Variant Of Hypospadias Research Articles

An Unusual Variant of Mid-penile Hypospadias with Intact Prepuce and Patulous Urethra - Addition of a Drop to the Sea of Hypospadias Variants.

Hypospadias is one of the most common and extensively studied pathology of paediatric surgery. Although a plethora of research articles describing hypospadias and its variants exist, new variants are often encountered and they never cease to surprise us. We, in our case, are trying to add a drop to the sea of variants of hypospadias. A 2-year-old boy was brought with an abnormally large and patulous urethral opening at the mid-penile region with intact prepuce and chordee. In this case report, we will review the available literature on this rare variant and discuss its management.

Megameatus intact prepuce, a rare variant of hypospadias: report of two cases and literature review

Megameatus intact prepuce is an unusual variety of the distal hypospadias, characterized by a widely splayed (fishmouth) coronal or subcoronal meatus, a deep glanular groove with normal prepuce, and no chordee. Physically, the glans penis has disunion with an abnormally large meatus associated with a deep glans cleft. Because the foreskin is intact, the condition is frequently overlooked; as a result, the patient seeks medical attention later, when the purpose is to address other urogenital issues. Cosmetic remodeling should be performed to avoid affecting a child’s psychological state. We present 2 cases of the mentioned condition (circumcised and uncircumcised) with blunderbuss external urethral meatuses, admitted to our pediatric surgery department. Both patients underwent tubularized incised plate urethroplasty along with spongioplasty and a vascularized dartos flap over the urethroplasty for fistula prevention. The cosmetic and functional results were satisfactory.

Megameatus intact prepuce, a rare variant of hypospadias: report of two cases and literature review: Erratum

Megameatus intact prepuce, a rare variant of hypospadias: report of two cases and literature review: Erratum

Tips and Tricks in the Management of Megameatus Intact Prepuce Variant of Hypospadias: A Review Article

Introduction: Hypospadias is congenital anomalies with various spectrum and variants, presenting with abnormal urethral meatus short of the native tip of the glans. megameatus intact prepuce is a rare variant of glanular hypospadias seen in about 3-6 % of hypospadias cases. The main features of megameatus intact prepuce are large urethral external meatus with deep with deeply grooved glans penis and the preputial skin is usually present and intact with no chordae. Seven named procedures for megameatus intact prepuce were discussed. Methodology: We use the following search engines for out study where we found the following articles and reviews as follows in Scopus search, we found 26 articles, in AJOL we there were 7 articles and in PubMed Central Search we found 32 articles, then in Google scholar the search revealed 388 articles, 45 articles were reviewed and summarised and 7 established procedures were discussed. Results: Seven named established procedures for megameatus intact prepuce variant of hypospadias were summarized and discussed and include Pyramid Procedure, Glanular Approximation Procedure, Tubularised Urethral Plate Urethroplasty, Tubularised Incised Urethral Plate Procedure, Mathieu Technique, Cutaneous advancement procedure and The Inframeatal Vascularised Flap Procedure. DISCUSSION: The Surgical procedures for repair of megameatus intact prepuce is technically challenging not only for the surgeon but the anesthethiogist alike because the patients are paediatric with small organs, therefore appropriate instruments and proper timing of the surgical intervention is paramount. Duckett and Keating et al in their study identified the first challenge is to identify those patients who truly need surgical repair. In a study by Marc Cendron et al they found out that the features identified as important in the decision-making process were (1) meatal opening close to or below the coronal margin; (2) A deep glans cleft; (3) a wide, splayed-out glans; and (4) an abnormal urinary stream if witnessed. in a study by Duckett JW, Keating MA, Hatch DA et at and Austin Hill G, Wacksman J they reported a satisfactory outcome with the various described surgical procedures. Conclusion: The tip and tricks of the surgical procedures of megameatus intact prepuce rare variant of hypospadias is a review article to aimed to improve on the surgical outcome including normal conical appearance of the glans, a urethral meatus of normal caliber, and a single, normal urinary stream with no symptoms and to minimise the complications such as urethrocutenous fistula as extracted from the expert’s vast experience and modifications of the existing techniques, in our study we summarised the experts seven established techniques and the modifications to achieve the desired objectives.

