Hypospadias Repair Research Articles

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

Hypospadias 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. 148 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. The 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). The 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.

Anterior and Mid-Penile Hypospadias Repair with TIP Technique—Is It Possible with 20-Hour Catheterization?

Background/Objectives: Several surgical procedures have been proposed for the treatment of hypospadias, a common and heterogeneous congenital abnormality in males. Most surgeons utilize either a urethral stent or bladder catheter for 2–14 days as a postoperative urine diversion method depending on the severity of each case and the surgeon’s preferences. The aim of the present study was to evaluate the feasibility of anterior and mid-penile hypospadias repair while placing the urethral catheter for only 20 h. Methods: A single-centre retrospective study was conducted, including all patients who underwent anterior or penile hypospadias repair from January 2012 to January 2023. All operations were performed based on the Tubularized Incised Plate (TIP) Urethroplasty. At the end of the operation, a 6 Fr 100% silicon catheter was stabilized. The catheter was removed 20 h postoperatively, and all patients were discharged on the first postoperative day. The primary endpoint of the study was the complication rate. Results: In total, 104 patients were enrolled. Eighty (76.9%) patients presented with distal penile hypospadias, while 24 patients (23.1%) had mid-penile hypospadias. The mean age at the operation was 20.8 ± 12.4 months, while the mean operative time was 114.2 ± 28.7 min. All the operations were successfully completed. During the follow-up period (mean duration 101.1 ± 44.8 months), complications were recorded in 16.3% of the patients. Conclusions: The application of 20-h catheterization seems to be an effective alternative with outcomes comparable to other conventional drainage approaches, as it reduces the discomfort of the patients without increased risk of complications.

2-stage STAG vs 3-stage STAC for primary proximal hypospadias repair

2-stage STAG vs 3-stage STAC for primary proximal hypospadias repair

Persistent Penile Erection Following Spinal or General Anesthesia During Pediatric Hypospadias Repair: A Case Report

Persistent Penile Erection Following Spinal or General Anesthesia During Pediatric Hypospadias Repair: A Case Report

Outcomes of a 3-day transparent film dressing protocol after hypospadias repair

This study aimed to evaluate a 3-day transparent film dressing protocol after hypospadias repair. A retrospective observational study was conducted in boys with hypospadias who were operated in our institution between 2022 and 2023. Postoperatively, the penis was wrapped with a transparent film dressing, which was removed after 3 days. Postoperative complications were observed until postoperative day 14. The associations of age, meatal location, and type of procedure were analyzed using Chi square, Fisher exact, Mann Whitney, and Kruskall Wallis test (p < 0.05 = significant). Sixty-five patients were studied. Median age was five years, the majority had proximal meatus (58.5%), and underwent urethroplasty (76.9%). After dressing removal, positive bacterial culture was found in 43.1%, mild penile edema in 33.8%, bleeding in 10.8%, and SSI in 49.2% of cases, with pus formation (10.8%), dehiscence (9.2%), and urethrocutaneous fistula (10% after urethroplasty procedure). Surgical site infection and positive culture were significantly higher in patients with proximal meatus compared to distal (p = 0.031, p = 0.019; respectively). A 3-day transparent film dressing prevented penile edema and bleeding in most cases. However, the rate of SSI and positive wound culture was high, and was associated with proximal meatal location.

Comparative Study Between Autologous Platelet-rich Fibrin Membrane and Local Flaps as Intervening Layer in Management of Distal Hypospadias

