Can sealing promote healing?: A systematic review and meta-analysis highlighting the adjunctive role of tissue sealant application during urethroplasty for hypospadias

      Summary

      Background

      A significant proportion of children require multiple surgeries for successful repair of hypospadias. This is not only a source of a financial burden to the family but also causes long-term social and psychosexual issues. Tissue sealant application can provide additional coverage to the suture line and subsequently prevents operative failure. However, a consensus statement regarding its usage during urethroplasty is lacking. This systematic review and meta-analysis aims to compare the outcomes of hypospadias surgery, in terms of its complications, in children with and without tissue sealant application.

      Method

      The authors systematically searched the databases PubMed, EMBASE, Web of Science and Scopus through September 2020. The occurrence of overall complications, and specific complications (including urethrocutaneous fistula, wound-related complications, flap-related complications, complications involving the neo-urethral tube and meatal stenosis) were the primary and secondary outcomes, respectively. Statistical analysis was performed using a random-effects model, and pooled risk ratio (RR) and heterogeneity (I2) were calculated. The methodological quality of the studies was assessed utilizing the Downs and Black scale.

      Result

      Four comparative studies were included in the meta-analysis. The different types of tissue sealants such as fibrin glue, cyanoacrylate glue, BioGlue and cryocalcium glue were used in these studies. As compared to without sealant application, hypospadias repair performed with sealant application showed no significant difference in the incidence of overall postoperative complications (RR 0.63; 95% CI 0.34–1.14, p = 0.13). However, a significant reduction in some specific complications including urethrocutaneous fistula (RR 0.37; 95% CI 0.19–0.72, p = 0.003), wound-related complications (RR 0.57; 95% CI 0.38–0.86, p = 0.008) and complications involving the neo-urethra (RR 0.15; 95% CI 0.04–0.54, p = 0.004) was observed with sealant usage. The average Downs and Black scale scores ranged from 16 to 18, with all studies having a moderate risk of bias. Kappa statistics showed a value of 0.962 (p < 0.001), highlighting an almost perfect agreement among the two observers.