Dorsal penile curvature and megameatus intact prepuce hypospadias: A common association in a rare variant of hypospadias

Megameatus intact prepuce (MIP) is a rare variant of hypospadias. Unlike the hooded ventrally absent prepuce in non-MIP hypospadias, the prepuce in MIP hypospadias is fully circumferential and intact. The distal urethra remains wide with a deep glanular groove. While ventral curvature is a common finding in non-MIP hypospadias, neither ventral nor dorsal penile curvature has been reported in MIP hypospadias. To assess the association of the MIP hypospadias variant with penile curvature. We retrospectively reviewed the medical records of all children who underwent hypospadias repair and identified those who were documented as having the MIP variant of hypospadias and operated in our center from January 1998 to June 2020. The patients were considered as having MIP hypospadias if no hypospadias had been evident before circumcision, if a circumferential circumcision scar was present (instead of the inverted V-shaped scar in the ventral aspect of the penis following circumcision of the hooded prepuce associated with non-MIP hypospadias), and if there was a wide meatus. Penile curvature was diagnosed intraoperatively by an artificial erection test that uses saline solution for injection. Patients were considered surgical candidates if the degree of curvature was equal to or greater than 30°. The study cohort consisted of 118 male children who were identified as having the MIP hypospadias variant according to the inclusion criteria. The median age at repair was 1.1 years (interquartile range 8 months to 1.6 years). Penile curvature was found in 29 children (24%), of whom 23 had dorsal curvatures (19%) and 6 had ventral curvatures (5%). MIP hypospadias is associated with penile curvature, and more frequently with dorsal than ventral curvature. This study is retrospective and does now identify specific features of MIP associated with penile curvature. We encourage pediatric urologists to perform an artificial erection test intraoperatively in children with the MIP variant and repair associated curvatures. A dorsal curvature was found in 19% of patients with a MIP variant of hypospadias, and most of them (86%) required ventral plication due to the severity of the curvature.

Penoskrotal Perdenin Cerrahi Onarımı: Olgu Serisi ve Literatür Değerlendirilmesi

INTRODUCTION: Penoscrotal webbing (PSW) is an anomaly of penis and it includes penile and scrotal skin aberration. There are various surgical techniques for repairing PSW with different terminologies. Herein we present our surgical experience of Z-plasty procedure in these cases. METHODS: In this retrospective study, 5 patients with an average age of 46 months who were diagnosed and under follow-up for PSW, between June 2017 and May 2019 were included. Along with demographic and clinical characteristics, treatment and follow-up records were collected. RESULTS: Isolated PSW was observed in 4 patients and one patient had an associated megameatus intact prepuce (MMIP) of a hypospadias variant in addition to PSW. Circumcision and ventral prepuce reconstruction of the penis with the aid of "Z-plasty" solved problem and acceptable postoperative results were obtained. DISCUSSION AND CONCLUSION: PSW is a condition that warrants surgical treatment. During the management of these children, in the case of suspicion of penile skin abnormality at the time of circumcision, it should be deferred and should be consulted to a pediatric surgeon or a pediatric urologist. Gentle surgical treatment is recommended for a favourable surgical and psychological result

Megameatus intact prepuce treated with urethral plate-preserving surgery: a retrospective study of an unusual hypospadias variant

