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Al-Salihi M, Abbas T, Albakr A, Vallasciani S, Elkadhi A, Salle JLP. Outcome analysis of staged preputial graft technique for primary proximal hypospadias with and without post-operative vacuum physiotherapy. J Pediatr Urol 2023; 19:699.e1-699.e7. [PMID: 37558593 DOI: 10.1016/j.jpurol.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/16/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE Management of proximal hypospadias remains challenging. We assessed the results of staged preputial graft repairs (SPG) for proximal hypospadias and hypothesize that post-operative vacuum physiotherapy (VP) improves graft suppleness and overall outcomes. MATERIALS AND METHODS Retrospective analysis of n = 71 patients with proximal hypospadias and severe ventral penile curvature (PC) of ≥50° after degloving. PC was corrected using ventral transverse incisions of the tunica albuginea (VTITA) without applying a tourniquet, taking care to avoid injuring the underlying erectile tissue. The ventral raw area at the penile shaft, including VTITA, were covered with either divided and partially mobilized urethral plate, or with the inner preputial graft itself. During the second stage, a tunica vaginalis flap was often used to cover the tubularized neourethra. Outcomes and post-op complications were assessed after each stage, comparing patients who received vacuum physiotherapy (VP+, n = 49) with those who did not (VP-, n = 22). RESULTS Mean PC was 66°, average follow-up duration was 13.01 months, and overall complication rate was 22.5%. Only 6 of 49 VP + patients experienced complications (12.24%; 4 fistulas; 2 urethral strictures) and no recurrence of PC after second stage was observed in this group. VP- patients displayed a significantly higher rate of complications, with 10 of 22 cases (45.45%) exhibiting fistula development (n = 5) and glans dehiscence (n = 5). Recurrence of mild PC after first-stage repair was comparable between patient groups (12% VP+, 18% VP-) and easily corrected by simple graft tubularization or dorsal plication during second-stage repair. CONCLUSIONS Staged repair using VTITA is effective for correcting proximal hypospadias with severe chordee. VP appears to promote and expedite graft suppleness and significantly improves patient outcomes.
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Affiliation(s)
- Muthana Al-Salihi
- Department of Surgery, Division of Urology, Sidra Medicine, Doha, Qatar; Department of Surgery, Weill Cornel Medicine - Qatar, Doha, Qatar
| | - Tariq Abbas
- Department of Surgery, Division of Urology, Sidra Medicine, Doha, Qatar; Department of Surgery, Weill Cornel Medicine - Qatar, Doha, Qatar
| | - Ahmed Albakr
- Urology Department, Hamad Medical Corporation, Qatar
| | | | | | - J L Pippi Salle
- Department of Surgery, Division of Urology, Sidra Medicine, Doha, Qatar.
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Zhang Y, Wang X, Wu Y, Li S, Zhang D, Ma X, Wang C, Zhang Z, Ma Y, Wei B, Guan Y. Grafts vs. flaps: a comparative study of Bracka repair and staged transverse preputial island flap urethroplasty for proximal hypospadias with severe ventral curvature. Front Pediatr 2023; 11:1214464. [PMID: 37416816 PMCID: PMC10321133 DOI: 10.3389/fped.2023.1214464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Bracka repair and staged transverse preputial island flap urethroplasty are both significant methods in treating proximal hypospadias. They utilize the flap and graft techniques, respectively, to achieve a satisfactory success rate. This study aimed to compare the outcomes of these 2 methods in the treatment of proximal hypospadias with severe ventral curvature. Methods We retrospectively analyzed 117 cases of proximal hypospadias with severe ventral curvature who had undergone either Bracka repair (n = 62) or staged transverse preputial island flap urethroplasty (n = 55). All operations were performed by a single surgeon, and the choice of method was determined by the surgeon's preference based on his experience. Cosmetic outcome was evaluated with Pediatric Penile Perception Score (PPPS). Patients' characteristics including age, penis length, glans diameter, length of the urethral defect and ventral curvature degree, cosmetic outcomes, and complication rates were all compared. Results There was no significant difference in age, penis length, glans diameter, length of the urethral defect, or ventral curvature degree. In the Bracka group, there were 5 patients with fistula, 1 patient with stricture, and 1 case of dehiscence. In the staged transverse preputial island flap urethroplasty group, there were 4 patients with fistula, 1 with stricture, and 2 with diverticulum. The scores of shaft skin and general appearance were consistently higher in the Bracka group than in the staged transverse preputial island flap urethroplasty group. The differences in complication rate and cosmetic outcome were not statistically different (P > 0.05). Conclusions Bracka repair and staged transverse preputial island flap urethroplasty are both satisfactory staged surgical options for proximal hypospadias with severe ventral curvature and have similar complication rates. Bracka repair may create a better appearance, but more studies are needed to confirm this finding. Pediatric surgeons should consider additional factors, such as the patient's specific condition, parents' inclination, and personal experience, rather than safety, to make the best choice between the 2 methods.
