Single-stage Hypospadias Repair Research Articles

Clinical efficacy of transverse preputial island flap urethroplasty for single-stage hypospadias repair in Children Hospital Faisalabad” A Retrospective Study.

Objective: To summarize the clinical outcomes of single stage hypospadias surgery with preputial-island flap method in the Children Hospital, Faisalabad. Study Design: Retrospective Study. Setting: Department of Paediatric Urology, Children Hospital, Faisalabad. Period: March 2018 to March 2023. Material & Methods: First of all, approval of study from the Hospital Ethical Review Committee was taken for research work. For last five years, all patients of hypospadias repair were admitted in the ward via OPD of Pediatric Urology Department of Children Hospital, Faisalabad. According to inclusion and exclusion criteria, these patients were considered to be included in study. After analyzing the patients with history and physical examination, the diagnosis was confirmed and after the informed consent of surgery and consent of data for research purposes the patients were put in the research work. Results: There were one hundred and fifteen patients (n=115), who were operated using single stage hypospadias repair with method where we used dorsal prepuce in transverse manner as flap known as preputial-island-flap method during the study period time. The complication of surgery rate was found 48.7% in the study. There were five patients (4.34%) suffering from mild infection. Six patients (5.2%) had disruption of repair; secondary surgical correction was successful in all of them. Ten patients (6.7%) suffered necrosis and slugging of new urethral tube followed by disruption of repair. Urethro-cutaneous fistula was observed in sixteen patients (13-9%), it was single in eleven patients and the rest of five had more than one fistula. Four patients needed fistula repair, rest of the eleven healed with self-urethral dilatation, seven patients (6%) had meatal stenosis, while four patients (3.5%) had urethral stricture. Conclusion: Single staged hypospadias repair where dorsal prepuce in transverse manner were taken as flap known as preputial-island-flap is also an acceptable choice for surgery. Results of study showed transverse preputial-island-flap technique is an acceptable option. Because the vascularity of tube is intact and good, secondly results are better, thirdly this technique has lower rate of complications, fourthly we completed in single stage which was the time saving.

Correction of curvature in single stage hypospadias repair with foreskin reconstruction

Many surgeons offer foreskin reconstruction (FR) as a routine part of hypospadias repair. We present a step-by-step video of the procedure of Tubularised Incised Plate (TIP) repair, FR and dorsal plication through a ventral skin incision. A ventral incision is made between the inner preputial mucosa and the outer skin extending below the meatus. Ventral degloving is carried out. The dissection is extended laterally around the corporal bodies. The point of maximal curvature (PMC) is marked on the dorsal midline. A vertical incision is made and closed transversely with 5-0 prolene suture in a Heineke- Mikulicz fashion. Urethroplasty is performed in 2 layers using 7-0 polydioxanone (PDS). Spongioplasty and ventral dartos are used as barrier layers. Glansplasty is performed in 2 layers.FR is carried out in 3 layers. Curvature correction is key to good outcome. Dorsal degloving can be achieved through a ventral incision allowing exposure of the dorsal midline for plication sutures. The patient had good cosmetic and functional outcome at 1 month follow up. FR can be safely performed during TIP repair for distal hypospadias repair. Curvature of less than 30° can be corrected through a ventral incision only.

Are there anatomical limiting factors to foreskin reconstruction at the time of single-stage hypospadias repair?

