The effect of suturing technique and material on complication rate following hypospadias repair

Post-urethroplasty complications in hypospadias repair: a systematic review and meta-analysis comparing polydioxanone and polyglactin sutures

Background

Polyglactin (PG) and polydioxanone (PDS) sutures are extensively used based on the surgeon's preference. The development of post-reconstruction urethrocutaneous fistula (UCF) is variably attributed to the choice of suture material for urethroplasty. This meta-analysis compares complications of hypospadias repair using PG and PDS sutures.

Methods

The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors conducted thorough searches in databases including MEDLINE, EMBASE, CENTRAL, Scopus, Google Scholar, and clinical trial registries. Outcome measures included UCF, meatal stenosis, wound infection, urethral stricture, glans dehiscence, and overall complications. Quantitative analysis was used with fixed or random-effect models to find the pooled risk ratio and I2 heterogeneity.

Results

The criteria for inclusion were met by five comparative studies with the inclusion of 1244 children altogether. Pooled analysis failed to show a statistically significant difference in the incidence of meatal stenosis, urethral stricture, wound infection, and total complications using PG and PDS sutures. However, it showed a reduction in the incidence of UCF with PDS suture hypospadias repairs (risk ratio=0.66, 95% CI 0.48 to 0.92).

Conclusions

PDS sutures are associated with decreased incidence of UCF than PG after hypospadias repair. The incidence of meatal stenosis, urethral stricture, wound infection, and total complications was not affected by the type of suture material used for repair.

Clinical implications

This meta-analysis suggests decreased incidence of UCF when PDS sutures are used for hypospadias repair which may impact the choice of suture material for repair.

PROSPERO registration number

CRD42023409710.

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network

BACKGROUND

Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series.

OBJECTIVE

With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network.

STUDY DESIGN

A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation.

RESULTS

Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons.

CONCLUSION

Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Comparison of post-urethroplasty complication rates in pediatric cases with hypospadias using Vicryl or polydioxanone sutures

Objective

Hypospadias is a common congenital problem among male newborns. Both rapid absorbable sutures (polyglactin, Vicryl) and delayed absorbable sutures (polydioxanone, PDO) are used in hypospadias repair based on the surgeon's preference. This study was conducted to compare post-urethroplasty complication rates in pediatric patients with hypospadias using Vicryl or PDO sutures.

Methods

This is a retrospective study which was designed and performed on 583 children aged 1–7 years old who had undergone hypospadias repair from January 2012 to December 2018. Required data were obtained from the patients' medical records.

Results

Overall, post-surgical complications were observed in 60 (10.3%) patients comprising urethro-cutaneous fistula (n=39, 6.7%), meatal stenosis (n=10, 1.7%), urethral stricture (n=7, 1.2%), and glans dehiscence (n=4, 0.7%). The mean age of the children with complications was 3.0±1.3 years. According to Kaplan-Meier estimate, the interval between surgery and development of complications was significantly shorter in the Vicryl group (p=0.037). Overall, complications were more prevalent in Vicryl suture than PDO suture (15.1% vs. 5.3%, p<0.001). Regression model revealed that in comparison to the distal type, proximal hypospadias (odds ratio [OR]:103.9, 95% confidence interval [CI]: 32.2–334.9, p<0.001) and mid-shaft hypospadias (OR: 82.9, 95% CI: 25.9–264.6, p<0.001) while using Vicryl suture instead of PDO suture (OR: 62.4, 95% CI: 21.2–183.8, p<0.001) increased the odds of developing post-urethroplasty complications.

Conclusion

We suggest PDO suture in the repair of hypospadias due to its lower complication rate, especially in cases of proximal and mid-shaft hypospadias which can get more complicated than the distal type.

Does the suturing technique (continuous versus interrupted) have an impact on the outcome of tubularized incised plate in hypospadias repair with adequate urethral plate? A prospective randomized study

INTRODUCTION

Hypospadias is one of the most common anomalies of male external genitalia. The aim of hypospadias repair is to achieve a normal phallus with a satisfactory functional and cosmetic result and to develop a single and consistent urinary stream while in standing position. The introduction of tubularized incised plate (TIP) urethroplasty by Snodgrass in 1994 resulted in revolutionizing management of different types of hypospadias. While there is consensus on the use of absorbable sutures in hypospadias repair, there are no specific guidelines for the suturing technique and the technique itself remains debatable.

