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Summary Background The rare inversa subtype of recessive dystrophic epidermolysis bullosa (RDEB-I) is characterized by predominant intertriginous skin blistering and marked mucosal involvement. Specific recessive missense mutations in the collagen VII triple helix are implicated in the disease. To date, otological complications have been reported infrequently in this patient group. Methods We conducted an observational, retrospective, double institution case record review of patients with RDEB-I who presented with otological complications between January 2000 and June 2020. Diagnosis was established on the basis of clinical features, family history and mutation analysis of the COL7A1 gene. Results In total, 11 (44%) of 25 patients with RDEB-I in our database (2 paediatric, 9 adult; mean age 40.9 years, range 8–72 years) experienced otological complications. Of these 11 patients, 10 (90.9%) had recurrent otitis externa, 7 (63.6%) had meatal stenosis and 7 (63.6%) had recurrent blistering of the external auditory canals. All 11 patients reported hearing difficulties, with conductive hearing loss confirmed by audiology testing in 6 (54.5%) of these. Of the 11 patients, 3 (27.3%) went on to have implantable hearing aids [2 bone-anchored hearing aids (BAHA) and 1 middle ear implant (MEI)] fitted with favourable outcome, while a fourth paediatric patient presented with a cholesteatoma that was surgically managed. Discussion We observed a higher prevalence of otological morbidity in RDEB-I than previously reported, and present the first case of cholesteatoma in epidermolysis bullosa (EB). Our data indicate that BAHA and MEI are safe and effective treatment options for hearing loss in EB. Clinicians should be vigilant in screening for ear symptoms in RDEB-I and consider early referral to an Ear, Nose and Throat specialist.

OBJECTIVE The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology). MATERIAL AND METHODS These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables. RESULTS Anterior urethral strictures are a common condition (0,1 a 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (

Introduction. Hypospadias is one of the most frequent penile malformations in newborn boys. Warren Snodgrass developed the «tubularized incised plate» (TIP) urethroplasty that is the most often procedure used in the surgical treatment of distal hypospadias for the last 20 years. Despite the great popularity of the technique, its no less famous Grafted TIP (GTIP) modification appeared. The technique is aimed at filling the defect in the urethral site with a foreskin free flap followed by tubularized urethroplasty.Purpose of the study. To compare the outcomes of TIP and GTIP procedures in our clinic which have been performed in the last 10 years.Materials and methods. One hundred-fourteen boys with hypospadias (aged 6 mo – 15 years) were operated on using the TIP technique and its modification GTIP during 2010 – 2020 (Sochi Center of Motherhood and Childhood Protection). The patients were: boys up to 1 year – 27 (23.7%), from 1 to 3 years – 57 (50%), 4 – 7 years – 19 (16.7%), from 8 to 14 years – 14 (12.3%). Primary repair was done in 112 cases (98.2%), the second procedure was done in 2 (1.8%) cases. There were 94 (82.5%) boys with distal hypospadias and 20 (17.5%) children with mid-shaft hypospadias. All patients were examined 3 and 12 months after surgery. We assessed the degree of skin scar process on the penile shaft, the location of the meatus and the quality of urination during the examination.Results. We observed 27 (23.7%) complications after urethroplasty out of 114 treated boys. There were 13 (11.4%) cases of urethral fistula, which were secondary repaired 6 months later. Meatal stenosis was observed in 2 (1.8%) cases, which required secondary meatoplasty. Repeat urethroplasty was done in 10 (8.7%) cases due to neourethral suture failure. There were also 2 (1.8%) cases of secondary penile curvature that required repeat surgery. The good cosmetical and functional results were achieved finally in all children.Conclusion. The analysis of our ten-year experience of using TIP-urethroplasty and its GTIP modification did not reveal significant differences in the overall incidence of postoperative complications. Yet, using the TIP procedure is associated with more fistulas. There were more cases of urethral suture failure in children whom the GTIP technique was performed. Our data suggest the need for a selective approach in the formation of indications for using TIP and GTIP procedures, along with research aimed at finding criteria for patient selection.

Summary Background Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade. Methods A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: 5 cases operated per year and compared the post-operative outcomes. Results The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8–14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load. Conclusions Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.

Background: Various methods have been used to reconstruct mid-penile hypospadias; still, massive failure rates and leading complications have been indicated. The present study observes the effectiveness of a technique using a well-vascularized dartos flap as a second layer in distal and mid- penile hypospadias repair. Methodology: This is a cross-sectional study conducted between 2017-2019. A total of 110 male children with hypospadias were operated on. The children with mid-penile or slightly more proximal hypospadias, with or without ventral chordae and with the intact prepuce, were included in the study. Outcome measures comprised of surgical results with the absence of any serious side effects, decent flow, meat stenosis, fistula and dehiscence of glans. Results: The median follow-up duration was 12 months. There were 72 cases of mid penile hypospadias (66.7%), and in 36 cases (33.3%), the meatus was slightly more dorsal. The age of the patients ranged from 1.1 to 11 years, with a mean age of 3.52 ± 2.74 years. Surgery was successful in 105 (95.5%) cases. Four patients presented with meatal stenosis and one with meatal stenosis plus fistula, more than 2 months after surgery. Meatal stenosis was managed by meatoplasty, and in the case of a urethral fistula, the patient was re-operated after at least 6 months. Conclusion: Ventral dartos flap is a safe, effective method with less adverse effect and less time-consuming in patients with distal and mid-penile hypospadias.

Background: One stage urethroplasty through parameatal foreskin flap (OUPF) available for all types of hypospadias was first described by Tomohiko Koyanagi (1983). High complication rates were reported. Objective: To evaluate the outcome of Koyanagi technique modification using dartos muscle as a 2nd layer because it has a high vascularity, very thin, easily elevated, and leaves no complications. Patient and methods: This study was conducted in the Plastic Surgery Department at Menoufia University, during the period of April 2017 to April 2019. Thirty cases for proximal hypospadias were included during this study. After chordee release, urethra was constructed using Koyanagi technique and adding scrotal dartos muscle flap as a 2nd layer. Results: Patient's age ranged from 1 to 4 years with mean age of 2.83 ± 1.17. All of the 30 cases were with proximal hypospadias and had severe chordee. Early complications were detected as bleeding in 2 patients (6.6%). One patient (3.3%) reported for retention due to obstruction of the inserted catheter. Another case (3.3%) showed wound infection. The reported late complications were fistula in 6 patients (20%), meatal recession in 5 patients (16.6%), meatal stenosis in 3 patients (10%), and diverticulum in one patient (3.3%). Conclusion: The modified Koyanagi one stage repair of proximal hypospadias is an innovative technique and realize many criteria for expected effective operating results. The use of dartos muscle flap as a cover for the urethroplasty improves the results and minimize complications.

