Slit-like Meatus Research Articles

A single-stage dorsal inlay buccal mucosal graft placement through subcoronal vertical sagittal ventral urethrotomy without glansplasty for reconstruction of meatal stenosis, fossa navicularis, and distal penile urethral stricture: Our initial experience.

Reconstruction of fossa navicularis stricture (FNS) poses a challenge in providing acceptable functional and cosmetic outcomes. We describe our novel surgical technique and its short-term results. This urethroplasty technique is a single-stage dorsal inlay buccal mucosal graft placement with subcoronal vertical sagittal ventral urethrotomy without glansplasty. Twenty-one operated patients were followed up at 2 months and 6 months postoperatively. We studied the functional outcome of the International Prostate Symptom Score, quality of life (QoL) score, maximum flow rate, postvoid residual (PVR) urine, and reconstructed urethral luminal caliber. Sexual function was studied via a brief male sexual function inventory. Hypospadias objective score evaluation (HOSE) was used to assess the cosmesis. Patient satisfaction was evaluated using the global response assessment score (GRA). FNS is seen commonly associated with lichen sclerosus (n = 12). Nine patients had stricture that extended into the distal penile urethra. The mean stricture length was 2.76 cm. At the end of the study, a significant improvement in mean IPPS (18.81), mean QoL score (2.25), mean Qmax (20.94 mL/s), mean PVR (103.05 mL), and mean urethral caliber (16.06 Fr) were noted. No difference in sexual drive and erectile function but significant improvement in ejaculation was noted. All patients had single-stream urine, reconstructed urethral caliber ≥16Fr, HOSE ≥14, and GRA ≥2 at 6 months. Except for two patients, all had vertical slit-like meatus. This technique is feasible, with good cosmetic, functional, and subjective outcomes with marked patient' satisfaction.

Separation of the glanular part of the urethral plate, mobilization of the distal part of the neourethra, and creation of the glanular groove: a new modification of second-stage Thiersch-Duplay urethroplasty in proximal hypospadias repair.

To evaluate the effect of separation of the glanular part of the urethral plate from the underlying glans penis with creation of a glanular groove for free accommodation of the neourethra as a new modification of Thiersch-Duplay urethroplasty in proximal hypospadias repair. Between January 2016 and January 2022, 35 patients with proximal hypospadias underwent a modified Thiersch-Duplay two-stage procedure. The glanular portion of the urethral plate was either separated from the underlying glanular tissue or discarded if found scared with mobilization of the distal portion of the neourethra to reach the tip of the glans penis. In all patients, a few millimeter of glanular tissue is excised to create a glanular groove in which the neourethra is embedded freely. 35 patients were involved in this study. The patient's age at the time of operation ranged from 18months to 10years (median 3.7years). The mean follow-up period was 15.7months (ranging from 12 to 18months). Two patients developed urethrocutaneous fistula; while, none of the patients had meatal stenosis, urethral stricture, or meatal retraction. All patients have a slit-like meatus at the tip of the penis and a good cosmetic conical shape glans appearance. We believe that in Thiersch-Duplay urethroplasty, separation of the urethral plat from the underlying glanular tissue and creation of good glandular groove to accommodate the neourethra is associated with adequate glanular closure and minimization of post-operative meatal stenosis, glanular dehiscence, and meatal retraction.

Assessment of functional and cosmetic outcomes of Extended-Tubularized incised plate for mid-shaft and distal hypospadias as a modification of Snodgrass repair: a cross-sectional study.