Background/PurposeThe most frequent complication following hypospadias correction is fistula formation. Recently, fibrin glue has been employed as a 2nd layer covering the urethroplasty resulting in a reduction in the incidence of fistulas. Platelet-rich fibrin (PRF) is an autologous growth factor-rich source. Although the authors recommend the use of additional layers in hypospadias correction, there remains a controversy. In a trial to address this issue, our research was conducted to compare the accessibility of urethroplasty coverage using PRF to traditional local flaps, aiming to prevent fistula formation in hypospadias repair. Patients and methodsThis is a prospective single-blinded randomized controlled study that involved 60 hypospadias cases admitted to Mansoura University Children Hospital's Pediatric Surgery department between March 2021 and March 2023. These 60 cases were randomly divided into 2 equal groups: (group A platelet-rich fibrin coverage membrane & group B local dartos flap as an additional layer). Both groups were compared regarding the rate of complications. All cases were evaluated regarding age at repair, type of hypospadias, urethral plate width, length of urethroplasty, and size of the 2nd layer. The blood loss and operative time were documented and post-operatively; the cases were assessed for the repair intactness, shape, and size of the neo-meatus, existence of any post-operative problems such as urethral fistula, urethral stricture, meatal stenosis, failure of the repair, or diverticulum. Statistical analysis was carried out following data collection. ResultsThe median length of the 2nd layer in group A was 20 mm (range 15–23 mm) and in group B was 22.5 mm (range 19.5–25 mm) and the difference between the two groups was statistically significant (p = 0.012∗), while its median width in group A was 10 mm (range 10–11 mm) and in group B was 15 mm (range 10–18 mm) and also there was statistically significant difference (p = 0.001∗). The mean operative time in group A was 95.73 ± 11.9 min and in group B was 102.33 ± 10.32 min and there was a statistically significant difference (P < 0.001). The length of hospital stay in group A was 5.47 ± 1.11 days and in group B was 5.47 ± 0.89 days. The urethral fistula was detected in 4 cases of group A (13.3%) and 3 cases of group B (10%). The failure of repair was similar, one case of each group (3.3%). The meatal stenosis was reported in only one case of group A (3.4%) and 7 cases of group B (24.1%) (P = 0.02∗) and the difference was statistically significant. There were no reports of urethral strictures among the cases in either group over the follow-up period (mean 9 months, range 5–17 months). ConclusionPRF patch may be employed as a coverage layer over the urethroplasty in repair of the distal hypospadias, especially in cases without accessible vascular flap with comparable outcome to traditional local flaps. Type of studyA prospective single blinded randomized controlled trial (computer-generated numbers method). Level of evidenceLevel 2.

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".

Penoscrotal transposition: Long-term outcome in 29 patients.

Penoscrotal transposition (PST) is a rare anomaly of the external genitalia characterized by malposition of the penis in relation to the scrotum. This transposition may be partial or complete and may be associated with hypospadias, chordee, and other anomalies. We have reviewed our experience with the surgical repair of PST utilizing a modified Glenn-Anderson technique. Twenty-nine patients with a median age of 5.6 years (8 months -15 years) underwent surgical repair of PST at our institution between 2004-2022. Of those, 20 (69%) had complete PST, while 9 (31%) had partial PST. All children were divided into three groups. In the first group of 8 (28%) children, repair of PST was an integral part of one-stage male genitoplasty; in the second group of 18 (62%) children, repair of PST was an isolated last stage of the staged hypospadias repair and the remaining 3 (10%) children underwent PST repair without the presence of hypospadias. All patients underwent modification of the Glenn-Anderson technique involving utilization of bilateral rotational advancement scrotal flap, complete de-tethering of the testis from the internal part of the scrotum when indicated, and relocation of the scrotal compartment in a normal dependent position. The follow-up ranged from 6 months to 18 years. In the first group, five children (62%) underwent Onlay Prepucial Island Pedicle Flap (OIF) hypospadias repair, and three (38%) underwent Long Tubularized Incised Plate Repair (TIP). In the second group, 8 (44%) underwent OIF hypospadias repair, 2 (12%) had Long TIP repair, and the remaining 8 (44%) underwent staged hypospadias repair. Post-operative Clavien Dindo grade III presented among three patients in group I and only one patient in group II. In the third group, no postoperative complications were observed. Our data show that penoscrotal transposition correction utilizing the Glenn-Anderson technique is a reliable and durable surgery in the pediatric population. These children require careful monitoring till adolescence to ensure that no re-operation is needed.

Reducing fistula rate in hypospadias repair

Reducing fistula rate in hypospadias repair

Long term outcomes from uncorrected hypospadias: a scoping review

IntroductionThe goal of hypospadias repair is to optimize urinary and sexual function, improve cosmesis and minimise the psychosocial effects associated with a penile anomaly. However, a lack of clarity exists regarding the role of surgery in milder hypospadias where the anomaly is inconspicuous and there is no anticipated impact on function. The aim of this study was to review the long term functional, cosmetic and psychosocial outcomes in men with uncorrected hypospadias. This information may be helpful for parents who are burdened with deciding the correct treatment for their child's hypospadias. MethodsA scoping review of PubMed, EMBASE, and CINAHL + databases was performed in adherence with PRISMA guidelines. Eight studies were identified for inclusion in the review. ResultsMen with mild uncorrected hypospadias have similar functional outcomes to those without hypospadias, preferring to void standing and reporting similar IPSS scores. However, those with severe untreated hypospadias experience significant urinary difficulties, higher IPSS scores, and are more likely to sit when voiding. They reported worse SHIM scores, more ventral curvature, and greater difficulty with intercourse. Most men with incidentally identified hypospadias are unaware of their condition and are satisfied with their penile appearance. There was no difference in the attainment of psychosocial milestones between men with uncorrected hypospadias versus no hypospadias. ConclusionThere is a lack of research regarding the experiences of adult men with uncorrected hypospadias. However, there is some evidence to support the non-operative management of mild hypospadias. Therefore, the decision to defer surgery in infancy should balance parental wishes and physician guidance, particularly in cases where the risk of functional impairment is low.

