Hypospadias Repair Research Articles

Single-Layer Acellular Porcine Bladder Matrix as Graft in Corporoplasty for Ventral Curvature in Pediatric Proximal Hypospadias Repair: An Initial Experience

Single-layer ACell Cytal matrix (ACell Inc, Columbia, MD) is a commercially available, acellular scaffold derived from porcine bladder epithelial basement membrane and tunica propria. We describe our initial experience using Cytal as corporal graft in pediatric patients who underwent correction of ventral curvature in proximal hypospadias repair. A retrospective review of a single-institution, 4 surgeon hypospadias database was performed between January 2020 and December 2021. Outcomes assessed were postoperative recurrent ventral curvature, corporal diverticulum, scarring on corporoplasty site on physical exam, and parental reports of atypical adverse effects. Ten males underwent correction of ventral curvature with Cytal as corporal graft for correction of ventral curvature were identified. All completed planned operations. Median age was 18.6 months (IQR 14.6-27.0). Median follow up was 14.1 months (IQR 8.9-16.5). Mean ventral curvature after degloving was 80 ± 50 degrees. All patients had straight erections. Nine of the 10 patients had straight erections verified at a subsequent artificial erection test at least 6 months from the corporoplasty (90%). The remaining patient underwent a double face onlay-tube-onlay transverse island preputial flap as a single-stage hypospadias repair and did not require any additional procedures. He had straight erections per parental history. None developed corporal diverticulum or demonstrated induration at site of corporoplasty on physical exam. There were no parental reports of atypical adverse systemic effects. In the short term, single-layer Cytal is effective as corporal graft for correction of ventral curvature in proximal hypospadias repairs without incurring additional donor site morbidity.

Buccal versus skin graft for two-stage repair of complex hypospadias: an Egyptian center experience

BackgroundUrethral reconstruction in complex hypospadias poses a significant challenge. We report our 10-year experience with buccal mucosa graft (BMG) in the two-stage repair of complex hypospadias and compare its results to the skin graft.MethodsWe retrieved the data of 15 patients with complex hypospadias who underwent two-stage repair using the BMG at our institution. The data were compared to 13 patients who underwent skin graft during the same period.ResultsThe median follow-up duration was 14 (12–17) months in the BMG group and 16 (13.5–22.5) months in the skin graft group. Patients in the BMG had a numerically lower incidence of the diverticulum, wound dehiscence, fistula, and infection than the skin graft group, however, without statistically significant difference (p > 0.05). On the other hand, the incidence of meatal stenosis and urethral stricture was significantly lower in the BMG group (0% each) compared to the skin graft group (30.8% each; p = 0.02). At the same time, there were no reported cases of graft contracture. The frequency of donor site morbidity was significantly higher in the skin graft group compared to the BMG group (p = 0.003). The BMG led to a lower incidence of postoperative straining than the skin graft (0% vs. 38.5%, p = 0.03). Only one patient needed revision surgery after skin graft, compared to no case in the BMG (p = 0.27).ConclusionThe present study demonstrates the feasibility and durable outcomes of the BMG in the setting of two-stage repair of complex hypospadias.

Effects of Caudal and Penile Blocks on the Complication Rates of Hypospadias Repair

Background:The major influencing factors for complications during hypospadias repair are the original location of the meatus, previous urethral surgery, surgical technique, and surgeon’s experience. While the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.hile the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.Aims:To determine the effect of caudal block and penile block on complication rates of hypospadias repair in patients with subcoronal hypospadias.Study Design:Retrospective cross-sectional study.Methods:Data of children who underwent hypospadias repair between 2011 and 2019 in our clinic (n = 770) were reviewed retrospectively. Only patients with subcoronal hypospadias and who underwent tubularized incised plate urethroplasty, performed by the same two experienced surgeons (n = 279), were included in the study. The exclusion criteria were incomplete data and follow-up time shorter than 12 months. Data of 279 patients were analyzed. Patients were divided into two groups according to the analgesia type: caudal block (n = 95) and penile block (n = 184), and complication rates were compared between these groups.Results:The median age was 36 months in the caudal block group and 30 months in the penile block group (P = 0.390). The median follow-up times were 54 and 42.7 months in the caudal and penile block groups, respectively. Total complication rates did not differ significantly between the groups and were determined as 10.5% and 12.5% in the caudal and penile groups, respectively. Urethrocutaneous fistula rates were observed as 2.1% and 4.3% (p=0.50). None of the patients had penile chordee and no penile plication was performed in the whole group.Conclusion:This study shows that there is no increase in post-repair complications in patients with subcoronal hypospadias who underwent caudal block.