Objective: During meatotomy procedure for children with meatal stenosis (MS), a straight clamp used as a hemostat on the ventrum of the meatus before incised with scissors for clamping and holding bleeding from the site of operation. The aim of this study was to evaluate the optimum clamping time for meatotomy in children with MS. Materials and methods: All the patients with MS between 2014 to 2019 were enrolled in this retrospective study. Patients with uncircumcised penis, traumatic catheterization, any kind of penile abnormality such as hypospadias or penile curvature, and active urinary tract infection (UTI) were excluded. The indication of meatotomy was a pinpoint meatus that develops with dorsal or lateral deflection of the urinary stream and high-velocity urine flow. During meatotomy procedure, clamping time was examined in different groups such as 2, 3, and 4 minutes. The main symptoms of presentation and ultrasonography (US) findings were recorded and compared between groups. To assess the optimum time clamping, postoperative bleeding was noted carefully in all groups. The success rate was recorded at onemonth postoperative follow-up in the clinic. Results: Of the 120 patients with MS who underwent a meatotomy procedure, there were 40 (33.3%) participants in each group. The main symptoms were painful urination and urine stream deviation that represented in 54 (46%) patients. Bladder wall thickness was the main pre-operation finding in the US which was observed in 67 (55.8%) patients. In comparison between the groups related to clamping time, bleeding was observed and required suturing when clamping was applied for 2 minutes in 4 (3.3%) patients (p = 0.016). With a minimum follow-up of 12 months, no recurrent meatal stenosis was reported. Conclusions: Clamping time for more than 2 minutes may prevent bleeding during and after meatotomy.

Urethrocutaneous fistula is the most prevalent complication after hypospadias repair. The aim of this study was to evaluate whether incised urethral diversion was superior to traditional transurethral diversion in minimizing complications.We retrospectively collected and analyzed 113 cases with proximal penile or penoscrotal hypospadias that were repaired by one-stage transverse preputial island flap urethroplasty between January 2016 and January 2020. Of those cases, 60 used incised urethral diversion (group A), whereas the remaining 53 were managed by transurethral diversion (group B) for urinary drainage after surgery. Postoperative complications in both groups were assessed for fistula, urethral diverticulum, meatal stenosis, wound infection, and distal urethral breakdown.Fistula was reported in 2 patients (3.3%) in group A, while it was observed in 15 patients (28.3%) in group B (p 0.001). Wound infection occurred in one patient (1.7%) in group A, compared with six patients (11.3%) in group B (p 0.05). The incidence rates of distal urethral breakdown were 1.7% (1/60) and 11.3% (6/53) for group A and group B, respectively (p 0.05). One patient (1.7%) in group A and three patients (5.7%) in group B had a meatal stenosis (p 0.05). There were two patients who developed urethral diverticulum in either group (p 0.05).The use of incised urethral diversion for urinary drainage had an advantage over transurethral diversion in one-stage hypospadias repair with respect to the post-operational fistula occurrence, wound infection, and distal urethral breakdown.

Background. After tubularized incised plate (TIP) urethroplasty meatal and urethral dilatation is a common practice. There are some complication of uretheral dilatation like urethral bleeding,urethral perforation and creating a false passage. Moreover dilating the urethra regularly is physically or psychologically painful both for the child and the parents. The aim of this study was to justify the necessity of uretheral dilatation after TIP urethroplasty. Material and Methods. This study was a prospective, comparative study performed in Dhaka Shishu (Children) Hospital from July 2017 to June 2020. Total 60 respondents were participated in this study with maintain inclusion criteria. Respondents with primary distal and mid-shaft hypospadias where TIP urethroplasty was indicated, admitted in Dhaka Shishu Hospital during study period were included. Group 1 was assigned non dilatation group and Group 2 was assigned to regular urethral ditatation group after TIP urethro- plasty. Fistula formation, meatal stenosis and neourethral stricture were compaired between two groups. Informed written consents were taken from legal guardians. Data ware analyzed by SPSS Program. Results. In this study there was no significant difference of ages between two groups. In Group 2 10 %( 3)respondents developed urethrocutaneous fistula, 10% (3) respondents developed meatal stenosis and 3.33% (1)respondents developed neourethral stricture. On the other hand. In Group 1 10% (3) respondents developed urethrocutaneous fistula, 6.66% (2) respondents developed meatal stenosis. None of patient in Group 1 developed neourethral stricture. Conclusion. There was no significant difference in fistula formation, meatal stenosis and neourethral stricture in between regular urethral dilatation group and non-dilatation group after TIP urethroplasty.

Aim: Stenosis in the external orifice of the neo-urethra is one of the most common complications after hypospadias surgery. Meatotomy and dilation are the most commonly used methods in the treatment of these cases. However, there is insufficient data about which treatment will be used in what order or the treatment algorithm. In this study, we aimed to evaluate the effectiveness of treatment methods used in patients with meatal stenosis after hypospadias surgery. Materials and Methods: Hospital records of patients who were operated for distal hypospadias and diagnosed with meatal stenosis and underwent meatotomy or urethral dilatation under general anesthesia were reviewed retrospectively between 2009-2019. The demographic data of the patients, the first surgical method used for hypospadias repair, the duration between the treatment of meatal stenosis and hypospadias repair, the success of the treatment and the method used in the treatment of recurrent stenosis were recorded. Patients whose complaints did not recur during controls were considered to have been successfully treated. Chi-square, Student T, and Kolmogorov-Smirnov tests were used for statistical analysis with help of IBS-SPSS Statistics 23 program. Results: In the 10-year period included in the study, 56 patients with a mean age of 45.07 ± 36.60 months developed meatal stenosis after distal hypospadias surgery distal hypospadias surgery. The mean number of procedures for meatal stenosis was 1.67 ± 0.91 per patient. The median duration between the hypospadias surgery and the first treatment for meatal stenosis was 25,97 months in meatotomy and 13,72 months in dilatation cases, respectively (p

We conducted a study to compare two different methods of water proofing in hypospadias repair. All 30 cases in our study were repaired by using Snodgrass technique. In 15 cases water proofing was done using inner preputial de-epithelialized skin flap. This group was named as group A in our study. In another group Dartos fascia was used as water proofing layer. This group was named Group B in this study. The minimum period of follow-up in this series was 18 months. In Group A: One patient had fistula which healed spontaneously. One patient had partial wound dehiscence that resolved on conservative measures. Skin necrosis, meatal stenosis, stricture of neourethra and residual chordee was not seen in this group. One case required catheter removal on 3rd day because of severe bladder spasm. In Group B: Urethrocutaneous fistulae were seen in two cases. One healed by itself but one persisted. Skin necrosis occurred in two cases. One healed spontaneously but in other we have to cover it with scrotum (Cecil-Culp Procedure) to salvage the repair. Meatal stenosis, urethral stricture and residual chordee were not seen in any patient. We conclude that inner preputial de- epithelialized skin flap may have an edge over Dartos fascia for coverage of the neourethra as water proofing layer.