OBJECTIVE

To compare the outcome of interrupted- and continuous-suture in hypospadias repair using TIP technique.

STUDY DESIGN

This was a prospective randomized study. It comprised 260 uncircumcised hypospadiac boys with adequate urethral plate who underwent TIP repair. Boys with glanular, recurrent, proximal hypospadias and inadequate urethral plate were excluded from the study. The boys were randomized into two groups: Group A consisted of 130 boys who underwent TIP repair using continuous subcuticular suture urethroplasty and Group B of 130 boys who underwent TIP repair using interrupted subcuticular suture urethroplasty.

RESULTS

The operative time was of lower statistical significance in group A (P = 0.006) while the rate of complications were of higher statistical significance in group A (P = 0.027). Urethrocutaneous fistulae occurred in 20 patients (14 in Group A and six in Group B), which is a statistically significant difference (P = 0.048). On the other hand, superficial wound infection, partial glans dehiscence, meatal stenosis, urethral stricture, and aesthetic appearance were statistically insignificant.

DISCUSSION AND CONCLUSION

The effect of suturing techniques in bowel anastomosis has been studied and it has been found that the use of an interrupted-suturing technique results in a decreased complication rate compared to continuous suturing. This agrees with our study where the running sutures groups was associated with a higher complication rate compared to interrupted sutures.

A comparative study of polydioxanone (PDS) and polyglactin (Vicryl) in hypospadias repair

BACKGROUND

Hypospadias is a fairly common problem, and it is the most common genital congenital anomaly.

OBJECTIVE

This study was carried out to compare polyglactin and polydioxanone in hypospadias repair by assessing the rate of complications, especially urethrocutaneous fistula (UCF) formation.

PATIENTS AND METHODS

This is a prospective observational cross-sectional hospital-based study carried out at the Department of Paediatric Surgery, Ribat University Hospital, from June 2015 to November 2016. In Group A, there were 55 patients who underwent repair using polyglactin, and in Group B, there were 50 patients who underwent repair using polydioxanone. All patients were operated by the same surgeon.

RESULTS

The mean age of Group A was 5.7 ± 4.3 years and 5.1 ± 3.9 years in Group B. Meatal advancement and glanuloplasty incorporated operation was done in 47.6%, Tubularized incised plate urethroplasty in (31.4%), Theirsch-Duplay in 20% and Mathieu's repair in 1%. The complication rate was 34% in Group A and 10.9% in Group B. The most frequent complication was UCF, as 19 patients (18.1%) of the study candidates developed UCF; most of them were in Group A (14 patients) and 5 patients in Group B. Another significant complication was meatal stenosis, which occurred in 11 patients (10.5%): 9 in Group A and 2 in Group B.

CONCLUSION

Polydioxanone (PDS) is satisfactory in hypospadias repair as it is associated with better outcome, especially UCF, which is most common and most difficult to treat complication.

Comparison of interrupted- and continuous-suture urethroplasty in tubularised incised-plate hypospadias repair: A prospective study

Objective

To compare the effect of interrupted- and continuous-suture urethroplasty on complication rates in Snodgrass tubularised incised-plate (TIP) hypospadias repair.

Patients and methods

This was a prospective randomised study comprising 100 boys (age range 1–5 years) with primary subcoronal, distal- and mid-penile hypospadias who underwent repair from October 2010 to March 2015 in a tertiary care hospital. Boys with glanular, recurrent, and proximal hypospadias were excluded from the study. The boys were prospectively randomised into two groups: Group A, comprised 50 boys who underwent interrupted subcuticular suture Snodgrass TIP urethroplasty; and Group B, comprised 50 boys who underwent continuous subcuticular suture Snodgrass TIP urethroplasty. Outcomes were assessed in terms of complication rates and aesthetic appearance during follow-up.

Results

There was no significant difference in the occurrence of complications between the groups. There were 21 complications, with 10 occurring in Group A and 11 in Group-B. Urethrocutaneous fistula was the most common complication in both groups (six in Group A and seven in Group B), the fistulae were <2 mm in nine patients and 3–5 mm in the remaining four. Partial glans dehiscence occurred in one patient in each group. One patient from each group also had superficial wound infection, meatal stenosis and urethral stricture respectively, all of which were managed conservatively. The resultant urinary stream was single and good in all patients of both groups.