Megameatus intact prepuce (MIP) is a unique variant of hypospadias and is a clinically rare condition. Due to the anatomical characteristics of the MIP hypospadias variant presenting a unique challenge to surgeons, no single urethroplasty method provides a universal solution for all patients. The purpose of this study was to evaluate the outcomes of hypospadias after MIP repair by urethral plate-preserving urethroplasty. A retrospective study was performed on 25 coronal or distal MIP patients, with a median age of 8, with most deficiencies being discovered during their first hospital visit for phimosis. Correction with urethroplasty was performed for all patients; 5 underwent the Mathieu procedure, 13 underwent the tubularized incised plate (TIP) procedure, and 7 underwent the Duplay procedure. The 25 patients were followed up for 6 to 36 months to evaluate the surgical outcomes. There were no significant differences in intraoperative bleeding, hospital stays, postoperative analgesia rate, and cure rate among the three surgical procedures. The operative time for the Mathieu procedure was longer than that for the TIP and Duplay procedures, which did not differ. Complications occurred in 4 of the 25 patients (16.0%), and the overall complication-free survival rate at 1 year after surgery was 80.5%. The age at the time of surgery, urethral plate width, urethroplasty length, surgical procedures, or meatal location (coronal or distal penis) were not independently predictive of complications. The clinical manifestations of MIP are often concealed and then accidentally discovered during hospital visits for phimosis; thus, the actual incidence of MIP might be higher. The urethral plate should be preserved during MIP-correcting treatment, especially for coronal or distal MIP. The same satisfactory outcomes can be obtained with Mathieu, TIP, or Duplay urethroplasty.

Megameatus Intakt Prepisyumda Glanuler Yaklaştırma Prosedürü: Olgu Serisi

Objective: The megameatus intact prepuce (MIP) is a rare type of hypospadias which is usually diagnosed during circumcision. In this study, it is aimed to present our experience with glanular approximation procedure (GAP) in the management of MIP. Material and Methods: A retrospective study of 13 patients with MIP variant of hypospadias who were repaired between September 2017 and April 2019 using GAP technique was performed. The total number of hypospadias cases during the study period was 85 and MIP cases constituted 15.3% of these patients. The surgical aims in GAP are to achieve a conical glans containing vertical slit, tip-cited meatus and a normal projectile urine flow. Results: The age range of the patients was between 18 months and 7 years. The locations of urethral meatus were glanular in 8 and coronal in 5. In all the cases, the neourethra was constructed using 7/0 polydioxanone (PDS)® in a subcuticular and uninterrupted fashion. Except for 5 patients with coronal meatus that an intermediate layer from nearby dartos fascia was interposed to support urethroplasty suture line, no intermediate layer was transposed between the tissue layers with two overlying suture lines. Good cosmetic result was obtained in all patients with a normal appearing conical glans penis. One patient developed urethrocutaneous fistula requiring surgical closure. Conclusion: The MIP is a simple form of hypospadias which sometimes may produce problems to surgeons. The GAP procedure is a simple technique with good cosmetic results producing patient satisfaction. Except for more severe MIP cases, GAP technique is useful in hypospadiac patients with MIP especially having glanular and coronal meatus.

Single Stages Repair of Hypospadias Using The Snodgrass Technique: A Modern Choice

Background: Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct. During the last 10 years, the approach to severe hypospadias has been controversial.Materials & Methods: This is a hospital based observational study conducted in the plastic surgery unit of department of surgery at Nepalgunj Medical College and Teaching Hospital Kohalpur from 2012 March to 2016 September. All patients underwent single staged procedures using Snodgrass technique.Results: Thirty three patients were operated. Twenty four patients had no complications. Single fistula was present in 6(18.18%) patients. Two (6.06%) patients had 2 fistulae; one at the original site of the hypospadias and the other was sub-coronal. One (3.03%) patient had moderate meatal stenosis, which was successfully treated by repeated dilatations.Conclusion: Single Staged procedure using the principles of Snodgrass's technique; is a versatile operation that can be used for the proximal hypospadias. It decreases the rate of fistula formation; disruption; stenosis and gives a satisfactory cosmetic appearance. JNGMC, Vol. 14 No. 2 December 2016, Page: 50-52

The Megameatus, Intact Prepuce Variant of Hypospadias: Use of the Inframeatal Vascularized Flap for Surgical Correction.