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.

Enhancing Tubularized Incised Plate (TIP) Technique for Hypospadias Repair: The Role of Tunica Vaginalis Flap in Minimizing Urethrocutaneous Fistula

Enhancing Tubularized Incised Plate (TIP) Technique for Hypospadias Repair: The Role of Tunica Vaginalis Flap in Minimizing Urethrocutaneous Fistula

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.

Resultados a largo plazo de hipospadias no intervenidos: una revisión exploratoria

Introduction: The goal of hypospadias repair is to optimize urinary and sexual function, improve cosmesis and minimise the psychosocial effects associated with a penile anomaly. However, a lack of clarity exists regarding the role of surgery in milder hypospadias where the anomaly is inconspicuous and there is no anticipated impact on function. The aim of this study was to review the long term functional, cosmetic and psychosocial outcomes in men with uncorrected hypospadias. This information may be helpful for parents who are burdened with deciding the correct treatment for their child's hypospadias.Methods: A scoping review of PubMed, EMBASE, and CINAHL+ databases was performed in adherence with PRISMA guidelines. Eight studies were identified for inclusion in the review.Results: Men with mild uncorrected hypospadias have similar functional outcomes to those without hypospadias, preferring to void standing and reporting similar IPSS scores. However, those with severe untreated hypospadias experience significant urinary difficulties, higher IPSS scores, and are more likely to sit when voiding. They reported worse SHIM scores, more ventral curvature, and greater difficulty with intercourse. Most men with incidentally identified hypospadias are unaware of their condition and are satisfied with their penile appearance. There was no difference in the attainment of psychosocial milestones between men with uncorrected hypospadias versus no hypospadias.Conclusion: There is a lack of research regarding the experiences of adult men with uncorrected hypospadias. However, there is some evidence to support the non-operative management of mild hypospadias. Therefore, the decision to defer surgery in infancy should balance parental wishes and physician guidance, particularly in cases where the risk of functional impairment is low.

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 &amp; 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.

Cumulative re-operation rates during follow-up after hypospadias repair.

To assess the cumulative rates of re-operations after hypospadias repair and evaluate long-term surgical outcomes at a tertiary paediatric urology centre. Retrospective analysis of 293 boys born between 1991 and 2003 undergoing hypospadias surgery was conducted. The study included 274 patients: 165 with distal, 34 with midshaft, and 75 with proximal hypospadias. Kaplan-Meier methods were used to evaluate the re-operation data. The median age at primary surgery was 1.3 years, with a median follow-up of 14.4 years. The overall re-operation rate was 48.2%, with approximately half of the problems detected within the first 3 months after surgery. The risk of re-operation was correlated with hypospadias severity, with 5- and 15-year re-operation risks at 39.3% and 51.8%, respectively. Limitations of the study include its retrospective nature and variations in surgical techniques from current standards. There is a significant risk of unplanned re-operations following hypospadias repair, increasing with the severity of the original condition. This underscores the need for extended follow-up and effective communication with patients and their families about the likelihood of requiring multiple surgeries for optimal outcomes.

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

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

Understanding health-related quality of life after hypospadias repair: A qualitative study with pre-adolescent males and parents