Risk factors for postoperative complications in children with proximal hypospadias with severe chordee who underwent urethral plate transection.

To identify the risk factors associated with developing complications after transection of the urethral plate for proximal hypospadias with severe chordee. We used a prospective database to identify patients with proximal hypospadias and severe chordee who underwent transection of the urethral plate and primary hypospadias repair in 2011 and 2021. All patients underwent urethroplasty with a follow-up period of >12 months. The association between variables (age, surgical technique, length of urethral defect, and surgeon volume) and postoperative complications (fistulas, urethral strictures, diverticula and glans dehiscence) was analyzed. Altogether, 493 patients were included, of whom 133 (26.9%) had postoperative complications. Univariate and multivariate analyses revealed that the preoperative proximal meatal position, one-stage repair, longer urethral defect length, and low surgeon volume were significant risk factors for postoperative complications with proximal hypospadias with severe chordee who underwent transection of the urethral plate. A urethral defect length of ≥4.55 cm was considered the best cutoff value for predicting postoperative complications. Preoperative proximal meatal location, one-stage repair, longer urethral defect length, and low surgeon volume were associated with postoperative complications in patients with proximal hypospadias with severe chordee who underwent transection of the urethral plate. A urethral defect length of ≥4.55 cm was significantly associated with the development of complications.

Invited commentary on Herzberg et al.: Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision

The repair of hypospadias has evolved over time with multiple available techniques for reconstruction. Most “hypospadologists” utilize one or more of the available techniques for reconstruction, at times combining features of multiple techniques in their daily practice. Refinements in repair have, over time, lead to a significant reduction in complications and excellent long-term functional and cosmetic outcomes.

Invited commentary on Herzberg et al.: Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision

In this issue of the Journal of Pediatric Surgery, Dr. Yuval Bar-Yosef and colleagues from Tel-Aviv Medical Center present their retrospective, single-institution series examining the reoperation rates among patients with subcoronal hypospadias repair following newborn circumcision. The authors have a N = 69 over 20 years of study. This is a well-written, organized paper which highlights the complexity of subcoronal hypospadias repair in the child who has been previously circumcised.

Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision

PurposeTo present the results of hypospadias repair in the absence of preputial skin following neonatal circumcision, and the analyses of surgical techniques and predictors of procedural success. MethodsRecords of all children who underwent hypospadias repair between 10/1999 and 12/2018 were retrospectively reviewed. All of those who underwent neonatal circumcision prior to surgery were included. Patients with any prior penile reconstruction surgery and those with the megameatus intact prepuce variant were excluded. The primary endpoint was the need for reoperation. ResultsA total of 69 patients with a history of neonatal circumcision underwent surgical reconstruction of hypospadias during the study period. Their mean age at surgery was 14 months (interquartile range [IQR] 9,22). Forty-five cases (65%) involved distal hypospadias, and ventral curvature was present in 24 (35%). Dartos flaps were harvested from the dorsal aspect in 37/58 (64%) patients and from the ventral aspect in 21/58 (36%). Twenty-two patients (22/69, 32%) required reoperation after a median follow-up of 9 years (IQR 6,13). Indications for revision surgery included urethral fistula (n = 16, 22%), meatal stenosis (n = 5, 7%), and skin redundancy (n = 1). Ventral curvature (odds ratio [OR] 3.5, p = 0.02) and higher grades of hypospadias. (OR 3.3, p = 0.03) had a higher probability of reoperation (univariate logistic regression). ConclusionHypospadias repair following neonatal circumcision in the absence of preputial skin is a challenging reconstruction. The reoperation rate in our cohort was 30%, similar to reoperative hypospadias surgery. Parents of newborns diagnosed with hypospadias should be encouraged to refrain from pre surgical neonatal circumcision. Level of evidenceTreatment study, level IV

Urethral Plate Characteristics in Cases of Non-proximal Hypospadias May Not Be Associated With a Higher Risk of Complications When a Two-Stage Repair Is Applied.

