The contemporary role of 1 vs. 2-stage repair for proximal hypospadias

This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved—a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and—depending on technique—have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.     

Penoscrotal transposition: review of 53 patients

PURPOSE: Penoscrotal transposition is a rare congenital abnormality of the external genitalia. We determine whether there is a genetic basis for this disorder, define the incidence of coexisting organ system anomalies, and compare the results of surgical techniques to correct transposition and hypospadias. MATERIALS AND METHODS: We report the largest, single institution series of 53 patients 1 day to 30 years old with penoscrotal transposition. RESULTS: Of the patients 13% had a family history of penoscrotal transposition. Interestingly, we identified 1 family in which inheritance occurred in an X-linked recessive manner. There were 17 (32%) patients who had abnormalities in other organ systems, with the genitourinary system in 9 affected most. A total of 79% of patients had hypospadias and 81% chordee. These anomalies were corrected with a single stage Thiersch-Duplay urethroplasty in 6 patients and complex repair with bladder or buccal mucosa, or a staged procedure in 34. Complication rates for urethroplasty were similar. Correction of the transposition included a Glenn-Anderson technique in 37 patients, Singapore rotational flaps in 7 and V-Y procedure in 6. The Glenn-Anderson repair produced the best cosmetic results and was associated with a significantly lower incidence of complications (p = 0.001). CONCLUSIONS: We identified a subgroup of patients with a family history of penoscrotal transposition. Treatment requires an awareness of the association with other organ system anomalies. The Glenn-Anderson technique was the most successful method to correct transposition. Most patients required release of chordee and complex urethroplasty for hypospadias.     

One-stage repair of perineal hypospadias and scrotal transposition

Our experience with one-stage repair of severe perineal hypospadias and scrotal transposition is described. In essence the urethra is formed by our (extended parameatal) wing flap-flipping method, while the scrotum is normally repositioned with skin closure. Comparison is made with other repairs, while the safety of the extended parameatal pedicle flap is stressed.     

One-stage total repair of severe hypospadias with scrotal transposition: experience in 18 cases

This is a report detailing further experience with our one-stage repair of severe hypospadias and scrotal transposition performed on 18 patients. Initial success was obtained in 12 cases, while two more were improved by secondary repair. The operative technique, as modified, assures a parameatal preputial flap, which is well vascularized and easily constructed into a neourethra. The advantages of this improved "glanulomeatoplasty" and scrotoplasty are discussed. The method is recommended as an excellent functional and cosmetic procedure for one-stage correction of severe hypospadias.     

Free graft patch 1-stage procedure to repair penile hypospadias unsuitable for the flip-flap procedure: indications and experience

From January 1983 to December 1985, 14 procedures were performed in which a free graft of skin from either the foreskin or elsewhere was substituted for the flipped flap in the repair of hypospadias. This obviates the problem of thin skin below the urethral meatus, since a flipped flap in such a case will result in devascularization of the flap. Moderate chordee was not necessarily a contraindication to the use of this procedure, provided the chordee could be corrected without moving the meatus proximally. Cosmetic and functional results have been good, and there was only 1 urethral fistula. Nevertheless, because of the need for a scrotal flap of fat to prevent fistula formation and to ensure vascularization of the graft, and because of the availability of a vascularized flap from the foreskin in most cases, the free graft patch procedure is best reserved for cases in which the foreskin is either absent or deficient.     

Female epispadias repair: a new 1-stage technique

PURPOSE: Female epispadias is a rare anomaly. According to the literature it is usually treated with staged procedures, including bladder neck reconstruction, to achieve continence. We developed a 1-stage surgical technique that offers the possibility of achieving continence and a cosmetically normal appearance of the vulva. MATERIALS AND METHODS: We treated 4 patients 4 months to 8 years old. The main point of the technique is to free completely the urethral plate and bladder neck from surrounding tissue. After tubularizing the urethral plate into a urethra modified needle suspension brings the bladder neck and proximal urethra into the intra-abdominal position. The pelvic floor is then reconstructed between the anterior vaginal wall and urethra. Thus, continence may be attained by intra-abdominal positioning of the bladder neck and proximal urethra as well as by pelvic floor reconstruction. RESULTS: Of our 4 consecutive cases of primary untreated epispadias the technique proved successful in 3, while followup is too short in 1. One patient is completely dry and voids without a further procedure. Postoperatively 2 patients with 5 years or more of followup required injection of a bulking agent at the bladder neck level to achieve continence, including 1 who is damp during the day without the need to change clothes and 1 on clean intermittent catheterization twice daily because post-void residual urine volume causes recurrent urinary tract infection. CONCLUSIONS: The described technique is promising for treating this disabling anomaly.     

