Hypospadias Repair Research Articles

Residency graduates should not be expected to perform hypospadias repair without fellowship training: Results from a survey of SPU membership

Trainee autonomy has eroded over time as surgery has become more subspecialized and as attending oversight has increased, causing many trainees to seek additional fellowship training beyond residency. Less clear is whether there are cases that attendings view as "fellowship-level" or "privileged" cases in which resident-level trainees should not have high levels of autonomy due to complexity or high-stakes outcomes. We sought to better understand current attitudes and practices with regards to trainee autonomy in hypospadias repair as it represents a high complexity procedure within pediatric urology. We administered a RedCap survey to the SPU membership, asking respondents to describe the level of autonomy afforded to trainees in various types of hypospadias repair (distal, midshaft, proximal, perineal) as measured by the Zwisch scale. The Zwisch scale describes the role of the attending in the attending-trainee relationship in a low-to-high trainee autonomy fashion: show and tell; active help; passive help; supervision only. 177 of 761 (23%) unique recipients completed our survey and 174 of 177 (98%) of respondents felt that trainees should not perform hypospadias repair independently in practice without additional fellowship training. Among pediatric urologists who train residents, trainee autonomy as measured by the Zwisch scale decreased as the type of hypospadias repair moved from distal to proximal. There was near unanimous agreement among respondents that urology trainees should not perform hypospadias repair in practice without additional pediatric urology fellowship training, and that current practice affords little trainee autonomy in hypospadias repair at the resident level. These findings introduce a new wrinkle into the issue of trainee autonomy: cases in which trainees perhaps should not have autonomy. Concurrently, the concern with such findings is that this intentional lack of autonomy may extend to other urologic procedures that one would expect trainees to be able to perform independently. Urology trainees are not expected to be able to perform hypospadias in practice without additional training. This raises the question that there may be other such procedures in urology, and if so, should we as instructors, be forthcoming about the limitations of urology residency training to set appropriate trainee expectations?

Vas Deferens-Sparing Laparoscopic Removal of a Large Prostatic Utricle—Video Display and Technical Report, Highlighting Anatomical Considerations

Introduction and Aim: A large prostatic utricle (PU) is difficult to remove, when symptomatic, thus indicated, because of its proximity and adherence to the vas deferens, on each side and the occasional ectopic vasal opening into the utricle. Inadvertent vasectomy or deliberately transecting the vas deferens, on one or both sides, is often inevitable, leading to infertility. This work offers an insight into the pertinent surgical anatomy and the aforementioned challenges, as well as a modification of technique in children. Clinical Presentation: A case of a then 4-year-old boy, with penoscrotal hypospadias and a large PU, complicated with recurrent urinary tract infections (UTIs), after a staged hypospadias repair is reported. The hypospadias repair was deemed effective, as judged by cystoscopy. During subsequent laparoscopy, we found the vas deferens bilaterally entering a high point into the PU fundus and running along its wall. Surgical Technique: Definitively, a cystoscopy-assisted laparoscopic technique was performed. The PU was bihalved, then a tubular structure was eventually constructed, from the wall of the utricle on each lateral edge, as an extension of the vas deferens, thus preserving it running towards the urethra and connected to the ejaculatory pathways. The bulky central part of the utricle was discarded. Progress: Recovery was uneventful. The patient was discharged on the next morning and remains asymptomatic for >1 year after surgery. Conclusion: This technique allows for preservation of the vas deferens while excising the main bulk of the utricle. Prospects of sperm delivery are thus kept, as the primary goal of preventing UTIs is fulfilled. A spermatogram could be obtained in the future, when age permits, to confirm this, as it is still not possible during childhood. Authors' Contributions: Both authors share authorship and contribution. Both authors shared the surgical care of the reported patient and acquisition, analysis, and interpretation of the data. Both authors contributed to the literature review, drafted and produced the article then responded to the peer reviewers' critique. The article has been read and approved by both authors. The requirements for authorship as stated in the Instructions to the Authors have been met. Each author believes that the article represents honest work. Ethics Declaration and Consent for Publication: This report followed the principles of the Declaration of Helsinki. It was conducted under the auspices of a university/teaching medical center, which operates under directives allowing utilization of nonidentifiable clinical data. Consent for any clinically indicated surgical procedure or medical intervention followed the standard informed and written documentation, which entails parental consent for sharing the data/findings for educational purposes. Availability of Data and Material: The data and material for this study are available and stored confidentially. No competing financial interests exist. Funding: No funding was received for this article. Runtime of video: 5 mins A preliminary abstract/summary related to this study was presented at the European Society of Paediatric Endoscopic Surgeons, Online Conference, on September 18, 2020, ESPES 2020, Xth Annual Meeting, E-congress (Part 2), hosted at IRCAD France. https://www.espes.eu/media/content/2020_09_15_Abstract_booK.pdf and as a poster at the 20th BAPES Annual Scientific Meeting (virtual), on November 5th–6th, hosted in London. https://www.bapes.org.uk/london2020posters

Repair of proximal hypospadias with single-stage (Duckett's method) or Bracka two-stage: a retrospective comparative cohort study.

