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Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias:

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Yuk Him Tam
Yuk Him Tam
Yuk Him Tam
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Kristine Kit Yi Pang
Kristine Kit Yi Pang
Kristine Kit Yi Pang
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Wong Yuen Shan at The Education University of Hong Kong
Wong Yuen Shan
Bess Siu-yan Tsui at The Chinese University of Hong Kong
Bess Siu-yan Tsui
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Purpose: To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique. Methods: We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra. Results: There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture. Conclusions: Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.
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ORIGINAL ARTICLE
Improved outcomes after technical modifications in tubularized
incised plate urethroplasty for mid-shaft and proximal
hypospadias
Yuk Him Tam
1
•Kristine Kit Yi Pang
1
•Yuen Shan Wong
1
•Siu Yan Tsui
1
•
Hei Yi Wong
1
•Jennifer Wai Cheung Mou
1
•Kin Wai Chan
1
•Kim Hung Lee
1
Accepted: 27 July 2016 / Published online: 29 July 2016
ÓSpringer-Verlag Berlin Heidelberg 2016
Abstract
Purpose To investigate and compare the outcomes after
tubularized incised plate (TIP) urethroplasty in mid-shaft
and proximal hypospadias using a standard and a modified
technique.
Methods We conducted a retrospective study in 104 con-
secutive children who underwent mid-shaft or proximal
TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort
One had dorsal dartos (DD) neourethral coverage while
patients in Cohort Two had either de-epithelialized split
preputial (DESP) or tunica vaginalis (TV) flap coverage.
TV flap was used only when DESP flap was not sufficient
to cover the neourethra.
Results There were 52 patients each in Cohort One (DD,
n=52) and Cohort Two (DESP, n=38; TV, n=14)
with no difference in ratio of mid-shaft/proximal between
the two cohorts. At a median follow-up of 28 months, 36
patients (34.6 %) developed 47 complications including
fistula (n=19; 18.3 %) and neourethral dehiscence
(n=4; 3.8 %). Cohort One patients had significantly more
fistula (28.8 vs 7.7 %; p=0.005) and neourethral dehis-
cence (7.7 vs 0 %; p=0.04) than Cohort Two. There was
no difference between the two cohorts in the complication
rates of meatal stenosis, recurrent ventral curvature and
neourethral stricture.
Conclusions Both DESP and TV flap appear to be superior
to DD in preventing fistula and neourethral dehiscence in
non-distal TIP repairs.
Keywords Hypospadias Tubularized incised plate
urethroplasty Dorsal dartos flap Tunica vaginalis flap
De-epithelialized split preputial flap
Introduction
It has been two decades since tubularized incised plate
(TIP) urethroplasty was described by Snodgrass for
hypospadias repair [1]. To date, TIP has become the most
popular technique for distal hypospadias repair [2,3]. A
recent systematic analysis has reported an overall compli-
cation rate less than 10 % for distal TIP repair [4]. Repair
of proximal hypospadias, however, remains a challenge
despite evolution of different techniques over the past
years. Reported complication rates of available techniques
vary from 15 to 45 % [5]. A single technique that is ideal
for every case of proximal hypospadias does not appear to
exist. Extending the use of TIP to more proximal defects
has been widely investigated in the recent decade [6–9].
The current evidence suggests that TIP is one of the
established techniques in proximal hypospadias repair
when the urethral plate can be preserved in the correction
of penile ventral curvature [5].
Urethrocutaneous fistula and neourethral dehiscence
have remained to be the major concern following non-
distal TIP repairs and such complications account for the
majority of reoperations [10,11]. Neourethral coverage
with an extra layer of vascularized tissue is found to reduce
the risk of reoperation [10] and using dorsal dartos (DD)
for barrier flap coverage has been widely adopted as a
&Yuk Him Tam
pyhtam@surgery.cuhk.edu.hk
1
Division of Paediatric Surgery and Paediatric Urology,
Department of Surgery, Prince of Wales Hospital,
The Chinese University of Hong Kong, Shatin, NT,
Hong Kong, China
123
Pediatr Surg Int (2016) 32:1087–1092
DOI 10.1007/s00383-016-3954-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... 4 Studies indicate that well-vascularized coverage of the primary urethroplasty effectively decreases the incidence of fistula. [4][5][6][10][11][12][13][14][15] There are four ways in which a waterproof layer of tissue is commonly created: (1) using a dorsal dartos flap that is buttonholed and transposed ventrally to cover the entire neourethra; 5 (2) using ventral vascular dartos tissue; 6 harvesting tissue from the tunica vaginalis; 11,15 or (4) using a de-epithelialized split preputial flap. [12][13][14] The procedure described by Snodgrass uses a vascularized dorsal dartos flap to provide additional coverage of the neourethra. ...