Purpose We conducted this meta-analysis to compare postoperative outcomes between meatal-based flap (Mathieu) and tubularized incised plate (TIP) techniques for distal hypospadias. Methods A comprehensive literature search of PUBMED, Web of Science, EMBASE, and Cochrane Library was conducted. Outcomes evaluated in this review were fistula, meatal stenosis, wound dehiscence and flap necrosis. We calculated odds ratio (OR) with 95% confidential interval (CI) to compare postoperative outcomes between Mathieu and TIP after data extraction and literature identification. All data were analyzed using Review Manager 5.2. In order to find potential affective factors, meta-regression and subgroup analyses were applied. Results 16 studies, 1386 patients, including 762 patients receiving Mathieu and 624 individuals subjected to TIP met the inclusion criteria. The synthetic data suggested that Mathieu and TIP were comparable in terms of fistula (OR = 0.93; 95% CI: 0.65 to 1.33; P = 0.70, I2 = 14%), wound dehiscence (OR = 0.89; 95% CI: 0.33 to 2.39; P = 0.81, I2 = 11%), and flap necrosis (OR = 1.9; 95% CI: 0.51 to 7.09; P = 0.20, I2 = 38%) without significant heterogeneity for each comparison group. Pooled estimates showed a significantly lower rate of meatal stenosis with Mathieu than with TIP (OR = 0.41; 95% CI: 0.24 to 0.73; P = 0.002, I2 = 4%). Subgroup analyses showed that the difference between Mathieu and TIP was more obvious in the studies published before 2013 in meatal stenosis. The modified Mathieu technique and a running suture for urethroplasty might be relevant to a lower rate of meatal stenosis in the data, although no statistical significance in the present effects model overall was found. One-way sensitivity analysis showed that the results were stable. There was no publication bias detected using both funnel plot and Egger's test. Conclusion This meta-analysis suggested that Mathieu and TIP technique were equivalent for primary distal hypospadias in terms of fistula, wound dehiscence, and flap necrosis. Pooled estimates indicated that there was a lower rate of meatal stenosis with Mathieu rather than with TIP significantly. The modified Mathieu technique and a running suture for urethroplasty might be relevant to a lower rate of meatal stenosis. Type of study Meta-analysis. Level of evidence IV

Objectives To report our immediate and delayed outcomes of non-stented tubularized incised plate (TIP) distal hypospadias repair. Methods We retrospectively reviewed all charts of children who underwent distal hypospadias repair in a single children's hospital from 2013 to 2018. Patients’ demographics, hypospadias characteristics, operative technique, and immediate and delayed outcomes were recorded. Results Of 280 consecutive distal hypospadias repairs that were identified, 74 were excluded due to the use of a repair other than TIP. Eleven stented TIP repairs were excluded as well. Of 195 non-stented repairs, immediate post-operative voiding complications were recorded in 11 (5.6%) and included multiple/ split stream in 6 (3%), dysuria and voiding difficulty in 2 (1%), urinary retention in 2 (1%), and gross hematuria that spontaneously resolved in 1 (0.5%). Late follow up was recorded in 142/195 (72.8%) repairs. Delayed urethroplasty/glansplasty complications were recorded in 12 (8.5%) and included urethrocutaneous fistula (UCF) in 10 (7.0%), meatal stenosis (MS) in 6 (4.2%) and glans/urethroplasty dehiscence (GD) in 2 (1.4%). Conclusion Avoiding post-operative urethral stents in distal hypospadias TIP repair reduces the morbidity associated with the stent and is a feasible option that carries acceptable immediate and delayed complication rates. Avoiding the stent eliminates stent-related bladder spasms, the need for other medications, and the short-term office visit for stent removal, therefore reducing parental anxiety, patient discomfort, and reducing cost.

Introduction: Hypospadias continues to be a challenging problem for reconstructive surgeon. As urethral plate preservation got an important role, transverse preputial island flap (TPIF) urethroplasty is one of the preferred technique for sub-coronal and distal penile hypospadius. Methods: This study was conducted at urology department, DMCH, from February, 2014 to June, 2017 where 15 patients underwent TPIF urethroplasty. Inner preputial flap with its pedicle was developed and separated from the dorsal penile skin which was sutured to the urethral plate in an onlay manner over a stent by running suture. Glanuloplasty and meatoplasty was done and skin closed.SPC was done in every cases. Dressing was checked on 5th POD, stent was removed after 03 weeks. SPC was removed 2 to 3 days after satisfactory voiding. All patients were followed up at 6th and 12th week. Results: Among the 15 patients age range was 2-14 years and mean age. Sub-coronal in 4 and distal penile was in 11 patients. Following TPIF urethroplasty wound disruption was noted in one patient for that glans closure was done successfully. There was no meatal stenosis and urethrocutaneous fistula in follow up. Regarding cosmetic outcome 12 were good, 2 were acceptable and 1 was poor. Conclusion: Success rate of TPIF urethroplasty in case of sub-coronal and distal penile hypospadias is excellent. Cosmetic outcome should be considered most challenging and with experience of surgeons this aspect will be improved. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.43-47

Acquired meatal stenosis is a difficult entity to treat with a significant recurrence rate. It is normally approached posteriorly via post aural approach and reconstructed using split thickness skin graft. We are presenting a novel method of surgery for acquired meatal stenosis using a pre auricular flap via endaural approach only. The aim was to evaluate the success rate of using a pre auricular flap in acquired atresia of the external auditory canal using the endaural approach. Twenty patients with acquired atresia of the external auditory canal that was surgically treated were retrospectively studied from July 2012 to July 2018. All cases were done using endaural approach only. During the surgery, the atretic tissue was removed, wide canaloplasty done and the stenotic segment widened. Reconstruction of the external auditory canal was done using a pedicled anteriorly based pre auricular flap rotating it into the external auditory canal to cover the bare bone. Of the 20 patrients there were good results in 18 patients with restenosis occurring only in 2 patients. However, a skin tag developed in 2 other patients which was excsiced as OPD procedure and patient was asymptomatic on further follow ups. In all the 20 cases preauricular flap was used for reconstruction along with use of Split thickness skin graft in 10 cases. All 20 cases were operated via endaural route only. Use of a Preauricular flap in surgical treatment of acquired aural stenosis gives good results with a wide dry cavity as the flap is pedicled with its vascular supply and it can be tailor made according to each case and requirement.

Proximal hypospadias associated with severe chordee represents a major surgical challenge and the debate over its optimal treatment is ongoing. The objective of this study is to compare the outcome of two-stage Bracka and Byar’s repair in proximal hypospadias. This study was conducted from January 2013 to February 2018 in a tertiary care centre. Patients of hypospadias with severe chordee who required urethral plate transection were included in the study. Patients were randomly divided into two groups by simple randomization method. Bracka staged repair was done in Group A and Byar’s staged repair in Group B. Postoperatively complications including graft loss, flap necrosis, fistula formation, meatal stenosis, stricture, diverticula formation, residual chordee were noted in both the groups and compared. p value of

Objectives: To our knowledge, the incidence of congenital meatal abnormalities associated with hypospadias varies from 9.6% to 31%, of which meatal stenosis is the most common, affecting 9.1–16.7% of patients. Traditionally, meatal stenosis has been dealt with by meatal dilatation, although ventral meatotomy until the normal urethra is encountered has also been used. Here, we report the outcome of a technique where, during hypospadias repair, a dorsal midline incision was performed instead of a ventral urethral incision, starting at the narrow meatus and subsequently extending proximally to treat the meatal stenosis. Methods: Patients having distal hypospadias with meatal stenosis were included in this study. In this technique, a dorsal midline incision was extended until normal calibre urethra was encountered. Patients with chordee >15°, proximal hypospadias, redo cases, glans width Results: Five (6.85%) patients developed UCF: one (5%) in the subcoronal group, two (8.0%) in the distal penile group and two (14.3%) in the mid-penile hypospadias group. Postoperatively, only one patient had meatal stenosis. Conclusion: We think hypospadiac meatal stenosis is best treated by a dorsal midline incision, as it does not lead to a proximal shift of the meatus, and this defect heals by re-epithelisation without significant scarring, which in turn decreases the possibility of UCF. That is why the fistula rate in our study was 6.85%, which is lower than in various published series.

