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Cousin I, Basmaison C, Cousin E, Lebonvallet N, Germouty I, Leven C, De Vries P. Complication rates of proximal hypospadias: meta-analyses of four surgical repairs. J Pediatr Urol 2022; 18:587-597. [PMID: 36058812 DOI: 10.1016/j.jpurol.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/28/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques. METHODS The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included. RESULTS Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin. DISCUSSION The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short. CONCLUSION This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.
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Affiliation(s)
- Ianis Cousin
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire de Brest, Hôpital Augustin Morvan, 4 Avenue Foch, 29200 Brest, France; Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France.
| | - Camille Basmaison
- Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France
| | - Elie Cousin
- Department of Pediatry, Centre Hospitalier Universitaire de Rennes, 16 Boulevard de Bulgarie 35200 Rennes, France
| | - Nicolas Lebonvallet
- Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France
| | - Isabelle Germouty
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire de Brest, Hôpital Augustin Morvan, 4 Avenue Foch, 29200 Brest, France
| | - Cyril Leven
- Department of Pharmacology, Centre Hospitalier Régional Universitaire de Brest, Hôpital de la Cavale Blanche, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Philine De Vries
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire de Brest, Hôpital Augustin Morvan, 4 Avenue Foch, 29200 Brest, France; Laboratoire Intéraction épithéliums Neurones, Université de Bretagne Occidentale, 6 Rue Colbert, 29200 Brest, France
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Wani SA, Baba AA, Mufti GN, Rashid KA, Bhat NA, Buch M, Faheem M. Bracka verses Byar's two-stage repair in proximal hypospadias associated with severe chordee: a randomized comparative study. Pediatr Surg Int 2020; 36:965-970. [PMID: 32533236 DOI: 10.1007/s00383-020-04697-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Proximal hypospadias associated with severe chordee represents a major surgical challenge and the debate over its optimal treatment is ongoing. The objective of this study is to compare the outcome of two-stage Bracka and Byar's repair in proximal hypospadias. MATERIALS AND METHODS This study was conducted from January 2013 to February 2018 in a tertiary care centre. Patients of hypospadias with severe chordee who required urethral plate transection were included in the study. Patients were randomly divided into two groups by simple randomization method. Bracka staged repair was done in Group A and Byar's staged repair in Group B. Postoperatively complications including graft loss, flap necrosis, fistula formation, meatal stenosis, stricture, diverticula formation, residual chordee were noted in both the groups and compared. p value of < 0.05 was considered statistically significant. RESULTS Over a period of 5 years, 74 patients in group A and 68 patients in group B were operated. Fistula occurred in 6.8% and 10.2% in group A and group B, respectively (p value 0.629). Meatal stenosis was seen in 4% in group A and 3% in group B (p value 0.731). Stricture was seen in 1% in each group (p value 0.339). Diverticula formation was seen in 2% in group B and none of the patient in group A (p value 0.960). None of the patient had recurrence of chordee in either group. CONCLUSION Bracka and Byar's two-stage repair have similar postoperative outcome and the choice between the two depends up on the surgeon's choice and experience rather than scientific evidence.
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Affiliation(s)
- Sajad Ahmad Wani
- Consultant Paediatric Surgery and Paediatric Urology, GMC Srinagar, Married Hostel, Room No 205, Srinagar, Jammu and Kashmir, 190001, India.