... 4 Studies indicate that well-vascularized coverage of the primary urethroplasty effectively decreases the incidence of fistula. [4][5][6][10][11][12][13][14][15] There are four ways in which a waterproof layer of tissue is commonly created: (1) using a dorsal dartos flap that is buttonholed and transposed ventrally to cover the entire neourethra; 5 (2) using ventral vascular dartos tissue; 6 harvesting tissue from the tunica vaginalis; 11,15 or (4) using a de-epithelialized split preputial flap. [12][13][14] The procedure described by Snodgrass uses a vascularized dorsal dartos flap to provide additional coverage of the neourethra. ...
... Additionally, ventral skin necrosis following the harvest of a dorsal dartos flap has been reported. 7,11 Soygur et al. reported that ventral-based flaps were easier to harvest and transpose to cover the neourethra; complications of fistula and meatal stenosis occurred in 8.3% and 10% of cases, respectively. 6 However, in our experience, in most cases, there is insufficient ventral-based vascular dartos tissue to harvest to cover the suture line. ...
A simple technique to repair distal and mid-shaft hypospadias using a de-epithelialized Byars’ flap
Article
Full-text available
Objective To describe standard and modified de-epithelialized Byars’ flap techniques in tubularized incised plate urethroplasty and evaluate postoperative outcomes. Methods We retrospectively evaluated data for 404 primary hypospadias repair patients who underwent standard (Group A) or modified (Group B) urethroplasty between January 2016 and 2021. Group B’s data were analyzed to evaluate whether our modified technique was effective for all hypospadias types. Results There was no difference in the ratio of different hypospadias types between Groups A (n = 145) and B (n = 259). Median follow-up duration was 35 months. Fistula occurred in 19 patients in Group A and 12 in Group B (statistically significant difference). The total complication rate was statistically significantly different between the groups. In Group B, 3/142 patients with distal hypospadias developed urethrocutaneous fistula vs 4/95 with mid-shaft hypospadias and 5/22 with proximal hypospadias. No difference was noted between the distal and mid-shaft groups. Significant differences were observed when comparing distal and mid-shaft groups with the proximal group; total complication rates were similar. Glans dehiscence and meatal stenosis rates were similar between Groups A and B, and among the hypospadias phenotypes. Conclusion Our modified procedure is simple to perform and yields excellent results in distal and mid-shaft hypospadias repair.
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... The use of well-vascularized tissue as a protective intermediate layer between the neourethra and the skin is considered an effective measure to prevent urinary fistula, and various tissues (e.g., dartos, de-epithelialized penile skin flap, tunica vaginalis, and corpus spongiosum) have been used (9)(10)(11)(12). In 2000, Beaudoin and Yerkes first reported the separation of two branches of the bifurcated urethral spongiosum, which were combined and then used to cover the ventral side of the new urethra, this procedure was termed "spongioplasty" (13,14). ...
Effects of spongioplasty on neourethral function following hypospadias repair: an experimental study in rabbits
Article
Full-text available
  • May 2020
Purpose: Spongioplasty (mobilization and midline approximation of the two branches of the bifid dysplastic distal corpus spongiosum) can form a covering layer for the neourethra to prevent urethrocutaneous fistula in hypospadias repair surgery. However, it remains unclear whether spongioplasty affects neourethral function. The objective of this study was to compare neourethral function after hypospadias repair with and without spongioplasty. Materials and methods: Fourteen congenital hypospadiac New Zealand male rabbits were randomly allocated into two groups, seven animals underwent Duplay hypospadias repair and spongioplasty (experimental group), while seven underwent Duplay surgery alone (control group). Functional differences between groups were assessed by comparing neourethral compliance and flow rate. Two months after surgery, in vivo neourethral compliance was assessed by measuring intraluminal pressure with a digital pressure meter of an isolated neourethral segment, following progressive distension with 1, 2, and 3mL of air. Penises were harvested for uroflowmetry test using a simple device. Results: Postoperatively, fistula developed in one and zero rabbits in the control and experimental groups, respectively. Mean pressures tended to be higher in the experimental group than in the control group (82.14 vs. 69.57, 188.43 vs. 143.26, and 244.71 vs. 186.29mmHg for 1, 2, and 3mL of air, respectively), but the difference was not statistically significant. Mean flow rates also did not significantly differ between the experimental and control groups (2.93mL/s vs. 3.31mL/s). Conclusion: In this congenital rabbit model, no obvious functional differences were found between reconstructed urethras after hypospadias repair with and without spongioplasty.
