Coronal fistula repair under the glans without reoperative hypospadias glansplasty or urinary diversion

What are the factors affecting glanular dehiscence after hypospadias surgery?

BACKGROUND

Glanular dehiscence (GD) is one of the main complications after hypospadias surgery. There is a limited number of publications regarding GD in the literature.

OBJECTIVE

The aim of this work is to reveal the factors that affect GD after a literature review.

EVIDENCE ACQUISITION

A literature search for relevant articles was performed in database using the search term glans dehiscence without setting date range limit or any other limits. All articles related to GD after hypospadias surgery were included in this study. After collecting the information from full text articles, 71 articles were included in this systematic review. In these studies, localization of hypospadic meatus, type of surgery, and other clinical data which were thought to behave as risk factors for GD were obtained. Chi-Square test was used to evaluate the differences between the parameters, where p < 0.05 was taken as statistically significant.

RESULTS

After evaluating the 71 articles that met the inclusion criteria, 309 cases (3.48%) of GD after 8858 hypospadias repairs were obtained in this review. GD rates were found significantly high for proximal hypospadias (5%), two-stage hypospadia repairs (5%) and re-do hypospadias repair (8.75%) (p = 0.002, 0.022, and 0.004, respectively). Glans width <14 mm, urethral plate (UP) width <7 mm, hypospadias surgeries performed before 6 months of age and after puberty, and caudal block anesthesia increased the rate of GD.

CONCLUSIONS

The rate of GD increases after proximal, cripple and staged hypospadias surgeries, a glans width <15 mm and UP width <8 mm, postpubertal surgeries, and caudal anesthesia use during surgery.

A three-step repair of post circumcision coronal fistula: A glans flap, urethral closure, and dartos flap interposition

PURPOSE

To evaluate the outcomes of patients who underwent a post-circumcision coronal fistula repair by means of a three-step repair technique: glans flap, urethral closure, and dartos flap interposition.

MATERIALS AND METHODS

We retrospectively reviewed the outcomes of 23 patients with postcircumcision urethrocutaneous fistulas who were treated at our institution between January of 2014 and December of 2018. The patients included in this review had exclusively a coronal fistula with an adequate glans bridge between the fistula and the urethral meatus and underwent surgical repair at least 6 months after the initial injury. We excluded from the study patients who had multiple level fistulas, glans dehiscence and patients that were lost to follow-up less than 6 months post fistula repair.

RESULTS

The median age at the time of the repair was 9.2 (range: 6.3 to 31) months. The fistulas were classified according to their size as small (ranging from pinpoint to ≤4 mm; n = 19) or large (>4 mm; n = 4). The overall success rate was 87% (20 of 23 patients). The success rates for the small and the large fistulas were 94.7% (18 of 19) and 50% (2 of 4), respectively. An indwelling urethral stent was used in all patients, except in those with pinpoint fistulas. The mean follow-up was 19.9 (6-60) months.

CONCLUSIONS

Post-circumcision coronal urethrocutaneous fistulas less or equal to 4 mm in diameter without glans dehiscence can be successfully repaired using a three-step repair technique, with a recurrence rate of less than 6%. For larger fistulas, a formal urethroplasty is recommended due to high recurrence rate of the three-step repair technique.

LEVEL OF EVIDENCE

Case Series (Level IV).

Application and efficacy of reconstructing forked corpus spongiosum in distal/midshaft hypospadias repair

