Proximal Hypospadias Repair Research Articles

Unexpected outcome of a modification of Bracka repair for proximal hypospadias: High incidence of diverticula with flaps

Various graft and flap techniques have been proposed for urethral reconstruction in proximal hypospadias repair. The Bracka repair involving the transfer of inner prepuce like a Wolfe graft mostly results in satisfactory results besides a high fistula rate. The aim was to decrease the high fistula rate with Bracka repair; we wanted to use the advantages of vascularized skin in the Bracka method. The aim of this study was to evaluate our results with this modification. Our modification involves using a flap instead of a graft. In the first stage, chordee was corrected by transection of the urethral plate and dorsal midline plication when necessary. Instead of a graft as suggested by Bracka, inner preputial skin with ample blood supply was transferred and stitched to the denuded ventral penile surface. In the second stage after 6 months, this flap was tubularized in the Thiersch-Duplay fashion. Hospital records of patients who had undergone two stage modified Bracka repair between June 2007 and July 2012 were reviewed, including complaints, complications, and need for interventions. Thirty-eight patients had undergone this operation. Four patients were lost to follow-up. The main complaint was obstructed urinary flow. Voiding symptoms were first attributed to urethral stenosis, but were, however, found to be due to diverticulum and vortex of the urine in the dilated urethra. Twenty-one patients (61%) had voiding problems and 10 patients (29%) had urinary tract infections. Fistula was observed in 23 and diverticula were observed in 24 patients. Of these, 16 patients had both fistula and diverticula. Only two patients (5%) were free of complications and totally satisfied with the operation, and 23 of the 34 patients had complications requiring intervention (Figure). Inner preputial flaps used in proximal hypospadias repairs are prone to diverticula formation. They become redundant in time requiring reoperation, thus decreasing the success rate. Careful fixation of the flap to the corpora and allowing time for additional attachment of the urethral plate substitution through fibrotic activity could not overcome this complication. Our modification of the Bracka technique using a flap for the plate resulted in a high rate of complications (in particular diverticulum formation) and was therefore abandoned. We recommend careful use of flaps in hypospadias surgery and long-term follow-up studies to evaluate actual functional and cosmetic results.

Long-term functional outcomes after penoscrotal hypospadias repair: A retrospective comparative study of proximal TIP, Onlay, and Duckett

A variety of techniques are available for proximal hypospadias repair. Onlay, proximal tubularized incised plate (TIP), and Duckett are among the popular choices because they can be performed as a one-step procedure. However, the decision to select a procedure often comes down to the surgeon's preference rather than that supported by evidence-based data. In particular, there is a paucity of literature on the long-term urinary outcomes after proximal hypospadias repair. The aim of this study was to evaluate the evolution of long-term uroflowmetry parameters after proximal hypospadias surgery over a long-term follow-up including the adolescent period. Files from patients who underwent primary proximal hypospadias repair at our institution between 1997 and 2001 were reviewed. Only patients with documented serial postoperative uroflowmetry profiles at follow-up visits were included. Comparison between surgeries (pTIP vs. Onlay vs. Duckett) was performed according to the following postoperative time interval endpoints: 0-1 years, 1-2, >2-4, >4-6, >6-10, >10-12, and >12 years. Maximal urinary flow rate (Qmax) in relation to voiding volume (VV) adjusted for age or body surface area (BSA) were also evaluated in comparison to normal children using established Miskolc nomograms and compared between surgery techniques. Fifty-two patients met the inclusion criteria with a median follow-up of 10 years: 25 (59.6%) TIP, 18 (34/6%) Onlay, and nine (17.3%) Duckett. Overall, Qmax increased progressively according to time and age in particular during the period covering adolescence. At follow-up 12 years postoperatively, median Qmax values were 18.5mL/second, 13.8mL/second and 16.6mL/second for TIP, Onlay, and Duckett, respectively, with no significant differenced detected between groups (p=0.5) see figure). Compared with normal children when adjusted for voiding volume and BSA, the proportion of obstructive uroflowmetry patterns defined as Qmax<25th percentile of nomograms was more prevalent in patients aged 3-7 years old at 83.8% but decreased to less than 21.2% in patients aged >13 years for all procedures (see figure). These results are consistent with previous work showing frequently reduced Qmax after hypospadias surgery with great potential for improvement at puberty. These results suggest that the obstructive urinary flow pattern observed in patients early on is a frequent finding after proximal hypospadias surgery. However, because of the remarkable improvement observed at puberty a watchful waiting approach is proposed in order to avoid unnecessary intervention.

