Urology Annals

ABSTRACT
Year
: 2016  |  Volume : 8  |  Issue : 6  |  Page : 90--101

Hypospadias


 

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How to cite this article:
. Hypospadias.Urol Ann 2016;8:90-101


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. Hypospadias. Urol Ann [serial online] 2016 [cited 2020 Feb 21 ];8:90-101
Available from: http://www.urologyannals.com/text.asp?2016/8/6/90/181197


Full Text

Experience with Asopa's urethroplasty

Dixit Syammohan

Department of Urology, Najran General Hospital, Najran, Saudi Arabia

A review demonstrating the technique of Asopa's Urethroplasty used with good functional and cosmetic results in 65 hypospadiacs with Mid (42), Proximal (20) and Peno-Scrotal (3) types some with penideviation.

These are among 129 cases operated from July 1983 through July 1990 with follow up of 3-70 months and mean age of 29 months. Among presenting series 59 were primary, rest were crippled. Secondary procedure were done for fistula (4), meatal stenosis (1), anastomotic stenosis (1) and for diverticula (1).

Presented at the: 6 th Saudi Urological Conference

National Guard King Khalid Hospital - Jeddah

27-28 November 1991

Experience with hypospadias repair

Raymond Anikwe, Saud A. Taha, Mohammad Hegazi, Baher Kamal, Tharwat Abdel-Ghaffer, Mohammad Hashish, Hamed Darawani

Department of Urology and Plastic Surgery, King Fahd Hospital of the University, Al Khobar, Saudi Arabia

Reconstruction of hypospadias was carried out on 104 patients over a 5 years period. Based on the location of the meatus after the release of any existing chordee, 63%, 20% and 16% were anterior, middle and posterior hypospadias, respectively. The commonest associated anomalies were undescended testes in 14%, inguinal herniae in 8% and intersex disorders in 8%, 47% of posterior hypospadias being associated with intersex disorders. Eighty four percent of patients has primary single-stage repairs while 16% had multi-staged procedures. The choice of operation of chordee and the site of the meatus after correction of any existing chordee. Following the initial operations, 63% of patients had no chronic complications, the success rate for glandular and coronal hypospadias being 88%. Chronic complications had an overall incidence of 18% fistulae, 8% of disruption of repair, 6% meatal retraction and stenosis, and 2% anastomic strictures. Following a subsequent operation, the overall success rate improved to 84%.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Ten years experience of hypospadia repair in children

M. T. Said, M. S. Abomelha, K. E. Al Otaibi, M. Kourah, S. Orkubi, A. Shaaban

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

During a ten year period (1983-1993) 287 patients with hypospadias were seen at Riyadh Armed Forces Hospital. Associated anomalies included undescended testis (6%), hernia (4%), upper urinary tract anomalies (1.7%) and congenital heart disease (3.5%). Of the above total, 173 children underwent primary repair and form the subject presentation. Others not included in this study were patients not requiring repair, infants awaiting repair, and a small number of adults. The age group of children at the time of primary repair included 91 aged 6 to 18 months, 65 aged 18 months to 5 years and 17 older than 6 years. 47 (27%) of the children had chordee while 31 (18%) were circumcised before primary repair. 125 (73%) children had anterior, 18 (10%) had middle and 30 (17% had posterior hypospadias. Primary repairs included 112 (66%) MAGPI or extended MAGPI, 6 (3.5%) Mathieu, 18 (9.5%) Horton Devine, 9 (5%) Duckett, and 28 (16%) Dennis Brown.

170 (98.3%) children were followed up for 1 year or more. Secondary repairs were required in 30 (17.5%). The main complications were urethrocutaneous fistulae in 42 (42.5%) and meatal stenosis in 12 (7%). 144 (85%) children had good cosmetic and functional results. of these, only 27 (16%) required successful closure of post repair fistulae. 15 (9%) children still have persisting fistulae and 11 (6%) have failed repair.

We conclude that in spite of a large number of patients were circumcised before primary repair, our results compare well with most published series.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Experience with scrotal septal Island skin flap in repair of penile hypospadias

Osman Fathi Osman

Department of Urology, Fakry Hospital, Al Khobar, Saudi Arabia

We started use of the vascularized scrotal septal island skinflap in one stage repair of complicated or circumcised cases of penoscrotal and proximal penile hypospadias since 1989, with encouraging results. Recently we extended use of this well vascularized hairless flap to repair 18 cases of mid and distal penile hypospadias cripples in which 14 cases achieved satisfactory results and 4 required revision for meatal stenosis diverticulae formation. We describe the technique refinements and discuss the encouraging results and complications.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Urethral advancement for distal hypospadias

Mohamed M. Abozeid

Department of Urology, Al Salama Hospital, Jeddah, Saudi Arabia

Hypospadias repair continues to be a surgical challenge.

The presence of numerous operative techniques means failure of any single operation to have uniform acceptance. Urethral mobilization and advancement is characterized by moving the external meatus to granular tip without constructing new urethra. The operative technique will be described in detail. This procedure has been done in 23 boys and 3 adults. The urethral defect after release of chordee was 1.5 to 2 cm. in boys and 3 to 5 cm. in adults. Excellent cosmetic result was obtained in more than 80% of cases. Complications were encountered in 4 boys and one adult. Complications in boys included meatal stenosis in 2, mild urethral stricture in 1, and glans separation in 1. The adult complication was severe distal urethral stricture and residual chordee.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Transposition of the scrotum

Faris M. Ayyat

Dhahran Health Centre, Saudi Aramco, Dhahran, Saudi Arabia

Definition: This is a form of ambiguous genitalia characterised by a triad of the overriding of the scrotum on the penis, a severe form of hypospadias and severe penile chordee.