The megameatus intact prepuce (MIP) variant of hypospadias is a rare variant of hypospadias that is diagnosed either early at the time of circumcision or later as the foreskin is retracted. The true incidence of the anomaly is difficult to determine precisely as some patient never come to medical attention but is felt to under 5% of all cases of hypospadias. The purposes of this study are to review the embryology and clinical findings of MIP and then, in light of a personal experience, present a series of patients evaluated for MIP who were treated with a modification of the Mathieu technique. A PubMed search of all articles in the MIP variant of hypospadias was carried out followed by an exhaustive review of the literature. The charts of all patients evaluated and treated at Boston Children's Hospital by MC between 2007 and 2017 were reviewed retrospectively. The patients were divided into two groups: those who underwent the standard procedure and those who underwent a repair using a modification of the Mathieu procedure using an inframeatal flap. The embryologic explanation of the MIP variant is not clear but failure of the distal, glanular portion of the urethra to tubularize results in spectrum of abnormality characterized by a deep glanular groove and an abnormal opening of the urethra anywhere from the mid-glans to a subcoronal location. Surgical repair is complicated by a wide distal urethra which may be injured if not properly identified. Overall good outcomes were noted with one patient experiencing a urethra cutaneous fistula in the first group and one patient having a mild glans dehiscence in the second. The MIP variant of hypospadias is a rare variant of hypospadias that presents as a spectrum of urethral anomaly. Surgical repair may not always be necessary but if surgical repair is carried out, the Mathieu technique modification may offer better anatomic delineation of the urethra and will provide an extra layer of tissue to cover the reconstructed urethra. Low complication rates should be expected with adequate functional outcome such as a normal urinary stream. In addition, criteria for selecting patients for surgical repair are provided.

Results of tubularized urethral plate urethroplasty in Megameatus Intact Prepuce.

Objective:The megameatus variant of anterior hypospadias with an intact complete foreskin occurs in approximately 1%–3% of hypospadias. Hence, the objective of the study was to evaluate the results of tubularized urethral plate urethroplasty (TUPU) in megameatus intact prepuce (MIP).Materials and Methods:A retrospective study (June 1996–June 2015) of MIP from our hypospadias registry was conducted. All patients with megameatus, either with an intact prepuce or with one previously removed, were included in the study. Case sheets of clinical records, investigations, clinical photographs, and videos were reviewed. Patients were classified into, glanular, coronal, subcoronal, and distal penile. TUPU were done. Patients were called for follow-up at 1, 3, 6, and 12 months postoperatively, and then yearly for the assessment of the cosmetic appearance and fistula, meatal stenosis, or other complications.Results:Of 1026 patients with hypospadias, we identified 13 cases of megameatus variant of hypospadias; three of the 13 had been circumcized previously. Glanular approximation was done for the one patients of the glanular variant, and another had frenuloplasty. These two patients were excluded from the study. Incision in the inner preputial skin was closed in 10 patients to have an intact prepuce. Follow-up period varied from 6 months to 4 years (median follow-up 2½ years). None of the patients developed complications such as fistula, meatal stenosis, and/or wound dehiscence.Conclusions:Surgical correction of MIP in the era of increased cosmetic awareness is justified. Excellent results are obtained with TUPU and along with spongioplasty and frenuloplasty because of availability of wide urethral plate and well-developed spongiosum in these patients. TUPU should be the preferred procedure in cases of MIP.

Megameatus with intact prepuce (MIP) hypospadias variant applicated tubularized incised plate (TIP) urethroplasty: A rare case report

A megameatus with intact prepuce (MIP) is an unusual variant of an anterior hypospadias that accounts for 3% of hypospadias repairs. It is characterized by a widely splayed coronal or subcoronal meatus, a deep glanular groove, a normally conformed prepuce, and no chordee.In this case, good cosmetic and functional outcomes, such as achievement of a straight urine stream and patient satisfaction, were achieved using the tubularized incised plate (TIP) procedure. However, each case of MIP is unique, and a suitable procedure should be tailored to individual cases.

Repair of megameatus: A modified approach

To demonstrate surgical reconstruction of a megameatus variant of hypospadias by using a modified, patient-specific approach. An 8-month-old male had a megameatus, which was discovered after newborn circumcision. In repair of megameatus, it is important to recognize the full extent to which the distal urethra is widened, in order to avoid inadvertent urethrotomy during mobilization of the glans wings and skin immediately proximal to the glans. In this case, a small wedge of tissue was excised from the ventral aspect of the urethra, and a midline relaxing incision of the urethral plate was made. Standard principles of hypospadias repair should be followed, with tension-free urethral tubularization, coverage of the neourethra with well-vascularized tissue, and adequate mobilization of the glans wings to allow midline reconstruction without compression of the underlying neourethra. There were no perioperative or postoperative complications in this case. The urethral meatus was positioned near the tip of the glans penis, and there was no evidence of meatal stenosis or urethrocutaneous fistula at 5-months follow-up. Each case of megameatus is unique, and a variety of surgical techniques can be used in formulating an approach that achieves optimal cosmetic and functional outcomes.