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... The surgical techniques followed the principles described in the literature 10,11 with our modification on the choice of barrier flaps. 12 The median ventral curvature before degloving was 45 degrees (range 10-90). Twelve patients had a full correction of ventral curvature after degloving while 16 required additional dorsal midline plication for the remaining ventral curvature <30 degrees. ...
The Hypospadias Phenotype With A Distal Meatus In The Presence Of Distal Penile Penoscrotal Angle Fixation
Article
Full-text available
  • Sep 2019
Objective: Hypospadias patients may present with the phenotype that features the migration of scrotum to distal penile shaft below a coronal/subcoronal meatus. Patients with this phenotype differ widely in the severity of the hypospadias and the complexity of the surgical repair. We aimed to investigate the operative findings and the outcomes of consecutive patients who presented with this phenotype. Methods: We retrospectively reviewed the medical charts of 31 consecutive patients who underwent hypospadias repairs from January 2014 to May 2017, and the hypospadias was characterized by i) the external urethral meatus at coronal/subcoronal region, ii) scrotal skin encroaching distally resulting in fixation of penoscrotal angle at distal penile shaft, and iii) urethral plate below the glans on penile shaft invisible or barely visible. Results: The median age at the time of surgery was 15.5 months (10-63). The division of corpus spongiosum was noted at distal penile shaft (n=2; 6.5%), mid-shaft (n=5; 16.1%) and proximal location (n=24; 77.4%). The median ventral curvature before degloving was 45 degrees (10-90). Twenty-eight and 3 patients underwent tubularized incised plate and 2-stage preputial flap repairs, respectively. Twenty-nine of 31 patients required cutback of the hypoplastic urethra. At the time of urethroplasty, 2 (6.5%), 7 (22.6%) and 22(70.9%) patients underwent distal, mid-shaft and proximal repairs, respectively. At a median follow-up of 30 months (14-50), 6 (19.4%) patients developed one or more complications (fistula=3; meatal stenosis=5). Conclusion: Patients affected by this particular phenotype likely require non-distal hypospadias repair with possibly higher complication rate and should be treated by surgeons with expertise in complex hypospadias repair.
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... While two recent studies stated that the most important factors causing meatal stricture were technical mistakes and surgeons' lack of experience, another stated that meatal strictures and obstructions could be evaluated objectively through preoperative and postoperative uroflowmetry and were more common after TIPU (19,20). Another study reported that fistulae occurred less often in dorsal dartos flaps and preputial flaps (21). We covered the neourethra with a subdartos flap in all our patients, and believe that our fistula rate is low compared to that reported in the literature. ...
The Use of Tubularized Incised Plate Urethroplasty to Repair Distal Hypospadias in A Peripheral State Hospital
Article
Full-text available
  • Sep 2019
Objective:Hypospadias is a congenital anomaly of the male urethra that is becoming increasingly prevalent. In this paper, we share the results of our series of 45 distal hypospadias cases treated with tubularized incised plate urethroplasty (TIPU) at a single center in Şanlıurfa, Turkiye.Materials and Methods:Hypospadias repairs were made by two urologists who had completed their urology residencies at the same clinic in a state hospital. The TIPU technique was used for all 45 patients. To prevent bladder contractions and reduce anal itching during hospitalization, the patients were administered low-dose oxybutynin and 2 mg/mL hydroxyzine hydrochloride; they were also followed up postoperatively for a mean duration of 9.3 (6-12) months.Results:The average age of the patients was 9.5±0.5 (2-24) years. Ten patients had been circumcised previously, preoperative skin chordee was observed in 35, and none experienced preoperative complications. Postoperative catheterization lasted seven days. Postoperatively, one patient developed a fistula and two developed meatal strictures. No other complications were observed in the other patients.Conclusion:Hypospadias is an anomaly frequently seen in pediatric urology practice and requires considerable attention and experience. TIPU is an ideal technique for correcting hypospadias, especially distal hypospadias, due to its low complication rate and favorable cosmetic results. Although hypospadias surgery requires experience, it can be done quite easily in peripheral hospitals by surgeons who have trained in clinics experienced in this field, provided that they follow the rules pertaining to surgery.