Objective: Is to evaluate the appropriate age, surgical procedure and its outcome in reconstruction of transposition of the scrotum. This is a retrospective study carried out at Dhahran Health Centre between 1985 and 1993. 11 patients with this description were seen. This is a very rare anomaly of the ambiguous genitalia. 9 of these patients underwent reconstruction and 2 have not undergone the surgery yet. 5 had complete transposition and 5 incomplete. Follow up of the surgical procedure ranges between 1 and 92 months, with an average of 34.7 months., i.e. after completion of the surgical reconstruction. 3 patients had cryptorchidism and it is interesting that transposition of the scrotum is associated with a high incidence of congenital anomalies, e.g. heart disease in 3 patients, eye problems in 2, microcephaly in 2, Meckel-Grober Syndrome in 1, and Dobbin-Johnson Syndrome in 1 patient. The age of reconstruction ranged between 6 months and 30 months, with a mean age of 18 months.

Surgical Procedure: In the initial period of the study, reconstruction took place in two stages. The first stage was correction of the transposition with the release of penile chordee. The second stage was reconstruction of the severe form of penile hypospadias. All patients underwent some form of Duckett's Island tuboplasty. 4 patients, i.e. 44% has urethrocutaneous fistula. This was mainly in the patients with complete form of transposition.

Recommendation: Surgical reconstruction of transposition of the scrotum should be carried out by a skillful Paediatric Urologist. We had a better outcome when we used 7/0 Vicryl for suturing of the Duckett's tube under magnification. All patients with transposition of the scrotum should be evaluated for other associated congenital anomalies. In the complete form of transposition, a Duckett's tuboplasty should be coupled with a flip-flap procedure at the base of the hypospadias.

Presented at the: 8th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Hypospadias repair in Eastern Province of Saudi Arabia

Raymond Anikwe, Saud A. Taha, Mohammed Hegazi 1 , Baher Kamal, Mohammad Hashish, Hamed Darawani

Department of Urology and Plastic Surgery, King Faisal University, Dammam, Saudi Arabia

Hypospadias repair was carried out on 204 patients over a 9 year period. The patients were aged 1 month to 34 years, the median age being 3 years. Most patients (72%) presented with anterior hypospadias, while middle and posterior hypospadias occurred in 16% and 12% of cases, respectively. The most common associated malformations were undescended testis (12%), inguinal hernias (8%), and intersex disorders (5%). Primary single-stage repairs were performed in 88% of the patients and staged-repairs in the remaining 12%. Success rate was highest (92%) for patients with anterior hypospadias. Urethral fistula (12%) and urethral stricture (10%) occurred mostly in patients for whom a neourethra was constructed while retraction of the external meatus (6%) occurred mainly following MAGPI procedure. Although a significant proportion of our repairs fell within the reported vulnerable age range of 2 to 6 years, we did not observe the adverse psychological effect of genital surgery on children reported by some workers. Our results in this regard may be, in part, attributable to the fact that most of our patients and their parents saw a successful repair as an enhancement to their manhood.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Hypospadias repair: KFHU experience

R. M. Anikwe, S. A. Taha, M. Hegazi 1 , B. Kamal, M. Hashis, H. Darawani

Departments of Urology and 1 Plastic Surgery, King Fahad Hospital University, Dammam, Saudi Arabia

The common practice of placement of the neomeatus at the tip of the gland for all cases of glanular and coronal hypospadias has promoted us to determine the complication rates of these repairs and to explore whether such repairs are necessary in a community where voiding is in a squatting position.

A prospective study of 204 hypospadias repairs at ages 6 months to 34 years was carried out. Repairs were by standard methods currently in use.

A complication rate of 9% for anterior hypospadias and 6% for glanular and coronal hypospadias was obtained. Patients with glanular and coronal hypospadias and a straight penis sought treatment principally to avoid apparent sexual and reproductive dysfunctions. Most repairs in past-pubertal patients were prompted by a wish to get married. Such patients reported normal married life after repair.

Our complication rates for anterior hypospadias are consistent with reports in other urological centers. Glanular and coronal hypospadias are reported not to impact adversely on sexual and reproductive functions. Our preliminary studies show that 22 of 24 (18%) of normal married and fertile men had the meatus located proximal to the distal one third of the glans.

Information to patients that glanular and coronal hypospadias are not associated with sexual and reproduction dysfunctions seems warranted before repair of these types of hypospadias in communities where voiding is in a squatting position. In the last 2 years informed consent for such repairs was given only in 26% of patients with glanular and coronal hypospadias.

Presented at the: 11 th Saudi Urology Conference

King Fahd Military Medical Complex - Dhahran

24-26 February 1998 (27-29 Shawwal 1418)

Snodgrass hypospadias repair: Indications and results in 100 consecutive personal cases

R. De Castro, E. Merlini, J. M. Abu Daia, M. Prestipino, F. Burattini

Division of Pediatric Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: In 1994 Snodgrass described a personal procedure for hypospadias repair. Snodgrass called his technique "TIPU" (tabularized incised plate urethroplasty) to underline the essential innovation of the procedure compared to the classical Thiersch-Duplay technique. The TIPU was first applied only for glandular, coronal and subcoronal hypospadias repair and later also for penile and penoscrotal hypospadias repair, with or without chordee.

Objective: The aim of this presentation is to report our personal results and to contribute to the diffusion of this brilliant technique in this country.

Patients and Methods: In the last 3 years, we used the TIPU in 100 consecutive patients (from 6 months to 21 years of age) treated in 4 different hospitals in the Kingdom of Saudi Arabia (6 cases treated by DCR) and in Italy (49 by DCR and 45 by ME). We have had 64 cases of distal hypospadias (6 glandular, 39 coronal and 19 subcoronal), 26 cases of penile and 10 of penoscrotal hypospadias. In 16 patients, the TIPU was used as secondary repair.

