Radical bulbar dissection to correct severe chordee and proximal hypospadias

PURPOSE: We describe a technique of proximal hypospadias correction that involves freeing the proximal normal bulbar urethra from perineal attachments to lengthen the ventral penis and decrease chordee. MATERIALS AND METHODS: Correction was performed in 9 patients with a mean age of 11.5 months who had proximal hypospadias and severe chordee that was perineal in 2, mid scrotal in 6 and penoscrotal in 1. After the penis was degloved the bulbar urethra was detethered to or beyond the perineal body without lifting the urethra from the corpora cavernosa. Any remaining penile chordee was corrected and the urethral plate was transected only when chordee persisted. When the urethral plate was intact and the penis straight, tubularized incised plate urethroplasty was done to correct hypospadias in 1 stage. Otherwise 2-stage repair was performed. RESULTS: Using this maneuver penile straightening was achieved in 2 of the 9 patients, resulting in a glanular urethral or penoscrotal meatus. Dorsal plication sutures required in 4 cases resulted in a mid shaft and penoscrotal meatus in 1 and 3, respectively. Residual chordee in the remaining 3 patients necessitated division of the urethral plate and 2-stage repair despite aggressive mobilization of the proximal urethra. Simultaneous tubularized incised plate urethroplasty was then performed in the 4 penoscrotal and 1 mid shaft meatus. All 6 patients who underwent a successful 1-stage procedure have excellent cosmetic results, while 1 required meatotomy. No fistula or chordee was present at a mean of 13.8 months of followup (range 3.9 to 27.1). CONCLUSIONS: This safe, rapid technique may compensate for significant penile tethering and chordee in a subpopulation of patients with proximal hypospadias, such as 6 of the 9 in our study. It also allows successful tubularized incised plate urethroplasty to be done simultaneously.     

Tubularized incised plate urethroplasty: expanded use in primary and repeat surgery for hypospadias

PURPOSE: We evaluated the impact of tubularized incised plate urethroplasty on primary and repeat hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all boys who underwent hypospadias repair at our institution during a recent 3-year period. The level of the hypospadias defect, technique of repair, primary repair versus reoperation, age at surgery and complications were recorded. RESULTS: A total of 520 hypospadias repairs were done from May 1996 through June 1999. We began to perform tubularized incised plate urethroplasty in November 1996. During the ensuing consecutive 32 months 181 primary and 25 repeat hypospadias repairs were done using this technique. Mean patient age at surgery was 22 months (range 3 months to 30 years). During the 6 months immediately before we began to use this method the Mathieu flip-flap procedure was the most commonly performed technique, accounting for 38% of all hypospadias repairs. In contrast, during the last 6 months reviewed tubularized incised plate urethroplasty accounted for 63% of all repairs, including 41 of 65 primary operations (63%) and 4 of 6 reoperations (67%), while no Mathieu procedures were performed. Postoperative followup was 6 to 38 months for tubularized incised plate repair. Overall meatal stenosis and a urethrocutaneous fistula developed in 1 and 14 boys, respectively (7% complication rate). CONCLUSIONS: Tubularized incised plate urethroplasty has become the preferred technique of primary and repeat hypospadias repair at our institution. The technique has few complications as well as proved success and versatility that continues to expand its applicability and popularity.     

Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients

Objectives To determine the key points for a successful redo hypospadias procedure using tubularized incised plate urethroplasty operation. Methods A retrospective chart review of a cohort of 100 patients (Mean age: 4.5 years, range: 2–12) who had undergone a redo tubularized incised plate urethroplasty operation was performed. Fischer exact and Chi square tests were used for statistical analysis. Results The incidence of complications of tubularized incised plate urethroplasty reoperation after failed repairs of meatal advancement and glanuloplasty procedure (n: 14), meatal based flap (n: 36), and tubularized incised plate urethroplasty (n: 50) were 29% (n: 4), 22% (n: 8) and, 28% (n: 14) respectively (P > 0.05). The overall complication rate was 26% (n: 26). Eighteen patients (18%) had fistula, five had meatal stenosis (5%), two had dehiscence (2%) and one had neourethral stenosis (1%). Postoperatively, fistula was closed in 18 patients and 5 underwent meatoplasty. Two patients with dehiscence and one with neourethral stenosis underwent an unsuccessful third redo tubularized incised plate urethroplasty reoperation and they were candidates for a complex hypospadias repair (3%). The ultimate success rate of tubularized incised plate urethroplasty reoperation after treatment of complications was 97%. Conclusion Tubularized incised plate urethroplasty is a safe and efficacious alternative procedure for hypospadias reoperations if the urethral plate has no scars and outcome is favourable if the first failed hypospadias repair is a meatal based flap procedure. The complication rate increases if the urethral plate has been previously incised in the midline and a redo third redo must be avoided.     