Foreskin reconstruction (FR) at the time of primary hypospadias repair is a truly anatomically complete reconstruction of the hypospadic penis. We prospectively collected penile and preputial measurement of children undergoing single-stage hypospadias repair and FR with the aim to identify possible relations between penile and preputial anatomy and the likelihood to develop complications. We prospectively studied children who underwent single stage hypospadias repair associated with FR from 2016 to 2019. We recorded intra-operative foreskin and penile measurements and post-operative outcomes. Logistic Regression analysis was performed to explore independent factors affecting urethroplasty and skin complications. Chi square test was used to compare outcomes in different groups based on ventral foreskin defect (VFD) width, Glans size, age at surgery and meatal location. From a total of 181 consecutive patients, 86 boys who underwent a single stage hypospadias repair combined with FR were included in the study. Patients were excluded because they were either lost at follow up (n=10), required a 2-stage repair (n=2), were circumcised at birth (n=3) or parents requested a circumcision (n=78); in 2 patients, a decision to perform circumcision was made intraoperatively due to aesthetic reasons (monk-hood deformity of the prepuce). Median age at surgery was 17 months. Mean glans width was 14.4mm. Mean unstretched and stretched foreskin circumference were 29.5mm and 40.9mm, respectively. Mean VFD (the distance between the proximal insertion of the foreskin hood on either side of the midline at the level of the coronal sulcus) was 7.2mm (Fig.1). At median follow-up of 8 months (6-23), 9 complications were recorded (10.4%): foreskin dehiscence occurred in 1% (1/86), a foreskin fistula was noted in 4.6% (4/86), tight, non-retractile, foreskin in 1% (1/86); urethrocutaneous fistula in 2.3% (2/86) and complete dehiscence of the glans and foreskin in 1 (1.2%). Multiple logistic regression analysis demonstrated that none of the measurements obtained was an independent risk factor for developing urethroplasty or skin complications. There was no significant difference in complications between wide VFD (>7mm) vs. narrow VFD (≤7mm), large glans (>14mm) vs. small glans (≤14mm), age at surgery ≤24 months vs.>24 month and meatal location distal (glanular, coronal, subcoronal and distal penile) vs. proximal (midpenile, proximal penile and penoscrotal). To the best of our knowledge, this is the first study reporting a prospective and objective assessment of the foreskin in the context of single stage hypospadias repair. Individual anatomical differences in preputial and penile anatomy do not seem to affect the likelihood of skin and urethroplasty complications. FR can, therefore, be offered to all boys undergoing primary single stage hypospadias repair . Further studies on larger numbers and external validation of these measurements is necessary.

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

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

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.

Preoperative Factors Affecting the Outcome of Single Stage Hypospadias Repair- An Observational Study

Background:Hypospadias is one of the commonest congenital anomaly in boys which requires either a single stage repair or staged repair. The success of the procedure depend upon the type, anatomy, experience of the surgeon, method of repair and preoperative hormonal stimulation. Aim: The aim of the study was to evaluate the various preoperative factors responsible for outcome of single stage repair in distal penile, mid penile and proximal penile hypospadias. Methods: There were 48 patients in this observational study which were divided into two groups. Group A comprised of 24 patients with glanular and coronal hypospadias while Group B comprised of 16 patients with distal penile, 5 mid penile and 3 proximal penile types with minimal chordae. All the 24 (50%) patients in group A underwent meatal advancement and glanuloplasty incorporated (MAGPI) repair while in group B 15 (31.25%) patients underwent Tabularized Incised Plate (TIP) repair and 9 (18.75%) patients underwent combined TIP and Mathieu’s repair. Results: Overall operative success rate observed in the study was 41 (85.41%) patients. In 7 (14.58%) patients urethrocutaneous fistula as a major complication occurred which included 1 patient in Group A and 2 patients with Distal Penile Hypospadias (DPH), 2 patients with Mid Penile Hypospadias (MPH) and 2 patients with Proximal Penile Hypospadias (PPH) in Group B. In 2 (4.16%) patients, mild meatal stenosis was noted which settled with meatal dilatation. Urethrocutaneous fistula (UCF) disappeared in 2 (4.16%) patients on follow up with regular urethral dilatation. Conclusion: MAGPI is the ideal procedure for glanular/coronal hypospadias. For distal penile hypospadias, TIP alone or combined TIP and Mathieu’s repair gives equally good results. Preoperative testosterone therapy reduces the incidence of complications in a single stage hypospadias repair.

Parental home removal of urethral catheters after urological surgery—a prospective benchmarking study