Surgical correction of proximal hypospadias is challenging. The complication rate of proximal hypospadias is still high, and the debate over its optimal treatment is ongoing. Duckett's method is a classic non-staging operation, and two-stage Bracka repair is an attractive alternative procedure. Herein, we retrospectively analyzed the effects of two surgical techniques on proximal hypospadias in order to reduce the complication rates of proximal hypospadias, and analyzed the various risk factors that cause complications. This study retrospectively evaluated 94 consecutive patients who underwent repair of penoscrotal or proximal defects between 2015 and 2019. Patients were assigned to two groups: 46 patients were treated with Bracka and 48 with Duckett. Patient age at surgery, urethral meatus location, and postoperative complications were recorded. One-way analysis of variance (ANOVA) was used to analyze the length and curvature of the penis and the length of the urethral defect. There was no significant difference between the two groups in terms of age and type of hypospadias. In the Bracka group, there was 1 case (2.2%) of meatal stenosis after the first stage, which was restored with ureteral dilatation. After second-stage repair, a urethral fistula was noted in 4 cases (8.7%) and strictures in 2 cases (4.3%). In the Duckett group, urethral fistulas were noted in 8 cases (16.7%), strictures in 4 cases (8.3%), partial glans dehiscence in 4 cases (8.3%), and diverticulum in 1 case (2.1%) postoperatively. Compared with the Duckett group, the overall complication rate for Bracka repair was lower (35.4% vs. 13%, P=0.016). In addition, compared with the Duckett group, children with perineal hypospadias who were treated with the Bracka operation had fewer postoperative complications (100% vs. 13%, P=0.015). Risk factor analysis showed that the initial curvature of the penis, initial urethral defect, and degree of penile curvature after skin degloving were not correlated with complications. There was a significant correlation between urethral defects after correction of the chordee and urethral fistulas (P=0.019). Compared with the Duckett procedure, the Bracka two-stage repair may be a safer and more reliable approach for proximal hypospadias in children. The Bracka two-stage repair should be used for perineal hypospadias. The larger the urethral defect after chordee correction, the greater the possibility of a postoperative urethral fistula.

Extended caudal analgesia using caudally administered nalbuphine as an adjuvant for levobupivacaine in toddlers undergoing hypospadias repair: A randomized controlled clinical trial

Extended caudal analgesia using caudally administered nalbuphine as an adjuvant for levobupivacaine in toddlers undergoing hypospadias repair: A randomized controlled clinical trial

Caregiver disclosure of common early childhood pediatric urologic surgeries

Certain pediatric urologic diagnoses can have serious long-term adverse health outcomes. As a result, it is important for a child to be aware of their diagnosis and a prior surgery. When children have surgery prior to the age of memory formation, it is incumbent upon their caregiver to disclose this surgery. When and how to disclose this information and even if this occurs, is not clear. We developed a survey to assess caregiver plans to disclose early childhood pediatric urologic surgery and evaluate for predictors of disclosure and resources needed. A questionnaire was distributed to caregivers of male children ≤4 years old undergoing single stage repair of hypospadias, inguinal hernia, chordee, or cryptorchidism as part of an IRB approved research study. These surgeries were chosen due to being outpatient surgeries with potential long-term complications and impact. The age criteria was chosen due to likely being before patient memory formation and thus reliance on caregiver disclosure of prior surgery. Surveys were collected the day of surgery and contained information on caregiver demographics, validated health literacy screening, and plans to disclose surgery. 120 survey responses were collected (Summary Table). The majority of caregivers responded affirmatively to planning to disclose their child's surgery (108; 90%). There was no impact of caregiver age, gender, race, marital status, education level, health literacy, or personal surgical history on plans to disclose surgery (p≥0.05). Plan to disclose was also not different across urologic surgery type. Race was significantly associated with being "concerned or nervous about disclosing the surgery to the patient". The median patient age for planned disclosure was 10 years (IQR: 7-13). Only 17 respondents (14%) stated they received any information about how to discuss this surgery with the patient, however 83 (69%) felt this information would be helpful. Our study suggests that most caregivers plan to discuss early childhood urologic surgeries with children, however want further guidance in how to talk to their child. While no specific surgery or demographic factor was found to be significantly associated with plans to disclose surgery, it is concerning that one in ten patients will potentially never learn about impactful surgery they had as a child. There is an opportunity for us to better counsel our patients' families about surgical disclosure and fill this gap with quality improvement efforts.