Results: A minimum of 6 months follow up is available in 94 our patients. A complete failure was observed in 2 cases (both secondary repair), a meatal stenosis in 2 cases (1 with a urethral fistula) and a urethral fistula alone in 4 cases. The complication rate is 8.51% (8/94) if we consider all the patients. 5.06% (4/79) for the primary patients only and 26.66% (4/15) for the secondary patients only. The complication rate is 2% (1/50) if we consider the primary but distal cases only and 10.34% (3/29) for the primary but proximal cases only.

Conclusions: Compared to the author's experience with different surgical techniques for the same forms of hypospadias (Magpi, Mathieu and onlay island flap), these results are very interesting themselves. But they will be even more interesting considering the superior cosmetical appearance of the penis, the glands and the meatus achievable with the Snodgrass procedures. Longitudinal midline incision of the skin, from the hypospadic meatus to the tip of the gland, before the tubularization of the new urethra, allows reaching two important advantages: first to augment the urethral plate, obtaining a good caliber new urethra, second to obtain a vertical adequate external meatus at the top of the gland. The Snodgrass' TIPU is applicable from the penoscrotal hypospadias to all the more distal forms, but it seems to achieve the best results with coronal, subcoronal and anterior penile cases.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)

A naturally apperaing glanular meatus after mathieu procedure combined with snodgrass hinge of the urethral plate

S. M. Soliman

Division of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Background: Since the early contemporary repairs reported by Theirsch and Duplay in the late 19 th century, hypospadias is still standing as a continuing challenge to paediatric urologists. Various techniques have been described of which the Mathieu meatal based flap has stood the test of time since its early description in 1932. In spite of the very low fistula rate (2-4%) and stricture formation (1%), the final cosmetic outcome is not entirely satisfactory as it creates a horizontally oriented meatus, and additionally the operator experiences various degrees of difficulty in achieving penile skin coverage. Recently, the tabularized incised plate concept popularized by Snodgrass has evolved as a simple versatile technique for correcting various forms of hypospadias, and it creates a ertically oriented meatus, yet with a higher fistula/disruption rate (7%) compared to the Mathieu procedure especially with those patients having a flat, conical or rigid urethral plate. Herein, we describe a technique combining the Mathieu principal with Snodgrass incision/hinging aiming to augment the advantages and nullify the disadvantages of both procedures.

Patients and Methods: From 1998 through 2000, in a non-randomized signle-observer study, two groups of patients with non-MAGPI complaint distal penile hypospadias without chordee were compared, group A comprised 47 patients with (age range 5 months - 12 years), operated by a narrow Mathieu flap (6 mm) laid over a Snodgrass hinged plate. Group B comprised 14 patients (age range 9 months - 5 years) that underwent a classical Mathieu procedure. In both groups, transurethral diversion was maintained for 5 days. A compressive Coban; dressing was maintained till removal of the catheter. Both groups were compared with regard to postoperative cosmetic appearance, urinary stream fistula/disruption and reoperation rate.

Presented at the: 14 th Saudi Urology Conference

King Fahd Military Medical Complex - Dhahran

13-15 February 2001 (19-21 Dhu Al Qa'dah 1421)

Use of double dartos flap in tubularized incised plate hypospadius repair

Baher A. Kamal

Department of Urology, King Faisal University, Dammam, Saudi Arabia

Objective: Two overlapping layers of dartos flap were fashioned and fixed in front of the neourethra after tabularized incised plate hypospadias repair to prevent development of urethrocutaneous fistula and glanular torsion.

Patients and Methods: One hundred and twelve boys with distal hypospadias were treated with tabularized incised plate urethroplasty. There were 3 groups. Group A (22 patients) did not have dartos flap covering. Group B (54 patients) had a dartos flap covering. Group C (36 patients) had double dartos flaps coverings. The dissected dartos flap was bisected vertically to form two pedicled wings. Each wing was laterally rotated from either side of the glans to cover the neourethra ventrally in a double fashion.

Results: Eight patients developed fistula: 6 in group A (27.2%) and 2 in group B (3.7%). None of the group C patients had fistula post-operatively. Additional complications included glanular torsion in all group B patients and dehiscence in 1 group A patient.

Conclusion: Interposition of double dartos flaps between the neourethra and the overlying glans and skin closures prevented development of urethrocutaneous fistula following tabularized incised plate urethroplasty. Fistula was present occasionally when single dartos flap was used and more often when dartos flap was not used. Double dartos flaps were not associated with glanular torsion or dehiscence.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Tubularized incised plate urethroplasty: KFMMC experience

A. Al Zahrani, I. Al Oraifi, S. Egail, A. Al Dayel, S. Abu Anz, S. Al Zahrani, E. El Sayed

Department of Urology and Nephrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Objectives: To evaluate the outcome of primary and secondary hypospadias repair using Tubularized Incised Plate (TIP) urethroplasty which was performed at King Fahd Military Medical Complex (KFMMC), Dhahran.

Patients and Methods: We retrospectively reviewed the medical records of 104 patients who underwent hypospadias repair between October 1999 and September 2004. Out of these, 35 patients had TIP urethroplasty, 3 patients lost follow up. Out of the 32 patients, 27 (84.4%) were primary and 5 (15.6%) were secondary hypospadias. The mean follow up was 15.5 months.

Results: The functional and cosmetic results were excellent. The overall success rate was 81%. Complications were encountered in 6 patients. Meatal stenosis was seen in 4 (12.5%), combined meatal stenosis and fistula in 1 (3.1%), and fistula in 1 (3.1%) patients. The later was a secondary hypospadias.

