Hypospadias in toddlers: a multivariable study of prognostic factors in distal to mid-shaft hypospadias and review of literature

BackgroundTubularized 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.MethodsA 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.ResultsPersistent 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).ConclusionsOur 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.

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A Prospective Study of Outcomes After Tubularized Incised Plate (TIP) Urethroplasty: a Multivariable Analysis of Prognostic Factors in Children

10.1101/2020.09.15.20193037 ◽

2020 ◽

Author(s):

M. Reza Roshandel ◽

Fahimeh Kazemi Rashed ◽

Tannaz Aghaei Badr ◽

Samantha Salomon ◽

Mohammad Seyyed Ghahestani ◽

...

Keyword(s):

Prognostic Factors ◽

Young Children ◽

Prospective Study ◽

Multivariable Analysis ◽

Fistula Formation ◽

Hypospadias Repair ◽

Urethral Plate ◽

Tubularized Incised Plate ◽

Study Population ◽

The Impact

SummaryBackgroundTubularized incised plate (TIP) urethroplasty as the most common hypospadias repair method, aims to achieve normal functioning of the penis along with cosmetic reconstruction. However, there are remaining questions toward anatomical prognostic factors affecting the results of surgery. Lack of age-matched controls or controlling for meatal location, employment of several surgical techniques or multiple surgeons, or age heterogeneity of the study population are the problems affected the results of the current body of literature.ObjectiveThis prospective study aimed to evaluate the preoperative factors to predict future complications associated with hypospadias repair outcomes in males aged between 1-3 years and performed by a single surgeon with employing multivariable analysis.Patients and methodsA prospective cohort of 101 males aging from 1 to 3 years with distal to mid-shaft hypospadias were consecutively selected for TIP repair. The urethral plate dimensions in erect and flaccid states, penile length, glans diameter, and chordee were evaluated individually before reconstruction. After surgery and during follow-up visits, the subsequent transient and persistent complications were recorded.ResultsPostoperatively, the acute transient events were observed in 42 cases (41.6%) and the persistent complications in 16 cases (15.8%). The uncomplicated group had a higher percentage of patients with distal meatal location than the complicated group (P=0.01%). Furthermore, fistula formation was notably higher in the group with acute surgical site infection (P<0.001). wedThe analysis also shothe width of the urethral plate to be associated with the development of complications (P=0.03).ConclusionBy performing TIP by a single surgeon on a homogenous study population and eliminating the impact of severe chordee as a potential cofounding variable, this study prospectively found that out of the anatomical specifications, pre- and postoperative factors, the urethral meatus location was the only significant and independent predictor of the development of complications in young children with midshaft to distal hypospadias. Moreover we found that in young children the wider the plate was, the more complications happened. Consequently, we hypostatized that in young children who their anatomical dimensions are almost in same range of values, a combination of urethral width and depth should be considered in the investigation of prognostic factors for hypospadias repair outcomes. (figure 1)

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A modification of the TIP procedure for distal hypospadias: The burrowing technique

Canadian Urological Association Journal ◽

10.5489/cuaj.1677 ◽

2014 ◽

Vol 8 (5-6) ◽

pp. 425 ◽

Cited By ~ 1

Author(s):

Erin D. Wishart ◽

Peter D. Metcalfe

Keyword(s):

Odds Ratio ◽

Complication Rates ◽

Hypospadias Repair ◽

Multiple Series ◽

Urethral Plate ◽

Tubularized Incised Plate ◽

Tubularized Incised Plate Urethroplasty ◽

Distal Hypospadias ◽

Hypospadias Surgery ◽

Reoperation Rates

Introduction: The tubularized incised plate urethroplasty (TIP) hypospadias repair is a commonly performed procedure for hypospadias. Multiple series document excellent cosmetic outcome in conjunction with low complication rates. We describe a modification that we have named the “burrowing technique.” We believe that this technique facilitates dissection of the glans, which improves mobility, decreases tension with closure, and potentially improves outcomes.Methods: A retrospective review was performed of 193 coronalor mid-shaft hypospadias repairs by a single surgeon. The first 98 were performed using the TIP procedure, then the burrowing technique was developed and a subsequent 95 were analyzed for outcomes using this modification. Urethral plate characteristics and glandular size did not influence the choice of surgical technique. Cases were selected to allow for a “learning curve,” and were consecutively accrued. None of the boys had undergone prior hypospadias surgery. Proximal 2 stage repairs and distal (glanular) repairs were excluded.Results: A total of 193 boys underwent repair, 98 with the traditional TIP procedure and 95 using the burrowing modification. In total, 37 (19.2%) patients required re-operation for either fistulas or dehiscence; 23 (23.5%) in the non-burrowing group and 14 (14.7%) in the burrowing group, odds ratio 0.54 (p = 0.10).Conclusions: The TIP procedure has revolutionized the management of distal hypospadias. The burrowing modification increases glandular mobility simplifying the procedure and demonstrates a non-statistically significant trend in reducing reoperation rates.

