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Sholklapper T, Crigger C, Morrill C, Harris TGW, Haney N, Lue K, Young E, Gearhart JP. Application of Tunica Vaginalis Flap for Epispadias Repair in the Epispadias-Exstrophy Complex. Urology 2023; 171:190-195. [PMID: 36336142 DOI: 10.1016/j.urology.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/13/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe long-term outcomes and experience with the tunica vaginalis flap (TVF) as a tissue augment for complex epispadias repair. METHODS A prospectively maintained institutional database was reviewed for patients who underwent epispadias repair with TVF from 2010 to 2021. Evaluation of patient characteristics between those who developed dehiscence or UCF and those who did not was performed via Mann-Whitney U, Kruskal-Wallis, or Fisher's exact test, as appropriate. RESULTS A total of 47 male patients were identified, of whom, 1 (2.1%) had cloacal exstrophy, 38 (80.9%) had classic bladder exstrophy or a variant, and 8 (17.0%) had epispadias as their primary exstrophy-epispadias complex diagnosis. The median age at epispadias repair was 13 months (IQR 11 - 19). The overall rate of fistula or dehiscence development was 19.1% (9 patients), of whom, 7 developed urethrocutaneous fistulae, 1 dehiscence, and 1 both. Notably, 0 of the 5 patients who had undergone prior epispadias repair and 0 of the 8 patients with a diagnosis of isolated epispadias developed a UCF or dehiscence after repair with TVF. Differences in age at repair, primary EEC diagnosis, prior epispadias repair, pre-repair testosterone, fibrin sealant utilization, closure layers, stent removal time, and bladder capacity at repair were not statistically significant (P>.05) CONCLUSION: Our expanded evaluation indicates that utilization of the tunica vaginalis as an adjunct to epispadias repair may provide durable protection against fistula development in EEC patients who have undergone prior epispadias repair and in primary repair of patients with isolated epispadias.
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Affiliation(s)
- Tamir Sholklapper
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chad Crigger
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christian Morrill
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas G W Harris
- Division of Plastic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nora Haney
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kathy Lue
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ezekiel Young
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John P Gearhart
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision. J Pediatr Surg 2022; 57:676-680. [PMID: 35927070 DOI: 10.1016/j.jpedsurg.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/19/2022] [Accepted: 06/14/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE To present the results of hypospadias repair in the absence of preputial skin following neonatal circumcision, and the analyses of surgical techniques and predictors of procedural success. METHODS Records of all children who underwent hypospadias repair between 10/1999 and 12/2018 were retrospectively reviewed. All of those who underwent neonatal circumcision prior to surgery were included. Patients with any prior penile reconstruction surgery and those with the megameatus intact prepuce variant were excluded. The primary endpoint was the need for reoperation. RESULTS A total of 69 patients with a history of neonatal circumcision underwent surgical reconstruction of hypospadias during the study period. Their mean age at surgery was 14 months (interquartile range [IQR] 9,22). Forty-five cases (65%) involved distal hypospadias, and ventral curvature was present in 24 (35%). Dartos flaps were harvested from the dorsal aspect in 37/58 (64%) patients and from the ventral aspect in 21/58 (36%). Twenty-two patients (22/69, 32%) required reoperation after a median follow-up of 9 years (IQR 6,13). Indications for revision surgery included urethral fistula (n = 16, 22%), meatal stenosis (n = 5, 7%), and skin redundancy (n = 1). Ventral curvature (odds ratio [OR] 3.5, p = 0.02) and higher grades of hypospadias. (OR 3.3, p = 0.03) had a higher probability of reoperation (univariate logistic regression). CONCLUSION Hypospadias repair following neonatal circumcision in the absence of preputial skin is a challenging reconstruction. The reoperation rate in our cohort was 30%, similar to reoperative hypospadias surgery. Parents of newborns diagnosed with hypospadias should be encouraged to refrain from pre surgical neonatal circumcision. LEVEL OF EVIDENCE Treatment study, level IV.