Tubularized incised plate urethroplasty for proximal hypospadias

OBJECTIVES: Numerous surgical procedures have been used to correct distal hypospadias. Among them, the tubularized incised plate urethroplasty (Snodgrass procedure) has become a mainstay for the repair of distal hypospadias. We applied the procedure to proximal hypospadias. METHODS: Three patients with proximal hypospadias underwent a tubularized incised urethral plate urethroplasty. The location of the meatus was proximal penis in one, penoscrotal margin in one and scrotum in one. A perimeatal incision was made and the two paramedian incisions were extended to the tip of the glans. The skin of the penile shaft was dissected free to the penoscrotal junction and bands of fibrous tissue were excised until the corpus spongiosum proximal to the meatus was completely exposed inside the scrotum. The urethral plate was then incised in its midline from the tip of the glans to the hypospadiac meatus and was tubularized without tension. The neourethra was covered with a pedicle of subcutaneous tissue dissected from the dorsal skin or the scrotal skin to avoid fistula formation. RESULTS: The tubularized incised urethral plate urethroplasty was carried out successfully in one stage on three patients with proximal hypospadias. CONCLUSIONS: The Snodgrass procedure is suitable for correcting hypospadias in patients with a healthy urethral plate. It is also suitable in patients with proximal hypospadias.     

A new algorithm for primary hypospadias repair based on tip urethroplasty

Background/Purpose: Decision making in hypospadias repair potentially can be simplified by tubularized incised plate (TIP) urethroplasty. The authors report management and outcomes in a consecutive series of primary hypospadias repairs in which the intent was to perform TIP.Methods: Records of 106 consecutive boys undergoing hypospadias repair by 1 surgeon were reviewed. Position of the meatus, degree and management of curvature, technical details of the urethroplasty, and postoperative complications were recorded.Results: Curvature was noted in 24 (23%) of patients, but could be corrected with preservation of the urethral plate in all but 3. In another boy, the incised plate was thought “unhealthy” for tubularization. The remaining 102 underwent TIP, of whom, 75 had distal and 27 had proximal hypospadias. Complications, primarily fistulas, occurred in 14 (13%) of these patients. The other 4 boys underwent staged repairs that utilized TIP for the glanular urethra at the second operation.Conclusions: The authors found decision making was no longer determined by meatal location as in the past, but by severity of curvature and appearance of the incised urethral plate. Because severe curvature requiring plate transection or an “unhealthy” incised plate are uncommonly encountered, TIP repair can be performed for most hypospadias operations.     

Tubularized incised-plate urethroplasty for secondary hypospadias surgery

PURPOSE: Reoperation for failed hypospadias has been considered to be seriously bothersome because abundant penile skin does not tend to remain for urethroplasty or for penile shaft skin coverage. In this study, the tubularization of incised urethral plate was employed for those who had no excessive penile skin after failure of hypospadias repair. METHODS: Five patients with hypospadias underwent tubularized incised-plate urethroplasty as salvage surgery. The surgical techniques necessary for the performance of the reoperation were not different from those for the primary repair. The urethral plate was incised sufficiently deeply in its midline from the tip of the glans to the regressed meatus. The incised urethral plate was tubularized without tension over a catheter of an appropriate size. RESULTS: Four of those who underwent secondary tubularized incised-plate urethroplasty were successfully repaired without complications. A urethrocutaneous fistula occurred at the corona in the remaining patient. CONCLUSIONS: The absence of preputial skin in reoperative cases makes tubularized incised-plate urethroplasty the ideal option, although the series was small and postoperative duration is still short. In addition, this procedure can give excellent functional and cosmetic results even in patients who require revisional hypospadias surgery.     

