our findings to places where post-natal circumcision is less commonplace. Consent to their son's post-neonatal circumcision was regretted by 13.8% of parents. Time since surgery significantly influenced the reduction of their negative attitudes.

CYSTOSTOMY DIVERSION REDUCED COMPLICATIONS FOLLOWING HYPOSPADIAS REPAIR: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: This study aims to investigate the associations between the use of cystostomy diversion and the incidence of complications following hypospadias repair. Material & Methods: An extensive search of PubMed, ScienceDirect, Embase, and the Cochrane Library, was performed to identify studies that assessed the impact of cystostomy diversion on complication rates after hypospadias repair. To evaluate potential biases, the RoB 2 tool was applied for randomized controlled trials (RCTs), while the ROBINS-I tool was used for observational studies. Data analysis was conducted using Review Manager 5.4. Results: This review included ten studies involving 1.120 patients who underwent hypospadias repair. The overall complication was 16.9%. The meta-analysis revealed that opting against cystostomy diversion after hypospadias repair led to a notably increased risk of complications, as evidenced by a pooled odds ratio (OR) of 1.48 (95% confidence interval (CI) 1.07–2.03). The significant negative effect of not performing cystostomy on the risk of complications was consistent in sub-analysis of distal hypospadias (OR 1.97; 95% CI 1.11–3.51) and primary hypospadias repair (OR 1.80; 95% CI 1.19–2.73). In the funnel plot, there was no significant publication bias identified. Conclusion: Our meta-analysis demonstrated that cystostomy diversion reduces the incidence of complications following hypospadias repair. The positive effects were consistent in both distal hypospadias and primary hypospadias repair. Keywords: Complications, cystostomy, hypospadias.

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 outcome of TIP urethroplasty with or without Buck’s Fascia repair

ObjectiveTIP is the most common preformed type of Urethroplasty. The intermediate barrier is used as a waterproofing layer to prevent fistula formation. Many tissues have been utilized as a barrier layer, with varying success rates. The search for a better intermediate layer will continue. In this study, we aim to evaluate the role of Buck’s Fascia as a covering for the neo-urethra to prevent fistula formation in patients who underwent Snodgrass Urethroplasty.MethodsThis prospective study was conducted between 2018 and 2022. Patients were randomly assigned to either Group ‘A’ or Group ‘B’. Group A included patients who underwent the Snodgrass procedure with a Buck’s Fascia cover, while Group B included patients whose neo-urethra was covered with the dartos flap. These patients were closely monitored for the development of short- and long-term complications in both groups, and the results were recorded.ResultsThe study involved 164 patients, who underwent midpenile and distal hypospadias repair using the Snodgrass technique. In Group ‘A’ (84 patients), the neo-urethra was covered with Buck’s Fascia, while in Group ‘B’ (80 patients), the neo-urethra was covered with the dartos flap. The mean age of the children was (23.06 ± 16.12) months in group ‘A’ & (26.06 ± 14.07) months in group ‘B’. mean operating time was (40 ± 11.43) minutes, in Group ‘A’, and (70 ± 17.43) minutes, in Group ‘B’. Meatal stenosis occurred in 3.57% of children in Group ‘A’ and 10% of patients in Group ‘B’. Urethral fistulas were encountered in 2.35% of cases in Group ‘A’and 10% in Group ‘B’. The difference between the groups was statistically significant.

Urethral Mobilisation and Glanuloplasty Technique for Primary and Second-Stage Repair of Hypospadias: A Single Hospital Experience.

Background Over the years, the technique used to correct hypospadias has undergone several modifications to improve outcomes and reduce complication rates. In this study, a modification has been made to the second stage of the two-stage repair of proximal hypospadias. This modification utilises urethral mobilisation and glanuloplasty, traditionally used to repair distal hypospadias, in the second stage of repair of proximal hypospadias. This study aims to assess the implications of this modification on the outcomes in addition to adding to the pre-existing literature on the outcomes of urethral mobilisation and glanuloplasty in the repair of distal hypospadias. Methodology A prospective study was conducted at Salmaniya Medical Complex in Bahrain between January 2016 and December 2021. All patients with either proximal or distal hypospadias who underwent a surgical repair using the urethral mobilisation and glanuloplasty technique were included. The following cases were excluded: patients with proximal hypospadias who did not undergo a first-stage repair, those with a hypoplastic urethra, and those aged 14 years or more. Results The mean operative time for the proximal hypospadias group was 78 minutes, while it was 62 minutes in the distal hypospadias group. Furthermore, the catheter remained in situ for a mean of three days postoperatively in the proximal hypospadias group. Overall, four of 35 patients (11.4%) experienced complications in the proximal hypospadias group. Of these, there were two(5.7%) cases of meatal stenosis, two(5.7%) cases of wound dehiscence, and no cases of diverticula or urethrocutaneous fistulas. Meanwhile, in the distal hypospadias group, one of 117 patients (0.9%) experienced a complication; the complication was meatal stenosis. there was a significant correlation between the age of patients and the complication rate (p = 0.06). The operative time was also found to be a significant factor influencing the occurrence of complications. The follow-up duration ranged between five months and 12 months. All patients had good cosmetic outcomes. Conclusions This study found that urethral mobilisation and glanuloplasty for the second-stage repair of proximal hypospadias resulted in lower complications than the traditional two-stage operation and a short duration of urinary catheterisation. There is a need to conduct studies with longer follow-up durations and objective measures of function to provide a better comparison between the different techniques used.