Conclusions

The type of suture technique had no significant effect on complication rates after Snodgrass hypospadias repair and thus the choice of technique depends on surgeon preference.

Complications of hypospadias surgery: Experience in a tertiary hospital of a developing country

BACKGROUND

Over 300 different operations have been described for the management of hypospadias. In recent times, the numbers of operations used in various centres have gradually reduced as the principles necessary to ensure adequate cosmetic and functional results with minimum complications are better understood. The aim of this article was to review the different types of operations used for managing hypospadias in a tertiary hospital in a developing country, to analyse the complications of surgery and discuss the factors that contribute to complications.

MATERIALS AND METHODS

Patient folders, theatre, and ward records were used to obtain the required information. The age at surgery, types of hypospadias at presentation, types of operations done and complications were analysed.

RESULTS AND CONCLUSION

With three main types of operations, tubularised incised plate urethroplasty and meatal advancement and glanuloplasty incorporated for anterior hypospadias (glanular, coronal, subcoronal, distal, midpenile), and lateral based flap urethroplasty for posterior hypospadias (proximal penile, penoscrotal, scrotal, perineal), most hypospadias were corrected with acceptable complication rates.

Effect of human urine on the tensile strength of sutures used for hypospadias surgery

INTRODUCTION

Hypospadias is the most common congenital condition affecting between 1 in 250 and 300 live births. Even in experienced hands, surgery to repair this congenital defect can have a high complication rate. Wound dehiscence is reported to occur in 5% and fistula formation in 6%-40% depending on technique. The choice of suture material has been shown to affect the complication rate although there is (currently) no consensus about the best suture material to use. Ideally, the sutures used for urethroplasty should be absorbable while maintaining sufficient mechanical strength to support the wounds until they are self-supporting and able to resist urinary flow. Previous studies have compared the effects of human urine on different suture materials especially catgut. However, catgut is now banned in Europe. Our study examined the tensile and breaking strength as well as rate of degradation for four types of absorbable suture now commonly used for hypospadias repairs in the UK.

MATERIAL AND METHODS

We examined the effect of prolonged storage (up to 27 days) in human urine on 6/0 gauge Vicryl, Vicryl Rapide, Monocryl and polydioxanone (PDS) sutures. These four suture materials are commonly used by the senior plastic consultant surgeon (NK) for hypospadias repairs. 50 mm sections of these suture materials were stored in either urine or saline as control. At specified time points, each suture was placed in a uniaxial load testing machine to assess the stress-strain profile and the mechanical load required to break the suture was measured.

KEY RESULTS

Exposure to urine reduced the tensile and breaking strength of all the suture materials tested. PDS demonstrated the greatest resilience. Vicryl Rapide was the weakest suture and degraded completely by day 6. Vicryl and Monocryl had similar degradation profiles, but Vicryl retained more of its tensile strength for longer.

CONCLUSIONS

There is a balance to be struck between the duration that a suture material must remain in any surgical wound and the risk that it causes foreign body effects. The results of this study suggest that Vicryl has the best characteristics for urethroplasty of the four suture materials tested.

Vascularized Dartos Flap in Conjunction with Tubularized Incised Plate Urethroplasty: Single versus Double Flaps for Management of Distal Hypospadias

OBJECTIVE

To compare the results of Snodgrass repair with single versus double vascularized dartos pedicle flap for neouretheral coverage.

PATIENTS AND METHODS

Fifty-eight pediatric patients with mean age 41.5 ± 21 months (range 9-96 months) underwent primary hypospadias repair, 39 uncircumcised and 19 circumcised, classified into 2 groups according to coverage of the neourethra. Single layer coverage (Group I) was performed in 28 (48.3%) while double layers coverage (Group II) was done in 30 (51.7%) cases.

RESULTS

After mean follow-up 8.6 ± 5.4 months (range 3-24 months), good cosmetic results with vertical slit like meatus at the tip of conical shaped glans were obtained in 53 cases (91.4%). Totally 5 cases occurred postoperative complications, of which 4 cases in Group I [2 (7.1%) with urethrocutaneous fistula, 1 (3.6%) with meatal stenosis and 1 (3.6%) with skin necrosis], 1 case in Group II [glanular dehiscence (3.3%)]. No fistula was observed in Group II.