One-stage repair of hypospadias.

A new one-stage procedure for repair of penile hypospadias is presented. Seventeen cases have been performed with minimum complications. The steps of the procedure are described.     

Tisseel in hypospadias repair.

Tisseel (Immuno AG, Vienna, Austria), a fibrin sealant, adhesive and hemostatic agent made up of sterilized human and bovine components, was used in hypospadias repairs. The incidence of fistula and significant edema and the duration of hospitalization were all reduced in 30 patients who underwent modified Mustardé repairs in which Tisseel was used when compared with a matched group of 30 repairs without Tisseel. In addition, the rate of complications in fistula repairs and complex revisions was reduced when Tisseel was used on urethral suture lines and under all skin flaps.     

One-stage hypospadias repair. Experience with 544 cases.

PURPOSE: We evaluated one-stage hypospadias repairs in providing a normal looking penis with a normal functioning urethra. Also we looked critically at the effects of the severity of hypospadias, the type of repair and the experience of the surgeon on the outcome. Materials and METHODS: From 1987 to 1996 we performed 578 primary hypospadias repairs. The type and surgical results as well as the effects of certain variables on outcome were reviewed retrospectively. RESULTS: 544 single-stage hypospadias repairs have been followed up for a mean of 19 months (range 12-49). They included: MAGPI (92), ARAP (78), Mathieu (205), Mustarde (12), Duckett's tubularized preputial flap (142) and Onlay preputial flap (15). Despite an initial overall complication rate of 19%, the final success rate was 96%, after a mean of 1.3 procedures. Complications included fistula in 48 (9%) cases, meatal stenosis or retraction in 28 (5%), residual chordee in 17 (3%), stricture in 14 (2.5%), tubal abnormality in 10 (2%), and flap necrosis in 9 (2%). Complication rates were significantly higher (p < 0.05) when the meatus was proximal, the degree of chordee was moderate or severe and in the early series. Complication rates were also significantly higher with flap procedures and when the urethral plate was resected. Cosmetic defects occurred mainly with meatal advancement procedures. CONCLUSIONS: A repertoire of different types of single stage procedures has allowed the successful treatment of most hypospadias cases presenting to one surgeon. Complication rates increases with the severity of hypospadias or transection of the urethral plate. A cumulative experience allows for better results via a proper selection of the procedure and a perfection of a few techniques.     

尿道下裂伴阴茎阴囊转位的诊治(附83例报告)

目的:通过分析尿道下裂伴阴茎阴囊转位的诊治,总结手术方式及经验。方法:回顾性分析2003年1月至2009年6月间收治的尿道下裂合并阴茎阴囊转位的83例病例资料,并分析手术方式、诊治情况及术后随访外观情况。结果:矫治尿道下裂时同期或分期作阴囊成形术,术后随访6个月至5年。术后81例阴茎阴囊矫正外观满意,仅2例重度尿道下裂复位不满意需再次行阴茎阴囊复位手术。所有患者在阴茎阴囊复位后经同期或分期尿道成形术后最终均达到尿道下裂修复的标准。结论:本手术方法术后阴茎伸直好,阴茎阴囊复位整形效果满意,最终尿道成形术后预后良好,术后并发症少。     

The Denis-Browne hypospadias repair revisited.

Sixty-four cases of hypospadias repair by the Denis-Browne technique are reviewed. A urethrocutaneous fistula was the most common postoperative complication. Other less frequent complications were urethral stricture, residual chordee and improper location of the urethral meatus. These complications were corrected adequately and the results were satisfactory in all patients. This technique is simple, sound and trustworthy.     

Long-term follow-up of hypospadias repair.

A long-term follow-up study was carried out on the results of the van der Meulen one stage (vdMI) and two stage (vdMII) technique as well as the combination of a Byars orthoplasty with a Denis Browne urethroplasty (By/DB) for hypospadias. Special attention was paid to the functional outcome (spraying, dribbling, urinary deviation), findings at physical examination (curvature, skin surplus, stenosis, fistula, torsion, etc) and the correlation between complaints on function and physical abnormalities. An attendance score of 32% was achieved out of 567 patients. With the primary referred patients, spraying was encountered infrequently (vdMI 8%, vdMII 12% and By/DB 12%). Postmicturitional dribbling was reported by 16% of patients treated with vdMI repairs, 24% of the vdMII operations and after 30% of the By/DB repairs. Deviation of urinary stream was mentioned by 32% of the vdMI patients, 18% of the vdMII patients and 21% of the By/DB patients. There was no correlation between the findings at physical examination and the functional complaints. Mild torsion of the penile body and skin surplus were observed without having clinical consequences. Fistulae were not seen at follow-up and six patients had mild residual curvature of the penile body without clinical significance. Surplus of skin was observed in approximately 20% of patients, but none of the patients requested correction of this cosmetic problem.     