Conclusion: TIP urethroplasty is a simple and versatile technique that gives an excellent cosmetic appearance. It can be used for primary and secondary hypospadias. We believe regular urethral dilatation is advisable to prevent/decrease meatal stenosis.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

De-epithelialized preputial flap versus tunica vaginalis flap for augmentation of neourethra in tubularized incised plate urethroplasty

Safwat E. Abou Hashem, Ahmed M. Kamal 1

Departments of Urology and 1 General Surgery, Zagazig University, Zagazig, Egypt

Objective: Urethrocutaneous fistula is the most common complication after hypospadias repair (2-29%). The key measure to ensure a successful repair is separation of urethral suture line from skin by well vascularized tissue. Many tissues were used for this purpose, and in this work, we compared the use of de-epithelialized preputial flap and tunica vaginalis flap for augmentation of urethral suture line.

Patients and Methods: A unified hypospadias repair was used, tabularized incised plate (TIP) urethroplasty. This work was done in Pediatric Surgery Unit of General Surgery Department and Urology Department of Zagazig University Hospitals. 24 cases were randomly categorized into two groups each of 12 patients. Group A in which de-epithelialized preputial flap was used, while tunica vaginalis flap was used in group B to augment urethral suture line. There was no difficulty in harvesting the flaps in both groups.

Results: There was one fistula in group B, one case of infection without dehiscence in each group. There was no meatal stenosis in both groups. There was no difference in final results of both groups.

Conclusion: Anatomically, the preputial flap appears to be suitable for distal hypospadias, and tunica flap to be more accessible to proximal types. Versatility and frequent availability of tunica flaps from both side of scrotum may make it more beneficial in recurrent and crippled hypospadias cases with deficient shaft skin.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Factors affecting outcome of tubularized incised plate urethroplasty: Single-center experience with 500 cases

Ashraf T. Hafez, Osama Sarhan, Mohamed T. El-Sherbiny, Mohamed S. Dawaba

Mansoura Urology and Nephrology Center, Mansoura, Egypt

Purpose: Evaluation of different factors affecting the outcome of tabularized incised plate urethroplasty (TIPU).

Materials and Methods: Between January 1998 and December 2003, 500 children, with a mean age of 6 years (SD = 3.7, range of 1-18) underwent TIPU at our center. Patients included 439 (87.8%) boys with denovo hypospadias and 61 re-operative. The site of hypospadias was coronal in 110 (22%), distal penile in 261 (52.2%), mid-penile in 78 (15.6%), proximal penile in 21 (4.2%) and penoscrotal in 30 (6%). Chordee were present in 98 (19.6%) patients. The neo-urethra was covered by spongiosal and/or dartos flap in 472 boys 994.4%). The repair was non-stented in 49 boys (9.8%). Logistic regression was used for statistical analysis.

Results: The mean follow up was 34 ΁ 18 months. Overall success rate was 81.4%. Re-operation was required in 93 patients (18.6%) due to fistula and/or stenosis. On univariate analysis, complications were significantly more common in stented repairs, proximal hypospadias, in those with no neourethral coverage (spongioplasty), and in repairs in the first years of the study. Nevertheless, the last three factors were the only significant independent risk factors in multivariate analysis.

Conclusions: The TIPU is a reliable method for treating both distal and proximal hypospadias and is suitable for reoperative cases. Significantly better outcome is achieved with distal hypospadias, covering the neourethra by the mobilized corpus spongiosum (spongioplasty), and experience. Stenting of the repair, patient age, or previous failed repaired has no statistical significant impact on outcome.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Techniques to salvage failed hypospadias repairs

Michael P. Leonard, Ahmed J. Al Sayyad

Department of Urology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada

This lecture will review the techniques commonly employed in the reconstruction of failed hypospadias repairs. In addition, a review of the author's own experience, as compiled by Dr Al-Sayyad, will be presented (please refer to appended abstract). At the completion of the lecture, the following objectives will be reached:

Knowledge of the varied techniques, which can be applied to salvage patients who have failed hypospadias repairs

Appreciation of the ongoing challenges in managing such patients as evidenced by the review of a clinical series.

Introduction: Treatment of patients who have had failed hypospadias repairs can be challenging. Herein we review our experience.

Materials and Methods: Retrospective chart review of patients who had a redo hypospadias repair at our institution over the past 6 years. Type and number of previous repair(s), type and number of redo procedure(s), complications and functional outcomes were recorded.

Results: 28 patients failed hypospadias repair, aged 1-12 years (mean 3.8).

Initial severity of hypospadias : Perineal (1), penoscrotal (9), proximal shaft (1), mid-shaft (9), distal shaft (4), coronal (3) and mega-meatus (1).

Number of previous repairs : 1 (24/28), 2 (3/28), 3 (1/28).

Initial repair : Tubularized island flap (TIP) (11), Snodgrass (TIP) (8), Mathieu (5), MAGPI (1), Pyramid (1), Arap (1), Thiersch-Duplay (1).

Number of redo operations : 1 = 21/28, 2 = 5/28, 3 = 1/28, 4 = 1/28.

TIP procedures accounted for the majority of redo operations, with TIF being used 6 times and buccal mucosa graft thrice. Follow up 1-5 years (mean 3.5).

Final location of urethral meatus: glans (18), corona (6), mid-shaft (3), and penoscrotal (1).

Complications after redo: Urethrocutaneous fistula (4), meatal stenos (2), stricture (1), and dehiscence (3). 16 patients were followed with yearly uroflow with Q-max range of 8-22 ml/s (mean 14.6 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.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Application of bracka's repair in primary posterior hypospadias with severe chordee? Initial experience

S. M. Soliman, M. Salem

Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Objective: The long standing debate of treating posterior hypospadias and severe chordee with one versus 2-stage repair is yet to be settled. Herein we present our initial experience with the 2-stage repair in a selected group of boys utilizing the Bracka's technique which offers a full thickness skin graft as a foundation for future urethroplasty.