| | | | | | - Kumar Abdul Rashid
- Consultant Paediatric Surgery and Paediatric Urology, GMC Srinagar, Married Hostel, Room No 205, Srinagar, Jammu and Kashmir, 190001, India
| | | | - Mudasir Buch
- Registrar Paediatric Surgery, SKIMS, Srinagar, Kashmir, India
| | - Mir Faheem
- Registrar Paediatric Surgery, SKIMS, Srinagar, Kashmir, India
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Gorduza D, Plotton I, Remontet L, Gay CL, El Jani M, Cheikhelard A, Blanc T, El Ghoneimi A, Leclair MD, Roy P, Pirot F, Mimouni Y, Gaillard S, Chatelain P, Morel Y, Kassai B, Mouriquand P. Preoperative Topical Estrogen Treatment vs Placebo in 244 Children With Midshaft and Posterior Hypospadias. J Clin Endocrinol Metab 2020; 105:5835305. [PMID: 32386308 DOI: 10.1210/clinem/dgaa231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/06/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Urethral fistula and dehiscence are common after hypospadias surgery. Preoperative androgens have been considered to reduce these complications although this consideration is not evidence-based. Dermatologists have reported the benefits of topical estrogens on skin healing. We investigated whether the preoperative use of topical promestriene could reduce healing complications in hypospadias surgery. Our primary objective was to demonstrate a reduction of healing complications with promestriene vs placebo. Impact on reoperations and other complications, clinical tolerance, bone growth, and biological systemic effects of the treatment were also considered. METHODS We conducted a prospective, randomized, placebo-controlled, double-blind, parallel group trial between 2011 and 2015 in 4 French centers. One-stage transverse preputial island flap urethroplasty (onlay urethroplasty) was selected for severe hypospadias. Promestriene or placebo was applied on the penis for 2 months prior to surgery. The primary outcome was the presence of postoperative urethral fistula or dehiscence in the first year postsurgery. For safety reasons, hormonal and anatomical screenings were performed. RESULTS Out of 241 patients who received surgery, 122 patients were randomized to receive placebo, and 119 patients received promestriene. The primary outcome was unavailable for 11 patients. Healing complications were assessed at 16.4% (19/116) in the placebo vs 14.9% (17/114) in the promestriene arm, and the odds ratio adjusted on center was 0.93 (95% confidence interval 0.45-1.94), P = 0.86. CONCLUSIONS AND RELEVANCE Although we observed an overall lower risk of complications compared to previous publications, postsurgery complications were not different between promestriene and placebo, because of a lack of power of the study or the inefficacy of promestriene.
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Affiliation(s)
- Daniela Gorduza
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service de Chirurgie Uro-Viscérale de l'Enfant-Hôpital Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Ingrid Plotton
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service d'Endocrinologie Pédiatrique, Hôpital Mère-Enfant, Centre Hospitalo-Universitaire de Lyon, Bron Cedex, France
| | - Laurent Remontet
- Université de Lyon, Lyon, France
- Université Lyon 1; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
- Hospices Civils de Lyon, Service de Biostatistiques, Lyon, France
| | - Claire-Lise Gay
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service d'Endocrinologie Pédiatrique, Hôpital Mère-Enfant, Centre Hospitalo-Universitaire de Lyon, Bron Cedex, France
| | - Meriem El Jani
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Alaa Cheikhelard
- Service de chirurgie viscérale et urologie pédiatrique, APHP, Hôpital Necker, Paris, France; Université Sorbonne Paris cité, Paris, France
| | - Thomas Blanc
- Service de chirurgie viscérale et urologie pédiatrique, APHP, Hôpital Necker, Paris, France; Université Sorbonne Paris cité, Paris, France
| | - Alaa El Ghoneimi
- Service de chirurgie viscérale et urologie pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Robert Debré, APHP, Université Paris Diderot, Paris, France
| | - Marc-David Leclair
- Service de chirurgie pédiatrique, CHU de Nantes, Nantes, Loire Atlantique, France
| | - Pascal Roy
- Université de Lyon, Lyon, France
- Hospices Civils de Lyon, Service de Biostatistiques, Lyon, France
| | - Fabrice Pirot
- Service pharmaceutique, Plateforme FRIPHARM, Groupement Hospitalier Edouard Herriot, Lyon Cedex, France
- Laboratoire de Recherche et Développement de Pharmacie Galénique Industrielle, Plateforme FRIPHARM, Faculté de Pharmacie, Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique - UMR 5305, Université Claude Bernard Lyon 1, Lyon Cedex, France
| | - Yanis Mimouni
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Segolene Gaillard
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Pierre Chatelain
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service d'Endocrinologie Pédiatrique, Hôpital Mère-Enfant, Centre Hospitalo-Universitaire de Lyon, Bron Cedex, France
| | - Yves Morel
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Laboratoire d'Hormonologie d'Endocrinologie Moléculaire et des Maladies Rares, INSERM 1208, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Behrouz Kassai
