Retrospective Analysis of Mathieu's Urethroplasty for Anterior Hypospadias Repair in Circumcised Children: a Single Center Experience

Introduction: Mathieu's technique (peri-meatal based flap) makes use of the urethral plate in the repair of anterior hypospadias; thereby creating an almost natural neo-urethra. In a circumcised baby or after previous unsuccessful repair; Mathieu's flap may be one of the few options left to repair anterior hypospadias. Objectives: To evaluate the result of Mathieu's flap repair for anterior hypospadias in a resource poor setting.Materials and Method: This is a retrospective review of post-circumcision anterior hypospadias managed by Mathieu's flap repair between January 1996 and December 2006 in the paediatric surgical unit of the Obafemi Awolowo University Teaching Hospital; a tertiary hospital in the South Western Nigeria. Results: Mathieu's flap repair was performed in 16 patients with isolated anterior hypospadias; 15 (93.8) were circumcised before presentation. The complications were urethrocutaneous fistula in 3 (18.8); wound infection in 2 (12.5) and flap necrosis in 1 patient (6.3). Final outcome was satisfactory in all patients. Conclusion: Mathieu's flap remains a viable option in the repair of anterior hypospadias even after circumcision

Challenges of Surgical Repair of Hypospadias in Ile-Ife; Nigeria

Objective: To document the presentation; outcome and challenges of management of hypospadias in a resource-limited setting. Patients and Methods: For this retrospective study we analyzed the files of all patients with hypospadias managed at the Obafemi Awolowo University Teaching Hospital; Ile-Ife; Nigeria between 1996 and 2006. The parameters studied were the patients' bio-data; clinical presentation; treatment and outcome. Results: During the 10-year period under review 51 cases of hypospadias were managed. The majority of the patients (n=39; 76.5) presented within the first year of life with a mean age at presentation of 1 year and 8 months; though most of the repairs were done in the 2nd; 3rd and 4th years of life. Of the 51 patients 46 (90.2) came from rural and semi-urban areas and 18 (35.3) had been circumcised before presentation. Surgical repair consisted of preputial island flap in 22 patients (43.1) followed by a peri-meatal based flap (Mathieu procedure) in 16 patients (31.4). The MAGPI procedure was used in 5 patients (9.8) and the Snodgrass procedure in 1 (2). Staged repair was necessary in 7 patients (13.7). Post-operative complications were encountered in 15 patients with urethrocutaneous fistula being the commonest one (11 patients; 21.6). Conclusion: Our results show that hypospadias can be successfully managed in a low- resource setting

Tubularized incised plate urethroplasty with de-epithelialized flap

Aim: To improve the results of tubularized plate urethroplasty by adding de-epithelized flap. Patients and Methods: Twenty-five cases of hypospadias who underwent Snodgrass urethroplasty using de-epithelialized flap were studied. The minimum period of follow-up in this series was 1 year. Results: The resultant neo-meatus was vertically oriented and slit like. Glans was conical which is cosmetically well accepted. Penile raphe was in the midline. None of the patient had residual chordee; penile torsion; or glans dehiscence. Excellent cosmetic results were observed in all cases. The complication rate in our series was 8(two cases). Two patients developed fistula. Conclusion: De-epithelialized flap is a simple method to provide additional covering to the constructed neourethra after Snodgrass urethroplasty. It achieves our goal of noncrossing suture lines and providing maximum vascularity

Short hospital stay versus day-care Mathieu hypospadias repair

Objective: This study compared the outcome of Mathieu repair between patients who went home within 24 hours on catheter and dressing and patients who were managed in hospital for 48 hours and had their catheters and dressings removed before going home. Patients and Methods: A retrospective study of Mathieu hypospadias repair performed by the same surgeon for 11 years. Outcome measures were catheter and dressing related problems/complications. Results: Sixty five patients were included in the study; 43(66.2) were managed in-hospital for the first 48 hours (Group A); while 22(33.8) were managed as day-care cases (Group B). Complication rate was 6(14.0) and 3(13.6) respectively; with fistula rate of 2(4.7) in Group A and 1(4.5) in Group B. Conclusion: Day care Mathieu repair of hypospadias does not increase the occurrence of complications

