Hypospadias update

Missed urethral duplication associated with hypospadias, post-hypospadias repair urethral stenosis, and recurrent urinary tract infections in an adult: a case report

Background

Duplication of urethra is a very rare congenital disorder. Several types of this anomaly have been reported around the world, and are also discussed in this report. However, the mechanism of this anomaly is still unclear.

Case

A 45-year-old Persian man with a complaint of recurrent urinary tract infection was referred to our clinic. He had a history of repairing penoscrotal hypospadias in childhood along with obstructive and irritating symptoms in adolescence. On his last voiding cystourethrogram and retrograde urethrogram, stenosis was observed in the proximal bulbar urethra along with a double urethra in the dorsal region of the main urethra. The double urethra was removed with operation, and he was followed for 1 month after surgery. He had no complaints of recurrence or urinary incontinence.

Conclusions

This report shows the different classification systems, types of double urethra, and approach and management, which mainly involves surgery; however, surgical management should be done according to the anatomical findings of the abnormality.

Deepithelialized glans reconfiguration (DeGRe) for distal hypospadias repair

INTRODUCTION

Our objective was to present our experience with a novel technique for distal hypospadias repair consisting of deepithelialized glans reconfiguration.

PATIENTS AND METHOD

We reviewed the clinical data of all patients who underwent distal hypospadias using Deepithelialized Glans Reconfiguration between January 2015 and December 2019. We noted age at surgery, position of meatus, duration of urethral catheterization and hospitalization, as well as early and late complications. Standard postoperative care included follow-up examination at 1, 6 and 12 months. Successful repair was defined as a patient presenting with a straight penis with an apical meatus, no stricture nor fistula.

RESULTS

Sixty-seven patients were included. Average age at surgery was 12.5 months (6-23 months). All patients presented distal hypospadias (3 glanular, 61 coronal, 3 subcoronal). 36% of patients were operated as day case surgery. No intra-operative complications were recorded. Eleven patients did not complete the designated follow up. They attended the post-operative appointment at six months but not the one-year visit. All patients presented satisfactory urinary streams according to the parents. All parents were satisfied with the cosmetic appearance of their child's penis. Two patients presented with glans dehiscence (3%). The mean HOPE score for the last 10 patients was 47.4 ± 3.2 out of a maximum of 50.

DISCUSSION

Deepithelialized Glans Reconfiguration is a simple technique with satisfactory results. Though it has similarities with existing techniques, it contains specific aspects not described previously. Contrary to the MAGPI technique, there is no meatal advancement, no rotation of the glans wings, and it is the glans lateral and proximal to the meatus which is approximated in the midline. As opposed to the GAP procedure, there is no closure of the ventral aspect of the urethra. We rely on secondary healing within the glans to reconstruct the missing ventral aspect of the urethra. We reserve this technique for coronal hypospadias with a wide, deep glanular groove. Deepithelialization favours rapid healing of the glans wings on the midline. There is no formal urethroplasty. The limits to this study include lack of long-term (>1 year) follow-up and uroflow. Though careful observation did not identify fistulas, the absence of functional stenosis has to be more clearly evaluated at a later age. Finally, this technique is not suitable for the completely flat glans as it relies on being able to approximate the glans ridges in the midline.

CONCLUSION

Deepithelialized Glans Reconfiguration is a simple technique which achieves good cosmetic results, without complications associated with meatal or urethral advancement or formal urethroplasty.

[Application of cavernosum reduction technology in glanuloplasty during repair of moderate-severe hypospadias]

Objective

To investigate the application of cavernosum reduction technology in glanuloplasty during the repair of moderate-severe hypospadias and evaluate the effectiveness.

Methods

The clinical data of 192 patients with moderate-severe hypospadias between November 2015 and May 2017 were retrospectively analyzed. Among them, 103 patients were treated with the cavernosum reduction technology in glanuloplasty during the repair (observation group), 88 patients were treated with repair and glanuloplasty without the cavernosum reduction technology (control group). There was no significant difference in maximum transverse diameter of glans and the height of glans between 2 groups ( t=1.652, P=0.152; t=1.653, P=0.077). The length of reconstructed urethra, complications (e.g. glans dehiscence and fistula), and the maximum flow rate at 3 months after operation in 2 groups were recorded.