Frequency of urethrocutneous fistula following snodgrass repair for distal penile hypospadias in children

Objective: To determine the frequency of urethra-cutaneous fistula during three months following Snodgrass repair for distal penile hypospadias in children. Methods and Material: This Descriptive Cross Sectional study included 135 Children with distal penile hypospadias without chordee and was conducted at Department of Pediatric Surgery, Khyber Teaching Hospital, Peshawar from 15 Jan, 2021 to 14 Jan, 2023. All patients underwent Snodgrass repair for distal penile hypospadias. Patients were followed for 3 months for fistula formation. Results: Sixty (44.17%) patients were recorded in 4-8 years age group whereas 76 (55.88%) patients were recorded in 9-14 years age group. As per frequencies and percentages for urethrocutaneous fistula, 09 (6.6%) patients were recorded with urethrocutaneou fistula. Conclusions: for the management of distal hypospadias, TIP urethroplasty is simple, single stage operation and has good functional and low complication rate.

Impact of caudal block on revision rates after hypospadias repair: Multi-institution review

There is controversy surrounding the association between caudal block and complication rates after hypospadias repair. Conflicting results have been reported mostly from single-center, low volume studies and those that did not include relevant variables. We hypothesized that caudal block is not associated with increased rates of reoperation after primary repair and is associated with more complex hypospadias surgery. The Clinical Practice Solutions Center database was queried to identify patients who received a primary hypospadias repair between 2009 and 2010. Primary hypospadias repair was further categorized as meatal advancement and glanduloplasty, distal, one-stage proximal, or one-stage perineal repair. Anesthesia coding was evaluated to identify those who received a caudal block. Any revision surgery was captured between 2009 and 2019 and the types of revision surgeries were identified. Variables such as caudal block, age, insurance type, surgeon volume, and surgeon years in practice were analyzed with mixed effects multiple logistic regression models. The dataset query identified 3343 pediatric males who had primary hypospadias repair. The procedures were performed by 50 surgeons at 27 hospitals. Primary surgeries included meatal advancement and glanduloplasty (23%), distal (69%), proximal (6.9%), and perineal repairs (1%). Caudal block was administered to 42% of patients. Utilization of caudal block was not associated with type of primary surgery (p=0.21). Adjusting for all other variables, increased patient age was associated with decreased usage of caudal block (p<0.001). Analysis did not demonstrate a statistically significant association between utilization of caudal block with rates of revision surgery. This large, multi-institution study demonstrates that the use of caudal block was not associated with more complex hypospadias surgery nor statistically significantly associated with increased rates of revision surgery after primary hypospadias repair.

Age-dependent early complications of hypospadias repair: a single institutional experience.

To correlate age at hypospadias repair with early post-operative complications and highlight need for adaptation to post-operative care in older children. Anecdotal evidence suggests boys with delayed surgery for hypospadias suffer increased rates of early post-operative complication. Hence, a retrospective analysis was conducted of all patients undergoing hypospadias repair between March 2019 and 2022. Ninety eight patients were divided into Group A (< 2years of age at first surgery) or Group B (> 2years). While patients in Group A encountered no early post-operative complications, seven in Group B (11%) suffered a range of complications including dislodged stents (3/7), significant spasmodic pain requiring prolonged hospital stay (2/7) and urinary retention (2/7). More than half of these children required emergency supra-pubic catheter insertion. Significantly more children undergoing hypospadias surgery after the age of 2years suffered complications within the early post-operative period. This resulted in prolonged hospital stays and a number returning to theatre for insertion of a supra-pubic catheter. We recommend a tailored approach to the post-operative care of older children undergoing hypospadias repair, including strict parental education regarding dressing/stent care and medication compliance, as well as efforts to enhance robustness of dressings and stent anchorage in children likely to pull at stents.