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Xie Q, Liu Y, Zhao X, Huang J, Chen C. The effect of staged TIP urethroplasty on proximal hypospadias with severe chordee. Front Surg 2022; 9:892048. [PMID: 36090335 PMCID: PMC9452824 DOI: 10.3389/fsurg.2022.892048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/20/2022] [Indexed: 12/04/2022] Open
Abstract
Background Proximal hypospadias with severe chordee is still a formidable challenge for most pediatric urologists, and the treatment approach remains controversial. Here, we describe a modified two-stage technique to repair proximal hypospadias with severe chordee. Methods We retrospectively identified 53 children referred for proximal hypospadias with severe chordee from July 2016 to July 2019, who underwent a two-stage urethroplasty. In group 1, the children were repaired with staged tubularized incised plate (TIP) urethroplasty, while Byars’ two-stage urethroplasty was attempted in group 2. We corrected chordee by releasing all remaining attachments to the corpora after degloving the penis, transceting the urethral plate, and dorsal plication. The mean age of patients in the first stage of surgery was 26.6 months in group 1 and 24.8 months in group 2. Postoperative complications in the two groups included: fistula, urethral stricture, urethral diverticulum, and glanular dehiscence. Results A total of 20 cases were repaired with staged TIP urethroplasty (group 1), and 33 cases were repaired with Byars’ two-stage urethroplasty (group 2). The length of follow-up in group 1 was 39.8 ± 10.1 months, and in group 2, it was 38.1 ± 8.7 months (P > 0.05). After the second stage of surgery, 1 case (5%) in group 1 and 11 cases (33.3%) in group 2 developed a urinary fistula (P < 0.05). One case (5%) in group 1 and three cases (9.1%) in group 2 had urethral stricture (P > 0.05). All strictures were cured by repeated dilation, and no patient required reoperation. No cases in group 1 and one case (3%) in group 2 had urethral diverticulum (P > 0.05). There was no residual chordee in both groups. Two cases (10%) in group 1 and 13 cases (39.3%) in group 2 required reoperation (P < 0.05). Conclusions Staged urethroplasty is appropriate to repair proximal hypospadias with severe chordee. Particularly, staged TIP urethroplasty is a good choice for patients with proximal hypospadias and severe chordee, especially those with better penile development, wider urethral plate, larger glans, and deeper navicular fossa of the urethra.