Results

The length of reconstructed urethra were (35.51±7.79) mm in observation group and (32.17±6.37) mm in control group. In observation group, the meatus location after the correction of chordee was proximal in 24 cases and scrotum-perineum in 79 cases. In control group, the meatus location after the correction of chordee was proximal in 21 cases and scrotum-perineum in 67 cases. There was no significant difference in the meatus location between 2 groups ( χ ²=0.008， P=0.920). All patients were followed up 6-12 months after operation (mean, 9 months). There were 3 cases of urethral fistula, 2 cases of glans dehiscence, and 3 cases of urethral orifice stricture in observation group, with the incidence of complications of 7.8%. There were 7 cases of urethral fistula, 3 cases of glans dehiscence, and 4 cases of urethral orifice stricture in control group, with the incidence of complications of 15.9%. There was a significant difference in the incidence of complications between 2 groups ( χ ²=4.027, P=0.040). The appearance of the penis was satisfactory, and the urethral orifice was fissured, which was close to the appearance of the normal urethral orifice. At 3 months after operation, the maximal flow rates were (6.23 ± 0.54) mL/s in observation group and (5.44±0.92) mL/s in control group. There was significant difference in the maximum flow rate between 2 groups ( t=1.653, P=0.000).

Conclusion

Cavernosum reduction technology being applied in the repair of moderate-severe hypospadias can reduce the probability of glans dehiscence, urethral fistula, urethrostenosis, and other postoperative complications, and improve the success and satisfaction of surgery.

Modified double face onlay island preputial skin flap with augmented glanuloplasty for hypospadias repair

OBJECTIVE

To present and evaluate our initial results with a modified double face onlay preputial flap (DOPF) for repair of different degrees of hypospadias.

MATERIAL AND METHODS

From April 2004 to April 2009, 182 patients with different degrees of hypospadias (distal penile hypospadias = 122, mid penile hypospadias = 38, proximal penile hypospadias = 22) were included in our study. All patients were treated with a modified DOPF. Their age ranged from 6 months to 10 years (mean 3.03 years). Selection criteria were those cases with urethral plate<8 mm with either flat or conical glans, and non-circumcised patients. The technique of repair was to use the distally tapered inner preputial mucosa as onlay to augment the narrow urethral plate, while the outer face was tapered distally to augment the closed proximal part of the glanular wings and as skin cover. Suitable urethral catheter was inserted for 3-5 days. Follow-up duration was 27-30 months (mean 24 months).

RESULTS

Functional and cosmetic success was reported in 176 patients (96.6%). Six patients (3.29%) had developed complications that affected the success rate: 1 (0.5%) glanular disruption, 2 (1.09%) fistula, 1 (0.5%) urethral diverticulum and 2 (1.09%) lateral penile torsion. Three (1.6%) patients had developed minor complications with no effect on functional and cosmetic success in form of superficial epidermal loss.

CONCLUSION

Modified DOPF is a suitable technique for repair of different types of hypospadias as it results in satisfactory functioning and an acceptable cosmetic appearance.

[Pedicled prepuce flap plasty: results in patients with hypospadias or urethral sticture]

BACKGROUND

Operative interventions of the urethra remain challenging procedures. The vascular onlay flap of the inner prepuce is a possible technique for short and long segment urethral defects.

PATIENTS AND METHODS

A total of 195 patients were surgically treated with a vascular prepuce flap between 1994 and 2010 at the Urology Department of Essen Medical University. Patient data were analyzed retrospectively and a questionnaire was sent to all patients.

RESULTS

Of the patients 115 answered the questionnaires and were included in the study. Of these 61 patients were treated in childhood due to hypospadias and 54 patients suffered from acquired urethral stricture. Major complications were postoperative fistulas in 8.2 % and 7.4 % and hematomas in 6.6 % and 11.1 % of cases, respectively. Operative revision had to be performed in 13.1 % and 14.8 % of cases and severe obstructive micturition problems (IPSS score ≥ 20) were observed in only 3.3 % and 11.1% of patients, respectively. Subjective overall satisfaction with the result of the operation was high (67.2 % and 88.9 %, respectively).