Biocompatible dressing for pediatric hypospadias repair

The search for an ideal Hypospadias repair dressing continues. We aimed to develop a hypoallergenic optimized biocompatible dressing (BD). BD with a multi-layered structure of hydrophilic treated Polypropylene with three-layered technologies; Absorbent-spunlaced hydroentangled polyester/viscose blend, outer Polypropylene, Polyester, Acrylic, and Spandex, with super Absorbent Polymer and Acrylic adhesive. Wistar rat abdominal wound model was divided into two groups: control (normal gauze dressing with adhesive) and Study (BD).The physical properties and wound characteristics were compared. Average mass: thickness of BD was 626.7 ± 5.6gm-2: 2.6 ± 0.015mm. Absorption was 1425.2 ± 127.6%. Percentage desorption of solution A from dressings at 24:40h was 1249 ± 150%:1417 ± 230%. BD was hydrophilic with no particles/residue after immersion and pH neutral. The average air permeability was 11.6 ± 1.6 cm3/cm2/sec. The tensile force was 200N-220N with an extension on the breaking point at 24mm. BD was superior for ease of removability on Day 6 (p = 0.012) and sticking quality (p = 0.036), absorption (p = 0.036), ease of removability(p = 0.036), and sustenance (p = 0.030) on Day 10. BD dressing demonstrated better wound healing (p = 0.015) and decreased redness (p = 0.002) on Day 10. Histopathological healing was better with BD on Day 14(p = 0.025) and Day 20 (p = 0.034). BD demonstrated better desirable physical and wound healing qualities with less inflammation compared with control normal dressing.

Spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty for primary hypospadias repair

Neourethral covering is an essential technique for preventing complications such as fistula and glans dehiscence in hypospadias repairs. The spongioplasty has been reported for neourethral coverage about 20 years ago. However, reports of the outcome are limited. This study aimed to retrospectively evaluate the short-term outcome of spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty (DIGU). From December 2019 to December 2020, 50 patients with primary hypospadias (median age at surgery, 37 months; range, 10 months-12 years) were treated by a single pediatric urologist. The patients underwent spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty in single stage. The penile length, glans width, urethral plate width and length, and the location of the meatus of the patients were recorded preoperatively. The patients were followed up,complications noted, and postoperative uroflowmetries at the one-year follow-up time were evaluated. The average width of glans was 12.92±1.86mm. A minor penile curvature was observed in all patients (≤30°). The patients were followed up for 12-24 months, and 47 patients (94%) were free from complications. A neourethra formed with a slit-like meatus at the tip of the glans, and the urinary stream was straight. Three patients had coronal fistulae (3/50) and no glans dehiscence, and the mean±SD Qmax of postoperative uroflowmetry was 8.13±3.8ml/s. This study estimated the short-term outcome of the DIGU covered using spongioplasty with Buck's fascia as the second layer in patients diagnosed with primary hypospadias with a relatively small glans (average width <14mm). However, only a few reports emphasize spongioplasty with Buck's fascia as the second layer and the DIGU procedure performed on a relatively small glans. The major limitations of this study were its short follow-up time and the retrospective data collection. Dorsal inlay graft urethroplasty combined with spongioplasty with Buck's fascia as coverage is an effective procedure. In our study, this combination had good short-term outcomes for primary hypospadias repair.

Comparison of Caudal Block and Dexmedetomidine Infusion in Pediatric Patients Undergoing Hypospadias Repair Surgery: A Prospective, Randomized, Double-blinded Clinical Study.

Many parents continue to reject caudal block since they worry about a rare neurological consequence that may happen. A parenteral surrogate is sought because it can induce recovery with features such as local analgesia. To compare the efficacy and safety of intravenous dexmedetomidine versus caudal and general anesthesia (GA) in children undergoing hypospadias surgery repair. A randomized prospective study was conducted on 135 pediatric patients scheduled for hypospadias repair surgery in the hospital affiliated to Tanta University. The participants were divided into a control group (Group C) receiving GA, a caudal group receiving caudal block after GA, and a dexmedetomidine group (Group D) receiving intravenous dexmedetomidine after GA. The postoperative modified objective pain score (MOPS), the total pethidine received in the first 24 h postoperatively, and complications were recorded. The patients receiving GA required a significantly higher pethidine dose than the other two groups without a significant difference between caudal and dexmedetomidine. The patients receiving dexmedetomidine were extubated significantly later than patients in the other two groups. Regarding the MOPS score, there was a significant difference between Group C and the other two groups 30 minutes and one hour after operation regarding movements, posture, and agitation. Moreover, a significantly larger number of patients developed tachycardia in Group C compared to the other groups. With the caudal block, the benefits of smooth emergency can be obtained by intravenous dexmedetomidine; however, it had less analgesic efficacy in the pediatric patients undergoing hypospadias repair surgery.