Tubularized incised plate (TIP) urethroplasty : extended use in hypospadias re-operation

Objective: Recently; tubularized incised plate (TIP) urethroplasty (Snodgrass repair) has gained popularity for the primary repair of distal and proximal hypospadias. This study was carried out to evaluate TIP urethroplasty in the repair of failed and complicated hypospadias cases. Patients and Methods: This study was carried out in the pediatric surgery unit; Departments of General Surgery and Urology; Zagazig University Hospital. Twenty-four patients with failed and complicated hypospadias with an intact urethral plate were included in this work. Thirteen patients (54) were younger than 3 years; and 3 patients (13) older than 6 years. The original hypospadias was coronal in 4; midshaft in 11 and penoscrotal in 9 cases. Wide fistula was present in 8 cases (32) and dehiscence was found in 6 cases (26). Previous procedures included meatal advancement and glanuloplasty incorporated (MAGPI) in 5 (21) cases; Mathieu procedure in 4 (17); and preputial flaps in 13 (55) cases. Two patients (8) had been subjected to previous TIP urethroplasty. Twenty cases had had a single preceding procedure; while 4 cases had been subjected to two previous trials of correction. The time that had elapsed before re-operation was less than 6 months in 14 cases (58). Results: Fistula occurred in 3 cases; two of them had had preoperative fistula. Meatal and anastomotic strictures occurred in 2 cases each and were completely managed by dilatation for 3-6 months. Wound infection occurred in 5 cases. Good cosmetic and functional results were achieved in 15 cases (63). TIP urethroplasty was found to be suitable for re-operating previously failed hypospadias cases because it reconstructs the urethra entirely from the urethral plate which is the least affected part after all types of repair. Also; no relation was found between the morphology of the urethral plate and the success of TIP repair. Most of the cases had an intact urethral plate which had not been incised in the primary procedure. Further studies are needed to assess the possibility of using a urethral plate which was previously incised in a primary procedure. Conclusion: TIP urethroplasty could be a reasonable procedure in failed and complicated hypospadias cases. It provides good cosmetic and functional results and can be done using minimal residual tissues remaining after primary procedures

Distally folded onlay flap : a new technique for repair of hypospadias

Objective: This study was carried out to evaluate the cosmetic and functional results of this new technique for repair of hypospadias. Patients and technique: 28 patients (2-22 years) with distal penile hypospadias were included in the study. Eleven of them had had a failed previous repair. An unhealthy urethral plate and/or thin ventral penile skin were found in 17 patients. The technique follows the steps of the island onlay preputial flap or dorsal penile fasciocutanous flap except in that the length of the flap is; at least; 1 cm longer than the length of the urethral plate. The proximal part of the flap is used for urethral reconstruction. The distal free part of the flap is reflected back to be sutured to the edges of the glanular wings and the penile skin. The urethral stent is removed after 5 days. The patients were followed monthly up to 6 months. Results: In 26 patients an excellent cosmetic appearance of both the penile shaft and glans was achieved with a slit-like or elliptic neo-meatus resulting in a good urine stream satisfying both the patients and their parents. Partial disruption of one side of the suture line and urethrocutanous fistula was reported in one patient each. These two complications were corrected surgically with good results. Conclusion: We conclude that this new technique that we named distally folded onlay flap is easy and versatile with excellent cosmetic and functional results and a low rate of complications when used for the repair of distal and mid-shaft hypospadias in either virgin or redo cases. It should also be considered as a salvage procedure when other techniques are no feasible options

The use of tissue expanders in hypospadias cripples and complex anterior urethral stricture : early experience

