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Proximal hypospadias: a continuous challenge. Outcome analysis of 3 surgical techniques over a 10-year period
Salwa Sayed, Ana Salle, Fahad Alyami, Armando Lorenzo, Darius Bagli, Walid Farhat, Martin Koyle, Joao Luiz Pippi Salle*, Toronto, Canada

INTRODUCTION AND OBJECTIVES: The optimal treatment of proximal hypospadias remains controversial, with several techniques described. Herein we analyze the outcomes of 3 surgical alternatives for primary proximal hypospadias with and without ventral curvature (VC).

METHODS: Single-center retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. Surgical techniques analyzed included long tubularized incised urethral plate (TIP), dorsal inlay graft TIP (DIG) or stage preputial graft repairs (SR). DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive UP mobilization (UPM), dorsal plication and/or deep transverse incisions of tunica albuginea (DTITA) were selectively done when attempting to spare transecting the UP. UP division and SR was favored in cases with severe VC (>500), often concurrently managed with DTITA. Tubularization of the graft was done 6 months later.

RESULTS: A total of 140 patients were included. Demographics and outcomes are presented in the table. The initial 10 patients in DIG series had the graft sutured only to the muco-cutaneous junction of the urethra, while in the remaining 13 patients the glans was deeply spatulated, advancing the graft all the way to the tip of the incision. UPM was performed in 12 initial DIG patients. Most complications with DIG occurred in the first 2 years (80%) compared to 25% in the recent years after modifications were introduced. A significant number of patients had decreased initial post-op flow rates regardless of the technique.

CONCLUSIONS: Proximal hypospadias remains challenging regardless of technique utilized for its repair. SR repair appears to achieve the best outcomes despite been utilized for the most severe cases. Approximately half of patients undergoing long TIP and DIG needed re-interventions, although such percentage decreased significantly with late modifications in the DIG group. These results suggest that both DIG and SR may be suitable techniques for proximal hypospadias repair since better or similar outcomes to TIP were achieved despite being utilized for more difficult cases. Extended follow up is needed to confirm these findings.

Source of Funding: None

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