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Management of urethral fistula after hypospadias repair with particular reference to purse-string sutures: a 24-year review. Pediatr Surg Int 2022; 38:919-925. [PMID: 35286476 DOI: 10.1007/s00383-022-05109-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To review our management of urethral fistulae following hypospadias repair over a 24-year period. To showcase our innovations, particularly the purse-string closure technique. METHODS We reviewed our prospectively maintained database from 1997 to 2020 to identify patients with fistula. Two main surgical techniques were used: traditional linear closure and purse-string suture. Other innovations included anchoring skin to corpora and intersectional skin closure. RESULTS Sixty two patients presented with 73 urethral fistulae after hypospadias repair. 55/62 were operated: 28-purse-string technique, 23-linear closure, 4-redo urethroplasty. Cure after the first attempt was achieved in 26/28 (93%) in the purse-string group and 16/23 (70%) in the linear group (p = 0.015). Spontaneous resolution occurred in 6/62 patients (9.6%), in 3 spontaneously and in 3 after a single dilation. 1 patient awaits surgery. Closure after first fistula repair was 22/24 (92%) in distal hypospadias and 20/27 (74%) in proximal hypospadias (p = 0.051). CONCLUSION Remarkably, conservative management was succesful in almost 10% of urethral fistulae, either spontaneously or after a single dilation. Purse-string closure, rarely described in the literature, coupled with our other innovations, helped bring down our recurrence rates significantly with no patient needing more than two surgeries for cure.
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Lin H, Wang YY, Li SB, Chen ZT, Su LJ. Staged transverse preputial island flap urethroplasty for some proximal hypospadias with moderate-to-severe chordee. BMC Urol 2021; 21:182. [PMID: 34949173 PMCID: PMC8697458 DOI: 10.1186/s12894-021-00948-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 12/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to assess the outcome of staged transverse preputial island flap (TPIF) urethroplasty for repairing certain cases of primary proximal hypospadias with moderate-to-severe chordee in children. METHODS Nighty-two consecutive boys who underwent either one-stage or staged TPIF urethroplasty for the repair of proximal hypospadias with moderate-to-severe chordee between August 2015 and December 2019 were evaluated retrospectively. Patients were divided into two groups: one-stage TPIF urethroplasty group (n = 44) and staged TPIF urethroplasty group (n = 48). We noted and compared the postoperative complications, including urethrocutaneous fistula, urethral diverticula, residual penile curvature, and urethral stricture in both groups. RESULTS Both groups were followed up for 1-5 years, with an average of 3 years. No cases of residual or recurrence of penile chordee were reported in either group. In Group A, 9 patients (9/44, 20.4%) had postoperative urethrocutaneous fistula, and all patients underwent urinary fistula repair or urethroplasty. In Group B, postoperative urethrocutaneous fistula occurred in 2 cases (2/48, 4.1%), and one patient developed a urethrocutaneous fistula after the first operation, which was successfully repaired during the second operation. A urethrocutaneous fistula occurred in 1 case after completion of the second-stage operation; urethral fistula repair was performed successfully 6 months later. There were 2 cases of urethral stricture in Group A (2/44, 4.5%) and none in Group B. There were 6 cases of urethral diverticulum in Group A (6/44, 13.6%) and no cases of urethral diverticulum in Group B. The operative success rates were 61.3% and 95.8% in Group A and Group B, respectively (P < 0.001). CONCLUSIONS Compared with one-stage TPIF urethroplasty, staged TPIF urethroplasty in the treatment of certain cases of primary proximal hypospadias with moderate-to-severe chordee resulted in fewer postoperative fistulas, urethral strictures and urethral diverticula. The staged TPIF urethroplasty procedure was effective in reducing the operation difficulty and complication rate of hypospadias, improving the curative effect of complex hypospadias and having good clinical application value.
