Tip Of Glans Research Articles

Evaluation of Double Face Preputial Flap for Management of Hypospadias in Children

Background: hypospadias is a congenital anomaly in which meatal orifice opens in the vental aspect of penis instead of the glans tip. The meatal orifice may be located anywhere between the tip of the penis and the perineum.Objective: the aim of this study was to evaluate double face preputial flap for management of hypospadias in children about success rate, cosmetic result and appearance of complications such as fistula, strictures or disruption. Methodology: this study was conducted on 30 patients who were suffered from mid penile, proximal penile and peno scrotal hypospadias. The age of our cases at the time of repair were ranged between 4-12.5 years. Results: after finishing results of our study we noticed that was no statistically significant difference between results after double face preputial flap technique and ordinary transverse preputial island flap technique (Duckett's procedure) regarding fistula formation or skin infection. Conclusion: although the incidence of fistula formation was lower than that was reported in the classic Duckett repair, however, there was no statistically significant difference between results of double face preputial flap technique and current Duckett's procedure regard skin disruption and fistula formation.

Limited Urethral Mobilization Technique in Distal Hypospadias Repair : An Overview

Background: Fistula formation is the most common complication with various rates among different techniques of hypospadias repair. The urethral advancement as an one stage technique for repair of hypospadias is considered a good technique. As no new urethral tube is constructed there is no risk of fistula. We assess the outcomes of the Limited Urethral Mobilization (LUM) technique in distal hypospadias repair.Methods: Our study included 20 patients aged upto 12 years who were treated with Limited urethral mobilization technique for distal hypospadias in Shaheed Suhrawardy Medical College Hospital from December 2014 to December 2015. The urethra proximal to the meatus was mobilized for a distance sufficient to allow it to reach the glans tip without tension. Then the urethra was placed in the glanular bed and glanular reconstruction was performed.Results: Three-fold urethral mobilization was sufficient for construction of tension-free urethra-glanular anastomosis. Cosmetically normal looking circumcised penis with ventrally slit meatus achieved in all but one subcoronal case where the most distal of the glans approximation sutures disrupted leading to a minor detachment in the glans. The minor complications includes preputial edema in one patient, two patients had wound infection, one had meatal stenosis which was treated with gentle dilatations. Postoperative urethro cutaneous fistula, retraction of the urethral meatus or recurrent chordee were not observed.Conclusion: Distal hypospadias repair with the LUM technique can be effective with satisfactory cosmetic and functional results. There is no chance for development of urethro cutaneous fistula, a major postoperative complication of other surgical techniques of creating a neourethra. Postoperative management is simple and a brief hospital stay is sufficient.Chatt Maa Shi Hosp Med Coll J; Vol.16 (1); Jan 2017; Page 37-41

Outcomes of variation in technique and variation in accuracy of measurement in penile length measurement.

Accurate data regarding the size of the erect penis is of great importance to several disciplines working with male patients, but little data exists on the best technique to measure penile length. While some previous small studies have suggested good correlation between stretched penile length, others have shown significant variability. Penile girth has been less well studied, and little data exist on the possible errors induced by differing observers and different techniques. Much of the published data report penile length measured from the penopubic skin junction-to-glans tip (STT) rather than pubic bone-to-tip (BTT). We wished to assess the accuracy of different techniques of penile measurements with multiple observers. Men who achieved full erection using dynamic penile Doppler ultrasound for the diagnosis of sexual dysfunction or a desire for objective penile measurement were included in the study. Exclusion criteria were penile scarring, curvature, or congenital abnormality. In each case, the penis was measured by one of the seven andrology specialists in a private air-conditioned (21 °C) environment. Each patient had three parameters measured: circumference (girth) of the penile shaft, length from suprapubic skin-to-distal glans (STT), and pubis-to-distal glans (BTT). The three measurements were recorded in the stretched flaccid state, and the same three measurements were then repeated in the fully erect state, following induction of full erection with intracavernosal injection. We analyzed the accuracy of each flaccid measurement using the erect measurements as a reference, for the overall patient population and for each observer. In total, 201 adult men (mean age 49.4 years) were included in this study. Assessing the penis in the stretched and flaccid state gave a mean underestimate of the erect measurement of ~20% (STT length 23.39%, BTT length 19.86%, and circumference 21.38%). In this large, multicenter, multi-observer study of penis size, flaccid measurements were only moderately accurate in predicting erect size. They were also significantly observer dependent. Measuring penile length from pubic bone to tip of glans is more accurate and reliable, the discrepancy being most notable in overweight patients.