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Pierre Mouriquand
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service de Chirurgie Uro-Viscérale de l'Enfant-Hôpital Mère Enfant, Hospices Civils de Lyon, Bron, France
- Université Claude-Bernard-Lyon 1, Lyon, France
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Blanc T, Peycelon M, Siddiqui M, Muller C, Paye-Jaouen A, El-Ghoneimi A. Double-face preputial island flap revisited: is it a reliable one-stage repair for severe hypospadias? World J Urol 2020; 39:1613-1624. [PMID: 32601982 DOI: 10.1007/s00345-020-03324-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/20/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE We have studied outcome of double-face preputial island flap (DFPIF) technique in severe types of hypospadias: penoscrotal, scrotal and perineal. METHODS We have used DFPIF in 75 boys at a median age of 1.1 years (1.0-1.5). The meatus was penoscrotal, scrotal or perineal after de-gloving the penis. The inner face of the foreskin was used for urethroplasty and the outer face for ventral skin covering. Modifications were added: proximal anastomosis was protected by a spongioplasty; in case of urethral plate transection, we anastomosed on onlay proximal and distal segments of the flap (onlay-tube-onlay) and the tubularized part was sutured to corpus cavernosa. FU was scheduled at one month then every 3 months for a year then annually. At each consultation, the surgeon filled out a detailed cosmetic and functional sheet including flowmeter. RESULTS Thirty-four patients had onlay preputial flap repair with urethral plate preservation. Forty-one had the onlay-tube-onlay technique. All children had a curvature, 19 had a significant residual curvature after dissection, corrected by dorsal plication (n = 9) and ventral lengthening (n = 10). Median FU was 4.2 years (2.7-6.5). 36 children (48%) had complications and needed redo surgery: 12 fistulas, 11 diverticula, 7 meatal stenosis, 3 strictures and 2 residual curvatures. All children but three voided within the normal limits for their age. CONCLUSION DFPIF remains a good option for a one-stage repair of severe hypospadias. After a median of 1.8 procedures, the final success rate was 96%. The healthy well-vascularized ventral skin allows safe redo surgery when needed.
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Affiliation(s)
- Thomas Blanc
- Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Centre de Référence Maladies Endocriniennes de la Croissance et du Développement (CRMERC), APHP, University of Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Centre de Référence Maladies Endocriniennes de la Croissance et du Développement (CRMERC), APHP, University of Paris, Paris, France
| | - Mohammed Siddiqui
- Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Centre de Référence Maladies Endocriniennes de la Croissance et du Développement (CRMERC), APHP, University of Paris, Paris, France
| | - Cecile Muller
- Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Centre de Référence Maladies Endocriniennes de la Croissance et du Développement (CRMERC), APHP, University of Paris, Paris, France
| | - Annabel Paye-Jaouen
- Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Centre de Référence Maladies Endocriniennes de la Croissance et du Développement (CRMERC), APHP, University of Paris, Paris, France
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Centre de Référence Maladies Endocriniennes de la Croissance et du Développement (CRMERC), APHP, University of Paris, Paris, France.
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Abbas TO, Ali TA, Uddin S. Urine as a Main Effector in Urological Tissue Engineering-A Double-Edged Sword. Cells 2020; 9:cells9030538. [PMID: 32110928 PMCID: PMC7140397 DOI: 10.3390/cells9030538] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 12/15/2022] Open
Abstract
In order to reconstruct injured urinary tract tissues, biodegradable scaffolds with autologous seeded cells are explored in this work. However, when cells are obtained via biopsy from individuals who have damaged organs due to infection, congenital disorders, or cancer, this can result in unhealthy engineered cells and donor site morbidity. Thus, neo-organ construction through an alternative cell source might be useful. Significant advancements in the isolation and utilization of urine-derived stem cells have provided opportunities for this less invasive, limitless, and versatile source of cells to be employed in urologic tissue-engineered replacement. These cells have a high potential to differentiate into urothelial and smooth muscle cells. However, urinary tract reconstruction via tissue engineering is peculiar as it takes place in a milieu of urine that imposes certain risks on the implanted cells and scaffolds as a result of the highly cytotoxic nature of urine and its detrimental effect on both growth and differentiation of these cells. Both of these projections should be tackled thoughtfully when designing a suitable approach for repairing urinary tract defects and applying the needful precautions is vital.
