Megameatus intact prepuce variant reconstruction: Long-term outcomes and comparison to post-circumcision hypospadias repair.

BACKGROUND: Megameatus intact prepuce (MIP) variant is considered a surgical challenge with associated high complication rates. It is usually diagnosed and corrected only after neonatal circumcision, which is discouraged in non-MIP hypospadias. OBJECTIVE: In order to determine whether the features of the MIP variant or the performance of a secondary reconstruction following circumcision comprise the cause of higher complication rates, we now compared the results of post-circumcision MIP hypospadias repair to the results of children who underwent repair of non-MIP hypospadias following neonatal circumcision. STUDY DESIGN: Reoperation rates of children operated for hypospadias repair following neonatal circumcision between 1999 and 2020 were compared between those with MIP and those with classic non-MIP hypospadias. RESULTS: In total, 139 patients who had undergone neonatal circumcision underwent surgical reconstruction at a mean age of 13 months. Sixty-nine had classic hypospadias and 70 had the MIP variant. The median follow-up was 10 years (interquartile range 6,13). The classic group had a higher rate of meatal location below the corona compared to the MIP variant group (53 % vs. 28 %, respectively, p = 0.002). The reoperation rate was comparable for the two groups (32 % vs. 27 %, p = 0.58, Table). Univariate analysis for the MIP hypospadias group showed no association between reoperation and the initial patient characteristics, while a higher probability of reoperation was demonstrated in the presence of ventral curvature (odds ratio 3.5, p = 0.02), and a higher grade of hypospadias (odds ratio 3.3, p = 0.03 for meatal location lower than the coronal sulcus) in the non-MIP group. DISCUSSION: The limitations of our work include its retrospective design wherein the patients' characteristics, including classification as MIP vs. non-MIP, are derived from medical records. More patients in the non-MIP group were documented to have penile curvature. The non-MIP group was composed of more patients with meatal location under the coronal sulcus, a factor which may increase the rates for reoperation in that group. Still, with the comparison of the largest reported cohort of circumcised MIP with circumcised non-MIP patients together with an extended follow-up period, we believe that we present strong evidence of the possible role of previous circumcision in the surgical challenge of reconstructing MIP hypospadias. CONCLUSIONS: Reoperation rates in MIP hypospadias are high but similar to those of classic hypospadias, both following circumcision, suggesting that circumcision, rather than the unique features of the variant, is the cause for complications.

Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision.

PURPOSE: To present the results of hypospadias repair in the absence of preputial skin following neonatal circumcision, and the analyses of surgical techniques and predictors of procedural success. METHODS: Records of all children who underwent hypospadias repair between 10/1999 and 12/2018 were retrospectively reviewed. All of those who underwent neonatal circumcision prior to surgery were included. Patients with any prior penile reconstruction surgery and those with the megameatus intact prepuce variant were excluded. The primary endpoint was the need for reoperation. RESULTS: A total of 69 patients with a history of neonatal circumcision underwent surgical reconstruction of hypospadias during the study period. Their mean age at surgery was 14 months (interquartile range [IQR] 9,22). Forty-five cases (65%) involved distal hypospadias, and ventral curvature was present in 24 (35%). Dartos flaps were harvested from the dorsal aspect in 37/58 (64%) patients and from the ventral aspect in 21/58 (36%). Twenty-two patients (22/69, 32%) required reoperation after a median follow-up of 9 years (IQR 6,13). Indications for revision surgery included urethral fistula (n = 16, 22%), meatal stenosis (n = 5, 7%), and skin redundancy (n = 1). Ventral curvature (odds ratio [OR] 3.5, p = 0.02) and higher grades of hypospadias. (OR 3.3, p = 0.03) had a higher probability of reoperation (univariate logistic regression). CONCLUSION: Hypospadias repair following neonatal circumcision in the absence of preputial skin is a challenging reconstruction. The reoperation rate in our cohort was 30%, similar to reoperative hypospadias surgery. Parents of newborns diagnosed with hypospadias should be encouraged to refrain from pre surgical neonatal circumcision. LEVEL OF EVIDENCE: Treatment study, level IV.

Dorsal penile curvature and megameatus intact prepuce hypospadias: A common association in a rare variant of hypospadias.

BACKGROUND: Megameatus intact prepuce (MIP) is a rare variant of hypospadias. Unlike the hooded ventrally absent prepuce in non-MIP hypospadias, the prepuce in MIP hypospadias is fully circumferential and intact. The distal urethra remains wide with a deep glanular groove. While ventral curvature is a common finding in non-MIP hypospadias, neither ventral nor dorsal penile curvature has been reported in MIP hypospadias. OBJECTIVE: To assess the association of the MIP hypospadias variant with penile curvature. STUDY DESIGN: We retrospectively reviewed the medical records of all children who underwent hypospadias repair and identified those who were documented as having the MIP variant of hypospadias and operated in our center from January 1998 to June 2020. The patients were considered as having MIP hypospadias if no hypospadias had been evident before circumcision, if a circumferential circumcision scar was present (instead of the inverted V-shaped scar in the ventral aspect of the penis following circumcision of the hooded prepuce associated with non-MIP hypospadias), and if there was a wide meatus. Penile curvature was diagnosed intraoperatively by an artificial erection test that uses saline solution for injection. Patients were considered surgical candidates if the degree of curvature was equal to or greater than 30°. RESULTS: The study cohort consisted of 118 male children who were identified as having the MIP hypospadias variant according to the inclusion criteria. The median age at repair was 1.1 years (interquartile range 8 months to 1.6 years). Penile curvature was found in 29 children (24%), of whom 23 had dorsal curvatures (19%) and 6 had ventral curvatures (5%). DISCUSSION: MIP hypospadias is associated with penile curvature, and more frequently with dorsal than ventral curvature. This study is retrospective and does now identify specific features of MIP associated with penile curvature. We encourage pediatric urologists to perform an artificial erection test intraoperatively in children with the MIP variant and repair associated curvatures. CONCLUSIONS: A dorsal curvature was found in 19% of patients with a MIP variant of hypospadias, and most of them (86%) required ventral plication due to the severity of the curvature.

In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair.

OBJECTIVE: To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair. STUDY DESIGN: We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair. RESULTS: Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs. CONCLUSION: Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children.