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.

May cachexia be an advantage for penile length?

IntroductionThe aim of the present study was to assess the relationship between penile length and somatometric parameters, especially cachexia. Material and methodsWeight and heights of all patients were measured and recorded by an internal medicine specialist. Flaccid and stretched states of penis were measured from pubic bone to tip of glans along the dorsum of the penis using a rigid metric ruler by a single urology specialist. Patients with urogenital abnormalities were excluded from the study. Penile length, age, weight and height values were recorded. Body mass index (BMI) was computed as the ratio of weight to the square of height. Patients were divided into three groups according to BMI cachexia, normal weight and obesity. Groups were defined: Group 1: Cachexia, BMI<18.5; Group 2: normal weight BMI, between 18.5 and 25; Group 3: obesity, BMI>30. Mean and median penile lengths were calculated. These three groups were evaluated in terms of whether there is a difference between flaccid and stretched penile length. Also correlation between weight, height and penile length was determined.Statistical analyses were performed using the SPSS for windows ver. 16.0 (SPSS Inc., Chicago, IL, USA). Statistical significance was set at p<0.05. ResultsOne hundred and twenty four patients enrolled in the study. Fourteen patients were in the cachectic group. Fifty six patients were in the normal weight group. Fifty four patients were in the obese group. Both flaccid and stretched penile lengths were statistically different in these groups (p<0.001; p<0.001). When we compared the groups separately, cachectic group's penile lengths were significantly longer than the normal weight group at both (p<0.01; p=0.02). Cachectic group's penile lengths were significantly longer than the obese group (p<0.001; p<0.001). Also normal weight group's penile lengths were longer than those of the obese group (p<0.001; p<0.001). ConclusionThe present study is the first one assessing the relationship between cachexia and penile length. As a result, cachexia may be an advantage for penile length.

Tubularized parameatal based dartos-spongiosum flap urethroplasty in distal hypospadias with flat glans, shallow meatal groove, and severe glans tilt

Objective: To report the technique and results of single stage tubularized parameatal based dartos-spongiosum flap urethroplasty for distal hypospadias with flat glans, shallow meatal groove, and severe glans tilt. Materials and Methods: The study was conducted over a period of 2-year from October 2013 to October 2015, and 19 patients with distal hypospadias were included in the study with flat glans, poor urethral groove, and severe glans tilt, who otherwise would have been subjected to transection of urethral plate and a two-stage procedure. In this technique, bilateral flaps were fashioned along the preputial edge beginning from the hypospadiac meatus with intact dartos, keeping the base of the flaps attached to the bifurcated spongiosum. The urethral plate was transected. Glans was split wide open. Bilateral flaps joined at ventral midline creating new urethral plate which was tubularized with the creation of slit like wide meatus at the tip of glans. Neourethral coverage was provided with double dartos flap. Complications and aesthetic appearance on a score of 1-10 were outcome measures. Results: There was no urethral stricture, residual chordee, penile rotation, or asymmetrical penis. The average aesthetic score was 8.5. Meatus was at the tip of glans with adequate caliber in all patients. Two (10.5%) out of 19 patients developed subcoronal fistula that required surgical closure. Conclusion: Tubularized parameatal-based dartos-spongiosum flap urethroplasty is viable and easy to reproduce option for management of a specific group of patients with distal hypospadias (with flat glans, poor urethral plate, and glans tilt) and is associated with very low complication rate.

