Severe Hypospadias Research Articles

Ultrasound-guided Pudendal Block Is a Viable Alternative to Caudal Block for Hypospadias Surgery: A Single-Surgeon Pilot Study

To evaluate pudendal nerve block as an alternative to caudal block for hypospadias surgery. Data were obtained by chart review. Children who underwent hypospadias repair between 2012 and 2016 by a single surgeon at an academic institution were included. Patients received ultrasound-guided pudendal block (n = 21) or caudal block (n = 19) as a regional adjunct to general anesthesia. Primary outcomes included analgesic requirement and postoperative length of stay in the recovery unit. The pudendal block cohort was slightly older (27.6 vs 18.5 months, P = .017) and had more severe hypospadias than the caudal block cohort (53% vs 35% proximal hypospadias, respectively). We detected no statistically significant difference in intraoperative opioid, postoperative opioid, or nonopioid analgesic requirement (17.9 vs 12.9 mcg fentanyl, P = .267; 0.3 vs 0.3 doses, P = .92; 0.2 vs 0.1 doses, P = .46, respectively). Postoperative length of stay was significantly shorter in the pudendal block cohort (96 vs 128 minutes, P = .016). We are the first to report the use of ultrasound-guided pudendal block for hypospadias repair. This appears to be a safe and effective alternative to caudal block with no perioperative delays. Pudendal block has several advantages over caudal block. It avoids the risks of urinary retention and lower extremity weakness and can be administered to older patients and children with spinal anomalies. Compared with caudal block, ultrasound-guided pudendal nerve block is safe, provides equivalent pain control for hypospadias repair, and results in a shorter time to discharge.

A new modification of the Duckett technique for one-stage repairing urethral plate transected hypospadias: Another option for severe hypospadias?

The study aimed to evaluate the new modification of the Duckett technique in decreasing the incidence of urethral strictures for urethral plate transected hypospadias and also explored its clinical application. Thirty-three patients (aged 7months to 12years, mean age 2.8years) who underwent repair of primary hypospadias using the new one-stage urethroplasty were enrolled. Clinical data, including cosmetic and its complications, and uroflowmetry data were documented. Uroflowmetry data of 19 patients who underwent Duckett urethroplasty were used as a comparison. The length of the urethral defect ranged from 2.5 to 5.0cm. The postoperative follow-up was 14-30months. Ten patients (30.3%) had fistulas; no patients had strictures or diverticula. All ten fistulas were small (<0.5cm) and repaired with fistula repairing operation. The appearance of the penis remained satisfactory, and the meatus was located in the normal anatomic position. Among 17 patients who underwent uroflowmetry, all patients were bell-shaped or platforms, and Q max was 7.37±2.45ml/s. Compared with 14 of 19 patients who underwent Duckett urethroplasty, the urethral function achieved with new one-stage urethroplasty was significantly better (p<0.05). The incidence of strictures was dramatically lowered in patients with proximal hypospadias. Small fistulas are common complications and can be repaired easily. Based on the uroflow pattern results, the quality of neourethra and function of it were better than Duckett urethroplasty. These preliminary results suggested that the modified procedure seems to be reliable and can be a suitable option for proximal hypospadias.

Hypospadias, Intrauterine Growth Restriction, and Abnormalities of the Placenta

Hypospadias is more common among male infants with growth restriction, defined as a birth weight less than the 10th centile, than in infants with a normal birth weight. Intrauterine growth retardation (IUGR) has been associated, also, with abnormalities of the placenta, such as maternal vascular malperfusion. In a consecutive sample of newborn infants, the association between hypospadias, IUGR and abnormalities of the placenta could be analyzed. Affected infants were identified among 289,365 liveborn and stillborn infants in the Active Malformations Surveillance Program between 1972 and 2012. The four anatomic locations of the ectopic urethral opening, based on the recorded physical examination findings, were: (1) glandular; (2) subcoronal; (3) penile; (4) penoscrotal. Affected infants with associated malformations, a chromosome abnormality, teratogenic exposure, maternal diabetes mellitus, or multiple gestations were excluded. Three hundred sixteen affected infants were identified: 52.2% glandular, 11.7% subcoronal, 27.8% penile, and 8.2% penoscrotal. The highest frequency of IUGR (34.6%) was in the infants with the most severe hypospadias (penoscrotal). The 39 reports of placenta findings showed a high frequency of abnormalities. An increased rate of occurrence of hypospadias and abnormalities of the placenta were present in infants with intrauterine growth restriction. The postulated cause of this association is a deficiency in the function of the placenta during weeks 10 to 14 of gestation when normal masculinization occurs due to an increase in the level of placental human chorionic gonadotropin and fetal testosterone. The cause of the placental deficiency has not been established. Birth Defects Research 110:122-127, 2018.© 2017 Wiley Periodicals, Inc.

