尿道板纵形切开卷管尿道成形术治疗小儿尿道下裂

目的探讨尿道板纵形切开卷管（TIP）尿道成形术治疗小儿尿道下裂的适用范围和疗效。方法2000年3月至2005年12月,收治尿道下裂患儿171例,手术年龄10个月～16岁,中位数3岁。尿道下裂程度按Barcat分型：前型65例（38．0％）、中间型29例（17．0％）、后型77例（45．0％）。术中根据病因分类,将尿道下裂阴茎下弯程度分为0～4级。原则上首选TIP尿道成形术式,少数无法一期完成手术者,在矫正阴茎下弯后中转其他方法。结果171例患儿中,完成了TIP手术161例（94．2％）。术中测量尿道板宽度0．6～0．9cm,平均（0．72±0．06）cm,修复尿道缺失长度0．4～4．5cm,平均（1．87±0．78）cm。阴茎下弯彻底矫正129例,新建尿道口位于阴茎头部,阴茎外观类似于包皮环切术后形态,一次性手术成功率80．1％（29/161）。1例阴茎阴囊型尿道下裂伴4级阴茎下弯者,术后1年阴茎下弯复发,行前尿道延伸再手术治愈。术后并发尿道口狭窄2例（1．2％）,经定期尿道口扩张后治愈。并发尿瘘26例（16．1％）,14例经再手术修补治愈。新建尿道裂开1例（0．6％）、新建尿道口裂开后移2例（1．2％）。结论TIP尿道成形术适用于大多数小儿尿道下裂病例的治疗。对于尿道板下组织有明显纤维索带造成严重阴茎下弯者,需横断尿道板才能彻底矫正阴茎下弯,不适用TIP手术。     

Comprehensive analysis of tubularized incised-plate urethroplasty in primary and re-operative hypospadias

OBJECTIVE: To retrospectively review our experience of the tubularized incised-plate (TIP) urethroplasty over the last 4 years. PATIENTS AND METHODS: From 1998 to December 2001, 133 patients (mean age 7 years, sd 4, range 1-22), had a TIP urethroplasty by one surgeon for primary (103) and re-operative (30) hypospadias; the defects included 106 (79%) distal and mid-shaft, and 27 (21%) posterior shaft. The neourethra was covered by a subcutaneous flap in 66 (50%) patients or by corpus spongiosa (spongioplasty) in 31 (23%), with no cover in the remaining 36 (27%). In the last 20 patients (15%) a modified meatoplasty was used; the site and size of the new meatus was predetermined on the glans around a suitable catheter before any incision. Urethral stents were not used after repair in 39 (29%) patients, and regular meatal dilation was used only in patients with voiding difficulty and obvious tendency to stenosis. The presence of complications requiring re-operation and overall general appearance were recorded. RESULTS: The mean (sd) follow-up was 10 (5) months; there were 24 complications in 20 patients (15%), including a small fistula in 12 (9%), complete disruption of the repair in 4 (3%), meatal stenosis in seven (5%) and neourethral stricture in one (0.8%). Complications were not significantly different between primary and re-operative cases, and unaffected by the use of the stents. On univariate analysis complications were significantly higher with running than interrupted sutures, in repairs in the first 2 years of the study, in patients with posterior hypospadias, and in those with no neourethral coverage. However, the last two factors were the only significant independent risk factors in a multivariate analysis. Regular urethral dilatation was indicated in 43 patients (32%). Modified meatoplasty was associated with a significantly lower requirement for regular dilatation (P < 0.05) and no meatal stenosis. In the 113 complication-free patients the operation gave an excellent cosmetic appearance with a vertical slit meatus on the tip of conical glans in 110 (97%); there was slight meatal retraction in the remaining three patients. CONCLUSION: The TIP repair is a reliable method for treating both distal and proximal penile shaft hypospadias, is suitable for both primary and re-operative cases, and is more versatile than other repairs. Covering the neourethra with a flap or spongioplasty significantly improves the results. Regular urethral dilatation is required in a third of patients but modified meatoplasty obviates the need for regular dilatation and eliminates the risk of meatal stenosis.     

Prepuce-Sparing hypospadias repair with tubularized incised plate urethroplasty

Objectives:   Modifications in surgical methods of hypospadias repair have been influenced by social considerations. Most Japanese parents wish their children to retain their foreskin during hypospadias repair. We report on short-term results of foreskin reconstruction associated with hypospadias repair.
Methods:   Of 44 tubularized incised plate urethroplasty-patients, 42 (95%) underwent foreskin reconstruction at the time of urethroplasty during the last 2 years. After the urethroplasty was completed, the foreskin was re-approximated in three layers.
Results:   Complications related to urethroplasty consisted of fistula in two patients with penoscrotal hypospadia, and mild stenosis of the glandular urethra in one patient. Complications related to foreskin reconstruction included dehiscence of the ventral foreskin in two patients. In all cases parents were well satisfied with the reconstructed prepuce.
Conclusions:   Pre-operative information about preputial reconstruction should be given to parents if they would prefer their son to be uncircumcised.     

