Summary
Extended Summary
Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened
while preserving the urethral plate to use TIP repair. That is usually done by dorsal
plication (DP). However, we reported recurrent VC was commonly found after DP in boys
with proximal urethroplasty complications, and have diagnosed VC in patients similarly
straightened by WS. We reviewed our proximal TIP patients and now report their recurrent
VC.
Methods
We used a prospectively-maintained database to identify all patients with proximal
TIP by WS and document recurrent VC. Penile straightening was primarily done by midline
DP using 5–0 or 6–0 polypropylene, and/or other maneuvers including combinations of
urethral plate elevation off the corpora, mobilization of the urethra to the external
sphincter, and ventral corporotomies. Recurrent VC was suspected by a characteristic
‘hunched-over’ appearance and resistance to lifting the glans cephalad (Figure), and
confirmed in all cases by artificial erection intraoperatively.
Results
58 of the 77 patients with follow up had VC straightened. Recurrent VC was diagnosed
in 26%. It was suspected during this review in another 10% who had recurrent urethroplasty
complications which we now know often indicate VC, or urethral plate elevation with
no treatment for corporal disproportion. This recurrent VC was objectively measured
in nearly half those diagnosed, averaging 52 (30–75). It was diagnosed before puberty
in all cases. There was no difference in recurrent VC in those managed with DP alone
versus those straightened by DP and/or other maneuvers.
Discussion
The finding that 1 of every 4 patients had recurrent VC after proximal TIP, and that
as many as 1 of every 3 might have had that complication, is concerning. During most
the study the extent of VC was visually estimated, and most patients were thought
to have <45° with no tension on the UP after straightening.
We reported 70% of patients operated elsewhere for proximal hypospadias and presenting
with urethroplasty complications had recurrent VC ≥ 30° following earlier DP. In that
series, in the current patients, and in an earlier report by Braga et al., an intact
urethral plate correlated with increased risk for recurrent VC. Despite our improved
ability to diagnose recurrent VC, we have not found it in boys who underwent STAG
repair with urethral plate transection.
Conclusions
Graphical AbstractRecurrent ventral curvature > 30 after proximal TIP with dorsal plication. In addition
to the ‘hunched over’ appearance, there is resistance to lifting the glans cephalad
and the penis snaps back to this position when released.
Keywords
Abbreviations:
VC Ventral Curvature (DP Dorsal Plication), TIP Tubularized Incised Plate (WS Warren Snodgrass), UP Urethral Plate (STAG Staged Tubularized Auto-Graft), AE Artificial Erection (CD Corporal Disproportion)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: November 30, 2020
Accepted:
November 22,
2020
Received in revised form:
November 19,
2020
Received:
August 13,
2020
Identification
Copyright
© 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
