Primary Hypospadias Repair Research Articles

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.

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 outcomes in three surgical techniques for proximal hypospadias: staged transverse preputial island flap urethroplasty versus single-stage repairs.

To evaluate and compare the outcomes and complications of three different surgical techniques for treating primary proximal hypospadias with ventral curvature (VC) ≥30°, we retrospectively reviewed the medical records of patients who underwent primary repair of proximal hypospadias with VC ≥30° after degloving at Beijing Children's Hospital Affiliated to Capital Medical University (Beijing, China) from January 2019 to January 2021. A total of 152 patients were divided into three groups: transverse preputial island flap (TPIF) combined with Duplay, modified Koyanagi, and staged TPIF, which were performed on 55, 16, and 81 patients, respectively. A total of 39 (25.7%) patients had complications. Complications rates were similar for the TPIF combined with the Duplay group (40.0%) and modified Koyanagi group (50.0%) but lower for the staged TPIF group (11.1%; P < 0.01). The incidence of urethrocutaneous fistulas was significantly higher in TPIF combined with Duplay group (21.8%) compared to staged TPIF group (4.9%; P = 0.01). In univariate analysis, the length of the urethral defect was the single factor that could predict complications; the cutoff was 4.55 cm. More patients in the long urethral defect group than in the short one had complications (34.1% vs 15.7%, P = 0.01). These results indicate that staged TPIF produced a better outcome, whereas more patients in the TPIF combined with Duplay group presented with two or more complications.

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

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

Analysis of factors associated with postoperative complications after primary hypospadias repair: a retrospective study.

To determine the risk factors for postoperative complications after primary hypospadias repair. Hypospadias has a high postoperative complication rate, and the risk factors of postoperative complications have attracted extensive attention. A total of 857 children who received primary surgical repair for hypospadias in our center between 3 January 2017 and 29 January 2021 were retrospectively analyzed. The collected data included age at time of surgery, type of hypospadias, body mass index (BMI), surgeon, operation time, length of reconstructed urethra, method of anesthesia (general anesthesia or general anesthesia combined with caudal anesthesia), and postoperative constipation. The risk factors for postoperative complications were analyzed by multivariate analysis. The follow-up time in this study was 6-54 months, with a mean follow-up time of 29 months. A total of 96 (11.2%) of the 857 pediatric patients had postoperative complications, including 44 (45.8%) cases of urethral fistula, 14 (14.6%) cases of urethral stricture, 5 (5.2%) cases of urethral diverticula, 5 (5.2%) cases of distal dehiscence, 3 (3.1%) cases of poor exposure, 2 (2.1%) cases of residual curvature, 1 (1.0%) case of penoscrotal transposition, 6 (6.3%) cases of urethral stricture and diverticulum, 6 (6.3%) cases of urethral fistula and diverticulum, 3 (3.1%) cases of urethral fistula and postoperative residual curvature, 2 (2.1%) cases of urethral fistula and distal dehiscence, and 1 (1.0%) case each of urethral fistula and transposition, urethral diverticulum and poor exposure, urethral stricture and poor exposure, distal dehiscence and transposition, and residual curvature and transposition. After univariate analysis, type of hypospadias (P=0.038), operation time (P<0.001), length of reconstructed urethra (P=0.007), and postoperative constipation (P=0.019) were included in the multivariate logistic regression analysis. The results showed that postoperative constipation was an independent risk factor for complications [P=0.027, odds ratio (OR) =1.793, confidence interval (CI): 1.067 to 3.012]. Postoperative constipation is an important influencing factor for postoperative complications following primary hypospadias repair. Therefore, defecation management should be strengthened for hypospadias patients during the perioperative period.