Tubularized incised-plate urethroplasty for proximal hypospadias

OBJECTIVE: To report the experience of one surgeon using tubularized incised-plate (TIP) urethroplasty to repair proximal hypospadias in a consecutive series of boys. PATIENTS AND METHODS: The records of 33 consecutive patients with midshaft to scrotal hypospadias undergoing TIP repair by one surgeon were reviewed. Dorsal plication was used as necessary for penile straightening, to preserve the urethral plate. Standard TIP urethroplasty was undertaken, and the follow-up included the selective use of neourethral calibration and urethroscopy. RESULTS: Plication was necessary in 18 (55%) patients. The incised plate had a supple appearance in all but two boys. The mean (range) follow-up was 9 (1-48) months and included calibration in 16 (48%) and urethroscopy in 13 (39%) patients. Complications were noted in 11 (33%) boys, of whom seven (21%) developed small fistulae. The two patients in whom the incised plate appeared unhealthy had dehiscence of the repair and contracture of the neourethra with recurrent penile curvature, respectively. There was one meatal stenosis and one short neourethral stricture. CONCLUSIONS: TIP urethroplasty can be used to repair proximal hypospadias in the absence of severe penile curvature, and if the incised urethral plate has a supple appearance. As with distal hypospadias repair, the procedure creates a normal-appearing penis with a slit-like meatus.     

Tubularized incised-plate urethroplasty for hypospadias reoperation

OBJECTIVE: To review our preliminary results of tubularized incised-plate (TIP) urethroplasty for reoperative hypospadias repair. PATIENTS AND METHODS: The study comprised 15 patients, of whom eight had undergone a previous repair by techniques that included incision into the midline of the urethral plate, while in the remaining seven the midline of the plate had been left undisturbed. The meatus at reoperation was subcoronal or on the distal shaft in all but one boy, who had a midshaft hypospadias. All had previously undergone one attempt at hypospadias repair, except for one patient presenting after two failed 'meatal advancement and glanuloplasty incorporated' procedures. The TIP repair was undertaken as described for primary surgery, except that the dorsal dartos flaps for interposition between the neourethra and skin closure were available less often. RESULTS: TIP resulted in a functional neourethra and a cosmetically normal meatus in 13 of the 15 patients. One boy healed with a slightly rounded meatus and the other had wound dehiscence; fistulae developed in another two boys, giving three patients with complications. The fistulae occurred in boys whose original surgery did not include urethral plate incision, while the dehiscence was in a patient with partial excision of the plate during previous tubularized preputial flap repair. CONCLUSIONS: TIP urethroplasty can potentially be used for hypospadias reoperation. Previous incision of the urethral plate was not a contraindication in these selected cases in which the plate appeared supple. However, TIP repair should be avoided in repeat hypospadias surgery if the plate has been resected or is obviously scarred.     

Comparison of the perimeatal-based flap (Mathieu) and the tubularized incised-plate urethroplasty (Snodgrass) in primary distal hypospadias

OBJECTIVES: To determine whether the perimeatal-based flap technique or the tubularized incised-plate repair is the more appropriate treatment for distal hypospadias in terms of fistula rate, cosmesis of the meatus and operative duration. PATIENTS AND METHODS: Between July 1997 and August 1998, 60 children (none of whom had previously undergone a procedure for hypospadias) underwent primary distal hypospadias repair in a prospective randomized trial. Thirty patients were allocated to undergo a Mathieu repair (mean age 24.9 months, range 9-72) and 30 a Snodgrass procedure (mean age 23.1 months, range 7-19). The mean follow-up was 15.4 months. RESULTS: The mean duration of surgery was significantly lower for the Snodgrass procedure than for the Mathieu repair (75 vs 115 min, P < 0.05). Three children undergoing a Mathieu repair had complications (two a urethrocutaneous fistula and one a meatal stenosis), compared with only one in the Snodgrass group (glanular dehiscence). The resultant meatus was slit-like in all patients undergoing the Snodgrass repair whereas those with a Mathieu repair had a rounded and horizontal meatus. CONCLUSION: The overall complication rate was lower and the surgery significantly quicker with the Snodgrass urethroplasty, which also had a better cosmetic outcome. The Snodgrass technique is recommended as a primary treatment for distal hypospadias.     