CONCLUSION

The Snodgrass tubularized incised-plate repair in conjunction with double layer coverage of the neourethra could be considered the procedure of choice for distal hypospadias with low complications rate especially urethrocutaneous fistula.

General considerations in hypospadias surgery

Nonsystemic review of the literature was done for timing of surgery, preoperative evaluation and plan, anesthesia, suture materials, magnification, tissue handling, stent and diversion problems, intra and postoperative care, dressing, and follow-up protocol. The best time for hypospadias repair is between 6 and 18 months. Preoperative evaluation in proximal hypospadias includes hormonal and radiological examination for intersex disorders, as well as for upper tract anomalies along with routine evaluation. General anesthesia is a rule but local blocks help in reducing the postoperative pain. Magnification, gentle tissue handling, use of microsurgical instruments, and appropriate-sized stent for adequate period help in improving the results. Hormonal stimulation is useful to improve growth and vascularity of urethral plate and decrease the severity of chordee in poorly developed urethral plate with severe curvature. Urethral plate preservation urethroplasty with spongioplasty is the procedure of choice in both proximal and distal hypospadias. Algorithms are proposed for management of hypospadias both with curvature and without curvature. Two-stage urethroplasty has its own indications. A good surgical outcome may be achieved following basic surgical principles of microsurgery, fine suture materials, choosing one or two-stage repair as appropriate, proper age of surgery, and with good postoperative care. Future of hypospadiology is bright with up coming newer modalities like laser shouldering, robotics, and tissue engineering.

Acute postoperative complications of hypospadias repair

Purpose

Complications in hypospadias surgery are higher than other reconstructive procedures. The incidence of complications can be reduced if proper preventive measures are taken. The review aims to highlight incidences, causes, and preventive measures of acute complications of hypospadias repair.

Materials and Methods

Literature reports were reviewed in Pubmed by giving the key word acute complications of hypospadias repair, wound infection, wound dehiscence, flap necrosis, edema, penile torsion, urethral fistula, bleeding and hematoma and urethral stents problems. Summaries of all articles were reviewed with full text of relevant article and results were analyzed.

Results

Besides mentioning the complications of hypospadias repair in individual articles on the subject, we did not come across any separate article on this subject in the published English literature. Fistula is the commonest complication followed by edema and penile torsion.

Conclusions

Most acute complications can be prevented with adherence to principles of plastic and microsurgery, meticulous preoperative planning, and judicious postoperative care. Deviation from these principles may lead to disaster and even failure of the repair. The aim in hypospadias surgery should be following these principles and bring down the complication rates < 5% in distal hypospadias and < 10% in proximal hypospadias.

Effect of suturing technique and urethral plate characteristics on complication rate following hypospadias repair: a prospective randomized study

PURPOSE

We studied the effect of suturing technique and the impact of urethral plate characteristics on the complication rate following tubularized incised plate urethroplasty.

MATERIALS AND METHODS

We prospectively studied 80 boys (mean age 4.5 years, range 3 to 7) with primary hypospadias in a randomized fashion between January 2004 and May 2005. Of the patients 64 had anterior and 16 had mid penile hypospadias. Patients were allocated into 2 groups according to suture technique, with continuous sutures used in 40 boys and interrupted sutures in 40. We evaluated urethral plate depth, length and width before and after incision. Correlation between suture technique, plate type, width and length, and complication rate was performed.

RESULTS

Mean followup was 3 years. Success rates were 90% and 69% for anterior and mid penile hypospadias, respectively (p = 0.037). Complications developed in 11 patients (13.8%) and consisted of fistula (8), dehiscence (2) and meatal stenosis (3). On univariate analysis the suture technique, depth and length of urethral plate, width after incision and presence of hypoplasia had no impact on complication occurrence. However, urethral plate width before incision was significantly related to complication occurrence (p = 0.048).

CONCLUSIONS

Suture technique has no influence on the outcome of tubularized incised plate urethroplasty. Urethral plate characteristics do not affect the complication rate except for plate width, which significantly affects the outcome. Adequate urethral plate width (8 mm or greater) is essential for successful tubularized incised plate repair.

