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.

Predictors of successful outcome of tubularized incised plate for primary distal hypospadias repair

Background Several preoperative factors affect the outcome of Tabularized Incised Plate (TIP) repair. Our aim was to collect and analyze all these factors to define what the most important predictive factors are. Methods Hundred patients (1–5 years old) with primary distal hypospadias were included. Exclusion criteria included previous penile operations and hormonal treatment or associated congenital anomalies. Anogenital distance (AGD), stretched penile length (SPL), meatal site, glanular shape, chordee and torsion degree, plate width and glans meatus shaft (GMS) score were assessed. TIP repair was done to all patients and followed up for one year. The outcome was correlated with the above parameters. Results Mean ± SD of age of patients was 3.5 ± 1.5 years, while weight was 14.1 ± 3.0 kg. Complication rate was 18% including urethrocutaneous fistula (UCF) and meatal stenosis 14%, repair breakdown 1% and urethral stricture 3%. Patients with chordee degree < 30° and distal penile meatal location were associated with increased risk for complications by 11.6 and 8.2 times; 95% CI was (1.46–91.75) and (1.02–66.52), respectively (p < 0.05 for each). Plate width ≥ 9 mm, AGD > 5 cm, GMS score ≤ 7 (p < 0.001 for each), age of patient ≤ 2 years old, and SPL > 3.5 cm (p < 0.01 for each) were associated with successful outcome of repair. Conclusion The proposed successful criteria of TIP repair were absent chordee, coronal/subcoronal penile meatal location, plate width ≥ 9 mm, AGD > 5 cm, age of patient ≤ 2 years old, GMS score ≤ 7, SPL > 3.5 cm and grooved glanular shape.

Cosmetic outcomes of grafted tubularized incised plate urethroplasty in primary distal penile hypospadias: prospective comparative study with the classic Snodgrass repair

Background To compare the outcomes between classic tubularized incised plate (C-TIP), known as Snodgrass urethroplasty, and grafted TIP (G-TIP) in the repair of primary distal penile hypospadias. Methods Parents of all children presented to our tertiary care institution with primary distal penile hypospadias were asked to participate in this study. Patients were equally randomized using closed envelope method into two groups; Group A underwent repair using G-TIP and Group B underwent repair using the C-TIP. Circumcised cases and/or cases with penile chordee > 30 degrees were excluded from this study. Urethral catheter was kept for 7 to 10 days after surgery. The success rate and cosmetic outcomes assessed by HOSE score were evaluated at 6-month postoperatively. Results A total of 55 patients were recruited in each group. One hundred and seven patients of the 110 patients (54 and 53 in groups A and B, respectively) were evaluated at 6-month postoperatively using HOSE score. All preoperative data were comparable in both groups. Success was documented in 49/54 patients (90.7%) in group A. The five failures were secondary to two cases of glans dehiscence and three cases of residual postoperative chordee. Whereas, success was documented in 48/53 patients (90.5%) in group B. Complications were: a case of meatal stenosis, three cases of fistula, and a case of combined meatal stenosis and fistula. The HOSE score was comparable between the two groups (15.4 ± 1.09 vs. 15.6 ± 0.55; p = 0.29). However, the operative time was statistically longer in the G-TIP compared with the C-TIP (91.4 ± 6.2 min vs. 85.2 ± 6.3 min; p < 0.001), respectively. Conclusion The G-TIP urethroplasty provided comparable results with C-TIP in terms of cosmoses, success rate, and complications. However, G-TIP was accompanied with significantly longer operative time.

A comparative study of two operative procedures in anterior hypospadias repair: limited urethral mobilization and tubularized incised plate urethroplasty.

Objectives: This study is aimed to compare the results of limited urethral mobilization and tubularized incised plate urethroplasty in the management of anterior hypospadias, in terms of cosmetic and functional outcomes, complication rate, operative time, and hospital stay. Study Design: Prospective Randomized Controlled study. Settings: Department of Pediatric Surgery, DHQ Teaching Hospital Sahiwal. Period: January 2019 to December 2020. Material and Methods: A total of 89 patients with anterior hypospadias were included. Patients were divided randomly into two groups. In group A, limited urethral mobilization was performed and in group B, tubularized incised plate urethroplasty was carried out. A self-structured performa was used to collect the data of all patients. Both groups were compared in terms of the operation time, hospital stay, postoperative complications, cosmetic appearance, and functional outcomes. Results: Forty-five patients were included in group A, age ranged from 2.5 to 12 years (mean 4.83years). Forty-four patients were included in group B and their ages ranged from 3.5 to 11years (mean 4.76 years). The operation time was significantly less for group A than for group B. In group A, it ranged from 54 to 69 min with an average time of 60.51 min and in group B from 70 to 88 min, with an average of 79.34 min. The mean hospital stay period in group A was 7.37 days, ranged from 7 to 9 days, and in group B was 11.04 days, ranging from 10 to 13 days. The mean follow-up period in both groups was 7.45 months, ranging from 3 months to 12 months. Meatal stenosis was the most common complication in group A, which developed in 6.66% (n=3) patients. Urethrocutaneous fistula was the most common complication in group B, which developed in 6.81% (n=3) patients. Cosmetic appearance and functional outcome were good and comparable in both groups. Conclusion: Although both techniques, tubularized incised plate and limited urethral mobilization urethroplasty are acceptable modalities for the management of anterior hypospadias. But limited urethral mobilization urethroplasty seems to be a good option due to its simplicity, short hospital stay, significant shorter operative time, low fistula formation rate, and good cosmetic and functional outcomes.