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

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

PD06-06 THE EFFECT OF NEUROVASCULAR BUNDLE PRESERVATION ON CHANGES IN PENIS LENGTHS AND ELASTICITY SCORES FOLLOWING RADICAL PROSTATECTOMY

You have accessJournal of UrologyImaging/Radiology: Uroradiology II1 Apr 2016PD06-06 THE EFFECT OF NEUROVASCULAR BUNDLE PRESERVATION ON CHANGES IN PENIS LENGTHS AND ELASTICITY SCORES FOLLOWING RADICAL PROSTATECTOMY Nurullah Hamidi, Evren Suer, Ilker Gokce, Namik Altinbas, Cemil Yagci, Sumer Baltaci, and Kadir Turkolmez Nurullah HamidiNurullah Hamidi More articles by this author , Evren SuerEvren Suer More articles by this author , Ilker GokceIlker Gokce More articles by this author , Namik AltinbasNamik Altinbas More articles by this author , Cemil YagciCemil Yagci More articles by this author , Sumer BaltaciSumer Baltaci More articles by this author , and Kadir TurkolmezKadir Turkolmez More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2626AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To date, many articles have been published about penile atrophy following radical prostatectomy (RP). In this study, we aimed to evaluate the changes in penis lengths and cavernous body elasticity scores in patients who underwent RP with neurovascular bundle (NVB) preserving or not. METHODS We prospectively recorded data of 65 pre-op potent patients who underwent RP for organ-confined prostate cancer, at our institution, between April 2014-March 2015. Patients who have penile deformity were excluded. Patients were divided into three groups(G): non-nerve spared (G1=22 patients), unilateral (left or right) nerve spared (G2=22 patients) and bilateral nerve spared (G3=21 patients). Data include pre and post-op (3rd and 6thmonths) penis lengths and elasticity scores. Elasticity of cavernous tissue (at level of peno-scrotal junction) was assessed with real-time elastography. All elastography measures performed by a single radiologist between 0-6 scores (0: elastic, 6: fibrotic). Penis lengths were measured from pubo-penile junction to tip of glans with maximum contraction of flaccid penis. RESULTS Age, mean pre-op penis lengths and elasticity scores were similar for three groups (p=0.22, p=0.82, p=0.36, respectively). Pre-op, post-op 3rd and 6th months penis lengths and elasticity scores were showed in fig 1. The differences of post-op penis lengths and elasticity scores between G1-G2 and G1-G3 were statistically significant. However, difference between G2 and G3 was not statistically significant (table 1). Also negative correlation was detected between penis lengths and elasticity scores in Spearman’s correlation test at post-op 3rd(r=-0.243) and 6th (r=-0.263) months. CONCLUSIONS Shorter penis lengths and higher elasticity (in favor of fibrosis) scores were observed in bilateral non-nerve sparing group after RP. Although further prospective and large sample trials are needed for confirmation our results, preserve of NVB in at least one side mediates less penile atrophy and lower elasticity scores. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e176 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Nurullah Hamidi More articles by this author Evren Suer More articles by this author Ilker Gokce More articles by this author Namik Altinbas More articles by this author Cemil Yagci More articles by this author Sumer Baltaci More articles by this author Kadir Turkolmez More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

Testing hypotheses of bat baculum function with 3D models derived from microCT

The baculum (os penis) has been extensively studied as a taxon-specific character in bats and other mammals but its mechanical function is still unclear. There is a wide consensus in the literature that the baculum is probably a sexually selected character. Using a novel approach combining postmortem manipulation and three-dimensional (3D) imaging, we tested two functional hypotheses in the common noctule bat Nyctalus noctula, the common pipistrelle Pipistrellus pipistrellus, and Nathusius' pipistrelle Pipistrellus nathusii: (i) whether the baculum can protect the distal urethra and urethral opening from compression during erection and copulation; and (ii) whether the baculum and corpora cavernosa form a functional unit to support both the penile shaft and the more distal glans tip. In freshly dead or frozen and thawed bats, we compared flaccid penises with artificially 'erect' penises that were inflated with 10% formalin. Penises were stained with alcoholic iodine and imaged with a lab-based high-resolution x-ray microtomography system. Analysis of the 3D images enabled us to compare the changes in relative positions of the baculum, corpora cavernosa, urethra, and corpus spongiosum with one another between flaccid and 'erect' penises. Our results support both functional hypotheses, indicating that the baculum probably performs two different roles during erection. Our approach should prove valuable for comparing and testing the functions of different baculum morphologies in bats and other mammals. Moreover, we have validated an essential component of the groundwork necessary to extend this approach with finite element analysis for quantitative 3D biomechanical modeling of penis function.