Objective: This procedure was introduced to evaluate the use of tissue expanders in patients with complex anterior urethral strictures and hypospadias cripples where there is not enough healthy penile skin to bridge the urethral defect or to cover the neourethra. Patients and Methods: Six patients with a mean age of 23.3 years were included in this study. Four patients presented with complex hypospadias after failed multiple repairs. Three of them presented with penoscrotal meatus; residual chordee and scarred ventral penile skin. The fourth patient had multiple proximal fistulas with a scarred narrow distal urethra. The fifth patient was circumcised with a concealed penis and a congenitally short urethra. The sixth patient was referred from another institution after previous unsuccessful urethrotomies and urethroplasties. He had a curved penis; a calcified urethral plate and a proximal penile urethral meatus after first-stage Johanson procedure. The tissue expander was placed under the dorsal penile skin through a subcoronal incision. Penile skin expansion was performed gradually over 5-8 weeks. Urethroplasty was then performed using the Thiersch-Duplay technique with penile covering using the excess dorsal penile skin. Results: Expansion of the dorsal penile skin was performed successfully in all cases. There were no complications related to the use of tissue expanders except for minimal discomfort at the start of expansion. Complications related to urethroplasty included mild skin infection and temporary penoscrotal urethrocutaneous fistula (which closed spontaneously); a subcoronal fistula that required surgical closure and disruption of the glandular sutures in one case each. Conclusions: The initial good results of this technique are encouraging in patients presenting after multiple failed urethroplasties. It seems to provide an alternative to free grafts; which at present is the only solution for such cases. However; further evaluation on a larger number of patients is required

Prevalence of hypospadias abdominal and peno-scrotal abnormalities among primary school boys in a Nigeria community

Objectives To determine the prevalence of hypospadias; patent processus vaginalis; umbilical hernia; splenomegaly and cryptorchidism in primary school boys of a Nigerian community. Patients and Methods A community-based observational study using the cluster-sampling method was done. One thousand and ninety-six primary school boys aged between 5 and 13 years from five randomly selected schools in the administrative district of the Ogbaru Local Government Area (LGA) of Eastern Nigeria participated in this study; while in only 1080 boys some specific information on umbilical hernia was available. Each participant underwent a general; abdominal; groin and peno-scrotal physical examination. Results The prevalence of hypospadias was 1.1and this was equivalent to the incidence. The prevalence of a patent processus vaginalis was 1.0with an estimated incidence of 1.3. Cryptorchidism was present in 0.8and retractile testis in 3.2. The prevalence of umbilical hernia was 26and the splenomegaly rate was 7. Conclusion The incidence and prevalence of simple hypospadias was higher than previously suggested by a tertiary hospital-based report from Western Nigeria. Umbilical hernia was very common but apparently only few patients needed treatment. The incidence of a patent processus vaginalis was similar to that reported in other parts of the world; although surgical correction was delayed. Splenomegaly was common; not only due to endemic malaria; but also due to sickle-cell disease; with implications for the management of childhood trauma in this part of the world

Does tubularized incised plate urethroplasty fit primary and repeat shat hypospadias repair ?

Objective To evaluate prospectively our experience using tubularized incised plate (TIP) urethroplasty in primary and repeat penile shaft hypospadias. Patients and Methods Thirty-two boys with penile shaft hypospadias were selected to undergo TIP procedure. Their age ranged from 22 months to 9 years. Twenty-two cases were primary and 10 cases were repeat hypospadias repairs. To correct penile chordee; complete degloving of the penis and lateral dissection of tethering tissues was done in every case. This was followed by tunica albuginea plication in 7 cases; while ellipse excision was needed in 3 cases. Using the preserved urethral plate; single-layer urethroplasty was done in all cases. A vascularized subcutaneous flap (36 cases) or tunica vaginalis (4 cases) was always used to cover the neourethra. A postoperative stent was used for 8 - 12 days in all cases. Results The patients were followed up for a mean of 14.2 months. Postoperative clinical evaluation revealed success rates of 95.5and 90for primary and repeat cases; respectively. Among the primary cases; only one patient had urethro-cutaneous fistula concomitant with meatal stenosis; while among the repeat cases urethro-cutaneous fistula occurred in one patient. No case of urethral stricture or wound dehiscence was encountered. Our criteria for success were a single unimpeded forward-directed urine stream; a straight penis; good cosmesis and no need for further surgery. Conclusion We feel that TIP urethroplasty in primary and repeat cases of penile hypospadias is a reasonable option in cases with chordee not severe enough to necessitate excision of the urethral plate and when midline incision of the plate yields an adequate width amenable to tubularization