Cumulative sum learning curve analysis of tubularized incised plate repair for hypospadias: a study of a single surgeon with a single surgical procedure.

To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis. We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency. CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min [interquartile range (IQR) = 125-155] to 92 min (IQR = 80-100) (P < 0.001), CR decreased from 28 (28%) to 8 (5.3%) (P < 0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P < 0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P = 0.013, P = 0.006, and P = 0.028, respectively). Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99,231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.

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.

Retrospective Comparative Study between Duplay and Koff Methods in Repair of Distal Hypospadias.

Hypospadias repair is a complicated surgery even in the best of hands. To date, there is a lack of consensus on which surgical technique offers more favourable post-operative outcomes. The present work was undertaken to evaluate and compare the outcomes and complications rates of two single-stage techniques widely used to repair primary anterior hypospadias, namely Thiersch-Duplay Tubularized Plate Urethroplasty and Koff Urethral Mobilisation and Advancement. Data from the medical records of 120 patients operated on for primary anterior hypospadias were retrospectively analysed and compared. The patients were divided into two groups: 60 patients underwent Thiersch-Duplay procedure (Group A) and 60 patients underwent Koff procedure (Group B). They were compared using the Chi-squared or Fisher's exact test to assess the relationship between the adopted surgical technique and the complications' development with a P < 0.05. Neither intraoperative complications nor acute post-operative complications occurred, whereas 28.3% ( n = 34/120) cases have exhibited at least one late post-operative surgical complication, including 38.3% ( n = 23/60) in Group A and 18.3% ( n = 11/60) in Group B, revealing a better outcome of the Koff procedure despite the statistical insignificance ( P = 0.102). We did not objectify any other complication besides meatal stenosis (MS), urethro-cutaneous fistula (UCF) and wound dehiscence. Overall, our study could not demonstrate the superiority of one technique above another. At the same time, it established the versatility, satisfactory cosmetic and functional results, low MS and UCF rates of Koff urethral mobilization and advancement technique in primary anterior hypospadias repair.

Comparative study between polydioxanone 6.0 and polyglactin 6.0 suture material in distal hypospadias repair

Comparative study between polydioxanone 6.0 and polyglactin 6.0 suture material in distal hypospadias repair

The cosmetic outcome of distal penile hypospadias repair using stitch-by-stitch glanuloplasty versus TIP: a non-randomized retrospective study

The cosmetic outcome of distal penile hypospadias repair using stitch-by-stitch glanuloplasty versus TIP: a non-randomized retrospective study

Is antibiotic prophylaxis generally safe and effective in surgical and nonsurgical scenarios? Evidence from an umbrella review of randomized controlled trials.

The authors aimed to comprehensively evaluate the efficacy and safety of antibiotic prophylaxis through surgical and nonsurgical scenarios and assess the strength of evidence. The authors performed an umbrella review of meta-analyses of randomized controlled trials (RCTs). An evidence map was created to summarize the absolute benefits of antibiotic prophylaxis in each scenario and certainty of evidence. Seventy-five meta-analyses proved eligible with 725 RCTs and 78 clinical scenarios in surgical and medical prophylaxis. Of 119 health outcomes, 67 (56.3%) showed statistically significant benefits, 34 of which were supported by convincing or highly suggestive evidence from RCTs. For surgeries, antibiotic prophylaxis may minimize infection occurrences in most surgeries except Mohs surgery, simple hand surgery, herniorrhaphy surgery, hepatectomy, thyroid surgery, rhinoplasty, stented distal hypospadias repair, midurethral sling placement, endoscopic sinus surgery, and transurethral resection of bladder tumors with only low to very low certainty evidence. For nonsurgery invasive procedures, only low to very low certainty evidence showed benefits of antibiotic prophylaxis for cystoscopy, postoperative urinary catheterization, and urodynamic study. For medical prophylaxis, antibiotic prophylaxis showed greater benefits in nonemergency scenarios, in which patients were mainly with weakened immune systems, or at risk of recurrent chronic infections. Antibiotics prophylaxis may increase antibiotic resistance or other adverse events in most scenarios and reached significance in cystoscopy, afebrile neutropenia following chemotherapy and hematopoietic stem cell transplantation. Antibiotic prophylaxis in surgical and nonsurgical scenarios is generally effective and seems independent of surgical cleanliness and urgency of diseases. Its safety is not well determined due to lack of available data. Nevertheless, the low quality of current evidence limits the external validity of these findings, necessitating clinicians to judiciously assess indications, balancing low infection rates with antibiotic-related side effects.

