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Recurrent ventral curvature after proximal TIP hypospadias repair

Published:November 30, 2020DOI:https://doi.org/10.1016/j.jpurol.2020.11.030

      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

      Figure 1
      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)
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