We reviewed our experience in reconstructing forked corpus spongiosum (FCS) in distal/midshaft hypospadias repair and analyzed the efficacy of this surgical technique. From August 2013 to December 2018, 137 consecutive cases of distal/midshaft hypospadias operated by the same surgeon in Urology Department, Children's Hospital of Fudan University (Shanghai, China), were retrospectively analyzed. Sixty-four patients who underwent routine tubularized incised plate (TIP) or onlay island flap (ONLAY) surgery were included in the nonreconstructing group, and 73 patients who underwent reconstructing FCS during TIP or ONLAY surgery were included as the reconstructing group. Thirty-eight cases underwent TIP, and 26 underwent ONLAY in the nonreconstructing group, with a median follow-up of 44 (range: 30–70) months. Twenty-seven cases underwent TIP, and 46 underwent ONLAY in the reconstructing group, with a median follow-up of 15 (range: 6–27) months. In the nonreconstructing/reconstructing groups, the mean age at the time of surgery was 37.55 (standard deviation [s.d.]: 29.65)/35.23 (s.d.: 31.27) months, the mean operation duration was 91.95 (s.d.: 12.17)/93.84 (s.d.: 14.91) min, the mean neourethral length was 1.88 (s.d.: 0.53)/1.94 (s.d.: 0.53) cm, and the mean glans width was 11.83 (s.d.: 1.32)/11.56 (s.d.: 1.83) mm. Twelve (18.8%)/5 (6.8%) postoperative complications occurred in the nonreconstructing/reconstructing groups. These included fistula (5/2), glans dehiscence (3/0), diverticulum (1/2), residual chordee (3/0), and meatus stenosis (0/1) in each group. There was a significant difference in the overall rate of complications (P = 0.035). These results indicate that the technique of reconstructing FCS provides excellent outcomes with fewer complications in distal/midshaft hypospadias repair.

In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair

OBJECTIVE

To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair.

STUDY DESIGN

We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair.

RESULTS

Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs.

CONCLUSION

Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children.

Re-operative urethroplasty after failed hypospadias repair: how prior surgery impacts risk for additional complications

PURPOSE

The primary aim of this report was to compare urethroplasty complications for primary distal and proximal repairs with those after 1, 2, 3, and 4 or more re-operations.

METHODS

Prospectively collected data on consecutive hypospadias repairs (tubularized incised plate (TIP), inlay, two-stage graft) from 2000 to 2015 were reviewed. Isolated fistula closures were excluded. Extracted information included patient age, meatal location, repair type, primary vs. re-operative surgery, number of prior operations, any testosterone use, glans width, and urethroplasty complications. Pre-operative testosterone stimulation was used during the study period until 2012. Initially, it was given for a subjectively small-appearing glans, but from 2008 to 2012 use was determined by glans width <14 mm. Patients initially managed elsewhere were queried for any testosterone treatment. The number of prior operations was determined by patient history and confirmed by review of records. Calibrations, dilations, cystoscopies, and/or isolated skin revisions were not considered as prior urethroplasty operations. Multiple logistic regression was performed for all patients, and for the subset of patients undergoing re-operation, using stepwise regression for the following potential risk factors: meatal location (distal vs. midshaft/proximal), number of prior surgeries (0, 1, 2, 3, ≥4), pre-operative testosterone use (yes/no), small glans (<14 vs. ≥14), surgery type (TIP, inlay and two-stage graft), and age (continuous in months), with P-values <0.05 considered statistically significant.

RESULTS

In contrast to the 135/1085 (12%) complication rate in patients undergoing primary distal and proximal TIP repair, re-operative urethroplasty complications occurred in 61/191 (32%) TIP, 16/46 (35%) inlay, and 49/124 (40%) two-stage repairs, P<0.0001. Data regarding testosterone use was available for 1490 (96%) patients. A total of 139 received therapy, of which 65 (46%) had urethroplasty complications vs. 229 of 1351 (16%) without treatment, P = 0.0001. Logistic regression in 1536 patients demonstrated that each prior surgery increased the odds of subsequent urethroplasty complications 1.5-fold (OR 1.51, 95% CI 1.25-1.83), along with small glans <14 mm (OR 2.40, 95% CI 1.48-3.87), mid/proximal meatal location (OR 2.54, 95% CI 1.65-3.92), and use of pre-operative testosterone (OR 2.57, 95% CI 1.53-4.31); age and surgery type did not increase odds (AUC = 0.739).