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Wang X, Guan Y, Wu Y, Wang C, Ma X, Zhang Z, Zhang D. Evaluation of tunica vaginalis flap-covering combined with modified Glenn-Anderson in one-stage repair of proximal hypospadias with incomplete penoscrotal transposition. Front Pediatr 2022; 10:872027. [PMID: 36582507 PMCID: PMC9792690 DOI: 10.3389/fped.2022.872027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To explore a novel repair method for proximal hypospadias with incomplete penoscrotal transposition in children and evaluate its safety and outcomes. METHODS A retrospective analysis of clinical data was conducted for 86 children with severe proximal hypospadias with incomplete penoscrotal transposition who were hospitalized in our department between June 2018 and February 2021. In total, 42 patients (Group A) underwent repair following a one-stage method in which tunica vaginalis flap-covering was combined with a modified Glenn-Anderson procedure, while 44 patients (Group B) underwent a two-step repair consisting of tunica vaginalis flap-covering using the Duplay technique and the modified Glenn-Anderson procedure. The two groups were compared on operation time, length of postoperative hospital stay, postoperative complications, and associated costs. RESULTS All operations were successful in both groups. No statistical difference was observed between the two groups in incidence of stenosis of the urinary meatus (2.38% vs. 4.54%, P = 0.279), urethral stricture (2.38% vs. 2.27%, P = 0.948), urinary fistula (7.14% vs. 6.82%, P = 0.907), or urinary infection (7.14% vs. 4.55%, P = 0.309). Additionally, there was no statistical difference between the groups in operation time (63.21 ± 5.20 vs. 62.07 ± 4.47 min, P = 0.059), postoperative off-bed time (7.02 ± 1.32 vs. 6.84 ± 1.20 days, P = 0.456), or duration of hospitalization (10.55 ± 1.15 vs. 10.15 ± 1.45 days, P = 0.092). However, Group B patients underwent an additional second-stage operation, incurring extra costs. Three months after surgery, Group A were judged more positively on the PPPS (specifically receiving higher scores on shaft skin and general appearance) by both the parents (shaft skin: 2.10 ± 0.82 vs. 1.93 ± 0.62, P = 0.024; general appearance: 2.16 ± 0.91 vs. 1.93 ± 0.72, P = 0.042) and the surgeon (shaft skin: 2.42 ± 0.70 vs. 2.25 ± 0.58, P = 0.025; general appearance: 2.38 ± 0.69 vs. 2.29 ± 0.51, P = 0.041). In most cases, the parents and surgeon were satisfied with the appearance of the genitals after one-stage repair. CONCLUSION The advantages of the novel repair technique include use of a single-stage operation, producing a better appearance at a lower cost. The tunica vaginalis flap-covering method is not only demonstrated to be safe and effective, but it is also a simpler method than the conventional operation.
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Affiliation(s)
- Xin Wang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, PR China
| | - Yong Guan
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, PR China
| | - Yong Wu
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, PR China
| | - Cong Wang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, PR China
| | - Xiong Ma
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, PR China
| | - Zhenhua Zhang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, PR China
| | - Dongzheng Zhang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, PR China
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Lin H, Wang YY, Li SB, Chen ZT, Su LJ. Staged transverse preputial island flap urethroplasty for some proximal hypospadias with moderate-to-severe chordee. BMC Urol 2021; 21:182. [PMID: 34949173 PMCID: PMC8697458 DOI: 10.1186/s12894-021-00948-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 12/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to assess the outcome of staged transverse preputial island flap (TPIF) urethroplasty for repairing certain cases of primary proximal hypospadias with moderate-to-severe chordee in children. METHODS Nighty-two consecutive boys who underwent either one-stage or staged TPIF urethroplasty for the repair of proximal hypospadias with moderate-to-severe chordee between August 2015 and December 2019 were evaluated retrospectively. Patients were divided into two groups: one-stage TPIF urethroplasty group (n = 44) and staged TPIF urethroplasty group (n = 48). We noted and compared the postoperative complications, including urethrocutaneous fistula, urethral diverticula, residual penile curvature, and urethral stricture in both groups. RESULTS Both groups were followed up for 1-5 years, with an average of 3 years. No cases of residual or recurrence of penile chordee were reported in either group. In Group A, 9 patients (9/44, 20.4%) had postoperative urethrocutaneous fistula, and all patients underwent urinary fistula repair or urethroplasty. In Group B, postoperative urethrocutaneous fistula occurred in 2 cases (2/48, 4.1%), and one patient developed a urethrocutaneous fistula after the first operation, which was successfully repaired during the second operation. A urethrocutaneous fistula occurred in 1 case after completion of the second-stage operation; urethral fistula repair was performed successfully 6 months later. There were 2 cases of urethral stricture in Group A (2/44, 4.5%) and none in Group B. There were 6 cases of urethral diverticulum in Group A (6/44, 13.6%) and no cases of urethral diverticulum in Group B. The operative success rates were 61.3% and 95.8% in Group A and Group B, respectively (P < 0.001). CONCLUSIONS Compared with one-stage TPIF urethroplasty, staged TPIF urethroplasty in the treatment of certain cases of primary proximal hypospadias with moderate-to-severe chordee resulted in fewer postoperative fistulas, urethral strictures and urethral diverticula. The staged TPIF urethroplasty procedure was effective in reducing the operation difficulty and complication rate of hypospadias, improving the curative effect of complex hypospadias and having good clinical application value.
