Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex

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Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
10/9/2019

Posterior Hypospadias: how to
 choose the Best Technique
                Haytham BADAWY MD PhD, FEBU
  Professor of pediatric Urology, University of Alexandria, Egypt

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Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
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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?

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Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
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• 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%

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Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
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  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

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Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
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              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.

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Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
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             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

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Posterior Hypospadias: how to choose the Best Technique 10/9/2019 - UroAlex
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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%

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Redo of the first stage

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Second stage

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Résultats

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         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

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            second stage                   Meatal stenosis: 0
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 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

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The dilemma continues

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