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Urethrographic evaluation of the constructed neourethra after dorsal inlay grafting (upper photo), in comparison to tubularization of the incised plate without grafting (lower photo). DIGU, dorsal inlay graft urethroplasty; TIPU, tubularized incised plate urethroplasty.
Source publication
Introduction:
Dorsal inlay graft urethroplasty using inner-face preputial graft was described as an adjunct method to the classic tubularized incised plate (TIP) urethroplasty, aiming at reducing the risk of neourethral stenosis.
Objectives:
To evaluate the impact of dorsal inlay grafting of preservable narrow plates, in relation to native plate...
Context in source publication
Context 1
... studies were performed for five toilettrained boys who needed postoperative dilations, 3 months postrepair or later. A bell-shaped patterned urinary flow was evident in all but two cases with plateauing, for whom a voiding urethrogram was carried out. It showed an adequate caliber of neourethra with a noteworthy constructed fossa navicularis (Fig. 4). Urethroscopic examination was performed for both cases; it proved proper graft intake without noticeable neourethral scarring or contraction (Fig. 5). Though no plausible explanation, both cases outgrew these symptoms by the one year follow-up ...
Citations
... Similarly, the study by Omran et al. (2021) reported only one case of fistula and glandular dehiscence in 23 cases (5.3%) with narrow urethral plate augmented by inlay graft in anterior and middle hypospadias repair, while the onlay flap urethroplasty group (20 patients) reported urethral fistulas in five patients (25%), glandular dehiscence in two patients (10%), diverticulum in one patient (5%), and flap loss in one patient (5%) [18], while in our study we didn`t report any case with urethral diverticulum in the only flap group. Also, Seleim et al. reported two cases of fistulas in 81 patients with narrow urethral plates corrected by inlay graft (2.5%) [19]. In our study the success rate in TIPU was significantly low (p < 0.05) in comparison to inlay graft group, also higher number of complications; fistulas occurred in 5/40 (12.5%), glandular dehiscence occurred in eight cases (20%), and narrow meatus occurred in 7/40 (17.5%); two cases showed both narrow meatus with fistula, nearly similar, Shimitokahara et al., performed 100 operations and reported that complications were significantly less frequent in the dorsal inlay graft group (4 cases) than in the TIPU group (15 cases, p < 0.05); in the dorsal inlay graft group, no patients exhibited meatal stenosis, only one case exhibited neourethral stenosis without distal diverticulum, and three cases exhibited urethrocutaneous fistulas. ...
Purpose
We conducted this study, comparing the outcomes among Transverse Onlay Island Flap, inlay grafted incised plate and our previous records of tubularized incised plate urethroplasty (TIPU) in patients with narrow urethral plates, aiming to determine which method of repair provides a good outcome.
Methods
This hybrid study included two datasets. The first from a prospective randomized study evaluating outcomes of two treatment modalities; Inlay graft and only flap for distal hypospadias with shallow urethral plate with 80 patients (40 patients in each group) included, the second based on our previous records of TIPU in 40 patients with distal primary hypospadias with narrow urethral plate.
Results
The success rate in inlay graft urethroplasty group (n = 40) was 87.5%; glandular dehiscence occurred in one case (2.5%), fistulas occurred in 2 cases (5%), and narrow meatus occurred in two cases (5%). Success rate in onlay flap urethroplasty group (n = 40) was 82.5%; glandular dehiscence occurred in two cases (5%), fistulas occurred in two cases (5%), and narrow meatus occurred in three cases (7.5%). TIPU group (n = 40) had success rate of 62.5%; glandular dehiscence occurred in eight cases (20%), fistulas occurred in five cases (12.5%), and narrow meatus occurred in seven cases (17.5%), with five cases exhibiting both narrow meatus with fistula.
Conclusion
Inlay graft and onlay flap urethroplasty for repair of distal penile hypospadias with narrow urethral plate had higher success rate and fewer complications than traditional TIPU. Moreover, operative time was shorter in TIPU.