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... We believe the improved operative success under the NS model is attributable to the establishment of the dedicated team, which has also introduced some technical modifications in the existing techniques. 20 Our overall failure rate of 20.2% of patients requiring reoperation or reintervention in the NS cohort is in agreement with the 18.1% reported by a national population-based study in the United Kingdom 21 and the 24.1% reported by a regional tertiary centre in Europe. 22 Both studies included primary repairs of all types of hypospadias performed by multiple techniques, such as those used in the present study. ...
Hypospadias surgery in children: Improved service model of enhanced recovery pathway and dedicated surgical team
Article
  • May 2018
Introduction: Children in Hong Kong are generally hospitalised for 1 to 2 weeks after hypospadias repairs. In July 2013, we introduced a new service model that featured an enhanced recovery pathway and a dedicated surgical team responsible for all perioperative services. In this study, we investigated the outcomes of hypospadias repair after the introduction of the new service model. Methods: We conducted a retrospective study on consecutive children who underwent primary hypospadias repair from January 2006 to August 2016, comparing patients under the old service with those under the new service. Outcome measures included early morbidity, operative success, and completion of enhanced recovery pathway. Results: The old service and new service cohorts comprised 176 and 126 cases, respectively. There was no difference between the two cohorts in types of hypospadias and surgical procedures performed. The median hospital stay was 2 days in the new service cohort compared with 10 days in the old service cohort (P<0.001). Patients experienced less early morbidity (5.6% vs 15.9%; P=0.006) and had a lower operative failure rate (20.2% vs 44.2%; P<0.001) under the new service than the old service. Multivariable analysis revealed that the new service significantly reduced the odds of early morbidity (odds ratio=0.35, 95% confidence interval=0.15-0.85; P=0.02) and operative failure (odds ratio=0.32, 95% confidence interval=0.17-0.59; P<0.001) in comparison with the old service. Of the new service cohort, 111(88.1%) patients successfully completed the enhanced recovery pathway. Conclusions: The enhanced recovery pathway can be implemented safely and effectively to primary hypospadias repair. A dedicated surgical team may play an important role in successful implementation of the enhanced recovery pathway and optimisation of surgical outcomes.
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Cumulative sum learning curve analysis of tubularized incised plate repair for hypospadias: a study of a single surgeon with a single surgical procedure
Article
Full-text available
  • Apr 2024
Purpose To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis. Methods We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency. Results CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min [interquartile range (IQR) = 125–155] to 92 min (IQR = 80–100) (P < 0.001), CR decreased from 28 (28%) to 8 (5.3%) (P < 0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P < 0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P = 0.013, P = 0.006, and P = 0.028, respectively). Conclusions Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99,231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.
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CUSUM Learning Curve Analysis of TIP Repair for hypospadias: a Study of a Single Surgeon with a Single Surgical Procedure
Preprint
Full-text available
  • Nov 2023
To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis. We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency. CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min (interquartile range [IQR]=125-155) to 92 min (IQR=80-100) (P<0.001), CR decreased from 28 (28%) to 8 (5.3%) (P<0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P<0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P=0.013, P=0.006, and P=0.028, respectively). Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99 231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.
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Pediatric MIS Hernia Repair—Going Beyond the Quis, Quid, and Quando of Intracorporeal vs. Extracorporeal Suturing
Article
  • Apr 2023
Pediatric minimally invasive surgery (MIS) is growing exponentially in terms of its applications and complexity. The repair of hernia in children with the laparoscopic approach is known not only for its elegance but also the sheer number of ways to bell the cat. Broadly though, the two main categories are the “intra”- and “extra”-corporeal methods. Very few groups have focused on gathering objective evidence to reach a conclusion regarding the superiority of either technique. This historical narrative review was written after combing through the available literature on pediatric laparoscopic hernia surgery especially in the light of the aforementioned approaches. The article is presented within a conceptual framework of the gradual evolution of the thought process behind this particular surgery (based on landmark publications) which eventually builds up to the current data available regarding that specific inquiry.