Prevention and treatment of urethral stricture after hypospadias repair in children

Urethral stricture is one of the common complications after hypospadias repair, and it is related with the blood supply of materials used in urethra formation.The more severe and proximal hypospadias is, the higher possibility of stricture is.The patients with urethral stricture have the symptoms of stranguria and urinary retention, and they usually need re-surgery.The repair with well vascularized flap can decrease the occurrence of urethral stricture after hypospadias repair. Key words: Hypospadias; Urethral stricture; Child

Two-stage flap repair of severe hypospadias: Usefulness of the tubularized incised plate urethroplasty

The use of flaps in the two-stage repair of posterior hypospadias associated with severe chordee has been well established. Despite the almost certain guarantee of flap take, complications such as diverticuli are still relatively high. While different applications of the tubularized incised plate have been described, experience with the application of the technique to the two-stage flap repair is very limited. A previous local review of 15 cases performed at the present institution during the period 1998-2003, using the technique as described by Rekit, revealed fistulae and diverticulum rates of 20% and 27%, respectively. With the primary objective of improving surgical outcome, the midline incision was incorporated into the two-stage flap repair. Between 2004 and 2015, 35 boys (aged 2-15 years) with severe hypospadias that required excision of the urethral plate were operated using the two-stage flap technique. The first stage involved mobilization of preputeal or dorsal penile skin (if circumcised) to the ventral surface, as described by Retik. After a minimum interval of 6 months, the second-stage operation was performed in a way similar to the technique of tubularized incised plate urethroplasty, as popularized by Snodgrass, and involved a preliminary midline incision on the neo-urethral plate followed by tubularization and multilayered closure. All but one flap took successfully. The outcome was satisfactory in 80% of patients, and there was a fistula rate of 14% ( Summary Table). One patient had a complete breakdown of the flap and was successfully treated about 12 months later by repeating the second stage of the operation. No case of diverticulum or stricture was recorded. Even though there was a marginal improvement in the fistula rate, the most striking observation was the complete absence of diverticulum or stricture. With a reported incidence rate of 20-63%, different authors have reported diverticulum formation (despite the absence of distal obstruction) to be a major problem of the two-stage flap technique. Attempts by these authors at reducing the risk of diverticulum by reducing flap size have tended to increase the risk of strictures. This has been the main reason given by some authors for abandoning the technique. The main limitations of the present study included the wide age range of the patients and the small sample size. The inclusion of a midline incision in a two-stage flap urethroplasty for proximal hypospadias appears to prevent the development of diverticulum.

The modified Ulaanbaatar procedure: Reduced complications and enhanced cosmetic outcome for the most severe cases of hypospadias