... Расхождение раны на головке -хорошо известное осложнение пластики уретры, частота его развития достигает 15 % [5]. Свищи и стриктуры уретры встречаются еще чаще и наблюдаются преимущественно при коррекции сложных форм гипоспадии, недостатке пластического материала, повторных операциях с выраженным рубцовым процессом в области уретральной площадки [1][2][3][5][6][7]. Хирурги продолжают поиск более надежных способов коррекции осложненных форм гипоспадии. ...
... Определяющее значение, по нашему мнению, имеет состояние уретральной площадки. Многие факторы, в частности, дефицит пластического материала, анатомические особенности строения, рубцовый процесс в области ранее перенесенной операции, приводят к уменьшению размеров уретральной площадки [1,[3][4][5][6][7]. По нашим наблюдениям, исходно маленькие анатомические размеры головки полового члена, отсутствие выраженной ладьевидной ямки встречаются у 25 % первичных больных. ...
... Многие хирурги выделяют разные по степени варианты плоской головки (рис. 5) [3,6,7]. ...
Background. Important causes of complications of hypospadias repair are the deficit of tissues for plastic surgery, grooveless and small size of glans, obliteration of the urethral platewith varying degrees of scarring. The coronal urethral fistula is the most common complication of urethroplasty. Surgeons continue to search for reliable methods of correction of complications.
Materials and methods. Between 2011 and 2019, 85 children aged 2 and 17 years presented with coronal fistula of urethra after hypospadias repair. (TIP) Snodgrass – 78 (91.7 %) and Mathiue – 7 (8.2 %) procedures have been performed them earlier. In our clinic previously operated 28 (32 %) boys, primary surgery of the remaining 57 (67 %) was performed in other medical institutions.
Results. All patients (85), conditionally, were divided into two groups. The first group included 39 children (45.8 %), with stitching a fistula, the second group consisted of 46 patients (54.1 %), with augmentation of the urethral plate of the glans and distal urethra with the implantation of a rectangular preputial or oral mucosa free graft. Recurrent urethral fistula after stitching was observed in 10 boys (25.6 %) of the first group, and only in 2 cases (4.3 %) in children with the augmentation of the urethral plate (p <0.05). The decrease of urine flow according to the data of uroflowmetry was observed in 15 patients (52 %) the first group, the children of the second group did not have a decrease in the flow of urine.
Discussion. The shape, size of the glans and the condition of the urethral plate affect to the result of urethroplasty. The connection of the wings of the glans in accordance with normal anatomy, avoid obstruction in the distal part of urethra. A wide urethra in the glans and meatal area improves urine flow.
Conclusion. The augmentation of the urethral plate of the penile glans and the distal urethra with the implantation of a wide rectangular free flap in to the meatus, in our opinion, an advantage over the implantation of diamond-shaped grafts using the GTIP or TIP graft technique.
... Tubularization of the urethral plate has constituted the standard surgical approach for treating distal hypospadias; either by incorporating the plate in the reconstruction of a fully epithelialized neourethra (after has been boosted with local skin flaps or grafts) or by relying solely on the plate for the reconstruction of an incompletely epithelialized neourethra, hoping for secondary healing with minimal scarring. 10,11 Mobilization of the wings of the glans and closure over the tubularized plate, or even tunneling the glans to incorporate a reconstructed neourethral flap, has been considered another constituent of successful hypospadias repair. This notion might have emerged from the assumption that the distal part of the urethra -within the glans -originates during embryogenesis from canalization of a solid ectodermal ingrowth. ...
Background
Outcomes of hypospadias surgery continually lagged behind anticipations among practitioners, prompting continuing refinement of approaches. Refinements typically involved modified surgical techniques.
Objective
Herein, the author aimed for reporting the comparative anatomical topography of distal hypospadias anomaly vs normal controls, to boost its reparative approach.
Patients and Methods
This is a prospective clinical study of distal hypospadias cases presented to the author’s facility between June 2018 and June 2020. Anatomical topography of the hypospadias penis was studied concerning the corresponding marks in another control cohort with normal penile development. Meatal marks, glans wings alignment, frenulum, and corpus spongiosum were the anatomical landmarks looked into. Operative correction of the anomaly was carried out considering these landmarks, aiming for pinpoint reassembly. The control group served to identify the normal topography.