Hypospadias is a congenital abnormality of anterior urethral and penile development where the urethral meatus is ectopically located on the ventral aspect of the penis. It is a relatively common condition affecting ~1 in 250 male birth. Extended-Tubularized Incised Plate (E-TIP) is a modification of Snodgrass repair by extending the midline incision to the apical part of the glans resulting in a more normal appearing location of the meatus and straight urinary stream without increasing the risk of complications. To evaluate functional and cosmetic outcomes of E-TIP repair for mid-shaft and distal hypospadias as a modification of Snodgrass repair. A prospective cross-sectional study including 53 cases of mid-to-distal hypospadias repaired with the E-TIP technique between November 2019 and February 2022 in Baghdad. The authors start with the standard technique described by Snodgrass, but the midline incision of the urethral plate extended up to the apical part of the glans tip, and tabularization started distally creating a slit-like a neomeatus. Outcome assessment depended on an objective evaluation of the following parameters: maximum flow rate, post-void residual, Hypospadias Objective Score Evaluation (HOSE) score, and direction of the urinary stream. The mean age was 3.4±2.1 years, ranging from 0.6 to 9 years. The mean duration of follow-up was 14.4±6.9 months, and the location of the meatus was coronal in 16 patients (30%), subcoronal in 25 (47%), and mid-distal shaft in 12 (23%). The glans width was greater than or equal to 14mm in 46 patients (87%) and less than 14mm in 7 (13%). Q.max was above the fifth percentile of age-related uroflowmetry nomograms for healthy children 5-15 years old in 29 boys (93.5%) and below the fifth percentile in 2 (6.5%). Post-void residual urine was less than 10% of voided volume in 28 out of 31 boys (90%) and greater than 10% in 3 (10%). Regarding cosmetic outcomes, 50 boys (94%) had good penile appearance and their HOSE score greater than or equal to 14 with a slit-like meatus located at the tip of the glans, while 3 (6%) of them their score was less than 14. The overall mean HOSE score postoperatively for all patients was 15±0.9. Six patients (11%) had a deviated urinary stream and 47 (89%) had a straight stream. E-TIP repair is a good alternative to standard Snodgrass repair for mid-shaft to distal hypospadias with a good functional and cosmetic outcome, particularly the neomeatus position at the tip of the glans, which is similar to the normal one without increasing the risk of meatal stenosis.

Spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty for primary hypospadias repair

Neourethral covering is an essential technique for preventing complications such as fistula and glans dehiscence in hypospadias repairs. The spongioplasty has been reported for neourethral coverage about 20 years ago. However, reports of the outcome are limited. This study aimed to retrospectively evaluate the short-term outcome of spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty (DIGU). From December 2019 to December 2020, 50 patients with primary hypospadias (median age at surgery, 37 months; range, 10 months-12 years) were treated by a single pediatric urologist. The patients underwent spongioplasty with Buck's fascia covering dorsal inlay graft urethroplasty in single stage. The penile length, glans width, urethral plate width and length, and the location of the meatus of the patients were recorded preoperatively. The patients were followed up,complications noted, and postoperative uroflowmetries at the one-year follow-up time were evaluated. The average width of glans was 12.92±1.86mm. A minor penile curvature was observed in all patients (≤30°). The patients were followed up for 12-24 months, and 47 patients (94%) were free from complications. A neourethra formed with a slit-like meatus at the tip of the glans, and the urinary stream was straight. Three patients had coronal fistulae (3/50) and no glans dehiscence, and the mean±SD Qmax of postoperative uroflowmetry was 8.13±3.8ml/s. This study estimated the short-term outcome of the DIGU covered using spongioplasty with Buck's fascia as the second layer in patients diagnosed with primary hypospadias with a relatively small glans (average width <14mm). However, only a few reports emphasize spongioplasty with Buck's fascia as the second layer and the DIGU procedure performed on a relatively small glans. The major limitations of this study were its short follow-up time and the retrospective data collection. Dorsal inlay graft urethroplasty combined with spongioplasty with Buck's fascia as coverage is an effective procedure. In our study, this combination had good short-term outcomes for primary hypospadias repair.

Grafted tubularised incised plate: A right option in the management of failed mid-penile and distal hypospadias.

