Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
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10/9/2019 Posterior Hypospadias: how to choose the Best Technique Haytham BADAWY MD PhD, FEBU Professor of pediatric Urology, University of Alexandria, Egypt 1
10/9/2019 Key Points of The Repair of Proximal Penile Hypospadias • In Least Number Of Operations: • Straightening of the penis • Construction of normal calibre urethra with accepted complication rate • Achievement of good cosmetic outcome Is it possible To Answer This question? 2
10/9/2019 • problems are numerous: • Urethral reconstruction: single versus multistage • Management of curvature: dorsal plication versus ventral corporotomies • Definition of complications: obstruction, partial dehiscence, meatal stenosis • definition of the least time for follow up and frequency • shortage of prospective well designed studies Seul temps opératoire deux temps opératoire (Braka) 40 enfants 25 enfants âge moyenne: 2.8 ans âge moyenne 4.5 ans Duckett Onlay 29 soit 72.5% greffe preputial 17 Tube 11 soit 27.5% P=.04 greffe de la muqueuse orale 8 45% complications 20% complications fistule 15% fistule 4 soit 16% sténose du méat 12.5% lâchage complet 1 soit 4% lâchage complet 10% diverticule urétérale 5% 3
10/9/2019 Curvature is the most important parameter • Penile curvature is classified into: • Mild: less than 30 degrees (nothing may be done) • Moderate: 30-45 ( degloving, extended bulbar dissection, plate mobilization +/- dorsal plication) • Severe : more than 45 (plate transection +/- ventral corporoplasty) Mingin and Baskin et al 4
10/9/2019 Is there any prospective study comparing dorsal plication to ventral lengthening? NO • Braga et al reported a retrospective comparison: • Group I: 32 ventral lengthening with 30 UP transections • Group II: 68 dorsal plication only 16 UP transections • • Mean follow up: 2 years • Recurrence of ventral curvature: group I Vs group II (9.4% Vs 27.9%) Braga LH, Lorenzo AJ, Bagli DJ, Dave S, Eeg K, Farhat WA, Pippi Salle JL, Khoury AE. Ventral penile lengthening versus dorsal plication for severe ventral curvature in children with proximal penile hypospadias. J Urol 2008;180:1743-7. 5
10/9/2019 43 children curvature more than 30 degrees preputial graft 88% oral graft in 12 % ventral corportomies 65% no recurrence of curvature complications: 10 children 23% fistula and glanular dehiscence overall success after multiple surgeries 98% Staged procedure Graft Vs flap 6
10/9/2019 Complications Following Staged Hypospadias Repair Using Transposed Preputial Skin Flaps Irina Stanasel J Urol 2015,Texas USA 56 enfant âge moyenne 14 mois le suivi 34 mois médiane 68% complications: 57% fistule 14% diverticule 9% sténose de méat 14% sténose de l’uretre 5% lâchage de gland Management of Proximal Hypospadias with 2-Stage Repair: 20 Year Experience Marc Cendron et al J Urol 2015 Multicentre study 1993-2012 134 enfant âge médiane 8.8 mois suivi médian 3.8 ans 53% complications 30% fistule Reprise chirurgicale dans 59% 7
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10/9/2019 Redo of the first stage 24
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10/9/2019 Second stage 26
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10/9/2019 Résultats 36
10/9/2019 2011-2018 43 children first stage mean age 20 months (6-132) curvature: meatal position plate transection 62.8% 18.6% penoscrotal 67.4% scrotal ventral corporotomies 37.2% 14% périnéal Inner Prepuce in all children scrotal anomalies scrotal transposition: 9 first stage bifid scrotum: Sucess 90.7% 14 children : Z- plastie, 4 Redo buccal Graft 15 children : midline closure 37
10/9/2019 second stage Meatal stenosis: 0 37 success after second stage: 56.8% Urethral stenosis: 0 urethral complications 43.2% Fistula : 24.3% Complete dehiscence: 0 success of redo fistula: 100% Diverticulum: 0 glanular dehiscence 24.3% Recurrence of curvature: redo in 4 children (25% succès) , 5.4% 3 children 75% re glanular dehiscence overall success : 83.3 % Mean follow up: 3.2 years 38
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10/9/2019 The dilemma continues 40
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