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Necrosis of the Ventral Penile Skin Flap: A Complication of Hypospadias Surgery in Children
Article
Full-text available
  • Apr 2015
Objectives. To review cases of hypospadias that were repaired with TIPU method and consequently resulted in the necrosis of ventral penile skin flaps. Methods. Eighty-three patients with hypospadias underwent TIPU procedure by two surgeons. Neourethra in all patients was covered with dartos flap prepared from the preputium or penile shaft. In cases where ventral skin could not be covered primarily, closure was ensured by using preputial Ombredanne or Byars’ flaps to repair ventral defects. Results. The median age of patients was 4 years. Twenty-five (30.12%) patients that underwent hypospadias repair had urethral opening at the coronal level, 33 (39.75%) at the distal penis, 10 (12.04%) at the midpenis, and 15 (18.07%) at the proximal penis. The ventral skin defect could not be primarily covered in 10 patients with penile shaft hypospadias. Consequently, Byars’ method was used in 8 of these patients to cover the defect and the Ombredanne method was used in the remaining 2. Ventral skin flap necrosis developed in 5 patients (4 Byars and 1 Ombredanne). It was medically treated in 4 patients. Urethral fistula developed in the other patient whose necrosis was deeper. The mean hospital stay was 7 days for patients without necrosis, and 14 for those with necrosis. Conclusion. We are of the opinion that dartos flaps used in the TIPU method in order to cover neourethra and decrease the incidence of fistula development lead to necrosis in the Ombredanne or Byars’ flaps by causing low blood supply to the preputium and thus extend hospital stay.
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Learning curve for TIP urethroplasty: A single-surgeon experience
Article
Full-text available
  • Nov 2013
We evaluate the influence of surgeon experience and other clinical factors on the success of primary hypospadias repair, using the tubularized incised plate urethroplasty (TIPU) technique. We retrospectively reviewed pediatric cases of primary hypospadias repair performed by a single pediatric urologist (soon after his fellowship training) using TIPU between July 2002 and January 2011. The surgical techniques (including the fact that the procedure was an outpatient one) were the same for each patient. The overall complication rate (CR) was analyzed for the following factors: patient age, use of a stent, meatal position, and surgeon experience. All significant covariates on univariate analysis or with a clinical relevance were entered into a multivariable logistic regression model. A non-linear model was created to estimate the change in the CR over the years. Pediatric patients (median age 1.4 years old) presenting with distal (n = 251), midshaft (n = 22) or proximal (n = 30) hypospadias and with a minimum 6-week follow-up (median 13 months) were included. Most patients (87%) had a urethral stent postoperatively (mean duration 9.8 days). In total, 96 patients had 133 complications: 27 meatal stenosis, 25 meatal coronal migrations, 22 urethrocutaneous fistulas and 59 other complications. Of these, 53 patients underwent a second operation. On multivariate analysis, the only factor increasing the CR was a non-distal meatus. The non-linear model demonstrated a significant learning curve with a decreasing CR over the years. The limitations of this study are its retrospective nature and lack of long-term follow-up. When using TIPU, the CR significantly increases as the meatal position gets more proximal; the learning curve stabilizes after about 50 to 75 cases.
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Current practice in paediatric hypospadias surgery; A specialist survey
Article
Full-text available
  • May 2013
Aim: To undertake an online survey of current hypospadias surgery practice among those specialists attending the IVth World Congress of the International Society for Hypospadias and Disorders of Sex Development (ISHID), 2011. Materials and methods: An online survey covering 22 separate questions relating to proximal and distal hypospadias surgery was set up, and all delegates registered for the conference were invited to complete this questionnaire anonymously. The data was analysed by three of the authors. Results: A total of 162 delegates registered for the conference of whom 74% were paediatric surgeons, paediatric urologists, plastic surgeons and adult/adolescent urologists. 93 delegates completed the online survey, and most of them (57%) were from Europe. The majority of surgeons see over 20 new patients/year (90%) and perform primary hypospadias surgery in over 20 patients/year (76%). The tubularized incised plate (TIP) repair is the most frequent technique used for the management of distal hypospadias (59%); other techniques used included Mathieu, onlay and TIP with graft. A variety of techniques are used for proximal hypospadias, but nearly half of the respondents (49%) preferred a staged approach. Self reported complication rates for distal hypospadias surgery are favourable (less than 10%) for 78% of the respondents. However, proximal hypospadias complication rates are higher. Conclusions: With a majority of paediatric urologists and European delegates responding to our survey, the results suggest that there are differences in the management of proximal and distal hypospadias between surgeons, yet no differences were observed according to the region of their practice. Variations in long-term outcomes appear to be in keeping with the current literature.
