Tubularized Incised Plate Repair Research Articles

Cumulative sum learning curve analysis of tubularized incised plate repair for hypospadias: a study of a single surgeon with a single surgical procedure.

To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis. We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency. CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min [interquartile range (IQR) = 125-155] to 92 min (IQR = 80-100) (P < 0.001), CR decreased from 28 (28%) to 8 (5.3%) (P < 0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P < 0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P = 0.013, P = 0.006, and P = 0.028, respectively). Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99,231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.

Reducing fistula rate in hypospadias repair: A comparative study between standard tubularized incised plate repair and incorporation of a layer of spongiosum tissue

The most prevalent complication in hypospadias repair is fistula formation. Adhering to the principle of providing urethroplasty coverage to mitigate fistula occurrence, we implemented a modification by integrating a spongiosum layer between the urethroplasty and the dartos flap. Our hypothesis posited that this approach would result in a reduced fistula formation rate. This study is a comparative analysis involving patients under 18 years of age who underwent primary hypospadias repair. The cases were allocated into two groups. In the study group, in addition to performing tubularized incised plate (TIP) repair, a spongiosum layer harvested from both sides of the urethra was used to cover the urethroplasty (modification of the Y-to-I urethroplasty). The control group underwent a standard TIP repair. The primary outcome was to assess urethrocutaneous fistula formation. Secondary outcomes included evaluating the development of meatal stenosis and glans dehiscence, along with assessing cosmetic results by the Hypospadias Objective Penile Evaluation (HOPE) score. Overall, 154 hypospadias cases were included in the study. Eighty-seven patients (56%) were allocated to the study group, and 67 (44%) were allocated to the control group. Urethrocutaneous fistula developed in 3 (3.4%) and 11 (16.4%) patients in the study and control group, respectively (p=0.006). Glans dehiscence occurred in 2 (2.3%) patients in the study group and 4 (6%) patients in the control group (p=0.198). Meatal stenosis was observed in 4 (4.6%) patients in the study group and 5 (7.5%) patients in the control (p=0.452). The mean HOPE score was 59 in both groups (p=0.36). This study details our encounters with the novel modification and compares the results with standard TIP. Our data suggest that adding a layer of spongiosum tissue over the urethroplasty reduces the complication of urethrocutaneous fistula without increasing the occurrence of dehiscence, significant meatal stenosis, or compromising cosmetic outcomes. We advocate for implementing the described surgical modification as a viable option for hypospadias repair.

Outcomes of hypospadias repair and factors associated: A study in a tertiary care hospital

ABSTRACT Background: Hypospadias is the most common congenital abnormality of the urethra affecting 1 in 300 live male births worldwide. The results of hypospadias surgery are still frequently unfavorable with a reported complication rate as high as 50% or above. Aims and Objective: The aim of our study was to determine the demographics and analyze the surgical management and factors influencing the postoperative outcomes of hypospadias repair. Materials and Methods: This hospital-based prospective study was conducted in the Department of Plastic and Reconstructive Surgery, Regional Institute of Medical Sciences, Imphal, Manipur, for 2 years from December 2019 to November 2021. The study was conducted on 28 male patients who underwent hypospadias repair. Demographics, operative techniques reviewed, and the outcome of hypospadias repair were evaluated for results and complications. Statistical Analysis: Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS version 21). Descriptive statistics such as mean, median, and percentage were used to summarize the data. The Chi-square test, Fisher’s exact test, and t-test were used to see the associations between variables of interest and prognosis of repair. P &lt; 0.05 was taken statistically significant. Results: A total of 28 male patients with a mean age of 7.46 ± 5.25 standard deviation presented for hypospadias repair. Mid-penile hypospadias was the most common type in the study population accounting for 60.71% of patients, followed by penoscrotal 35.71% of cases. 82.14% of the hypospadias were associated with some degree of chordee. Meatal stenosis, cryptorchidism, and inguinal hernia were observed in 17.8%, 3.57%, and 7.14%, respectively. 46.42% of hypospadias were repaired in two stages, while 25% were subjected to tubularized incised plate repair, and 28.57% of patients were repaired with the Asopa technique. The most common complications were edema and urethrocutaneous fistula. The complications were significantly lower in the hands of specialists than residents (P = 0.037). Two-stage repair has higher complications than single-stage repair (P = 0.0001). Conclusion: Hypospadias surgery has a long learning curve because it requires a great deal of temperament, surgical skill, and acquaintance with magnifications along with knowledge of surgical anatomy. Regular periodic audits should also be performed to improve the outcome of the hypospadias repair.