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Affiliation(s)
- Hai Lin
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China.
| | - Yu-Yun Wang
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Shi-Bing Li
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Ze-Ting Chen
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Liang-Ju Su
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
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Koyanagi urethroplasty for proximal hypospadias: A stage procedure? Prog Urol 2021; 32:312-318. [PMID: 34688536 DOI: 10.1016/j.purol.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To report experience and technical refinements with the Koyanagi urethroplasty for proximal hypospadias. METHODS A retrospective study was conducted between 2004 and 2017. Medical records of patients treated by the Koyanagi technique were investigated. The penile ventral skin was closed either with a Byars flap or using an "Ombredanne's chasuble" (OC). The cohort was divided chronologically into two groups of the same number of patients (early -E- and late experience group-LEG-). Demographics, anatomical findings and surgical outcomes were compared between groups using univariate analysis. A logistic regression was performed to assess factors associated with the occurrence of a postoperative urethrocutaneous fistula or urethroplasty dehiscence (UD). RESULTS The Koyanagi urethroplasty was performed in 67 patients, 33 in the EEG and 34 in the LEG. The overall surgical complication rate was 64.2% (n=43), including 42 fistula or UD, higher in the EEG (81.8%) than in the LEG (44.1%, P<0.01). However, in the LEG, patients underwent the surgery older and the use of OC more frequent. After multivariate analyses, factors associated with a postoperative fistula or UD were the year of surgery (OR=0.71 [0.53-0.96] P=0.02), the age at surgery (OR=1.11 [1.01-1.22], P=0.03); contrary to the skin coverage method or the stenting duration (P>0.05). An urethral stenosis occurred in 1 patient (1.5%). At last follow-up, 64.2% of patients required a further procedure and 80.6% of urethral meatus were glandular. CONCLUSION In this study the complication rate, particularly the urethrocutaneous fistula, remained high. Urethral stenosis, were rare but the follow-up was too short to clearly identified them. Considering as a 2 stage procedure koyanagi uretroplasty allows to obtain finally good results. LEVEL OF EVIDENCE III.
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Radhakrishnan CN, Radhakrishna V. The tunica-vaginalis flap to prevent postoperative fistula following severe hypospadias repair: Has the search for Holy Grail ended? Actas Urol Esp 2021; 45:552-556. [PMID: 34531163 DOI: 10.1016/j.acuroe.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Fistula following hypospadias repair remains a bane of the hypospadiologist resulting in the evolution of various techniques. Despite all these, the incidence of postoperative fistula varies from 10 to 30% and it increases with the severity of the hypospadias. Hence, a study was conducted to evaluate the efficacy of tunica vaginalis flap in preventing fistula formation following severe hypospadias repair. MATERIALS AND METHODS An observational study was carried out in a tertiary center between 2008 and 2017. The study included children with severe hypospadias (Proximal penile, Penoscrotal, scrotal, and Perineal). In all the patients, a Tunica-Vaginalis flap was used to buttress the urethroplasty. All the patients were followed up for at least a year after the completion of treatment. RESULTS A total of 210 patients were included in the study. Bracka's two-stage repair was performed in 180 patients who had either Penoscrotal hypospadias or a meatus even more proximal. The rest 30 patients with proximal penile hypospadias underwent a single-stage Snodgrass repair. Four (2%) patients developed a fistula, all following two-stage repairs, and half of them required surgical repair. Two (1%) patients had a partial breakdown of repair and underwent a residual repair after six months. CONCLUSION The Tunica-Vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.
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Affiliation(s)
- C N Radhakrishnan
- Department of Paediatric Surgery, Manipal Hospital, Bengaluru, India
| | - V Radhakrishna
- Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, India.
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Radhakrishnan CN, Radhakrishna V. The tunica-vaginalis flap to prevent postoperative fistula following severe hypospadias repair: Has the search for Holy Grail ended? Actas Urol Esp 2021; 45:S0210-4806(20)30273-4. [PMID: 33965283 DOI: 10.1016/j.acuro.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/11/2020] [Accepted: 06/07/2020] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Fistula following hypospadias repair remains a bane for the hypospadiologist resulting in the evolution of various techniques. Despite all these, the incidence of postoperative fistula varies between 10 to 30% and it increases with the severity of the hypospadias. Hence, a study was conducted to evaluate the efficacy of tunica vaginalis flap in preventing fistula formation following severe hypospadias repair. MATERIALS AND METHODS An observational study was carried out in a tertiary center between 2008 and 2017. The study included children with severe hypospadias (proximal penile, penoscrotal, scrotal, and perineal). In all the patients, a tunica-vaginalis flap was used to buttress the urethroplasty. All the patients were followed up for at least a year after the completion of treatment. RESULTS A total of 210 patients were included in the study. Bracka's 2-stage repair was performed in 180 patients who had either penoscrotal hypospadias or a meatus even more proximal. The rest 30 patients with proximal penile hypospadias underwent a single-stage Snodgrass repair. Four (2%) patients developed a fistula, all following 2-stage repairs, and half of them required surgical repair. Two (1%) patients had a partial breakdown of repair and underwent a residual repair after 6 months. CONCLUSION The tunica-vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.