Modification of the Koyanagi Technique for the Single-Stage Repair of Proximal Hypospadias.

We describe a modification of the Koyanagi technique for hypospadias in an attempt to reduce complications and improve results. Between January 2005 and July 2012, 21 patients underwent treatment of proximal hypospadias using a modified hypospadias repair. The procedure involved making a U-incision similar to that in a Thiersch-Duplay repair to preserve the blood supply to the tubular neourethra. The neourethra was reconstructed by island penile skin. An M-incision was made in the glans, and the meatus was attached to tip of glans. Flaps were harvested from both sides of the penis preventing postoperative penile turn. Cosmetic and functional, long-term (mean, 12 months) recovery was excellent. Complications consisted of 3 cases of urethrocutaneous fistula (14.2%), which were corrected surgically, and 2 cases of penile skin necrosis. There were no instances of meatal stenosis, diverticulum, or urethral stricture. Bifid scrotum was present in 6 patients, and associated penoscrotal transposition was present in 15 patients. Both of these associated defects were corrected at the time of surgery. The modified technique permits 1-stage repair of proximal hypospadias with a low complication rate, the satisfactory recovery.

Our experience of proximal hypospadias repair using the Cloutier-Bracka technique at the Gynaeco-Obstetric and Paediatric Hospital, Yaounde-Cameroon.

Background:In parts of Africa, routine circumcision is practised and sometimes even on children with hypospadias. The lack of preputial foreskin renders urethroplasty more difficult and often requires to use of a mucosal graft as described by Bracka.Objective:The authors describe their experience of hypospadias repair using Bracka's technique.Materials and Methods:Over a period of 5 years, 100 cases of proximal hypospadias were operated in our institution. All patients aged 0–18 years who had already been circumcised were included in this study.Results:The outcome of the 12 cases operated according to Bracka's technique was analysed. The mean age was 11.5 years. The ectopic meatus was penoscrotal in three cases, scrotal in one case and perineal in eight cases. After reconstruction, the new meatus was sutured at the top of the glans in one case, at the prepuce in seven cases and at the penile midshaft in one case. The main complications noted were surgical site infection, wound dehiscence, residual chordee and urethrocutaneous fistula. No neourethral stenosis nor uretrocele was recorded.Discussion:The buccal mucosal graft urethroplasty as described by Bracka is associated with a lower risk of meatal strictures compared to other free mucosal grafts. The buccal mucosa is easier to harvest and causes less scarring than bladder mucosa.Conclusion:Repair of severe hypospadias remains a challenge for paediatric surgeons. The functional and cosmetic outcomes depend on the choice of the donor site for the graft and objective assessment of successful reconstruction criteria during follow-up.

Can separation of the scrotal sac in proximal hypospadias reliably predict the need for urethral plate transection?

One of the main challenges in proximal hypospadias repair is correcting curvature. The best technique to achieve this remains the object of debate. Indeed, some authors believe the urethral plate should be kept and used as often as possible. In some cases, however, even after extensive mobilization and dorsal plication, significant curvature remains and it is necessary to transect the urethral plate. Having a reliable pre-dissection marker of the need for urethral transection would be useful in choosing a technique.We wanted to determine if presence of marked separation of the scrotal sac (SSS), also referred to as bifid scrotum, could reliably predict the need for urethral plate transection. We prospectively enrolled a series of boys with proximal hypospadias. We noted age, degree of hypospadias, meatal position, presence of cryptorchidism, and presence or absence of SSS. During surgery we fully degloved the penile shaft, freeing all ventral tissues, and radically dissected the more proximal bulbar urethra. We then performed an erection test. If there was residual curvature <30° we performed a dorsal plication, if it was >30° we transected the urethral plate. Twenty-nine patients were included, of whom 18 presented SSS. The average age was comparable in both groups, as was type of hypospadias and meatal position. We estimated transection of the urethral plate to be necessary in 15 out of the 18 children with SSS, and 2 out of the 11 children without SSS. The relative risk for requiring urethral plate transection in case of SSS in this series was 4.58. Techniques that commit to urethral plate transection are criticized because they preclude using the urethral plate. In our study presence of SSS was predictive for the need to transect the plate. Obviously one can decide to keep the urethral plate at all cost, and mobilize it more than we did, or accept more residual curvature, but in reality our aim was to determine a preoperative marker allowing us to define a patient category. We believe presence of SSS is a marker of severity, and that this "severity" translates into "a less usable urethra". As recent studies caution us about the evolution of the reconstructed native urethra and the possibility that it may not grow as well as the other penile tissues, we believe this extra information could influence the surgeon's decision as to the most appropriate technique for each patient.