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Affiliation(s)
- Tariq O. Abbas
- Laboratory for Stem Cell Research, Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark
- Pediatric Urology Section, Sidra Medicine, Doha 26999, Qatar
- College of Medicine, Qatar University, Doha 2713, Qatar
- Surgery Department, Weill Cornell Medicine—Qatar, Doha 24144, Qatar
- Correspondence: or ; Tel.: +974-550-93-651
| | - Tayyiba A. Ali
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, Doha 3050, Qatar; (T.A.A.); (S.U.)
| | - Shahab Uddin
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, Doha 3050, Qatar; (T.A.A.); (S.U.)
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Sebastião YV, Brown CT, Cooper JN, McLeod DJ, DaJusta DG. Risk of re-operation after outpatient distal hypospadias repair in a large, multistate cohort. J Pediatr Urol 2019; 15:471.e1-471.e6. [PMID: 31327660 DOI: 10.1016/j.jpurol.2019.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 06/15/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Repair of distal hypospadias is one of the most common pediatric urology procedures in the US. However, the risk of postsurgical complications has been reported primarily from single-institution and tertiary center studies, with short duration of patient follow-up. OBJECTIVE The aim of the study was to examine the incidence of re-operation and risk factors for re-operation following outpatient distal hypospadias repair in a large, representative sample of US children. METHODS A retrospective cohort study of patients aged 0-18 years undergoing single-stage distal hypospadias repair was conducted. Data were obtained from the State Ambulatory Surgery and Services Databases of 9 participating states. Patients who underwent outpatient surgery in 2008-2013 were identified using Current Procedural Terminology (CPT) codes. Patients with records suggesting prior surgery for hypospadias (CPT) were excluded, as were patients who underwent the initial repair <2 years before the end of state data availability. Return outpatient surgery visits across institutions within each of the 9 states were tracked to identify re-operations after the single-stage repair, using CPT codes for surgical treatment of hypospadias complications in 2008-2015. Time-to-event analyses were used to estimate the probability (risk) of re-operation over time and to examine whether patient and institutional characteristics were predictive of re-operation (age, race/ethnicity, health insurance, facility ownership, and institutional volume of hypospadias repair). RESULTS A total of 4673 children treated across 148 institutions were included. The median follow-up time was 4.1 years (range: 2-7.9). Most patients were <1 year of age at the time of initial repair (53%). The risk of re-operation was 2.6% (95% confidence interval [CI]: 2.1-3.0%) at 1 year and 6.7% (95% CI: 6.0-7.5%) at 5 years after initial repair (Figure). Approximately 13% of re-operation patients had the re-operation at a different institution. None of the patient or institutional factors examined was a significant predictor of the risk of re-operation. DISCUSSION In this population-based cohort, the estimated 5-year risk of re-operation following single-stage distal hypospadias repair was 6.7% (95% CI: 6.0-7.5). Most re-operations occurred after the first year, informing long-term expectations about postoperative complications. This study was limited by a lack of data on severity of hypospadias and surgeon characteristics and the inability to track re-operations outside of the state in which the original repair was performed. CONCLUSION Approximately 7% of children undergoing distal hypospadias repair undergo a re-operation within 5 years. None of the factors studied were predictive of re-operations.