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Redo hypospadias repair by a single surgeon after failed hypospadias surgeries: Experience from a developing country

10.36811/gju.2020.110010 ◽

2020 ◽

pp. 17-23

Author(s):

Md. Abdullah Al Farooq ◽

MA Mushfiqur Rahman ◽

Tanvir Kabir Chowdhury

Keyword(s):

Developing Country ◽

Complication Rate ◽

Hypospadias Repair ◽

Urethral Plate ◽

Meatal Stenosis ◽

Tubularized Incised Plate ◽

Tubularized Incised Plate Urethroplasty ◽

Principal Author

Background: Hypospadias surgeries are often complicated with fistulas, meatal stenosis and disruptions. We report our series of redo surgeries for failed primary repairs. Methods: We prospectively observed all the redo hypospadias repairs done by the principal author between 2013 and 2017. Thiersch-Duplayurethroplasty was done if the urethral plate was adequately wide and intact; tubularized incised plate (TIP) urethroplasty was performed if the urethral plate was intact but, narrower than 8 mm; 2 stage procedures were done with oral mucosal graft (OMG) if the urethral plate was deficient or scarred with significant chordee. Result: There was a total of 31 patients. Age ranged from 18 months to 15 years (mean 8.05 ±4.27 years). Sixteen (51.61%) patients underwent only one surgery, 10 (32.26%) patients underwent 2 surgeries, 2 patients (6.45%) underwent 3 surgeries, and 3 patients (9.68%) underwent 4 surgeries prior to presenting to us before our redo surgeries.We had performed TIP urethroplasty in 16 (51.61%) patients, meatal based flap urethroplasty in 12 (38.71%), OMG followed by urethroplasty in 2 (6.45%), and repair of urethra-cutaneous (UC) fistula in 1 (3.23%) patient. Ten (32.26%) Complications occurred in 8 (25.80%) patients. Unsuccessful repair was noted in 03 (9.67%) patients (UC fistula 1, glans dehiscence with UC fistula 1, and glans dehiscence 1). Conclusion: Thiersch-Duplay and TIP repair can be successfully performed in redo hypospadiassurgeries with acceptable complication rate. OMG graft can be reserved for cases with gross scarring of the urethral plate. Keywords: Failed hypospadias repair; Tubularized incised plate urethroplasty; Thiersch-Duplay; Outcome

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TUBULARIZED INCISED PLATE URETHROPLASTY FOR ONE-STAGE HYPOSPADIA REPAIR IN CHILDREN AT HASAN SADIKIN HOSPITAL BANDUNG

Indonesian Journal of Urology ◽

10.32421/juri.v24i2.330 ◽

2017 ◽

Vol 24 (2) ◽

Author(s):

Harris Oetama ◽

Safendra Siregar

Keyword(s):

Fistula Formation ◽

Hypospadias Repair ◽

One Stage ◽

Tubularized Incised Plate ◽

Operative Complications ◽

Highly Effective ◽

Tubularized Incised Plate Urethroplasty ◽

The Mean ◽

Post Operative Complications

Objective: To determine the outcome of tubularized incised-plate (TIP) urethroplasty for one stage hypospadia repair in children. Material & methods: A 7-year retrospective experience at Hasan General Sadikin Hospital Bandung on the outcome of tubularized incised plate for one-stage hypospadias repair in children during 2009-2015. Results: A total of 102 children was undergone one stage hypospadias repair with TIP urethroplasty. The mean age was 6.97 years old. As much as 65 (63.72%) children had distal, and 37 (36.28%) children had proximal hypospadia. The mean length of surgery was 112.56 minutes. Post operative complications was rarely found, consisting of 5 (6.32%) children had urethrocutaneus fistula formation and 11 (13.9%) children had haematoma. 4 (10.81%) children with proximal hypospdia and 1 (1.53%) children with distal hypospadia had urethrocutaneus fistula formation. 4 (6.15%) children with distal hypospadia and 7 (18.91%) children with proximal hypospadia had haematoma. Conclusion: Tubularized incised-plate (TIP) urethroplasty for one stage hypospadia repair in children was highly effective with rare complications comparable with recently published study.