Many urological operations require placement of a urethral Foley catheter. The catheter often needs to remain in situ for a period of time after discharge; and patients subsequently require either a further hospital admission or community nurse review for catheter removal. Parents can easily remove the catheter at home by cutting the balloon port. This disrupts the valve and hence deflates the retaining balloon, thereby facilitating spontaneous passage of the catheter. The authors introduced this practice to their institution. The aim was to assess safety and success of parental home catheter removal. A prospective data study was performed in a large pediatric urology center over a 12-month time period. Patients <16 years after single-stage hypospadias repair or other penile surgery were included on a voluntary basis. Parents of eligible patients were instructed verbally and with an information leaflet, including date for removal. Telephone follow-up after removal was undertaken to assess the outcome. Thirty-eight patients were included over a 12-month time period. Patient age ranged from 9 months to 12 years (median age 2.5 years). The majority (82%) of patients had required a catheter after hypospadias repair. Home catheter removal was successful in 92% cases. Three children required professional support for catheter removal. Median time until catheter passage was 3h (range 0-24h). Considering that cost for day case admission for catheter removal averages at 130£ per patient, home catheter removal saved the NHS 4550£ in the time period. This is the first study to report the safety and feasibility of parental home catheter removal by cutting the balloon port valve in the pediatric population. It offers a number of distinct advantages compared with traditional methods for removal. These include, namely, (i) positive patient experience: catheter removal in a familiar environment by a relative minimizes stressful experiences for the family; (ii) minimal trauma to healing tissues through spontaneous catheter passage; and (iii) health care-related cost savings. This was an initial benchmarking study, so patient numbers were relatively small. Nevertheless, it shows that the method is safeand received positive parental feedback. Parental home removal of a urethral catheter is a feasible and safe alternative to catheter removal by a health-care professional. It minimizes parental anxiety and inconvenience related to the catheter removal appointment and allows for significant cost savings.

Foreskin reconstruction at the time of single-stage hypospadias repair: is it a safe procedure?

Foreskin reconstruction (FR) is a recognised, yet debated, option for patients undergoing single-stage hypospadias repair (HR). We evaluated the incidence of complications after single-stage HR in our institution. This is a retrospective review of all single-stage HR. Patients were classified into group 1 (circumcision) and group 2 foreskin reconstruction (FR). Urethroplasty and foreskin complications were recorded. Statistics used are as follows: Mann-Whitney test to compare age at operation and length of follow-up (FU); Chi-Square test to analyse the incidence of urethral complications and need for reoperation; Log rank test to compare the survival curves; p statistically significant < 0.05. Data are presented as median (range). 304 patients were identified, operated between January 2010 and December 2016, and 20 were excluded: 6 already circumcised at the time of the surgery, 3 with megameatus intact prepuce, 11 lost at FU. 284 patients were included: 161 circumcised and 123 FR. Median age at the operation was 17months (8-179) (group 1) and 17months (8-148) (group 2) (p = 0.71). Length of FU was 19months (8-91) (group 1) and 17months (4-87) (group 2) (p = 0.45). The survival curve was homogeneous (p = 0.28). Urethroplasty complications occurred in 32/161 (20%) (group 1) and in 21/123 (17%) (group 2) (p = 0.55). Foreskin complications occurred in 18/123 (15%). A second operation was required in 33 boys in each group, (20% group 1 and 27% group 2) (p = 0.21). FR does not increase the complication rate or the need for a reoperation after single-stage HR. Parents should be offered the option between the two procedures according to their personal preference.

Para-meatus Skin Incision With Long Channel Technique for Midshaft Hypospadias Repair Without Penile Curvature

To report a new surgical technique for midshaft hypospadias repair without penile curvature. From September 2007 to October 2010, 21 patients, aged 13 months to 8.9 years, underwent single-stage hypospadias repair by 1 surgeon. The skin incision was created around the meatus, and a long channel beneath the urethral plate was created through the incision to the apex of the glans. The inner preputial flaps were tubularized into a neourethra, which was then transposed to the ventral channel through a ventrolateral tunnel beneath Buck's fascia. Most of the neourethra was covered by the intact soft tissue of the distal ventral penis. The proximal portion of the neourethra was covered by Buck's and dartos fascia around the skin incision, and the skin incision was closed longitudinally. The length of the urethral defect and channel and the postoperative complications were collected and analyzed. A total of 21 patients underwent single-staged hypospadias repair. The average length of the channel was 30 mm (range 25-35). The average length of the neourethra was 35 mm (range 30 to 40). The mean operative time was 60 minutes (range 50-70). The mean hospital stay was 12 days (range 10-14). With an average follow-up of 20 months (range 6-37), no postoperative complication was detected. This technique provides excellent short-term results for midshaft hypospadias without penile curvature and is a safe and simple solution.

Is tubularization of the mobilized urethral plate a better alternative to tubularization of an incised urethral plate for hypospadias repair?