Fibroepithelial polyp of the glans penis

Fibroepithelial polyps are a benign growth of mesodermal origin that usually arises in the urinary tract. A 38-year-old man presented with painless polypoid penile mass at tip of penis. He had been using a cloth in the form of pad to clean urine from tip of glans for past 3 years. Wide local excision was done. The histopathologic diagnosis was fibroepithelial polyp. A fibroepithelial polyp of the penis is very rare and is strongly linked with long-term condom catheter use. We present a case of fibroepithelial polyp of the glans that has no link with condom catheter use.

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.

COMPLETE PENILE DISASSEMBLY FOR ISOLATED EPISPADIAS REPAIR WITH MITCHELL-CAIONE TECHNIQUE: TWO CASES

Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Many surgical technique have been described for repair of male epispadias. The aim of surgical repair is to get cosmetically acceptable and functional penis with a ventrally located urethra opening at the tip of the glans and moreover to give the patient a urinary continence. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. We present two cases of our experience where we used the complete penile disassembly tecnique by Mitchell-Caione in wich we acts on the voluntary control of urination by the reapproximation of the muscular plane of pelvic diaphragm and elevator muscle around the posterior urethra reconstructed. Epispadias repairs was performed on two incontinent male epispadias patient, aged 2 to 3 years. Both cases were untreated. Complete disassembly of penil components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies and the glans were split on the sagittal plane according to Grady-Mitchell. The central portion of the urethral plate was preserved intact. An electric stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. “Z plasties” were necessary according to initial urethral length and width: the urethra was reconstructed over a double catheters, using 5/0 polyglicolic acid interrupted sutures in a single layer. In one patient we sutured symphisis pubis opened precedently, using 1/0 polyglicolic acid. The urethra was placed ventrally in the reconstructed shaft under the two corpora as Mitchell technique. Glanduloplasty was then performed. Patients were followed up for one month (June 2012). The penis of the two patients had a satisfactory cosmetic appearance with no dorsal chordee. Morover, our patients obtained urinary continence. The limitation of our study was the low follow-up. The electric stimulator used to identify pelvic muscle components in the sagittal plane for reapproximate the posterior tabularized urethra to form the periurethral muscle complex and the “Z-plasties” that elongated the urethra significantly.This procedure seems to be satisfactory for the repair of cases of isolated male epispadias because we have good results in cosmetic appearance and in urinary continence. Our study is a preliminary report and a longer follow-up with a larger number of cases is needed to document further the success of the procedure.

Snodgrass urethroplasty for hypospadias repair: A retrospective comparison of two variations of the technique

The Snodgrass technique is a widely accepted method for hypospadias repair. In this paper, we compare two methods of performing this technique with respect to postoperative complications and outcome, with emphasis on meatal stenosis, fistula formation, residual chordee and penile torsion. We reviewed the results of 320 cases treated by Snodgrass urethroplasty between March 2007 and February 2012 at the maternity and children’s hospital of Almadinah Almunawwarah, Kingdom of Saudi Arabia. The two methods differed in the extent of urethral plate incision, the type of flap used and the degree of degloving of the penile skin. In group A (115 boys), the urethral incisions and the sagittal deep longitudinal incision were extended from the posterior edge of the hypospadiac meatus to the tip of glans, and the neourethra was covered by a dorsal preputual flap. In group B (205 boys), the urethral incisions and the deep longitudinal incision extended to the mid-glans, and the neourethra was covered by a lateral dartos flap. After tubularization of the urethral plate and a circumferential incision proximal to the coronal sulcus from each edge of the urethral plate, the penile skin was degloved from 1 cm proximal to the hypospadiac meatus in group A and to the penoscrotal junction in group B. The mean age of the children was 1.5 years. Complications occurred in 45 patients (14.1%). A urethrocutaneous fistula occurred in 8 patients (2.5%), with 6 in group A (5.2%) and 2 in group B (0.98%). Ten patients (3.1%) developed meatal stenosis, with 7 in group A and 3 in group B. Penile torsion was recorded postoperatively in 13 patients (total rate, 4.1%), with 9 cases in group A (7.8%) and 4 in group B (2.0%). The differences between the two groups were statistically significant. A shorter urethral plate incision, use of a lateral dartos flap to cover the neourethra and more extensive skin degloving in Snodgrass urethroplasty reduce the rate of complications.

