'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis.

OBJECTIVE: To summarize the available evidence and to quantitatively evaluate the global results of different waterproofing layers in substantiating the UCF repair. MATERIAL AND METHODS: After defining the study protocol, the review was conducted according to the PRISMA guidelines by a team comprising experts in hypospadiology, systematic reviews and meta-analysis, epidemiology, biostatistics and data science. Studies published from 2000 onwards, reporting on the results of UCF closure after hypospadias repair were searched for on PUBMED, Embase and Google Scholar. Study quality was assessed using Joanna Briggs Checklist (JBI) critical appraisal tool. The results with different techniques were compared with the two samples independent proportions test with the help of Microsoft Excel, MedCalc software and an online calculator. RESULTS: Seventy-three studies were shortlisted for the synthesis; the final analysis included 2886 patients (71 studies) with UCF repair failure in 539. A summary of various dimensions involved with the UCF repair has been generated including time gap after last surgery, stent-vs-no stent, supra-pubic catheterization, suture material, suturing technique, associated anomalies, complications, etc. The success rates associated with different techniques were calculated and compared: simple catheterization (100%), simple primary closure (73.2%), dartos (78.8%), double dartos flaps (81%), scrotal flaps (94.6%), tunica vaginalis (94.3%), PATIO repair (93.5%), biomaterials or dermal substitutes (92%), biocompatible adhesives (56.5%) and skin-based flaps (54.5%). Several techniques were identified as solitary publications and discussed. CONCLUSIONS: Tunica vaginalis and scrotal flaps offer the best results after UCF closure in the synthesis. However, it is not possible to label any technique as ideal or perfect. Almost all popular waterproofing layers have depicted absolute (100%) success sometimes. There are a vast number of other factors (patient's local anatomy, surgeon's expertise and technical perspectives) which influence the final outcome.

[Iatrogenic hypospadias a preventable rare complication with two-stage repair with buccal mucosa graft: a case presen- tation].

Urethral catheterization is a common procedure, but it is associated with a number of complications. Iatrogenic hypospadias can rarely occur. There is a limited literature dedicated to this condition. We report a young patient with COVID-19 with iatrogenic hypospadias of grade 3. He was undergone to a two-stage procedure with acceptable outcome. Surgical repair should be offered and performed for young patients to ensure good function with acceptable penile appearance. A surgical treatment will improve psychological, sexual and social outcomes.

Quantifying Glans Width Changes in Response to Preoperative Androgen Stimulation in Patients Undergoing Hypospadias Repair.

PURPOSE: Testosterone (T) administration prior to hypospadias surgery to increase glans size remains controversial. Understanding T's effect on glans width (GW) is essential to understanding its potential impact on surgical outcomes. We hypothesized that preoperative T in prepubertal boys significantly increases GW at the time of hypospadias surgery. MATERIALS AND METHODS: Our single institutional database was queried to identify patients who underwent hypospadias surgery from 2016 to 2020, in which data for T administration and GW were available. Descriptive, nonparametric and categorical statistics were performed as indicated. RESULTS: A total of 579 patients were eligible for analysis. Median age at surgery was 0.9 years (IQR 0.6-1.6). A total of 247/579 patients (42.7%) received T. The median GW at surgery was 15 mm (IQR 13-17). When comparing patients who had T administered to those who did not, we found a significant difference in GW at surgery (16 mm vs 14 mm, p <0.001). The median change in GW from the office to surgery was 4 mm for those receiving T vs 0 mm for those not receiving T (p <0.001). We identified a greater change in GW from preoperative to intraoperative measurements in patients who received 2 doses of T vs 1 dose (4 mm vs 2 mm, p <0.001). A histogram plot revealed the distribution of GW change at surgery. CONCLUSIONS: In our prospectively collected cohort of patients undergoing hypospadias surgery, we were able to quantitate the change in GW from preoperative T. Two doses of T resulted in a significant increase in GW vs 1 dose.