The Role of Tissue Expanders in the Reconstruction of Proximal Hypospadias

OBJECTIVETo report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias. METHODSProximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage. RESULTSA total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%). CONCLUSIONProximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage.

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network

Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Distal hypospadias repair: Comparative study between snodgrass and transverse preputial onlay flap

Distal hypospadias repair has several operative strategies such as tubularized incised plate (TIP); Transverse preputial onlay flap (TPOF) and Modified Mathieu Procedure. The aim of our work is to compare between TIP and TPOF techniques in the outcome. We conducted this comparative study on 66 patients with different types of distal hypospadias divided in two groups A and B for TIP and TPOF respectively. We reported outcome and complications for both TIP and TPOF repair. Our results revealed mean operative time was significantly higher in group B (123.1±6.8min) than in group A (93.73±3.9min, P value<0.001). Postoperative urinary fistula was reported in group A (15.2%) while no fistula in group B (p value=0.05). The vertical slit appearance of meatus was better in group A (54.5%) than in group B (24.2%, P value 0.023). As regard to hypospadias objective scoring evaluation (HOSE) (Summary Figure) the meatal shape score was higher in group A (1.55±0.51) than in group B (1.24±0.44, p value=0.0l), the urinary stream score was significantly higher in group A (1.82±0.39) than in group B (1.97±0.17, p value=0.04) and the urinary fistula score was significantly higher in group A (3.79±0.60) than in group B (4±0, p value=0.04). Complications are more common after TIP than in TPOF. As regard the meatus shape, the naturally looking vertical slit like meatus was achieved more in the TIP than in TPOF. We advocate further studies with a large number of patients with a long follow up period. TPOF is a great option to consider in cases of distal hypospadias because it is an effective technique for primary distal hypospadias repair with a good cosmetic outcome and a low associated complication.

Role of tunica vaginalis flap and dartos flap in tubularized incisional plate for primary hypospadias repair: A retrospective monocentric study.

In the tubularized incised plate (TIP) procedure, flap interposition between the skin and neourethra is highly recommended to decrease the postoperative fistula rate. However, there is no consensus regarding the ideal flap for this procedure. This study aimed to report our experiences in the one-stage TIP hypospadias surgery utilizing dartos flap (DF) (penile skin subcutaneous tissue) and tunica vaginalis flap (TVF) (parietal layer of the testis) as a tissue coverage of neourethra. In a retrospective study from Sep 2018 to May 2021, 16 cases of hypospadias with different types, ranging from midpenile to penoscrotal types, were managed with TIP urethroplasty using DF or TVF as a tissue coverage of neourethra were enrolled. The demographic characteristics of the participants, type of hypospadias, outcome, and complications were analyzed and compared. We used TVF and DF as soft tissue coverage in 11 (68.8%) and 5 (31.3%) patients, respectively. The mean age was 56.38 ± 47.83 months. Mid-penile, proximal, and penoscrotal hypospadias were presented in 3 (18.8%), 8 (50.0%), and 5(31.2%) patients, respectively. The total success rate was 14 (87.5%), while 2 (12.5%) patients developed a urethrocutaneous fistula, which required delayed closure later. In comparison between TVF and DF groups: the TVF was applied in all patients with moderate and severe chordee and all patients with penoscrotal hypospadias, and six patients with proximal hypospadias, while only three patients with mild chordee and two patients with proximal hypospadias used the DF and showed statistical significance between groups (p < 0.001 and 0.012) respectively. The success rate was 90.9% vs. 80.0% in TVF and DF groups, respectively, with no statistical significance between groups (p = 1.000). In the primary TIP repair, the TVF is a practical option as a DF for the interposition cover of a neourethra, especially in penoscrotal and proximal hypospadias with severe chordee.

Tubularized incised plate repair in 473 primary distal hypospadias cases: An evaluation of outcomes according to coverages and stent types

AimWe have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair. Materials and MethodsOnly distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent). ResultsA total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference. ConclusionsSpongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training.