Proximal hypospadias is one of the most challenging conditions that pediatric urologists have to deal with. Many procedures have been devised over the years, but nothing has been proven to be the best option. Although there have been some attempts at correcting severe hypospadias in one procedure, most have advocated a staged approach. The classic approach - laying penile skin or a graft within a split glans followed by glanuloplasty at the second stage - by definition requires two operations on the glans. In the Ulaanbaatar procedure the distal glanular urethra is constructed at the first stage, allowing for a single glans procedure and thus potentially better cosmetic outcomes. The present study discusses experience with the Ulaanbaatar procedure for severe hypospadias. The study retrospectively reviewed every child who underwent both stages of this procedure at the present institution. It reviewed age, associated diagnoses, surgical technique and outcomes. The first stage was analogous to a classic first-stage procedure with regard to division of the urethral plate and correction of penile curvature. However, an island flap of preputial skin was mobilized and tubularized to create the glanular urethra. No attempt was made to bridge the native meatus and this reconstructed urethra, and the remaining penile skin was placed between the two. The second stage was performed 6 months later by tubularizing the penile skin between the two meatuses. The series consisted of 34 boys. Mean age at surgery was 18.3 months (range 6-118). Nineteen underwent evaluation for genital ambiguity at birth (56%). Thirty (88%) received pre-operative testosterone or human chorionic gonadotropin (HCG). After urethral plate transection, persistent curvature was addressed during the first stage, with dorsal plication in 12 (35%), urethral plate transection alone in six (18%) or ventral grafting with small intestinal submucosa in 16 (47%). Twenty-three boys (67%) had the neourethra tunneled through the glans, and 11 (33%) had the glans split followed by glanuloplasty. Average time between the two stages was 7 months (range 4.0-13.9). Four patients (12%) developed urethral diverticula that required repair. One developed recurrent epididymitis related to an abnormal ejaculatory duct (no stricture) and underwent vasectomy. No patient developed a fistula. Mean length of follow-up was 15.2 months (range 0.3-55.5). This modification of the classic staged hypospadias repair may allow for better cosmetic outcome, since the majority of boys required no formal glanuloplasty. There were reduced complications, perhaps because the urethral defect acted like a controlled fistula, allowing for better tissue healing prior to final urethral reconstruction.

Staged Tubularized Autograft Repair for Primary Proximal Hypospadias with 30-Degree or Greater Ventral Curvature

We report outcomes in consecutive patients with primary proximal hypospadias and ventral curvature 30 degrees or greater after degloving, all repaired with 2-stage tubularized autografts, a variation of the Nicolle-Bracka procedure. Consecutive boys with proximal hypospadias and ventral curvature 30 degrees or greater after degloving underwent transection of the urethral plate. In addition, those with persistent ventral curvature 30 degrees or greater underwent 3 ventral corporotomies without corporal grafting for straightening. Staged graft urethroplasty was performed using prepuce, or labial mucosa, when the family requested preputioplasty. The goal in all cases was a straight penis with a normally positioned neomeatus. A total of 43 boys completed both stages with postoperative followup. Mean ventral curvature was 70 degrees, which necessitated corporotomy in 65%. There was no recurrent ventral curvature. Preputial grafts were used in 88%. A skin graft or scrotal flap was needed for ventral shaft coverage at the second stage in 4 boys (9%). During followup of an average of 22 months urethroplasty complications were diagnosed in 10 (23%), mostly glans dehiscence and fistulas. Of these patients 9 underwent 12 reoperations. Success was achieved in 42 (98%) patients. Staged tubularized autograft resulted in a straight penis with a normally positioned neomeatus in boys with the most severe proximal hypospadias in 77%, increasing to 98% after 1 or 2 distal reoperations for complications. There was no recurrent ventral curvature after 3 corporotomies without corporal grafting. Urethroplasty graft take was reliable.

Complications after Hypospadias Correction: Prognostic Factors and Impact on Final Clinical Outcome.

The purpose of this study was to analyze the influence of patient and treatment characteristics on the occurrence of complications after hypospadias correction and the impact of complications on final clinical outcome. The study cohort consisted of 205 hypospadias patients who had surgery in the Medical Centre Leeuwarden (1996-2011). Patient and treatment characteristics were hypospadias severity (preoperative meatal location and chordee), number of planned surgeries, reconstruction technique, operation year, and patient's age at the time of surgery. The final clinical outcome was measured with the Hypospadias Objective Scoring Evaluation (HOSE) (maximum score = 16) and compared between patients with and without complications. Sixty-four patients (31%) had complications, most of which were fistulas (n = 40). An increased complication risk was seen in patients with severe hypospadias (preoperative proximal meatus or chordee), multistage reconstruction, reconstruction techniques other than Mathieu, and surgeries performed before 2005. Uncomplicated treatment resulted only in a marginally higher HOSE (15.7) compared with complicated treatment (15.4). Fistulas and multiple complications reduced clinical outcome more (15.3 and 14.9, respectively), while urinary tract infections, wound dehiscence, or prepuce related complications did not (16.0, 16.0, and 15.8, respectively). The complication risk after hypospadias correction is influenced by hypospadias severity and type and year of reconstruction. Certain, but not all complications diminish final clinical outcome.