BACKGROUND: Urethroplasty techniques generally can be divided into two methods, the flap method (Mathieu and Onlay Flap) and no flap with tubularized incised plate (TIP) urethroplasty method. Complications are common after urethral reconstructioninclude urethrocutaneous fistulae and cosmetic appearance, which is usually measured by Hypospadias Objective Penile Evaluation (HOPE) scoring system. AIM: The aim of this study was to determine whether there are differences in the outcome of flap method compare to TIP method in distal hypospadias patients who underwent urethroplasty. PATIENTS AND METHOD: The subjects of this study were patients with distal hypospadias who underwent urethroplasty in Sanglah General Hospital from September 2017 to December 2017. Thirty-six samples were selected by consecutive sampling. RESULTS: The results showed a significant difference in the incidence of meatal stenosis (p = 0.05) and urinary stream disturbances(p = 0.05) between two methods. No significant differences were found in the incidence of urethrocutaneous fistulae (p = 0.500) and the unsatisfactory HOPE score (p = 0.169). CONCLUSION: This research showed that meatal stenosis andthe maximum urinary stream were better in flap method compared to TIP method in distal hypospadias patients underwent urethroplasty.

The aim of the present systematic review is to evaluate the impact of gender reassignment surgery on the development of urethral complication. A systematic search in accordance the Preferred Reporting Items for Systematic Review and Meta-Analyses statement for original articles published up until June 2019 was performed using the Pubmed, Scopus, Embase, and Web of Science databases. Pooled analyses were done when appropriate. The bibliographic search with the included terms ((“Transsexualism”[Mesh])) AND (“Sex Reassignment Surgery”[Mesh]) produced a literature of 879 articles altogether. After removing papers of not interest or articles in which the outcomes could not be deduced, 32 studies were examined for a total of 3463 patients screened. Thirty-two studies met our inclusion criteria and were evaluated, and references were manually reviewed in order to include additional relevant studies in this review. Female-to-male (FtM) surgery and male-to-female (MtF) surgery was discussed in 23 and 10 studies, respectively. One study discussed both. Varying patterns of complications were observed in FtM and MtF surgeries, with increased complications in the former because of the larger size of the neourethra. Meatal stenosis is a particular concern in MtF surgery, with complication rates ranging from 4 to 40%, and usually require meatotomy for repair. Stricture and fistulization are frequently reported complications following FtM surgery. In studies reporting on fistulae involving the urethra, 19–54% of fistulae resolved spontaneously without further surgical intervention. High rates of complications are reported in the current literature, which should be understood by patients and practitioners alike. Shared decision making with patients regarding incidence and management of urethral complications including stricture disease and fistulae, particularly after FtM surgery, is critical for setting expectations and managing postoperative outcomes.

Introduction Idiopathic urethritis (IU) is a known entity in the childhood and adolescent age groups and is described as blood spotting of the underwear in these populations. Typically, IU presents clinically as terminal void haematuria or blood spotting, accompanied with dysuria, occasional suprapubic pain and rarely constitutional symptoms. Sometimes IU may progress to formation of urethral strictures. It carries a high morbidity because of its chronicity and recurrent course, which often persists to puberty. In spite of no single aetiology being confirmed, several treatment approaches have shown some efficacy. Although no consensus has yet been established, the consideration of previous authors' experience and expertise may contribute to the development of a possible unified algorithm. Aim This article considers IU, collecting pertinent data and case series from the literature. The authors attempt to describe all presumptive aetiologies, endoscopic findings with established grading classifications and finally the various treatment modalities proposed. In addition, highlights from the senior's author experience regarding this entity including endoscopic, radiographic and histological images are mentioned. Methods Retrospective review and analysis of all relevant articles present on PubMed, SCOPUS and Cochrane Library from the time of inception to the date of first submission. Results A total of 19 series concerning IU have been reported since year 1971 to present time (Table 1). Many aetiologies have been postulated, but some have been refuted, including infectious pathogens. Children with dysfunctional voiding and meatal stenosis are more prone to exhibit IU. A variation in the urethral milieu during the prepubertal period, secondary to systematic hormonal alteration, may lead to squamous cell metaplasia resulting in IU and possible urethral strictures. Grading classifications for IU are described. Up to 20% of IU may develop urethral strictures. Various treatment approaches are discussed. Conclusion A summary of current understanding of the pathogenesis and spectrum of IU has been achieved. Successful treatment can be achieved with steroids and dysfunctional voiding protocols. It may be possible to develop a consensus unified management algorithm.

Introduction The complication rates of proximal hypospadias, especially fistula, are much higher than those of distal hypospadias. Urethral coverage is an effective method for reducing fistulas. Acellular dermal matrix (ADM) has been shown to exhibit structural compatibility and biocompatibility, both of which promote tissue healing. Methods The present non-randomized study evaluated the efficiency, feasibility, and safety of using ADM for urethroplasty coverage in patients with proximal hypospadias. This prospective study enrolled 35 patients (age range 15–60 months) with proximal hypospadias who underwent operation between September 2018 and March 2019 at Beijing Children’s Hospital (Beijing, China). Urethroplasties were performed by the transverse preputial island flap (TPIF) technique. ADM was applied and sutured over the urethroplasty as an additional covering layer. Patient outcomes were compared with those of 80 non-matched control patients with proximal hypospadias who underwent the same procedure, with dartos as a covering layer. Results During a median follow-up of 11.56 months (range 9–15 months), urethral fistula occurred in six patients (17.1%) in the ADM group and 28 patients (35%) in the dartos group. Superficial wound infection was observed in six patients (17.1%) in the ADM group and 10 patients (12.5%) in the dartos group. One patient in the ADM group had diverticulum, compared with five patients (6.25%) in the dartos group. Meatal stenosis and urethral stricture were observed in four patients (11.4%) in the ADM group and six patients (7.5%) in the dartos group; all of these complications were treated conservatively. No glans dehiscence was observed in either group. Conclusion Use of ADM may be a safe and efficient covering technique to provide an additional coverage layer for proximal hypospadias repair, thereby reducing the incidence of fistula formation, especially among patients who have poor-quality covering materials.