The Impact of Perioperative and Operative Variables on Early Postoperative Complications Following Primary Hypospadias Repair

ObjectiveTo evaluate possible risk factors for complications following primary hypospadias repair relative to factors associated with timing of hypospadias repair in terms of case order, morning or afternoon scheduling, perioperative delays, and surgeon's daily work schedule as well as individual operative techniques. MethodsWe retrospectively reviewed charts of 422 boys undergoing primary hypospadias repair with a sutured urethroplasty by 1 of 3 surgeons over a 10-year period and the surgeon's daily schedule. ResultsThe median age and IQR of the patients at time of operation was 0.79 (0.57) years, and median follow-up was 259 (664) days. A significant increase in the rate of any complication was noted with morning vs afternoon cases for the group overall with morning cases having a hazard 2.3 times higher than afternoon cases (P =.012). Additionally, there was a significant increase in hazard of complication with increasing difference in time between actual procedure duration vs scheduled duration, with hazard of complication increasing 5% for each increase of 15 minutes of surgical time (P =.043). ConclusionA variety of previously identified potential risk factors for hypospadias complications were identified. Our analysis also demonstrated variability in level of risk of different factors between surgeons, reinforcing the utility of surgeons monitoring their own results in response to changes in technique. Novel potential risk factors for some surgeons identified in our study included an increased risk of complications when the hypospadias was done in the morning rather than the afternoon and when the procedure lasted longer than scheduled.

A simple technique to repair distal and mid-shaft hypospadias using a de-epithelialized Byars' flap.

ObjectiveTo describe standard and modified de-epithelialized Byars’ flap techniques in tubularized incised plate urethroplasty and evaluate postoperative outcomes.MethodsWe retrospectively evaluated data for 404 primary hypospadias repair patients who underwent standard (Group A) or modified (Group B) urethroplasty between January 2016 and 2021. Group B’s data were analyzed to evaluate whether our modified technique was effective for all hypospadias types.ResultsThere was no difference in the ratio of different hypospadias types between Groups A (n = 145) and B (n = 259). Median follow-up duration was 35 months. Fistula occurred in 19 patients in Group A and 12 in Group B (statistically significant difference). The total complication rate was statistically significantly different between the groups. In Group B, 3/142 patients with distal hypospadias developed urethrocutaneous fistula vs 4/95 with mid-shaft hypospadias and 5/22 with proximal hypospadias. No difference was noted between the distal and mid-shaft groups. Significant differences were observed when comparing distal and mid-shaft groups with the proximal group; total complication rates were similar. Glans dehiscence and meatal stenosis rates were similar between Groups A and B, and among the hypospadias phenotypes.ConclusionOur modified procedure is simple to perform and yields excellent results in distal and mid-shaft hypospadias repair.

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.

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.

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.

Effect of surgical steps in primary hypospadias repair on penile length

To document the effect of surgical steps, including penile degloving, plate transection, dorsal plication, and fasciocutaneous coverage, in primary hypospadias repair on penile length. A consecutive series of 209 prepubertal boys with primary hypospadias repair was included with the age ranged from 10 to 97 months (mean, 31.7 months). Intraoperative stretched penile length (SPL) was measured before operation ( n=209), and after each step, namely penile degloving ( n=152), plate transection ( n=139), dorsal plication ( n=170), and fasciocutaneous coverage ( n=209). SPLs before and after each steps or the entire operation were analyzed. The SPL was compared between plate transection group and plate preservation group, dorsal plication group and non-plication group, and plate preservation with plication group and plate preservation without plication group, respectively. Differences of SPL between before and after each steps were analyzed with factors including neourethra length, rest dorsal penile length, rest ventral penile length, preoperative SPL, and the degree of penile curvature after penile degloving, with multivariate linear regression analysis. All the four steps resulted in SPL difference. The SPL increased after penile degloving and plate transection ( P<0.05), and decreased after dorsal plication and fasciocutaneous coverage ( P<0.05). The SPL increased after all steps were completed ( P<0.05). In patients with plate transection, postoperative SPL increased when compared with that before operation ( P<0.05). No significant difference was noted in patients without plate transection ( P>0.05). And there was significant difference in the increased length of SPL between patients with and without plate transection ( P<0.05). In patients with dorsal plication, a significant increase of postoperative SPL ( P<0.05) was noted. No significant difference was noted in patients without dorsal plication ( P>0.05). And there was no significant difference in increased length between patients with and without dorsal plication ( P>0.05). When patients with plate transection were excluded, dorsal plication resulted in no significant difference on postoperative SPL ( P>0.05). The increased length of SPL after penile degloving, dorsal plication, or cutanofascial coverage was not related to the neourethra length, the rest dorsal penile length, the rest ventral penile length, the preoperative SPL, and the degree of penile curvature ( P>0.05). However, the neourethra length and preoperative SPL were the influencing factors for the increased length of SPL after plate transection ( P<0.05). The main steps in primary hypospadias repair can change SPL. The lengthening effect of plate transection would not be counteracted by dorsal plication. Dorsal plication makes no significant difference on postoperative SPL.