Bhat's modifications of Glassberg–Duckett repair to reduce complications in management severe hypospadias with curvature

ObjectiveDisadvantages of two-stage hypospadias repair are the necessity of 2 or 3 surgeries, loss of time/money, complications like splaying of the stream, dribbling of urine or ejaculate and milking of the ejaculate due to a poor-quality urethra. The current article details our modifications of flap repair allowing to manage such patients in one stage and reducing the complications. Subjects and methodsTwenty one patients (aged 2–23 years, between January 2006 and June 2012 mean 11.5 years) of severe hypospadias were managed with flap tube urethroplasty combined with TIP since June 2006 and June 2012. Curvature was corrected by penile de-gloving, mobilization of urethral plate/urethra with corpus spongiosum and transecting urethral plate at corona. Buck's fascia was dissected between the corporeal bodies and superficial corporotomies were done as required. Mobilized urethral plate was tubularized to reconstruct proximal urethra up to peno-scrotal junction and distal tube was reconstructed with raised inner preputial flap after measuring adequacy of skin width. Both neo-urethrae were anastomosed in elliptical shape and covered with spongiosum. Distal anastomosis was done 5–8mm proximal to tip of glans preventing protrusion of skin on glans. Tubularized urethral plate was covered by spongioplasty. Skin tube was covered by dartos pedicle and fixed to corpora. Scrotoplasty was done in layers, covering the anastomosis. ResultsType of hypospadias was scrotal 10, perineo-scrotal 5, penoscrotal 4 and proximal penile in 2 cases. Chordee (severe 15 and moderate 6) correction was possible penile de-gloving with mobilization of urethral plate with spongiosum after dividing urethral plate at corona 8, next 5 cases required dissection of corporal bodies, superficial corporotomy 5 and 3 cases lateral dissection of Buck's fascia. Length of tubularized urethral plate varied from 3 to 5cm and flap tube varied from 5.5 to 13cm (average 7.5cm). Complications were fistula 2, meatal stenosis 1, and dilated distal urethra1 with overall success rate of 81%. None of them had residual curvature, torsion, splaying or dribbling urine in follow up of 10–36 (average 18) months. ConclusionsTIPU with spongioplasty of proximal urethra and dartos cover on skin tube reconstructs functional urethra. Distal end skin sutured to glans mucosa 5–8mm proximal to the tip of glans reconstructs a cosmetically normal looking meatus. An exact measurement of the width and length of the stretched dartos, fixation of the skin tube to the corpora and covering the skin tube with dartos helps in prevention of diverticula. Elliptical anastomosis covered with spongiosum prevents fistula and stricture at anastomotic site.

Establishing disability weights for congenital pediatric surgical conditions: a multi-modal approach

BackgroundBurden of disease (BoD) as measured by Disability-Adjusted Life Years (DALYs) is one of the criteria for priority-setting in health care resource allocation. DALYs incorporate disability weights (DWs), which are currently expert-derived estimates or non-existent for most pediatric surgical conditions. The objective of this study is to establish DWs for a subset of key pediatric congenital anomalies using a range of health valuation metrics with caregivers in both high- and low-resource settings.MethodWe described 15 health states to health professionals (physicians, nurses, social workers, and therapists) and community caregivers in Kenya and Canada. The health states summaries were expert- and community-derived, consisting of a narrated description of the disease and a functional profile described in EQ-5D-5 L style. DWs for each health state were elicited using four health valuation exercises (preference ranking, visual analogue scale (VAS), paired comparison (PC), and time trade-off (TTO)). The PC data were anchored internally to the TTO and externally to existing data to yield DWs for each health state on a scale from 0 (health) to 1 (dead). Any differences in DWs between the two countries were analyzed.ResultsIn total, 154 participants, matched by profession, were recruited from Kijabe, Kenya (n = 78) and Hamilton, Canada (n = 76). Overall calculated DWs for 15 health states ranged from 0.13 to 0.77, with little difference between countries (intra-class coefficient 0.97). However, DWs generated in Kenya for severe hypospadias and undescended testes were higher than Canadian-derived DWs (p = 0.04 and p < 0.003, respectively).ConclusionsWe have derived country-specific DWs for pediatric congenital anomalies using several low-cost methods and inter-professional and community caregivers. The TTO-anchored PC method appears best suited for future use. The majority of DWs do not appear to differ significantly between the two cultural contexts and could be used to inform further work of estimating the burden of global pediatric surgical disease. Care should be taken in comparing the DWs obtained in the current study to the existent list of DWs because methodological differences may impact on their compatibility.