Two-Stage Repair for Severe Proximal Hypospadias Using Oral Mucosal Grafts: Combination of a Modified Bracka Method and a Modified Byars Flap Method: Should Local Flaps be Used for Urethral Reconstruction in Hypospadias Repair?

Two-Stage Repair for Severe Proximal Hypospadias Using Oral Mucosal Grafts: Combination of a Modified Bracka Method and a Modified Byars Flap Method: Should Local Flaps be Used for Urethral Reconstruction in Hypospadias Repair?

128 Ventral buccal mucosa grafting for concomitant curvature correction and urethroplasty in proximal hypospadias repair: A new approach

128 Ventral buccal mucosa grafting for concomitant curvature correction and urethroplasty in proximal hypospadias repair: A new approach

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias.

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias. All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty. Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52%) children required a tunica albuginea plication for chordee correction. In total, 16 (17%) patients developed 24 complications and 11 children (12%) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus. Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

Management of Proximal Hypospadias with 2-Stage Repair: 20-Year Experience

We describe our experience with 2-stage proximal hypospadias repair. We report outcomes, and patient and procedure characteristics associated with surgical complications. We retrospectively studied patients with proximal hypospadias who underwent staged repair between January 1993 and December 2012. Demographics, preoperative management and operative technique were reviewed. Complications included glans dehiscence, fistula, meatal stenosis, nonmeatal stricture, urethrocele/diverticula and residual chordee. Cox proportional hazards model was used to evaluate the associations between time to surgery for complications and patient and procedure level factors. A total of 134 patients were included. Median patient age was 8.8 months at first stage surgery and 17.1 months at second stage surgery, and median time between surgeries was 8 months. Median followup was 3.8 years. Complications were seen in 71 patients (53%), with the most common being fistula (39 patients, 29.1%). Reoperation was performed in 66 patients (49%). Median time from urethroplasty to surgery for complication was 14.9 months. Use of preoperative testosterone decreased risk of undergoing surgery for complication by 27% (HR 0.73, 95% CI 0.55-0.98, p = 0.04). In addition, patients identified as Hispanic were at increased risk for undergoing surgery for complications (HR 2.40, 95% CI 1.28-4.53, p = 0.01). We review the largest cohort of patients undergoing 2-stage hypospadias repair at a single institution. Complications and reoperation rates were approximately 50% in the setting of complex genital reconstruction.

Tunneled Buccal Mucosa Tube Grafts for Repair of Proximal Hypospadias

Buccal mucosa is the favored graft material for patients with long urethral defects and a paucity of skin. Since 2007, we have used the novel tunneled buccal mucosa tube graft urethroplasty technique in these patients. We describe this operative technique and report our surgical and functional outcomes. Between 2007 and 2013, 37 males with proximal hypospadias underwent tunneled buccal mucosa tube graft urethroplasty. After the penile shaft was optimized at a prior stage a free buccal graft was tubularized and tunneled under the intact ventral shaft skin and into the glans. We retrospectively reviewed all charts to report our results. We assessed uroflowmetry and bladder ultrasound for post-void residual urine. The overall complications rate in 34 patients with more than 1-year followup was 32% (11), including fistula in 5, proximal stricture in 4 and meatal stenosis in 2. In the first 10 patients a total of 7 complications (70%) developed but there were only 4 complications in the next 24 (16%). Surgeon experience was the only significant predictor of complications (p = 0.003). We obtained uroflow and post-void residual urine data on 13 of 37 patients, of whom 9 achieved a normal flow pattern and post-void residual urine, and 4 had a blunted flow pattern. The novel technique of the tunneled buccal mucosa tube graft in patients with proximal hypospadias represents a good alternative for a long urethroplasty in patients with a paucity of skin. After the learning curve plateaus the rate and degree of complications decrease. Furthermore, voiding function is adequate, as assessed by uroflow studies and post-void residual urine measurement.

