Tubularised incised-plate versus tubularisation of an intact and laterally augmented plate for hypospadias repair: A prospective randomised study.

OBJECTIVES: To compare the outcome of hypospadias repair using tubularised incised-plate (TIP) urethroplasty and tubularisation of an intact and laterally augmented urethral plate. PATIENTS AND METHODS: This prospective randomised study included 370 patients with primary distal hypospadias. All had urethral plate widths of 8-10 mm and a glans of ⩾15 mm. Exclusion criteria were previous repair, circumcision, a wide urethral plate of >10 mm or a narrow plate of <8 mm in diameter, a small glans of <15 mm in diameter, chordee of >30°, and hormonal stimulation. Patients were randomised into two groups: Group 1 (185 patients) underwent TIP urethroplasty and Group 2 (185 patients) underwent tubularisation of the intact plate with lateral augmentation of the urethral plate using penile skin. The follow-up period was 12-28 months. RESULTS: There were 172 evaluable patients in Group 1 and 177 in Group 2. The urethroplasty was successful in 83.2% and 94.4% in Groups 1 and 2, respectively. Complications occurred in 16.8% in Group 1 and 5.6% in Group 2 (P = 0.001). Meatal stenosis occurred in 7% and 3.4% in Groups 1 and 2, respectively (P = 0.130). There were statistically significant differences in the wound dehiscence, fistula, and re-operation rates of Group 1 versus Group 2, at 6% versus 0%, 9.8% versus 2.8%, and 13.4% versus 5.6%, respectively. The presence of mild chordee did not affect the complication rate (P = 0.242). The mean (SD) operative time was 56.7 (8.9) min in Group 1 and 93.7 (8.3) min in Group 2 (P < 0.001). CONCLUSION: The outcome of tubularised intact and laterally augmented plate is better than classical TIP urethroplasty of hypospadias. Further trials are mandatory to extend the indications of the technique.

Microvasculature and healing potential of the inner versus outer preputial skin: preliminary immunohistochemical observations.

PURPOSE: To assess healing potential of the inner and the outer layers of the prepuce and to determine which layer is better for hypospadias neourethral reconstruction. MATERIALS AND METHODS: The study has been carried out to assess the microvessels density and epidermal growth factor receptor (EGFR) concentration in the inner and the outer preputial layers. Specimens from the outer and the inner prepuce were harvested during hypospadias repair in 26 children. Control specimens were collected during elective circumcision of 10 normal and age-matched children. Sections were prepared, and immunohistochemical staining was done using monoclonal antibodies of CD34 (vascular marker) and of the EGFR. CD34-positive microvessels were assessed under the outer and the inner layers of the prepuce and were counted in five high-power fields under each layer. Expression of EGFR in both layers was assessed using H-score system. RESULTS: The density of microvessels and EGFR expression are significantly higher in control group either for inner or for outer preputial layers (p < 0.05). Microvessels density in the inner prepuce in hypospadias group is slightly higher than that of the outer prepuce (p < 0.05). However, the wider lumen and well-developed wall of the microvessels in the outer layer may compensate for decreased number in comparison with the inner layer. Expression of EGFR was reduced in both inner and outer layers of the hypospadias prepuce with no significant difference (p > 0.05). CONCLUSION: In hypospadias patients, the healing potential of both inner and outer prepuce is nearly similar. However, it is markedly reduced than that of normal prepuce. It seems that both layers can be used for hypospadias repair without obvious preference to either of them. The usual tradition to use inner prepuce in hypospadias repair has no scientific evidence.

The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion.

OBJECTIVES: To evaluate the effectiveness of urethral mobilisation for correcting moderate and severe penile torsion associated with distal hypospadias. PATIENTS AND METHODS: Nineteen patients with distal hypospadias and congenital moderate and severe penile torsion were treated surgically. The hypospadias was at the distal shaft, coronal and glanular in seven, eight and four patients, respectively, and six had mild chordee. The mean (SD, range) angle of torsion was 94.7 (19.9, 75-160)°. The urethra was mobilised down to the perineum. If the urethral mobilisation was insufficient the right border of the tunica albuginea was anchored to the pubic periosteum. The hypospadias was repaired using the urethral mobilisation and advancement technique, with a triangular plate flap for meatoplasty. The patients were followed up for 12-18 months. RESULTS: All patients had a successful functional and cosmetic outcome, with no residual torsion. Two patients had a small subcutaneous haematoma that resolved after conservative treatment. Massive oedema occurred in three patients and was treated conservatively. Urethral mobilisation did not correct the penile torsion completely. Although the mean (SD, range) angle of torsion was reduced to 86.1 (14.3, 65-130)°, statistically significantly different (P = 0.001), it was not clinically important. The presence of chordee had no significant correlation with the reduction of penile torsion. CONCLUSION: Urethral mobilisation cannot completely correct moderate and severe penile torsion but it might only partly decrease the angle of torsion. Periosteal anchoring of the tunica albuginea might be the most reliable manoeuvre for the complete correction of penile torsion.

Classification of pelvic fracture urethral injuries: Is there an effect on the type of delayed urethroplasty?

The posterior urethral injury due to pelvic fracture is a challenging problem. Because pelvic fractures are widely varying in severity, direction and mechanism, a wide spectrum of pelvic fracture urethral injuries (PFUIs) is clinically identified. Previously published data indicate that the proposed classifications of PFUIs are neither ideal nor universally acceptable. Moreover, these classifications might not have a significant effect on the delayed definitive techniques of urethral reconstruction. The currently available classifications and management strategies of PFUIs lack consensus and are based on accumulated surgical experience and clinical case studies. In the current era of evidence-based medicine there should be clear and appropriate guidelines for managing PFUIs, based on meta-analysis of well-designed controlled studies and evidence-based surgical science. In this way several controversies in the management of PFUIs will be resolved and the quality of life of patients who have sustained PFUIs will be improved.

Prostatic specific antigen in patients with hypogonadism: effect of testosterone replacement.

INTRODUCTION: The effect of parenteral testosterone replacement therapy on prostatic specific antigen (PSA) level or the development or growth of prostate cancer is unclear. AIM: To assess the effect of testosterone replacement on PSA level in patients with hypogonadism associated with erectile dysfunction (ED). METHODS: A total of 187 male patients above the age of 45 with hypogonadism associated with ED were enrolled in this study. Patients were screened for ED by the erectile function domain of the International Index of Erectile Function (IIEF). Patients underwent routine laboratory investigations, plus total testosterone, and PSA assessment. Replacement treatment with parenteral testosterone every 2-4 weeks for 1 year was instituted. Total testosterone and PSA serum levels were assessed every 3 months during the treatment course. RESULTS: Mean age +/- SD was 62.8 +/- 11.4. Of the patients 87.7% were sexually active. Of the patients 10.2% had mild, 40.6% had moderate and 49.2% had severe ED. Of the study population, 62.5% had ED complaints for less than 5 years and 84.5% had gradual onset of their complaint. The majority of the patients (91.4%) had either progressive or stationary course while the minority reported regressive course and improvement of the condition. There was a significant increase of the post-treatment testosterone level in comparison to pretreatment level (P < 0.05). No significant increase in the post-treatment PSA level in comparison to pretreatment (P > 0.05). No significant difference between pre- and post-treatment categories of PSA level (normal, borderline, high) in relation to the severity of ED (P > 0.05). There was no significant association between PSA level and the duration of testosterone replacement therapy in the study population (P > 0.05). CONCLUSION: The current study demonstrated that the level of PSA was not significantly changed after 1 year of testosterone replacement therapy in patients with hypogonadism associated with ED.