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Affiliation(s)
- C N Radhakrishnan
- Department of Paediatric Surgery, Manipal Hospital, Bangalore, India
| | - V Radhakrishna
- Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Bangalore, India.
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Use of dCELL (Decellularized Human Dermis) in Repair of Urethrocutaneous Fistulas or Glans Dehiscence. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3152. [PMID: 33173673 PMCID: PMC7647633 DOI: 10.1097/gox.0000000000003152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/02/2020] [Indexed: 11/25/2022]
Abstract
Background In hypospadias repairs, there is some evidence to suggest that a "waterproofing" layer can be helpful in reducing the risk of urethrocutaneous fistula formation. The most likely role of this layer is to prevent the creation of overlapping suture lines. Many hypospadias surgeons use a dartos fascia interposition flap for this purpose. However, raising a dartos fascia flap adds time to the procedure, can result in devascularization of the overlying skin, and can create unsightly torsion of the penis, which may be hard to correct. To avoid these problems, the senior author has started to use dCELL (decellularized human dermis) as an alternative to dartos fascia to separate the suture lines. Methods Between March and July 2018, a pilot study was performed in 8 patients undergoing closure of a urethrocutaneous fistula or glans dehiscence combined with dCELL. Data on infections, wound breakdown, length of stay and catheterization, surgical time, and hospital stay were collected. Results All patients had a successful reconstruction. One patient developed a urinary tract infection, possibly related to prolonged catheterization following his repair. Conclusion Our results suggest that dCELL may be useful in the repair of urethrocutaneous fistulas and glans dehiscence after hypospadias surgery.
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Yang H, Xuan XX, Hu DL, Zhang H, Shu Q, Guo XD, Fu JF. Comparison of effect between dartos fascia and tunica vaginalis fascia in TIP urethroplasty: a meta-analysis of comparative studies. BMC Urol 2020; 20:161. [PMID: 33059661 PMCID: PMC7559339 DOI: 10.1186/s12894-020-00737-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Tubularized incised plate (TIP) urethroplasty is the most commonly performed procedure for hypospadias. Several flap procedures have been recommended to decrease the postoperative complication rate in TIP repair, but no single flap procedure is ideal. This study aimed to compare the outcomes of dartos fascia (DF) and tunica vaginalis fascia (TVF) as intermediate layers in TIP urethroplasty. Methods We searched PubMed, EMBASE, the Cochrane Library, Web of Science, clinicaltrials.gov, and other sources for comparative studies up to April 16, 2020. Studies were selected by the predesigned inclusion criteria. The primary outcomes were postoperative complications. The secondary outcomes were functional and cosmetic outcomes. Results The pooled RR with 95% CI were calculated. We extracted the relevant information from the included studies. Only 6 comparative studies were included. No secondary outcomes were reported. The RR of the total complications rate for DF was 2.41 (95% CI 1.42–4.07, P = 0.0001) compared with TVF in TIP repair. For each postoperative complication, the RRs were 6.48 (2.20–19.12, P = 0.0007), 5.95 (1.13–31.30, P = 0.04), 0.62 (0.25–1.52, P = 0.29), and 0.75 (0.23–2.46, P = 0.64) for urethrocutaneous fistula, prepuce-related complications, meatal/urethral stenosis, and wound-related complications, respectively. Conclusions This meta-analysis reveals that compared to DF, TVF is a better option in TIP repair in terms of decreasing the incidence of the total postoperative complications, urethrocutaneous fistula, and prepuce-related complications. However there is limited evidence for functional and cosmetic outcomes. Overall, larger prospective studies and long-term follow-up data are required to further demonstrate the superiority of TVF over DF. Trial registration PROSPERO CRD42019148554.