Patients and Methods: 13 boys (age range 1-14 years, median 4.5) underwent 2-stage reconstruction utilizing the Bracka's technique. Indications for correction included in addition to severe chordee and poor quality urethral plate: proximal penile hypospadias (7), penoscrotal hypospadias (4) and scrotal hypospadias (2). Chordee rectification was done by urethral plate transaction with dorsal midline placation in eight and tunical vaginalis flap ventral orthoplasty in five. The graft was harvested from the ventral prepuce and was laid from the tip of the deeply split glans down to the hypospadic meatus. Tubularization at a second stage 6-8 months latter completed the reconstruction. Follow up range was 4-33 months (median 16).

Results: In all patients grafts were taken without need for revision. Complications after second stage included partial dehiscence (1), urethrocutaneous fistula (2) and two with residual mild chordee. Eight had a slit like vertical meatus at the glanular tip and 4 at a coronal level. The overall reoperation rate was 23% (3/13).

Conclusion: Based on this initial experience, the Bracka's 2-stage reconstruction appears to be a reliable and reproductive technique for urethroplasty with an acceptable complication rate in this difficult subset of hypospadic boys. We observed that the utilization of a preputial skin graft had a skin sparing effect for redressing the phallus in contrast to conventional 2-stage repairs.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Outcome of hypospadias repair using the tubularized incised plate urethroplasty (snodgrass procedure)

S. S. Al Khateeb, A. M. Al Shammari

Department of Surgery, Division of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Objective: We reviewed our results using the tabularized incised plate urethroplasty (Snodgrass procedure) for repair of both proximal and distal hypospadias.

Materials and Methods: Between October 2997 and September 2005, 145 patients (aged 4-182 months, mean 29.8 months) underwent Snodgrass repair by one pediatric urologist at our institution. Their charts were reviewed for pre-op meatal position, association chordee and/or torque, whether they were primary or redo repair of failed hypospadias done elsewhere. In the follow up we looked into the meatal position and complications including chordee, torque, fistula and meatal stenosis.

Results: 101 (69.7%) patients had distal, 38 (26.2%) mid-shaft and 6 (4.1%) penoscrotal hypospadias. 139 patients (95.95%) were operated for the first time and 6 (4.1%) had a redo repair for a failed previous hypospadias surgery done elsewhere. 83 (57.2%) patients had ventral chordee out of whom 40 required dorsal tunica albuginea plication (TAP) for correction. Urethroplasty coverage consisted of subcutaneous layer of the dorsal preputial skin in 141 (97.2%) patients, tunica vaginalis flab in 2 (1.4%) and local tissue in 2 (1.4%). 120 (82.8%) patients were available for follow up between 4-144 weeks (mean 26.3 weeks). Among those with distal hypospadias, the meatus was in a glandular position in 95.1%, and 4.9% required a redo repair. Meatal stenosis, fistula, chordee and torque requiring correction were encountered in 8.9%, 6.9%, 1% and 1% respectively. In patients with mid-shaft and penoscrotal hypospadias, the meatus was glandular in position in 84%, and 16% required redo surgery for failed repair. Fistula, persistent significant chordee and torque requiring correction occurred in 9%, 9% and 6.8% respectively.

Conclusion: The tabularized incised plate urethroplasty achieves satisfactory results with acceptable complications for the repair of distal hypospadias, while in the proximal types patients should be carefully selected.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Urethral mobilization/advancement in the repair of distal hypospadias with a deficient urethral plate: Resurrection and modification of a technique

Sherif M. Soliman, Mahmoud Salem, Khalid A. Fouda

Department of Urology, Pediatric Urology Unit, College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

Background/Purpose: Preservation of the urethral plate is a fundamental principle in hypospadiology. In a special subset of boys, the urethral plate is found to be atretic or virtually non-existent especially in some reoperative cases. We describe a medication of urethral mobilization/advancement technique in addressing this problem.

Methods: Forty six hypospadic boys (29 coronal, 17 distal, 11 chordee, 21 reoperative) associated with deficient urethral plate were operated by urethral mobilization/advancement technique modified by careful preservation of its ventral attachments and a ventral 2-3 mm slit at its tip. The anastomosis to the glans was performed after wide separation of the glans wings and excision of the medially located remnants of the atretic plate. A urethral catheter was left for a mean duration of 4 days (range 1-9 days). Mean defect length was 1.1 cm (range 0.7-1.8) mean mobilization distance was 4.7 cm (range 2.5-7 cm) with a mean mobilization to defect ration of 4.3 (3.1-5.4).

Results: Follow up ranged from (3-50 months). The overall complications rate was 11% (5/46, total dehiscence, 3 meatal retraction). None had residual or developed new chordee. Reviewing their records showed evidence of undermobilization due to an initially "short" phallus. Early in the series, 4 boys presented with dysuria/retention after removal of an overnight catheter. These retentive episodes mandated a longer duration of drainage in the following cases.

Conclusion: The described technique allows addressing the problem of plate deficiency in distal hypospadias with an excellent cosmetic and functional outcome. It is not suitable for boys with a phallic length that cannot provide an adequate defect/mobilization ratio. A longer duration of catheterization is needed more than anticipated initially with this neourethroplasty-free technique.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February-01 March 2007

The impact of the urethral plate depth and width on the outcome after tubularized incised plate urethroplasty

A. Maarouf, I. Ibrahim, L. El Bendary, S. Khalil

Department of Urology, King Abdullah Hospital, Bisha, Saudi Arabia

Aim of the Work: To study if the preoperatively assessed urethral plate depth and width can affect the outcome after tabularized incised plate urethroplasty (TIP).