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.     

Autologous platelet gel improves outcomes in tubularized incised plate repair of hypospadias

Backgroundhypospadias is one of the most widespread male congenital anomalies, occurring in 1:250 to 1:300 live births. Several repair techniques have been developing to improve the outcomes.Purposea randomized prospective controlled study was adopted to evaluate effectiveness of autologous platelet gel in healing promotion and improving the outcomes of hypospadias repair.Methodsthirty children who aged between 6 months and 12 years were recruited and subdivided into two groups; group A had tubularized incised plate (TIP) repair with autologous platelet gel application and group B had TIP repair without autologous platelet gel.Resultsthere was no significant difference in duration of operation between both groups. All patients in groups A and B had slit-like meatus shape in the distal glans. While all those of group A had one urine stream, yet only 11 of group B had one. There were complications that happened exclusively in group B such as spray stream (27%) and fistula (20%). Whereas other complications occurred insignificantly more in group B than in A including meatal stenosis (53 versus 27%), glans dehiscence, (20 versus 7%), bleeding (33 versus 13%), infection (33 versus 27%), edema (27% versus13), respectively. The incidence of skin necrosis was equal in both groups.Conclusionautologous platelet gel usage in TIP hypospadias repair can be a reliable technique to promote wound healing, and to limit of postoperative surgical complications.     

加盖与管形包皮岛状皮瓣法在尿道下裂治疗中的应用

目的评价加盖包皮岛状皮瓣法（Onlay island flap法）与管形包皮岛状皮瓣法（Tubularized island flap法）手术治疗尿道下裂的适应证及疗效.方法总结分析166例尿道下裂修复手术及术后并发症.患儿年龄1～15岁,平均5.1岁.冠状沟型及阴茎体前型尿道下裂36例,阴茎体型81例,阴茎根型36例,阴囊及会阴型13例,其中外院行阴茎下弯矫正术后11例.合并阴茎下弯139例,轻度43例,中度43例,重度53例.采用加盖包皮岛状皮瓣法79例,管形包皮岛状皮瓣法87例.结果 166例手术成功率为90.4%.166例随访2年均未发生尿道狭窄、尿道憩室、阴茎皮肤坏死等合并症.加盖包皮岛状皮瓣法术后发生尿瘘4例（5.1%）,阴茎下弯复发7例（8.9%）,手术成功率为86.1%.管形包皮岛状皮瓣法术后发生尿瘘4例（4.6%）,阴茎下弯复发1例（1.1%）,手术成功率为94.2%.2种术式尿瘘发生率比较,差异无统计学意义;而阴茎下弯复发率比较,差异有统计学意义.结论加盖包皮岛状皮瓣法适用于尿道板发育好的阴茎体及阴茎根型病例,管形包皮岛状皮瓣适用于尿道口位于冠状沟至会阴合并重度阴茎下弯的各型尿道下裂.     

Hallucinations after hypospadias repair

The authors report a case of a 4-year-old child who developed hallucinations after hypospadias repair. He was brought to the emergency department the morning after outpatient surgery where the diagnosis of central anticholinergic syndrome was made. We review oxybutynin overdose and the importance of providing clear instruction to parents and caregivers about the administration of medications.     

One-stage repair of moderately severe hypospadias using a transverse preputial tubularized island flap

BACKGROUND: Transverse preputial tubularized island flap (TPTIF) urethroplasty has been used for the repair of moderately severe hypospadias since Duckett described the procedure in 1980. In spite of the excellent results reported by Duckett, subsequent studies showed high complication rates. A TPTIF procedure modified to reduce the complication rate is presented. METHODS: Between 1996 and 1997, 13 boys with moderately severe hypospadias were repaired with the TPTIF procedure. Patient age ranged from 10 months to 3 years with an average age of 23 months. To prevent urethrocutaneous fistula, the neourethra was constructed with a two-layer closure and the portion of anastomosis was wrapped between the native urethra and the neourethra with the tissue of the corpus spongiosum. RESULTS: The moderately severe hypospadias was repaired without complication in 12 of 13 patients. A urethrocutaneous fistula developed at the midshaft of the penis in one patient. No meatal stenosis, urethral stricture or diverticulum developed. CONCLUSION: Transverse preputial tubularized island flap urethroplasty provided excellent cosmetic and functional results for moderately severe hypospadias, and postoperative complications could be decreased by the two-layer closure of the neourethra and application of the wrapping technique of the proximal anastomosed portion with corpus spongiosum tissue.