Proximal hypospadias repair with principles of progressive perineal urethroplasty

Background: Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct. Significant variability exists for preferred approaches of repair. Often combinations of procedures are required in staged manner. Here, we have combined steps of pelvic fracture urethral distraction defects (PFUDD) repair with tubularized incised plate procedure in a single stage. Materials and Methods: A total of 8 patients consisting of 5 adults (mean age 20 years) and 3 children less than 3 years old that presented with proximal hyposphadias were included. All patients underwent degloving and progressive perineal approach as described by Webster for repair of PFUDD including mobilization of the entire bulbar urethra from the neomeatus to the membranous urethra with division of lateral attachments, division of attachment from perineal body and corporal separation. Mobilization of the urethral plate from the corpora cavernosa to the glans was carried out. The urethral plate was tubularized with a dorsal incision. Results: The neomeatus was advanced by a distance of 2.5-3.8 cm in all eight patients. Dartos fascia was used in 5 adults and 1 child for cover. Two patients required a tunica vaginalis flap as dartos was tethered during the harvesting. Catheter drainage was 18 days on an average (14-21 days). Fistula (pinpoint) occurred in one adult, which healed with further catheter drainage. All the patients were voiding normally and satisfied in terms of cosmetic appearance. None of the patients had wound infection or total disruption, residual chordee, meatal stenosis or any erectile difficulties. Conclusion: The steps of progressive perineal approach for repair of posterior urethral distraction defects if followed aids in achieving the goals of proximal hypospadias surgery in a single stage.

Megameatus intact prepuce variety of hypospadias

Background/purpose Megameatus and intact prepuce (MIP) is an unusual, anterior hypospadias variant. Cosmetic remodeling is usually carried out to avoid disturbing the child’s psychological state. Several approaches are used for MIP repair. The purpose of this study was to present a single institution’s experience with the modified glanular approximation procedure (GAP) in the treatment of the MIP variant of hypospadias and the tips needed to obtain the best outcome. Patients and methods Seventeen patients with MIP were repaired between May 2004 and May 2009 by the modified GAP technique. The technique was used to achieve a conical glans with a vertical slit, tip-cited meatus, and a straight urine stream. Patient/parent satisfaction was assessed by a subjective score that ranged between 0 and 3 and complications were reported. Results All patients were repaired using the modified GAP technique. The age of the patients ranged from 6 months to 28 years. Four patients were circumcised with a history of intact prepuce. An intermediate layer was added in seven patients. Excision of a part of the redundant urethral plate was carried out in six cases. Disruption of the repair occurred in one patient as a result of wound infection. Excellent cosmetic results were achieved in 14 patients (10 with a subjective score of 3 and four with a subjective score of 2). Two patients expressed an acceptable score of 1 and one patient was dissatisfied with a subjective score of 0. Conclusion Good cosmetic results, such as achievement of a straight urine stream and patient satisfaction, can be achieved using the modified GAP procedure. The steps should be tailored to individual cases. Keywords: hypospadias, megameatus, modified glanular approximation procedure

Proximal hypospadias with skin-covered shaft of penis and absent urethral plate: An unknown variant and its management

We report a case of proximal hypospadias with an absent urethral plate having intact ventral shaft skin with hooded dorsal prepuce and a good glans groove. Such a variant of hypospadias has not been reported in the literature.