CONCLUSION

The vascular prepuce flap is a reliable method for correction of short and long segment urethral defects and is associated with high patient satisfaction.

Kutlay technique for hypospadias repair

OBJECTIVE

Although many techniques have been described, new techniques with a wide range of therapeutic options are needed. The Kutlay technique is a novel technique that is based on the reconstruction of the neourethra with two horizontal meatal-based skin flaps. In the present study, the data of 31 patients who underwent surgery with the Kutlay technique are presented.

PATIENTS AND METHODS

Thirty-one patients with hypospadias with an average age of 5.6 years who did not have previous hypospadias repair were operated on with the Kutlay technique. Ten patients had chordee. Among those patients, three patients were circumcised.

RESULTS

The patients were followed up for 4-13 months (average, 9.3 months). During the follow-up period, a fistula was observed in only one patient. None of the patients developed neourethral dehiscence, meatal stenosis, urethral stricture, wound infection, penile torsion, hematoma, or persistent or recurrent chordee. On uroflowmetry studies, the maximum flow rate of the patients was approximately 10.5 ml/s (range, 6-17 ml/s). The patients were observed to void with a single straight urinary stream in a forward direction.

CONCLUSION

The Kutlay technique is a technique that is easily applied in patients with chordee and that provides a low risk of fistulas and acceptable functional and esthetic results. The factors that reduce the risk of fistula are the lack of the superposition of the suture lines of the skin and the urethra, the reconstruction of the urethra with well-vascularized flaps, and the replacement of the neourethra in its appropriate location through the tunnel created in the glans.

Evaluation of distally folded onlay flap in repair of distal penile hypospadias

OBJECTIVE

To evaluate the results of using a distally folded onlay flap in the repair of distal penile hypospadias, with regard to meatal stenosis, urethrocutaneous fistula and esthetic outcome.

PATIENTS AND METHODS

This prospective study involved 36 patients with mean age 3.2 years (range 1-4); 18 had a shallow urethral plate, 10 a small glans, and 8 had undergone a previous operation but still had available preputial skin. All underwent the elective technique of distally folded onlay flap, which was carried out under general anesthesia using a 4× magnifying loupe. Starting with penile degloving and then harvesting the transverse island preputial flap provides a flap about 1 cm longer than the urethral plate. Two lateral incisions are made along the urethral plate with no need for dissection deep into the glanular wings. The flap is sutured to the urethral plate, leaving 1 cm distal to the tip of the glans, which is folded back to be sutured to the edges of the glanular wings.

RESULTS

There were no cases of meatal stenosis or requirement for urethral dilatation. Two patients had a urethrocutaneous fistula; one closed spontaneously while the other needed surgical repair 6 months later. Regarding esthetic appearance, 32 were scored good and 4 satisfactory.

CONCLUSION

This versatile technique offers satisfactory results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.

Increasing prevalence of hypospadias in Western Australia, 1980-2000

OBJECTIVES

Hypospadias, a common birth defect, has shown widespread variation in reported rates and temporal trends across countries over the last 30 years. The aim of this study was to determine the prevalence and trends of hypospadias in an Australian population.

DESIGN

Population-based study of all male infants born in Western Australia (WA) between 1980 and 2000 diagnosed with hypospadias and notified to the WA Birth Defects Registry.

MAIN OUTCOME MEASURES

Prevalence of hypospadias, birth outcome and association with other congenital anomalies, stratified by degree-of-severity.

RESULTS

1788 cases of hypospadias were registered in WA in 1980-2000 with an overall prevalence of 34.8 (95% confidence interval (CI): 33.2 to 36.4) cases per 10 000 births. The prevalence increased by 2.0% per annum (95% CI: 1.2% to 2.8%) from 27.9 in 1980 to 43.2 per 10 000 births in 2000 (p<0.001). Hypospadias was mild in 84% of cases, moderate-severe in 11% and unspecified in 5%, with the number of moderate-severe hypospadias almost doubling over time (p<0.01). There were 1465 (82%) cases of isolated hypospadias and 323 (18%) had co-existing anomalies. Infants with co-existing genital (relative risk (RR) 4.5; 95% CI: 3.3 to 6.1) or non-genital (RR 1.5; 95% CI: 1.0 to 2.2) anomalies were more likely to have moderate-severe hypospadias compared with isolated cases.