605 - Our modifications in Glassberg–Duckette technique to prevent fistula and stricture at proximal anastomosis of inner prepucial flap tube and urethra in severe hypospadias

605 - Our modifications in Glassberg–Duckette technique to prevent fistula and stricture at proximal anastomosis of inner prepucial flap tube and urethra in severe hypospadias

Proximal hypospadias repair with bladder mucosal graft: Our 10 years experience

A great variety of different surgical techniques has been described for proximal hypospadias repair and an ideal tissue has not been determined yet. We present our 10 years of surgical experience using a bladder mucosal graft for urethroplasty. Bladder mucosal graft urethroplasty was performed between 2005 and 2015 in 50 patients with severe proximal hypospadias. The mean age of patients was 45.1 months (range 24-164 months). Hypospadias were perineal in 18 patients, scrotal in 22, and penoscrotal in 10. In all cases a chordee correction was performed and median time between the first and the second stages was 12 months (mean 17 months, range 4-68 months). Both foley catheter and a suprapubic cystostomy were positioned and maintained for 2-4 weeks. Follow-up was performed at 1-3 and 6-12 months after surgery, and afterwards annually with clinical examination and flowmetry test. Mean follow-up was 5.3 years (median 5, range 1-10 years). Mean graft length was 57.4mm (median 55mm, range 35-85mm). Among all the only early complication registered was a postoperative infection in one patient (2%) at the site of anastomosis. The long-term complications observed were urethrocutaneous fistula in nine patients (18%), urethral stricture in 15 patients (30%), meatal stricture in four patients (8%), and prolapse of meatus in seven patients (14%). The mean time of complication occurrence was 15 months (median 15.5 months, range 1-96 months). The functional and cosmetic appearance after surgery was satisfactory in 42/50 patients (84%) during the follow-up period. There is still an open debate regarding the optimal surgical approach for management of severe proximal hypospadias. Compared with other approaches, our technique showed acceptable results even though encumbered by slightly higher complication rates. Our results show that bladder mucosal graft for primary severe proximal hypospadias in selected patients is a possible alternative to other commonly used techniques, with the aim of restoring recovery of the normal continuity of the distal urinary tract see figure below.

Late surgical correction of hypospadias increases the risk of complications: a series of 501 consecutive patients.

To evaluate the outcomes of hypospadias surgery according to age and to determine if some complications are age-related. This retrospective study was based on 722 boys with hypospadias undergoing primary repair. A total of 501 boys underwent urethroplasty and were included in the study. Complications requiring an additional procedure (stenosis, fistula, dehiscence, relapse of curvature, urethrocele) were included in the analysis, as well as healing problems, infections, haematomas and detrusor-sphincter dyssynergy. Logistic regression analysis was performed. Hypospadias was anterior in 63.1%, mid-penile in 20.5%, posterior in 8.4% and scrotal in 7.9% of the boys. The median (range) age was 4 (1-16) years. The overall rates of re-intervention and complications were 22.8% and 36.2%, respectively. Age >2 years was a significant predictor of complications (P = 0.002, odds ratio 1.98 [95% confidence interval 1.26-3.13]). Some periods of time appeared to be associated with a specific complication: dyssynergy was more common between the ages of 24 and 36 months (12.5 vs 3.6%; P = 0.01) and healing problems were more common in boys aged >13 years (1.5 vs 28.5%; P = 0.06). Delayed surgery may be detrimental for patients. Factors related to age may influence the rate of complications. After the age of 2 years, urethral surgery may interfere with the normal toilet-training process. During puberty, endogenous testosterone may alter healing. Even if no specific data exist for severe hypospadias, it may be prudent to continue to advocate early surgery in patients with disorders of sex development.