Tubularización e incisión de la placa uretral para reparación de hipospadias distal primario en 473 casos: evaluación de los resultados según la cobertura y el tipo de sonda

AimWe have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair. Materials and methodsOnly distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent). ResultsA total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference. ConclusionsSpongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training.

The Effect of Pre-Incision Urethral Plate Width and Glanular Width on the Outcome of Tubularized Incised Urethral plate repair surgery in Distal Penile Hypospadias, A prospective study.

To determine hypospadias repair's cosmetic and functional outcome concerning the urethral plate width and glanular width. A prospective study including 38 patients. The urethral plate width (UPW) was measured preoperatively. The cosmetic outcome was evaluated by hypospadias objective penile evaluation [HOPE] score, and the urinary stream evaluated functional outcome. We included boys with distal penile hypospadias and excluded recurrent cases with severe chordee. All patients were operated on by Snodgrass tubularized incised plate repair (TIP); they were followed up for one year. Success was defined as slit-shaped meatus at the tip of the glans without fistula. The mean age of surgery was 4.5 ± 2.1 years. UPW was < 8 mm in 24 patients (63.2 %) (Group A), while 14 patients (36.8 % ) (Group B) had a UPW ≥ 8 mm. Overall, the mean ± SD of UPW was 4.84 ± 1.29 mm. The mean ± SD of GW was 9.52 ± 1.56 mm. Overall success was documented in 35/38 patients (92.1 %). No significant relation was founded between the complications and UPW of the patients (p-value = 0.7). Overall, the mean ± SD HOPE score was 39.1 ± 8.83. A significant relation was found between the cosmetic outcome of the two groups and the HOPE score (p-value = 0.02). The pre-incision urethral plate width and glanular width were not correlated with the TIP outcome. A better HOPE score is associated with a wide urethral plate.

The adolescent glans penis: Functional and aesthetic issues following childhood hypospadias repair

As children with childhood hypospadias repairs transition into adolescence, the function and appearance of the genitalia acquire greater importance. For some, the direction and shape of the urinary stream can be embarrassing if abnormal, and the appearance of the glans penis and meatus are a concern as they develop the capacity for self-awareness. Herein, we address the surgical correction and outcomes of urine spraying with or without fistulae, and cosmesis over 12 years. We also analyze if any specific prior repairs were more related to their complaints i.e. cosmesis, spraying, and/or fistulae. We retrospectively reviewed hypospadias revisions by a single surgeon over 12 years. We included adolescents and young adults who complained of abnormal urinary stream and/or aesthetic complaints. Patients then evaluated the post op result as very good, good, acceptable, or unsatisfactory. Of 542 patients who underwent revisionary procedures, 90 (16.6%) presented with complaints of urinary spraying, and appearance of the glans penis and/or meatus (see figure). Of these, 19 (21.1%) presented with aesthetic complaints alone, 37 (41.1%) presented with aesthetic complaints and spraying, and 34 (37.7%) presented with aesthetic concerns, spraying, and were noted to have urethral fistula either during preoperative examination or during surgery. 3/90 patients (3.3%) developed wound infection and dehiscence (one had a tubularized incised plate repair, another a Thiersch-Duplay repair, and the primary repair of the third patient was unknown). Adolescents and young adults who underwent hypospadias repair during childhood can return with concerns regarding functional and aesthetic abnormalities of the glans penis. Glans sculpting and meatal contouring may be utilized to normalize the urinary stream and achieve a normal aesthetic appearance of the glans penis. Surgeons should follow these patients through adolescence and into adulthood, because complications from hypospadias repairs acquire greater significance later and young adults seek to normalize their phalluses.