© 2020, Yuzuncu Yil Universitesi Tip Fakultesi. All rights reserved.Hypospadias is one of the most frequent congenital anomalies in birth. Many factors may have part in etiology. Its treatment is possible only through surgical intervention, and there are more than 300 methods in literature identified for hypospadias repair. The purpose of this study is to compare Snodgrass and Bracka methods, the methods most frequently used for hypospadias repair, in terms of urethral fistula and meatal stenosis. In this study, the data of 40 patients operated between 2014 and 2019 years have been used. 20 of the patients have been operated with Snodgrass, and the others have been operated with Bracka method. The average ages of the patients operated with Snodgrass method and Bracka method were 4 years 3 months and 2 years 9 months respectively. Average length for follow-up for the patients operated with Snodgrass method was 18 months 9 days, and it was 35 months 1 day for the patients operated with Bracka method. Urethral fistula was observed to develop in %30 of the patients operated with Snodgrass method and %25 of those operated with Bracka method totally. In both methods, rates of meatal stenosis were more frequent compared to fistula (Snodgrass: %35, Bracka %40). Fistula development is found numerically more in the patients operated with Snodgrass method while meatal stenosis development is observed numerically more in those operated with Bracka method.

Assessment of the outcome of G-TIP technique in primary distal hypospadias repair in comparison to TIP repair using HOSE score This study had been performed between June 2018 and June 2019 which included 50 patients all presented to urological outpatient clinic of Benha university hospital -Egypt- with different types of primary distal hypospadias. They were divided into two groups (Group A operated upon using classic Snodgrass TIP urethroplasty and Group B operated upon using G-TIP urethroplasty technique), each group included 25 patients. Circumcised cases or cases with penile chordea more than 30 degree were excluded from the study. Urethral catheter might have been exited set up for particular case week on 10 times. Catch up might have been consistently during 1st, 3rd Also 6th months (3 patients didn't go to the 6th month catch up 2 from one assembly An tip Also particular case starting with the G-TIP assembly B). Mean hose score a t 6th month might have been 15. 7 out about 16 Previously, tip and 15. 5 Previously, G-TIP (P 0. 52 (NS)). In the tip aggregation those score might have been because of difficulties which incorporated an instance for urethrocutaneous fistula and an instance about meatal stenosis with urethrocutaneous fistula same time in the G-tip an instance from claiming glans dehiscence What's more an instance about gentle remaining chordea. Constantly on effects demonstrated no noteworthy measurable distinction between the two bunches but more agent chance 91. 4±6. 2 minutes in the G-TIP assembly contrasted with main 85. 2±6. 3 to tip gathering (P 0. 002 (S)), those time used for harvesting, get ready Also inlaying those graft. We finished up that G-TIP urethroplasty is a great elective procedure of the excellent tip repair shed for tantamount comes about Furthermore Despite there were no noteworthy measurable distinction the middle of those 2 gatherings in regards complications, G-TIP gatherings demonstrated preferred outcomes Concerning illustration view meatal stenosis Also urethrocutaneous fistula yet all the for longer agent run through.

Introduction: We aimed to assess the outcome of free tube graft urethroplasty for single-stage repair of hypospadias with chordee in children. Materials and Methods: We retrospectively evaluated a series of 56 patients (16 months to 9 years old, median 24 months) who underwent free graft urethroplasty for repair of hypospadias with chordee between May 2005 and November 2017. The median follow-up was 7 years (range 1–11). Results: After releasing the chordee, the hypospadiac orifice was retracted to become penile in 32 patients (57%), penoscrotal in 18 patients (32%), and scrotal in 6 patients (11%). Single-stage repair was achieved without complications in 42 patients (75%). Of the remaining 14 patients with postoperative complications requiring surgical intervention, 2 had meatal stenosis, 9 had urethrocutaneous fistula, 1 had urethral diverticulum without meatal stenosis, and 1 had meatal regression. One patient who complained the urine stream went upwards in an arc underwent cutback meatoplasty to correct the stream. In all patients, a neomeatus with a vertically oriented slit-like appearance was eventually achieved at the tip of the glans. Conclusion: A free graft is an appropriate choice for repairing hypospadias with chordee. Our procedure achieved favorable functional and cosmetic outcomes with a low postoperative morbidity rate.

Background Bleeding, hematoma, edema, wound infection, and scar formation are the common problems linked with hypospadias reconstruction. Hormone treatment is recommended before surgical treatment to improve intraoperative circumstances. However, no meta-analysis has explored the effectiveness and side effects of testosterone treatment before surgery in hypospadias. Main body of the abstract The purpose of this paperwork is to evaluate the impact of preoperative testosterone treatment in hypospadias based on clinical data from published trials. This study searched MEDLINE, Science Direct, and the Cochrane Library without regard to year. However, only English journals were included, with a manual search using the Preferred Reporting Items for Systematic Reviews and Meta-analysis of Observational Studies in Epidemiology Guidelines supplementing the search. In this meta-analysis, five papers were considered. Two of these investigations were multicenter randomized clinical trials. Two of the studies were prospective, with a median follow-up of varying lengths. A retrospective investigation was conducted. There were 585 patients in all that took part in this trial. After surgery, the complication rate was measured in both the intervention and control groups, including meatal stenosis, fistula, glans dehiscence, scarring, reoperation rate, urethral diverticulum, fine pubic hair, and sexual precocity. The only significant difference between the intervention and control groups was that the intervention group had a decreased frequency of glans dehiscence following surgery (OR 0.40 with the 95% CI of 0.17 until 0.97). Conclusions This study discovered that a patient who got testosterone before surgery had a considerably decreased complication risk for glandular dehiscence. Reoperation rate, urethral-cutaneous fistula, meatal stenosis, and penile scarring in children with hypospadias, on the other hand, revealed no significant difference in the testosterone-treated group against the control group.

Surgical resection is the standard treatment for the management of localized penile cancer and a neo-urethral meatus is generally created on the penile stump or perineum. Neo-urethral meatus is often stenosed and requires repeated transurethral manipulations such as dilation and urethrotomy. These procedures are generally futile and are associated with poor quality of life. Here, we report a case of penile cancer that developed a neo-meatal stenosis after total penectomy, which was subsequently salvaged by perineal urethrostomy using Blandy technique. A 72-year-old male who was diagnosed with localized penile cancer, underwent total penectomy and creation of neo-meatus on the perineum. Neo-meatus stenosis had developed in the patient and he received repeated urethral dilations without any success. Finally, when the patient was unable to void, he was referred to us for the amelioration of meatal stenosis through the placement of a suprapubic catheter. Because the condition of the residual bulbar urethra was adequate and its length was enough, we planned to create a non-transecting perineal urethrostomy by Blandy technique. An inverted U-shaped perineal incision was made, and a skin flap was created. The scarred neo-meatus and spongiofibrosis at the distal bulbar urethra were completely excised. The residual bulbar urethra was exposed, and a longitudinal ventral incision of 4 cm was made. The edge of the bare urethral mucosa and tunica albuginea of the corpus spongiosum were sutured by 4-0 PDS for hemostasis. The apex of the U-shaped skin flap was brought to the proximal margin of the urethrotomy and a tension-free anastomosis was created between the skin flap and the urethral plate. Thereafter, the skin of the perineum was sutured to the open longitudinal urethrotomy. The patient started to void on the 5th day post-surgery. The subject could void without the help of any intervention and did not require any instrument, sixteen weeks after the surgery.