Prepenile scrotum- an extreme form of penoscrotal transposition.

A full-term newborn male baby was brought with abnormal genitalia. The baby was a product of non-consanguinous marriage and the antenatal checkups and sonography were unremarkable. The boy had passed urine and meconium before arrival. Baby was warm, pink and active. There was no abnormal facies. Limbs and spine were normal. Local examination (Fig. 1) revealed a normal phallus with meatus at the tip of glans but it was positioned in the perineum between the scrotum and anus. The hemiscrotums were well developed and contained testis on either side. The anus was patent and its site was normal. Sonography of spine,cranium and urinary tracts showed no pathology. Echocardiogram was also normal.

The importance of patient selection in the treatment of distal hypospadias using modified Koff procedure

We present our experience in the treatment of distal hypospadias using a modified Koff procedure, emphasizing the importance of patient selection for a good outcome. In 2003-2008, 90 patients, mean age 52.1 months, underwent surgical repair of distal hypospadias using urethral advancement according to Koff, modified with a Ψ incision on the tip of the glans. Meatal defect was glanular in six (8%), subglanular in 24 (26%) and coronal in 60 (66%) cases. Mild chordee was present in 19 patients (21%). Follow-up was 8-66 months. All patients were evaluated in terms of cosmetic results, and early and late postoperative complications. All patients showed excellent cosmetic results with urethral meatus on the tip. There was only one postoperative fistula due to extensive use of electrocautery during urethral mobilization that was surgically corrected 8 months after appearance. One patient had a postoperative meatal stenosis treated conservatively. No cases of residual chordee were detected. Successful use of the modified Koff procedure depends on careful selection of patients. Good candidates are those with distal or mid-shaft hypospadias, presenting with: (1) absence or low degree of ventral chordee; (2) distal plate of urethra well developed; (3) distance between meatus and tip of glans at most 10-12 mm; and (4) glanular morphology preserved.

Achieving a natural glanular meatus for distal hypospadias with a narrow and shallow plate: Tubularized incised plate versus modified Barcat repair

Although the tubularized incised plate (TIP) repair has become the most popular surgical procedure for distal hypospadias, some authors suggest that this is not suitable for hypospadias with a narrow plate or shallow groove. The configuration and position of the reconstructed meatus were postoperatively analyzed in patients with distal hypospadias whose preoperative urethral plates were shallow or narrow. The findings were compared between six patients undergoing TIP repair and seven patients undergoing modified Barcat (BAVIS) repair. Among those undergoing the TIP procedure, a slit-like meatus at the tip of the glans was achieved in one patient, a slit-like meatus at the mid portion of the glans in four patients and a round meatus at the mid portion of the glans in one patient. In those repaired by the BAVIS procedure, a slit-like meatus at the tip of glans was achieved in three patients, a round or irregularly shaped meatus at the tip of the glans in two patients, an irregularly shaped meatus at the mid portion of the glans in one patient and neourethral dehiscence in one patient. The present study confirms that a higher rate of achieving slit-like meatus but a lower rate of locating in the glans tip can be attained after TIP repair. On the other hand, there is a higher rate of locating the meatus in the glans tip but a lower rate of achieving a slit-like meatus after BAVIS repair.