Hypospadias is a common congenital anomaly of the urogenital system. The goal of the initial repair is to correct any curvature, ensuring that the penis is straight, allowing for successful intercourse, to create a functional neourethra to direct the urinary stream in a forward direction and to produce a cosmetically normal-appearing penis with a slit-like meatus at the tip of the glans. Failures and complications do occur. Failed hypospadias repair is often associated with penile skin loss or deficient local tissue, which leaves the penis short, scarred and hypovascular. Repair of a failed hypospadias surgery represents one of the most challenging and difficult tasks. We retrospectively evaluated our series of children who underwent reoperative grafted tubularised incised plate (G-TIP) repair for a mid-penile or distal penile hypospadias. With permission obtained from the university/institutional ethics committee, we retrospectively reviewed the inpatient and outpatient records of all children ≤18 years of age who underwent a reoperative G-TIP hypospadias repair. During the study period, a total of 22 children (mean age: 6.8 years) underwent reoperative G-TIP repair. The mean number of previous repairs was 1.36. Nine (40.9%) of the children had persisting chordee. Complications were noted in five (22.7%) children. G-TIP is a good option in the management of mid-penile or distal penile failed hypospadias repairs. Although complications are noted, they are easily manageable.

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

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

Extended TIP vs. Standard TIP for primary distal hypospadias repair: randomized study for comparing functional and cosmetic outcomes

Objectives The aim of this study was to critically evaluate distal extension of the midline urethral plate incision, extended tubularized incised plate (e-TIP) technique, with the standard TIP and investigating predictors of functional and cosmetic success. Methods In a prospective study, consecutive patients with primary distal hypospadias presented for repair were randomized to undergo either extended TIP (e-TIP) or standard TIP (s-TIP) technique. Cosmetic outcome was evaluated postoperatively using Hypospadias-Objective-Penile-Evaluation (HOPE) score and measurement of ventral-glans-closure-length (VGCL) and meatal length (ML). Functional outcome was evaluated by maximal flow rate (Qmax), average flow rate (Qave), and postvoid residual urine (PVR). The effect of preoperative parameters on the outcome was assessed with regression analysis. Results In all 94 cases, out of 110 randomized, were available for analysis. Forty-six in e-TIP group and 48 cases in s-TIP group with comparable preoperative demographics. Median (inter-quartile range) of postoperative total HOPE-score was 57(45–60) vs. 55(44–60) for e-TIP and s-TIP (p < 0.001), respectively. The mean (SD) ratio of VGCL/ML was 87% (26) versus 46% (12) for e-TIP vs. s-TIP, respectively (p < 0.001). Both complications and functional outcomes were comparable. Urethral plate (UP) width and the use of e-TIP technique were significant predictors of successful cosmetic outcome in regression analysis (p = 0.019 and p = 0.001), respectively. Conclusion Extension of midline urethral plate can potentially create a vertical slit-like meatus located at the glans tip without compromising the functional outcome, thus providing better cosmetic outcome compared with the standard technique. The UP width was a significant predictor of superior cosmetic outcome.

Comparison of Modified Mathieu versus Standard Tubularised Incised-Plate Urethroplasty for Distal Hypospadias Repair

Objective: To compare the outcomes of modified Mathieu versus standard tubularised incised-plate urethroplasty for distal hypospadias repair. Materials and Methods: This prospective comparative study was conducted on 54 cases affected by distal hypospadias presenting to Institute of Kidney Disease, Hayatabad, Peshawar form February 2015 to June 2020. The inclusion criteria was patients with distal hypospadias (coronal, sub-coronal, or distal penile), age range of 15 to 60 months. Cases with severe chordee/ventral curvature, history of previous hypospadias repair, and poorly developed urethral plate were excluded. The patients with distal hypospadias were divided into two equal groups: in-group I repair done with Mathieu procedure plus incision of the urethral plate (modified Mathieu) and in-group II repair was performed with Tubularized Incised Plate (TIP). The principal author performed functional and cosmetic assessment at follow up visits which includes; denvo meatus; size and pressure of the stream; and complications like meatal stenosis, urethral cutaneous fistula. Fisher Exact test was used to compare categorical variables between the two groups and student t test for continuous variables. Results: The mean age of the study was 38.13±12.55 months. The operating time was less in TIP than modified Mathieu procedure statistically (P=0.036, 95% CI=0.315, 9.02). In modified Mathieu procedure the sprayed stream of micturition was higher (n=4, 14.8%) while in TIP procedure the frequency of narrow stream was higher (n=4, 14.8%). The difference was statistically significant (P=0.054). Only in modified Mathieu procedure the meatus shape was round in 4 (14.8%) cases and the results were statistically different (P=0.038). Post-operative fistula was higher TIP (n=6, 22.2%) than modified Mathieu (n=1, 3.7%) statistically (P=0.043). Only in TIP procedure postoperative meatal stenosis was found in 5 (18.5%) and the difference was statistically significant (P=0.019). Conclusion: The modified Mathieu technique can improve the cosmetic outcome through creation of slit-like meatus, low incidence of fistula and meatal stenosis than tubularized incised plate urethroplasty in the repair of distal hypospadias.