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A Comparative Study to Evaluate the Outcome of Double Dartos Flap in Tubularized Incised Plate Urethroplasty for Distal Hypospadias Repair

Journal of Paediatric Surgeons of Bangladesh ◽

10.3329/jpsb.v3i2.23915 ◽

2015 ◽

Vol 3 (2) ◽

pp. 65-70

Author(s):

Abhi Kumar Chakraborty ◽

Sajal Kumar Majumdar ◽

Mirza Kamrul Zahid ◽

Sayed Mahmudur Rahman ◽

Dipankar Kumar Saha ◽

...

Keyword(s):

Double Layer ◽

Fistula Formation ◽

Hypospadias Repair ◽

Tubularized Incised Plate ◽

Superficial Skin ◽

Group A ◽

Dartos Flap ◽

Tubularized Incised Plate Urethroplasty ◽

Distal Hypospadias ◽

Group B

Background/purpose: The tubularized incised plate urethroplasty (Snodgrass technique) presents the procedure of choice for distal hypospadias repair. Fistula formation is the most common complication with various rates. Avoiding overlap of suture lines in the Snodgrass repair is critical to minimize fistula formation through second-layer coverage of the neourethra. We compared the outcome of double- layer dartos flaps to flapless procedure in the tubularized incised plate urethroplasty for distal hypospadias repair to assess the effectiveness of dartos flap in this method.Methods: Our study included 28 patients aged upto 12 years who were treated with tubularized incised plate urethroplasty for distal hypospadias in Shaheed Suhrawardy Medical College Hospital from April 2010 to December 2011. They were divided into two groups. Group A (14 patients) had double dartos flap coverings. Group B (14 patients) had no dartos flap covering. The dissected dorsal dartos flap was bisected vertically to form two pedicle wings. Each wing was rotated laterally from either side of the glans to cover the neourethra ventrally in a double-layer fashion.Result: Mean follow up period was 9 months. In Group A, one patient (7%) developed fistula and one (7%) superficial skin necrosis. On the other hand three (21%) patients developed fistula and one patient (7%) meatal stenosis in group B, who were treated with Snodgrass procedure without using dartos flap. All successful repaired hypospadias patients of both groups had a cosmetically normal looking circumcised penis with ventrally slit meatus.Conclusions : Double dartos flaps covering of the neourethra is a simple procedure and could be effective for the prevention of urethrocutaneous fistula after tubularized incised plate urethroplasty.J. Paediatr. Surg. Bangladesh 3(2): 65-70, 2012 (July)

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Role of the urethral plate characters in the success of tubularized incised plate urethroplasty

Indian Journal of Plastic Surgery ◽

10.4103/0970-0358.138956 ◽

2014 ◽

Vol 47 (02) ◽

pp. 221-237 ◽

Cited By ~ 2

Author(s):

Hamdy Aboutaleb

Keyword(s):

Fistula Formation ◽

Success Rates ◽

Flat Plates ◽

Urethral Plate ◽

Tubularized Incised Plate ◽

Plate Shape ◽

Fistula Rate ◽

Universal Applicability ◽

Complications Rate ◽

Plate Width

ABSTRACT Background: Today, tubularized incised plate (TIP) urethroplasty is the most commonly performed operation for distal and mid-penile hypospadias. Reports from different centers worldwide confirm its nearly universal applicability and low complications rate. Aim: Evaluation of the urethral plate characters and its effect on the outcome of TIP urethroplasty. Materials and Methods: Between 2010 and 2013, 100 children with primary distal penile hypospadias underwent TIP urethroplasty. Urethral plates were categorized as flat, cleft, and deeply grooved. Postoperatively, patients were followed-up for evaluation of meatal stenosis, fistula formation, and glandular dehiscence at 1 st , 3 rd and 6 th months. Patients were followed-up for urethral calibration by urethral sound 8 Fr at 3 rd and 6 months follow-up. Data were statistically analysed using Epi info program to correlate between the width, plate shape, and complications. Results: Mean age at surgery was 4.3 years. Patients were followed-up for an average period of 6.4 months. Pre-operative location of the meatus was reported as coronal in 46, subcoronal in 50 and anterior penile in 4 cases. Urethral plate characters were flat in 26 cases, cleft in 52, and deeply grooved in 22. Urethral plate width was >8 mm in 74 cases and <8 mm in 26. Patients with urethral plate <8 mm had a statistically significant higher fistula rate (P = 0.004) and failed 8 Fr calibrations in 26.9% (P = 0.01) compared with the patients with urethral plate >8 mm. In addition, we also founds higher fistula rate and failed 8 Fr calibrations in flat urethral plate. Conclusions: An adequate urethral plate width (>8 mm) is essential for successful TIP repair. Lower success rates with flat plates may need buccal mucosal augmentation to improve the results.

