One-stage hypospadias repair. Experience with 544 cases

Hypospadias: A Comprehensive Review Including Its Embryology, Etiology and Surgical Techniques

Hypospadias is among the most prevalent urogenital malformations in male newborns. It is characterized by the displacement of the urethral meatus to the ventral side of the penis, an aberrant ventral curve of the penis referred to as "chordee," and an abnormally arranged foreskin with a "hood" found dorsally and lacking foreskin ventrally. Patients may have an extra genitourinary abnormality based on the area of the lesion. In around 70% of cases, the urethral meatus is positioned distally to the shaft, representing a milder form of the disease. The remaining 30% of cases are located proximally, are more complicated, and require further evaluation. Although the origin of hypospadias is mostly obscure, several suggestions exist about genetic susceptibility and hormonal factors. The objective of hypospadias restoration is to restore aesthetic and functional regularity, and surgery is currently advised at a young age, mostly between six and 18 months. At any age, hypospadias can be repaired with an equivalent risk of complications, functional outcomes, and aesthetic outcomes. However, the best age of treatment is still undetermined. Even though the long-term effects on appearance and sexual function are usually good, males may be less likely to make the first move after rectification. Also, people who have hypospadias treated are twice as likely to have problems with their lower urinary tract. These problems can last for years after the initial repair.

MAGPI under local anaesthesia without catheter as an alternative to standard TIP procedure in distal hypospadias repair

To evaluate the surgical outcomes of meatal advancement and glanuloplasty incorporation (MAGPI) and tubularised incised plate (TIP) urethroplasty. We retrospectively reviewed the patient records who had hypospadias repairing surgery between March 2017 and March 2020 in terms of age, meatal position, operative and anaesthesia techniques and surgical outcomes. Hypospadias repair was performed in 85 patients. TIP urethroplasty was performed in 17 patients where MAGPI was performed in 63 patients. Preoperative meatal stenosis was present in 10. Coronal glanular and subcoronal hypospadias were present in 65 and 15 patients respectively. Mean operative time was 41.3 ± 28 min. The mean duration of the catheter was 7.56 days. A significant chordee was present in 35 patients where 45 patients had no chordee. The overall success rate was 93.75%. MAGPI ended up with an unfavourable result in 1 and TIP urethroplasty in 4. Postoperative urethral stenosis was seen in 1. Of those who ended up with an unfavourable result, 4 were with subglandular hypospadias. Urethral catheter required in 4 of those who failed, whereas 1 had no catheter following surgery. Therefore, MAGPI is a useful method in selected glandular and subglandular hypospadias repair with favourable surgical outcomes including no stent requirement.

Management of High-Grade Penile Curvature Associated With Hypospadias in Children

Penile curvature is a frequent feature associated with hypospadias with also a great variability of severity among each patient. While the low-grade curvature (<30°) can be relatively easily corrected by simple techniques like penile degloving and dorsal plication, severe cases often demand more complex maneuvers to manage it. A great number of surgical techniques have been developed to adequately correct curvatures greater than 30°; however, each one of them should be individualized to different patients and local conditions encountered. In this article, we will review the evaluation of the pediatric patient with penile curvature associated with hypospadias with a special attention to high-grade cases, their management, indications for surgical treatment, and several surgical options for their definitive treatment.

Risk factors for the development of urethrocutaneous fistula after hypospadias repair: a retrospective study

Purpose

The purpose of this study was to investigate the risk factors for urethrocutaneous fistula development after hypospadias repair.

Materials and Methods

Between January 1990 and May 2010, 348 patients underwent hypospadias repair. This study included 294 patients who were followed up for more than 6 months. Potential risk factors for the development of fistula after operation included age, location of hypospadias, type of hypospadias repair, suture materials and methods, methods and duration of catheterization, combined congenital urologic disorders, timing of presentation and repair of fistula, and location of fistula. Data were analyzed retrospectively. Binary logistic regression analysis was used for univariate and multivariate analysis.