      Conclusion

      The present meta-analysis revealed no additional benefit of the repair of hypospadias performed with tissue sealants as compared to without sealants in terms of reducing the overall postoperative complications. However, a significant reduction in the occurrence of some specific complications, including UCF, wound-related complications and complications involving the neourethra was observed with sealant application. The level of evidence of the published comparative studies is limited. Therefore, further studies need to be conducted for optimal comparison between the sealant and no sealant (or placebo), and different types of sealants.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-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 Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hadidi A.T.
        History of hypospadias: lost in translation.
        J Pediatr Surg. 2017; 52: 211-217https://doi.org/10.1016/j.jpedsurg.2016.11.004
        • Lu Y.-C.
        • Huang W.-Y.
        • Chen Y.-F.
        • Chang H.-C.
        • Pong Y.-H.
        • Shih T.-H.
        • et al.
        Factors associated with reoperation in hypospadias surgery - a nationwide, population-based study.
        Asian J Surg. 2017; 40: 116-122https://doi.org/10.1016/j.asjsur.2015.07.010
        • Kocherov S.
        • Lev G.
        • Chertin B.
        Use of BioGlue surgical adhesive in hypospadias repair.
        Curr Urol. 2013; 7: 132-135https://doi.org/10.1159/000356265
        • Hosseinpour M.
        • Etezazian S.
        • Hamsaieh M.
        Cryocalcium glue in hypospadias surgery.
        J Indian Assoc Pediatr Surg. 2019; 24: 226-227https://doi.org/10.4103/jiaps.JIAPS_159_18
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384https://doi.org/10.1136/jech.52.6.377
        • Yang H.
        • Xuan X.-X.
        • Hu D.-L.
        • Zhang H.
        • Shu Q.
        • Guo X.-D.
        • et al.
        Comparison of effect between dartos fascia and tunica vaginalis fascia in TIP urethroplasty: a meta-analysis of comparative studies.
        BMC Urol. 2020; 20: 161https://doi.org/10.1186/s12894-020-00737-9
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159https://doi.org/10.2307/2529310
        • Higgins J.P.T.
        • Green S.
        Cochrane handbook for systematic reviews of interventions version 5.1.0.
        2011
        https://handbook-5-1.cochrane.org/
        Date accessed: October 24, 2020
        • Sheng X.
        • Xu D.
        • Wu Y.
        • Yu Y.
        • Chen J.
        • Qi J.
        The risk factors of Urethrocutaneous fistula after hypospadias surgery in the youth population.
        BMC Urol. 2018; 18: 64https://doi.org/10.1186/s12894-018-0366-z
        • Ambriz-González G.
        • Aguirre-Ramirez P.
        • García-de León J.M.
        • León-Frutos F.J.
        • Montero-Cruz S.A.
        • Trujillo X.
        • et al.
        2-octyl cyanoacrylate versus reintervention for closure of urethrocutaneous fistulae after urethroplasty for hypospadias: a randomized controlled trial.
        BMC Urol. 2014; 14: 93https://doi.org/10.1186/1471-2490-14-93
        • Chandrasekharam V.V.S.
        Temporary re-catheterization as a treatment for early fistulas after hypospadias repair.
        J Pediatr Urol. 2016; 12: 129-130https://doi.org/10.1016/j.jpurol.2016.01.005
        • Bao Z.
        • Gao M.
        • Sun Y.
        • Nian R.
        • Xian M.
        The recent progress of tissue adhesives in design strategies, adhesive mechanism and applications.
        Mater Sci Eng C Mater Biol Appl. 2020; 111: 110796https://doi.org/10.1016/j.msec.2020.110796
        • Tsur H.
        • Slutzky S.
        • Shafir R.
        Hypospadias repair with subcutaneous suture and tissue adhesive for surface closure.
        Plast Reconstr Surg. 1979; 64: 532-535https://doi.org/10.1097/00006534-197910000-00015
        • Kinahan T.J.
        • Johnson H.W.
        Tisseel in hypospadias repair.
        Can J Surg. 1992; 35: 75-77
        • Ambriz-González G.
        • Velázquez-Ramírez G.A.
        • García-González J.L.
        • de León-Gómez J.M.G.
        • Muciño-Hernández M.I.
        • González-Ojeda A.
        • et al.
        Use of fibrin sealant in hypospadias surgical repair reduces the frequency of postoperative complications.
        Urol Int. 2007; 78: 37-41https://doi.org/10.1159/000096932
        • Gopal S.C.
        • Gangopadhyay A.N.
        • Mohan T.V.
        • Upadhyaya V.D.
        • Pandey A.
        • Upadhyaya A.
        • et al.
        Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair.
        J Pediatr Surg. 2008; 43: 1869-1872https://doi.org/10.1016/j.jpedsurg.2008.04.022
        • Castañón García-Alix M.
        • Sancho Vendrell M.A.
        • Parri Ferrandis F.J.
        • San Vicente Vela B.
        • García Aparicio L.
        • Tarrado Castellarnau X.
        • et al.
        Utility of octyl 2-cyanoacrylate in pediatric surgery.
        An Pediatr (Barc). 2003; 59: 548-551https://doi.org/10.1016/s1695-4033(03)78778-5
        • Hosseini S.M.V.
        • Bahador A.
        • Foroutan H.R.
        • Sabet B.
        • Geramizadeh B.
        • Zarenezhad M.
        The application of a new cyanoacrylate glue in pediatric surgery for fistula closure.
        Iran J Med Sci. 2011; 36: 54-56
        • Kajbafzadeh A.-M.
        • Abolghasemi H.
        • Eshghi P.
        • Alizadeh F.
        • Elmi A.
        • Shafaattalab S.
        • et al.
        Single-donor fibrin sealant for repair of urethrocutaneous fistulae following multiple hypospadias and epispadias repairs.
        J Pediatr Urol. 2011; 7: 422-427https://doi.org/10.1016/j.jpurol.2010.06.004
        • Lapointe S.P.
        • Claire N.
        • Lortat-Jacob S.
        Early closure of fistula after hypospadias surgery using N-butyl cyanoacrylate: preliminary results.
        J Urol. 2002; 168: 1751-1753https://doi.org/10.1097/01.ju.0000028339.08334.d7
        • Prestipino M.
        • Bertozzi M.
        • Nardi N.
        • Appignani A.
        Outpatient department repair of urethrocutaneous fistulae using n-butyl-cyanoacrylate (NBCA): a single-centre experience.
        BJU Int. 2011; 108: 1514-1517https://doi.org/10.1111/j.1464-410X.2010.10083.x
        • Tan H.-L.
        • Nah S.A.
        • Budianto II,
        • Sehat S.
        • Tamba R.
        The use of octyl cyanoacrylate (superglue) in hypospadias repair including its use as a fixator for urethral stents.
        J Pediatr Surg. 2012; 47: 2294-2297https://doi.org/10.1016/j.jpedsurg.2012.09.022
        • Bhamidipati C.M.
        • Coselli J.S.
        • LeMaire S.A.
        BioGlue in 2011: what is its role in cardiac surgery?.
        J Extra Corpor Technol. 2012; 44: P6-P12