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 | 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) | |||||||
| 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
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Pediatric UrologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The history of hypospadias and hypospadias repairs.Urology. 2011; 77: 1277
- A one-stage hypospadias repair.J Urol. 1970; 104: 281
- Transverse preputial island flap technique for repair of severe hypospadias.Urol Clin. 1980; 7: 423
- Surgical repair of hypospadias.Surg Clin. 1950; 30: 1371
- Tubularized incised plate proximal hypospadias repair: continued evolution and extended applications.J Pediatr Urol. 2011; 7
- Primary severe hypospadias: comparison of reoperation rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs.J Urol. 2013; 189: 1508
- Intermediate-term followup of proximal hypospadias repair reveals high complication rate.J Urol. 2017; 197: 852
- Proximal hypospadias: a persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period.J Pediatr Urol. 2016; 12
- Complications following staged hypospadias repair using transposed preputial skin flaps.J Urol. 2015; 194
- Management of proximal hypospadias with 2-stage repair: 20-year experience.J Urol. 2015; 194: 1080
- Two-stage hypospadias repair with a free graft for severe primary and revision hypospadias: a single surgeon's experience with long-term follow-up.J Pediatr Urol. 2017; 13
- Comparative analysis of tubularized incised plate versus onlay island flap urethroplasty for penoscrotal hypospadias.J Urol. 2007; 178: 1451
- Outcome of proximal hypospadias repair using three different techniques.J Pediatr Urol. 2010; 6: 45
- Surgical management of primary severe hypospadias in children: systematic 20-year review.J Urol. 2010; 184: 1469
- Current challenges with proximal hypospadias: we have a long way to go.J Pediatr Urol. 2017; 13: 457
- Staged repair of proximal hypospadias: reporting outcome of staged tubularized autograft repair (STAG).J Pediatr Surg, 2020
- Goniometer not better than unaided visual inspection at estimating ventral penile curvature on plastic models.J Pediatr Urol. 2019; 15: 628
- Ventral penile curvature estimation using an app.J Pediatr Urol. 2020; 16
- Time to complication detection after primary pediatric hypospadias repair: a large, single-center, retrospective cohort analysis.J Urol. 2020; 204: 338-344
Article info
Publication history
Published online: December 11, 2020
Accepted:
December 8,
2020
Received in revised form:
December 1,
2020
Received:
September 9,
2020
Identification
Copyright
© 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