Dorsal inlay graft urethroplasty for primary hypospadiac repair

Tubularized incised plate urethroplasty has become a popular technique for repairing distal and proximal hypospadias in many institutions. Dorsal inlay graft urethroplasty has been used in our institution since 2003 to reduce the risk of meatal stenosis. In the present study, we evaluated the results of the dorsal inlay graft procedure. A total of 28 patients with no deep groove and no severe curvature underwent one-stage urethroplasty using an inner preputial-based dorsal inlay graft. The medical records of all patients were retrospectively reviewed with regard to complication rate and cosmetic appearance. Mean patient age at surgery was 21 months (range, 14 months to 4.6 years). Preoperatively the urethral meatus was coronal in two cases, distal shaft in 17, proximal shaft in six and penoscrotal in three. Nine patients required testosterone therapy before surgery. Mean operative time was 200 min (range, 154-249 min). Mean length of inlay graft was 20.9 mm (range, 12-30 mm). In all patients, a straight penis was achieved without dorsal plication of the corposa cavernosa, and the neomeatus with a slit-like appearance was positioned at the glans tip. At a mean of 22 months of follow up, a urethrocutaneous fistula developed in only one patient (3.6%), requiring repair surgery 6 months after urethroplasty. No patient had meatal stenosis, neourethral stricture or urethral diverticulum along the inlay graft. Dorsal inlay graft urethroplasty is an effective method for hypospadiac repair and leads to good cosmetic outcome with low risk of complications.

Urethral Advancement for Recurrent Distal Hypospadias Fistula Treatment

Hypospadias fistula may be persistently recurrent in some patients. In distal hypospadiac fistula cases, carrying the fistulous opening to the glans tip may be possible with extensive urethral mobilization and advancement. In 9 patients who were operated for urethrocutaneous fistula, we used the urethral advancement technique. Patient ages ranged from 5 to 14 years (mean, 8 years). In all of the cases, the urethra was mobilized proximally to at least penoscrotal junction, and in some cases, the bulbar urethra was mobilized partially. Follow-up ranged from 6 months to 16 months. In all but 1 child, a straight penis with the neomeatus at the glans tip was maintained without any urethrocutaneous fistula. In 1 child, chordee, which was already present, could not be prevented.Urethral advancement technique may effectively solve the problem of persistently recurrent hypospadias fistula. We recommend the technique to plastic surgeons' armamentarium.

Comprehensive analysis of tubularized incised‐plate urethroplasty in primary and re‐operative hypospadias

To retrospectively review our experience of the tubularized incised-plate (TIP) urethroplasty over the last 4 years. From 1998 to December 2001, 133 patients (mean age 7 years, sd 4, range 1-22), had a TIP urethroplasty by one surgeon for primary (103) and re-operative (30) hypospadias; the defects included 106 (79%) distal and mid-shaft, and 27 (21%) posterior shaft. The neourethra was covered by a subcutaneous flap in 66 (50%) patients or by corpus spongiosa (spongioplasty) in 31 (23%), with no cover in the remaining 36 (27%). In the last 20 patients (15%) a modified meatoplasty was used; the site and size of the new meatus was predetermined on the glans around a suitable catheter before any incision. Urethral stents were not used after repair in 39 (29%) patients, and regular meatal dilation was used only in patients with voiding difficulty and obvious tendency to stenosis. The presence of complications requiring re-operation and overall general appearance were recorded. The mean (sd) follow-up was 10 (5) months; there were 24 complications in 20 patients (15%), including a small fistula in 12 (9%), complete disruption of the repair in 4 (3%), meatal stenosis in seven (5%) and neourethral stricture in one (0.8%). Complications were not significantly different between primary and re-operative cases, and unaffected by the use of the stents. On univariate analysis complications were significantly higher with running than interrupted sutures, in repairs in the first 2 years of the study, in patients with posterior hypospadias, and in those with no neourethral coverage. However, the last two factors were the only significant independent risk factors in a multivariate analysis. Regular urethral dilatation was indicated in 43 patients (32%). Modified meatoplasty was associated with a significantly lower requirement for regular dilatation (P < 0.05) and no meatal stenosis. In the 113 complication-free patients the operation gave an excellent cosmetic appearance with a vertical slit meatus on the tip of conical glans in 110 (97%); there was slight meatal retraction in the remaining three patients. The TIP repair is a reliable method for treating both distal and proximal penile shaft hypospadias, is suitable for both primary and re-operative cases, and is more versatile than other repairs. Covering the neourethra with a flap or spongioplasty significantly improves the results. Regular urethral dilatation is required in a third of patients but modified meatoplasty obviates the need for regular dilatation and eliminates the risk of meatal stenosis.