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Tubularized Incised Plate Repair for Penoscrotal Hypospadias: Role of Surgeon's Experience
Article
Full-text available
  • Feb 2012
To give a retrospective analysis of factors affecting outcome of tubularized incised plate (TIP) repair for penoscrotal hypospadias. Data of all patients who underwent TIP repair for penoscrotal hypospadias by a single surgeon were retrieved. Follow-up was carried out every 3 months within the first year and annually thereafter. Repairs were divided into 2 groups: Group 1 included surgeries performed in the first 2 years after fellowship training, and group 2 included repairs performed afterward. Chi-square test was used for statistical analysis. Statistical significance was defined as P<.05. Data for 90 patients were retrieved for july 2001 through march 2009: Group 1 included 20 patients and group 2 included 70. The neourethra was covered with spongioplasty in 25 and dartos flap in 65. The overall success rate was 86%. Group 2 patients showed a statistically significant higher success rate of 91% compared with only 65% for group 1. Use of dartos flap was associated with statistically significant higher success (92%) compared with coverage of the neourethra with spongioplasty (68%). In group 1, use of dartos flap was associated with statistically significant better success (82% vs 33%). In group 2 patients, use of dartos flap showed no statistically better success (94% vs 81%). TIP is a valid procedure for repair of penoscrotal hypospadias with chordee<30 degrees. The overall success (86%) is satisfactory. Surgeon's experience is the pillar for better success.
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Comparison of dartos flap and dartos flap plus spongioplasty to prevent the formation of fistulae in the Snodgrass technique
Article
Full-text available
  • Mar 2011
  • INT UROL NEPHROL
The aim of our study was to evaluate the role of paraurethral spongial tissue plus dartos flap using an additional urethral cover to prevent fistula formation in patients who underwent surgery with the Snodgrass technique. A retrospective study was performed on 161 patients aged 10 months to 15 years who underwent midpenile and distal hypospadias repair using the Snodgrass technique. The patients were assigned to one of two groups. In Group I (75 patients), the neourethra was covered with the dartos flap, and in Group II (86 patients), the neourethra was covered with the dartos flap plus spongioplasty. Urethral fistulae were encountered in six cases (8%) in Group I, and no fistulae were encountered in Group II. The use of corpus spongiosum as an intermediate layer in urethral coverage, combined with the dartos flap, reduces the likelihood of fistula formation. This procedure can be applied easily and effectively to prevent the formation of fistulae.
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Coverage of urethroplasty in pediatric hypospadias: Randomized comparison between different flaps
Article
  • Feb 2013
  • INT J UROL
Objectives The use of covering urethroplasty with flaps in hypospadias surgery has been well recommended. Various techniques have been described for flap harvesting. The aim of the present study was to compare the outcome and complication rate of dorsal preputial flaps and ventral dartos flaps. MethodsA total of 130 patients were prospectively evaluated from January 2008 to December 2011. Using the tubularized incised plate urethroplasty procedure, urethroplasty was carried out by a single surgeon. Patients were randomly divided in two groups: group A (57 patients), in which a preputial flap was carried out using three different techniques; and group B (73 patients), in which a single or a double ventral dartos flap was used. ResultsA total of 41 complications occurred in 24 patients. Urethrocutaneous fistulas were observed in 14.9%, quite equally distributed between groups A and B. There was only one urethrocutaneous fistula in a patient treated with the double ventral dartos flaps. Five cases (3.8%) of glans dehiscence were observed: four after single ventral dartos flap and one after dorsal preputial flap. Six patients in group A and seven in group B experienced meatal stenosis. In three cases of iatrogenic torsion of the penis, a dorsal preputial flap was laterally transposed. Finally, a lower complication rate was observed for double ventral dartos flap versus the other techniques. Conclusions The use of a double ventral dartos flap should represent the first-line technique for coverage of distal urethroplasty.
