Pediatric penile biometry guides the surgical outcome following tubularised incised plate urethroplasty for hypospadias: a single centre study

Background: In hypospadias urethral meatus opens onto the ventral surface of the penis proximal to tip of glans and its surgery is challenging. Recent focus of hypospadias surgery is on reduction of postoperative complications and objective assessment of penile anthropometry which can affect outcome. Aim of study was to assess the surgical outcome of tubularised incised plate urethroplasty on penile biometric parameters among children with coronal, distal penile and mid penile hypospadias.Methods: Study was conducted in the department of pediatric surgery in IPGMER and SSKM Hospital in Kolkata during November 2019 to October 2021.Results: Among 42 boys mean urethral plate length is 4.286 (coronal), 7.643 (distal penile) and 8.846 (mid penile), mean urethral plate width is 3.321 (coronal), 5.786 (distal penile) and 5.923 (mid penile), mean diameter at mid glans level is 4 (coronal), 5.071 (distal penile) and 5.923 (mid penile), mean diameter at coronal level is 5.75 (coronal), 6.429 (distal penile) and 6.769 (mid penile), mean stretched penile length is 39.2143 (coronal), 41.857 (distal penile) and 40.308 (mid penile) hypospadias respectively. P value is less than 0.05 for all except urethral plate depth which has a non-significant p value.Conclusions: Urethral plate length, urethral plate width, mid glans diameter, glans diameter at coronal sulcus level and stretched penile length affect the outcome of the surgical process TIP urethroplasty in coronal, distal penile and mid penile type hypospadias but urethral plate depth does not.

Effect and prognostic factors of OIF and TIP in children with hypospadias / 临床外科杂志

Objective To explore the efficacy and prognostic independent factors of modified island flap(OIF)and urethroplasty(tip)in the treatment of hypospadias in children.Methods The 164 children with hypospadias analyzed retrospectively were treated from February,2013 to February,2021.They were divided into two groups according to the operation method.82 patients in tip group were treated with tip and 82 patients in OIF group were treated with OIF.The treatment effects of the two groups were compared.Then they were divided into two groups according to the cure condition,namely,the good prognosis group(cured by operation,151 case)and the poor prognosis group(not cured by operation,13 case).Independent factors affecting the prognosis of children were analyzed by binary logistic regression.Results The cure rate of OIF group was 96.34％,which was higher than that of the tip group(87.8％),and the incidence of postoperative complications in OIF group was 7.32％,which was lower than that of the tip group(23.17％,P＜0.05).The operation time in tip group(95.95±12.35)min,which was shorter than that of the OIF group(P＜0.05).At the same time,the binary logistic regression analysis showed that the degree of hypospadias and the classification of barcat were the prognostic factors of children with hypospadias.The degree of penis bending,the width of penis head and the method of operation were suspicious factors.Conclusion OIF and tip have good effects in the treatment of hypospadias in children.OIF has a higher success rate,tip has a shorter operation time and fewer postoperative complications.However,the independent factors affecting the prognosis of children are preoperative hypospadias classification and barcat classification.This operation method is not an independent factor affecting the prognosis.

Treatment of hypospadias in children with urethral plate combined with one crescent flap / 中华泌尿外科杂志