Repair of hypospadias complications using the tubularized, incised plate urethroplasty

BACKGROUND/PURPOSE: Secondary procedures to correct complications after hypospadias repair remain challenging especially for "hypospadias cripples." The tubularized, incised plate urethroplasty was first introduced by Snodgrass for the repair of primary hypospadias in 1993. The authors used this procedure to correct the complications after hypospadias repair in patients who had no abundant local skin flaps to be used for a neourethra. METHODS: Six patients underwent tubularized, incised plate urethroplasty for the correction of complications of hypospadias repair performed the previous year, including a large urethrocutaneous fistula (n = 1) and disruption of the neourethra (n = 5). Prior surgical procedures included transverse island tube urethroplasty in 4 cases and 2-stage urethroplasty in 2 cases. The average patient age at the time of secondary procedure was 4.6 years (range, 1 to 12 years). RESULTS: The mean follow-up period was 6 months (range, 2 months to 1 year). All the patients obtained a functional neourethra with a vertical, slitlike meatus. A small fistula developed in one child and mild meatal retraction in another. CONCLUSIONS: The tubularized, incised plate urethroplasty offers few complications and good cosmetic results. The authors recommend its use for patients who have had repeated surgeries for hypospadias repair, especially those in whom only limited local skin flaps can be utilized for a neourethra.     

The Concept of Tubularized Incised Plate Hypospadias Repair for Different Types of Hypospadias

Purpose: Using the concept of tubularized incised plate (TIP) urethroplasty technique for proximal, distal, primary, secondary and complicated cases of hypospadias. Material and methods: From June 2002 to December 2003 TIP urethroplasty was performed in 15 patients between the age of 1–18-year-old with penosecrotal, mid shaft and subcoronal hypospadias. In 13 of them TIP urethroplasty used as the primary repair while in two of them as secondary repair. Results: No clinically important complications were observed in those boys who underwent primary reconstruction. One of them had meatal stenosis at the early postoperative period which was corrected by dilatation of the external meatus by feeding catheter at intervals up to 2 months postoperatively. Three boys had very narrow fistula which just allow leak of few drops of urine through urination. One boy with penoscrotal hypospadias who underwent two-stage repair had fistula. Conclusion: The concept of TIP urethroplasty is the procedure of choice for the treatment of proximal hypospadias and, it seems to be suitable for distal, secondary and even complicated hypospadias reconstruction. The advantages of this procedure include its simplicity, low complication rates and very good appearance of the glance with normal meatus.     

Tubularized incised plate urethroplasty for proximal hypospadias

OBJECTIVE: To review our experience of using the tubularized incised plate (TIP) urethroplasty (useful in the treatment of distal hypospadias) to treat proximal hypospadias. MATERIALS AND METHODS: From March 1997 to March 2000 primary repairs were carried out on 40 boys (mean age 4.5 years) with proximal hypospadias. After degloving the penile skin the meatus was at the mid-shaft in 10 boys, at the proximal penile shaft in 11, at the penoscrotal junction in 16, at the scrotum in two and at the perineum in one. The 21 patients with a mid or proximal shaft meatus were categorized as having mid-shaft and the other 19 as having posterior hypospadias. Tunica albuginea plication (TAP) was used to correct residual ventral curvature. The method of urethroplasty was adapted from that described by Snodgrass. The key step of the TIP repair is a midline incision of the urethral plate; a subcutaneous tissue flap dissected from the inner prepuce is used to cover the neourethra. An 8 or 10 F nasogastric tube is used as a urethral stent and removed 7 or 8 days after surgery. Follow-up endoscopy and urethral sounding were carried out in 17 of the patients aged < 6 years; the mean follow-up was 12.5 months. RESULTS: TAP was used to correct penile curvature in nine (23%) of the patients. Excluding stenosis, the TIP repair was successful in 20 (90%) of those with mid-shaft and in 16 of the 19 with posterior hypospadias; for all complications the respective rates were 19 of 22 and 15 of 19. The overall success rate was 88% for all 40 patients with proximal hypospadias; a urethrocutaneous fistula occurred in two of those with mid-shaft and three of those with posterior hypospadias. Urethral meatal stenosis occurred in four (12%) of the patients (two in each group); two were associated with a fistula and the other two had only mild meatal stenosis. The overall complication rate was 17.5% (three and four in the mid and the posterior hypospadias groups, respectively). The meatal stenosis was managed by simple dilatation in three and meatoplasty in one patient. Endoscopically, the mucosa of neourethra was pink and smooth in all 17 patients assessed. The calibre of all 17 neourethra was > or = 8 F and in 13 was > or = 10 F. CONCLUSION: TIP repair is a reliable method for treating both mid-shaft and posterior hypospadias.     