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Midshaft Hypospadias: Review of Surgical Technique

10.2310/uro.11047 ◽

2019 ◽

Author(s):

Erin R. McNamara ◽

Bryan Sack ◽

Alan B. Retik

Keyword(s):

Surgical Technique ◽

Key Words ◽

Common Type ◽

Hypospadias Repair ◽

Urethrocutaneous Fistula ◽

Tubularized Incised Plate ◽

Dartos Flap ◽

Tubularized Incised Plate Urethroplasty ◽

Skin Coverage

Surgical technique for midshaft hypospadias has evolved since the time of Horton and Devine. The most common type of repair that is currently used is the tubularized incised plate urethroplasty, which is a modification of the Thiersch-Duplay hypospadias repair. The authors review the steps of this procedure in detail and discuss troubleshooting for issues that may arise during the repair. Alternatives for chordee correction and skin coverage are reviewed. The authors briefly discuss outcomes and possible complications. In addition, there is a step-by-step video of a midshaft hypospadias repair that highlights the surgical technique. This review contains 9 figures, and 23 references. Key Words: chordee, dartos flap, hypospadias, midshaft hypospadias, surgical technique, tubularized incised plate (TIP), urethrocutaneous fistula, ventral curvature

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Histological and Biochemical Evaluation of Urethral Scar following Three Different Hypospadias Repairs: An Experimental Study in Rabbits

European Journal of Pediatric Surgery ◽

10.1055/s-0037-1605347 ◽

2017 ◽

Vol 28 (05) ◽

pp. 420-425 ◽

Cited By ~ 1

Author(s):

Xiao-Hui Tan ◽

Chun-Lan Long ◽

De-Ying Zhang ◽

Tao Lin ◽

Da-Wei He ◽

...

Keyword(s):

Transforming Growth Factor ◽

Smooth Muscle Actin ◽

White Male ◽

Transforming Growth Factor Β1 ◽

Rational Approach ◽

Hypospadias Repair ◽

Tubularized Incised Plate ◽

Biochemical Evaluation ◽

Tubularized Incised Plate Urethroplasty ◽

Tgf Β1

Introduction Several urethroplasties have been employed in the surgical treatment of hypospadias. Neourethral strictures are among the most common postoperative complications that often require reoperation. Materials and Methods We created a hypospadias model in New Zealand white male rabbits through a hypospadias-like defect and acute repair. A total of 24 animals were randomly allocated into three groups: tubularized incised-plate urethroplasty (TIPU) group (8), perimeatal-based flap urethroplasty (Mathieu) group (8), onlay island flap urethroplasty (onlay) group (8), and corresponding surgical procedures were immediately performed to reconstruct neourethra. The rabbits were killed postoperatively at 5 days, 2 weeks, 6 weeks, and 3 months, respectively. The penile tissue was harvested for histological and biochemical investigations to evaluate the expressions of transforming growth factor β1 (TGF-β1) and α-smooth muscle actin (α-SMactin) in all groups. Results All rabbits were operated on uneventfully. The amount of collagen content was increased in the Mathieu and onlay groups than in the TIPU group (p < 0.05). Biochemical analysis showed that the expression of TGF-β1 in the TIPU group was decreased compared with the two other groups at 2 or 6 weeks postoperatively (p < 0.01). The expression pattern regarding α-SMactin was similar at 6 weeks or 3 months postoperatively (p < 0.01). Conclusion The neourethra repaired by TIPU was practically resumed to normal anatomy and scarring was less apparent than the two other groups. Therefore, TIPU is considered as a relatively rational approach for hypospadias repair. The activity of fibroblasts has been increased in the long term, which may be the pathogenesis of neourethral stricture following hypospadias repair.