Buccal versus skin graft for two-stage repair of complex hypospadias: an Egyptian center experience.

BACKGROUND: Urethral reconstruction in complex hypospadias poses a significant challenge. We report our 10-year experience with buccal mucosa graft (BMG) in the two-stage repair of complex hypospadias and compare its results to the skin graft. METHODS: We retrieved the data of 15 patients with complex hypospadias who underwent two-stage repair using the BMG at our institution. The data were compared to 13 patients who underwent skin graft during the same period. RESULTS: The median follow-up duration was 14 (12-17) months in the BMG group and 16 (13.5-22.5) months in the skin graft group. Patients in the BMG had a numerically lower incidence of the diverticulum, wound dehiscence, fistula, and infection than the skin graft group, however, without statistically significant difference (p > 0.05). On the other hand, the incidence of meatal stenosis and urethral stricture was significantly lower in the BMG group (0% each) compared to the skin graft group (30.8% each; p = 0.02). At the same time, there were no reported cases of graft contracture. The frequency of donor site morbidity was significantly higher in the skin graft group compared to the BMG group (p = 0.003). The BMG led to a lower incidence of postoperative straining than the skin graft (0% vs. 38.5%, p = 0.03). Only one patient needed revision surgery after skin graft, compared to no case in the BMG (p = 0.27). CONCLUSION: The present study demonstrates the feasibility and durable outcomes of the BMG in the setting of two-stage repair of complex hypospadias.

High grade persistent ventral curvature after multiple hypospadias surgery: how to correct?

INTRODUCTION: A challenging situation in proximal hypospadias is the presentation of patients with successful urethroplasty but with persistent or recurrent ventral curvature (VC) after multiple hypospadias repair. MATERIALS AND METHODS: We present a 13 year-old boy with 7 previous surgeries (long TIP, Duplay, meatoplasty) to treat hypospadias presenting with 60 degrees of VC, in spite of a well-accepted coronally neomeatus. We degloved the penis and artificial erection clearly appointed corporal disproportion causing curvature. We disconnected urethra from corpora. After excision of remnant fibrotic tissue, there was a residual curvature so a lenghtening corporoplasty with dermal graft from groin was performed. We have adjusted the urethral meatus position into a proximal penile shaft. We used a buccal mucosa graft placed in an inverted U-shape position planning a second stage urethroplasty (1). An indwelling silicone Foley tube was left for one week. The patient was discharged the day after surgery. RESULTS: The aspect after corporoplasty proved satisfactory curvature correction. Patient had an excellent outcome and is scheduled for a second-stage after 6 months. DISCUSSION: Snodgrass and Bush (2) reported that on 73 patients with an average of 2.7 operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50°. We do believe that some good results with minimal dorsal plicature may recur in adolescence and therefore when these procedures may be considered, they should be performed by classic Nesbit technique (3). Otherwise, the choice for primary ventral lengthening should be taken. CONCLUSION: Severe curvature associated with hypospadias should undergo a major procedure at early stage to avoid decompensation after dorsal plicature in adolescence. We had a very satisfactory result, the patient awaits the second stage procedure (Figure-1).

[Treatment of severe hypospadias and analysis of related problems].

Hypospadias is one of the common congenital malformations of the urogenital system in children, with a high incidence and an increasing trend. And the incidence rate of severe hypospadias is increasing year by year, which seriously affects the penile development of the patient. With deepened understanding of hypospadias, accumulated experience in its diagnosis and treatment, and continuous improvement of surgical strategies, the success rate of surgical repair of hypospadias has been elevated to a certain extent. However, quite a few problems remain to be studied, such as the high rate of complications, insufficient understanding of penile curvature, long-term follow-up recurrence of penile curvature, selection of strategic staged surgery, etc. This article analyzes the treatment of severe hypospadias and related problems, and provides some reference for clinicians in surgical repair of severe hypospadias.

