Duckettversus Modified Bracka Technique for Proximal Hypospadias Repair A10-Year Experience

Abstract

Background: There are various techniques for treatment of proximal hypospadias disease.Surgical correction is often associated with complications. Proximal hypospadias can be repaired by Duckett or Bracka two-stage repair procedure. This study was to evaluate the outcomes, complications and long term follow-up of these two techniques in our referral hospital. Methods: From January 2006 to January 2015 totally 1550 cases of hypospadias were diagnosed in our hospital, of which 164 patients with high type hypospadias underwent Duckett (78 cases) and modified Bracka (86 cases) surgical repair procedures. Sufficient data were analyzed for age at operation, type of pathology, chordee type, number of operations, complications, outcomes and follow-up. Results: One hundred sixty four cases with a mean age of 2.70 ± 2.6 (range 0.5-13) years underwent proximal hypospadias repair. Follow up ran in average to 5 (range 1-10) years.Chordee was seen in 19 (11.58%) cases which 15 (78.9%) cases released and 4 (21.1%) corrected by dorsal Nesbit plication. Fifteen of 164 (9.1%) cases had meatal stenosis: 5 in Bracka and 10 in Duckett group, all of which were repaired by dilatation. Six patients in Duckett group and only one in Bracka series had urethrocutaneous fistula. One case in Bracka group and five cases in Duckett series underwent re-operation. Conclusions: Our study shows that proximal hypospadias repair with modified Bracka procedure has significantly a lower complication rate, also a better and more cosmetic outcome than Duckett technique.