Complications following Staged Hypospadias Repair Using Transposed Preputial Skin Flaps

Proximal hypospadias repair using a staged approach is a complex reconstructive operation with the potential for significant complications requiring repeat surgery. We report outcomes of staged hypospadias repair using transposed preputial skin flaps and factors predictive of postoperative complications. We retrospectively analyzed patients who underwent staged proximal hypospadias repair using transposed preputial skin flaps between 2002 and 2013. Patient demographics, operative details, complications, reoperations and factors predictive of complications were reviewed. A total of 56 patients were identified with a mean age of 14.1 months (median 14.3) at first stage. Mean followup was 38.6 months (median 34.1). Complications requiring additional unplanned operation(s) were observed in 38 patients (68%), including fistulas in 32 (57%), diverticula in 8 (14%), meatal stenosis in 5 (9%), urethral stricture in 8 (14%) and glans dehiscence in 3 (5%). In addition, redo first stage repair was performed in 4 patients (7%). Since some patients had more than 1 complication, the total number of complications is greater than the number of patients undergoing a redo operation. On univariate analyses the use of small intestinal submucosa was significantly associated with an increased risk of fistula (91% vs 49%, p = 0.02) and urethral diverticulum (64% vs 24%, p = 0.04). Incision of the tunica albuginea of the corpora was associated with an increased likelihood of fistula (77% vs 44%, p = 0.03). Finally, patients with glans dehiscence were significantly younger at first stage (5.8 vs 14.8 months, p = 0.01). The reoperation rate for complications in children undergoing staged hypospadias repair using transposed preputial skin flaps is higher than previously reported.

Two-Stage Repair for Severe Proximal Hypospadias Using Oral Mucosal Grafts

One-stage repair is a conventional treatment of hypospadias. If hypospadias is severe as in the scrotal type and perineal type, penile curvature sometimes cannot be corrected by dorsal midline plication alone. In addition to resection of the urethral plate, ventral grafting becomes necessary for insufficient skin and subcutaneous tissue. In recent years, there has been renewed interest in 2-stage repair for such severe cases and salvage of failed cases with scarring. In the present study, novel 2-stage urethroplasty was performed in 6 cases to repair severe proximal hypospadias which required resection of the urethral plate. This novel method consisted of a combination of a modified Bracka method using oral mucosal grafts and a modified Byars flap of the dorsal foreskin. Good results were obtained using this novel method.

The Bracka two-stage repair for severe proximal hypospadias: A single center experience.

Background:Surgical correction of severe proximal hypospadias represents a significant surgical challenge and single-stage corrections are often associated with complications and reoperations. Bracka two-stage repair is an attractive alternative surgical procedure with superior, reliable, and reproducible results.Purpose:To study the feasibility and applicability of Bracka two-stage repair for the severe proximal hypospadias and to analyze the outcomes and complications of this surgical technique.Materials and Methods:This prospective study was conducted from January 2011 to December 2013. Bracka two-stage repair was performed using inner preputial skin as a free graft in subjects with proximal hypospadias in whom severe degree of chordee and/or poor urethral plate was present. Only primary cases were included in this study. All subjects received three doses of intra-muscular testosterone 3 weeks apart before first stage. Second stage was performed 6 months after the first stage. Follow-up ranged from 6 months to 24 months.Results:A total of 43 patients operated for Bracka repair, out of which 30 patients completed two-stage repair. Mean age of the patients was 4 years and 8 months. We achieved 100% graft uptake and no revision was required. Three patients developed fistula, while two had metal stenosis. Glans dehiscence, urethral stricture and the residual chordee were not found during follow-up and satisfactory cosmetic results with good urinary stream were achieved in all cases.Conclusion:The Bracka two-stage repair is a safe and reliable approach in select patients in whom it is impractical to maintain the axial integrity of the urethral plate, and, therefore, a full circumference urethral reconstruction become necessary. This gives good results both in terms of restoration of normal function with minimal complication.

Impact of penile degloving and proximal ventral dissection on curvature correction in children with proximal hypospadias.