Neo-yoke repair for severe hypospadias: A simple modification for better outcome

Although staged repair for reconstructing severe hypospadias is more popular, various one-stage repairs have been attempted. Koyanagi repair (parameatal-based and fully extended circumferential foreskin flap urethroplasty) has enabled correction of severe hypospadias in one stage. However, its un-acceptably high incidence of complications has initiated a series of technical modifications, including the "yoke" repair. To retrospectively analyze the outcome of a proposed modification of the originally described yoke repair, for patients with severe hypospadias. This modification was developed to reduce complications. Over 4 years (between Jan 2011 and Jan 2015), all cases of severe hypospadias were included in this study; except those with prior attempts at repair, circumcised cases, and cases with severe hypogonadism - because of partial androgen insensitivity - not responding to hormonal manipulations. The make-up of the neo-urethra in this modification is the urethral plate with its spongiosal tissue proximally, a circum-coronal preputial pedicled flap in the middle, and an incorporated part of the augmented preputial flap and the preserved V-shaped glanular urethra, distally. Close postoperative follow-up was conducted to investigate the outcome. Thirty-one children with a median age of 32.48 months had repair of severe hypospadias using the neo-yoke technique. After a median follow-up of 26.7 months, the overall complication rate was 16.1%. Four children developed urethrocutaneous fistula (12.9%). Meatal drop-back occurred in one case (3.2%). No meatal stenosis or urethral sacculation was detected during follow-up of the studied group. Almost all cases had cosmetically appealing outlook. Single-staged repair of severe hypospadias using parameatal foreskin-based urethroplasty has passed through different modifications, all aimed at optimizing the outcome (Table). Neo-yoke repair for severe hypospadias is a natural development of established one-stage techniques, which resulted in better mid-term outcomes. However, an extended study is needed to declare the long-term results.

High GMS score hypospadias: Outcomes after one- and two-stage operations

Established criteria to assist surgeons in deciding between a one- or two-stage operation for severe hypospadias are lacking. While anatomical features may preclude some surgical options, the decision to approach severe hypospadias in a one- or two-stage fashion is generally based on individual surgeon preference. This decision has been described as a dilemma as outcomes range widely and there is lack of evidence supporting the superiority of one approach over the other. The aim of this study is to determine whether the GMS hypospadias score may provide some guidance in choosing the surgical approach used for correction of severe hypospadias. GMS scores were preoperatively assigned to patients having primary surgery for hypospadias. Those patients having surgery for the most severe hypospadias were selected and formed the study cohort. The records of these patients were reviewed and pertinent data collected. Complications requiring further surgery were assessed and correlated with the GMS score and the surgical technique used for repair (one-stage vs. two-stage). Eighty-seven boys were identified with a GMS score (range 3-12) of 10 or higher. At a mean follow-up of 22 months the overall complication rate for the cohort after final planned surgery was 39%. For intended one-stage procedures (n=48) an acceptable result was achieved with one surgery for 28 patients (58%), with two surgeries for 14 (29%), and with three to five surgeries for six (13%). For intended two-stage procedures (n=39) an acceptable result was achieved with two surgeries for 26 patients (67%), three surgeries for eight (21%), and four surgeries for three (8%). Two other patients having two-stage surgery required seven surgeries to achieve an acceptable result. Complication rates are summarized in the Table. The complication rates for GMS 10 patients were similar (27% and 33%, p=0.28) for one- and two-stage repairs, respectively. GMS 11 patients having a one-stage repair had a significantly higher complication rate (69%) than those having a two-stage repair (29%) (p=0.04). GMS 12 patients had the highest complication rate with a one-stage repair (80%) compared with a complication rate of 37% when a two-stage repair was used (p = 0.12). Guidelines to help standardize the surgical approach to severe hypospadias are needed. Staged surgery for GMS 11 and 12 patients may result in a lower complication rate but may not reduce the number of surgeries required for an acceptable result. Although further study is needed, the GMS score may be helpful for establishing such criteria.