Results
The author studied 49 cases of distal hypospadias and 10 uncircumcised boys with an otherwise normal penile anatomy. In distal hypospadias, the corpus spongiosum splayed out – at about mid-penile level – ending at a consequently splayed glans penis, rather than involving a primary glans defect. After the corpus spongiosum had been closed/zippered up, no further glans wings’ surgical dissection was deemed necessary to attain the anatomical topography identified by the control group. By the end of a median follow-up period of 14 months, no urethrocutaneous fistulae or meatal stenoses were reported, with a typical apical re-assembled meatus, glans ventrum, and frenulum.
Conclusion
Topographic mapping against control subjects revealed that the glans penis is fully developed in boys with distal hypospadias. After the spongiosal plate has been adequately zippered up, no glans wings’ surgical dissection was deemed necessary to attain the typical glanular topography identified by the control group.
... However, the investigators had excluded patients with "shallow UP" which jeopardized objectivity, reproducibility and potentially skewed the results by masking the beneficial effect of Snodgraft in patients with very narrow "shallow" UP. This can be further explained by the study of Seliem et al. [26] who showed the clear negative effect of UP < 4 mm on the results of TIP and recommended using Snodgraft instead in such cases. ...
Background
The variability of the urethral plate (UP) characteristics is one of the factors that influence technical choices for hypospadias correction. However, it is difficult to objectively evaluate the UP, leading to controversies in this subject, and vague terms utilized in the literature to describe its characteristics.
Objective
We aim to analyze the previously described methods used to characterize and evaluate UP quality, emphasizing the pros and cons of each system, and highlighting its possible influence on different postoperative outcomes.
Methods
We searched several databases such including PubMed, Embase, and Cochrane Library CENTRAL from January 1, 2000 to August 20, 2020. The following concepts were searched: urethra reconstruction/urethra replacement/urethroplasty AND hypospadias/hypospadias, AND children AND "plate" with the gray literature search. Subgroup analyses were also carried out. The quality of the involved studies was reviewed operating a modified version of the Newcastle–Ottawa Scale (NOS).
Results
996 citations perceived as relevant to screening were retrieved. Thirteen studies were included comprising a total of 1552 cases. The number of patients in each study varied between 42 and 442, and the average post-surgical follow-up duration ranged between 6 months and twenty-six months. All studies used postoperative urethral stents of variable sizes and types. The impact of UP was most frequently assessed for cases treated with the tubularized incised plate (TIP) repair.
Conclusion
The UP quality seems to play a role as an independent factor influencing postoperative outcomes of hypospadias repair. Currently used strategies for the appraisal of UP quality are highly subjective with a low index of generalizability. Various attempts to overcome these limitations exist but none was consistently accepted, leaving a wide space for creative investigation in order to obtain an objective, reproducible, precise, and well-validated tool.
... respectively), in the flow rate data (Q-max p=0.18 and voided time p=0.12) or the cosmetic outcome with a significantly longer operative time in the GTIP group (p= 0.005) (19) . A lower fistula rate (2.5%) was reported in the study of Seleim et al. in 2019; only two cases were complicated by fistula out of their 81 patients with urethral plate width from 4 to < 8 mm operated by GTIP (20) . Kolon and Gonzales reported a nearly similar glandular dehiscence rate (6.25%) in their 32 patients repaired by DIGU, more than half of them were posterior cases (21 cases) with dorsal plications needed in ten patients to correct cases (30.4%) complicated with one glandular dehiscence (4.2%) and 6 urethral J o u r n a l P r e -p r o o f stenosis (26.1%) and two fistulae (8.4%) were reported (7) . ...
Introduction
The measurement of the urethral plate width (as an objective parameter) and its effect of this width on the results of tubularized incised plate urethroplasty (TIPU) have been reported in two series and both authors reported that a urethral plate width < 8 mm is associated with higher complication rates.
The augmentation of the urethral plate either by dorsal inlay graft urethroplasty (DIGU) or Onlay flap has been compared with the original TIPU in different degrees of hypospadias with better surgical results in augmented cases.
Objective
To evaluate the surgical results of longitudinal Onlay preputial flap (LOF) vs (DIGU) techniques in augmentation of the narrow urethral plate.