Autologous platelet gel improves outcomes in tubularized incised plate repair of hypospadias

Backgroundhypospadias is one of the most widespread male congenital anomalies, occurring in 1:250 to 1:300 live births. Several repair techniques have been developing to improve the outcomes. Purposea randomized prospective controlled study was adopted to evaluate effectiveness of autologous platelet gel in healing promotion and improving the outcomes of hypospadias repair. Methodsthirty children who aged between 6 months and 12 years were recruited and subdivided into two groups; group A had tubularized incised plate (TIP) repair with autologous platelet gel application and group B had TIP repair without autologous platelet gel. Resultsthere was no significant difference in duration of operation between both groups. All patients in groups A and B had slit-like meatus shape in the distal glans. While all those of group A had one urine stream, yet only 11 of group B had one. There were complications that happened exclusively in group B such as spray stream (27%) and fistula (20%). Whereas other complications occurred insignificantly more in group B than in A including meatal stenosis (53 versus 27%), glans dehiscence, (20 versus 7%), bleeding (33 versus 13%), infection (33 versus 27%), edema (27% versus13), respectively. The incidence of skin necrosis was equal in both groups. Conclusionautologous platelet gel usage in TIP hypospadias repair can be a reliable technique to promote wound healing, and to limit of postoperative surgical complications.

V06-01 SINGLE-STAGE RECONSTRUCTION OF FOSSA NAVICULARIS STRICTURES USING A “SLIDING-T” DORSAL INLAY URETHROPLASTY WITH BUCCAL MUCOSAL GRAFT

Objective To describe a single-stage urethroplasty for fossa navicularis strictures using a “sliding-T” dorsal inlay technique with buccal mucosa. Strictures of the fossa navicularis are challenging. Endoscopic treatments typically offer only temporary relief and necessitate lifelong instrumentation. Reconstruction should provide an unobstructed urethra, slit-like meatus, preserve sexual function, and create a cosmetically appealing glans. The ideal urethroplasty technique has not yet been elucidated despite various described single-stage and multistaged approaches. Methods A retrospective review from January 2013 to May 2018 was performed to identify patients undergoing single-stage urethroplasty for fossa navicularis strictures. The primary outcome was urethroplasty success defined as the ability to easily pass a 16 Fr flexible cystoscope with a minimum of 12-month follow-up. Secondary outcome measures included 90-day complications, de novo erectile dysfunction, chordee, and patient satisfaction assessed at ~6-months postoperatively with the question, “Overall, are you satisfied with the result of your operation for urethral stricture?” Results Twenty-seven patients underwent reconstruction of fossa navicularis strictures using buccal mucosa with a “sliding-T” dorsal inlay urethroplasty technique. Stricture etiology was most commonly lichen sclerosus (70.4%; n = 19), iatrogenic (18.5%; n = 5), or idiopathic (11.1%; n = 3). Mean stricture length was 3.2 cm ± 1.2 [1-4] and mean patient age was 47.3 years [19-71]. Around 92.6% (n = 25) of patients failed prior endoscopic treatment while 7.4% (n = 2) failed prior urethroplasty. At a mean follow-up of 29.6 (12-60) months the success rate was 92.4% (n = 25). Both recurrences were managed successfully with meatotomy. 90-day complications (Clavien ≥2) occurred in 2 patients (7.4%) (surgical site infection treated with antibiotics). Functionally, 1 patient (3.7%) experienced de novo erectile dysfunction, 1 (3.7%) reported mild chordee, and 96.3% (26/27) of patients were satisfied with the outcome of surgery. Conclusion Reconstruction of fossa navicularis strictures using buccal mucosa with a single-stage “sliding-T” dorsal inlay technique provides satisfying anatomic and functional outcomes with a low rate of associated complications.