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Affiliation(s)
- Hai Lin
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China.
| | - Yu-Yun Wang
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Shi-Bing Li
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Ze-Ting Chen
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
| | - Liang-Ju Su
- Department of Pediatric Surgery, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Xiuying District, Haikou, 570311, Hainan, People's Republic of China
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Babu R, Chandrasekharam VVS. Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade. J Pediatr Urol 2021; 17:681-689. [PMID: 34099397 DOI: 10.1016/j.jpurol.2021.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/08/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade. METHODS A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes. RESULTS The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load. CONCLUSIONS Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.
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Affiliation(s)
- Ramesh Babu
- Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.
| | - V V S Chandrasekharam
- Pediatric Surgery, Pediatric Urology and MAS, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India
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Ding Y, Gu S, Xia X, Yu Z. Comparison of Penile Appearance and Outcomes Between Prefabricated Urethra and Pre-implanted Urethral Plate for Treatment of Children With Severe Hypospadias: A Retrospective Study. Front Pediatr 2021; 9:719551. [PMID: 34595144 PMCID: PMC8476890 DOI: 10.3389/fped.2021.719551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To compare the effect of prefabricated urethra and pre-implanted urethral plate in the treatment of severe hypospadias in children. Methods: We retrospectively analyzed the clinical data of 53 patients who diagnosed as severe hypospadias underwent staging urethroplasty from January 2015 to January 2018 in the Department of Pediatric Surgery, First People's Hospital, Zunyi City. The patients were divided into two groups: group A (n = 25) were treated with prefabricated urethra and group B (n = 28) were treated with pre-implanted urethral plate. After the second stage surgery, the ratios of complications such as urethral fistula, urethral stenosis, urethrocele, and recurrence chordee were compared. The penis was scored from meatus, glans, shaft skin, general appearance by the parents, blinded urologists according to The Pediatric Penile Perception Score, and the scores were compared too. Results: All patients were followed up after two stage operations for an average of 28 months. Glans dehiscence occurred in two patients (8%), urethral orifice stenosis occurred in one (4%) and urethral fistula occurred in three (12%) in group A. No urethral stenosis, urethrocele and recurrence chordee was observed. One patient presented urethral plate inactivation (3.6%), two patients presented urethral fistula (7.1%) and one patient presented urethral stenosis (3.6%) in group B. No urethrocele, glans dehiscence and recurrence chordee was observed. The total complication rate in group A was 24 and 14.3% in group B, respectively, and the difference was not statistically significant (P = 0.582). The differences between two groups scored by parents in glans (P = 0.030) was statistically significant. The differences between two groups scored by operators in meatus (P = 0.041), shaft skin (P = 0.000), glans (P = 0.001), and general appearance (P = 0.007) were statistically significant. The differences between two groups scored by counterparts in meatus (P = 0.006), shaft skin (P = 0.003), glans (P = 0.010), and general appearance (P = 0.014) were statistically significant. Conclusion: Both prefabricated urethra and pre-implanted urethral plate methods are suitable for correction of severe hypospadias as staging surgery in children. In general, pre-implanted urethral plate is more worthy of spread because it is much more applied in patients with small glans and achieve good appearance of penis.
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Affiliation(s)
- Yuan Ding
- Pediatric Surgery, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi, China
| | - Shengli Gu
- Pediatric Surgery, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi, China
| | - Xingrong Xia
- Pediatric Surgery, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi, China
| | - Zhengbo Yu
- Pediatric Surgery, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi, China
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