Results

Out of 294 patients, 63 patients (21.4%, 63/294) developed urethrocutaneous fistulas after hypospadias repair. In the univariate analysis, fistula formation was statistically related with type of hypospadias and type of hypospadias repair. In the multivariate analysis with stratification by hypospadias site, however, only the location of hypospadias was a significant independent risk factor in urethrocutaneous fistula development after hypospadias repair (p<0.001).

Conclusions

Our results suggest that the risk of developing urethrocutaneous fistula after hypospadias repair is associated with the location of hypospadias (more proximal-type hypospadias). Type of hypospadias repair, suture materials, suture techniques, and number of other combined urologic disorders were not related to the development of urethrocutaneous fistulas.

Outcomes in distal hypospadias: a systematic review of the Mathieu and tubularized incised plate repairs

AIM

To compare complication rates after distal hypospadias surgery using the tubularized incised plate (TIP) and Mathieu techniques.

METHODS

For this meta-analysis, the Medline (1990-2009), Embase (1990-2009) and Cochrane databases were searched using the keyword 'hypospadias'. Inclusion criteria were: i) primary repairs; ii) distal hypospadias; iii) paediatric case series; iv) standard Mathieu and TIP techniques; v) complication data obtainable from the paper. Cases were only included in the denominator for each complication if explicitly identified in the paper. Fisher's exact was used for statistical analysis, with P < 0.05 considered significant.

MAIN RESULTS

129 papers were selected for full analysis; 23 papers met the inclusion criteria comprising 1872 TIP repairs and 1496 Mathieu repairs. We identified an increased incidence of urethral fistulae with the Mathieu technique (3.8% vs 5.3%, P = 0.028); however, this is lost on subgroup analysis. An increased incidence of meatal stenosis was identified in the TIP group (3.1% vs 0.7%, P < 0.001).

CONCLUSIONS

There is no clear consensus on the ideal method of repair for distal hypospadias. Both the Mathieu and TIP techniques have been shown to have low rates of postoperative complications. Comparison between series is difficult because of a lack of consistency in reporting complications and follow up. We advocate uniform standards for reporting outcomes of hypospadias.

Urethrocutaneous fistula after hypospadias repair: outcome of three types of closure techniques

OBJECTIVE

To evaluate the outcomes of three surgical techniques for the closure of urethrocutaneous fistula (UCF) after hypospadias repair.

MATERIALS AND METHODS

Fifty-one patients (mean age 6.5 years) who underwent UCF closure between June 1998 and February 2008 were divided in to three groups depending on fistula size; group I had <2 mm and (n = 17, 33.4%), group II had 2-4 mm (n = 21, 41.2%) and group III had >4 mm or multiple fistulas (n = 13, 25.4%). Group I patients were treated by excision and simple closure. Patients in group II and III were treated with flip flap technique along with the wrapping of repaired area with scrotal dartos flap and tunneled tunica vaginalis flap (TVF), respectively.

RESULTS

Mean surgical time was 45 min (range 30-55), 60 min (range 50-75) and 80 min (range 60-100) in three techniques, respectively. The mean follow-up was 3.5 years (range 6 months-10 years). No patient had recurrence of fistula in group III, while 2 (9.5%) and 4 (25.4%) patients in groups II and I, respectively, had recurrent UCF. No postoperative complications were encountered in the testis or the scrotum. No patient had torsion or deviation of penis.

CONCLUSION

Simple fistula closure carries a higher risk of recurrence even in small sized fistulas. The application of scrotal dartos or TVF for wrapping the repaired area gives excellent results and they are easy to harvest with no harmful effects on the scrotum or testis.

Hypospadias repair in a resource-poor region: coping with the challenges in 5 years

OBJECTIVE

To report the challenges and outcomes of hypospadias repair in a developing country such as Nigeria.

PATIENTS AND METHODS

This was a prospective study of children who underwent hypospadias repair at the University of Benin Teaching Hospital in 2003-2007. The challenges and outcome of repair were documented with photographs to assess cosmetic results.