Plate Objective Scoring Tool (POST) in distal hypospadias: Correlation with post-repair complications

The Plate Objective Scoring Tool (POST) accurately reflects configuration of the urethral plate in distal hypospadias. Here we assessed whether POST score also correlates with patient risk of complications after surgical repair. Data were obtained prospectively from pre-pubertal boys who underwent primary hypospadias repair between January 2020 and February 2023. Both POST and Glans-Urethral Meatus-Shaft (GMS) scores were determined in triplicate by three independent reviewers before evaluating correlation with complications after surgery. POST ratios were strongly correlated with incidence of post-repair complications in n=121 patients. Mean POST score was 1.10 (range 0.5-1.62) and average GMS value was 5.29±1.36 (median G=2, M=2, S=1). Bivariate correlation analysis indicated that POST score can accurately predict risk of complications after surgery (Pearson correlation coefficient r=0.821 [0.724-0.918], 95% CI). A POST threshold of 1.2 provided the highest specificity for risk of post-operative complications, which occurred in 4.4% of patients with POST score ≥1.2 (2/45 cases), compared with 25% among patients with POST score <1.2 (19/76 cases). This study confirms that POST index can be used as a surrogate marker of urethral plate quality and accurately predicts the outcome of distal hypospadias repair. Objective scoring of POST revealed that low ratios were significantly associated with high risk of postoperative complications. In future, this approach could be used to stratify patients and better identify cases that require close follow-up care.

Comparative outcomes among inlay grafted incised plate, onlay preputial flap and tubularized incised plate urethroplasty for the repair of distal penile hypospadias with a narrow urethral plate

PurposeWe conducted this study, comparing the outcomes among Transverse Onlay Island Flap, inlay grafted incised plate and our previous records of tubularized incised plate urethroplasty (TIPU) in patients with narrow urethral plates, aiming to determine which method of repair provides a good outcome.MethodsThis hybrid study included two datasets. The first from a prospective randomized study evaluating outcomes of two treatment modalities; Inlay graft and only flap for distal hypospadias with shallow urethral plate with 80 patients (40 patients in each group) included, the second based on our previous records of TIPU in 40 patients with distal primary hypospadias with narrow urethral plate.ResultsThe success rate in inlay graft urethroplasty group (n = 40) was 87.5%; glandular dehiscence occurred in one case (2.5%), fistulas occurred in 2 cases (5%), and narrow meatus occurred in two cases (5%). Success rate in onlay flap urethroplasty group (n = 40) was 82.5%; glandular dehiscence occurred in two cases (5%), fistulas occurred in two cases (5%), and narrow meatus occurred in three cases (7.5%). TIPU group (n = 40) had success rate of 62.5%; glandular dehiscence occurred in eight cases (20%), fistulas occurred in five cases (12.5%), and narrow meatus occurred in seven cases (17.5%), with five cases exhibiting both narrow meatus with fistula.ConclusionInlay graft and onlay flap urethroplasty for repair of distal penile hypospadias with narrow urethral plate had higher success rate and fewer complications than traditional TIPU. Moreover, operative time was shorter in TIPU.

Correction of curvature in single stage hypospadias repair with foreskin reconstruction

Many surgeons offer foreskin reconstruction (FR) as a routine part of hypospadias repair. We present a step-by-step video of the procedure of Tubularised Incised Plate (TIP) repair, FR and dorsal plication through a ventral skin incision. A ventral incision is made between the inner preputial mucosa and the outer skin extending below the meatus. Ventral degloving is carried out. The dissection is extended laterally around the corporal bodies. The point of maximal curvature (PMC) is marked on the dorsal midline. A vertical incision is made and closed transversely with 5-0 prolene suture in a Heineke- Mikulicz fashion. Urethroplasty is performed in 2 layers using 7-0 polydioxanone (PDS). Spongioplasty and ventral dartos are used as barrier layers. Glansplasty is performed in 2 layers.FR is carried out in 3 layers. Curvature correction is key to good outcome. Dorsal degloving can be achieved through a ventral incision allowing exposure of the dorsal midline for plication sutures. The patient had good cosmetic and functional outcome at 1 month follow up. FR can be safely performed during TIP repair for distal hypospadias repair. Curvature of less than 30° can be corrected through a ventral incision only.

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 &lt; 0.0001) was significantly shorter in TIPU (P &lt; 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.

Does Preoperative Testosterone Administration Decrease Complications in Distal Hypospadias Repair With Urethroplasty? Reply.

Does Preoperative Testosterone Administration Decrease Complications in Distal Hypospadias Repair With Urethroplasty? Reply.

Effectiveness of penile ventral curvature correction and the trend of hypospadias repair: a prospective study of the national center in China

BackgroundHypospadias repair is a complex surgical procedure that involves correcting penile ventral curvature (VC) and performing urethroplasty. This study aims to evaluate the effectiveness of different strategies for VC correction...