Editorial Comment

No AccessJournal of UrologyHypospadias1 Mar 2017Editorial Comment Warren Snodgrass and Nicol Bush Warren SnodgrassWarren Snodgrass More articles by this author and Nicol BushNicol Bush More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.11.110AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 197(3 Part 2), pp. 857–858 References 1 Duckett JW: Hypospadias. In: Campbell’s Urology, 5th ed. Edited by PC Walsh, RF Gittes, AD Perlmutter et al. Philadelphia: WB Saunders, 1986; vol. 2, chapt 47, p 1969. Google Scholar 2 : Trends in hypospadias surgery: results of a worldwide survey. Eur Urol2011; 60: 1184. Google Scholar 3 : Skin graft for 2-stage treatment of severe hypospadias: back to the future?. J Urol2002; 168: 1730. Link, Google Scholar 4 : Primary severe hypospadias: comparison of reoperation rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs. J Urol2013; 189: 1508. Link, Google Scholar 5 Snodgrass W and Bush N: 2-Stage graft repair for primary proximal hypospadias with ventral curvature >30°. Presented at annual meeting of European Society for Paedriatic Urology, Prague, Czech Republic, October 14-17, 2015. Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 197Issue 3 Part 2March 2017Page: 857-858 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Warren Snodgrass More articles by this author Nicol Bush More articles by this author Expand All Advertisement PDF downloadLoading ...

Two-stage hypospadias repair with a free graft for severe primary and revision hypospadias: A single surgeon's experience with long-term follow-up

Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation. To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up. Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n=208): indications for a two-stage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n=93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months. For the primary repairs (n=208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n=93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8). In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the two-stage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%. The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity.

Two-stage tubularized transverse preputial island flap and two-stage urethral plate reconstruction procedures in the treatment of severe hypospadias

Objective To compare the treatment efficacy of severe hypospadias between two-stage urethral plate reconstruction procedure and two-stage tubularized transverse preputial island flap procedure. Methods From 2010 December to 2014 December, we retrospectively analyzed 82 cases with severe hypospadias, using two-stage urethral plate reconstruction and two-stage tubularized transverse preputial island flap urethroplasty, respectively. Their mean age in the first operation was 2.4 years, ranged from 2 to 3 years. Hypospadias were penoscrotal type in 32 cases, perineal type in 50 cases. In group A, 42 cases, including penoscrotal type in 15 cases, perineal type in 27 cases, with urethral plate reconstruction procedure underwent two-stage urethroplasty. The transected ventral penile urethral plate and to strip the ventral fibrous tissue were needed in correction of chordee of penis. The patients in group A were underwent the second urethroplasty with urethral plate reconstruction procedure 6-12 months later. In group B, 40 cases, including penoscrotal type in 17 cases, perineal type in 23 cases, who underwent one stage operation in the correction of chordee of penis, only with tubularized preputial island flap forming the part of the urethra. The patients in group B were underwent the second urethroplasty 6 ~12 months later. Results Patients were followed up for 1 to 5 years, mean 3.5 years. No recurrence of penis chordee was noticed. In group A, 6 cases (14.3%) had postoperative fistula. The second fistula repairing was perform 6 to 12 months after the second stage operation. However, still 3 cases were noticed the fistula recurrence, which was cured after the fourth operation. In group B, 3 cases (7.5%) developed fistula, which appeared in the second urethroplasty (P<0.01). They were all treated after the second repairing procedure. In group A, 4 cases were noticed urethral stricture, the urethral stricture rate was 9.5%.The stricture occurred 1 to 3 months after the second operation. After dilation and indwelling catheter, 3 cases resolved the problem. Another case still found the recurrence after 2 months, which the one stage urethral plication and second urethral reconstruction were considered to treat this patient. In group B, 1 cases of urethral stricture, the urethral stricture rate was 2.5% (P<0.01). After dilation and indwelling catheter, this case resolved the problem. In group A, 3 cases had urethral diverticulum, which occurred at a rate of 7.1%, whereas without urethral diverticulum occurred in group B (P<0.01). Those patient with urethral diverticulum accepted the diverticulum removing procedure 3 to 6 months after the second stage procedure. One case was found the urethral fistula, which was treated one year later. The success rate of operation was 69.0% in group A, the success rate of the operation was 90.0% in group B. The difference of the success rate between two groups was statistically significant (P<0.01). Conclusions With respect to two-stage urethral plate reconstruction procedure in treatment of severe hypospadias, there were the low complication rates of postoperative urinary fistula, urethral stricture and diverticulum in two-stage tubularized transverse preputial island flap procedure. Urethral meatus could be done at the glans of the penis. In addition, the two-stage tubularized transverse preputial island flap procedure provides a good opportunity to practice to master complex hypospadias operation. Key words: Hypospadias; Two-stage procedure; Urethroplasty