RESULT

A total of 149 operations were performed on 127 children with hypospadias, aged between 9 days and 12 years (mean 2.3 years+/-2.1) with 33 (26.0%) presenting after circumcision; 118 (92.9%) were single and 9 (7.1%) multistage, while 13 had closure of post-hypospadias repair fistulae and redo surgery. Non-availability of suitable pediatric urethral catheters, special dressing materials and microsurgical instruments/sutures, presentation after circumcision, and lack of parents/caregivers' motivation were major challenges. Transurethral urinary diversion, dressing with petroleum jelly impregnated with antibiotic/chloramphenicol ointment, mosquito forceps, scrotal skin flaps, size 6/0 polyglactin sutures, and organized counseling/home visits were employed. Repair was successful in all the children: excellent cosmetic results in 121 (95.3%), fair in 5 (3.9%) and poor in 1 (0.9%). Urethrocutaneous fistula was the main complication with no mortality recorded.

CONCLUSION

Despite the challenges, improvising with available materials, counseling of parents/caregivers, adequate patient recruitment and appropriately timed repairs gave encouraging results.

[Salvage strategies after complications of hypospadias repair]

The complication rate of hypospadias repair still ranges between 20 and 30%, although operative skills and technical devices have improved. Different aspects like dressing are important for prevention of complications. Early complications are bleeding, hematoma, and infection. Late complications are fistulas, meatal stenosis, partial and complete breakdown, persisting curvature, a hairy urethra, and hypospadias cripples. Detailed preoperative diagnostics are important. There are several operative techniques that can be used for repair including the use of mesh graft or foreign material. Two or multiple stages are often needed. The surgery to correct complications after hypospadias repair is a challenge, which should only be done by an experienced surgeon.

[Hypospadias repair with Snodgrass' technique]

Retrospective study of 124 patients (average age: 3.8 years) with midpenile hypospadias: 48.3% (60 children), distal penile: 45.9% (57) and coronal 5.6% (7), of which the 25.8% (16) presented ventral curvature and the 4.8% (6) resulting from the complication of another previous technique. All of them were operated according to Snodgrass' technique, removing the catheter between the 6th and 7th day in most of them. The global rate of complications was of 12%: 9 fistulae (7.2%) and 6 meatal stenosis (4.8%). Aesthetic result was satisfactory in all cases, getting glans covered by foreskin in 57.3%.

Urethral Advancement and Glanuloplasty with V Flap of the Glans in the Repair of Anterior Hypospadias

BACKGROUND

Hypospadias is a common urethral anomaly in boys. More than 65% of hypospadias cases are anterior (glanular, coronal and distal penile shaft). More than 200 original techniques have been applied to correct hypospadias. Each of these techniques has some complications, the most common of which are fistula and meatal stenosis.

METHODS

A total of 74 boys with anterior hypospadias underwent the procedure of urethral advancement and glanuloplasty (UAGP) with V flap of the glans in our medical centres between March 1994 and March 2000. The procedure included degloving, correction of chordee, urethral mobilization and glans plasty.

RESULTS

Cosmetic results were excellent in most patients. There was no fistula, and meatal stenosis was also not observed after applying V flap of the glans. In a 1-6-year follow-up (mean +/- SD, 3.15 +/- 1.79 years), the results, functionally and cosmetically, were satisfactory in all cases, with no long-term complication or chordee.

CONCLUSION

Our findings suggest that UAGP is an excellent technique for repairing anterior hypospadias with satisfactory results and low complication rate.

[Concepts for correction of penile hypospadias]

The repair of penile hypospadias encompasses correction of the penile curvature, urethral reconstruction, glanuloplasty, and coverage of the penile shaft with skin. A straight penis can be achieved by chordectomy alone or in combination with a dorsal plication technique (Nesbit and modifications). For urethral reconstruction, pedicled foreskin flaps, incision of the urethral plate with subsequent tubularization (Snodgrass, TIP procedure) as well as free buccal mucosa onlays have been used. The operative technique of the respective procedures with their results obtained are described and discussed. The pedicled onlay flap with a complication rate of up to 22% in larger series is the most commonly used technique. Comparable results can be obtained with the free buccal mucosa graft. Long-term data are lacking for final evaluation of the TIP procedure published by Snodgrass.