Full text

Iran J Pediatr. 2017 December; 27(6):e7752.
Published online 2017 November 18.
doi: 10.5812/ijp.7752.
Research Article
Duckett versus Modified Bracka Technique for Proximal Hypospadias
Repair A 10-Year Experience
Afsaneh Sadeghi,1Alireza Mirshemirani,2,* Ahmad Khaleghnejad Tabari,2Naser Sadeghian,2Mohsen
Rozroukh,2Javad Ghoroubi,2Leila Mohajerzadeh,2and Mehdi Sarafi2
1Department of Pediatric Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
2Pediatric Surgery Research Center, Research Institute for Children Health, Shahid Beheshti University of Medical Sciences, Tehran,IR Iran
*Corresponding author: Professor Alireza Mirshemirani, Pediatric Surgery Research Center, Research Institute for Children Health, Shahid Beheshti University of Medical
Sciences, Tehran, IR Iran. Tel:+98-2122924488, E-mail: almirshemirani@gmail.com
Received 2016 October 25; Revised 2017 July 24; Accepted 2017 October 17.
Abstract
Background: There are various techniques for treatment of proximal hypospadias disease.Surgical correction is often associated
with complications. Proximal hypospadias can be repaired by Duckett or Bracka two-stage repair procedure. This study was to
evaluate the outcomes, complications and long term follow-up of these two techniques in our referral hospital.
Methods: From January 2006 to January 2015 totally 1550 cases of hypospadias were diagnosed in our hospital, of which 164 patients
with high type hypospadias underwent Duckett (78 cases) and modified Bracka (86 cases) surgical repair procedures. Sufficient data
were analyzed for age at operation, type of pathology, chordee type, number of operations, complications, outcomes and follow-up.
Results: One hundred sixty four cases with a mean age of 2.70 ±2.6 (range 0.5 - 13) years underwent proximal hypospadias repair.
Follow up ran in average to 5 (range 1 - 10) years.Chordee was seen in 19 (11.58%) cases which 15 (78.9%) cases released and 4 (21.1%)
corrected by dorsal Nesbit plication. Fifteen of 164 (9.1%) cases had meatal stenosis: 5 in Bracka and 10 in Duckett group, all of which
were repaired by dilatation. Six patients in Duckett group and only one in Bracka series had urethrocutaneous fistula. One case in
Bracka group and five cases in Duckett series underwent re-operation.
Conclusions: Our study shows that proximal hypospadias repair with modified Bracka procedure has significantly a lower compli-
cation rate, also a better and more cosmetic outcome than Duckett technique.
Keywords: Hypospadias, Modified Bracka Technique, Duckett Technique, Outcome, Children
1. Background
Hypospadias is the most common congenital anomaly
of male external genitalia with an incidence rate of approx-
imately 1 in 250 live male neonates born with proximal hy-
pospadias. Proximal penile, penoscrotal and scrotal types
account for 20% of all cases (1,2). It is a significant sur-
gical challenge to achieve a cosmetically and functionally
acceptable straight penis in these patients. Surgical tech-
niques for repairing proximal hypospadias generally have
two categories: Free graft such as Bracka’s two-stage proce-
dure (3) and vascularized preputial island flap technique
as Duckett’s one-stage procedure (4). Each technique has
its own advantages, but one-stage procedures are often as-
sociated with complications and require reoperations. Re-
cent reports of one-stage repair state complication rates
of 20% - 50% (5-7), The debate over the optimal treatment
for proximal hypospadias is ongoing, and mostly believe
that two-stage procedure offers superior functional and
cosmetic results with fewer complications (8) Bracka is a
two-stage procedure: The first stage of Bracka repair con-
sists of orthoplasty and urethral bed substitution with free
preputial graft. After 6 months, the urethral plate created
from free graft is tabularized to form neourethra. Two-
stage repairs reduce the complications and create better
cosmetic view. In this study we compare outcomes of Duck-
ett’s one-stage technique with modified Bracka’s two-stage
procedure.
2. Methods
In a cross sectional study from January 2006 to January
2015 totally 1,550 cases of hypospadias were diagnosed in
our hospital, of which 164 cases of severe proximal hy-
pospadias with chordee and/or poor urethral plate under-
went Duckett one-stage (78 cases) and modified Bracka
Copyright © 2017, Iranian Journal of Pediatrics. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
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Sadeghi A et al.
two-stage (86 cases) surgical repair procedures. These
procedures were performed by one group of surgeons in
Mofid Children’s University Hospital. All data was col-
lected, retrospectively analyzed and variables were eval-
uated: Type of hypospadias, applied surgical technique,
presence of chordee, releasing type, duration of catheterin
place, type of dressing, duration of hospital stay, meatal
stenosis, fistula development, need for re-operation, and
outcomes were recorded. For statistical analysis SPSS ver-
sion 18.0 and for descriptive statistics Chi-square and Stu-
dent test were used. P 0.05 was considered as significant.
Surgical techniques: 1) Bracka is a two-stage procedure:
The first stage of Bracka repair consists of orthoplasty and
urethral bed substitution with free preputial graft (Figure
1). After 6 months, the urethral plate created from free
graft is tabularized to form neourethra. In modified type
of this technique that we have used, the graft is a vascular-
ized preputial graft. 2) Duckett is a one-stage vascularized
preputial island flap procedure.
3. Results
Within a period of 10 years, 164 patients aged 2.7 ±2.6
(range 0.5 - 13) years, underwent proximal hypospadias re-
pair, and were followed up for 5 (range 1 - 10) years(Table
1), Hypospadias repairs between January 2006 to January
2015 were performed in our center using Duckett (78 cases)
and modified two-stage Bracka procedure (86 cases).From
all patients. 72 had mid-penile hypospadias cases of which
38 were treated with Bracka and 34 with Duckett repair.
Eighty four cases of proximal penile were treated either
with Bracka (43patients) or Duckett (41 patients) repair and
8 patients had penoscrotal hypospadias of whom 5 cases
were treated with Bracka and 3 patients with Duckett tech-
nique (Table 2).
Chordee was seen in 19 cases (9 mid penile, 6 proximal
penile and 4 penoscrotal) of which 10 were released and 9
corrected by dorsal Nesbit plication. All patients had Fo-
ley silastic catheter in average.8 (range 5-8) days. Sandwich
dressing was left in site for an average of 6.2 (4 - 7) days. All
patients received caudal block, antibiotics (Cephalosporin
at least for 7 days) and post operative Oxybutynin. Fifteen
of 164 (9.1%) cases developed meatal stenosis: 10 (12.8%) in
Duckett and 5 (5.8%) in Bracka group, these all were re-
solved by dilatation. Six (7.7%) patients with Duckett re-
pair had urethrocutaneous fistula, and only one (1.2%) in
Bracka group. Five cases (6.4%) with Duckett group (one
urethral diverticulum and four unsuccessful glans appear-
ances) and one (1.2%) with Bracka (glandular wound dehis-
cence) had redo operation. The hospital stay was longer in
Duckett series (mean stay of 6.5 days for Duckett and 3.5 for
Bracka group). Overall cosmetic result and complications
were better in Bracka group compared with Duckett group
(Table 3).
Table1. Characteristics of the Patients with Hypospadiasa
Characteristics Result
Totalpatients 164
Totalduration of study, y 10
Age 2.7 ±2.6 y (6 mo - 13 y)
Proximal penile 84 (51.2)
Penoscrotal 8 (4.9)
Mid-penile 72 (43.9)
Chordee 19 (11.6)
Mild 11 (6.7)
Moderate 3 (1.8)
Severe 5 (3)
Follow up, y 5±2.7 (1 - 10)
Fistulas 7 (4.3)
Meatalstenosis 15 (9.1)
Re-operation 6 (3.7)
aValues are expressed as mean ±SD or No. (%).
Table2. Surgical Procedure Type According to the Site of Hypospadiasa
Mid-Penile Proximal Penile Penoscrotal
Bracka 38 (44.2) 43 (50) 5 (5.8)
Duckett 34 (43.6) 41 (52.6) 3 (3.8)
Total 72(43.9) 84(51.2) 8 (4.9)
aValues are expressed as No. (%).
4. Discussion
Surgical repair of proximal hypospadias still remains
the greatest challenge, and it is important to select the cor-
rect technique to minimize complications and optimize
the functional result and final appearance. Hypospadias
repair is highly based on type and anomaly status, the
surgeon’s experience and technical selection (9,10). The
most common complications in hypospadias repair are fis-
tula and meatal stenosis. The ultimate surgical goal is to
achieve a normal or near normal appearance of penis, ade-
quate meatal caliber, neourethra extending to the apex of
glans for normal urine stream, and create a straight penis
adequate for sexual intercourse (11,12).
2Iran J Pediatr. 2017; 27(6):e7752.