One-stage repair of proximal hypospadias by in situ tubularization of the transverse preputial island flap

PurposeThis study aimed to compare the efficacy of modified transverse preputial island flap (TPIF) repair with the traditional TPIF procedure and Byar’s two-stage procedure in proximal hypospadias repair, especially in the postoperative urethral stricture incidence rates.Materials and methodsPatients admitted for proximal hypospadias treated with modified TPIF repair, the traditional TPIF procedure, or Byar’s two-stage procedure at our institution from 2017 to 2021 were identified, and the incidence of postoperative complications among them was compared.ResultsIn total, 142 patients were included (modified TPIF group, 43; traditional TPIF group, 37; and Byar’s two-stage group, 62). The length of the neourethra was 4.21 ± 0.63 cm in the modified TPIF group, 4.18 ± 0.71 cm in the traditional TPIF group, and 4.20 ± 0.68 cm in the Byar’s two-stage group. The rate of urethral stricture in the modified TPIF group (two cases, 4.65%) was significantly lower than that in the traditional TPIF group (four cases, 10.81%) (P = 0.008). Seven (16.28%) cases of urethrocutaneous fistula occurred in the modified TPIF group, six (16.22%) in the traditional TPIF group, and eight (12.90%) in the two-stage group. Additionally, one case (2.33%) of urethral diverticulum occurred in the modified TPIF group, one (2.70%) in the traditional TPIF group, and three (4.84%) in Byar’s two-stage group.ConclusionsModified TPIF repair can ensure a wedge anastomosis between the proximal urethral meatus and the neourethra, provide support and blood supply for the neourethra. Furthermore, it extended the urethral plate width at the anastomosis and urethral meatus, effectively reducing the incidence of urethral strictures.

Glans dehiscence after severe hypospadias repair. Is it a real complication? Clues from a study in post-pubertal patients

IntroductionGlans dehiscence (GD) is reportedly a common complication after proximal hypospadias repairs. However, the need for surgical correction is controversial. The aim of this study was to assess awareness, risk factors, and outcome of GD in post-pubertal patients. The agreement with surgeon assessment was also evaluated.MethodsThe design was retrospective. All consecutive patients treated for proximal hypospadias between 2000 and 2011 were included. The presence of GD was self-reported, and the participants could optionally upload a photograph for surgeon assessment. Cosmetic and functional outcomes were assessed by validated questionnaires (HOSE, PPPS, KINDL®, IIEF-5). Results were compared between patients with and without GD.ResultsOf 219 patients, 34 (16%) participated. Fourteen of them (41%) self-reported GD. Eighteen patients (8%) also uploaded a photograph and, in ten of them (56%), the surgeon noted the presence of GD with poor agreement [k = − 0.444 (95 CI − 0.856 to − 0.033)] with patient report. Patients self-reporting GD had had more frequently a penile curvature at diagnosis (12/14 = 86%, p = 0.01), and had undergone a single-staged repair (100% vs. 65%, p = 0.03). No difference was found in cosmetic and functional outcomes. Results were similar also comparing groups with and without GD as assessed by the surgeon.ConclusionGD was a common finding after severe hypospadias repair. It was more common in case of surgeon assessment with poor agreement between patients and surgeons. GD did not prove to have clear clinical implications. Therefore, in our opinion, surgical repair of GD should be recommended only on patients request.

Flap/graft modified Bracka two stages repair vs. original Bracka for proximal penile hypospadias with moderate and severe chordee repair

Flap/graft modified Bracka two stages repair vs. original Bracka for proximal penile hypospadias with moderate and severe chordee repair

Primary proximal hypospadias repair in in toilet-trained males is associated with a higher risk of post-operative complications and parental dissatisfaction

Primary proximal hypospadias repair in in toilet-trained males is associated with a higher risk of post-operative complications and parental dissatisfaction

Is dorsal inlay graft urethroplasty safe and effective for revisional hypospadias repair in the pediatric age?

Is dorsal inlay graft urethroplasty safe and effective for revisional hypospadias repair in the pediatric age?

The December effect in pediatric elective surgery utilization: differences between privately and publicly insured children.