One-stage repair of distal hypospadias.

This paper reviews a short series of patients with distal hypospadias who were treated by Mustarde's one-stage technique, to which we have added a minor modification by tubing the flap before penis tunnelization. A single-stage repair has obvious advantages over a more conventional multistage procedure. The advantage of tubing the flap is early healing, and it reduces the risk of fistula formation, even in the presence of infection, which is very common in this country. The new urethral opening is situated at the fossa navicularis, and the functional results are excellent.     

Suture tracks after hypospadias repair.

OBJECTIVE: To determine the incidence of suture tracks after hypospadias repair in which 6-0 chromic catgut was used to close the skin. PATIENTS AND METHODS: From an initial series of 72 boys undergoing tubularized, incised-plate hypospadias repair, 23 (32%) were evaluated 1 year or more after surgery. RESULTS: Of the 23 boys, 10 (43%) were found to have suture tracks. In all cases tracks were located on the ventral shaft skin and did not involve the glans or dorsal aspect of the circumcision. These tracks had not been detected at an earlier follow-up. CONCLUSIONS: Tracks resulting from small absorbable sutures may not be apparent soon after surgery because the sinus is small. With time, the sinuses fill with keratin and thereby become obvious. The location of these tracks suggests that relative hypovascularity of ventral shaft skin may contribute to their development. The use of subcutaneous sutures may diminish the incidence of this minor complication of hypospadias surgery.     

Surgical correction of incomplete penoscrotal transposition associated with hypospadias

A surgical technique for correction of incomplete penoscrotal transposition associated with hypospadias is presented. An inverted omega skin incision is made around the scrotal skin, and the base of the penis and scrotal flaps are brought beneath the penis. The operation is performed after the completion of hypospadiac repair. This technique was applied to 20 cases and cosmetic results were satisfactory.     

Koyanagi术修复近端型尿道下裂合并阴茎阴囊转位

目的 探讨应用Koyanagi手术方法治疗近端型尿道下裂合并阴茎阴囊转位的效果.方法 2005年7月至2010年6月,对26例此类患者采用以尿道口为基底的带蒂阴茎皮肤及包皮瓣连续缝合尿道成型手术(Koyanagi术)进行修复.结果 26例中一期手术成功22例,皮瓣长度4～7cm,平均5.5 cm,术后尿液引流时间10～12d,平均11.5 d;术后发生并发症4例,其中3例阴茎冠状沟处切口裂开发生尿瘘,1例龟头裂开,远端尿道口退缩至冠状沟,再次手术后均成功.22例中阴茎残留轻度腹曲畸形2例;1例术后尿道口轻度狭窄,于门诊用尿道扩张器行尿道扩张,每周1～2次,持续扩张8个月后治愈.术后随访20例,时间为6～36个月,平均10.5个月,阴茎外观、尿道功能满意,阴茎阴囊转位得以纠正.结论 Koyanagi术是一期修复近端型尿道下裂合并阴茎阴囊转位的较好术式之一.

Abstract：

Objective To investigate the application of Koyanagi technique for repairing proximal hypospadias with penoscrotal transposition. Methods Koyanagi procedure was used for repairing proximal hypospadias with penoscrotal transposition in 26 boys (mean age 4. 2 years) between July 2005 and June 2010. Results Primary healing was achieved in 22 cases. Three patients suffered from urinary fistula and the external urethral orifice in one patient was retracted to penis coronary sulcus, who were re-operated successfully. Two cases showed slight penile ventral curvature. Slight stricture of the urethral external orifice was noted in one case, which relieved after one to two times of urethral sounding every week for eight months. 20 patients were followed up for 6-36 months (mean 10.5 months) with good cosmetic result and normal urethra function. The penoscrotal transposition was also corrected. Conclusions The original Koyanagi procedure might be one of the simple and effective method for repairing proximal hypospadias with penoscrotal transposition.