Repair of distal hypospadias by construction of neourethra from augmented urethral plate with two lateral strips of glans skin and coverage with dartos flap followed by skin closure with preputial flap: single center series.

IntroductionHypospadias is one of the most common anomalies in boys. Many surgical techniques for reconstruction of distal hypospadias have been described, each method having a different success rate. Our objective in this study is the assessment of the surgical technique for repair of distal hypospadias by construction of a neourethra from the augmented urethral plate with two lateral strips of glanular skin, coverage with a dartos flap, and followed by skin closure with preputial skin flap.Material and methodsFrom March 2016 to November 2018, repair of distal hypospadias was performed in 56 children with a mean age of 3.2 years (range 2 to 8 years old). Minimum follow-up was 12 months, maximum up to 24 months. Success was defined by cosmetic appearance of the penis, parent perception of penile appearance, and urinary function. Uroflowmetry was done in 22 children at the 12 months follow-up. Parents evaluation of procedure was done by questionnaire using the pediatric penile perception score (PPPS).ResultsThe results were successful with straight penile shaft, conical glans, slit-like meatus located at the tip of the glans, with no rotation, and normal micturition. Five children had urethrocutaneous fistula (8.9%) that were treated with simple closure. Parents reported ‘very satisfactory’ (98.2%) and ‘satisfactory’ (1.8%).ConclusionsThe described technique of repair of distal hypospadias in children with different variants of urethral plate width and glans size showed good results, both operator’s and parent’s perception of the results being very satisfactory. This technique is categorised stage 2a in the IDEAL (Idea, Development, Evaluation, Assessment, and Long-term study) staging system for surgical innovations.

Outcome of urethral mobilization and advancement after anterior hypospadias surgery

BackgroundIn hypospadias surgery, despite continued refinement of various surgical procedures, there is no completely satisfactory technique in terms of complications and cosmesis. In recent literature, urethral mobilization and advancement (UMA) is gaining popularity in the management of distal penile hypospadias with no or very low complication rate as compared to all other techniques. The aim of this study is to share our results by using UMA in the management of anterior hypospadias with or without chordae.ResultsA total of 60 patients of anterior hypospadias having the mean age 57.15 ± 38.73 months were included. The mean length of hospital stay was 2.83 ± 1.33 days. The only peroperative complication was urethral injury during urethral mobilization seen in one patient. The most common postoperative complication was hematoma seen in five (8.3%) cases. Two patients (3.3%) had retraction of urethra. One patient had wound infection. Stenosis was labeled in four (6.6%). At 3 months follow-up, 93.3% patients had slit-like meatus and good urinary stream.ConclusionWe found that UMA technique had good functional as well as excellent cosmetic outcome, so the technique can be adopted for anterior hypospadias correction.

Correction of anterior hypospadias without urethroplasty

Objectives: The aim was to present a simple technique for the correction of anterior hypospadiases without meatal advancement or urethroplasty. Background: Most of the techniques described for the correction of anterior hypospadias had the risk of complications: recession, flaying of the glans, fistula, and meatal stenosis that is not accepted when dealing with a trivial anomaly that is done only for cosmetic correction. A simple technique for correcting granular and some forms of coronal hypospadias without meatal advancement or urethroplasty is presented. Patients and methods: From June 2013 to June 2016, 183 patients presented for surgical repair of glanular or coronal hypospadias. The technique of glanular rotation procedure (GRP) was applied only for those cases that matched the criteria settled after degloving of the penis with an incision made 2mm proximal to the meatus touching the glans on both sides for 3–4 mm. Once the uppermost part of the meatus is at the same line with the upper end of the glans on both sides, the technique is applicable. The patients were followed in the OPD for 1 year after the repair for the evaluation of the results of the technique: the urinary stream, meatal size and position, presence of fistula, and the final cosmetic appearance. Results: Ninety-eight out of 183 (53.6%) boys had matched the criteria for application of the GRP technique. Their age ranged from 6 months to 3 years. All but three had an apical, slit-like meatus with good stream without stenosis and 2–3mm glans tissue encircling the ventral side of the meatus. Four cases had complications in the form of meatal stenosis in two cases, disruption of the glans in one case, and coronal fistula in one case. The overall complication rate was 4.1%. Conclusion: In properly selected cases, GRP is a simple efficient technique that has the advantage of reconstructing the glans over the urethra without the need of meatal advancement or urethroplasty. Keywords: coronal hypospadias, glanular hypospadias, without urethroplasty

