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Challenging proximal hypospadias repairs: An evolution of technique for two stage repairs

  • Yvonne Y. Chan
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • Anthony D'Oro
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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  • Elizabeth B. Yerkes
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • Ilina Rosoklija
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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  • Lauren C. Balmert
    Affiliations
    Department of Preventative Medicine/Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • Bruce W. Lindgren
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • Edward M. Gong
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • Dennis B. Liu
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • Emilie K. Johnson
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • David I. Chu
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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  • Earl Y. Cheng
    Correspondence
    Correspondence to: Earl Y. Cheng, Divison of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave Box 24, Chicago, IL 60611, USA. Tel: +312 227 6340; Fax: +312 227 9412
    Affiliations
    Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
    Search for articles by this author
Published:December 11, 2020DOI:https://doi.org/10.1016/j.jpurol.2020.12.008

      Summary

      Introduction

      Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars’ flaps.

      Study design

      A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with <6 months follow-up and incomplete operative reports were excluded. Risk of complications (fistula, dehiscence, diverticulum, meatal stenosis, stricture) were evaluated following urethroplasty and stratified by first-stage repair technique. As technique refinements have been made since 2012, comparisons between two temporal subgroups (those who underwent repair in 2007–2012 and in 2013–2017) were made.

      Results

      78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4–128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14–0.65) and inlay grafts (HR 0.32; 95% CI 0.11–0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars’ flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p = 0.001), but differences in complication rates by first-stage technique were not statistically significant.

      Discussion

      In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars’ flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising.

      Conclusion

      Tabled 1Summary Table. Overall Complications and Unadjusted Cox Proportional Hazards Model Comparing Complications by First-stage Repair Technique
      Overall Complications All (N = 78) Inlay Graft (N = 13) Pedicled Preputial Flap (N = 33) Byars' Flaps (N = 21) Combined (N = 11)
      Complications
      This notes the number of patients who developed complications. If a patient developed two complications, they were only counted once for this variable.
      37 (47%) 4 (31%) 11 (33%) 17 (81%) 4 (36%)
      Median Number of Complications Per Patient 0 (0–2) 0 (0–2) 0 (0–2) 1 (0–2) 0 (0–1)
      Type of Complications (n, % of cohort)
      This notes the number of patients with each type of complication.
      Fistula 18 (23%) 2 (15%) 6 (18%) 8 (38%) 2 (18%)
      Glans/Partial dehiscence 10 (13%) 1 (8%) 0 6 (29%) 3 (30%)
      Stricture 6 (8%) 2 (15%) 1 (3%) 3 (14%) 0
      Diverticulum 3 (4%) 0 1 (3%) 2 (10%) 0
      Meatal Stenosis 3 (4%) 0 3 (9%) 0 0
      Dehiscence 2 (2.5%) 0 1 (3%) 1 (5%) 0
      Unadjusted Cox Proportional Hazards Model Comparing Complications by First-stage Repair Technique
      Repair Hazard Ratio 95% Confidence Intervals
      Inlay Graft versus Byars' Flaps 0.32 0.11–0.95
      Pedicled Preputial Flap versus Byars' Flaps 0.30 0.14–0.65
      Combined versus Byars' Flaps 0.48 0.18–1.31
      a This notes the number of patients who developed complications. If a patient developed two complications, they were only counted once for this variable.
      b This notes the number of patients with each type of complication.

      Keywords

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