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Affiliation(s)
- Hao Yang
- Zhejiang University School of Medicine, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiao-Xiao Xuan
- Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Dong-Lai Hu
- Department of Pediatric Surgery, Zhejiang University Jinhua Hospital, Jinhua, China
| | - Hang Zhang
- Zhejiang University School of Medicine, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Qiang Shu
- Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiao-Dong Guo
- Department of Pediatric Surgery, Zhejiang University Jinhua Hospital, Jinhua, China.
| | - Jun-Fen Fu
- Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China. .,National Clinical Research Center for Child Health, Hangzhou, China.
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Kambouri K, Aggelidou M, Deftereos S, Tsalikidis C, Chloropoulou P, Botaitis S, Giannakopoulos S, Pitiakoudis M. Comparison of Two Tubularized Incised Plate Urethroplasty Techniques in Hypospadias Reconstructive Surgery. World J Plast Surg 2020; 9:254-258. [PMID: 33330000 PMCID: PMC7734945 DOI: 10.29252/wjps.9.3.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Hypospadias repair is a challenging type of urogenital reconstructive surgery for which different techniques are currently used. The purpose of this study is to determine the outcomes of distal, mid-shaft and proximal hypospadias repair using two new variations of tubularized incised plate (TIP) urethroplasty (TIP-δ and TIP-ελ) and to compare their complication rates with other already known operative techniques made from the same surgical team. METHODS This study included 269 boys with hypospadias. The preoperative meatal site was distal in 179 patients, mid-shaft in 44 and proximal in 46. The average age at the operation was 17 months. The technique applied in distal hypospadias was Mathieu in 77 patients, Snodgrass in 28 and (TIP)-δ in 74. The technique applied in mid-shaft hypospadias was a tubularized island flap (TIF) in 12 patients, onlay island flap (OIF) in 5 and TIP-ελ in 27. The operative technique for proximal hypospadias was TIF in 15 patients, OIF in 10 and TIP-ελ in 21. TIP-δ and TIP-ελ are two new variants of TIP operation that we have used in our clinic since 2010. Postoperative complications were recorded, and we compared the outcomes obtained by applying the techniques. RESULTS The use of TIP-δ in the distal hypospadias and long TIP-ελ in the mid-shaft and proximal hypospadias resulted in significantly fewer complications than the other surgical methods across all cases of hypospadias (p<0.05). CONCLUSION The type of tissue used for neourethral coverage seems to play an important role in the outcome of hypospadias surgery.
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Affiliation(s)
- Katerina Kambouri
- Department of Anesthesiology, Department of Pediatric Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Maria Aggelidou
- Department of Anesthesiology, Department of Pediatric Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Savvas Deftereos
- Department of Radiology, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Christos Tsalikidis
- Department of Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Pelagia Chloropoulou
- Anesthesiology, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Sotirios Botaitis
- Department of Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Stelios Giannakopoulos
- Department of Urology, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - Michail Pitiakoudis
- Department of Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
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Han JH, Song SH, Lee JS, Park S, Kim SJ, Kim KS. Efficacy of additional tunica vaginalis flap coverage for protecting against urethrocutaneous fistulas in tubularized incised plate urethroplasty: A prospective, randomized controlled trial. Investig Clin Urol 2020; 61:514-520. [PMID: 32734722 PMCID: PMC7458875 DOI: 10.4111/icu.20200024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We compared the protective effect of additional tunica vaginalis flap coverage combined with a dartos flap against urethrocutaneous fistulas in tubularized incised plate (TIP) urethroplasty in a randomized controlled trial. MATERIALS AND METHODS This prospective, randomized controlled trial in a single tertiary center enrolled 50 patients in whom it was feasible to perform single TIP urethroplasty between 2016 and 2017. Consecutive children were randomly allocated to study group A (additional tunica vaginalis flap coverage, n=25) or control group B (dartos-only coverage, n=25). All patients were examined in the outpatient clinic at 1, 3, 12, and 24 months. Postoperative cosmetic outcomes were evaluated by surgeons and parents using the Pediatric Penile Perception Scale questionnaire. RESULTS In group B, 1 of 25 patients (4.0%) developed an urethrocutaneous fistula within 12 months. An additional two cases of fistula were found in all proximal-type hypospadias patients at 24 months in the same group without statistical significance (p=0.07). The penile cosmetic satisfaction rate was not significantly different between the groups according to scores on the Pediatric Penile Perception Scale. CONCLUSIONS Our randomized controlled trial did not show a significant decrease in the incidence of or a significant slowing of the progression of postoperative fistulas after TIP urethroplasty by the use of additional tunica vaginalis coverage. A tunica vaginalis flap is not routinely recommended but could have a selective role in proximal-type TIP urethroplasty with deficient dartos and subcutaneous tissue to cover the neourethra.