Study design
Primary anterior and middle hypospadias cases with narrow urethral plates were randomly allocated into two groups; group one operated by DIGU and group two operated by (LOF). The Success rate, individual complication rate, and operative times were compared.
Results
39 cases completed the study. No significant differences in patients' characteristics were detected.
In the DIGU group, one case (5.3%) complicated with fistula and glandular dehiscence wherein in the LOF group, 7 cases (35%) Complicated with 5 fistulae, 2 glanular dehiscences, one flap loss, one diverticulum (p= .02). No significant differences in the rates of individual complications.
Discussion
Variables affecting the success of hypospadias repairs are many. Urethral plate quality is an important variable among these variables. The definition of urethral plate quality is usually subjective.
In the DIGU group, only 1/19 (5.3%) case had two complications, fistula and glandular dehiscence. Mouravas et al., in their comparative study between TIPU and G-TIP without mention of urethral plate width reported a significant reduction of the overall complications and urethral stenosis without significant reduction in fistula rate. In their G-TIP group, only 2 cases out of 24 (8.3%) were complicated with one fistula and one glandular dehiscence where in the TIPU group, 7 cases (30.4%) were complicated with one glandular dehiscence and 6 cases with urethral stenosis.
In the LOF group, fistula in 5/20 cases (25%) was the commonest complication followed by glandular dehiscence in 2 cases (10%). Diverticulum and flap loss occurred in one case for each (5%).
In the multivariate analysis of 474 patients' cohort by Spinoit et al., there were no significant differences between the risk of re-intervention after TIP and Onlay flap in anterior and middle hypospadias (25.8% vs. 18.8%), and (22.2% vs. 20%) respectively.
Conclusion
Our data suggest that augmentation of the narrow urethral plate with DIGU has a better surgical outcome than with LOF. No significant difference in cosmetic outcomes detected.
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Summary Figure.
Background
There is yet no perfect Procedure for repairing hypospadias. In certain cases, a graft is required to reinforce the poor urethral plate (UP). The study aims to assess the efficacy of dorsal inlay preputial graft urethroplasty (DIGU) as a primary repair for narrow urethral plate distal and mid-penile hypospadias.
Patients and methods
A 40- child who underwent dorsal inlay preputial graft urethroplasty Repair for primary distal or mid-penile hypospadias at least 6 months old, as well as a UP less than 8 mm in a noncircumcised penis, were included in the research.
Results
The success rate was 75% (30 patients) and the Complications rate was 25% (10 patients). Six (60%) of the ten complicated patients had UP widths of 2.5–4 mm (total of 8 patients), implying that 75% of these patients had complications. There were four patients with fistula, two patients with meatal stenosis, two patients with meatal retraction, and two patients with failure.
Conclusion
One of the main factors influencing the surgical result of the hypospadias correction is the width and configuration of the UP.
Hypospadias displays a variety of phenotypic presentations and is rising in incidence globally, but to date no definitive etiological cause has been identified. Genetic, environmental, and parental factors appear to be involved, and emerging evidence suggests that interaction between these factors likely contributes to the majority of cases (Hypospadias ecosystem). In part due to this complexity, current classification methods lack sensitivity, objectivity, and reproducibility. New hypospadias classification systems are therefore being introduced to overcome these limitations. Among these are the Glans-Urethral Meatus-Shaft (GMS) scoring system, which generates a more elaborate picture of the anatomical defects associated with hypospadias, and the urethral defect ration (UDR) - Abbas 2022 system which identifies the level of bifurcation in the corpus spongiosum to quantify urethral hypoplasia. While several patient-related variables either alone or in combination can affect hypospadias grading, these newly developed methods represent significant advances over traditional assessments of predictive risk factors. Active efforts are being made to further refine these tools for quantifying hypospadias risk factors in order to improve patient outcomes. (See Video 1.1).
Objectives
: To evaluate the results and related factors of tubularized incised plate (TIP) urethroplasty at two institutions.
METHODES
: This was a prospective cohort analytical study conducted over a period of 12 months. All patients who underwent TIP urethroplasty in the specified period were studied. Quantitative and qualitative data of the intrinsic parameters of the penis were obtained and patients were followed up for an average period of 14.72±3.67 months (range 9-21months) after surgery.
