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

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

Tubularized incised plate urethroplasty for distal and midpenile hypospadias reoperation: A single institute experience

Journal of Clinical Urology ◽

10.1177/2051415817715401 ◽

2017 ◽

Vol 11 (3) ◽

pp. 178-183

Author(s):

Elsayed M Salih ◽

Abdelbaset Elemam ◽

Mohamed Elfeky ◽

Abdrabuh M Abdrabuh ◽

Hussein A Galal

Keyword(s):

Complication Rate ◽

Medical Records ◽

Functional Outcomes ◽

Alternative Procedure ◽

Urethral Plate ◽

Simple Closure ◽

Meatal Stenosis ◽

The Third ◽

Tubularized Incised Plate Urethroplasty

Objective: Our study aimed to evaluate our experience in tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Patients and methods: This was a retrospective study in which we reviewed the medical records of 56 patients who underwent tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Tubularized incised plate urethroplasty was performed using a surgical technique like the primary tubularized incised plate repair based on the Snodgrass’s method. We recorded complications and functional outcomes of redo procedures. Results: We reviewed 56 patients who ranged in age from 2–16 years (mean 7.02±3.8 years). The overall complication rate was 33.9% ( n=19). Eight patients (14.3%) had fistula, six had meatal stenosis (10.7%), four had dehiscence (7.1%), and one had neourethral stenosis (1.8%). The complications occurred in 13 of mid-penile cases representing 50% of mid-penile cases but occurred in six cases of distal-penile cases (20%). The success rate of tubularized incised plate urethroplasty reoperation was 94.6% after repair of fistula and meatal stenosis by simple closure of fistula and meatoplasty. Conclusion: Tubularized incised plate urethroplasty is a safe and effective alternative procedure for hypospadias reoperations. The outcome is favorable if the urethral plate has no scars and with distal meatal location. The complication rate increases if the third redo is done and with midpenile meatal location.

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

World Journal of Pediatric Surgery ◽

10.1136/wjps-2020-000225 ◽

2022 ◽

Vol 5 (1) ◽

pp. e000225

Author(s):

M Reza Roshandel ◽

Tannaz Aghaei Badr ◽

Fahimeh Kazemi Rashed ◽

Samantha Salomon ◽

Seyyed Mohammad Ghahestani ◽

...

Keyword(s):

Prognostic Factors ◽

Fistula Formation ◽

Hypospadias Repair ◽

Urethral Plate ◽

Factors Affecting ◽

Multivariable Regression ◽

Predicting Factor ◽

Hypospadias Surgery

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.

Comparison of Modified Mathieu versus Standard Tubularised Incised-Plate Urethroplasty for Distal Hypospadias Repair

Austin Journal of Urology ◽

10.26420/austinjurol.2021.1068 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Naeem M ◽

◽

Khan MK ◽

Shah G ◽

Izhar M ◽

...

Keyword(s):

Categorical Variables ◽

Fisher Exact Test ◽

Hypospadias Repair ◽

Urethral Plate ◽

Meatal Stenosis ◽

Group I ◽

Distal Hypospadias ◽

The Difference ◽

Mathieu Procedure

Objective: To compare the outcomes of modified Mathieu versus standard tubularised incised-plate urethroplasty for distal hypospadias repair. Materials and Methods: This prospective comparative study was conducted on 54 cases affected by distal hypospadias presenting to Institute of Kidney Disease, Hayatabad, Peshawar form February 2015 to June 2020. The inclusion criteria was patients with distal hypospadias (coronal, sub-coronal, or distal penile), age range of 15 to 60 months. Cases with severe chordee/ventral curvature, history of previous hypospadias repair, and poorly developed urethral plate were excluded. The patients with distal hypospadias were divided into two equal groups: in-group I repair done with Mathieu procedure plus incision of the urethral plate (modified Mathieu) and in-group II repair was performed with Tubularized Incised Plate (TIP). The principal author performed functional and cosmetic assessment at follow up visits which includes; denvo meatus; size and pressure of the stream; and complications like meatal stenosis, urethral cutaneous fistula. Fisher Exact test was used to compare categorical variables between the two groups and student t test for continuous variables. Results: The mean age of the study was 38.13±12.55 months. The operating time was less in TIP than modified Mathieu procedure statistically (P=0.036, 95% CI=0.315, 9.02). In modified Mathieu procedure the sprayed stream of micturition was higher (n=4, 14.8%) while in TIP procedure the frequency of narrow stream was higher (n=4, 14.8%). The difference was statistically significant (P=0.054). Only in modified Mathieu procedure the meatus shape was round in 4 (14.8%) cases and the results were statistically different (P=0.038). Post-operative fistula was higher TIP (n=6, 22.2%) than modified Mathieu (n=1, 3.7%) statistically (P=0.043). Only in TIP procedure postoperative meatal stenosis was found in 5 (18.5%) and the difference was statistically significant (P=0.019). Conclusion: The modified Mathieu technique can improve the cosmetic outcome through creation of slit-like meatus, low incidence of fistula and meatal stenosis than tubularized incised plate urethroplasty in the repair of distal hypospadias.

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 ◽

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.

The experimental study on the tubularized incised plate (tip) urethroplasty in children on the central India

International Surgery Journal ◽

10.18203/2349-2902.isj20181593 ◽

2018 ◽

Vol 5 (5) ◽

pp. 1838

Author(s):

Shobhita K. Mane ◽

Santosh Kumar

Keyword(s):

Experimental Study ◽

Experimental Research ◽

Complication Rate ◽

Central India ◽

Fistula Closure ◽

Urethral Plate ◽

Proximal Hypospadias ◽

Tubularized Incised Plate Urethroplasty

Background: The main objective of the present study is assessment of the tubularized incised plate (TIP) urethroplasty. The present study was done in experimental research design.Methods: We had started Tubularized incised plate urethroplasty as developed by Warren Snodgrass in all boys having coronal sub-coronal, distal, mid, and proximal hypospadias where urethral plate is intact.Results: Out of 37 patients 17 patients developed fistulas at different sites, 10 patients had coronal fistula, 2 distal penile and one mid-shaft fistula. 2 patients who had fistula closure with urethroplasty for distal urethra by TIP developed reopening of fistula. 7 patients had thinning of stream out of which 3 patients developed immediate post-operative. It was managed by meatal dilatation. 4 patients complained thinning of stream after l0 days to one month. All patients were advised meatal dilatation. Stream improved later on in 6 patients. In 7 patients fistulas also closed spontaneously.Conclusions: It is also found and concluded that the total number of the complication rate between primary and re-operative in TIP method is very low; it means TIP method is very useful and effective.

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 ◽

Dartos Flap ◽

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

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 ◽

Biochemical Evaluation ◽

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.

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 ◽

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.