Tubularized incised plate repair: functional outcome after intermediate followup

PURPOSE: We describe the functional outcome following tubularized incised plate repair of hypospadias in toilet trained children after an intermediate followup. MATERIALS AND METHODS: Children were included in this study only if they were toilet trained and had flow rate data not less than 6 months after primary tubularized incised plate hypospadias repair or 2 months after any secondary procedure to correct complications. Uroflow data (peak flow, voided volume and post-void residuals) were analyzed and plotted on previously determined age-volume dependent nomograms. RESULTS: Of the 48 boys 39 required no secondary procedures, while 9 secondary fistula closures were performed in 2, meatotomy in 2 and dilation in 5. After either primary (26) or secondary (7) procedures 33 of the 48 patients (68.7%) had normal peak flow rate and 15 (31.3%) had low peak flow rate. Of the 48 patients 46 had post-void residual urine less than 10% of voided volume. CONCLUSIONS: Most children will void efficiently with no straining and no post-void residual (1/2) to 4 years after tubularized incised plate hypospadias repair. Of our patients 68.7% have normal peak flow rate. Intermediate followup of larger series and followup at puberty are recommended to resolve the debate concerning the long-term functional outcome of tubularized incised plate hypospadias repair.     

Foreskin preservation in penile surgery

PURPOSE: Most hypospadias repairs performed in the United States involve the removal of any foreskin that is not used in the repair, resulting in a circumcised penis. Occasionally, the wishes of the parents or the child are for the final appearance to be that of a normal uncircumcised penis. We report our collective experience from 4 institutions in the reconstruction of the foreskin during penile surgery. MATERIALS AND METHODS: A total of 58 patients underwent penile surgery with reconstruction of the foreskin during a 6-year period. Of the patients 49 underwent hypospadias repair, 8 underwent phalloplasty for chordee correction without hypospadias and 1 underwent reconstruction of the foreskin for a dorsal hood without hypospadias or chordee. Of the 49 hypospadias repairs 46 were distal, 2 mid shaft and 1 proximal shaft. The technique for foreskin reconstruction consisted of a multilayered reapproximation of the lateral margins of the dorsal hood after completion of the urethroplasty and glanuloplasty. RESULTS: Among 49 hypospadias repairs 2 patients had dehiscence of the reconstructed foreskin, with development of a urethral fistula in 1. Of the 58 total patients undergoing penile surgery 56 had retractable foreskin, of whom 4 required postoperative steroid application. Three patients/parents requested a secondary circumcision, 2 for an unacceptable cosmetic result and 1 based on personal preference. CONCLUSIONS: Foreskin reconstruction in association with penile surgery can be performed safely and with a low complication rate in appropriately selected patients. Cases with a higher risk of complications include those involving more proximal hypospadias and those requiring complete degloving of the penile shaft. Of the reconstructions resulting in phimosis most can be salvaged with the application of steroids.     