Long-term outcome of urethral and genital reconstruction in hypospadias and exstrophy-epispadias complex.

PURPOSE OF REVIEW: Although immediate surgical outcomes of genitourinary reconstruction used to be the main focus in hypospadias and exstrophy-epispadias complex (EEC), recent research demonstrates rising concerns about long-term functional and psychosexual outcomes. Recent results about long-term outcomes of complex genitourinary reconstruction in those children transitioning into adulthood are summarized and discussed in this comprehensive review. RECENT FINDINGS: Long-term outcomes in hypospadias focus on psychosexual satisfaction and decisional regret. Interestingly, uncomplicated hypospadias repair results in equal satisfaction rates to those found in controls. Most adult patients are happy with their parents' decision to have them undergo surgery during childhood. No decisional regret was found in parents. Reinterventions were associated with a decline in satisfaction, as was a decrease in perceived penile length. Long-term, males with EEC are more dissatisfied with penile length than with continence problems. In cases of severe penile insufficiency, phalloplasty shows promising psychosexual outcomes at the price of a high complication rate. Female EEC patients show higher rates of pregnancy complications, portending a higher risk of miscarriage. SUMMARY: Psychosexual satisfaction of patients with repaired hypospadias transitioning into adulthood demonstrates equal satisfaction rates to those found in controls, without decisional regret associated with surgery during childhood. In EEC, more complications are seen when transitioning into a sexually active adult life.

Management of the Transitional Urology Patient: the Role of the Adult Reconstructive Urologist.

PURPOSE OF REVIEW: Patients with congenital urologic conditions present unique challenges as adults. Herein, we review the literature relevant to the adult reconstructive urologist confronted with complex surgical concerns affecting their patients with a history of hypospadias, spina bifida, and other syndromes affecting the genitourinary tract. RECENT FINDINGS: Urethral stricture disease related to hypospadias is complex, but successful urethroplasty and penile curvature correction can be achieved with an anatomically minded approach. Multiple urinary diversion techniques can be considered in a patient-centered approach to bladder management in the adult spina bifida patient, but complications are common and revision surgeries are frequently required. Strong evidence is lacking for most surgical techniques in this population, but experiences reported by pediatric and adult urologists with genitourinary reconstruction training can help foster consensus in decision-making. Urologists trained in genitourinary reconstruction may be uniquely positioned to care for the transitional urology patient as they enter adolescence and adulthood.

Comparison of effect between dartos fascia and tunica vaginalis fascia in TIP urethroplasty: a meta-analysis of comparative studies.

BACKGROUND: Tubularized incised plate (TIP) urethroplasty is the most commonly performed procedure for hypospadias. Several flap procedures have been recommended to decrease the postoperative complication rate in TIP repair, but no single flap procedure is ideal. This study aimed to compare the outcomes of dartos fascia (DF) and tunica vaginalis fascia (TVF) as intermediate layers in TIP urethroplasty. METHODS: We searched PubMed, EMBASE, the Cochrane Library, Web of Science, clinicaltrials.gov, and other sources for comparative studies up to April 16, 2020. Studies were selected by the predesigned inclusion criteria. The primary outcomes were postoperative complications. The secondary outcomes were functional and cosmetic outcomes. RESULTS: The pooled RR with 95% CI were calculated. We extracted the relevant information from the included studies. Only 6 comparative studies were included. No secondary outcomes were reported. The RR of the total complications rate for DF was 2.41 (95% CI 1.42-4.07, P = 0.0001) compared with TVF in TIP repair. For each postoperative complication, the RRs were 6.48 (2.20-19.12, P = 0.0007), 5.95 (1.13-31.30, P = 0.04), 0.62 (0.25-1.52, P = 0.29), and 0.75 (0.23-2.46, P = 0.64) for urethrocutaneous fistula, prepuce-related complications, meatal/urethral stenosis, and wound-related complications, respectively. CONCLUSIONS: This meta-analysis reveals that compared to DF, TVF is a better option in TIP repair in terms of decreasing the incidence of the total postoperative complications, urethrocutaneous fistula, and prepuce-related complications. However there is limited evidence for functional and cosmetic outcomes. Overall, larger prospective studies and long-term follow-up data are required to further demonstrate the superiority of TVF over DF. TRIAL REGISTRATION: PROSPERO CRD42019148554.