Urethrocutaneous fistula repair following hypospadias surgery using the PATIO technique for small fistulae: A single centre experience

Urethrocutaneous fistula (UCF) development following primary hypospadias repair is a common complication with high rates of recurrence despite attempts at repair. A novel technique for the management of these fistulae, the PATIO (preserve the tract and turn it inside out) repair, has been described and has shown encouraging outcomes in previous reports. The aim of this study was to evaluate fistula repair outcomes in patients undergoing the PATIO technique compared with standard repair. A retrospective chart-based review was performed for pediatric patients undergoing UCF repair from January 2005 to July 2018. Data including: age, follow-up, meatal location, meatal stenosis, number of fistulae and repairs, UCF location, complications, and outcomes was obtained. Cases were categorized into PATIO repair, standard repair, and PATIO repair following prior standard repair. Surgical outcome with respect to freedom from fistula recurrence was determined. In total, 586 patients underwent hypospadias surgery with 44 patients developing 52 UCF cases that required repair during the study period for a fistula rate of 8.9%. Mean age at repair was 19 months. Median follow-up time was 28 months. For PATIO repair alone, 21/26 (81%) had success. For standard repair alone, 8/18 (44%) had success and for standard repair followed by PATIO repair, 8/8 (100%) were successful. A statistically significant difference was noted for success when comparing standard repair with PATIO repair (p=0.023, p<0.05) and PATIO repair following standard repair (p=0.010, p<0.05). There was a statistically non-significant difference between PATIO repair and PATIO repair following standard repair (p=0.309, p<0.05). Failure following PATIO repair was found in cases where the procedure was early in implementation and experience was limited. UCF repair using the PATIO technique has shown encouraging results in the short-term, with a majority of patients achieving a successful outcome compared with standards techniques. As this procedure continues to be used and experience develops, a larger sample of cases will become available for analysis and longer follow-up will prove necessary in examining the long-term outcomes of this procedure. The outcomes examined have demonstrated consistency with previously reported outcomes in the literature. Limitations include small sample size, short-term follow up, and the retrospective nature of the review. The findings of this study have provided further support to the use of this technique in conventional UCF repair as a means to decrease the risk of recurrence and provide durable results in the short-term. Ongoing follow up will prove necessary to examine success in the long-term.

MP47-09 OVER 5,000 HYPOSPADIAS REPAIRS: IS CAUDAL ANESTHESIA ASSOCIATED WITH COMPLICATIONS?