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Affiliation(s)
- Y V Sebastião
- Center for Surgical Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - C T Brown
- Division of Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - J N Cooper
- Center for Surgical Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - D J McLeod
- Center for Surgical Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Division of Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - D G DaJusta
- Division of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
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Cambareri GM, Yap M, Kaplan GW. Hypospadias repair with onlay preputial graft: a 25-year experience with long-term follow-up. BJU Int 2016; 118:451-7. [DOI: 10.1111/bju.13419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Gina M. Cambareri
- Department of Urology; University of California San Diego (UCSD); San Diego CA USA
| | - Michael Yap
- Department of Urology; University of California San Diego (UCSD); San Diego CA USA
| | - George W. Kaplan
- Department of Urology; Rady Children's Specialists of San Diego; San Diego CA USA
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Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias. World J Urol 2015; 34:1019-24. [PMID: 26394625 DOI: 10.1007/s00345-015-1686-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/08/2015] [Indexed: 10/23/2022] Open
Abstract
AIMS AND OBJECTIVES Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias. MATERIALS AND METHODS All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty. RESULTS Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52 %) children required a tunica albuginea plication for chordee correction. In total, 16 (17 %) patients developed 24 complications and 11 children (12 %) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus. CONCLUSIONS Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.
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Badawy H, Fahmy A. Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues. Arab J Urol 2013; 11:174-81. [PMID: 26558078 PMCID: PMC4443004 DOI: 10.1016/j.aju.2013.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 03/14/2013] [Accepted: 03/16/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair. METHODS We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002-2012) for relevant articles, using the terms 'proximal hypospadias', 'posterior hypospadias' 'single stage', 'multiple stage', and 'complications'. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate. RESULTS AND CONCLUSIONS The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.
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Affiliation(s)
- Haytham Badawy
- Department of Urology, University of Alexandria, Alexandria, Egypt
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Chandrasekharam VVS. Single-stage repair of hypospadias using longitudinal dorsal island flap: Single-surgeon experience with 102 cases. Indian J Urol 2013; 29:48-52. [PMID: 23671365 PMCID: PMC3649600 DOI: 10.4103/0970-1591.109984] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Purpose: There are many techniques of harvesting vascularized skin flaps from penile skin for hypospadias repairs. Here, we review our experience with the use of longitudinal dorsal island flap (LDIF) for mid- and proximal hypospadias repairs and to assess the results and complications of onlay and tubularized repairs. Materials and Methods: We retrospectively reviewed the data of all children with hypospadias operated by a single surgeon using the LDIF technique. The severity of hypospadias, technique, complications, and follow-up were assessed. Results: Over a 9.4-year period, 102 children (mean age 4.2 years, range 6 months to 11 years) were operated for primary hypospadias using the LDIF technique. All children had poorly formed urethral plates and hence were considered unsuitable for tubularized incised plate repair. The hypospadias was classified as midpenile, proximal penile/penoscrotal or perineal in 29, 64, and 9 children respectively. Onlay LDIF repair was done in 85 children, while in 17 children, tubularized LDIF repair was performed. At a mean follow-up of 1.8 years, complications occurred in 12 (12%) children. Complications were more common after tubularized repairs than onlay repairs (24% vs. 9.5%). All glans dehiscences occurred after onlay repairs, while meatal stenosis and diverticulum occurred after tubularized repairs. No child had urethral stenosis after onlay repair, and uroflow studies in 16 children demonstrated normal curves and flow rates. Conclusions: We report the use of LDIF for single-stage mid and proximal hypospadias repair with good success and an acceptable complication rate. Onlay repairs had fewer complications than tubularized repairs. Our results indicate that the specific advantages and versatility of LDIF make it a good option to consider in cases of hypospadias with poorly developed urethral plates where onlay or substitution urethroplasty is indicated.
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Affiliation(s)
- V V S Chandrasekharam
- Department of Pediatric Surgery and Pediatric Urology, Rainbow Children's Hospitals, Hyderabad, Andhra Pradesh, India
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Abstract
The modern hypospadiologist must be proficient in the use of both vascularized flaps and free grafts. When choosing a repair for any given patient with hypospadias, one must consider the length of the urethroplasty, the presence and degree of ventral curvature and perhaps most importantly, the surgeon's own experience. Not all repairs are created equally and different complication rates and cosmetic outcomes can be seen among different surgeons utilizing the same technique. Each surgeon tends to infuse their own modifications to any given technique and many of these modifications go unreported. It is incumbent upon each surgeon to be familiar with a wide variety of techniques, which invariably includes the use of flaps and grafts. We present a spectrum of the uses of flaps and grafts in modern hypospadiology.