Meatal Mobilization and Glanuloplasty: A Viable Option for Coronal and Glanular Hypospadias Repair

To present the meatal mobilization with glanuloplasty inclusive (MMGPI) modification of meatal advancement and glanuloplasty inclusive. A total of 120 patients with anterior hypospadias underwent MMGPI between September 2008 and October 2014 at Kermanshah University of Medical Sciences. Satisfactory outcomes were defined as continuous straight urinary flow and catheterization of new meatus without difficulty. Cosmetic outcomes were considered acceptable if patients maintained a slit-like meatus at the glanular tip. Patients were examined at 1 week, 1, 3, 6, 12, and 24 months. The 120 patients with anterior hypospadias underwent MMGPI. There were no hematoma, meatal necrosis, or other early complications. In patients with glanular hypospadias, there were no meatal regressions or stenosis, all voiding patterns were normal, and all patients maintained a slit-like meatus at the glanular tip. Two patients with coronal hypospadias had meatal stenosis and 2 patients had meatal regression. Five patients with sub-coronal hypospadias had 2-mm meatal regression with downward sloping urinary stream, and 2 patients had meatal stenosis. In all, meatus remained distal to the preoperative meatus with no necrosis. Small sample size was the major limitation of this study. MMGPI represents a viable option for glanular and coronal hypospadias repair.

Eccentric circummeatal based flap with limited urethral mobilization: An easy technique for distal hypospadias repair

Hypospadias is a common congenital anomaly. Over 300 techniques have been described for repairing hypospadias. Eccentric circummeatal based flap with combined limited urethral mobilization technique (ECMB-LUM) is a simple procedure to repair distal hypospadias with minimal complication rate. This study presents results of this technique, highlighting surgical pitfalls to achieve the best result. Medical records of patients with distal hypospadias operated on using the same technique between 1998 and 2011 were reviewed retrospectively. Age at surgery, position of meatus preoperatively and postoperatively, duration of urethral catheterization and hospitalization, early and late complications, previous hypospadias repairs, and secondary surgical interventions were evaluated. In the surgical technique an eccentric circummeatal based flap is outlined. The proximal part of the flap is dissected from the underlying urethra and Buck's fascia. If the flap is not long enough, the distal urethra is mobilized a few millimeters (Figure). The eccentric flap is sutured to the tip of the glans. The glans wings are approximated in the midline. A urethral catheter of 6 Fr or 8 Fr is passed and left in the bulbous urethra or the urinary bladder. Diverged limbs of corpus spongiosum are approximated on the urethra, then, the glans and skin of the penile shaft are sutured. Of the 171 consecutive patients operated on using the ECMB-LUM technique; 115 had coronal, 47 had subcoronal, and nine had glanular meatus. The mean age at surgery was 4.5 (1-17) years. Patients were hospitalized for 2.2 ± 0.7 days. Mean duration of urethral catheterization was 2.3 ± 0.5 days. All but eight patients had ECBF-LUM as primary repair. There were no early complications such as bleeding, hematoma, and wound infection. All patients voided spontaneously after catheter removal. Late complications were meatal stenosis, urethrocutaneous fistula, meatal regression, and glandular dehiscence (Table). These patients were treated using dilatation, fistula repair, meatoplasty, and secondary repair with the same technique, respectively. Eventually all patients had a vertical slit-like meatus on the tip of a natural looking glans. The most commonly used distal hypospadias repair techniques are glanular approximation, meatal advancement and glanuloplasty, Koff, Mathieu, Thiersch-Duplay procedure, tubularized incised plate repairs, and modifications of these techniques. Cosmetic and functional results and complication rates of ECMB-LUM technique are comparable with those of the commonly used techniques.