RESULTS
: One hundred twenty-nine patients (N = 129) were included in the study. The mean age at surgery was 50.93 months. The mean glans size and pre-incised urethral plate width were 14.34 mm and 8.38mm respectively. The post-operative results were satisfactory with the meatus in a glanular position in 122(94.6%) patients. Overall, 49 patients (38%) developed complications. Eighteen patients (14%) developed early complications whereas forty-two (32.6%) patients had late complications. UCF and Meatal stenosis occurred in 27 (20.9%) & 14 (10.9%) patients respectively. Seven patients developed recurrent hypospadias and dehiscence of glans occurred in eight patients (6.2%).
CONCLUSIONS
: TIP can be used to repair for all types of hypospadias in the absence of severe penile curvature. It has more complications rate in proximal than distal hypospadias. Distal hypospadias was the most common type of hypospadias corrected with TIP. UCF and meatal stenosis were the most common complication followed by glans dehiscence and recurrent hypospadias. Glans size, age at surgery, plate width, location of meatus and stretched penile length were the most determinant factors for the outcome.
Background
Tubularized incised plate urethroplasty is the most common hypospadias repair technique. However, there are unanswered questions and debates about the anatomical prognostic factors affecting the repair outcomes. This study tried to address some of the problems in the studies compromising the results of the current body of literature.
Methods
A prospective cohort of 101 males aged 1–3 years undergoing primary distal to mid-shaft hypospadias repair were enrolled in the study. Complications including edema, erection, inadvertent removal of the urethral stent, surgical wound infection, bladder spasm, hematoma, and hemorrhage were evaluated. Studies in the current literature were reviewed to achieve a better perspective for future investigations.
Results
Persistent complications were found in 16 cases (15.8%) including fistula formation, the persistence of chordee, meatal stenosis, glans, and urethral dehiscence. The mean follow-up time was 6.6±3.4 months. In the single-variable analysis, the meatal location, the length and width of the urethral plate, and the reversible acute postoperative events were significantly associated with the complications. Furthermore, fistula formation was associated with acute surgical site infection (p<0.001). However, the multivariable regression study revealed the presurgical meatal location to be the only statistically significant factor (p=0.03). Notably, the glans diameter or glanular groove shape, urethral plate dimensions, or presence of mild chordee were not independently associated with the outcomes (p>0.05).
Conclusions
Our study on the toddlers with hypospadias surgery revealed that the location of urethral meatal was the main predicting factor in the development of major complications. Furthermore, the fistula formation at the infected surgical site emphasizes the importance of postsurgical care.
Introduction
Dorsal inlay graft urethroplasty (DIGU) has been described as an effective method for hypospadias repair with the proposed advantage of reducing the risk of complications. We aimed to systematically assess whether DIGU has any additional advantages over standard tubularized incised plate urethroplasty (TIPU) repair in children with primary hypospadias.
Materials and Methods
This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The a priori protocol is available at the PROSPERO database (CRD42020168305). A literature search was conducted for relevant publications from 1946 until January 10, 2020 in seven different databases. Randomized controlled trials (RCTs), comparative studies (TIPU vs DIGU) and single arm case series (>20 cases) of DIGU were eligible for inclusion. Secondary hypospadias, two-stage repairs, disorders of sex development, significant curvature of >30°, and a mean or median follow-up of less than 12 months were excluded.
Discussion
A total of 499 articles were screened and 14 studies (3 RCTs, 5 non-randomized studies (NRSs), and 6 case series) with a total of 1753 children (distal: 1334 (76%) and proximal: 419 (24%)) were found eligible. Mean follow-up of the studies was between 16 and 77 months. DIGU was found superior to TIPU in decreasing meatal/neourethral stenosis (p=0.02, 95% CI 0.02-0.78). All other parameters were found comparable including overall complications, fistula and glans dehiscence rates. Success rates were similar among the groups ranging between 48% and 96% for DIGU and 43-96% in the TIPU group. The lack of standardization in the definition of complications and success was the major limitation of this study.
Conclusions
Using an inlay graft during primary hypospadias repair decreases the risk of meatal/neourethral stenosis. However, current evidence does not demonstrate superiority of DIGU over TIPU in terms of treatment success and overall complication rates.