PurposeTo investigate whether a two-stage repair of distal- and mid-shaft hypospadias (non-proximal hypospadias) could eliminate the risk factors resulting from adverse urethral plate characteristics and eventually reduce complication rates.MethodsWe retrospectively reviewed all cases of primary surgical repair of non-proximal hypospadias performed in our center between 2009 and 2018. In all cases where adverse urethral plate characteristics were found, such as meatal stenosis, a shallow urethral groove, a thick web of tissue between the native meatus and the urethral groove or in the presence of a very “thin,” skin-like distal urethra, a two-stage repair was routinely undertaken. In cases of native meatal stenosis, a meatotomy, and meatoplasty were performed. In cases of a very “thin” distal urethra we incised the skin proximally up to the point of a normal urethral fold and a meatoplasty was performed at that point. Hypospadias repair was then performed in a second operation, 3–6 months following the first procedure. Urethroplasty, both in cases of a single-stage repair and in cases of a two-stage repair, was always performed using the Thiersch-Duplay technique. Patients with a follow-up of less than 12 months were excluded from this study.ResultsOver a period of 10 years, 208 boys underwent primary surgical repair of non-proximal hypospadias. Eighty-nine of the 208 patients (42.8%) underwent single-stage hypospadias repair. Two-stage repair of the hypospadias was required in 119 (57.2%) of the patients. The overall complication rate was 3.4% in the group operated in a single stage and 7.6% in the group that required a two-stage repair (p = 0.09). The most frequent complication reported was urethrocutaneous fistula (p = 0.31), followed by meatal stenosis (p = 0.37), urethral stricture (p = 0.08) and wound dehiscence (p = 0.16). There was no significant difference between the complication rates of the two groups.ConclusionPatients with distal hypospadias and poor urethral plate characteristics repaired in a two-stage approach have comparable low-complications to those with favorable urethral plate characteristics repaired in a single-stage.

Assessment of postoperative cosmetic outcomes of distal form hypospadias repair with the Hypospadias Objective Scoring Evaluation (HOSE).

Aim A standardized assessment for the optimal repair of hypospadias remains elusive. The aim of this study was to assess a postoperative cosmetic outcome of hypospadias repair using a validated questionnaire, Hypospadias Objective Scoring Evaluation (HOSE). Methods During the period between January 2016 and May 2019, 40 patients who underwent hypospadias repair were identified and they agreed to a follow-up using the HOSE. Distal hypospadias repairs underwent a cross-sectional assessment of the cosmetic outcome. Cosmetic assessment was performed by an independent physician using the HOSE scoring system. Results The native meatus was coronal in 10 (25%), subcoronal in eight (20%), and distal penile in 22 (55%) patients. Mean followup was 35.90 months (SD ±29.58) postoperatively (range 12-162 months). Complications occurred in one (2.5%) patient. Out of 40 uncomplicated repairs, 39 (97.5%) were satisfactory. A vertical slit-like meatus located at the distal glans was created in 33 (82.5%) boys, and at the proximal glans in seven (17.5%). The urinary stream was single and straight in 39 and spray in one patient. A straight erection was observed in 39 (97.5%) boys. The median HOSE score was 16 (range 12-16). One patient had a small, single coronal fistula. The technique used included tubularised incised plate urethroplasty. Conclusion The HOSE score is simple, easy, non-invasive and non-expensive tool for objective assessment of long-term outcomes of hypospadias repair.

Comparative study between the closure of small-sized and medium-sized urethral cutaneous fistula after hypospadias repair with and without autologous platelet-rich plasma graft

Background and aim Many complications have been recorded after hypospadias repair surgeries. The most common one is the urethrocutaneous fistula (UCF). In this study, we aimed to compare the closure outcome of the small-sized and medium-sized UCF after hypospadias repair with and without autologs platelet-rich plasma (PRP) graft. Patients and methods This is a prospective comparative study for managing UCF in the pediatric age group of over 1 year. They were randomly divided into two groups: group A included 20 patients who underwent repair without PRP and group B included 20 patients who underwent repair with PRP. Complication rates were compared between the two groups. Results There was a significant difference in the occurrence of complications between the two groups. Recurrence of the fistula was observed in five cases, three (15%) in group A and two (10%) in group B. In group A, the three cases with fistula failed to be treated conservatively and needed another operation 6 months after the primary repair, while in group B, two cases were treated conservatively, and spontaneous closure of the fistula occurred while only one case required another operation for closure of the fistula. Postoperative infection was reported in two (10%) cases in group A and three (15%) cases in group B; they were treated using topical and systemic antibiotics. An extensive scar was reported in one case in group A. Conclusion Autologs PRP graft could be used in hypospadias surgeries and the repair of post-hypospadias repair UCF as it is safe, easily applicable, and proven its role in decreasing complications.