Snodgrass procedure for distal penile and mid-shaft hypospadias repair in children

Introduction. Hypospadias is one of the most frequent penile malformations in newborn boys. Warren Snodgrass developed the «tubularized incised plate» (TIP) urethroplasty that is the most often procedure used in the surgical treatment of distal hypospadias for the last 20 years. Despite the great popularity of the technique, its no less famous Grafted TIP (GTIP) modification appeared. The technique is aimed at filling the defect in the urethral site with a foreskin free flap followed by tubularized urethroplasty.Purpose of the study. To compare the outcomes of TIP and GTIP procedures in our clinic which have been performed in the last 10 years.Materials and methods. One hundred-fourteen boys with hypospadias (aged 6 mo – 15 years) were operated on using the TIP technique and its modification GTIP during 2010 – 2020 (Sochi Center of Motherhood and Childhood Protection). The patients were: boys up to 1 year – 27 (23.7%), from 1 to 3 years – 57 (50%), 4 – 7 years – 19 (16.7%), from 8 to 14 years – 14 (12.3%). Primary repair was done in 112 cases (98.2%), the second procedure was done in 2 (1.8%) cases. There were 94 (82.5%) boys with distal hypospadias and 20 (17.5%) children with mid-shaft hypospadias. All patients were examined 3 and 12 months after surgery. We assessed the degree of skin scar process on the penile shaft, the location of the meatus and the quality of urination during the examination.Results. We observed 27 (23.7%) complications after urethroplasty out of 114 treated boys. There were 13 (11.4%) cases of urethral fistula, which were secondary repaired 6 months later. Meatal stenosis was observed in 2 (1.8%) cases, which required secondary meatoplasty. Repeat urethroplasty was done in 10 (8.7%) cases due to neourethral suture failure. There were also 2 (1.8%) cases of secondary penile curvature that required repeat surgery. The good cosmetical and functional results were achieved finally in all children.Conclusion. The analysis of our ten-year experience of using TIP-urethroplasty and its GTIP modification did not reveal significant differences in the overall incidence of postoperative complications. Yet, using the TIP procedure is associated with more fistulas. There were more cases of urethral suture failure in children whom the GTIP technique was performed. Our data suggest the need for a selective approach in the formation of indications for using TIP and GTIP procedures, along with research aimed at finding criteria for patient selection.

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

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.

Comparing Mathieu and Tubularized Incised-Plate Urethroplasties for Repairing Distal Penile Hypospadias: A Single-Center Experience with Long-Term Outcome

Background: Hypospadias is a congenital anomaly on the penis, in which the meatal orifice opens ventrally and proximal to the tip of the penis. In this regard, two common treatment methods are tubularized incised-plate urethroplasty (TIP) and the Mathieu incised-plate (MIP) technique. The present study aimed to compare the early and long-term outcomes of TIP and MIP among patients with distal penile hypospadias. Objectives: The study was also to evaluate the postoperative functional outcome of hypospadias over a long-term follow-up. Methods: Fifty-nine patients were randomly selected and assigned to two groups (TIP (n = 31) and MIP (n = 28)). Demographic information, preoperative findings, and postoperative complications were collected from the two groups. The Hypospadias Objective Scoring evaluation (HOSE) questionnaire and uroflowmetry were obtained to evaluate the long-term outcome of hypospadias repair. Results: The success rates of the surgical TIP and MIP techniques were 71.0% and 82.1%, respectively. Postoperative complications in the TIP group were three (9.7%) distal UCF and four (12.9%) meatal stenosis. In the MIP group, two (7.1%) and three (10.7%) patients suffered from distal UCF and meatal stenosis, respectively. Moreover, 89.3% of the patients in the MIP group and 80% of the patients in the TIP group had acceptable HOSE. Regarding the uroflow rates in the MIP group, 12% and 58% of the participants were below the 5th percentile and above the 25th percentile, respectively. Concerning the uroflow rates of TIP, 32% of the patients were below the 5th percentile, and 18% of the participants were above 25th percentile. Conclusions: Although there have been some reports on the superiority of TIP, we found these two techniques at approximately equal levels with a slightly higher success rate for the MIP regarding the early outcomes. With the exception of the long-term outcomes in cosmetic and functional evaluation, MIP is superior to TIP.

Comparison of Dartos flap and spongioplasty in Snodgrass urethroplasty in distal penile hypospadias

BackgroundHypospadias surgery has been continuously evolving, although there is no single technique which can be said to be perfect and suitable for all types of hypospadias. Tubularized incised plate (TIP) urethroplasty (Snodgrass procedure) is presently the most common surgical procedure performed for distal penile hypospadias (DPH). The aim of this study was to compare the outcome of TIP urethroplasty using Dartos flap (DF) and spongioplasty as second layer in DPH.MethodsA total of 30 patients of DPH were repaired using TIP urethroplasty with DF or spongioplasty as second layer from January 2017 to June 2018. Out of 30 patients, TIP with DF was done in 15 patients (group A) and TIP with spongioplasty was done in the remaining 15 patients (group B). Preoperative mean age and weight were comparable in both groups. Postoperative complications, namely, postoperative edema, residual chordee, urethrocutaneous fistula (UCF), meatal stenosis and final cosmesis, were recorded.ResultsIn both groups, complications included postoperative edema (Gp A-1Gp B-1), residual chordee (Gp A-1, Gp B-1), UCF (Gp A-3, Gp B-4), meatal stenosis (Gp A-1, Gp B-5) and poor cosmesis (Gp A-3, Gp B-4). Wound infection was managed with appropriate antibiotics, and meatal stenosis responded to calibration in five patients.Although it seems that DF has a better outcome clinically, the difference between the two techniques was statistically not significant.ConclusionDF as an additional cover to TIP is associated with an acceptable complication and has good cosmesis compared with spongioplasty; however, the difference is not statistically significant.