Comparison of two methods--Mmathieu and Snodgrass--in hypospadias repair

INTRODUCTION

Perimeatal flap (Mathieu) and tubularized incised-plate (Snodgrass) methods were compared regarding success rate, postoperative complications, and cosmetic appearance in primary and recurrent distal hypospadias cases with normal urethral plates.

PATIENTS AND METHODS

Between 1995 and 2001 Snodgrass-type repair was done in 32 primary and in 24 recurrent hypospadias cases (total 56 patients; mean age 5.8, age range 3-17 years), and Mathieu-type repair was done in 33 primary and in 21 recurrent distal hypospadias cases (total 54 patients; mean age 5.2, age range 2-19 years). There was no statistically significant difference between groups regarding demographics. Patients with primary hypospadias either without or with minimal chordee and patients with recurrent hypospadias only with a normal urethral plate were included in the study. The mean postoperative follow-up period was 24 months.

RESULTS

Meatal stricture formation, fistula formation, wound dehiscence, and flap necrosis were seen in 2, 4, 4, and 2 patients, respectively, treated with the Mathieu technique and in 5, 4, 3, and 0 patients, respectively, treated with the Snodgrass technique. Wound dehiscence and flap necrosis were seen less frequently, whereas meatal stenosis was more common in the Snodgrass group (p < 0.05, p < 0.05, and p > 0.05, respectively; chi(2) test). There was no difference between groups regarding fistula formation. Mean hospital stay, time to stent withdrawal, and urinary diversion period were shorter in the Mathieu group (7.5 +/- 1.19 vs. 5.7 +/- 1.38 days, 7.1 +/- 0.67 vs. 5.4 +/- 0.85 days, and 14.1 +/- 1.17 vs. 10.2 +/- 1.72 days, respectively; p < 0.001 for all). The total success rates were similar (78.6% in the Snodgrass group and 77.8% in the Mathieu group). Cosmetic appearance was highly satisfactory in the Snodgrass group.

CONCLUSIONS

We believe that the Snodgrass method should be preferred for primary and recurrent hypospadias cases without chordee or with minimal chordee and with a normal urethral plate due to its lower complication rate and its satisfactory cosmetic appearance. However, when a healthy urethral plate is not available, Mathieu-type repair can be preferred.

Rabbit urethra replacement with a defined biomatrix or small intestinal submucosa

OBJECTIVE

The evaluation of collagen-based biomatrix (SIS COOK((R))) in comparison to a biochemically reconstructed biomatrix for replacement of the urethra in a rabbit model as a preclinical model.

MATERIAL AND METHODS

Rabbits underwent partial urethra replacement (resection of 0.5 to 1.0 cm segment of the urethra), which was replaced with 1 or 4 layers Small Intestinal Submucosa (SIS COOK) patch grafts or with a biochemically defined collagen biomatrix, partly sutured with unresolvable sutures for future reference. Six animals underwent a sham control operation. The grafts of regenerated urethras were harvested at 1, 3 and 9 months after implantation. Urethrography was performed pre-operatively and before sacrificing. The animals were evaluated macroscopically and by routine histology and immunohistochemistry.

RESULTS

At 1 month after implantation, the biomatrices (1 layer, 4 layers and our biochemically defined biomatrix) were well distinguishable from the normal surrounding tissues and showed blood vessels at the periphery. Macroscopically, the unresolvable reference sutures were easy to find at all time points. At 3 months the graft was still distinguishable in the 4 layers SIS group. In the 1 layer and the defined biomatrix group a good regeneration of the urethra within the graft was seen with some central fibrosis. Histological and immunohistochemical evaluation showed urothelium regeneration on the 1 layer and on biochemically defined biomatrix with decreasing number of inflammatory cells from 1 month on. In the group treated with 4 layers SIS the urothelium was completely regenerated at 3 months. Histologically, the regeneration of muscle cells in the three biomatrices was comparable. The smooth muscle cells regenerated very slowly as 1 month after implantation no muscle cells were detectable within the grafts. At 3 months a few muscle cells were present in the graft, but cell density did not increase in the following 6 months. Strictures were not observed on control urethrography pre-operatively in the animals. In one case slight narrowing of the urethra on urethrography was seen, but apparently without causing voiding problems. One rabbit developed a fistula near the operation site.