A prospective randomized comparative study on the use of ventral subcutaneous flap to prevent fistulas in the Snodgrass repair for distal hypospadias

We evaluated the importance of urethral coverage using vascularized subcutaneous ventral flaps for the prevention of fistulas in patients undergoing distal hypospadias repair. Our prospective study included 130 patients, aged 9 months to 12 years, who underwent distal hypospadias repair using tubularized incised plate urethroplasty (TIPU), from January 2001 through January 2006. Patients were assigned to one of two groups by a computer-generated random selection: 65 patients underwent non-covered urethroplasty (NCU group); another group of 65 patients underwent covered urethroplasty (CU group) with a vascularized subcutaneous ventral flap. The results were evaluated by two pediatric surgeons unaware of the type of treatment each patient had undergone. Successful results were achieved in 99/130 patients (76.2%). We recorded 31 (23.8%) post-operative complications: 20 patients presented with a urethrocutaneous fistula (15 patients in the NCU group and 5 in the CU group); five with urethral stenosis (3 in the NCU and 2 in the CU group); and six with skin dehiscence of the preputioplasty (3 patients in each group). We analyzed the results using the chi2 test and the only statistically significant difference between the two groups (p < 0.05) was in terms of incidence of fistulas. Urethrocutaneous fistulas seem to be the most frequent complication of distal hypospadias after TIPU repair. Urethral coverage should be part of the Snodgrass procedure because it significantly reduces the formation of fistulas. A well-vascularized subcutaneous ventral flap represents, in our experience, a simple and optimal choice for the prevention of fistulas.

Repairing urethrocutaneous fistula in adults: is a catheter necessary?

OBJECTIVES

To demonstrate that urethrocutaneous fistulas can be repaired under local anesthesia in adult patients without catheters.

METHODS

From 1998 to 2006, 96 patients with urethrocutaneous fistulas underwent repair under local anesthesia. The patients were divided into two groups in terms of whether they did or did not have a catheter placed. The catheterized group included 45 patients and the uncatheterized group included 51 patients. The uncatheterized patients were discharged on the operation day, and the catheterized patients were discharged 1 to 4 days postoperatively. Patients were reevaluated on the 7th postoperative day and after 3 months in terms of wound infection, urethral stricture, and fistula recurrence.

RESULTS

All patients tolerated the fistula repair well under local anesthesia. The success rate of fistula repair was 93.3% and 94.1% in the catheterized and uncatheterized groups, respectively. Wound infection was seen in 6 patients in the first group but was not noted in the uncatheterized group. Fistulas recurred in 3 patients in each group (6.6% and 5.8%) after 3 months postoperatively.

CONCLUSIONS

Catheterless fistula repair with local anesthesia in adults is an effective, safe, and inexpensive procedure.

Factors affecting the outcome of foreskin reconstruction in hypospadias surgery

OBJECTIVE

Despite ongoing refinement of numerous techniques, the incidence of complications following hypospadias repair is still significant. The aim of this study is to evaluate the factors that affect the success in childhood of foreskin reconstruction with hypospadias repair.

MATERIALS AND METHODS

A retrospective study was carried out of all primary hypospadias repairs with foreskin reconstruction (n=408) over the last 23 years. The hypospadias was coronal in 160 (39%), glanular in 114 (28%), subcoronal in 78 (19%) and distal penile in 56 (14%) cases. Foreskin reconstruction was included in 362 cases suitable for a meatal advancement (191) or distal urethral tubularization (171), and 46 cases for a flip-flap procedure (37 Mathieu, nine Barcat). Outcome analysis was of foreskin-related complications post surgery.

RESULTS

Foreskin repair was successful in 333 cases (92%) that underwent meatal advancement/distal urethral tubularization, and 33 (72%) that underwent a flip-flap operation. Complications related to the foreskin occurred in 10% of the whole group with a urethral fistula rate of 8%. The median age at surgery was 13 months (2-120 months), and the median follow-up period was 11 months (1-100 months).

CONCLUSIONS

A good cosmetic and functional outcome can be achieved with foreskin reconstruction combined with a variety of hypospadias repairs. The outcome in this series was better in cases of distal hypospadias using interrupted polyglactin sutures.

Use of Fibrin Sealant in Hypospadias Surgical Repair Reduces the Frequency of Postoperative Complications

INTRODUCTION

Urethrocutaneous fistulas (UCF) and flap dehiscence (FD) are the most common postoperative complications after hypospadias (HS) surgical repair. The aim of this study was to evaluate whether the application of fibrin sealant over the site of surgery and suture lines reduces these complications.