Patients and Methods: Between February 2005 and January 2007 seventy nine patients underwent TIP urethroplasty for distal (53 boys) and midpenile (26 boys) hypospadias. Urethral plates were categorized according to their depth into shallow (22 cases), intermediate (23 cases) and deep (34 cases). Plate width was measured and the percentage of the plate width to the prospected neourethra was calculated. The prospected neourethra was assumed to match the calibration of the proximal urethra. Based on this calculation plates were classified into those with a plate width of less than 50% of the prospected neourethra and of more than. We suggested this formula to compensate for variation in the plate width according to the size of the penis, age of the patient, and the depth of the urethral plate groove. We choose the percentage of 50% as the expected increase in width of the urethral plate after the midline incision may reach 50% of the initial plate width. Patients were followed for a median of 15 months, repairs were examined for the presence or development of complications, streams were observed, and finally the neourethrae were calibrated.

Results: Of the 79 patients only 75 are available for follow up. Meatal stenosis developed in 4 boys with shallow plates (18.2%) and one boy with intermediate plates (4.5%). Urethral fistula developed in the same number of patients as above while no patients with deep plates developed such complications (p = 0.02). Meatal stenosis developed in 4 boys with narrow plates (16.6%) and one boy with wide plate (1.96%). Urethral fistula developed in the same number of patients (p = 0.03). Neourethral stricture as well as wound dehiscence were reported each in one boy with shallow plate (4.5%) while no patients with intermediate or deep plates develop such complications. In patients with narrow plates neourethral stricture and wound dehiscence were reported each in one boy (4.2%) while no patients with wide plate develop such complications.

Conclusion: Urethral plate width and depth have a considerable influence on the outcome after TIP urethroplasty and other alternative procedures have to be considered if urethral plate characteristics were unfavorable for this procedure.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Tubularized incised plate urethroplasty in redoes hypospadias

S. Abou Hashem, M. Mostafa, L. Bendary, A. Maroof, A. Kamal

Department of Urology, Zagazig University, Zagazig, Egypt

Aim of the Work: To evaluate the tabularized incised plate (TiP) technique for repair of hypospadias in patients who had undergone one or more failed attempts at repair.

Patients and Methods: A total of 36 children (age range 2-10 years) with failed and complicated hypospadias presented to our unit for redo hypospadias. The number of prior repairs was as follows: one in 21 patients, two in 11 patients and three in 4 patients. The meatus was at the distal shaft in 22 cases, mid shaft in 10 cases, and proximal shaft in 4 cases with intact urethral plate. The procedures done before included meatal advancement and glanuloplasty incorporated (MAGPI) in 9 (%) cases, Matheu in 11 (%) cases, and preputial flaps in 13 (%) cases. Previous TIP urethroplasty were done in 3 (%) cases. The neourethra was then reconstructed using the Sn9odgrass TIP technique.

Results: The cosmetic and functional results were satisfactory as judged by the parents. Overall complications were encountered in 9 patients (25%). Complications included 7 fistulae, 6 were associated with meatal stenosis and one with infection. Stand alone meatal stenosis occurred in 2 other cases required intervention. Fistula repair was successfully performed 6 months later in 6 patients with associated meatoplasty. One case had a revised repair. One case required meatotomy.

Conclusion: The TIP procedure is a viable option with satisfactory cosmetic and functional results for the correction of a previously failed hypospadias repair and can be done using minimal residual tissues remaining after primary procedures.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Bulbar substitution urethroplasty by use of tubularized ventral and dorsal onlay buccal mucosal graft

M. Abo El Enen

Department of Urology, Tanta University, Tanta, Egypt

Aim of the Work: We report our experience and evaluation of the outcome in men undergoing bulbar urethral reconstruction with tabularized neourethra from ventrally and dorsally situated buccal mucosal onlay grafts.

Patients and Methods: Twelve patients underwent substitution bulbar urethroplasty with buccal mucosal grafts. Preoperative evaluation was performed with complete urine analysis with culture and sensitivity tests, uroflow, retrograde and voiding cystourethrogram and urethral sonography. Complete excision of the stricture area was performed with preservation of the healthy corpus spongiosum intact as a separate vascular layer. Harvesting of 2 buccal mucosal grafts was done from cheek. The first graft was fixed dorsally onto the corporeal bodies. The second was graft fixed ventrally to the undersurface of corpus spongiosum. Fashioning of the grafts was performed as a tube over a 14 Fr catheter. Three months after catheter removal; urinary flow rate, AUA symptom score and retrograde urethrogram are performed.

Results: The average age of our patients was 33.5 years. Average follow up was 12 months. Of strictures, 2 patients (16.7%) was idiopathic in origin, 4 (33.3%) was traumatic, 4 (33.3%) was infectious and 2 (16.7%) was iatrogenic. The average stricture length was 3 cm. The average operative time was 165 min. The average estimated blood loss was 214 ml. Hospitalization averaged 3.2 days. AUA symptom scores decreased from an average of 20.5 preoperatively to 4.3 postoperatively (p < 0.001). Peak urinary flow rates improved from an average of 7.9 ml/second to 30.4 ml/second (p < 0.001). There were 2 early postoperative complications (%), 1 had a postoperative febrile UTIs and another patient had prolonged periurethral leakage which heal spontaneously. Three to 6 months after surgery, RGUG demonstrated small non symptomatic ventral sacculation in one patient and narrowing in another patient which require treatment. The other 11 patients have not required any further procedure. The overall success rate was 91.7%.

Conclusion: The creation of neourethra from modulation of ventrally and dorsally situated onlay buccal mucosal grafts after complete excision of strictured urethra is a new added reasonable and reconstructive option for management of long bulbar urethral strictures (>2 cm). However, more efforts, researches and extended follow up are necessary to establish and explain the hidden secrets of improving the outcome of substitution urethroplasty with buccal mucosal grafts.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Tubularized incised plate urethroplasty: KFMMC experience

I. Al Oraifi, A. Al Zahrani, A. Qahtani, S. Egail

Department of Urology and Nephrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Aim of the Work: To evaluate the outcome of our practice in the management of primary and secondary hypospadias using to Tubularized Incised Plate (TIP) Urethroplasty at King Fahd Military Medical Complex.