The effect of plasma rich platelet graft on post-operative complications in mid-penile hypospadias.

Hypospadias is one of the most common penile congenital anomalies, which often requires a surgical approach. After the hypospadias is repaired, urethral fistula can occur in around 20% of patients. In this study, we used platelet-rich plasma (PRP) to reduce the urethral fistula and other post-operative complications after hypospadias repair. Only patients with primary mid-penile hypospadias were included study. Patients with forms other than mid-penile hypospadias and cases with previous hypospadias surgery were excluded from the study. A total of 40 hypospadias patients were included in this study. These patients were divided into groups A and B with 20 patients in each group. Hypospadias repair was performed with the Snodgrass TIPU technique on both groups. PRP was used with group A, and PRP was not use with group B. These two groups were compared in terms of early and long-term post-operative complications. Both early and long-term post-operative UCF, urethral stenosis and post-operative infection rates were lower in the group using PRP, group A. PRP has the potential to prevent post-operative complications occurring after hypospadias repair, particularly post-operative infection.

TIPU outcomes for hypospadias treatment and predictive factors causing urethrocutaneous fistula and external urethral meatus stenosis in TIPU: Clinical study.

Our aim is to present patient outcomes for the TIPU method, currently mostly used for distal and sometimes proximal hypospadias treatment, and to identify predictive factors for the most commonly encountered complications of this surgery of urethrocutaneous fistula and urethral meatus stenosis. TIPU is a versatile, reliable, cosmetic and functionally successful surgical method mainly used for distal hypospadias patients but also in recent times for some proximal hypospadias patients. The main complications are urethrocutaneous fistula, urethral meatus stenosis, glans dehiscence and urethral meatus dehiscence. The pre-operative anatomic features of patients were assessed with the glans-meatus-shaft (GMS) scoring. Post-operative assessment of surgical outcomes was performed with the hypospadias objective scoring evaluation (HOSE). The mean total urethrocutaneous fistula and meatal stenosis development rates were 20 (12.3%) and 25 (15.4%). Both complications were found to be significantly high among hypospadias patients with narrow urethral plate, flat glandular groove and small glans (p < .001). Multivariate binary logistic regression analysis found urethral plate, glandular groove and glans shape were predictive factors for fistula and stenosis development.

The Application of Multilayer Direct Closure With a Longitudinal Relaxing Incision in Urethrocutaneous Fistula Repair.

The simple closure of a urethrocutaneous fistula is technically easy, but direct suture tension is associated with a higher urethral fistula recurrence rate. We describe a multilayer direct closure with a longitudinal relaxing incision in urethrocutaneous fistula repair, avoiding the tension associated with the direct suturing of the surgical skin wound. From March 2015 to January 2018, 46 urethrocutaneous fistulas in 34 patients were repaired at the Hypospadias Center of our hospital. During the operations, after the urethral fistula closure, a longitudinal penile skin incision was created 0.5 to 1.5 cm from the edge of the surgical wound. The penile skin wound was closed, and the longitudinal penile skin incision made during the operation was used as a relaxing incision to reduce the skin tension of the closed fistula area. The urethral fistula repairs were successful, and no signs of infection or poor healing were present at the closure sites of the penile skin wounds. The relaxing incisions gradually healed within 7 to 21 days after operation, and the residual scars were soft and did not significantly differ in color from normal skin. The key to increasing the success rate of urethrocutaneous fistula repair is creating a longitudinal relaxing penile skin incision. The technique aims to avoid the direct suture tension of the penile skin wound, thereby providing a favorable environment for the normal healing of the urethral fistula suture site.