Megameatus Intact Prepuce: Pyramid Procedure

Abstract Megameatus intact prepuce is a rare variant of hypospadias. The pyramid procedure, developed by Drs. Duckett and Keating in 1989, has proven to be a safe and effective technique. This is an historical video of an important urological procedure that may be of interest to urologists today. The content of the video reflects the views of the authors, and the techniques and technologies used by the authors, at the time the video was produced. The complete author disclosures are no longer available. Runtime of video: 9 min 42 sec

Circumcised hypospadias

Patients with circumcised hypospadias have been of significant concern over many decades due to the belief that prior circumcision might negatively affect the results of hypospadias' repair. We evaluated outcomes in consecutive males with anterior, distal penile, and the megameatus with intact prepuce variant of hypospadias (MIP). After IRB approval a retrospective of 48 consecutive males with circumcised hypospadias was reviewed. In all cases the urethroplasty was accomplished with either urethral plate tubularization or a MAGPI procedure. No skin flaps were used. A total of 48 patients with circumcised hypospadias (anterior, MIP variant, and distal penile) underwent operative reconstruction by one of us (RVP). All patients were followed for at least 8 months. Prior circumcision did not negatively affect the results of subsequent urethroplasty in patients with anterior, distal penile, and the MIP variant of hypospadias. The use of the tubularized incised plate urethroplasty (TIP) has virtually eliminated the need for skin flaps in anterior hypospadias repair.

Prior Circumcision Does Not Complicate Repair of Hypospadias With an Intact Prepuce

Hypospadias concealed by an intact prepuce is a concern to practitioners performing newborn circumcision, especially given reports that foreskin removal may complicate urethroplasty. However, distal hypospadias repair today less often relies on skin flaps, and some patients may have circumcision interrupted for suspected urethral anomalies when none is present. We evaluated outcomes in consecutive males with hypospadias and an intact prepuce to compare results of urethroplasty in those with vs without prior circumcision. A retrospective review of consecutive patients with hypospadias and an intact prepuce was performed. Patients circumcised before the urethral defect was recognized comprised group 1, while those presenting without circumcision comprised group 2. In all cases urethroplasty was accomplished by urethral plate tubularization without skin flaps, with coverage of the neourethra by a dartos flap. A total of 63 patients with hypospadias and an intact prepuce were operated on by one of us (WTS). Followup was at least 6 weeks for 36 of these patients, who comprised the study. There were no differences in age or followup among the 26 patients in group 1 compared to the 10 patients in group 2. The only complication was a fistula detected 4 years after surgery in a patient in group 1. Prior circumcision did not complicate subsequent hypospadias repair in males whose urethral anomaly was concealed by an intact prepuce. While circumcision should not be performed in newborns with obvious penile defects, it can be done in those with a normal foreskin without concern for the occasional discovery of hypospadias with an intact prepuce.

Megameatus intact prepuce hypospadias variant: Application of tubularized incised plate urethroplasty

Objectives The characteristics of the megameatus intact prepuce (MIP) hypospadias variant present a unique challenge to surgeons. Dissatisfaction with the results of conventional repair methods led to the emergence of several alternative surgical approaches, including the glanular approximation (GAP) and pyramid procedures. The application of tubularized, incised plate (TIP) urethroplasty has not been documented in this setting. Methods Twenty-four patients (mean age 18.5 months, range 6 to 60) presented with MIP. They had all been circumcised. The meatus was glanular in 6, coronal in 15, and distal shaft in 3 patients. Glanular MIP was repaired by meatal advancement and glanuloplasty (n = 2) or the GAP technique (n = 4). Coronal MIP was repaired by the GAP (n = 7) or TIP urethroplasty (n = 8), and distal shaft MIP was repaired by TIP urethroplasty (n = 3). Stents or catheters were used only with TIP urethroplasty. The mean follow-up period was 40 months (range 8 to 80). Results Satisfactory cosmetic and functional results were achieved in 20 patients (83%). The other 4 patients included 1 patient who underwent GAP and meatoplasty and 3 of the 11 patients who underwent TIP urethroplasty, of whom 2 underwent meatoplasty and 1 simple local repair of a urethrocutaneous fistula without the need for urethral reconstruction. Conclusions The success rates for all selected techniques were satisfactory. TIP urethroplasty can be successfully used in the more severe, proximal forms of MIP.