You have accessJournal of UrologyPediatric Urology III (MP47)1 Sep 2021MP47-09 OVER 5,000 HYPOSPADIAS REPAIRS: IS CAUDAL ANESTHESIA ASSOCIATED WITH COMPLICATIONS? Jonathan Hu, Craig Belon, Niroop Ravula, Blythe Durbin-Johnson, and Eric Kurzrock Jonathan HuJonathan Hu More articles by this author , Craig BelonCraig Belon More articles by this author , Niroop RavulaNiroop Ravula More articles by this author , Blythe Durbin-JohnsonBlythe Durbin-Johnson More articles by this author , and Eric KurzrockEric Kurzrock More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002068.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is controversy surrounding the association between caudal epidural blocks and complication rates after hypospadias repair. Single-center and/or low volume studies may lead to underpowered data and/or confounding variables. We hypothesized that caudal anesthesia is associated with more complex hypospadias surgery and not associated with increased rates of reoperation after primary repair. METHODS: The Clinical Practice Solutions Center database was used to query patients who received a primary hypospadias repair between 2009 and 2010. Primary hypospadias repair was further categorized as meatal advancement and glanduloplasty (MAGPI), distal, one-stage proximal, and one-stage perineal repair. Anesthesia coding was evaluated to identify those who received a caudal epidural block. Any secondary surgery was captured between 2009 and 2019 and the types of secondary surgeries were identified. Variables such as caudal anesthesia, age, insurance type, surgeon volume, and surgeon years in practice were analyzed with mixed effects multiple logistic regression models in order to incorporate for random effects of surgeon and institution. RESULTS: Our database identified 5,178 boys who had primary hypospadias repair. There were 84 surgeons at 46 institutions. 1,245 underwent primary MAGPI (24%), 3,466 distal (67%), 409 proximal (0.08%), and 58 perineal hypospadias repair (0.01%). 1,331 individuals in our cohort received caudal anesthesia (25.7%). The percentage of caudal anesthesia performed by each type of primary surgery was 21% for MAGPI, 28% for distal, 23% for proximal, and 16% for perineal hypospadias repair. Utilization of caudal anesthesia was not associated with type of primary surgery (p=0.19). Adjusting for all other variables, increased patient age was associated with decreased usage of caudal anesthesia OR 0.985 CI [0.98, 0.989] p<0.001). Increased surgeon years in practice was marginally associated with decreased usage of caudal anesthesia (OR 0.974 CI [0.947, 0.999] p=0.04). There was no association of caudal block and secondary surgery after primary MAGPI, (OR 1.104 CI [0.617, 1.976], p=0.74), distal (OR 1.127 CI [0.85, 1.495] p=0.41), proximal (OR 1.625 CI [0.852, 3.101] p=0.14), or perineal hypospadias repair (OR 0.692 CI [0.097, 4.919] p=0.71). CONCLUSIONS: This large, multi-institution study demonstrates that the use of caudal anesthesia was not associated with more complex hypospadias surgery and was not associated with increased rates of secondary surgery after primary hypospadias repair. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e826-e826 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Hu More articles by this author Craig Belon More articles by this author Niroop Ravula More articles by this author Blythe Durbin-Johnson More articles by this author Eric Kurzrock More articles by this author Expand All Advertisement Loading ...

Reoperation after Hypospadias Repair: Long-Term Analysis.

While the true incidence of secondary hypospadias repair is unknown, the current literature cites a 3.3% to 6.7% reoperation rate after distal hypospadias repair and an association with age. We hypothesized that secondary surgery rates are associated with patient factors and have been underreported due to limited followup. We used an academic practice plan consortium database to identify a population that underwent primary hypospadias repair in 2009 and 2010. Secondary surgeries between 2009 and 2019 were captured. The association of variables such as age, insurance type, region, surgeon volume and surgeon years in practice with all-inclusive and specific secondary surgery procedures were analyzed using mixed effects multiple logistic regression models. We identified 5,178 boys who had primary hypospadias repair performed by 84 pediatric urologists at 46 hospitals in 2009 and 2010. During the ensuing 9 to 10 years, distal, proximal and perineal hypospadias repair had a 12.6%, 37.9% and 46.6% rate of secondary surgery, respectively. After adjusting for all other variables in the model, patients with noncommercial insurance had a 26% (OR 1.26, p=0.04) increased odds of secondary surgery. Patient age and surgeon years in practice were not associated with all-inclusive secondary surgery except for endoscopic treatment. Surgeon volume was not associated with secondary surgery. This study demonstrated that secondary surgery rates are underreported if followup is limited to less than 6 years. Patient age, surgeon volume and experience did not associate with all-inclusive reoperation rates whereas insurance status was a major predictor of reoperation.