[Prevention of urethrocutaneous fistulas after urethroplasty in patients with glandular and midshaft hypospadias].

AIM: To compare the results of treatment of postoperative complications in children with hypospadias. MATERIALS AND METHODS: A total of 123 patients aged 6 months to 16 years were included in the study. An evaluation of the level of reactive oxygen species (ROS) and the state of the antiperoxide system in the eluate was carried out. RESULTS: In the tissues of patients with glandular and midshaft hypospadias after urethroplasty the generation of ROS was enhanced. The products of their interaction with lipid and protein macromolecules can result in the formation of urethrocutaneous fistulas. The use of urethral catheter which allowed to obstruct and rinse the neourethra by a water-soluble antioxidant solution had a good effect on the tissue regeneration and significantly reduced the frequency of urethrocutaneous fistulas. CONCLUSIONS: The proposed method of rinsing the neourethra after urethroplasty in patients with glandular and midshaft hypospadias with a water-soluble antioxidant dibunol allowed to reduce the generation of ROS in the eluate, which resulted in a decrease in the content of SMDA in the eluate by 1.88, an increase in APA by 11.1 and to decrease the frequency of urethrocutaneous fistulas by 2.6 times due to an increase in local regeneration.

[Correction of urethral stenosis after proximal hypospadias repair in children].

AIM: Urethral stenosis is one of the serious complications after proximal hypospadias repair. A variety of techniques has been suggested for its correction, such as urethral dilation using bougies, endoscopic incisions and one- or two-staged urethroplasty with buccal mucosa. The aim of our study was to improve results of urethral stenosis correction in children after multiple proximal hypospadias repairs. MATERIALS AND METHODS: A total of 24 patients with urethral stenosis after proximal hypospadias repairs underwent treatment in the Department of Uroandrology of the Russian Childrens Clinical Hospital from 2015 to 2019. The age of the patients was from 3-17 years (average - 4.2) with penoscrotal form of hypospadias in 12, scrotal in 8, and perineal in 4 patients. All children previously underwent 2-8 hypospadias repairs. Patients were divided into 2 groups. In group I, 16 patients had urethral stenosis from the glans of the penis to the penoscrotal area, urethral diameter of 3-4 Ch and ventral penile curvature of 45-60o. These patients were treated with a two-staged urethroplasty, similar to Brackas technique. In group II, 8 patients with urethral stenosis in the penile shaft area, urethral diameter of 6 Ch, without penile curvature were included. They underwent to a one-stage urethroplasty with buccal mucosa graft, which was sutured on the dorsolateral aspect of the urethra, with a formation of the age-appropriate urethra (Dorsolateral Inlay). RESULTS: All patients in both groups had successful results with flow rate of 8-12 ml/sec. CONCLUSIONS: The correction of urethral stenosis in children after proximal hypospadias repairs can be performed using buccal mucosa. In cases of long urethral stenosis, urethral diameter of 3-4 Ch, penile curvature, and scarring of the penile skin, a two-staged urethroplasty is recommended. In patients with stenosis of the penile shaft, urethral diameter of 6 Ch and lack of penile curvature, a one-stage urethroplasty with buccal mucosa fixation on the dorsolateral aspect of the urethra (Dorsolateral Inlay) allows to achieve successful results.

A rare case report: Penile lipoma after hypospadias repair.

Lipomas are the most common benign tumours that originate from adipose tissue and can develop in any anatomical location where the adipose tissue layer is present in the body. Penile lipoma cases are very rare in the literature. Our case is a 21-year-old male patient who underwent TIPU operation 8 years ago due to distal hypospadias. One year after the operation, a palpable swelling at the midline of the ventral portion of the penis occurred and this lesion grew over time. In this case report, we present a patient with lipoma that was developed in the surgical area 1 year after hypospadias surgery. To the best of our knowledge, this is one of the first cases of penil lipoma related to hypospadias procedure.