MATERIALS AND METHODS

A prospective cohort of consecutive patients was treated over a 3-year period. 30 patients were submitted to HS surgical repair plus application of fibrin glue over the suture line and surgical site; for comparison, another 56 subjects made up the control group which was submitted to surgical repair only. Variables assessed included: age, type of HS, fibrin sealant used, complications and number of surgical procedures required to treat recurrences.

RESULTS

In general, the frequency of complications was 10 vs. 41% for UCF (p = 0.002), 13 vs. 50% for FD (p = 0.001), and for flap necrosis (FN) 6.7 vs. 28.6% (p = 0.01) for the treatment and control groups respectively. The number of surgical reinterventions to treat recurrences was higher in the control group than in the study group (p = 0.04).

CONCLUSION

The incidence of UCF after HS surgical repair can be reduced by applying fibrin sealant over the site of surgery and the suture lines.

Modified tubularized incised plate urethroplasty (Snodgrass) procedure for hypospadias repair

OBJECTIVES

To report the outcomes in a large series using a modified tubularized incised plate (TIP) urethroplasty (Snodgrass) technique with a local de-epithelialized skin flap to cover the urethroplasty. The use of the TIP urethroplasty (Snodgrass) technique has gained wide acceptance among pediatric urologists for the correction of hypospadias repair because of its good cosmesis, low complication rate, and reliability in creating a vertically oriented meatus.

METHODS

A total of 101 boys, aged 6 months to 3 years, with distal (n = 85), mid-shaft (n = 8), or proximal (n = 8) hypospadias underwent one-stage repair using a modified TIP repair with a local de-epithelialized skin flap to cover the urethroplasty. Charts were reviewed for each patient to determine the complications, reoperations, cosmesis, and functional results after surgery.

RESULTS

With at least 6 months of follow-up, all patients had achieved excellent functional and cosmetic results, with the meatus at the tip of the penis on follow-up. Three repairs for meatal stenosis and two for fistula were needed.

CONCLUSIONS

The modified TIP procedure is a safe and reliable technique. It provides excellent cosmesis with a low reoperation rate.

Suture materials: do they affect fistula and stricture rates in flap urethroplasties?

INTRODUCTION

The effect of suture materials on urethroplasty complications is debated. Indeed, materials with a delayed absorption might either reduce the incidence of fistulas by ensuring a prolonged approximation of neo-urethral edges or increase the risk of urethral strictures due to a prolonged tissue reaction during suture absorption. We retrospectively evaluated the role of suture materials in the complication rate of urethroplasty procedures performed in our institution over a 10-year period.

PATIENTS AND METHODS

Three hundred and thirty-six boys undergoing a flap procedure (parameatal based, preputial tube, or onlay preputial flap) for hypospadias repair were considered for this study. The patients were stratified into two groups according to the suture material used for urethroplasty. Polyglactin (Vicryl), a polyfilament with intermediate absorption, was used in 254 group A patients, whereas polydioxanone (PDS), a monofilament with prolonged absorption, was used in 82 group B patients. The success of a one-stage repair and stricture and fistula rates were evaluated.

RESULTS

A successful one-stage repair was achieved in 82% of the group A and in 83% of the group B patients (p = 0.97). No statistically significant differences were noted in fistula and/or stricture rates in the two groups, even considering each procedure separately.

CONCLUSIONS

This series suggests that suture materials do not affect the complication rate in flap urethroplasty procedures. Appropriate technique, meticulous surgery, and surgeon experience seem to be more crucial factors. A randomized trial is warranted.

Snodgrass hypospadias repair with ventral based dartos flap in combination with mucosal collars

OBJECTIVE

In this study, we report our results of Snodgrass hypospadias repair in conjunction with use of ventral based vascularized dartos flaps. In all repairs, mucosal collars were created and incorporated into the repair to create a more normal appearing circumcised penis, as described by Firlit.

PATIENTS AND METHODS

Records of 60 patients with distal or mid-penil hypospadias who underwent standard Snodgrass repair were evaluated. During circumscribing incision mucosal collars were preserved and used to create a normal appearing circumcision line. A ventral based vascular dartos tissue was preserved as a flap and used as a second layer to cover the entire neourethra before glans closure.