Introduction Proximal hypospadias is the most severe type of hypospadias. Our approach to Koyanagi technique for proximal hypospadias aims to improve the blood supply to the neourethral flaps and reduce meatal complications. Methods Our prospective study included 75 patients who were operated for proximal hypospadias by our Koyanagi technique at Viet Duc hospital between January 2019 and December 2020. The clinical information obtained included a detailed medical history; preoperative, intraoperative, and postoperative data; short-term outcomes by the HOSE score were evaluated by a different physician. Results The mean (range) age was 3.59 ± 2.41 years (1.5–14), 86.7% under 5 years old. There are 31 penoscrotal, 31 scrotal, and 13 perineal hypospadias. The length of the neourethra ranged from 3.5 to 8 cm, mean 5.02 ± 0.88 cm. Evaluation of the surgeon at 6 months after surgery: primary success 81.3%. Complications occurred in 14 cases (18.7%), included 10 urethrocutaneous fistula and 4 dehiscence of the urethra. No cases of meatal stenosis or recession, urethral stricture, urethral diverticula. The mean HOSE score was found to be 14.47 ± 1.35, ranged 11 to 16. 57 patients (76%) had a total HOSE 14 and above and 18 patients had score below 14 (24%) Conclusion Our modified Koyanagi technique give us a good result for one-stage reconstruction of proximal hypospadias. Applying the HOSE score makes postoperative evaluation of hypospadias more objective and reliable., Highlights • Proximal hypospadias is one of the most challenging conditions. • Modified Koyanagi techniques improve the blood supply to the neourethral flaps. • The HOSE score is an objective appraisal of the outcome of hypospadias repair.

Background Hypospadias is one of the most common congenital anomalies affecting males worldwide, with distal variants representing up to 70% of all cases. Several surgical techniques are adopted for distal hypospadias repair. However, there is still much controversy about the ideal technique. Objectives The aim of this study is to compare between the most popular reconstructive techniques for distal penile hypospadias repair. Highlighting their effectiveness, in term of success rate as well as the risk of postoperative complications. Methods For this systematic review, PubMed/Medline and ScinceDirect online databases were searched using the keywords ‘distal hypospadias, complications and outcome’. Inclusion criteria were primary repairs; distal hypospadias; pediatric case series and standard techniques. Abstracts of articles identified were reviewed, and then relevant articles were retrieved in full. Papers were only included if data on at least one of the main outcome measures was obtainable, which are postoperative fistula, meatal stenosis and glanular dehiscence. Data were pooled using CMA software, effect sizes were reported as event rates with 95% confidence intervals (CI) been calculated for each outcome. Results A total of 25 studies, which included 4572 patients, met the inclusion criteria. The tubularised incised plate (TIP) was the most commonly adopted procedure followed by the peri-meatal flap (Mathieu). Few studies reported data for other techniques like onlay flap, Thiersch-Duplay, meatal advancement and MAGPI procedures, in addition to urethral mobilization technique. The overall incidence of main complications was 10.5% with comparable results among different techniques. The results are in favor of urethral mobilization and TIP procedures over Mathieu regarding the incidence of both meatal stenosis and post-operative fistula. Overall, the quality of the included studies was determined to be satisfactory. Conclusion Compared with Mathieu technique, urethral mobilization and the TIP procedure for distal penile hypospadias (DPH) reconstruction were associated with a lower risk of overall complications specifically postoperative fistula and meatal stenosis.

Background Hypospadias is one of the most common congenital defects affecting the external male genitalia. The incidence is 1 in 250 male newborns, although its incidence seems to be increasing. Hypospadias is defined as an insufficient development of the urethral fold and the ventral foreskin, with or without penile curvature. The urethral opening is located more proximally anywhere between the tip of the penis and the perineum. Aim of the Work The aim of this study is to determine the best surgical technique with the least complications for repair of mid-penile hypospadias. Materials and Methods This systematic review and meta-analysis was performed in accordance to the recommendations of the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. MOOSE is a reporting checklist for Authors, Editors, and Reviewers of Meta-analysis of interventional and observational studies. According to International committee of medical journal association (ICJME), reviewers must report their findings according to each of the items listed in those checklists. Results Fistula is less common after Preputial island flap technique. Fistula is more common with Modified koyanagi technique. Meatal stenosis is less common after Mathieu and Preputial island flap techniques. Meatal stenosis is more common after TIP technique. Wound Dehiscence is not common after lateral based flap and modified koyanagi and Onlay island flap techniques. Neourethral Stricture is not common after lateral based flap and Mathieu and Onlay island flap techniques. Conclusion The Mathieu and Preputial island flap techniques for mid-penile hypospadias reconstruction are associated with a significantly lower risk for postoperative urethral stricture and may be the preferred method for hypospadias. However, the clinical implications of the results can be discussed because the risk of stricture in all procedures was low. The implications for research are obvious because there had been no studies that provided firm guidelines on the best method for the operative intervention for hypospadias. Further trials are still needed to confirm our findings.

Background Aural atresia (CAA) is a congenital abnormality with hypoplasia or aplasia of the external auditory canal. Surgical procedures of CAA is not only difficult but has still not been embraced by surgeons. Many surgeons are doubtful to perform a repair due to poor hearing results and the risk of new canal stenosis. This article describes the writers’ expertise with surgical management of aural atresia. A retrospective study of 16 cases of CAA was undertaken in the Hearing and Speech Institute between 2015 and 2018. The study consisted of 16 patients, 8 patients for each group, 10 males and 6 females between 4 and 18 years of age with a median age of 6 years. Ten patients had bilateral atresia, and 6 had unilateral atresia. Postoperatively, patients were tested for hearing recovery and follow-up lasting up to 2 years to record any complications. Purpose of the study was to compare hearing effects and risks of anterior and transmastoid approaches to external and middle ear restoration in patients with CAA. Results All patients were satisfied with the surgery by improving the hearing up to 35 dB or less after 12 months. Four patients (25%) developed soft tissue meatal stenosis, with 2 patients in each group. There were no cases of bony canal stenosis. TM perforation was seen in two patients (12.51%), one patient in each group. Lateralization of the graft was seen in one patient in the transmastoid group, and no ossicular chain refixation. Five cases had postoperative otorrhea, one in the anterior mastoid group and four in the transmastoid group. There were no other complications. Conclusions Although the findings of the hearing are close. The previous approach, due to fewer postoperative complications, is now our favorite technique. Proper alignment and soft-tissue strategies are keys to the effective correction of the congenitally atretic ear canal.