Exploring the Benefits of Preoperative Androgen Stimulation in Hypospadias Surgery: A Histological Analysis of Neovascularization

Abstract Introduction: The administration of androgens prior to hypospadias surgery is recommended to enhance penile growth, improve neovascularization, and facilitate surgical correction, leading to improved cosmetic results. This study aimed to investigate the histological differences in neovascularization between hypospadiac patients who received preoperative testosterone and those who did not. Materials and Methods: A total of 33 boys aged 1–5½ years with anterior, medial, posterior penile or scrotal hypospadias were included in the study. Eighteen patients (Group A) received testosterone at a dosage of 25 mg intramuscularly every 4 weeks for 2–4 doses, with a maximum dose of 100 mg, as directed by an endocrinologist. Fifteen patients (control Group B) underwent hypospadias repair without androgen stimulation. During surgery, tissue samples were obtained from the prepuce and urethral plate (if possible). The samples were stained using immunohistochemical methods with anti-CD31 and anti-VEGF (Vascular Endothelial Growth Factor) antibodies. The number of microvessels with CD31 index and the intensity of VEGF expression in vessels, positive cells, and stroma were evaluated. Results: The microvessel count with CD31 index and the expression of VEGF in vessels and positive cells were significantly higher in hypospadiac patients who received preoperative testosterone compared to the control group (P < 0.001). Conclusion: These findings suggest that preoperative testosterone administration may enhance neovascularization in hypospadiac patients and should be considered in preoperative treatments, especially when using prepucial flaps. Further studies are needed to elucidate the role of vascularity in surgical repair and to validate these findings.

Small Intestinal Submucosa for corporeal body grafting in patients with proximal hypospadias and severe chordee: Long term follow-up assessing erectile function and genital self-perception

Proximal hypospadias and severe ventral chordee are often challenging to repair. To preserve penile length in chordee repair, Small Intestinal Submucosa (SIS) corporal grafting is often performed with potential long-term complications including recurrent curvature and erectile dysfunction (ED). There is a paucity of data evaluating sexual function in mid, late and post-pubertal patients. We aimed to assess long-term outcomes of genital self-perception and erectile function in mid, late and post-pubertal patients who underwent single-layer (1-ply) SIS corporal body grafting for correction of severe chordee. Patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting between 2001 and 2015 were retrospectively identified. Patients were evaluated for erectile and sexual function using the modified erection hardness score (mEHS) and the modified sexual health inventory for men (mSHIM). Perceived function and straightness were measured with Hypospadias Objective Scoring Evaluation (HOSE). Penile self-perception was assessed using the Pediatric Penile Perception Score (PPPS). Results were compared to an age-matched healthy control group. Categorical variables were analyzed using Fisher's exact test, and continuous variables using paired and unpaired t-test and ANOVA. Nineteen patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting and 18 controls participated in the study with a median age of 17 years for both groups. In the mEHS, 12 (63.2%) hypospadias-patients and 14 (87.5%) controls rated their erections as completely hard and very rigid. In the mSHIM, 1 (5.2%) hypospadias-patient was classified as having moderate ED. A total of 16 hypospadias-patients (84%) and 16 controls (88.9%) reported being very satisfied or satisfied with the straightness of their penis. No significant difference was observed in the mEHS, mSHIM and PPPS between groups (p<0.05). The straightness of the erection was rated lower by participants, than by the pediatric urologist. In the HOSE, 12 (63.2%) hypospadias-patients and 16 (88.9%) controls obtained an acceptable score. Our findings indicate favorable long-term outcomes in ED and genital self-perception; only 5% of our population reported having a mild-moderate to moderate presentation of ED, and there were no reports of severe ED. The overall PPPS satisfaction rates were statistically similar for the control and hypospadias groups. The small sample population limits the significance of our findings. Corporal body grafting with 1-ply SIS suggests positive long-term outcomes in genital self-perception and erectile function, with mid, late and post-pubertal patients who underwent hypospadias repair having comparable results to age-matched healthy controls.