Does the suturing technique (continuous versus interrupted) have an impact on the outcome of tubularized incised plate in hypospadias repair with adequate urethral plate? A prospective randomized study

Hypospadias is one of the most common anomalies of male external genitalia. The aim of hypospadias repair is to achieve a normal phallus with a satisfactory functional and cosmetic result and to develop a single and consistent urinary stream while in standing position. The introduction of tubularized incised plate (TIP) urethroplasty by Snodgrass in 1994 resulted in revolutionizing management of different types of hypospadias. While there is consensus on the use of absorbable sutures in hypospadias repair, there are no specific guidelines for the suturing technique and the technique itself remains debatable. To compare the outcome of interrupted- and continuous-suture in hypospadias repair using TIP technique. This was a prospective randomized study. It comprised 260 uncircumcised hypospadiac boys with adequate urethral plate who underwent TIP repair. Boys with glanular, recurrent, proximal hypospadias and inadequate urethral plate were excluded from the study. The boys were randomized into two groups: Group A consisted of 130 boys who underwent TIP repair using continuous subcuticular suture urethroplasty and Group B of 130 boys who underwent TIP repair using interrupted subcuticular suture urethroplasty. The operative time was of lower statistical significance in group A (P=0.006) while the rate of complications were of higher statistical significance in group A (P=0.027). Urethrocutaneous fistulae occurred in 20 patients (14 in Group A and six in Group B), which is a statistically significant difference (P=0.048). On the other hand, superficial wound infection, partial glans dehiscence, meatal stenosis, urethral stricture, and aesthetic appearance were statistically insignificant. The effect of suturing techniques in bowel anastomosis has been studied and it has been found that the use of an interrupted-suturing technique results in a decreased complication rate compared to continuous suturing. This agrees with our study where the running sutures groups was associated with a higher complication rate compared to interrupted sutures.

The association between caudal block and urethroplasty complications of distal tubularized incised plate repair: experience from a South China National Children's Medical Center.

BackgroundThe effect of caudal block (CB) on the incidence of urethroplasty complications in hypospadias repair remains controversial. The evidence is conflicting, and some confounding bias issues need to be addressed. We sought to study a more homogenous group of distal hypospadias patients undergoing primary tubularized incised plate (TIP) repair by a senior pediatric urology surgeon in the past 2 years to examine the relationship between urethroplasty complications and the use of CB.MethodsWe reviewed our database to identify consecutive patients who had undergone hypospadias repairs by a senior director surgeon at our Center between January 2018 and November 2020. To be eligible to participate in the study, patients had to meet the following inclusion criteria: (I) have distal hypospadias; (II) have undergone a primary TIP repair; and (III) have attended follow-up appointments for a minimum period of 6 months. The primary outcome was the development of urethroplasty complications during the follow-up period. The principal variable of interest was whether or not CB was used perioperatively. The patients were categorized into a CB group (general anesthesia combined with CB) or a control group (general anesthesia only). Other potential risk factors were analyzed, including patient age at operation, patient weight, glans width, and the length of the urethral plate defect.ResultsThirty (12.2%) of the distal patients developed postoperative surgical complications. The postoperative surgical complication rates were similar between the different anesthesia groups. Weight, the length of the urethral plate length, and glans width did not contribute to the risk. Age was the only independent risk factor for postoperative surgical complications, and the complication rates increased in older patients.ConclusionsOur data from consecutive TIP repairs in distal hypospadias patients indicated no association between the use of CB anesthesia and the postoperative urethroplasty complication rate. Patients who were older in age when they underwent surgery had a higher risk of complications.

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.

Evaluation of Ventral Dartos Fascia Flap as a Covering Layer in TIP (Tubularized Incised Plate) Repair for Distal Hypospadias Patients [Snodgrass Technique

Hypospadias is one of the most frequent congenital urological anomalies. Reports have suggested that the prevalence of hypospadias varies across different races, being highest among Caucasians, less in Hispanics, and least in blacks usually it occurring in 1–3 per 1,000 live births .The different degrees of hypospadias require different technique; which carry different complication rates and different prognoses. The aim of this study is to evaluate the outcome and efficiency of Ventral Dartos Fascia Flap as a covering layer in TIP [Tubularized Incised Plate] Repair for Distal Hypospadias Patients. Twenty-three patients with distal hypospadias was involved in this study. The Snodgrass technique was done to them using ventral Dartos fascia flap as a covering layer in this surgery.the risk of the fistula is about 4.3 %, and the cosmetic appearance was so acceptable in 22 patient out of 23 which is very convincing result from this simple technique. Glans dehiscence hadn’t occur, Meatal stenosis hadn’t occur, Skin infection occurred in one patient because he neglect the post-operative follow up visits and bad hygiene so the wound was moisture and infected, Edema , Inflammation and Encrustations. Urethral Stricture wasn’t reported in this study. Twisting of the penis is not reported in this study. TIP repair is a good procedure with no more complications than other procedures used in hypospadias surgery which can achieve both results, restore good function and normal appearance to the penis.