The learning curve in proximal hypospadias repair

Although the learning curve in various surgical procedures is increasingly discussed, there have been only a few reports about the learning curve especially in proximal hypospadias repair. To evaluate the learning curve in one-stage hypospadias repair for proximal hypospadias. We retrospectively reviewed 73 cases of primary hypospadias repair by a single pediatric urologist using one-stage urethroplasty with a preputial skin graft between 2007 and 2018. The overall complication rate included fistula, glans dehiscence, and meatal stenosis. To analyze the impact of the surgeon's experience on the complication rate, we compared the complication rates among different groups of 20 consecutive cases each. In addition, we graphed the actual data of the operative time and cumulative complication rate to evaluate the learning curve. The cumulative complication rate was defined as the surgeon's complication rate (the number of complications accumulated at a time/number of cases at that time). The median age at surgery was 18 months (range: 7-87). The median follow-up was 40 months (range: 3-114). In total, 13 (18%) children had complications: 9 fistulae, 3 glans dehiscence, and 2 metal stenoses. The analysis of each 20 cases revealed that the complication rate declined over time as the surgeon became more experienced. It was mainly attributed to a decline of the fistula rate. The diagram of the operative time showed a reduction with the increasing surgical experience. Additionally, the diagram of the cumulative complication rate demonstrated a plateau after 50 cases. Our study showed the positive impact of surgeon experience on the outcome of one-stage repair for proximal hypospadias. In addition, the learning curve in proximal hypospadias repair stabilized after about 50 cases although the supervision of experienced surgeons is required during the early phase of learning curve.

Effect of Caudal vs. Penile Block on the Incidence of Hypospadias Complications Following Primary Repairs: A Retrospective Cohort Study.

Primary repair of hypospadias is associated with risk of complications, specifically urethrocutaneous fistula and glanular dehiscence. Caudal block may potentially increase the risk of these complications. Therefore, we studied the incidence of hypospadias complications in children who underwent correction at our institution having received either penile or caudal block. We analyzed all primary hypospadias repair cases from December 2011 through December 2018 at Texas Children's Hospital with a minimum of 1-year followup for the presence of complications: urethrocutaneous fistula and glanular dehiscence. Surgical (surgeon, operative time, block type, local anesthetic, meatal position) and patient (age at correction, prematurity) factors were additionally analyzed. For the primary aim, 983 patients underwent primary hypospadias correction with a minimum of 1 year of postoperative followup data. There were 897 patients (91.3%) in which no complications were identified and 86 (8.7%) with either urethrocutaneous fistula (81) or glanular dehiscence (5). Of the 86 identified complications, 45/812 (5.5%) were distal, 41/171 (24%) were proximal (p <0.001) with a complication. Rate of complications was not associated with caudal block (OR 0.67, 95% CI 0.41-1.09; p=0.11). On univariable analysis, age (OR 1.12, 95% CI 1.04-1.20; p=0.04), surgical duration (OR 1.02; 95% CI 1.01-1.02; p <0.001), prematurity <32 weeks (OR 4.38, 95% CI 1.54-4.11 p <0.001) and position of meatus as proximal (OR 5.38 95% CI 3.39-8.53; p <0.001) were associated with an increased rate of complications. However, on multivariable analysis, associations of age (OR 1.13, 95% CI 1.05-1.22; p=0.001), surgery duration (OR 1.01, 95% CI 1.01-1.02; p <0.001) and meatal position (OR 3.85, 95% CI 2.32-6.39; p <0.001) were associated with increased rate of complications. Our data suggest that meatal location, older age, extreme prematurity and surgical duration are associated with increased incidence of complications (urethrocutaneous fistula and glanular dehiscence) following hypospadias correction. Analgesic block was not associated with increased hypospadias complication risk.

Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair

The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The 'M' component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in 'meatal mismatch.' To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development. We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with <6 months of follow-up. Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0-20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44-6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29-3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09-0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings. Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias. Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development.

Identification of risk factors associated with numerous reoperations following primary hypospadias repair

Complications remain the top evaluation priority subsequent to hypospadias repair. Complications vary in further management, and usually require one or more reoperations. Patients and/or their parents concern not only with the success rate of reoperation, but also with the risk of numerous reoperations. To identify the risk factors associated with numerous reoperations following primary hypospadias repair. Data were collected retrospectively from patients who underwent reoperations for complications following primary hypospadias repair at a single institution from August 2008 to October 2017. A total of 507 patients required reoperations following 2754 primary hypospadias repairs. Eventually, 486 patients were eligibly included with a median age of 2.2 years. The median follow-up period was 6.5 years. Preserved urethral plate urethroplasty for primary repair (including Snodgrass, Onlay and Mathieu techniques) was performed in 307 (63.2%) patients, Duckett technique was performed in 121 (24.9%) patients, and staged urethroplasty (including staged Duckett, Byars and Bracka techniques) was performed in 58 (11.9%) patients. The complications included 302 fistulas, 108 dehiscence, 50 urethral strictures, 18 meatal stenosis, 38 diverticula, 24 mild recurrent ventral curvature and 23 severe recurrent ventral curvature. A total of 363 (74.7%) patients needed 1 reoperation, 87 (17.9%) needed 2 reoperations, 19 (3.9%) needed 3 reoperations, and 17 (3.5%) needed >3 reoperations. Ordinal logistic regression demonstrated that severe recurrent ventral curvature, urethral stricture, dehiscence and primary staged hypospadias repair increased the risk of numerous reoperations, with odds ratios of 75.991-fold, 36.967-fold, 11.765-fold and 3.074-fold, respectively. In contrast, diverticulum decreased the risk, with an odds ratio of 0.443-fold. Our data demonstrated significant heterogeneity in the risk of numerous reoperations for each complication. Severe recurrent ventral curvature conferred the highest risk of numerous reoperations, followed by urethral stricture, dehiscence. In additional, our data showed an increased risk of numerous reoperations following primary staged repairs. Identification the risk factors confers advantages in the assessment of postoperative outcomes and anticipation of future reoperations. Severe recurrent ventral curvature, urethral stricture, dehiscence and primary staged hypospadias repair were associated with numerous reoperations following primary hypospadias repair.

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

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

A cover flap reduces the rate of fistula after urethroplasty whatever the severity of hypospadias.

To determine which patients should benefit from the interposition of a well-vascularized flap between the neourethra and the penile skin and if it should be performed even in mild hypospadias. A retrospective study on patients with a primary hypospadias repair was performed (2003-2017). Only patients undergoing urethroplasty based on the principle of a tubularization were selected to ensure comparable groups. Patients were assigned in two groups according to the use or not of a cover flap. Univariate analysis and adjusted logistic regression were used to evaluate the relation between postoperative complications, the severity of hypospadias, the use of flap and patients' characteristics. Three-hundred and seventy-six patients were included with anterior (59.3%), midshaft (27.4%) and posterior hypospadias (13.3%). The median follow-up was 54months (24months-17years). The overall rate of fistula was 11.7% (n = 44). Comparing the outcome in children with flap (n = 217) to controls (n = 159) showed that the use of a flap reduces the rate of fistula (6.5 vs 18.9%, p < 0.001). Stratification of the study according to the phenotype reveals that the more severe the hypospadias, the more protective was the flap (OR = 2.6 for anterior, 5.5 for midpenile, 7.1 for posterior hypospadias). The flap remains nevertheless significantly effective whatever the phenotype (p < 0.05 for anterior, p = 0.01 for midpenile, p = 0.02 for posterior hypospadias). The more severe the hypospadias, the more effective is the cover flap to avoid fistula. It remains nevertheless suitable even in anterior hypospadias and the use of a cover flap should not be limited to the surgery of severe phenotypes.