V2-03 THE MALONE MEATOPLASTY: A DORSAL APPROACH TO MEATAL STENOSIS IN PATIENTS WITH LICHEN SCLEROSUS

INTRODUCTION AND OBJECTIVES: The treatment of meatal stenosis associated with lichen sclerosus is traditionally treated either by meatal dilatation or ventral meatotomy. These operations have high recurrence rates or create a hypospadiac meatus. We present an established technique in the use of a dorsal approach. METHODS: Initially a small ventral meatotomy is performed. The epithelium of the urethra and glans is opposed with 3, 6-zero polyglactin (PG) sutures. This acts to widen the meatus slightly without making it hypospadiac but more importantly it allows the insertion of forceps to assess and ensure that the stricture does not extend significantly into the navicular fossa. Next a deeper dorsal meatotomy is performed. Again the epithelium of the urethra/glans are opposed. The combination of small ventral and deeper dorsal meatotomies should completely open the stenosed meatus but the cosmetic appearance at this stage is poor since the sutures of the dorsal meatotomy pucker the glans due to the thickness of the corpus spongiosum. This is overcome by an inverted V-shaped relieving incision with the apex of the V close to the proximal limit of the dorsal meatotomy. The edges of the relieving incision are freed by sharp dissection. The opposing left and right inner edges are closed with continuous PG to form the roof of the distal neourethra. The outer glans layer is opposed with interrupted PG. RESULTS: The final result is a slit-like but good calibre meatus at the tip of the glans. CONCLUSIONS: During a follow-up of 4.2 years there were recurrences in 6/116 patients, 5 of whom required re-operation (4.3%). 93% patients were either happy or very happy with the cosmetic result. Conclusion: This technique can achieve excellent aesthetic results, with low incidence of a spraying stream.

Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes

ObjectivesTo objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score. Patients and methodsIn a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3months after surgery, the flow pattern, maximum (Qmax), and mean urinary flow rate (Qave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system. ResultsThe native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5–14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3–24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3–14) years showed an abnormal Qmax below the fifth percentile in four (15%), with the Qave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13–16). Two patients had a small, single subcoronal fistula. ConclusionExtending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.

Tubularized incised plate technique for recurrent hypospadias

Objectives To evaluate our local experience of tubularized incised plate (TIP) repair Snodgrass method) in the management of recurrent hypospadias. Summary background data TIP repair has been well described for use in salvage hypospadias repairs, with good results. Patients and methods This prospective, descriptive study was carried out over a period of 5 years from December 2003 to December 2008. The study included 30 patients; all of these patients had previously undergone hypospadias repair, and the indication for surgery was complete failure of the previous repair. Classic TIP repair was performed, although tissues for barrier layers between the neourethra and skin closures were not as readily available. Results Secondary TIP repair was successful in 25/30 patients (83.3%). These patients showed no postoperative complications and had a slit-like meatus and a forwarddirected urinary stream without branching. Their parents were satisfied with the repair results. Conclusion Our local experience coincides with data of the literature that TIP is an excellent option in the treatment of recurrent hypospadias when the results of primary techniques are unsatisfactory. Keywords : recurrent hypospadias, salvage hypospadias, tubularized incised plate

Split Dorsal Dartos Flap Transposed Ventrally as a Bed for Preputial Skin Graft in Primary Staged Hypospadias Repair

To describe a modification of the 2-stage repair using a dorsal split dartos fascia flap, as a well vascularized bed for the graft in the first stage.The 2-stage repair is a commonly used technique in proximal hypospadias or in hypospadias with severe chordee, or in cases with urethral plate of poor or dubious quality. Between 2006 and 2009, 32 patients underwent a staged hypospadias repair: 8 (25.0%) midshaft with chordee and/or poor urethral plate, 14 (43.8%) proximal penile, 7 (21.9%) peno-scrotal, and 3 (9.4%) perineal hypospadias. Plication was necessary in 27 (84.4%). All cases received a preputial skin graft. Median age at the first stage was 21 months (range 15-26); median follow-up was 35 months (range 20-55) and the median time between the 2 stages was 8 months (range 6-12). Graft take was 100% after the first stage. Follow-up after second-stage repair showed 31 of 32 (96.8%) had a successful functional outcome (straight erection; good, single urine stream; voiding in a standing position) and cosmetic outcome (slitlike meatus positioned at the tip of the glans, "normal looking circumcised penis"); one fistula occurred. One patient has mild residual ventral curvature. Using a vascularized dorsal split dartos flap ventrally underneath and laterally of the skin graft in the first stage offers the advantages of an excellent graft take and the provision of versatile dartos tissue for a waterproofed and secured urethroplasty.