The objective of this study was to identify differences in December elective surgery utilization between privately and publicly insured children, given that increases in the prevalence and size of annual deductibles may be driving more families with commercial health insurance to delay elective pediatric surgical procedures until later in the calendar year. We identified patients aged <18years who underwent myringotomy, tonsillectomy±adenoidectomy, tympanoplasty, hydrocelectomy, orchidopexy, distal hypospadias repair, or repair of inguinal, umbilical, or epigastric hernia using the 2012-2019 state inpatient and ambulatory surgery and services databases of 9 states. Log-binomial regression models were used to compare relative probabilities of procedures being performed each month. Linear regression models were used to evaluate temporal trends in the proportions of procedures performed in December. Our study cohort (n=1 001 728) consisted of 56.7% privately insured and 41.8% publicly insured children. Peak procedure utilization among privately and publicly insured children was in December (10.1%) and June (9.6%), respectively. Privately insured children were 24% (95% CI 22%-26%) more likely to undergo surgery in December (P<.001), with a significant increase seen for 8 of 9 procedures. There was no trend over time in the percentage of procedures performed in December, except for hydrocelectomies, which increased by 0.4 percentage points/year among privately insured children (P=.02). Privately insured children are >20% more likely than publicly insured children to undergo elective surgery in December. However, despite increases in the prevalence of high deductibles, the proportion of procedures performed in December has not increased over recent years.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events. A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed. 1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p=0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p=0.009). There was no difference in unplanned encounters across repair types (p=0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter. The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution. The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Associations between suturing techniques and suture materials with complications of tubularised incised plate urethroplasty: A systematic review and meta-analysis

Tubularised incised plate (TIP) urethroplasty has received widespread acceptability for hypospadias repair. Differences in surgical approach might impact the outcome of TIP urethroplasty. This study was performed to examine the associations between suturing techniques and suture materials with complications of TIP urethroplasty. Following electronic databases: PubMed, ScienceDirect, EMBASE, and Cochrane Library were systematically reviewed for the studies that reported comparisons of interrupted and continuous suturing techniques and comparisons of several suture materials with complication rates during TIP urethroplasty. Risks of bias were evaluated with RoB 2 tool for randomised controlled trials (RCTs) and ROBINS-I tool for comparative non-RCTs. All data were analysed utilising review manager 5.4. Thirteen total studies involving 2,967 patients underwent TIP procedure were included in this study. However only nine studies fulfilled the criteria for quantitative synthesis. In meta-analysis, there was no significant difference of total complications rate among interrupted and continuous suturing techniques (OR 0.86; 95% CI: 0.46–1.59). Subgroup analysis for each complications (urethrocutaneous fistula, infection, dehiscence, meatal stenosis, and urethral stricture) were also not statistically different. The utilisation of absorbable synthetic braided suture compared to monofilament sutures did not increase the complications rate of TIP urethroplasty (OR 1.49; 95% CI: 0.83–2.68). No publication bias was observed in the funnel plot. Our meta-analysis showed that suturing techniques and suture materials had no significance on the complications of TIP urethroplasty. The selection of suturing techniques and suture materials should be based on surgeons or centre's local experience.

Normal Glanular and Meatal Measurements in Boys and Men

ObjectiveTo determine the normal vertical urethral meatus length (ML), maximum glanular width (MGW), the glanular seam length (between the lowest edge of urethral meatus and the glans closure line corona) (GSL) and GSL/ML ratio in all age groups. Materials and MethodsConsecutive patients presented to urology and pediatric urology outpatient clinics were included in the study. Penile abnormalities, known endocrinological disorders, history of penile/urethral surgery were excluded. MGW, ML, and GSL were measured with a caliper. Glanular and meatal measurements were compared according to ages. ResultsA total of 1398 boys and men (380 (27.18%) prepubertal (1-12), 203 (14.52%) adolescent (13-19), and 815 (58.30%) postpubertal (19-93)) with a median age of 31 years (range: 1-93) were included in the study. In consecutive age groups, ML and GSL gradually increased and became steady between 16-19 & 20-30 age groups and 10-12 & 13-15 age groups, respectively. On the other hand, MGW gradually increased until 20 years of age and became steady at median of 35 mm over 20 years of age. Another interesting finding was a rather stable GSL/ML ratio in all age groups. Pairwise comparison of different age groups seemed to be similar and suggests a fixed ratio of 1.33 (IQR: 0.6). ConclusionThe normal glanular and meatal measurements may guide the surgeons for better cosmetic results during hypospadias repair. The GSL/ML ratio appears to be a stable measure for all ages to achieve better cosmetic results.