CONCLUSION

The biomatrices investigated are feasible scaffolds to repair urethral lesions. The results with our biochemically defined biomatrix are comparable to one layer Small Intestinal Submucosa. Almost no smooth muscle cells population was observed after nine months for the three biomatrices. We conclude that an improved molecularly defined biomatrix focussed on stimulation of smooth muscle cell growth may be necessary to obtain optimal cellular grafting results.

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.

Onlay island flap urethroplasty: a comparative analysis of primary versus reoperative cases

OBJECTIVES

To compare the outcome of the onlay technique in cases with an untouched urethral plate (group 1) and patients who had undergone previous hypospadias repairs (group 2).

METHODS

The records of the 50 patients undergoing onlay island flap urethroplasty in the past 10 years were reviewed. The frequency of fistula formation in both groups was compared using the appropriate statistical methods.

RESULTS

Seventeen and 33 patients were enrolled into groups 1 and 2, respectively. No statistically significant difference in patient age was present between the two groups (P >0.05). Flap necrosis in 2 patients and skin necrosis in 1 patient were encountered in group 2, with the meatus located at the penoscrotal region. Ischemic skin changes occurred in one primary patient with a mid-penile meatus. Urethrocutaneous fistula occurred in 2 (11.7%) of 17 primary cases and in 14 (42.4%) of 33 cases with multiple previous operations (Pearson chi-square test, P <0.05). A fistula rate of 61.5% was recorded in group 2 when the urethral meatus was located at the penoscrotal region. After withdrawal of the cases with penoscrotal meatus, the incidence of urethrocutaneous fistula was 6.7% (1 of 15) and 30% (6 of 20) in groups 1 and 2, respectively.

CONCLUSIONS

Multiple previous operations affected the outcome of repair with the transverse onlay preputial flap, particularly in cases with a penoscrotal meatus. Repeat hypospadias repairs are more prone to complications.

Outcomes of one-stage techniques for proximal hypospadias repair

OBJECTIVES

To evaluate the success of three preputial flap techniques in the one-stage correction of proximal hypospadias.

METHODS

From 1993 to 1999, 43 children underwent one-stage proximal hypospadias repair using preputial flaps, which were performed by a single surgeon. Of the 43 patients, 21 (48.8%), 10 (23.2%), and 12 (27.9%) underwent tubularized island flap urethroplasty, double-faced tubularized island flap urethroplasty, and onlay island flap urethroplasty, respectively. The age range of the patients at surgery was 18 months to 14 years (mean 3.4). Dorsal plication was required for chordee repair in 12 patients (3 in tubularized island flaps, 3 in double-faced tubularized island flaps, and 6 in onlay island flaps). In addition to the dorsal plication, posterior dissection of the urethral plate without division was performed on 3 of the 6 patients with mild to severe chordee in the onlay island flap group. The incidence of complications requiring repeated surgery was evaluated for each group.

RESULTS

The follow-up was 8 months to 7 years (mean 4.1 years). The overall complication rate was 90% for the double-faced tubularized island flap repair, 38% for the tubularized island flap repair, and 33% for the onlay island flap repair. Recurrent chordee was observed in 2 (66.6%) of the 3 patients who underwent onlay island flap repair with urethral plate dissection.

CONCLUSIONS

The use of a tubularized island flap is suggested for one-stage repair of proximal hypospadias, especially in the patients with severe chordee. Because of the high complication rates, the double-faced tubularized island flap technique is not advocated. The onlay island flap may also be used for proximal hypospadias repair if mild chordee is present. Because of the high recurrent chordee rate, dissection of the urethral plate without division is not suggested in the onlay island flap technique.