Shorter anogenital and anoscrotal distances correlate with the severity of hypospadias: A prospective study

Anogenital distance (AGD) is a recognised marker of in utero androgen action. This study aimed to evaluate the relationship between severity of hypospadias and AGD. Boys undergoing hypospadias repair in a single tertiary centre between May 2012 and February 16 were included in the study. Anogenital distance was measured from the centre of the anus to the base of the penis, and anoscrotal distance (ASD) from the centre of the anus to the junction between the smooth perineal skin and scrotal skin. Trained paediatric urologists made all measurements using digital callipers. Fifty-nine boys with hypospadias and 31 age-matched controls undergoing circumcision (median age 1.37 years, range 1.01-1.96) had AGD and ASD measured under anaesthetic. The patients were divided into two groups, according to hypospadias severity: group 1-distal penile/subcoronal/glandular (n=40); and group 2-perineal/penoscrotal/midshaft (n=19). The median AGD for controls was 74.0mm (range 53.2-87.8) and for hypospadias it was 72.3mm (range 50.7-90.0) (P=0.816). The median ASD for controls was 42.3mm (range 31.0-56.1) and for hypospadias it was 39.4mm (range 20.7-77.0) (P=0.224). Considering severity of hypospadias, the median AGD for group 1 and group 2 was 73.7mm (range 50.7-90.0) and 63.3mm (range 53.6-77.0), respectively (P<0.001). The median ASD was also higher in group 1, at 41.3mm (range 20.7-65.0), compared to 35.2mm (range 23.5-77.0) in group 2 (P=0.119) (Summary Fig.). This study showed that more severe forms of hypospadias are associated with shorter AGD and ASD. These findings agree with two previous studies that identified reduced AGD in boys with hypospadias. However, these studies did not investigate an association with severity of hypospadias. As hypospadias is multifactorial, only a small proportion of cases are thought to be associated with impaired in utero androgen exposure. The shorter AGD in boys with severe hypospadias compared with mild hypospadias would indicate that AGD is a marker of the severity of androgen production. This may also suggest that less severe forms of hypospadias have a different aetiology involving a later stage of development, and that they are not the result of reduced androgen exposure in the male programming window between the 8-14 weeks gestation. This study identified that boys with more severe hypospadias are more likely to have a shorter AGD and ASD than boys with mild hypospadias. This may indicate that there is a more profound impairment of in utero androgen action in severe hypospadias.

Maternal hypertension and risk for hypospadias in offspring.

Hypospadias is one of the most common birth defects in male infants. Maternal hypertension is a suspected risk factor; however, few previous studies have addressed the possibility of reporting bias, and several previous studies have not accounted for hypospadias severity. We analyzed data from the Texas Birth Defects Registry for 10,924 nonsyndromic cases and statewide vital records for deliveries during 1999-2009, using Poisson regression. After adjustment for potential confounders, hypospadias was associated with maternal hypertension (adjusted prevalence ratio: 1.5, 95% confidence interval: 1.4-1.7). Similar associations were observed with gestational and pregestational hypertension, including separate analyses restricted to the subset of cases with severe (second- or third-degree) hypospadias. All of these associations were also similar among the subset of cases with isolated hypospadias (without additional birth defects). To evaluate the potential for bias due to potential hypertension misclassification, we repeated our analyses using logistic regression, comparing the cases to controls with other birth defects. In these analyses, the associations with gestational hypertension were similar, but adjusted associations with pregestational hypertension were no longer observed. Our findings support an association between gestational hypertension and hypospadias in offspring, but also suggest that previously observed associations with pregestational hypertension may have been inflated due to differential misclassification of hypertension (e.g., reporting bias). As gestational hypertension is recognized after hypospadias development, more research is needed to determine if this association reflects an increase in gestational hypertension risk secondary to hypospadias or if both conditions have shared risk factors (e.g., precursors of gestational hypertension). © 2016 Wiley Periodicals, Inc.