DISCUSSION

Urethroplasty complications doubled in people undergoing a second hypospadias urethroplasty compared with those undergoing primary repair. This risk increased to 40% with three or more re-operations. Logistic regression demonstrates that each surgery increases the odds for additional complications 1.5-fold. Mid/proximal meatal location, small glans <14 mm, and use of pre-operative testosterone also significantly increase odds for complications. These observations support the theory that previously operated tissues have less robust vascularity than assumed in a primary repair, and suggest additional adjunctive therapies are needed to improve wound healing in re-operations. The finding that even a single re-operative urethroplasty has twice the risk for additional complications vs. a primary repair emphasizes the need for hypospadias surgeons to 'get it right the first time'. The fact that 40% of the re-operative urethroplasties in this series followed distal repairs emphasizes that there is no 'minor' hypospadias.

CONCLUSIONS

A single re-operative hypospadias urethroplasty has twice the risk for additional complications vs. the primary repair, which increases to 40% with three or more re-operations. These results support a theory that vascularity of penile tissues decreases with successive operations, and suggest the need for treatments to improve vascularity. The higher risk for complications during re-operative urethroplasties also emphasizes the need to get the initial repair correct.

TIP hypospadias repair: A pediatric urology indicator operation

OBJECTIVE

We review development and evolution of TIP hypospadias repair, including technical changes made to improve its results. We also discuss general risk factors for hypospadias surgical complications.

METHODS

We describe use of a database with prospective data entry to first identify our most common complications and their frequency, and then to monitor results of technical modifications made to reduce their occurrence. Multiple logistic regression of various factors recorded in the database was done to identify those predicting increased risk for urethroplasty complications.

RESULTS

Fistula and glans dehiscence are the two most common complications we encountered after TIP repair. Changes in urethral plate tubularization and barrier layers covering the neourethra resulted in a significant reduction in fistulas after proximal TIP. Changes in glansplasty sutures and use of preoperative testosterone to increase glans size did not reduce likelihood for dehiscence, whereas increasing the extent of glans wings dissection did. Logistic regression analysis confirmed proximal meatal location and reoperation predicted increased complications, but also identified glans width ≤ 14 mm as an independent risk factor for hypospadias urethroplasty complications.

CONCLUSIONS

Systematic, prospective data collection facilitated identification of complications and their risk factors, and provided a means to assess results of modifications made to address them. Limiting the algorithm used for hypospadias repair increases expertise in those techniques used. Reported low surgical volumes for proximal hypospadias repair suggest subspecialization of these cases be carried out so that designated surgeons can achieve sufficient volume to analyze their results and make improvements.

Recent advances in understanding/management of hypospadias

Hypospadias is the second most common birth anomaly, affecting 1 of every 300 males. The abnormal position of the urinary opening, and associated downward curvature of the penis in some cases, potentially impact both urinary and sexual function. Modern surgical correction most often involves tubularization of the urethral plate, those tissues which normally should have completed urethral development. This article discusses recent progress in hypospadias repair. Prospective data collection in consecutive patients promotes better understanding of both patient and technical factors that influence surgical complications. Patients with a proximal urinary opening near or within the scrotum, those failing prior to repairs, and/or those with a small glans diameter have increased likelihood for urethroplasty complications. Quality review of reliable data led to two layer urethroplasty covered with tunica vaginalis in proximal repairs, significantly reducing postoperative fistulas. Neither preoperative androgens used to grow a small diameter glans, nor a change in sutures used to approximate the glans wings reduced wound dehiscence, but a recent technical modification of the glansplasty with more extensive dissection before suturing has. The observation that reoperation increases risk for further complications three-fold suggests the less common proximal repairs and reoperations should be subspecialized so that designated surgeons can gain greater expertise. In addition, surgeons performing hypospadias repair must better define the complications that occur so that scientific reporting of outcomes becomes more standardized. Standardized objective means to assess results are also needed so that surgeons performing different repairs can compare outcomes.