Long-term outcome of non-stented tubularized incised plate urethroplasty for distal hypospadias repair: a complication analysis.

IntroductionAlthough it is apparently simpler to perform unstented tubularized incised plate (TIP) repair for distal hypospadias repair, consensus on feasibility of the use of unstented repair is still a matter of debate. Evidence reporting that unstented repair outcome is comparable to stented repair, especially in the long-term, is still weak due to reporting outcome inconsistencies, different study designs, inclusion of more than one technique, and inherent variability in meatal locations. Thus, we need a continuous and evolving assessment of the outcome of unstented repair to compile adequate evidence on the advantage of unstented TIP repair in distal hypospadias entity. The aim of this article was to review our long-term results with tubularized incised plate urethroplasty for distal hypospadias repair without a postoperative stent to determine its outcome which might justify its use.Material and methodsAfter a review of 154 patients with distal penile hypospadias, who underwent repair in Minia Urology & Nephrology University Hospital in the period between June 2015 and February 2018, we excluded cases who underwent MAGPI repair, redo cases and patients who failed to complete follow-up. We chose 72 patients who had only 1st time TIP repair and whom we could contact. A total of 44 out of 72 cases with stented repair were assigned to Group A, while 28 cases with unstented repair were assigned to Group B. Success was assessed based on Hypospadias Objective Penile Evaluation (HOPE) score by three separate senior pediatric urology consultants, independent of the surgeon and in the absence of high post-void residual urine (PVR). Average rate was calculated to be compared between both study groups.ResultsThere was no statistically significant difference regarding preoperative meatal location and age at repair and short-term complications. In the long-term; there was no statistically significant difference between the occurrence of urethrocutanous fistula (UCF, 4 vs 2 cases in Group A & B, respectively) and complete disruption (2 cases in each group) with need for redo repair. Results of total mean of HOPE score calculated showed no statistically significant differences between study groups and also failed to showed statistical significance on individual domains of HOPE score.ConclusionsUnstented TIP repair showed a similar outcome to stented TIP repair of distal hypospadias especially in the long-term despite a more troublesome early postoperative period.

The outcomes of tubularized incised plate hypospadias repair and tubularized incised plate grafting using muccal mucosal graft and preputial free graft: a prospective randomized study