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Redo hypospadias repair: experience at a tertiary care children’s hospital

Canadian Urological Association Journal ◽

10.5489/cuaj.39 ◽

2012 ◽

Vol 1 (1) ◽

Author(s):

Ahmed Al-Sayyad ◽

John G. Pike ◽

Michael P. Leonard

Keyword(s):

Tertiary Care ◽

Institutional Review Board ◽

Hypospadias Repair ◽

Urethral Plate ◽

Institutional Review ◽

Tubularized Incised Plate ◽

Distal Shaft ◽

The Status ◽

Initial Severity

Objective: Treatment of patients with failed hypospadias repairs can be challenging.Our study aimed to determine the best type of redo repair dependingon the location and size of the urethral meatus, the status of the urethralplate and genital skin, the severity of residual chordee and the amount ofscar tissue.Methods: The Institutional Review Board approved our retrospective chart reviewof patients who had a redo hypospadias repair at our institution over the past6 years. We recorded the type and number of previous repair(s), the type andnumber of redo procedure(s),as well as the complications and functional outcomes.Results: There were 28 patients, aged 1–12 (mean 3.8) years, with failed hypospadiasrepairs. The initial severity of the hypospadias were as follows: perineal(1), penoscrotal (9), proximal shaft (1), mid-shaft (9), distal shaft (4), coronal(3) and mega-meatus (1). Of all the patients, 24 had 1 repair, 3 had 2 repairsand 1 had 3 repairs. The initial repairs comprised 11 tubularized island flaps(TIFs), 8 Snodgrass tubularized incised plate (TIP) techniques, 5 Mathieu repairs,1 Meatal Advancement and GlanuloPlasty Incorporated (MAGPI) technique,1 Pyramid, 1 Arap technique and 1 Thiersch-Duplay repair. Twenty-one of 28 patients had 1 redo operation, 5 had 2 redo operations, 1 had 3 redo operationsand 1 had 4 redo operations, for a total of 38 redo operations. Of these,26 were TIP techniques (68.4%), 3 were Mathieu (7.9%), 3 were TIF repairs(7.9%), 2 were onlay island flaps (5.3%) and 4 were buccal mucosal grafts(10.5%). Follow-up was 1–5 years (mean 3.5 yr). The final locations of urethralmeatus included glans (18), corona (6), mid-shaft (3) and penoscrotal (1).Complications after redo surgery comprised 4 urethrocutaneous fistulae, 2 meatalstenoses, 1 urethral stricture and 3 dehiscences. Sixteen patients were followedwith yearly uroflow with a Q-mean (mean uroflow) range of 3–14 mL/s (mean8.1 mL/s).Conclusion: The majority of hypospadias failures can be salvaged with one operation.The TIP repair is our procedure of choice in most cases. In the settingof a poor urethral plate, TIF or buccal mucosa may be necessary. Complicationsare not infrequent in redo procedures.

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Hypospadias Repair: A Single Centre Experience

Plastic Surgery International ◽

10.1155/2014/453039 ◽

2014 ◽

Vol 2014 ◽

pp. 1-7 ◽

Cited By ~ 6

Author(s):

Mansoor Khan ◽

Abdul Majeed ◽

Waqas Hayat ◽

Hidayat Ullah ◽

Shazia Naz ◽

...

Keyword(s):

Social Sciences ◽

Postoperative Complications ◽

Single Stage ◽

Hypospadias Repair ◽

Surgical Skill ◽

Two Stage ◽

Urethral Plate ◽

Single Centre Experience ◽

Male Patients ◽

Hypospadias Surgery

Objectives. To determine the demographics and analyze the management and factors influencing the postoperative complications of hypospadias repair. Settings. Hayatabad Medical Complex Peshawar, Pakistan, from January 2007 to December 2011. Material and Methods. All male patients presenting with hypospadias irrespective of their ages were included in the study. The data were acquired from the hospital’s database and analyzed with Statistical Package for Social Sciences (SPSS). Results. A total of 428 patients with mean age of 8.12 ± 5.04 SD presented for hypospadias repair. Midpenile hypospadias were the most common. Chordee, meatal abnormalities, cryptorchidism, and inguinal hernias were observed in 74.3%, 9.6%, 2.8%, and 2.1% cases, respectively. Two-stage (Bracka) and TIP (tubularized incised urethral plate) repairs were performed in 76.2% and 20.8% of cases, respectively. The most common complications were edema and urethrocutaneous fistula (UCF). The complications were significantly lower in the hands of specialists than residents (P-value = 0.0086). The two-stage hypospadias repair resulted in higher complications frequency than single-stage repair (P value = 0.0001). Conclusion. Hypospadias surgery has a long learning curve because it requires a great deal of temperament, surgical skill and acquaintance with magnifications. Single-stage repair should be encouraged wherever applicable due to its lower postoperative complications.

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