Role of tunica vaginalis flap and dartos flap in tubularized incisional plate for primary hypospadias repair: A retrospective monocentric study.

In the tubularized incised plate (TIP) procedure, flap interposition between the skin and neourethra is highly recommended to decrease the postoperative fistula rate. However, there is no consensus regarding the ideal flap for this procedure. This study aimed to report our experiences in the one-stage TIP hypospadias surgery utilizing dartos flap (DF) (penile skin subcutaneous tissue) and tunica vaginalis flap (TVF) (parietal layer of the testis) as a tissue coverage of neourethra. In a retrospective study from Sep 2018 to May 2021, 16 cases of hypospadias with different types, ranging from midpenile to penoscrotal types, were managed with TIP urethroplasty using DF or TVF as a tissue coverage of neourethra were enrolled. The demographic characteristics of the participants, type of hypospadias, outcome, and complications were analyzed and compared. We used TVF and DF as soft tissue coverage in 11 (68.8%) and 5 (31.3%) patients, respectively. The mean age was 56.38 ± 47.83 months. Mid-penile, proximal, and penoscrotal hypospadias were presented in 3 (18.8%), 8 (50.0%), and 5(31.2%) patients, respectively. The total success rate was 14 (87.5%), while 2 (12.5%) patients developed a urethrocutaneous fistula, which required delayed closure later. In comparison between TVF and DF groups: the TVF was applied in all patients with moderate and severe chordee and all patients with penoscrotal hypospadias, and six patients with proximal hypospadias, while only three patients with mild chordee and two patients with proximal hypospadias used the DF and showed statistical significance between groups (p < 0.001 and 0.012) respectively. The success rate was 90.9% vs. 80.0% in TVF and DF groups, respectively, with no statistical significance between groups (p = 1.000). In the primary TIP repair, the TVF is a practical option as a DF for the interposition cover of a neourethra, especially in penoscrotal and proximal hypospadias with severe chordee.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 Sep 2022This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002822AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Awake Intravesical Botulinum Toxin in Pediatric Neurogenic Bladder Many pharmacological agents are derived from natural products. What started out as reports of poison-tipped arrows and blowgun darts led to interest about the paralytic properties of curare. The medical benefits of paralysis led to research into the mechanism of action and commercially available sources with reliable dosages and effects.1 One of the earliest motivations was to try to limit the effects on severe muscle contractions during electroconvulsive therapy. These efforts led to its role in general anesthesia as the paralytic agent tubocurarine.2 While other agents such as pancuronium have become more commonly used,3 the precedent was set. Botulinum toxin (Botox®) is the neurotoxin produced by Clostridium botulinum bacteria. It affects the acetylcholine receptors at the neuromuscular junction, leading to flaccid paralysis. It is a potent lethal naturally occurring toxin and has led to medical interest in much the same fashion as curare was developed into a therapeutic.4 Commercial botulinum toxin has been shown to help with muscle spasticity and to improve storage pressures in neurogenic bladder patients when injected intravesically. These treatments are usually carried out under general anesthesia. Overland et al (page 702) from San Francisco, California discuss the use of botulinum neurotoxin in an awake setting.5 They note that physiatrists have been injecting intramuscular botulinum toxin without general anesthesia or sedation in their cerebral palsy and spasticity patients. They present a small series of patients (sensate and nonsensate) who received bladder botulinum toxin injection without general anesthesia but with support standing by if needed. They had good results, with only 2 patients requiring conversion to general anesthesia or sedation, and mitigating factors such general anxiety and communication issues were present. Because botulinum toxin effects are limited and repeat injections are often necessary, performing the procedure without repeated general anesthesia not only is economical and conserves operating room time, but also helps limit anesthesia exposure. Do New Complications Develop during Puberty after Hypospadias Repair? We are currently in a period of reassessment of hypospadias methods and the reporting of complications and reoperations.6 An experienced pediatric urologist once noted that “everyone’s repair looks good at the time of surgery; tell me what it looks like at 1 year.”7 This concern about late-presenting issues has led many to advocate long-term followup through puberty. While logical, given the many anecdotal reports of late-presenting fistulas, or perhaps more accurately, late-reported fistulas, more is needed to be known about late effects, particularly in those patients who had more complex procedures. Do the growth of the penis during puberty, erections and onset of sexual activity risk greater complications later in life, when many of these patients may be transitioning out of pediatric urology care? Snodgrass and Bush (page 696) from Dallas, Texas report on their experience with patients who presented with late complications.8 All were peripubertal or postpubertal. They found in their retrospective review that 86% recalled complications occurring before puberty. They noted a bimodal presentation, with most being reported before puberty and a few developing later into adulthood, usually related to obstruction and stenosis. Selection and recall bias clearly can affect these findings, because one can only report on patients who are unhappy enough to present, and recall of exact onset can be difficult in some to pin down. Adolescents and young men who might not have relished recurrent operations on their penis as a child may not have the most reliable recall of exact onset of complications. This bimodal presentation supports the finding of Barbagli et al.9 An initial group will have issues attributed to evaluation, surgical technique and approach, and postoperative care. The later group are those older men who have had good early results but who develop late strictures and stenosis; this is believed due to neourethras created out of skin and lack of a natural corporal spongiosum support. Followup through puberty seems warranted, and patients who present later in life with a prior history of hypospadias repair deserve further investigation despite making it through adolescence doing well.