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Affiliation(s)
- Jae Hyeon Han
- Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang Hoon Song
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Seong Lee
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Sungchan Park
- Department of Urology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sung Jin Kim
- Department of Urology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Kun Suk Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Akkary R, Ripepi M, Akokpe O, Louati H, Klipfel C, Geiss S. Two simple modifications can potentially change the future of proximal hypospadias surgery. Our series and a review of the literature. Int J Pediatr Adolesc Med 2020; 8:172-176. [PMID: 34350330 PMCID: PMC8319683 DOI: 10.1016/j.ijpam.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 05/01/2020] [Accepted: 06/28/2020] [Indexed: 11/04/2022]
Abstract
Background/Objective To draw a hint towards two simple modifications that could potentially decrease the complication rate. Patients and Methods It was a single center, single operator and retrospective study. All patients with severe hypospadias operated according to koyanagi with or without modifications were presented. The surgical technique was described. Complications like fistula, stenosis, dehiscence and urethral diverticulum were studied. Results and Limitations Nineteen patients were included and presented in a chronological manner. The first four patients were operated according to the original koyanagi technique. The next 15 patients were operated according to koyanagi and the urethroplasty was covered by a tunica vaginalis flap. In 10 of them, glanduloplasty was done primarily and in the last 5 patients, glanduloplasty was done as a secondary procedure. The complication rates were 100% in the original koyanagi group, and 0% in the subset were glanduoplasty was deferred. Conclusions Systematically covering the urethroplasty with a tunica vaginalis flap and deferring the glanuloplasty might ameliorate the results of the koyanagi technique.
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Affiliation(s)
- Rezkalla Akkary
- CHU Bicêtre, 78 Rue du Général Leclerc, 94270, Bicêtre, France
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Aldaqadossi HA, Eladawy M, Shaker H, Kotb Y, Azazy S. Tunica vaginalis graft for recurrent urethrocutaneous fistula repair after hypospadias surgery. Int J Urol 2020; 27:726-730. [PMID: 32557894 DOI: 10.1111/iju.14287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/14/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the outcomes of recurrent urethrocutaneous fistula repair using tunica vaginalis graft as an intermediate protective layer. METHODS We retrospectively reviewed the data of 45 children with recurrent urethrocutaneous fistula who underwent tunica vaginalis graft repair between February 2011 and January 2019. The repair was carried out at least 6 months after a previous fistula repair. Follow up at an outpatient clinic was scheduled on a weekly basis for 1 month, then monthly for 6 months and then annually. During follow up, every patient was evaluated by history taking. The site of repair and the act of micturition were inspected. Urine analyses together with culture and sensitivity tests were carried out if required. Successful repair was defined as the absence of recurrence, with good force and caliber of the urinary stream. RESULTS This study included 45 patients with recurrent urethrocutaneous fistula who were managed with a tunica vaginalis graft as a second layer. The mean age of patients was 6.7 ± 2.8 years. The mean postoperative hospital stay was 5.5 ± 0.7 days. The repair was successful for 43 (95.6%) patients, and urethrocutaneous fistula recurrence was reported for two (4.4%) patients, which were repaired after 6 months. In all patients, the cosmetic appearance of the penis was satisfactory without torsion or ventral chordee. CONCLUSION Tunica vaginalis graft is a simple and fast procedure that is highly effective as a protective second layer for recurrent urethrocutaneous fistula repair.