546 AN ALTERNATIVE FOR VENTRAL LENGTHENING IN CHILDREN WITH SEVERE PENILE CURVATURE THAT ALLOWS GRAFT COVERAGE DURING STAGED HYPOSPADIAS REPAIR

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Lower Urinary Tract & Genitalia1 Apr 2011546 AN ALTERNATIVE FOR VENTRAL LENGTHENING IN CHILDREN WITH SEVERE PENILE CURVATURE THAT ALLOWS GRAFT COVERAGE DURING STAGED HYPOSPADIAS REPAIR Bruno Leslie, Bryce Weber, Rodrigo Romao, Walid Farhat, Darius Bagli, Armando Lorenzo, and Joao Pippi Salle Bruno LeslieBruno Leslie toronto, Canada More articles by this author , Bryce WeberBryce Weber toronto, Canada More articles by this author , Rodrigo RomaoRodrigo Romao toronto, Canada More articles by this author , Walid FarhatWalid Farhat toronto, Canada More articles by this author , Darius BagliDarius Bagli toronto, Canada More articles by this author , Armando LorenzoArmando Lorenzo toronto, Canada More articles by this author , and Joao Pippi SalleJoao Pippi Salle toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1271AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Staged repair using preputial grafts has become a popular option for proximal hypospadias with severe curvature. Corporal ventral lengthening (CVL) with autologous, xenogenic or synthetic grafts are often employed, however the initial lack of vascular supply precludes simultaneous superposition of free grafts during first stage urethroplasty. Herein we report preliminary results of a surgical strategy aiming to overcome this limitation, allowing concurrent CVL and preputial grafting for urethroplasty. METHODS The medical records of patients who underwent staged preputial graft urethroplasty (SPGU) for primary repair of perineal or penoscrotal hypospadias with severe curvature were retrospectively reviewed. All patients received pre operative testosterone. The decision to divide the urethral plate was made after complete degloving and urethral mobilization. Multiple deep ventral transverse incisions of the tunica albuginea from 3 to 9 o'clock position were performed in patients with persistent intrinsic curvature after plate transection. An inner preputial graft was then harvested and quilted directly over the incised albuginea, and a tie-over dressing applied. Second stage was done approximately 6 months later, when the graft was tubularized and covered with tunica vaginalis or dartos flap. Prior to tubularization an erection test was repeated and residual curvature addressed with dorsal plication (DP), if necessary. Age, outcomes, need for DP and complications were recorded. RESULTS 30 patients completed the two stages from 2006 to 2010. Mean age at first stage was 18 months (range 10m–11y) and mean interval between stages was 8 months (range 6–11). Mean follow up after the second stage was 16 months (range 6–36). All grafts took well and were suitable for tubularization. DP was required for minor residual ventral curvature in 14/30 (47%) patients. Relevant complications included a long urethral stricture secondary to balanitis xerotica obliterans (1), ventral skin contracture (1), small urethrocutaneous fistulas (2), glans dehiscence (2) and recurrence of mild curvature (2). The remaining 22 cases have no ventral curvature and early excellent cosmetic results, with a slitlike meatus placed in the glans. CONCLUSIONS Our results suggest that the use of deep ventral transverse corporeal incisions for correction of severe curvature allows SPGU and concurrent CVL. The early cosmetic and functional results with this approach are satisfactory with an acceptable complication rate. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e221-e222 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bruno Leslie toronto, Canada More articles by this author Bryce Weber toronto, Canada More articles by this author Rodrigo Romao toronto, Canada More articles by this author Walid Farhat toronto, Canada More articles by this author Darius Bagli toronto, Canada More articles by this author Armando Lorenzo toronto, Canada More articles by this author Joao Pippi Salle toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...