CONCLUSION

Hypospadias affects one in 231 births and has been reported to have increased significantly over the last 20 years. Future investigation of the aetiology of hypospadias is important to identify potentially modifiable risk factors and ensure optimal male reproductive health in the future.

Hypospadias: an update

Hypospadias is the most common congenital anomaly of the penis. The problem usually develops sporadically and without an obvious underlying cause. The ectopically positioned urethral meatus lies proximal to the normal site and on the ventral aspect of the penis, and in severe cases opens onto the scrotum or perineum. The foreskin on the ventral surface is deficient, while that on the dorsal surface is abundant, giving the appearance of a dorsal hood. Chordee is more common in severe cases. Cryptorchidism and inguinal hernia are the most common associated anomalies. The frequency of associated anomalies increases with the severity of hypospadias. For isolated anterior or middle hypospadias, laboratory studies are not usually necessary. Screening for urinary tract anomalies should be considered in patients with posterior hypospadias and in those with an anomaly of at least one additional organ system. The ideal age for surgical repair in a healthy child is between 6 and 12 months of age. Most cases can be repaired in a single operation and on an outpatient basis. Even patients with a less than perfect surgical result are usually able to enjoy a satisfactory sexual life.

Hypospadias: anatomy, etiology, and technique

Hypospadias is one of the most common congenital anomalies defined by abortive development of the urethral spongiosum, the ventral prepuce and in more severe cases penile chordee. The etiology of hypospadias remains unknown with environmental exposure in the form of endocrine disruptors the most likely explanation for the worldwide increase in incidence in the last three decades. There are five sequential steps for the successful repair of hypospadias: 1) Orthoplasty or penile straightening, 2) Urethroplasty, 3) Meatoplasty and Glanuloplasty, 4) Scrotoplasty, and 5) Skin Coverage. The major technical advances in hypospadias surgery that have improved surgical outcomes are 1) Preservation of the urethral plate, 2) Incision of the urethral plate, 3) Dorsal midline plication, 4) Deepithelized urethroplasty dartos flap coverage, and 5) Two stage alternative techniques. This article reviews the pertinent embryology, anatomy and the most common hypospadias reconstructive operations to accomplish a successful repair.

Hypospadias in the neonate

Hypospadias is a common developmental disorder of the urogenital tract, occurring in approximately 1 in 125 live male births. Defined as an atypical urethral opening anywhere along the shaft of the penis, scrotum, or perineum, hypospadias is often associated with a deficient prepuce and chordee. Hypospadias usually occurs as an isolated defect, but can be part of a recognized syndrome or associated with other genital anomalies. The etiology of nonsyndromic hypospadias is unknown, and is believed to be multifactorial. Recent studies have implicated factors such as familial inheritance, low birth weight, assisted reproductive technology, advanced maternal age, paternal subfertility, and endocrine-disrupting chemicals in the pathogenesis of hypospadias. Infants with hypospadias should not undergo circumcision. Currently, most infants with hypospadias undergo surgical reconstruction between 4 and 8 months of age. Parents of a newborn with hypospadias may be anxious and have many questions about their infant's condition. They should be given the opportunity to speak to a pediatric urologist as early as possible. This article provides a guide to the embryologic origins of hypospadias and a photographic atlas to aid bedside clinicians in identifying the spectrum of hypospadias in the newborn.

Functional evaluation of one-stage urethroplasty with parameatal foreskin flaps repair of hypospadias using uroflowmetry

BACKGROUND

Uroflowmetry is a simple, accurate and non-invasive test. In the present study, we aimed to determine the role of uroflowmetry in the evaluation of the functional results of one-stage urethroplasty with parameatal foreskin flaps (OUPF) technique.