RESULTS

All repairs were completed in 1 stage. Mean follow-up was 10.5 months (3-37 months). There were 5 (8.3%) cases of fistula and 6 (10%) cases of meatal stenosis. All patients with fistula formation had meatal stenosis. All patients, except for patients with fistula and/or metal stenosis, were voiding a straight stream and have a slit like meatus with cosmetically normal looking circumcised penis.

CONCLUSION

Ventral based flaps are easier to harvest and transpose to cover the neourethra. Combining repairs with mucosal collars enhances the cosmetic results and makes the ventral flap harvesting process easier.

Successful hypospadias repair with ventral based vascular dartos pedicle for urethral coverage

PURPOSE

We describe an easy technique to reliably harvest a vascularized dartos pedicle for urethral coverage at the time of urethroplasty in hypospadias surgery. The complication of urethrocutaneous fistula in hypospadias surgery as a result of using this technique is also evaluated.

MATERIALS AND METHODS

A retrospective review (July 1999 to September 2002) identified 180 pediatric patients who had undergone primary hypospadias surgery by a single surgeon. A modified technique of harvesting a vascularized dartos pedicle was incorporated in 111 hypospadias repairs. A ventral based vascularized dartos pedicle of tissue was used to cover a modified urethroplasty as described by Snodgrass.

RESULTS

The intraoperative meatal position before urethroplasty was subcoronal in 95 cases, penile/midshaft in 11 and penoscrotal in 5. The majority of patients (90 of 111) were younger than 12 months at surgery. Ages ranged from 5 months to 16 years (mean 21.1 months). Of the 111 patients reconstruction using the ventral based vascularized dartos pedicle to cover the urethroplasty was successful in 109 (98.2%), and at followup they have an acceptable cosmetic result with no evidence of urethrocutaneous fistula. In 1 patient with distal hypospadias a urethrocutaneous fistula developed, which was recognized 20 months postoperatively. Another patient with penoscrotal hypospadias had a proximal fistula at 6 months. There were no recognized intraoperative urethral injuries or complications. Followup ranged from 3 to 38 months (mean 19.1).

CONCLUSIONS

The ventral based vascularized dartos pedicle urethral coverage procedure is an easy and reliable technique to harvest adequate vascularized tissue to cover a hypospadias urethroplasty. In this small single surgeon series, this technique appears to have contributed to a low rate of urethrocutaneous fistulas after hypospadias repair.

Outpatient urethrocutaneous fistula repair with local anesthesia in adult patients

The aim of this prospective study was to demonstrate that urethrocutaneous fistulas could be repaired under local anesthesia in adult patients without catheters. Between 1998 and 2000, 32 patients with urethrocutaneous fistulas were repaired under local anesthesia. The patients were divided into two groups in terms of whether they did or did not have catheters. The catheterized group (group I) included 15 patients and the uncatheterized group (group II) included 17 patients. Although the uncatheterized patients were discharged the same day as their operation, catheterized patients were discharged 4 to 6 days postoperatively. Patients were reevaluated on postoperative day 7 and month 3 in terms of wound infection, urethral stricture, and recurrence of fistula. All patients tolerated the fistula repair under local anesthesia. The success rate of fistula repair was 93.3% and 94.1% in the catheterized and uncatheterized groups, respectively. During postoperative days 1 through 7, wound infection was seen in 2 patients in group I but was not noted in the uncatheterized group. Fistulas recurred in one patient from each group (6.6% and 5.8%, respectively) after 3 months postoperatively. As a result, the authors suggest that catheterless fistula repair with local anesthesia in the adult age group is an effective, safe, and inexpensive procedure.

Current trends in hypospadias repair

There is no single, universally applicable technique for hypospadias repair. Command of a technically straightforward repair with few complications and proven success and versatility in a reasonable range of hypospadias defects are desired goals. Several well-established techniques exist for the repair of all hypospadias defects. The Snodgrass tubularized incised plate urethroplasty, a recent contribution with exemplary early results, has become a popular technique for primary and preoperative repair of middle and anterior hypospadias. Other innovative modifications, and technical advances, such as the use of laser and tissue solder, continue to emerge. With time, these may herald improvements to even the most basic of sound principles involved in all hypospadias repair.

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.