Urethral Plate Transection Research Articles

Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience.

It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20−60 months) and 35 months (18−60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.

Byars two-stage procedure for hypospadias after urethral plate transection

ObjectiveTo report on the outcomes of primary hypospadias repaired with the Byars two-stage procedure. Materials and methodsPrimary hypospadias repairs with the Byars two-stage procedure, between 2009 and 2012, were retrospectively reviewed. Medical charts were reviewed and analyzed. Follow up was at two weeks, three months, six months and one year after surgery. Complications, which included fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum, recurrent penile curvature and others, were documented and analyzed. ResultsOne hundred and twenty-eight cases were included in the present study. The median follow up was 30 months (range 13–44 months). All flaps took successfully after the first stage. Overall complication rates were 11.8%. Complications included: seven cases of fistula; five glans dehiscence; two urethral strictures, which developed after fistula repair; and one concealed penis. No recurrent penile curvature was recorded. ConclusionsThe Byars two-stage procedure is an option for primary hypospadias when the urethral plate is transected. It had an 11.8% complication rate in this present study.

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

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

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

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

Primary Severe Hypospadias: Comparison of Reoperation Rates and Parental Perception of Urinary Symptoms and Cosmetic Outcomes Among 4 Repairs

We compared complication rates, urinary symptoms and cosmetic outcomes as perceived by parents of patients undergoing 1 of 4 repairs for proximal hypospadias associated with ventral curvature. A total of 93 patients underwent hypospadias repair between 2004 and 2010. In patients requiring no urethral plate transection the repair consisted of tubularized incised plate urethroplasty (26 patients) or onlay island flap urethroplasty (31). In patients requiring urethral plate transection the repair consisted of onlay island flap on albuginea (18 patients) or 2-stage repair (18). Complications were assessed by chart review. A customized questionnaire and the Pediatric Penile Perception Score were administered to parents to evaluate their perception of urinary symptoms and cosmetic outcomes, respectively. After a median followup of 4.5 years (range 2.2 to 8.4) complications developed in 21 patients (23%) without any difference among procedures or between patients who did and did not require urethral plate transection. Parents of 75 patients (80%) participated in the survey without differences among repairs (p = 0.35). Reported urinary symptoms were not different among repairs. For Pediatric Penile Perception Score the only difference concerned the question about penile length (p = 0.03), with the score being significantly better for the techniques requiring urethral plate transection (p = 0.05). The 2-stage repair had a significantly better score for the question about penile length and overall Pediatric Penile Perception Score than all other techniques. Overall complication rates were comparable among repairs and did not increase after urethral plate transection. Urinary symptoms as reported by parents were comparable among the procedures. Perceived penile length was significantly better after urethral plate transection. The 2-stage repair yielded the best cosmetic results.

Onlay on Albuginea: Modified Onlay Preputial Island Flap Urethroplasty for Single-stage Repair of Primary Severe Hypospadias Requiring Urethral Plate Division

To describe a modified onlay preputial island flap (OIF) urethroplasty to also be used in patients requiring urethral plate transection for penile straightening. A total of 14 cases with primary severe hypospadias underwent the modified OIF urethroplasty as follows. After skin degloving, the corpora cavernosa were dissected ventrally. The urethral plate was mobilized and, if curvature >30° persisted, transected just proximally to the coronal sulcus. A pedicled preputial island flap was elevated and placed as an onlay to create the neourethra. It was sewn to the margins of the urethral plate proximally and distally. In contrast, in the portion of the shaft without a plate, it was sewn directly to the albuginea of the corpora cavernosa with 2 parallel suture lines. Glanuloplasty and skin closure followed as in standard onlay repairs. After a median follow-up of 7 months (range 5 to 27), 3 patients (21%) developed complications requiring additional surgery (1 simple fistula, 1 partial urethroplasty breakdown, and 1 ballooning of the neourethra). None of the remaining patients presented with residual curvature or voiding problems, according to the parental report. The results of the present preliminary experience suggest that OIF urethroplasty can also be performed in cases requiring urethral plate transection. It can be accomplished by suturing the preputial flap directly to the albuginea of the corpora cavernosa. Although we acknowledge that a larger number of cases and longer follow-up are necessary, we believe this technique should be incorporated into the armamentarium of hypospadiologists.

Straightening Ventral Curvature While Preserving the Urethral Plate in Proximal Hypospadias Repair

We report the efficacy of an expanded algorithm for penile straightening in proximal hypospadias surgery to preserve the urethral plate for urethroplasty. We also compared ventral corporotomy with grafting to multiple superficial ventral corporotomies without grafting for straightening greater than 30-degree ventral curvature. The need for urethral plate transection was compared in 2 groups comprising consecutive patients with proximal shaft to perineal hypospadias repair done by one of us (WS). The 47 patients in group 1 underwent surgery from 2000 to 2005 and had ventral curvature greater than 30 degrees after degloving, leading to urethral plate transection, while in 23 in group 2 from 2006 to 2008 mobilization of the corpus spongiosum/urethral plate and proximal urethra were also performed before urethral plate transection. Patients in group 1 with greater than 30-degree ventral curvature after urethral plate transection underwent ventral corporotomy with grafting (7) or multiple transverse corporotomies without grafting (4), while those in group 2 with greater than 30-degree ventral curvature after corpus spongiosum/urethral plate and urethral mobilization underwent multiple transverse corporotomies without grafting. Excluding 10 group 1 and 3 group 2 boys without ventral curvature after degloving the rate of urethral plate transection significantly decreased from 54% to 15% using the expanded algorithm (p = 0.005). At a mean followup of 11 months in those with corpus spongiosum/urethral plate and urethral mobilization there was no recognized recurrent ventral curvature. Seven patients with greater than 30-degree ventral curvature underwent ventral corporotomy with grafting, while 11 underwent multiple transverse corporotomies without grafting. At a mean followup of 27 and 19 months, respectively, no patient had recurrent ventral curvature. Mobilization of the corpus spongiosum/urethral plate and the urethra in proximal hypospadias cases with greater than 30-degree ventral curvature after penile degloving decreases the need for urethral plate transection. Ventral lengthening to correct corporeal disproportion can be achieved by corporotomy with grafting or by multiple transverse incisions without grafting.