Objective To investigate the clinical effect of urethral plate combined with unilateral crescent flap in the treatment of hypospadias in children.Methods The clinical data of 14 cases of hypospadias treated from March 2017 to March 2018 were retrospectively analyzed,with average age of (3.3 ± 2.1) years.The external urethral orifice was located in the middle and distal part of the ventral side of the penis,with mild and moderate bends of the penis.The prepuce was piling up on the penile dorsal side,the ventral skin was deficient,and there was no concomitant disease such as penis scrotum transposition or cryptorchidism.All children were primarily treated with urethroplasty with urethral plate and one crescent flap.One side of the free urethral plate had a crescent superficial fascia,which was used as the new urethral material together with the urethral plate.By design,the urethra sutured deviating from the midline.The external urethral orifice was formed by trimming the anterior opening of urethra in the form of shallow "V" shape,and the new urethra was covered with the dorsal fleshy vascular pedicle.The pterygoid flap of the penis was sutured to form the penile head,and the foreskin was cut to cover the body of the penis.The specimens were taken for HE staining.Results The operation was successfully completed in 14 children.The length of the penis was measured before it is stretched out.The penile length was(3.5 ±0.5)cm,the penile diameter was(1.2 ±0.3) cm at the coronal sulcus,and the diameter of the tortoise head was (1.5 ± 0.3) cm at the pterygoid.The width of urethral plate was (0.6 ± 0.1) cm.Remeasurement was performed after complete correction of penile bending deformity.The length of the penis was (3.5 ± 0.5) cm,and the urethral defect was (1.7 ± 0.7)cm.According to Barcat method,there were 2 cases of coronal sulcus type,7 cases of anterior penile type and 5 cases of middle penile type.The results of HE staining showed that the number of blood vessels in the dorsal prepuce and fascia was (8.5 ± 2.1),dorsal foreskin plate was (5.1 ± 1.6),ventral prepuce internal plates was (7.6 ± 1.8),and ventral outer prepuce plates was (4.8 ±1.6).The number of superficial fascia vessels and deep fascia vessels were (10.3 ± 1.4) and (4.2 ± 1.7).The analysis of variance showed that there was significant difference in the mean number among groups(P =0.036),which was compared with each other by SNK-q test.The number of fasciae in dorsal prepuce was the most abundant,there was significant difference between dorsal and outer prepuce(P =0.033),and there was also significant difference with ventral prepuce(P =0.047).But there was no significant difference between the two groups(P =0.326).There was no significant difference in the number of blood vessels between the dorsal and ventral prepuce (P =0.682).The number of superficial fascia vessels near the skin was significantly more than that of deep fascia(P =0.037).On the transverse plane,there are more branches of the superficial fascia to the urethral plate at the junction of the ventral external plate and the urethral plate.All 14 cases were followed up for 3 to 9 months with an average of(5.4 ± 2.1) months.The penis was straight and satisfactory,urethral orifice was not cracked,urination was laborious and not forked,and there was no fistula.One patient with middle penile type developed postoperative infection and was controlled after antiinfective treatment.One patient with anterior penile type had slight urination after operation,but had no difficulty in urination.F6 metal urethral dilator was used to dilate for 2 months,and the urination was normal.Conclusion Urethral plate combined with crescent flap urethroplasty for hypospadias has a satisfactory appearance and fewer complications.It provides an optional operative method for the children who need no transection of urethra plate to straighten the penis,especially for the poor development of the penis and the insufficiency of the new urethral materials.The superficial fascia tissue on both sides of the urethral plate is an ideal material for the new urethra because of its abundant blood supply adjacent to the urethral plate and direct vascular connection.

A modified two-stage procedure strategy treat severe hypospadias with preputial flap / 中华泌尿外科杂志

Objective To investigate the effect of a modified preputial flap urethroplasty in twostage treatment of severe hypospadias.Methods The clinical characteristics of the severe hypospadias patients (41 cases) who underwent the staged urethroplasty by using the procedure of preset urethral plate with preputial flap from January 2015 to December 2016 were analyzed retrospectively.We used a modified method (modified group,23 cases):Form the distal urethra with the transected distal urethral plate by using tubularize incised plate (TIP) procedure during the first stage operation,after completely straightened the penis,urethral plate was preseted with transverse preputial flap at the penis shaft.While in the traditional group (18 cases),urethral plate was preseted with preputial flap by using Bracka procedure after transecting urethral plate.The corresponding missing part of urethra underwent urethroplasty at the second stage operation six months later.The patients in the modified group were 9 to 18 months old,and the median age was 13 months;meatus were located at the penis shaft in 10 cases,scrotum in 12 cases,perineum in 1 case.The patients in the traditional group were 9 to 18 months old,and the median age was 13 months;meatus were located at the penis shaft in 6 cases,scrotum in 10 cases,and perineum in 2 cases.There was no statistic difference in age and meatus position between the two groups.Results During the first stage operation,distal urethra was repaired by 13-19 mm,with an average of (14.5 ± 1.3) mm,and the proximal urethra was repaired by 0-6 mm,with an average of (3.1 ± 2.4) mm at the modified group.While at the traditional group,the length of proximal urethra was repaired of 0-9 mm,with an average of (5.6:±:2.9) mm.The urethral length required for reconstruction was measured during the second stage operation,with an average of (26.3:t:4.4) mm in the modified group and (40.5 ± 3.3) mm in the traditional group (P ＜ 0.05).There were 3 case of urethral stricture after removed the catheter,with 2 cases in the modified group and 1 case in the traditional group.Postoperative follow-up was 2 to 3 years,with an average of 2.4 years.There were 3 cases (3/23,13.0％) of urethral fistula in the modified group and 3 cases (3/18,16.7％) in the traditional group.Ascended testis occured in 2 patients in the traditional group after operation.No case of urethrostenosis,diverticulum,chordee or concealed pennis was recorded.There was no significant difference in postoperative complications between the two groups (P ＞ 0.05).Conclusions The modified staged preputial flap method shorten the new forming urethra by making full use of its own materials at the second stage operation,which was helpful to reduce complications.