Trial of a new procedure of hypospadias repair based on the incorporation of the entire available innate urethral tissue for the formation of neo-urethra in patients with hypospadias. Fifteen consecutive children, nine with distal hypospadias and six with proximal hypospadias (all with severe chordee), whose parents consented to application of a new procedure of hypospadias repair, were the study subjects. This procedure is inspired by Cantwell Ransley procedure for epispadias repair and Snodgras procedure for hypospadias repair. The entire urethral plate was mobilized (i.e., lifted off the corpora) distal to the urethral meatus and was tubularized in two layers; inner urethral skin and outer spongiosal tissue, in Duplay fashion. The repair was reinforced with dartos vascularized flap. The skin incisions on the urethral strip are guided by the disposition of the spongiosal tissue underlying the urethral plate (rather than the conventional U-shaped incision on either side of hypospadiac urethral meatus). In the patients with proximal hypospadias with severe chordee urethral advancement was combined to achieve orthoplasty and a single stage hypospadias repair. The catheter was removed on tenth postoperative day. Even in patients with proximal hypospadias with severe chordee, good single staged repair was achieved without resorting to dorsal plication that would have been necessary had any other methods based on the preservation of urethral plate was performed in these subjects. Therefore, the procedure was found to have an extended applicability to even those patients where tubularized incised urethral plate urethroplsty is not advised. All patients had good results (in 1 year follow-up), except in three early subjects of the series; two of whom developed minor urethrocutaneous fistulae (probably due to frank urinary leak secondary to repeated catheter blockade) and one developed partial glanular wound dehiscence. Though the authors have an initial limited experience with this procedure, the procedure is likely to have a promising future due to its versatility and utilization of the entire urethral tissue.

Salvage Mathieu urethroplasty: Reuse of local tissue in failed hypospadias repair

Objectives To report our experience with Mathieu urethroplasty for revision of hypospadias repairs. Mathieu perimeatal-based flap urethroplasty remains a popular technique more than seven decades after its description for single-stage hypospadias repair. The excellent results of primary distal hypospadias repair are well documented, but reports of the results using the technique as a salvage procedure are sparse. The reuse of local tissue may be hampered by the presence of scar tissue and reduced vascularity. Methods A total of 40 patients underwent salvage urethral reconstruction. Of the 40 patients, 34 (mean age 70 months, range 11 to 216) underwent salvage Mathieu urethroplasty. All patients underwent surgery at least 6 months after the previous surgery. One, two, and three or more prior procedures had been performed in 22, 6, and 6 patients, respectively. The mean follow-up period was 29 months (range 1 to 84). In 6 patients, local tissue was scarred and immobile, and they underwent the procedure using buccal mucosal grafts. Results Satisfactory functional and cosmetic results after the initial procedure were achieved in 25 patients (74%). Two patients underwent reoperation for repair of meatal stenosis, and 5 (15%) underwent simple repair of fistula without the need for urethral reconstruction. Two patients underwent reoperation at other medical centers and were lost to follow-up. Overall, cure was achieved in 32 (94%) of the 34 patients. Conclusions Mathieu urethroplasty is an efficient technique for salvage hypospadias repair. Patient selection is the key to successful repair. Despite the effects of previous surgery, local tissue of adequate quality to facilitate repair exists in most patients.

Urologist's perspectives of single-stage hypospadias repair in the 1980s Experience of 100 Patients

During the last two decades major advances have been made in techniques of hypospadias repair. Many areas warrant meticulous attention to achieve further satisfactory results. We present areas of technique that have improved our results in genital reconstruction and hypospadias repair in particular. In addition to surgical technique modifications, we present technical refinements of patient positioning, use of cold antibiotic mixed saline, subcutaneous epinephrine at judicious sites, and microsurgical instruments as well as optical magnification and suture material. In genital anomalies, use of plastic surgical techniques with skin grafts and knowledge of the intrinsic vascular supply of the foreskin have further improved the outcome. Since 1982, 100 patients have been followed. Immediate complications total less than 1 percent; late complications total 10 percent including 9 percent fistula rate and 5 percent stenosis rate (urethral or meatal). No loss of skin flap or of neourethra were recorded.

Single-stage hypospadias repair: Techniques and results

Sixty-three children underwent one-stage hypospadias repair using one of three surgical techniques depending on the location of the meatus. The surgical aims were to achieve a functionally and cometically “perfect” phallus, which was accomplishedin 95.3 per cent.