A multicenter evaluation of technical preferences for primary hypospadias repair

PURPOSE: Considerable controversy exists regarding the optimal surgical technique for the repair of mid shaft and proximal hypospadias. We sought to evaluate differences in surgical preferences among an international cohort of pediatric urologists. MATERIALS AND METHODS: An anonymous questionnaire containing relevant demographic data as well as choices of technique to repair 5 representative hypospadias cases was developed and administered. RESULTS: Of 121 pediatric urologists contacted 101 completed the survey, representing an 83% response rate. The majority were full-time academic pediatric urologists who performed 6 to 10 hypospadias surgeries monthly. A total of 92 respondents (confidence interval [CI) 0.84 to 0.96) preferred the tubularized incised urethral plate (TIP) technique for the repair of distal hypospadias. Similarly, 82 (CI 0.72 to 0.88) preferred TIP for the repair of mid shaft hypospadias. The 2 most common techniques for repair of proximal hypospadias without chordee, preferred by 43 correspondents each (CI 0.33 to 0.53), were TIP and transverse island flap (TVIF) onlay. For repair of moderate (30-degree to 40-degree) chordee dorsal plication was preferred by 82 respondents, while a ventral approach was preferred by 12. When moderate chordee was associated TVIF onlay was preferred by 35 (CI 0.26 to 0.45) and TIP by 24 respondents (CI 0.16 to 0.34). For severe chordee (greater than 50 degrees) 31 respondents preferred dorsal plication, while 68 chose some form of ventral repair. Among the respondents 37 approach proximal hypospadias associated with severe chordee using a staged procedure, while 40 use a single stage procedure using a TVIF tube (CI 0.30 to 0.50). Using Spearman's rank correlation coefficient, no significant correlations were identified between respondent practice demographics and choice of repair for each hypothetical hypospadias case. CONCLUSIONS: In this cohort of pediatric urologists we observed that the majority prefers TIP to repair distal and mid shaft hypospadiac defects. Significant variability exists for preferred technique for proximal hypospadias and chordee correction. These results support the need for prospective trials comparing techniques for the repair of proximal hypospadias.     

Re-operative hypospadias repair using the Snodgrass incised plate urethroplasty

OBJECTIVE: To retrospectively assess the results of tubularized incised plate (Snodgrass) urethroplasty in a series of re-operative hypospadias repairs in children. PATIENTS AND METHODS: The study comprised a follow-up (from 1996 until 2000) of 13 patients (mean age 7.5 years, range 13 months to 27 years) who had at least one previous hypospadias repair and who then underwent a reconstruction using the Snodgrass repair. In all cases the urethroplasty was covered with an additional layer of subcutaneous tissue. The original location, associated complications and results were recorded. In some cases, the long-term follow up was conducted by telephone. RESULTS: Associated complications before the Snodgrass repair included urethral stricture in two, fistula in three and persistent chordee in one patient. The mean (range) follow-up was 22 (9-34) months. The cosmetic results were excellent, with two complications (one patient with a glans dehiscence and a urethrocutaneous fistula, and a second with meatal stenosis). The remaining patients required no further procedures and were voiding normally at the last follow-up. CONCLUSION: Excellent cosmetic and functional results can be obtained using the Snodgrass incised plate urethroplasty for re-operative hypospadias repair. Only one patient in this series had an initial operation in which the urethral plate was previously incised. Therefore, caution should be used when considering an incised plate urethroplasty in these patients.     

TIP术治疗尿道下裂分析(附27例报告)

目的 评价TIP术(尿道板纵切卷管尿道成形术)治疗尿道下裂的体会.方法 先天性尿道下裂患儿27例,年龄1-14岁,平均2岁.冠状沟型3例,阴茎体型16例,阴茎阴囊型5例,阴囊型3例.伴阴茎弯曲22例.均采用TIP术(尿道板纵切卷管尿道成形法),8例阴茎头明显向下弯曲者采用阴茎背侧白膜折叠术纠正.结果 随访6个月至3年,TIP术中20例手术一次成功.结论 TIP术手术简单,疗效好,是一种较好的尿道下裂成形术.     