Use of tubularized incised plate urethroplasty for secondary hypospadias repair or repair in circumcised patients

PURPOSE: To retrospectively review our experience of the tubularized incised plate (TIP) urethroplasty in a series of re-operative hypospadias repairs or circumcised children. MATERIALS AND METHODS: Between September 2001 and September 2007, 17 children (mean 4.6 years, range 7 months to 15 years), were referred for hypospadias re-operation. Some of these patients had previously undergone circumcision and missed hypospadias. In all cases, the TIP urethroplasty was covered with an additional layer of subcutaneous tissue or dartos flap. The original location, associated complications and results were recorded. RESULTS: There were 4 (30.7 percent), incidences of complications of TIP re-operation, 2 meatal stenosis, one stenosis with small fistula and one dehiscence. Re-operation was necessary in only one patient of our series (7.6 percent) and the others were cured by dilatation. No complications occurred in the circumcised patents. CONCLUSION: Using TIP urethroplasty as described by Snodgrass, is a suitable method for treating primary and re-operative cases. It can also be used successfully in patients, who do not have a healthy skin flap and in circumcised patients when there is a lack of foreskin.

Onlay Island Flap Hypospadias Repair ; Experience of 45 Cases / 대한비뇨기과학회지

PURPOSE: The onlay island flap urethroplasty, a variation of the transverse preputial island flap, was originally introduced as an alternative to the meatal-based flap urethroplasty for anterior hypospadias. Recently, the indications for use of the onlay island flap urethroplasty have been extended to include repair of more proximal hypospadias with/without moderate degrees of chordee. We evaluated application and outcome of onlay island flap hypospadias repair. MATERIALS AND METHODS: We analyzed medical records of 126 patients who underwent primary hapospadias repair at our hospital during recent 10 years with respect to age at surgery, type of hypospadias, surgical technique and outcome. A minimum follow-up of 6 months was necessary for inclusion of the study. RESULTS: Age ranged from 7 months to 32 years(mean 6.7 years). For 59 patients with anterior hypospadias, 14 onlay island flap, 21 MAGPI, 14 pyramid, 8 Mathieu and 2 tubularized incised plate urethroplasties were performed. For 67 patients with mid to posterior hypospadias, 31 onlay island flap, 29 transverse island flap, 3 King, 3 augmented Duckett (Transverse island flap+hiersch-Duplay) and 1 tubularized incised plate urethroplasty were performed. Out of total 129 patients, 45 patients underwent onlay island flap repairs including combined with 7 dorsal penile plications. Out of 31 patients who underwent onlay island flap repairs, 3 patients developed complications. Out of 29 patients who underwent transverse preputial island flap repair, 13 patients developed complications. During the period of first 5 years, we performed 10 onlay island flap and 21 transverse island flap repairs for 37 mid to posterior hypospadias, whereas during the second 5 years, we did 21 onlay island and 8 transverse island flap repairs for 30 mid to posterior hypospadias. CONCLUSIONS: The onlay island flap hypospadias repair with/without dorsal penile plication was even applied to mid and posterior hypospadias as well as anterior hypospadias. The onlay island flap hypospadias repair maintained its technical advantages and lower complication rate compared to transverse island flap. More favorable results were obtained through as possible as preservation of urethral plate in hypospadias repair.