Objective Hypospadias is the most common anomaly of congenital urogenital defects. Tubularized incised plate (TIP) repair is an established technique. High rates of its complication advocate the idea of grafting of TIP incision. Grafts may be buccal mucosa or prepuce in this study. Patients and methods This prospective study included 64 patients complaining of mid and distal penile hypospadias. The patients were randomized into three groups according to the technique used in the repair of hypospadias. The first group included patients repaired by TIP urethroplasty, whereas group B and group C included patients repaired by inner perpetual skin and buccal mucosa, respectively. Follow-up was for 6 months. Results This study included 64 cases. TIP repair (group A) was done for 20 patients, whereas in 44 cases, TIP grafting was performed; groups B and C included 21 and 23 cases, respectively. The TIP urethroplasty was successful in 85%, whereas in groups B and C, the success rates were 91.5 and 87%, respectively. There were statistically insignificant differences in complications among all groups (P>0.005). Conclusion Outcomes of TIP grafts have no significant difference than outcomes of TIP technique.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 Dec 2020This Month in Pediatric Urology Stacy T. Tanaka Stacy T. TanakaStacy T. Tanaka More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001267AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Three articles in this issue of The Journal focus on common pediatric urological diagnoses: bladder-bowel dysfunction (BBD), febrile urinary tract infection (fUTI) in infants and distal hypospadias. These authors paused while seeing these everyday cases to ask how we can improve care for patients with these routine diagnoses. Development and Validation of Symptom Score for Total Bladder-Bowel Dysfunction: Subscales for Overactive Bladder and Dysfunctional Voiding Because bladder-bowel dysfunction encompasses such a wide range of symptoms, including infrequent voiding, genital pain and urinary frequency, many clinicians take an “I know it when I see it” approach to clinical assessment. BBD negatively affects outcomes in children with vesicoureteral reflux and recurrent urinary tract infections. However, research studies on these topics are limited unless we have a standardized assessment method. Sillén et al (1333) from Sweden present a validated BBD symptom score for children 3 to 16 years old.1 Children with monosymptomatic enuresis, which is not included in the definition of BBD, were excluded. This instrument improves on existing pediatric questionnaires. It is able to distinguish between storage and emptying dysfunction, and it can assess treatment response. Currently the questionnaire has only been validated in Swedish. Use of a standardized BBD questionnaire across research studies should be a common goal of the pediatric urology community. Impact of Long-Term Low Dose Antibiotic Prophylaxis on Gut Microbiota in Children Following febrile urinary tract infection antibiotic prophylaxis is routinely started in infants with vesicoureteral reflux. There has been concern that altering the microbiome can increase the risk of obesity and pediatric allergic diseases. Akagawa et al (1320) from Japan performed 16S ribosomal gene sequencing on stool samples of infants treated for fUTI before, during and 5 to 6 months after antibiotic treatment.2 Continuous antibiotic prophylaxis with trimethoprim-sulfamethoxazole was started in those infants diagnosed with vesicoureteral reflux, while those without reflux served as controls. Although gut microbiota diversity initially decreased after treatment of fUTI, diversity recovered 1 to 2 months after treatment and was maintained in both groups. Antibiotic resistance could not be measured by this methodology. The results from this small study are reassuring and offer novel insights regarding the many infants who are started on antibiotic prophylaxis. Competency in Tubularized Incised Plate Repair for Distal Hypospadias: Cumulative Sum Learning Curve Analysis of a Single Surgeon Experience Distal hypospadias repair is a common pediatric urological procedure. Zu’bi et al (1326) from Canada and Madison, Wisconsin asked the question “How long does it take after establishing independent practice for a single surgeon to become competent and proficient?”3 They found that the complication rate and operative time started to decrease after the 234th case. The study has limitations because complications can continue to arise long after the initial procedure. Although the results are not surprising, the study prompts frank discussion of the importance of tracking our own complication rates, whether just starting or in practice for many years, and the technical modifications we can make to lower them.

Comparison Between Dorsal and Ventral Dartos Flap Interposition in A Tubularized Incised Plate Repair of Distal Hypospadias

Comparison Between Dorsal and Ventral Dartos Flap Interposition in A Tubularized Incised Plate Repair of Distal Hypospadias

Self-reported outcomes after the onset of puberty in patients undergoing primary distal hypospadias repair by the tubularized incised plate technique combined with preputial reconstruction vs. circumcision: A norm related study

PurposeWe assessed self-reported outcomes after the onset of puberty in patients undergoing tubularized incised plate (TIP) repair in combination with preputial reconstruction (PR) or circumcision for primary distal hypospadias, in comparison to normal controls. Material and methodsOut of 498 patients undergoing primary distal hypospadias repairs between 2001 and 2012, 83 underwent TIP repair associated with PR or circumcision before age 10-year, and had a Tanner stage ≥2 at study. Outcomes were assessed by online self-administration of validated questionnaires and additional non-validated questions. Results were compared between patients undergoing TIP repair vs. normal age-matched controls (healthy volunteers), and, between patients undergoing PR vs. circumcision. ResultsForty-one of the 83 eligible patients completed the study (response rate 49.3%). Of these, 26 had undergone PR. Median post-operative follow-up was 11.8 (range 6.5–16.2) years. The control group included 45 healthy boys. Comparing groups, there were no statistically significant differences in the cosmetic aspect of the penis, patient perception of penile appearance, and quality of life. Irrespective of preputial management, patients reported fear of being teased for the appearance of their genitalia much more commonly than controls (p = 0.02), but this did not affect their relationship patterns and quality of life. ConclusionSelf-reported outcomes after the onset of puberty were not significantly different between patients undergoing primary TIP repair of distal hypospadias in childhood and normal controls. Patients were significantly more commonly feared of being teased for their genital appearance, but this did not interfere with their social skills. Preputial management, namely PR vs. circumcision, did not affect the outcome.