Sadeghi A et al.
Figure 1. Free Graft in A, Two-Stage Bracka Technique;B, C, Vascularized Graft in Modified Bracka and Duckett Technique
Table3. Overall Results in 164 Patients Based on Technique of Hypospadias Repaira
Total Bracka Duckett P Value
Chordee 19 (11.6) 11 (12.8) 8 (10.3) 0.635
Fistula 7 (3.8) 1 (1.2) 6 (7.7) 0.054
Meatal stenosis 15 (9.1) 5 (5.8) 10 (12.8) 0.175
Re-operation 6 (3.7) 1 (1.2) 5(6.4) 0.103
Complications 28 (17) 7(8.1) 21 (26.9) 0.0017
Mean hospital stay 4.8 ±1.8 3.5 ±1.1 6.5 ±2.9 < 0.001
aValues are expressed as No. (%).
Contemporary series of single-stage repair report com-
plication rates of 20% - 50% (6,7). Generally surgical re-
pair of proximal hypospadias is performed by two cate-
gories: Free graft as Bracka technique (3) and vascularized
preputial island flap as Duckett procedure (4). Two-stage
procedure usually offers better functional and cosmetic re-
sults with fewer complications (8). The Bracka two-stage
repair is a choice procedure for severe hypospadias which
create a full circumference urethral reconstruction and
normal function with minimal complication (9,13). Fathi
et al. (11) report lower complications in Bracka technique
than in Duckett procedure. Joshi et al. (9) report that two-
stage Bracka repair for severe proximal hypospadias with
chordee and/or poor urethral plate is a good option with
satisfactory results. Second layer in form of vascularized
dartos or tunica vaginalis flap is perhaps mandatory to pre-
vent fistula formation. Haxhirexha et al. (10) reported that
overall complication rate of second stage was 8.3% (3 out of
36 patents) all of which occurred 6 months after surgery,
fistula developed in two (5.5%) patients that was repaired
surgically, and one partial glans dehiscence was repaired
with glansplasty. No meatal stenosis, urethral stricture, or
diverticula formation were reported (14,15). Current re-
ports believe that a two-stage Bracka procedure is a very
versatile technique which is being advised for all types of
hypospadias. This technique creates normal appearance
and function with minimal complications (12,13,16,17).
Cases with proximal hypospadias repair are at higher risk
of complications compared with distal repairs. Review of
literature notes that in one stage Duckett repair, fistula for-
mation and meatal stenosis are higher than in two-stage
techniques (18-20). Table 4 shows comparison of complica-
tions in three different studies.
4.1. Conclusions
Our study shows that in proximal hypospadias repair
modified Bracka procedure creates a better outcome and
Iran J Pediatr. 2017; 27(6):e7752. 3

Sadeghi A et al.
Table4. Comparison of Complications in Three Different Studiesa
Researcher Bracka Duckett
Fistula Meatal Stenosis Fistula Meatal Stenosis
Fathi et al. (11): 21cases 0 2 (0.4) 6 (1.2) 4 (0.8)
Joshi et al. (9): 43 cases 1 (0.2) 1 (0.2) 2 (0.5) 1 (0.2)
Current study: 164 cases 1 (1.2) 6 (7.7) 11(12.8) 8 (10.3)
aValues are expressed as mean ±SD or No. (%).
minimal complication rate compared with Duckett tech-
nique.
Acknowledgments
We would like to thank Mrs Sayeh Hatefi for her kind
help in preparing the references and submitting this
manuscript.
Footnote
Funding/Support: This study was financially supported
by the office of the vice chancellor for clinical research of
Mofid Children’s Hospital.
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