Objectives: The objective of the study is to investigate the feasibility and efficacy of urethroplasty with a Buck's fascia integral-covering technique (BFIC) to wrap and restore the normal anatomical structure of the penis in one-stage hypospadias surgery.Methods: One-stage surgeries for hypospadias management were performed using BFIC from January 2016 to September 2020 at four high-volume medical centers in China. The technique integrates Buck's fascia with glans wings to mobilize and wrap the urethra and restore penile anatomical relationships. The clinical data, postoperative follow-up data, and complications were recorded, and the results were analyzed.Results: A total of 1,386 patients were included in the study: 1,260 cases of primary hypospadias and 126 cases of re-operations; distal in 382 cases (27.6%), mid-shaft in 639 (46.1%), proximal in 365 (26.3%); tubularized incised plate (TIP) in 748 cases, inlay-graft in 124, onlay-graft in 49, Mathieu in 28, free-tube graft urethroplasty in 406, and 31 of hybrid procedures. One thousand one hundred forty-two patients (82.4%) were found to have penile curvature (>10°) after artificial erection and all corrected by dorsal plication/s or transection of the urethra plate (UP) simultaneously. The median followed-up time was 27 months (6–62). A total of 143 (10.3%) complications were recorded: 114 (9.0%) in the primary operations and 29 (23%) in the re-operations, 15 (3.9%) in distal hypospadias, 61 (9.5%) in mid-shaft, and 67 (18.4%) in proximal. The complication rate in UP preservation and transection was 10.1 and 10.8%, respectively. Of all case complications, there were 73 (5.2%) of fistula, 10 (0.6%) of dehiscence, 22 (1.6%) of meatal stenosis, 21 (1.5%) of stricture, 6 (0.7%) of diverticulum, and resident curvature in 11 cases (1.2%). The overall complication rate in TIP and free-tube procedure was 9.8 and 9.9%, respectively, and fistula occurred in primary TIP of 33 cases (4.9%).Conclusions: Buck's fascia with the glans can be used as an integral covering technique in one-stage distal to proximal hypospadias and primary or re-operative hypospadias repair. It is safe, feasible, and effective for the repair of hypospadias.

Background Authors describe a novel procedure in a group of patients for prepuce reconstruction, ensuring complete glans penis coverage who had either been circumcised in childhood or had congenitally short prepuce. Methods Case records of all cases done by the novel method which involved penile degloving and maintenance of neoprepuce, with the help of de-epithelization of glans penis and a few key sutures performed over the period from January 2010 to December 2019 were reviewed retrospectively. A total of 46 patients, 32 had congenitally short prepuce and 14 had previous circumcision. Results All the patients had complete glans penis coverage. None of the patients had complications like urinary infection, meatal stenosis, collection in neoprepucial sac, balanitis, or posthitis. The mean followup was 23.24 months in 37 patients. Nine lost to followup. Conclusions The procedure is simple, gives reliable results, and is customized to the needs of the patients. It does not interfere with penile erections.

Background: Hypospadias is a congenital anomaly on the penis, in which the meatal orifice opens ventrally and proximal to the tip of the penis. In this regard, two common treatment methods are tubularized incised-plate urethroplasty (TIP) and the Mathieu incised-plate (MIP) technique. The present study aimed to compare the early and long-term outcomes of TIP and MIP among patients with distal penile hypospadias. Objectives: The study was also to evaluate the postoperative functional outcome of hypospadias over a long-term follow-up. Methods: Fifty-nine patients were randomly selected and assigned to two groups (TIP (n = 31) and MIP (n = 28)). Demographic information, preoperative findings, and postoperative complications were collected from the two groups. The Hypospadias Objective Scoring evaluation (HOSE) questionnaire and uroflowmetry were obtained to evaluate the long-term outcome of hypospadias repair. Results: The success rates of the surgical TIP and MIP techniques were 71.0% and 82.1%, respectively. Postoperative complications in the TIP group were three (9.7%) distal UCF and four (12.9%) meatal stenosis. In the MIP group, two (7.1%) and three (10.7%) patients suffered from distal UCF and meatal stenosis, respectively. Moreover, 89.3% of the patients in the MIP group and 80% of the patients in the TIP group had acceptable HOSE. Regarding the uroflow rates in the MIP group, 12% and 58% of the participants were below the 5th percentile and above the 25th percentile, respectively. Concerning the uroflow rates of TIP, 32% of the patients were below the 5th percentile, and 18% of the participants were above 25th percentile. Conclusions: Although there have been some reports on the superiority of TIP, we found these two techniques at approximately equal levels with a slightly higher success rate for the MIP regarding the early outcomes. With the exception of the long-term outcomes in cosmetic and functional evaluation, MIP is superior to TIP.

Objectives To determine: (i) feasibility for a randomised controlled trial (RCT) comparing circumcision to preputioplasty and intralesional triamcinolone (PIT) to treat balanitis xerotica obliterans (BXO) and (ii) patient outcomes to inform future study design. Patients and methods Approval was obtained from the UK Health Research Authority and local Research Ethics Committee (Reference 16/NW/0364) and the trial protocol registered with ClinicalTrials.gov (NCT02854995). A total of 20 boys (aged 2-16 years) with BXO were randomised to either circumcision or PIT (online parallel group 1:1 allocation, non-blinded). Exclusion criteria were: (i) previous penile surgery and (ii) contraindication for either treatment. Follow-up (including satisfaction questionnaire) was at 6 weeks, 3 and 12 months. Data are presented as median (interquartile range [IQR]), continuous variables were compared by t-test. Results A total of 54 boys were approached over 18 months: 23 (45%) were recruited and randomised. The commonest reason for non-entry was treatment preference: 12 preferred circumcision, 18 preferred PIT. Four patients withdrew after randomisation, three did not want circumcision and one did not want PIT. The groups were similar in terms of age (median [IQR] 11 [6-12] vs 8 [7-10] years, P = 0.53) and duration of symptoms (median [IQR] 6 [6-15] vs 6 [2-24] months, P = 0.77). There were no protocol breaches, serious adverse events or postoperative meatal stenosis. There was one self-resolving haematoma after PIT and one suture granuloma after circumcision. Two boys went on to have a circumcision after PIT. Overall, satisfaction levels were high for both groups. Conclusion A definitive RCT of circumcision vs PIT for BXO appears feasible, with 39% of those approached completing the trial. More families preferred PIT. A robust comparison in the form of a multicentred RCT is required.

Purpose To evaluate the role of atopy (i.e. atopic dermatitis, allergic rhinitis, asthma, and food allergies) and its consequences on developing meatal stenosis in boys. Methods After obtaining ethics approval from institutional review board, a retrospective chart review was conducted to gather records of patients with meatal stenosis (Group A) presented to our pediatric urology center between August 2012 and May 2016. History of any allergic reactions including allergic rhinitis, asthma, skin, food and drug allergies was considered as positive history of atopy. A control group of children referring to our center due to other etiologies were considered as control group (Group B). Data were analyzed using student t-test and Chi-square test. Results During the study period, a total of 206 boys (mean age 41.01 months) were assigned to group A and 221 (mean age 35.56 months) to group B. 126 (61.16%) boys had history of allergic reactions in group A compared to 29 (13.12%) in the control arm (group B). Patients with meatal stenosis have a significantly higher (P-value Conclusions The pathophysiology of meatal stenosis remains not fully understood yet. This study reveals a significant relation between hypersensitivity reactions and meatal stenosis in boys. Persistent inflammation in meatal area could potentially lead to scarring and stenosis. However, more investigation is required to elucidate this pathophysiology. Type of Study Case–control study. Level of Evidence Level III.

