Comparison of onlay and tubularized island flaps of inner preputial skin for the repair of proximal hypospadias

Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures

Background

Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra.

Objective

To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction.

Design, setting, and participants

Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study.

Surgical procedure

The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula.

Measurements

Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure.

Results and limitations

We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5–8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5–26 ml/min). The median follow-up was 25 mo (IQR 10–30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique.

Conclusions

In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra.

Patient summary

Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.

Reconstructing forked corpus spongiosum to correct glans droop in distal/midshaft hypospadias repair

Purpose

We reviewed our experience and efficacy of reconstruction of a forked corpus spongiosum (FCS) to correct glans droop in distal/midshaft hypospadias repair.

Methods

Eighty-five consecutive patients who underwent distal/midshaft hypospadias repair by the same surgeon in our center from October 2015 to June 2018 were retrospectively analyzed. All cases were accompanied by different degrees of glans droop, which we corrected by cutting off and reconstructing the FCS along the plate. We recorded the degrees of glans droop, development of the FCS, and postoperative complications including residual chordee, fistula, diverticulum, glans dehiscence, meatus stenosis, and urethral stricture.

Results

The follow-up period ranged from 5 to 37 months (mean, 19.7 months). Two patients (2.3%) developed a coronal fistula and underwent a second repair. Two patients (2.3%) developed a mild urethral diverticulum and underwent continued observation. One patient (1.2%) developed a meatus stenosis that resolved after 1 month of meatus expansion combined with external mometasone furoate. No patients developed postoperative residual chordee or urethral stricture.

Conclusions

The degree of glans droop is closely associated with the development of an FCS. Reconstructing the FCS to correct the glans droop can yield satisfactory outcomes and should be popularized in distal/midshaft hypospadias repair.

Preoperative Topical Estrogen Treatment vs Placebo in 244 Children With Midshaft and Posterior Hypospadias

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.

Double-face preputial island flap revisited: is it a reliable one-stage repair for severe hypospadias?

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.

Single stage circumferential lingual mucosal graft urethroplasty in near obliterative bulbar urethra stricture: A novel technique

Aims:

This is a prospective study of the use and efficacy of a novel technique of circumferential tubularised lingual mucosal graft (LMG) in obliterative and near obliterative bulbar urethral stricture of >2 cm where excisional and augmented anastomotic urethroplasty are not feasible.

Materials and Methods:

The stenotic urethral segment was opened dorsally in midline and fibrosed urethra was excised taking care to preserve the healthy spongiosum tissue. LMG (av. Length 3 cm) was placed from one end of corporal body towards spongy tissue in a circumferential manner. Another LMG was placed in similar manner to deal with longer stricture. The urethra was tubularised over 14 Fr silicone catheter.

Results:

A total of 12 men, of mean age 47 years underwent this procedure. The mean follow up period was 11 months starting from July 2014 till manuscript submission. Follow up included voiding cystourethrogram at 3 weeks, cystoscopy at 3 months (one patient didn’t turned up) and subsequent follow up. Mean stricture length was 4.66 cm (range, 3–8.5 cm) and mean operative time was 195 min. (range, 160 to 200 min.). The technique was successful (normal voiding with no need for any post-operative procedure) in 11(91.6%) patients. One patient developed early recurrence at 4 month of surgery and had anastomotic stricture which was successfully managed by direct visual internal urethrotomy.

Conclusion:

Single stage circumferential tubularised graft urethroplasty is an excellent technique for strictures that include segments of obliterative and near obliterative diseased urethra. It provide a wider neourethra than patch graft urethroplasty.

The Use of Flaps and Grafts in the Treatment of Urethral Stricture Disease

The use of various grafts and flaps plays a critical role in the successful surgical management of urethral stricture disease. A thorough comprehension of relevant anatomy and principles of tissue transfer techniques are essential to understanding the appropriate use of grafts or flaps to optimize outcomes. We briefly review these principles and discuss which technique may be best suited for a given anterior urethral stricture, depending on the location and length of the stricture, the presence or absence of an intact corpus spongiosum, and the availability of adequate and healthy penile skin.

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias

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.

Single-stage repair of hypospadias using longitudinal dorsal island flap: Single-surgeon experience with 102 cases

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.

Hypospadias repair: an overview of the actual techniques

Hypospadias is one of the most common congenital genital anomalies for which surgery early in life is indicated. The surgical treatment is changing progressively, often by repeating treatment strategies that have been used decades ago. Indeed, historically two-stage procedures were replaced by one-stage procedures and nowadays two-stage procedures gain new interest. The same for reconstructions using the urethral plate, which decades ago were based on the Thiersch Duplay principle. In the 1980s, preputial onlay flaps were most often used and today we see a new interest in the use of the urethral plate. The actual surgical approach to hypospadias is described and technical details are given.

The role of flaps and grafts in modern hypospadiology

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.

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.

Two-stage repair for proximal hypospadias: a reappraisal

Great advances have been made in surgery for the correction of hypospadias. Proximal hypospadias remains the greatest challenge, but, despite many innovations and much progress, surgery can fail. Many authorities have introduced single-stage techniques, which have the purported advantage of correcting the defect with minimal hospitalization and family inconvenience. However, the wider published experience with these approaches would suggest that the ideal single-stage procedure has yet to be devised. A substantial number of children undergoing a single-stage procedure will have to undergo further surgery. A small, but irreducible number of patients will be rendered hypospadias "cripples." A number of these children will be dissatisfied as adults because of cosmetic or functional deficiencies. A two-stage approach for correction of proximal hypospadias and severe chordee remains the most credible and reliable solution for many of these patients. Pediatric urologists should maintain familiarity with these techniques and continue to advocate them for a select group of patients.

Clinical experiences with different one-staged surgical methods for primary hypospadias cases

The success of various types of operations for primary hypospadias was assessed taking the location of meatus and the degree of chordee as the basis. Totally 258 patients with primary hypospadias were operated: 94 by meatal and urethral advencement, 110 by perimeatal flap and tube repair and 54 by preputial flap. The rates of success in cases with meatal advencement, perimeatal flap and preputial flap were found as 88%, 81% and 66% respectively. The success of treatment in hypospadias cases is closely related to the age of the patient, the experience of the surgeon and the choice of an appropriate method. However, the presence of chordee and the proximally located meatus are among the leading factors that influence the rate of success.

One-stage repair of moderately severe hypospadias using a transverse preputial tubularized island flap

BACKGROUND

Transverse preputial tubularized island flap (TPTIF) urethroplasty has been used for the repair of moderately severe hypospadias since Duckett described the procedure in 1980. In spite of the excellent results reported by Duckett, subsequent studies showed high complication rates. A TPTIF procedure modified to reduce the complication rate is presented.

METHODS

Between 1996 and 1997, 13 boys with moderately severe hypospadias were repaired with the TPTIF procedure. Patient age ranged from 10 months to 3 years with an average age of 23 months. To prevent urethrocutaneous fistula, the neourethra was constructed with a two-layer closure and the portion of anastomosis was wrapped between the native urethra and the neourethra with the tissue of the corpus spongiosum.

RESULTS

The moderately severe hypospadias was repaired without complication in 12 of 13 patients. A urethrocutaneous fistula developed at the midshaft of the penis in one patient. No meatal stenosis, urethral stricture or diverticulum developed.

CONCLUSION

Transverse preputial tubularized island flap urethroplasty provided excellent cosmetic and functional results for moderately severe hypospadias, and postoperative complications could be decreased by the two-layer closure of the neourethra and application of the wrapping technique of the proximal anastomosed portion with corpus spongiosum tissue.