Preservation of the thin distal urethra in hypospadias repair

PURPOSE: We report our experience with preserving the thin distal urethra lacking corpus spongiosum for the treatment of hypospadias. MATERIALS AND METHODS: From January 1997 to October 1999 we treated primary hypospadias in 77 boys with a mean age of 4 years 10 months. After degloving the penile skin a segment of thin distal urethra lacking corpus spongiosum was noted in 18 patients (23.4%) with a mean age of 3 years 5 months. The thin distal urethra was preserved and incorporated as part of urethroplasty (group 1). The procedure was primarily completed by tubularized incised plate urethroplasty. We also performed tubularized incised plate urethroplasty in 31 boys (40.3%) with a mean age of 5 years 2 months who had normal coverage of the corpus spongiosum of a hypospadiac urethra (group 2). We compared the results of treatment in these 2 groups. The remaining 28 patients (36.4%) treated with other methods were excluded from study. RESULTS: In group 1 the distance from the original meatus to the urethra covered by healthy corpus spongiosum was 4 to 20 mm. (mean 8.2). If the thin distal urethra had been excised, the urethral meatus would have been relocated more proximal in these boys. Mean followup in groups 1 and 2 was 9.9 and 7.6 months, respectively. Postoperatively there were 2 (11.1%) urethrocutaneous fistulas in group 1 and 4 (12.9%) in group 2. Tubularized incised plate repair was successful in all 10 cases (100%) of distal hypospadias in group 2, and in 15 of 18 (83.3%) and 17 of 21 (81%) of proximal hypospadias cases in groups 1 and 2, respectively. There was no statistically significant difference in the success rate of hypospadias repair in the groups. CONCLUSIONS: We noted a significantly thin distal urethra in 23.4% of our cases of primary hypospadias. Mean length of the thin distal urethra was 8.2 mm. Preserving the thin distal urethra may simplify the operative procedure without compromising the surgical results of tubularized incised plate urethroplasty.     

Tubularization of the incised urethral plate (Snodgrass procedure) for primary hypospadias surgery

OBJECTIVE: To evaluate the Snodgrass procedure for patients with hypospadias who have not undergone previous surgery and whose urethral plate is too narrow for tubularization alone. PATIENTS AND METHODS: Thirty-two boys (mean age 18 months) underwent primary hypospadiac surgery performed by one surgeon (P.S.M.). Twenty-five boys had a distal hypospadias (coronal, subcoronal) and seven had a more proximal defect (penile shaft, penoscrotal). The operation involved incision of the urethral plate, which was then tubularized (Snodgrass procedure). The neourethra was then covered with a de-epithelialized pedicled dartos flap from the inner prepuce before glans and skin closure. RESULTS: With a mean follow-up of 10 months (range 2-14) there were two complications; one child with a coronal hypospadias developed a fistula whist one with a penile shaft defect had complete breakdown of the neourethra. The cosmetic appearance in the other 30 patients is that of a normal slit-like terminal meatus. CONCLUSION: Tubularization of the incised urethral plate is a safe advance in the surgery of hypospadias. We recommend it for both distal and proximal defects, in patients where the urethral plate is insufficient for tubularization alone.     

Komplikationen bei Hypospadiekorrekturen

Hypospadias is the most common congenital abnormality of the lower urinary tract affecting one of 300 male newborns. More than 300 different surgical hypospadias repair techniques have been described. Currently, tubularized incised plate and meatal advancement and glansplasty integrated repair are the preferred techniques for distal hypospadias, whereas two-staged procedures are most frequently used in proximal forms. Success rates are high in the hands of dedicated surgeons, although studies on long-term results are sparse. The most frequent complications of hypospadias repairs include urethrocutaneous fistulas, meatal stenosis, and urethral strictures. Urological follow-up into puberty is warranted, as well as further studies with standardized reporting of long-term results and complications.     

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

Objective

Treatment of patients with failed hypospadias repairs can be challenging. Our study aimed to determine the best type of redo repair depending on the location and size of the urethral meatus, the status of the urethral plate and genital skin, the severity of residual chordee and the amount of scar tissue.