Patients and Methods: We retrospectively reviewed the medical reports of 169 patients who underwent hypospadias repair between October 1990 and December 2006. Out of these, 52 patients had TIP urethroplasty, 4 patients lost follow up. Out of the 48 patients, 43 (89.6%) were primary and 5 (10.4%) were secondary hypospadias. The main follow up was 26 months.

Results: The functional and cosmetic results were excellent. The overall success rate was 80%. Complications were encountered in 10 (21%) patients. Meatal stenosis was seen in 6 (12.5%), combined meatal stenosis and fistula in 1 (2.1%), and fistula in 3 (6.3%). The later, 1 was secondary and 2 were primary hypospadias.

Conclusion: TIP urethroplasty is a simple and versatile technique that gives an excellent cosmetic appearance. It can be used for primary and secondary hypospadias. We believe regular urethral dilatation is advisable to prevent/decrease meatal stenosis.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Outcome analysis of tubularized incised plate urethroplasty in 100 children

A. Al Otay, A. Abdulbasit, Z. Nakshabandi, A. Hafez

Department of Urology, Division of Pediatric Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Objective: We evaluated the outcome of 100 consecutive TIPU in a training-tertiary referral facility where hypospadias repair is an integral part of fellows/residents training. Various parameters affecting success were studied.

Patients and Methods: The records of 100 patients who underwent TIPU between January 2005 and October 2008 were reviewed. All patients underwent TIPU either by/or supervised by a fellowship trained pediatric urologist. A unified follow up protocol was applied. All patients were evaluated at 6-8 weeks after surgery, at 3 month and at one year. The urethra was calibrated using 8F feeding tube at follow up. Routine urethral dilation was not performed in any patient. Univariate analysis was performed using Chi-square test, while Logistic regression was used for multivariate analysis. Statistical significance was defined as p value of less than 0.05.

Results: Mean age at surgery was 24 months (range 8 months - 12 years). The hypospadias was distal in 79 and proximal in 21. All but 4 cases were de novo. Urethral hypoplasia was present in 35 cases. Second layer coverage of the neourethra was performed in 98 patients. All but 9 patients had a urethral stent after surgery. The overall success was 89%. Age at surgery, hypospadias site, previous circumcision, previous repair, spongioplasty, dartos flap coverage, type/technique of suturing, use of stent, or stent duration did not statistically affect outcome in neither univariate nor multivariate analysis. Urethral hypoplasia was the only factor affecting outcome in both univariate as well as multivariate analysis. Presence of urethral hypoplasia reduces success from 94% to only 80% (p 0.04).

Conclusion: TIPU is the first therapeutic option for distal hypospadias with a success rate of 90%. If performed for proximal hypospadias, the failure rate is around 15% which is comparable, if not better, to other techniques. Presence of urethral hypoplasia significantly reduces the success of TIPU. These figures should be honestly introduced to the parents at the preoperative counseling setting.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14-16 April 2009

Versatility of tubularized incised plate urethroplasty in the management of different types of hypospadias: 5-year experience

Gamal Al Saied Ibrahim

Department of Urology, King Abdulaziz Specialist Hospital, Taif, Saudi Arabia

Introduction: The outcomes of urethroplasty in the management of different types of hypospadias have continued to improve since the introduction of the tabularized incised plate (TIPU) urethroplasty (Snodgrass method). The aim of this study was to evaluate the feasibility and applicability of TIP urethroplasty in the management of different types of hypospadias.

Methods: This work was carried out at Al-Azhar University Hospital, Cairo, Egypt in the period from January 2002 to December 2002 and King Abdulaziz Specialist Hospital, Taif, Saudi Arabia in the period from January 2003 to January 2007 by the same authors. The medical records of 175 boys with different type of hypospadias, who underwent TIP urethroplasty, were critically reviewed. Their age ranged from 9 to 36 months (mean age 22.72 ΁ 7.75 months). The period of follow up ranged from 7 to 60 months (mean 34.42 ΁ 15.41).

Results: All families were happy with penile aesthetic appearance. The total number of boys with different types of hypospadias was 175 (145 1 ry and 30 2 ry). Out of 175 cases, the overall urethrocutaneous fistula rate was 11 (6.29%), and the overall rates for glanular dehiscence, urethral stricture, meatal stenosis and meatal regression were 4 (2.29%), 5 (2.86%), 17 (9.71%), and 10 (5.71%), respectively. All cases of urethral stricture and most cases of meatal stenosis 12 (6.86%) responded well to regular urethral dilatation. Meatoplasty was performed in only 5 (2.85%) cases (1 of 1 ry and 4 of 2 ry cases). Secondary surgery for fistula repair and glans closure was successful in all patients. All children void with a single straight urinary stream in a forward direction, and have a rounded glans with vertical slit-like terminal glanular meatus. The mean hospital stay was 4.6 days.

Summary and Conclusion: TIP urethroplasty with neourethral coverage using a vascularized pedicle of dartos flap is versatile and simple operation in management of different types of hypospadias. It has a good functional and cosmetic outcome.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Evaluation of buccal mucosal onlay graft in treatment of complex proximal hypospadias

Safwat Elsayed Abouhashem, Salim Khalil, Ashraf Shahen, Khalid Abdelsamad, Mahmoud Eladl

Department of Urology, Zagazig University, Zagazig, Egypt

Purpose: Buccal mucosa has available in urethral reconstruction. The aim of this study is to evaluate the outcomes of complex proximal hypospadias repair using buccal mucosal onlay graft.

Methods: This study include 21 patients with complex proximal hypospadias, all cases of the study had history of previous unsuccessful procedures for repair proximal hypospadias other than onlay procedure with moderate degrees of scar tissue was evident in the urethral plate. Buccal mucosal graft was harvesting from the lower lip for all patients of the study. The buccal mucosa onlay graft was then sutured with a 6-zero running vicry to the urethral plate, the graft was covered by vascularized subcutaneous tissue.