METHODS

Twenty-one children who had undergone OUPF repair at our clinic were selected. Selection criteria were that patients were toilet trained and had no fistula. Uroflowmetry was performed using a rotating disk sensor. The maximum flow rate (Qmax) and average flow rate (Qave) were plotted against body surface related flow rate nomograms. The upper 95% tolerance limits for the 5th, 10th, 15th, 20th and 25th percentiles of the normal population were used for comparison. The flow pattern was classified as bell ring, plateau or intermittent.

RESULTS

The median age at the first uroflowmetry was 4.7 years (range 2.5-8.6) and the mean postoperative follow-up period was 25 months (range 1-58). Twelve children had Qmax above the 25th, six between the 5th and 25th and three less than the 5th percentiles of the normal population. A normal bell-shaped flow curve was obtained in 17 (80.6%) of the children. Of the three children with Qmax below the 5th percentile, two children had a plateau flow pattern and were found to have a urethal stricture. Dilation was performed successfully, after which the Qmax returned to the normal range and the symptoms disappeared.

CONCLUSION

The OUPF technique provided satisfactory functional results for hypospadias repair. We advocate the use of uroflowmetry for routine postoperative follow-up.

Spongioplasty and separation of the corpora cavernosa for hypospadias repair

OBJECTIVE

To describe a surgical method (a modified Duplay technique), and its results, for hypospadias repair, developed to avoid the common complication of fistula.

PATIENTS AND METHODS

The urethroplasty was modified so that it no longer comprises a simple approximation of the urethral plate with no dissection. The inferior surface of the corpora cavernosa is exposed as far as the lateral border and to the end of the glans, allowing tension- free suturing of urethral tissues, with a lengthening effect of the intermediate plane. This corrects chordee and especially the 'bucket-handle' glans, and protects the reconstructed urethra and proximal urethra. The study included 51 children who had their hypospadias repaired over a 9-month period (mean age at surgery 20.6 months, range 1-11 years); 14 had coronal, three anterior penile juxta-coronal, 23 anterior penile, four medium penile, five posterior and two penoscrotal hypospadias.

RESULTS

All children were followed and no fistula was apparent in any with anterior hypospadias; two fistulae occurred after repair of the posterior form. The risk of fistula is therefore reduced (two in 51).

CONCLUSION

This technical modification can be used to treat all forms of distal hypospadias (glanular, glanulo-preputial, and anterior penile). It was also used for several cases of more severe hypospadias. These good results must be confirmed in a larger series of patients.

The incidence of hypospadias in two English cities: a case-control comparison of possible causal factors

OBJECTIVES

To determine the incidence and severity of hypospadias amongst children born in Southampton and Portsmouth during 1992-94, and to identify possible causal factors by comparing patients with a control group.

PATIENTS AND METHODS

All patients with hypospadias born in Southampton and Portsmouth during 1992-94 were identified. The Southampton cases were matched with controls; the case notes of each affected child were reviewed. The incidence determined by this study was compared with data provided by the Central Statistics Office.

RESULTS

There was no apparent increase in the incidence of hypospadias in Southampton and Portsmouth during 1982-94. However, there was a clear local variation in incidence, with a significantly lower incidence in Portsmouth than in Southampton and the rest of England and Wales. The severity of hypospadias was also more marked in Southampton than in Portsmouth. The only recognisable aetiological factor was a positive family history, supporting the concept of a polygenic mode of inheritance. All the environmental factors investigated were unrelated, but there was a suggestion of clustering in a single water-quality zone.

CONCLUSIONS

This study identified no increase in the incidence of hypospadias but it did detect local variations in both the incidence and severity of the condition, and these need to be considered when planning surgical services.

Chordee: varied opinions and treatments as documented in a survey of the American Academy of Pediatrics, Section of Urology

OBJECTIVES

Consensus has not been established as to the best treatment of congenital chordee. Outcomes analysis of treatment options are limited by the prevailing use of ambiguous terminology. We sought to clarify the frequently used term "significant chordee" and to measure the utilization of current treatment strategies.

METHODS

A survey covering current practice patterns concerning congenital chordee with hypospadias was sent to 236 members of the American Academy of Pediatrics, Section of Urology.