Penile degloving is an important step in orthoplasty. Although its role in correcting mild curvature in distal and midshaft hypospadias has been previously reported, its impact on ventral curvature (VC) correction in proximal defects warrants further investigation. Therefore, we sought to document the effect of degloving and proximal urethral dissection on VC correction in children with proximal hypospadias. We retrospectively reviewed the records of 137 patients who underwent proximal hypospadias repair between 1998 and 2006. VC, defined as mild (<30%), moderate (30%-45%), and severe (>45%), was recorded before penile degloving and after erection test. Percent improvement in VC and need for further treatment (beyond degloving and proximal dissection) based on preoperative degree of curvature were assessed. ANOVA test was used to compare improvement among the 3 groups. Mean age at repair was 14 months (range: 6-24). Penile degloving associated with proximal urethral dissection when necessary was responsible for the improvement in the degree of curvature in 7 of 9 (77%) patients with mild VC, 23 of 44 (52%) with moderate and 35 of 84 (40%) with severe VC. Additionally, degloving alone was sufficient for VC correction in 7 of 9 (77%) mild cases, 14 of 44 (30%) moderate and only 2 of 84 (2%) severe cases. The difference among these 3 groups was statistically significant (p < 0.001). Penile degloving alone can correct VC. The percentage of improvement depends on the preoperative degree of curvature, with severe VC cases showing the least improvement.

The contemporary role of 1 vs. 2-stage repair for proximal hypospadias.

This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved—a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and—depending on technique—have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.

Video presentation of the second stage of a two-stage repair for proximal hypospadias: A safe and reproducible technique

ObjectiveThe aims of proximal hypospadias repair are good cosmetic outcomes with low rates of complication, with a low number of operative exposures, before the age of genital difference realisation. Neo-urethral fistula and stenosis are well recognised complications; with international rates of 3.8–16% and 1.3–15.6% respectively. We present the key steps of the second of a two staged repair in video format. MethodVideo recording of the procedure performed on an 18-month-old with mid-penile hypospadias is presented. The steps are described; the importance of tension free tubularisation, layered urethral closure, suture technique, vascularised prepucal graft technique, optimal glanuloplasty, and penile shaft skin repair are highlighted. ResultThe child was brought back to the day ward for catheter removal at 7 days; follow-up in clinic showed good postoperative appearance. This technique has been performed on 31 boys with a fistula rate and stenosis rate favourable to the literature. ConclusionWe demonstrate a two-stage technique by video format for proximal hypospadias which is reproducible and gives results comparable to the literature.

Comparative outcomes of the tubularized incised plate and transverse island flap onlay techniques for the repair of proximal hypospadias

The optimal management of proximal hypospadias remains uncertain. In this study, the surgical outcomes of tubularized incised plate repair (TIP) and transverse island flap (TVIF) onlay urethroplasty in boys with hypospadias were compared. A total of 176 patients with proximal hypospadias underwent TIP (n = 83) or TVIF onlay repairs (n = 93) by a single surgeon and were evaluated retrospectively. No patient received a testosterone injection prior to surgery. A retrospective review of their medical records collected data regarding age at surgery, chordee, dorsal plication, hypospadias site, penoscrotal transposition, bifid scrotum, congenital hernia, undescended testis and any postoperative complications, including fistula, recurrent curvature, dehiscence, diverticulum, meatal stenosis and urethral stricture. The pediatric penile perception score (PPPS) was completed by parents to evaluate their perception of cosmetic outcomes. There was no statistical difference in age or any of the anatomical and clinical features of hypospadias. The median follow-up duration was 22 months (range 12-48 months) and 25 months (14-51 months) for the TIP and TVIF onlay groups, respectively. The overall complication rate in the TVIF onlay group was 21.5% (20/93), which was higher than 18.1% (15/83) in the TIP group, but the difference was not statistically significant (P = 0.569). The most common complication was urethrocutaneous fistula, occurring in 9.6% (8/83) of the TIP group and 10.8% (10/93) of the TVIF onlay group. There were no significant differences in the rate of any complication and the overall PPPS between the two groups. TIP and TVIF onlay are clinically equivalent for the repair of proximal hypospadias.

One-stage repair of proximal hypospadias using lateral penile flap-preliminary results in a single-center experience.