Dorsal Versus Ventral Dartos Flap to Prevent Fistula Formation in Tubularized Incised Plate Urethroplasty for Hypospadias.

The purpose of this study is to evaluate the results of two different flap procedures for prevention of urethrocutaneous fistula in hypospadias patients undergoing tubularized incised plate urethroplasty . We retrospectively reviewed 89 patients who underwent hypospadias repair. The standard technique of tubularized incised plate urethroplasty was used. There were 45 patients in Group 1 and 44 patients in Group 2, in which ventral and dorsal dartos flaps were used to cover the neourethra respectively. Surgical complications were assessed as the main outcomes. The results were analyzed with Chi-square and Mann-whitney u tests. There was no significiant difference between the groups in terms of age and meatus location. We observed postoperative surgical complications in 15 (33.3 %) patients in Group 1 and in 4 (9.1 %) patients in Group 2. The complications noted in the Group 1 were urethrocutaneous fistula in 10 patients ( 22.2 %) and meatal stenosis in 5 patients ( 11.1 %). In Group 2, fistula was observed in 2 patients (4.6 %) and stenosis in again 2 patients (4.6 %). Urethrocutaneous fistulas occurred statistically more frequently when ventral based dartos flaps were used (P < .05). Several flap procedures and their modifications have been suggested to avoid fistula formation. Within these procedures, dartos flaps are reported to be very useful for primary distal or proximal hypospadias repair and reoperations. In this study, we concluded that ; vascularized dorsal preputial dartos flap procedure is safe and more effective than ventral based flap in prevention of fistula formation.

A Comparative Study on the Outcomes of Hypospadias Surgery Following Early Versus Late Bladder Catheter Removal.