RESULTS

Correction of chordee was the primary concern in hypospadias surgery of 31 % of those responding, but it was not the primary goal of 54% of respondents. Findings indicate that "significant chordee" is clinically defined as curvature greater than 20 degrees, in that 75% of respondents said they would proceed with further intervention. Placement of plicating sutures was the most common therapy chosen for 20 degrees chordee, with 50% of respondents electing this approach. Consensus was reached at 30 degrees chordee, with greater than 99% intervening at this degree of curvature. At 30 degrees curvature, 48% used an incisional Nesbit procedure. As the degree of curvature increased, division or mobilization of the urethral plate became the most common intervention. With 50 degrees chordee, urethral plate manipulation was used 34% of the time. Sixty percent of the respondents believed the urethral plate did not often contribute to chordee.

CONCLUSIONS

"Significant chordee" was believed to be a curvature greater than 20 degrees to 30 degrees. With 20 degrees, 30 degrees , and 40 degrees chordee, correction was most often approached dorsally. With 50 degrees chordee, 54% approached the problem ventrally. We hope to encourage the use of more objective measurements and terminology. Objective measurements and long-term follow-up will improve our understanding of the natural history of chordee and improve outcomes analysis.

Hypospadias

The incidence of hypospadias is increasing. Decreased androgen sensitivity, 5alpha-reductase deficiency and chromosomal abnormalities are causes of the disease. Nonirritant suture material, coverage of the urethral reconstruction by additional tissue and perioperative care positively influence the outcome. Complication rates after repair of distal hypospadias are low. For severe hypospadias staged procedures provide good results. Buccal mucosa is promising for initial repair and repeat cases. Psychosocial function in patients with severe hypospadias is normal.

Skin flap closure by dermal laser soldering: a wound healing model for sutureless hypospadias repair

OBJECTIVES

Laser tissue soldering (LTS) with the diode laser and human albumin-hyaluronate-indocyanine green solder is a safe and effective method of providing an immediate leak-free closure during hypospadias repair. In this report, we compare the physiology, histology, and immunohistochemistry of wound healing following LTS and suturing in a rat skin flap model.

METHODS

A 4 x 5-cm skin flap was raised and bisected (4 cm) on the dorsum of 48 Sprague-Dawley rats. The central wound was either closed from a dermal approach by suturing or LTS or left open, and studied at 0, 3, 5, 7, 10, 14, and 21 days postoperatively. An intraoperative comparison was made between suturing and LTS with respect to operative time. Postoperatively, flaps were excised for tensiometric analysis, and sections were stained with hematoxylin-eosin to define wound architecture. Resting skin temperature, laser exposed temperature without solder, and maximum temperature with solder (one drop) were measured at the level of the deep dermis, superficial striated muscle layer, and within the solder. Mean peak temperatures were recorded during a 1-minute laser activation time.

RESULTS

Mean continuous suturing time (4.9 +/- 1.1 minutes) was significantly (P < 0.001) faster than either LTS (7.7 +/- 0.77 minutes) or discontinuous suturing (8.2 +/- 0.62 minutes). Two seromas (sutured) and two instances of partial wound dehiscence (1 sutured, 1 LTS) were noted. Tensile strength was increased significantly (P < 0.001) for up to 5 days in the LTS group, but was equal to suturing at 7 and 10 days. Immediate tensile strength after LTS was equivalent to a 7-day healed wound. At 14 days, wounds initially left open and those closed by LTS were stronger than sutured wounds (P < 0.05). There was no evidence of thermal injury or foreign body reaction in the LTS group. Solder was incorporated within the dermis in all wounds at 21 days. Laser activation of solder resulted in significant increases in temperature at all three tissue levels: 65.0 +/- 5.2 and 69.9 +/- 6.8 degrees C in the deep and superficial skin (no significant difference between the two), and 101 +/- 15.6 degrees C within the solder (P < 0.001 versus superficial and deep skin).

CONCLUSIONS

Our results indicate that sutureless dermal LTS of skin flaps provides increased tensile strength for up to 7 days, with relatively greater tensile strength provided within the first 3 days. Our laser technique does not appear to alter the normal wound healing process. Rather, solder-tissue interaction initially, and extracellular matrix infiltration of solder later, provide the basis for improved wound strength. For hypospadias repair using skin flaps, these wound attributes may permit sutureless surgery.