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Tubularized incised plate proximal hypospadias repair: Continued evolution and extended applications. J Pediatr Urol 2011; 7:2-9. [PMID: 20598641 DOI: 10.1016/j.jpurol.2010.05.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 05/19/2010] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We report additional technical modifications and extended application of proximal TIP hypospadias repair in consecutive patients operated by a single surgeon. MATERIALS During a 39-month period, 36 patients underwent primary proximal hypospadias surgery, with 26 undergoing TIP and 10 two-stage repair for a thin urethral plate (UP) (1) or ventral penile curvature (VC) requiring UP transection (9). Of the TIP repairs, 16 had UP elevation from the corpora cavernosa to facilitate VC straightening while maintaining the UP for urethroplasty. All TIP patients underwent two-layer urethroplasty with tunica vaginalis coverage over the neourethra. RESULTS With mean follow up of 12 months (2-38) in 24 TIP patients, 16 had calibration and 11 urethroscopy 6-12 months postoperatively. Complications occurred in three (13%), glans dehiscence (2) and neourethral stricture (1), which represents a significant reduction versus our prior reports. Non-randomized preoperative testosterone in 8/24 with follow up did not influence complication rates. TIP incision of the elevated UP did not divide it into separate strips, or impair vascularity. CONCLUSIONS Dissection of the UP from the corpora facilitates correction of VC while preserving the plate, without increasing TIP urethroplasty complications. Overall, complication rates for TIP have significantly diminished with technical modifications and experience. The role for neoadjuvant hormonal therapy remains unclear. Despite straightening VC preserving the UP, intraoperative assessment deemed it unsuitable for TIP in one case (4%).
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de Mattos e Silva E, Gorduza DB, Catti M, Valmalle AF, Demède D, Hameury F, Pierre-Yves M, Mouriquand P. Outcome of severe hypospadias repair using three different techniques. J Pediatr Urol 2009; 5:205-11; discussion 212-4. [PMID: 19201261 DOI: 10.1016/j.jpurol.2008.12.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 12/17/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare the outcomes of three different urethroplasty techniques (onlay, buccal mucosa, Koyanagi type I) used in the reconstruction of severe hypospadias. PATIENTS AND METHODS Over 10 years (1997-2007), 300 severe hypospadias cases were treated with a mean follow up of 2 years (1-105 months); 203 were operated by the same surgeon of whom 184 completed follow up. Three main techniques were used according to the quality of the urethral plate: onlay urethroplasty (133), buccal graft urethroplasty (25) and Koyanagi type I (26). The mean age at surgery was 36 months (8-298); 76 required preoperative androgen stimulation (onlay 37, buccal 11, Koyanagi 26); 18 required a corporoplasty to straighten the penis (onlay 13, buccal 3, Koyanagi 2). RESULTS Thirty-eight onlay (28.5%); 14 buccal (56%); 16 Koyanagi (61.5%) urethroplasties had a complication. The fistula rate was 15% for the onlay group; 32% for the buccal mucosa group; 19.2% for the Koyanagi cases. The dehiscence rate was, respectively, 11.3%, 20% and 42.3%. The stricture rate was, respectively, 1.5%, 20% and 34.6%. Urethrocele was found in seven Koyanagi patients. Final functional and cosmetic results were satisfactory in 126/133 (94.7%) onlay, 20/25 (80%) buccal and 14/26 Koyanagi (53.8%) urethroplasties. Primary cases had better results (89%) than redo cases (75.9%). Patients submitted to preoperative androgen therapy developed more complications (onlay: 40.5% vs 23.9%; buccal: 70% vs 43.7%). CONCLUSION Two striking results are the low number of severe hypospadias cases requiring an additional corporoplasty, and the increased complication rate found in androgen-stimulated patients. The excellent results of the onlay procedure could be related to the use of dorsal preputial tissue, which in hypospadias is characterized by a well-balanced protein platform compared to the ventral tissues.
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Affiliation(s)
- Elisângela de Mattos e Silva
- Department of Pediatric Urology, Hôpital Mère-Enfants - GHE, Groupe Hospitalier Est, Université Claude-Bernard, 59, Boulevard Pinel, Lyon I, 69677 Bron Cedex, France
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