Several surgical techniques, involving one-stage or multistage procedure, have been described over the years (more than 300 techniques) [1, 2], but the standard and most feasible reconstruction has not yet been identified for reconstruction of proximal hypospadias. Lateral-based flap technique is a single-stage urethral reconstruction used for proximal hypospadias with chordee [3, 4]. The aim of the present study was to describe our preliminary experience in this technique and to compare the results with those obtained by other surgeons.

Response to editorial comment re: Urethral strictures following urethral plate and proximal urethral elevation during proximal tip hypospadias repair

A major impediment to progress in hypospadias surgery is decision-making based on subjective criteria. The reviewer states selection criteria for TIP in our report are unclear and wonders if a wide urethral plate or one supported by thick spongiosum might be suitable for mobilization and TIP with little risk for stricture. But different surgeons inevitably will define a “wide” plate and “thick” spongiosum differently, making it difficult to compare experiences and learn from each other. Commentary to ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’Journal of Pediatric UrologyVol. 9Issue 6PreviewMobilization of the urethral plate (UP) and native urethra is one of the manoeuvres that can be performed in order to straighten the penis while preserving UP continuity in severe hypospadias repair [1]. The authors of the present paper advocated it in conjunction with tubularized incised plate (TIP) urethroplasty in the recent past (see Ref. [2] in text). In the present series, they confirm that this combination is effective for penile straightening, as it allowed avoiding UP transection in some 25% of their cases with a 5% rate of recurrent curvature after a mean follow-up of 21 months. Full-Text PDF

Commentary to ‘Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair’

Mobilization of the urethral plate (UP) and native urethra is one of the manoeuvres that can be performed in order to straighten the penis while preserving UP continuity in severe hypospadias repair [1]. The authors of the present paper advocated it in conjunction with tubularized incised plate (TIP) urethroplasty in the recent past (see Ref. [2] in text). In the present series, they confirm that this combination is effective for penile straightening, as it allowed avoiding UP transection in some 25% of their cases with a 5% rate of recurrent curvature after a mean follow-up of 21 months. However, they also suggest that this combination is possibly hazardous and might predispose to stricture formation in the reconstructed urethra. The development of urethral strictures after TIP urethroplasty in patients undergoing UP/urethral mobilization is consistent with the concern that the latter might cause partial de-vascularization and ischemia in a UP that furthermore requires to be halved into two strips for tubularization. The 17% stricture rate is therefore a warning, but perhaps deserves some qualification. To begin with, this is a single-surgeon experience and, as the same authors acknowledge, other series of similar procedures did not include any such complication (see Refs. [3,4] in text). This cannot be attributed to the follow-up investigations performed, as the strictures reported in the present study were all symptomatic and none was diagnosed after a particular investigation in an otherwise asymptomatic patient. Moreover, it is worth noting that the stricture was very short, 1-mm to 3-mm long, in 3 of the 5 patients with this complication, and was associated with recurrent curvature due to contracture of the UP in only 1 case. In contrast, contracture of the UP was reported to be the cause of recurrent curvature in 2 of the 3 patients experiencing this complication in the group treated without mobilization. Yet, it is quite surprising that none of the patients undergoing mobilization developed any fistulas, as one would expect a higher rate of healing complications in the presence of ischemic tissues. According to the authors, technical refinements could account for the lower fistula rate in patients undergoing mobilization. This, however, points out that this study compares two series that were not contemporary, which is always a source of variability, and makes one wonder whether results in the patients undergoing TIP repair after UP/ urethral mobilization might improve as well with increasing experience. The latter might also include improvement in patient selection. Consistently, the authors suggest that TIP urethroplasty might still be an option in patients requiring mobilization of the UP, without mobilization of the native urethra or additional ventral lengthening procedures. Other possible criteria could be a UP wide enough after mobilization to make tubularization around a 10 Fr catheter possible (a 6 Fr was used in the present series), or a UP supported by thick spongiosum, especially if no injury to the latter and subsequent bleeding occurs during mobilization. Criteria for patient selection cannot be determined based on the data provided, but might account for the different results among series and deserve further enquiry. Finally, even fully accepting the authors’ conclusions, how can we incorporate them in our practice? Should we fully abandon UP mobilization, avoid combining it with a TIP repair, inlay graft the incised plate before tubularization, or always combine this maneuver with a flap urethroplasty?