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Tunica vaginalis flap is superior to inner preputial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias
Article
  • Nov 2012
Aims: The aims of this study are 1. to compare outcome of standard tubularised incised plate urethroplasty (TIP) repair using dartos flap in distal vs. midshaft hypospadias and 2. to determine whether tunica vaginalis flap (TVF) is superior to dartos flap in midshaft hypospadias in reducing early complications. Methods: All patients who underwent TIP repair between 2004 and 2011 by the same surgeon were divided into three groups based on type of hypospadias and choice of waterproofing layer: Group A: Distal hypospadias; inner prepucial dartos flap (n = 36); Group B: Midshaft hypospadias; inner prepucial dartos flap (n = 26); Group C: Midshaft hypospadias; TVF (n = 21). Early outcomes were compared between the groups using Fisher's exact test. Results: There was no significant difference in the age distribution or duration of follow up between the groups. There was no significant difference in terms of, glans dehiscence or meatal stenosis between the groups. In Group A, 0/36 had ventral skin necrosis and 3/36 (8.3%) developed urethrocutaneous fistula. In Group B, there was significantly higher ventral skin necrosis (6/26; 23%) and urethrocutaneous fistula (8/26; 30.7%) compared to Group A (p = 0.04). In Group C, there was significantly less ventral skin necrosis (0/21) and urethrocutaneous fistula (1/21; 4.7%) compared to group B (p = 0.03). There was no significant difference in outcomes between Group A and Group C. Conclusion: 1. TIP repair using inner prepucial dartos flap has significantly higher complications when used for midshaft hypospadias compared to distal hypospadias. 2. Tunica vaginalis flap reduces the fistula rate and is superior to inner prepucial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias.
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Trends in Hypospadias Surgery: Results of a Worldwide Survey
Article
  • Aug 2011
Hypospadias is a challenging field of urogenital reconstructive surgery, with different techniques currently being used. Evaluate international trends in hypospadias surgery. Paediatric urologists, paediatric surgeons, urologists, and plastic surgeons worldwide were invited to participate an anonymous online questionnaire (http://www.hypospadias-center.info). General epidemiologic data, preferred technique in the correction of hypospadias, and preferred technique in the correction of penile curvature were gathered. Three hundred seventy-seven participants from 68 countries returned completed questionnaires. In distal hypospadias (subcoronal to midshaft), the tubularised incised plate (TIP) repair is preferred by 52.9-71.0% of the participants. Meatal advancement and glanuloplasty (MAGPI) is still a preferred method in glandular hypospadias. In the repair of proximal hypospadias, the two-stage repair is preferred by 43.3-76.6%. TIP repair in proximal hypospadias is used by 0.9-16.7%. Onlay flaps and tubes are used by 11.3-29.5% of the study group. Simple plication and Nesbit's procedure are the techniques of choice in curvature up to 30°; urethral division and ventral incision of the tunica albuginea with grafting is performed by about 20% of the participants in severe chordee. The frequency of hypospadias repairs does not influence the choice of technique. In this study, we identified current international trends in the management of hypospadias. In distal hypospadias, the TIP repair is the preferred technique. In proximal hypospadias, the two-stage repair is most commonly used. A variety of techniques are used for chordee correction. This study contains data on the basis of personal experience. However, future research must focus on prospective controlled trials.
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Comparative Study of Dartos Fascia and Tunica Vaginalis Pedicle Wrap for the Tubularized Incised Plate in Primary Hypospadias Repair
Article
  • Nov 2004
To report a prospective comparative study on using dartos fascia, i.e. subcutaneous tissue of penile skin and tunica vaginalis pedicled wrap (TVPW) from the parietal layer of the tunica vaginalis of the testis, for a one-stage tubularized incised-plate (TIP) repair for hypospadias. Forty-nine patients (mean age 4.6 years, range 1-22) with hypospadias of different types (varying from coronal to penoscrotal) were repaired in one of three hospitals over 3 years. All patients were repaired using the TIP technique, with dartos fascia wrap used in 20 and TVPW in 29, without using a loupe or microscope during surgery. Urinary diversion and splinting were provided by a urethral catheter. The operative duration for both groups was similar at approximately 2 h. In the dartos fascia group there were three (15%) fistulae, but there were none in the TVPW group. Although the dissection for TVPW seems to be cumbersome theoretically, it is not difficult. The combination of TIP and TVPW in primary repair may be a good alternative to other techniques.
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