Results: The mean age was 11.2 +/- 3.4 years, the mean follow up was 17.4 +/- 2.9 months in 6-month intervals. The appearance was satisfactory by the patients and their family. Only one patient developed uroflowmetry below normal due to stricture urethra, which occur after 9 months in one out of 21 (4.8%) and managed by visual internal urethrotomy once. Fistulas were observed in the first 6 months in 2 cases (9.5%) which were repaired successfully.

Summary and Conclusion: Buccal mucosa is an ideal source of graft for reconstruction of complex hypospadias patients if no penile skin is available. Complex hypospadias repair should be done by an experienced surgeon. Meta-analysis studies are needed for assessment of buccal mucosal graft in complex hypospadias patients.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Hypospadias repair, TIPS and tricks

Faris M. Ayyat, Ali R. Mahmoud, Hussein Al Ghanim

Department of Surgery, King Fahad Medical City, Riyadh, Saudi Arabia

This video will illustrate selected cases of hypospadias repair with ventral chordee, the artificial erection and supra-pubic cystotomy if required, transposition of skin flaps and subcutaneous tissue for augmentation and replacement of atrophic corpus spongiosum. Different flaps and repairs for example Snodgrass, onlay dorsal flap and skin manipulation to close deficient skin areas ventrally especially if the patient was circumcised. The single stage procedure is usually done for penoscrotal hypospadias. Duration of this video is 5 minutes and will be presented in DVD format.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Evaluation of oral mucosa onlay graft in complex hypospadias repair

Salem Khalil, Khalid Abdalsamad,

Ehab R. Elsayed, Aref M. Maarouf, Safwat Abouhashem, Ashraf M. S. Shahin

Department of Urology, King Abdullah Bin Abdulaziz Hospital, Bisha, Saudi Arabia

Purpose: Recurrent complex hypospadias is mostly associated with penile skin loss and deficient local tissue, so extragenital skin is needed. Over the past few years oral mucosa emerged as a reliable and popular donor tissue for urethral substitution. The aim of this study is to evaluate the clinical outcome, safety and efficacy of buccal mucosa grafts in the repair of recurrent complex hypospadias.

Patients and Methods: Twenty one patients with complex hypospadias were prospectively included in the study. Their mean age was 14.1 ΁ 2.3. The number of previous unsuccessful hypospadias repairs ranged from 2 to 6. In this prospective study all cases had a history of previous unsuccessful procedures for hypospadias repair with severely scarred penile skin and mild to moderate degrees of urethral plate scarring. Buccal mucosa onlay graft was done for all patients in the study. Patients were instructed to have follow up visits in outpatient clinic every 3 months for 18 months.

Results: Duration of follow up ranged from 6-18 months, three patients were lost to follow up. The length of the graft ranged from 4.8-10.3 cm (mean 7.7 ΁ 2.1 cm) and width ranged from 1-1.3 cm. Only two cases in this series needed dorsal placation to achieve penile straightening. Of twenty one cases 16 cases (76.1%) were successful. Superficial wound infection occurred in one case and a small hematoma in another case, both were treated conservatively and both were considered as successful. Meatal stenosis occurred in one case (4.8%). Two cases (9.6%) developed urethral fistula (one of them was associated with meatal stenosis). Two patients (9.6%) developed stricture at anastomotic site. Only one case (4.8%) had partial wound dehiscence at the distal part of the graft and needed further repair. As regards donor site only 3 cases complained of parathesia, numbness for about 3 months that resolved spontaneously.

Conclusion: Buccal mucosa is an ideal source of onlay graft for reconstruction of complex hypospadias patients if the degree of scarring of urethral plate allows its preservation and there is a paucity of local tissues. Further larger studies with longer follow up are needed for assessment of the role of buccal mucosa graft in complex hypospadias repair.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital -

Dammam

21-24 February 2011

Outcome of longitudinal tubularized preputial and dorsal penile skin grafting for hypospadias

Salem Khalil, Safwat Abou Hashem, Ehab R. Elsayed, Khalid A. Samad, A. M. S. Shaheen, Mahmoud El Adl

Department of Urology, Zagazig University,

Zagazig, Egypt

Introduction: This study was carried out to evaluate the longitudinal transaction preputial and dorsal penile skin flap, in management of proximal hypospadias with severe chordee when urethral plate transaction is necessary.

Materials and Methods: This study included 31 patients with primary proximal hypospadias, age ranged from 18-84 months (average 43.2 months), the original meatal positions were mid penile in 6 patients, proximal penile in 20 patients and penoscrotal in 5 patients. All patients had penile curvature that needed urethral plate transaction and all underwent longitudinal preputial and dorsal penile tabularized flap urethroplasty. The average follow up period was 8.6 months. Patients were evaluated post-operatively for duration of surgery, success rate, cosmetic and functional outcome, complications and re-operation rate.

Results: Good cosmetic and functional results were obtained by longitudinal flap technique. The overall success rate was (22) patients (71.2%). Complication rate noticed in (9) patients (28.8%). Urethrocutenous fistula developed in (4) patients (12.8%). Two patients (6.4%) developed urethral stenosis at the site of anastomosis, two patients developed meatal stenosis (6.4%), total flap disruption and sloughing occurred in one patient (3.2%) and one patient developed penile recurvature at 6 month post-operatively. The mean operative time (20) minute ΁ was (105). Re-operation rate was 16% in 5 patients.

Conclusion: Single stage urethroplasty using tabularized longitudinal preputial and dorsal penile skin flap is an operation that should be in the armamentarium of the pediatric urologist especially in cases of proximal hypospadias with severe chordee necessitating transaction of the urethral plate. It has satisfactory functional and cosmetic outcomes with low morbidity.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital -

Dammam

21-24 February 2011