Hypospadias is a common disease that affects approximately 1 in every 200 live male births in the United States, and long-term studies of individuals who have undergone repair demonstrate complication rates of 15%-70%. The Hypospadias-Specific Health-related Quality of Life (HRQOL) Conceptual Framework for youth and adults suggests that additional morbidity may be incurred from poor psychological, social, and sexual health. The current study sought to clarify hypospadias-specific HRQOL and care priorities in a pre-pubertal population. This IRB-approved, semi-structured interview study used rigorous qualitative research methods. Eligible patients were English-speaking 8-12-year-old males with hypospadias and their parents. Families completed a demographic questionnaire and separate youth and parent 30-min telephone interviews. We used hybrid thematic analysis to develop an operational codebook, analyze participant responses, and generate conceptual themes. Mixed methods analysis was used to explore patterns of experiences across groups defined by socioeconomic level. We interviewed 10 parents and 8 children (Median age 9 years, Range 8-11). We generated three overarching themes: Penile Factors, Psychosocial Concerns, and Expectations of Surgery and the Healthcare Team. These highest-order themes were generated for youth, parent-proxy, and parent self-reported experiences, and there were different sub-themes for each participant type (Figure). Youth were focused on avoidance of disclosure and the psychological impact of self-comparisons and embarrassment, while the parental perspective centered on worries about future fertility, complications, psychological health, and normality. Some youth and parents from disadvantaged neighborhoods or those with public insurance indicated a need for more education on normal penile functions and provision of strategies for long-term self-monitoring and facilitation of long-term follow-up on mixed methods analysis. These findings add insight into the multifaceted experiences of pre-pubertal youth and families dealing with hypospadias, and underscore the consistent, wide-ranging interplay between medical, psychological, and social concerns. Patterns in themes across socioeconomic status and insurance coverage suggest that access to information and quality care may vary significantly and could contribute to health disparities. Urologists should employ an individualized approach to counseling and care delivery. Future studies will seek to characterize care priorities in pubertal and post-pubertal age groups to design developmentally adjusted support tools for youth and adults with hypospadias and their families.

A Comparative Study Of Caudal Epidural Bupivacaine And Midazolam-Bupivacaine Mixture For Post-Operative Analgesia In Children Repairing Congenital Inguinal Hernia

Background: Managing postoperative pain in pediatric anesthesia is challenging, with caudal epidural anesthesia being a preferred technique for its safety and efficacy. Enhancing analgesia duration through adjuvants like midazolam may improve outcomes. Objective: This study compares the effectiveness of caudal epidural bupivacaine alone versus a bupivacainemidazolam mixture in children undergoing repair of congenital inguinal hernia, circumcision, and hypospadias repair, focusing on postoperative analgesia duration and side effects. Materials and Methods: A double-blind randomized controlled trial was conducted at Islami Bank Medical College Hospital from October 2023 to March 2024, involving 50 children aged 2-8 years, divided into two groups: Group A (bupivacaine-midazolam) and Group B (bupivacaine alone). Pain was assessed using the FLACC scale at specified intervals up to 24 hours post-surgery. Results: Group A experienced significantly longer postoperative analgesia (10.72 ± 4.07 hours) compared to Group B (6.13 ± 1.98 hours). Mild pain was more common in Group A (72.7%) than Group B (87.5%), while moderate pain was higher in Group A (27.3%) than Group B (12.5%). Side effects were minimal, with Group A having no side effects and Group B experiencing 8% nausea and vomiting and 4% other side effects. Conclusion: The addition of midazolam to caudal bupivacaine significantly prolongs postoperative analgesia and reduces the need for rescue analgesia in children, with minimal side effects

Hypospadias Reconstruction Training: Development of an Ex-Vivo Model for Objective Evaluation of Surgical Skills

To objectively evaluate technical skill acquisition in hypospadias repair procedures during surgical training using noninvasive wearable sensor technology. We combined subjective video evaluations with objective electromyography (EMG) measurements in a hands-on hypospadias training course. Surgeons wore wireless EMG and accelerometer sensors on their dominant hand while performing tasks on ex-vivo cadaveric calf penises. The study focused on 4 skills as follows: urethral mobilization, dorsal inlay graft harvest/implantation, meatal-based flap urethroplasty, and dorsal plication. Machine learning techniques analyzed muscle activation patterns and attributes for assessing surgical precision. The course included 18 participants (10 female, 8 males; average age 40.18±8.46 years) categorized as novice (n=10, <3 years' experience), intermediate (n=5, 3-5 years), and expert (n=3, >5 years). Video evaluations did not reveal significant differences due to short-term training. However, EMG measurements showed significant reductions in average EMG power, total time, dominant frequency, and cumulative muscle workload after training. Additionally, the mean power spectral density of the EMG signal decreased notably post-training. This study presents a structured approach for hypospadias training and highlights the effectiveness of wearable sensor technology for objective skill assessment. While video evaluations did not detect significant changes, EMG data provided measurable differences in skill acquisition, suggesting that wearable sensors could enhance objective evaluations of surgical proficiency in residency programs.