Corporeal Body Grafting Using Buccal Mucosa for Posterior Hypospadias With Severe Curvature

Severe penile curvature correction by corporeal body grafting has been successfully performed using various grafts and biomaterials. We present our initial experience with buccal mucosa as a free corporeal graft to correct severe penile curvature as part of a multistage approach to posterior hypospadias repair. A total of 12 children with a mean age of 6.2 years (range 4 to 8) with posterior hypospadias and severe ventral chordee (greater than 45 degrees) necessitating ventral grafting underwent correction using buccal mucosa. Preoperative androgen supplement was given when penile and glanular size was significantly small for age. Buccal mucosa was harvested from the inner side of the cheek or the lower lip. The harvested graft was defatted, fashioned and fixed to the ventral corporeal defect. The pre-grafting penile angle, immediate post-grafting angle and penile angle at 6 months were assessed. All children had penoscrotal or perineal hypospadias, 4 had partial androgen insensitivity syndrome and 1 underwent multiple previous failed repairs. Androgen was given preoperatively in 3 children. After chordee release and urethral plate transection the penile angle was between 45 and 80 degrees. Mean graft length and width was 2.5 and 1.6 cm, respectively. All children had a straight penis at the end of the procedure and none required additive dorsal plication. At the last followup at 12 months all children had a straight penis except 2 with mild curvature (less than 10 degrees). No complications were noted with this technique. Preliminary results of the novel use of buccal mucosa as a corporeal graft for severe chordee appear satisfactory. Longer term followup is needed to further document these data.

Ventral Penile Lengthening Versus Dorsal Plication for Severe Ventral Curvature in Children With Proximal Hypospadias

The 2 main approaches to correct severe ventral curvature are dorsal plication of the corpora and ventral corporeal lengthening by tunica albuginea patching. Controversy persists since neither technique has been proved to be superior to the other with respect to initial or long-term outcome. However, to our knowledge a direct comparison of outcome of these 2 procedures has not been previously reported. A retrospective review of the records of 100 consecutive patients who underwent repair of penoscrotal or more proximal defects from 1996 to 2004 was performed. Children were divided into 2 groups, including group 1-32 who underwent a ventral penile lengthening procedure and group 2-68 who underwent dorsal plication. Meatal location, preoperative testosterone stimulation, severe ventral curvature (greater than 45 degrees) at the beginning of operation and after degloving, proximal ventral dissection, urethral plate transection and recurrent ventral curvature were compared between the 2 groups. Mean age was 17 months (range 9 to 56) in patients with ventral penile lengthening and 17.8 months (range 10 to 58) in patients with dorsal plication. Mean followup was 65 (range 29 to 120) and 62 months (range 30 to 116), respectively. Of the 32 group 1 children 30 (93.7%) had penoscrotal or more proximal hypospadias vs 57 of the 68 (83.8%) in group 2. Three of the 32 children who underwent ventral penile lengthening had recurrent ventral curvature vs 19 of the 68 who underwent dorsal plication (9.4% vs 27.9%, p = 0.03). On multivariate analysis dorsal plication remained significantly associated with recurrent ventral curvature independently of the other factors (OR 4.56, 95% CI 1.14-18.28, p = 0.03). Dorsal plication was more often associated with recurrent ventral curvature compared to ventral penile lengthening on univariate and multivariate analysis. Future studies adjusting for proximal ventral dissection and urethral plate transection are necessary to further elucidate the role of each technique in the correction of severe ventral curvature in children with proximal hypospadias.

Utilization of urethral plate in hypospadias surgery

Recognition the urethral plate comprises tissues that normally should have created the urethra was an important milestone in hypospadias surgery, giving rise to new operative repairs - most notably the tubularized incised plate technique. This article reviews the current state of the art for hypospadias repair using tubularized, incised plate (TIP). Personal experience and literature reports were reviewed to summarize use of TIP urethroplasty for distal, proximal, and re-operative hypospadias repairs. The TIP can be used to correct all distal and most proximal hypospadias. The major contraindication is ventral curvature that leads to urethral plate transection for straightening, which is only necessary in some proximal cases. Reoperations can also be performed using TIP provided the urethral plate has been maintained and is not grossly scarred. Complication rates are comparable to previously used techniques, while cosmetic appearance after TIP is considered superior to other available procedures. Recognition of the urethral plate and its incorporation into the neourethra has revolutionized hypospadias repair. The most commonly used operative procedure today is TIP.