BackgroundHypospadias is the most common penile malformation affecting up to one in 300 live male births. In general, a urinary diversion (urethral stent or bladder catheter) is maintained in situ for two to seven days or more after hypospadias repair. Because of the low level of evidence, the latest guidelines of the European Association of Urology and the European Society of Paediatric Urology provide no recommendations concerning the timing of catheter removal after hypospadias surgery. In this study, we aimed to compare the outcomes of hypospadias surgery (tubularized incised plate urethroplasty, TIPU) following early versus late bladder catheter removal.MethodologyIn total, 62 patients were included in this study. All patients underwent TIPU by the same team of surgeons. All patients were divided into the following two groups: group A (32 patients) had their catheter removed on or before the fifth postoperative day, and group B (30 patients) had their catheter removed after the fifth postoperative day. All patients were scheduled for an outpatient assessment after two weeks, at one month, after three months, and at six months if necessary.ResultsThe mean age of patients in group A was five years (three to seven years) and in group B was five years (four to 7.25 years) with a p-value of 0.378. Among the early complications of the surgery, the occurrence of wound infections, urinary tract infections, and urinary retention was comparable among the two groups. The rate of bladder spasms (0% versus 13.3%, p = 0.033) was significantly higher in group B than in group A. The rate of urinary retention (12.5% versus 0%, p = 0.045) was significantly higher in group A than in group B. Superficial wound infection occurred in two out of 32 patients in group A (6.3%) and two out of 30 patients in group B (6.7%) (p = 0.94). Both groups had similar incidences of wound complications. Urinary tract infections also had a similar incidence in both early and late catheter removal groups, i.e., one out of 32 patients in group A (3.1%) and three out of 30 patients (10%) in group B (p = 0.271). Urinary extravasation following hypospadias repair occurred in two out of 32 patients (6.3%). No extravasation was noted in the late catheter removal group. However, the difference was not clinically significant (p = 0.164). Two patients in both groups developed urethrocutaneous fistula (6.3% in group A versus 6.7% in group B). However, the difference was not clinically significant. Meatal stenosis developed in three out of 32 patients in group A and two out of 30 patients in group B (9.4% versus 6.7%; p = 0.696). One patient in the early catheter removal group developed urethral stricture as a late complication. None of the patients in the late catheter removal group developed this complication.ConclusionsThe occurrence of long-term complications of TIP hypospadias repair was not affected by the early removal of the bladder catheter. The shortcomings of our study were its descriptive nature and the small sample size. Further prospective randomized controlled trials are needed to ascertain the safety of early catheter removal and improvement in quality of life in the immediate postoperative period.

Commentary to ‘Is parenteral antibiotic prophylaxis associated with fewer infectious complications stented, distal hypospadias repair?’

In this report, Doersch and co-authors address the controversy of the use of antibiotics for hypospadias repair [ [1] Doersch K. Logvinenko T. Nelson C. Is parenteral antibiotic prophylaxis associated with fewer infectious complications stented, distal hypospadias repair?. J Pediatr Urol. 2022; 18: 759-763 Google Scholar ]. The two reasons to consider antibiotic prophylaxis during hypospadias repair are to reduce wound infections and symptomatic urine infections associated with a catheter. Both of these are quite uncommon, as shown in this study reporting only a single infectious complication in 100 boys undergoing distal repairs without preoperative parenteral antibiotics, and no infections in those not receiving postoperative antibiotics. Is parenteral antibiotic prophylaxis associated with fewer infectious complications in stented, distal hypospadias repair?Journal of Pediatric UrologyVol. 18Issue 6PreviewJudicious use of antibiotics for surgical prophylaxis is important for reducing antimicrobial resistance while preventing infectious surgical complications. In the setting of pediatric distal hypospadias repairs, it is unclear if antibiotic surgical prophylaxis is beneficial. Full-Text PDF

Impact of Pre-Operative Instructions Regarding Hypospadias Repair on Mothers’ Knowledge, Practices and Selected Post-Operative Outcomes

Impact of Pre-Operative Instructions Regarding Hypospadias Repair on Mothers’ Knowledge, Practices and Selected Post-Operative Outcomes

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Shared decision-making for pediatric elective penile surgery.

In pediatric surgery, proxy decision-makers are frequently involved in treatment planning and may experience decisional conflict (DC). Shared decision-making (SDM) approaches may be effective to remedy DC. This study investigates DC and SDM involvement in elective pediatric penile surgery. Forty-four parents of children aged <8 years undergoing elective penile surgery consultations at a tertiary pediatric hospital were prospectively enrolled. Patient and physician questionnaires were used to assess the SDM process and the SURE (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) screening test was used to assess DC. Thirty-seven (84.1%) mothers and seven (15.9%) fathers were enrolled for circumcision (n=33, 75.0%) and distal hypospadias repair (n=11, 25.0%) consultations, with 21 (47.7%) choosing to proceed with surgery. Seven (15.9%) participants experienced clinically significant DC. Participant gender was not associated with higher levels of DC (p=0.318). The average patient and physician SDM scores were 88.2±10.0 and 85.3±7.4, respectively, with no correlation found between participant and physician perception of SDM involvement (p=0.168, p=0.276). DC was significantly associated with lower participant and physician ratings of SDM. There was a high perception of SDM involvement by both parents and pediatric urologists regarding elective penile surgery. Of the 15% of parents experiencing DC, there was an association with lower participant and physician levels of SDM involvement. Despite high SDM scores overall, discrepancies exist between the perceived physician and participant SDM involvement.