Methods

The Institutional Review Board approved our retrospective chart review of patients who had a redo hypospadias repair at our institution over the past 6 years. We recorded the type and number of previous repair(s), the type and number 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 hypospadias repairs. 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 repairs and 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 operations and 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 urethral meatus included glans (18), corona (6), mid-shaft (3) and penoscrotal (1). Complications after redo surgery comprised 4 urethrocutaneous fistulae, 2 meatal stenoses, 1 urethral stricture and 3 dehiscences. Sixteen patients were followed with yearly uroflow with a Q-mean (mean uroflow) range of 3–14 mL/s (mean 8.1 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 setting of a poor urethral plate, TIF or buccal mucosa may be necessary. Complications are not infrequent in redo procedures.In current practice, hypospadias repairs are performed as outpatient procedures with high success rates. Despite the use of optical magnification, fine suture material and modern techniques, we still encounter the occasional failure that requires reoperation. Secondary operations can be challenging because of scarring and the paucity of penile skin. We review our experience with redo hypospadias operations at the Children''s Hospital of Eastern Ontario.     

Complete repair of bladder exstrophy: management of resultant hypospadias

PURPOSE: In our hands complete primary repair (CPR) of bladder exstrophy results in hypospadias in two-thirds of boys. To our knowledge hypospadias repair following CPR of bladder exstrophy has not been reported previously. We report our experience with hypospadias repair following CPR of bladder exstrophy. MATERIALS AND METHODS: A total of 22 boys with bladder exstrophy underwent CPR using Mitchell's technique between November 1998 and January 2002. The procedure resulted in hypospadias in 15 boys (68%). The site of the meatus was distal penile in 5 patients, mid penile in 3 and proximal penile in 7. Hypospadias repair was performed in all 15 boys. The 5 patients with distal penile hypospadias underwent repair consisting of Thiersch-Duplay urethroplasty with dorsal incision in 3 and tubularized vertical island flap with glanular tunnel in 2. All patients with mid (3) or proximal (7) penile hypospadias underwent Mustarde repair with glanular tunnel. RESULTS: Followup ranged from 6 to 18 months (median 13). The Thiersch-Duplay procedure with dorsal incision resulted in fistula/stenosis in 2 of 3 boys. None of the remaining 12 boys with tubularized penile flap urethroplasty (tubularized vertical island flap or Mustarde) with glanular tunneling had development of fistula or stenosis. Complete degloving of the penis and penile skin redistribution were not necessary with the Mustarde technique. CONCLUSIONS: Thiersch-Duplay urethroplasty with dorsal incision does not seem to be a good option for hypospadias repair following CPR of bladder exstrophy. The use of penile skin as a tubularized flap with glanular tunneling seems to yield excellent functional/cosmetic results.     

Mechanism of healing following the Snodgrass repair

PURPOSE: It has been suggested that healing after tubularized incised plate urethroplasty occurs through re-epithelialization with normal tissue ingrowth or by secondary intent through scarring. We investigated healing in tubularized incised plate urethroplasty. MATERIALS AND METHODS: Hypospadias was created in 5 dogs by incising the ventral urethra, allowed to heal for 21 days and subsequently repaired. During hypospadias creation a tattoo was made longitudinally in the midline dorsal urethral plate. The tattoo was bisected during repair, thus creating 2 distinct lines marking the edges of the incision. A neourethra was tubularized and closed in 2 layers. At 21 days the phallus was harvested, inspected and embedded for histology. RESULTS: The dorsal urethral plate incision contained 2 distinct lines in all samples representing the area of separation between the native and ingrowing urethras. The distance between these lines was 0.9 +/- 0.1 mm. Proximal urethral lumen diameter (3. 3 +/- 0.1 mm.) was not significantly different from that of the neourethral lumen (3.1 +/- 0.1 mm.). Histologically all repairs had intact squamous epithelium. There was normal appearing subepithelial architecture with scant perivascular lymphocytic infiltrates between the tattoos. In contrast, the area around the sutures showed a desmoplastic (fibroblastic) reaction with an inflammatory, primarily neutrophilic response. CONCLUSIONS: Healing of the incision in the dorsal urethral plate during tubularized incised plate urethroplasty occurs by re-epithelialization with normal tissue ingrowth. In contrast, the sutured closure heals with a desmoplastic and inflammatory response.