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Affiliation(s)
| | | | - Hossam Shaker
- Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Youssof Kotb
- Faculty of Medicine, Ain Shams University, Ain Shams, Egypt
| | - Samir Azazy
- Faculty of Medicine, Ain Shams University, Ain Shams, Egypt
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Mole RJ, Nash S, MacKenzie DN. Hypospadias. BMJ 2020; 369:m2070. [PMID: 32554436 DOI: 10.1136/bmj.m2070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Stuart Nash
- Plymouth Hospitals NHS Trust, Plymouth, Devon, UK
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15
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Xie L, Xi Y, Zhang X, Ding H, Li S. Effects of spongioplasty on neourethral function following hypospadias repair: an experimental study in rabbits. Int Braz J Urol 2020; 46:436-443. [PMID: 32167710 PMCID: PMC7088491 DOI: 10.1590/s1677-5538.ibju.2019.0453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/11/2019] [Indexed: 12/03/2022] Open
Abstract
Purpose: Spongioplasty (mobilization and midline approximation of the two branches of the bifid dysplastic distal corpus spongiosum) can form a covering layer for the neourethra to prevent urethrocutaneous fistula in hypospadias repair surgery. However, it remains unclear whether spongioplasty affects neourethral function. The objective of this study was to compare neourethral function after hypospadias repair with and without spongioplasty. Materials and Methods: Fourteen congenital hypospadiac New Zealand male rabbits were randomly allocated into two groups, seven animals underwent Duplay hypospadias repair and spongioplasty (experimental group), while seven underwent Duplay surgery alone (control group). Functional differences between groups were assessed by comparing neourethral compliance and flow rate. Two months after surgery, in vivo neourethral compliance was assessed by measuring intraluminal pressure with a digital pressure meter of an isolated neourethral segment, following progressive distension with 1, 2, and 3mL of air. Penises were harvested for uroflowmetry test using a simple device. Results: Postoperatively, fistula developed in one and zero rabbits in the control and experimental groups, respectively. Mean pressures tended to be higher in the experimental group than in the control group (82.14 vs. 69.57, 188.43 vs. 143.26, and 244.71 vs. 186.29mmHg for 1, 2, and 3mL of air, respectively), but the difference was not statistically significant. Mean flow rates also did not significantly differ between the experimental and control groups (2.93mL/s vs. 3.31mL/s). Conclusion: In this congenital rabbit model, no obvious functional differences were found between reconstructed urethras after hypospadias repair with and without spongioplasty.
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Affiliation(s)
- Linhai Xie
- Department of Plastic Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Yaqi Xi
- Department of Plastic Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Xue Zhang
- Department of Plastic Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Hongbiao Ding
- Department of Plastic Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Senkai Li
- Hypospadias Treatment Center, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Staged transverse preputial island flap urethroplasty for proximal hypospadias: a single-center experience. Pediatr Surg Int 2019; 35:823-827. [PMID: 31049665 DOI: 10.1007/s00383-019-04480-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the intermediate outcomes of our institution's experience with staged TPIF urethroplasty for proximal hypospadias repair. METHODS We retrospectively evaluated the medical records of patients who underwent repair of proximal hypospadias using staged TPIF urethroplasty at our hospital from 2011 to 2017. RESULTS One hundred and two patients were included in the present study. The mean follow-up was 52.4 months (range 13-74 months). The mean age at the time of the first surgery was 13.5 months (range 11-65 months). There were two main types of initial complications including meatal stenosis in four (3.9%) and urethrocutaneous fistula in three (2.9%) patients after the first stage. Surgical complications were seen in 15 patients after second stage, including urethrocutaneous fistulas in 8 (7.8%), urethral strictures in 5 (4.9%), urethral diverticula in 2 (1.9%). Overall complication rates after second stage were 14.7%. The incidence of fistulas was lower in patients who underwent repair with a tunica vaginalis flap (1/29, 3.4%) than with the dartos fascia (7/73, 9.6%; p = 0.435). CONCLUSIONS Our results show that staged TPIF urethroplasty is a viable and durable technique for primary severe proximal hypospadias. This procedure was associated with a 14.7% complication rate in the present study. Staged TPIF urethroplasty can reduce the incidence of urethral strictures and diverticula associated with the second stage.
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