Lichen sclerosus (LS) is a severe, chronic, dermatosis characterised by inflammatory, sclerotic, pruritic lesions that causes significant morbidity in patients of all genders and ages. In boys, the lesions typically affect the foreskin and glans (termed balanitis xerotica obliterans (BXO)), leading to phimosis and potentially meatal stenosis. The incidence of the disease is not well reported but the average age of affected boys is 8 years (range 1-16). Diagnosis can often be made clinically, although histological study remains important to rule out important differential diagnoses. Complications include genital scarring, urinary and sexual dysfunction as well as the development of carcinomas in adult life. Circumcision has been regarded as definitive management of BXO in boys, but this may be supplemented with medical therapies such as topical steroids, immune modulators, intralesional triamcinolone and ozonated olive oil. Supportive measures including emollients, avoidance of irritants, surveillance of complications and recurrence as well as education and counselling remain important.Conclusion: BXO remains an important cause of phimosis in boys. The frequency of this condition appears unclear but seems likely to be less than 1% of males. Treatment generally involves circumcision, with some evidence that topical steroids or immunomodulators may decrease the incidence of recurrent meatal stenosis.What is Known:• Surgical circumcision is considered the definitive management of BXO• Many aspects of BXO are still in contention or require further study including the epidemiology and aetiology.What is New:• There is increasing awareness of non-surgical modalities that may be used in adjunct to surgery including topical corticosteroids, immune modulators, intralesional triamcinolone and ozonated olive oil• Awareness of meatal stenosis-related BXO has led to the development of surgical techniques such as preputioplasty as well as buccal mucosal inlay grafts.

Objective To evaluate the presenting complications of patients to reconstructive urologists after masculinizing gender affirming genital reconstructive surgery (GRS) performed elsewhere. Methods We identified patients who underwent revision surgery by one of the co-authors for sequelae of masculinizing GRS. We reviewed patient demographics, medical history, details of prior GRS, and complications from GRS. Specific attention was paid to the presence of the following: suprapubic tube dependence, vaginal remnant, urethrocutaneous fistula (UCF) within the fixed urethra (pars fixa), UCF in the phallic urethra, phallic urethral stricture, meatal stenosis, and anastomotic urethral stricture. Statistical analysis was performed using the Fisher's exact test to determine differences in presenting symptoms by GRS. Results Fifty-five patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n = 47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n = 31, 56%) and vaginal remnant (n = 26, 47%). The majority of patients presented with 2 or more simultaneous complications (n = 40, 73%). Conclusion There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study.

Objective To report outcomes, complications, and risk factors of a population cohort undergoing male-to-female gender affirmation surgery via penile-inversion vaginoplasty by a single surgeon at a large academic institution. As gender dysphoria awareness increases among the medical community, so does the population of patients seeking gender-affirmation surgery. Materials and Methods A prospectively maintained database of patients undergoing penile-inversion vaginoplasty was retrospectively queried for all available patients with at least 1 week of postoperative follow-up. Univariate and multivariate analyses were performed using Fisher's exact test and logistic regression, respectively, in order to evaluate relationship of risk factors to complications at 30, 60, and 90 days, as well as the likelihood of revision/reoperation. Results From November 2016 to April 2018, 240 penile-inversion vaginoplasties were performed. Median follow-up was 87 days. When accounting for competing risk factors, only noncompliance with postoperative dilation regimen and activity restriction was significantly associated with increased risk of complications or reoperation/revision. Overall incidence of reoperation/revision was 7.9% (n = 19). Reasons for reoperation included cosmesis (3.8%; n = 9), neovaginal stenosis (2.1%; n = 5), and wound dehiscence (0.8%; n = 2), with less than 0.5% (n = 1) reoperations for meatal stenosis, hematoma or rectovaginal fistula, respectively. Incidence of Clavien IIIa-b complications was 1.7% (n = 4). There were no Clavien IV-V complications. Conclusion At short-term follow-up, gender-affirmation surgery is associated with low rates of reoperation and revision and few major complications when performed by an experienced, high-volume surgeon. Patient selection and compliance is imperative. Increased reporting among surgeons is necessary to continue to improve patient outcomes.

Background: Reported reoperation rates after primary hypospadias repair can exceed 50%. Failed hypospadias occurs when the primary surgery does not achieve the cosmetic and functional goals of a straight penis with glanular meatus that enables normal urinary and sexual function. Treatment of patients with failed hypospadias repair can be a challenging task in the majority of cases and the selection of the most appropriate technique for this repair is the corner stone for success in these cases.Aim of Study: Is to evaluate the results and success rate of some common techniques for redo urethroplasty in cases with failed hypospadias repair.Patients and Methods: The study included forty two patients with recurrent hypospadias and their ages ranged from 2-15 years. The final position of the external urethral meatus after release of chordee, was subcoronal (13 cases), distal penile (13 cases), mid-penile (13 cases) and penoscrotal (3 cases). TIP technique was applied in 12 cases, Mathieu technique in 10 cases, transverse dorsal preputial onlay flap in 10 cases and two-stage repair with buccal mucosa graft in 10 cases. The operative technique was selected according to the status of the urethral plate and the nearby penile skin.Results: Our overall results showed that 24 patients (57.14%) had successful repair while failed repair was reported in 8 patients (19.04%). Minor complications were also reported in 10 cases (23.80%) which included urethrocutaneous fistula, meatal stenosis and urethral diverticulum. The success rates of TIP, Mathieu, transverse dorsal preputial onlay flap and the two-stage repair were 58.33%, 50%, 50% and 70% respec-tively.Conclusion: TIP urethroplasty is an effective technique for redo hypospadias repair if the patient has a non-scarred and wide urethral plate. Similar results can also be achieved by Mathieu's repair or transverse onlay flap in patients with narrow and non-scarred urethral plate. However, patient with scarred unhealthy urethral plate should have a two stage repair with buccal mucosa graft.

Objective Hypospadias patients may present with the phenotype that features the migration of scrotum to distal penile shaft below a coronal/subcoronal meatus. Patients with this phenotype differ widely in the severity of the hypospadias and the complexity of the surgical repair. We aimed to investigate the operative findings and the outcomes of consecutive patients who presented with this phenotype. Methods We retrospectively reviewed the medical charts of 31 consecutive patients who underwent hypospadias repairs from January 2014 to May 2017, and the hypospadias was characterized by i) the external urethral meatus at coronal/subcoronal region, ii) scrotal skin encroaching distally resulting in fixation of penoscrotal angle at distal penile shaft, and iii) urethral plate below the glans on penile shaft invisible or barely visible. Results The median age at the time of surgery was 15.5 months (10-63). The division of corpus spongiosum was noted at distal penile shaft (n=2; 6.5%), mid-shaft (n=5; 16.1%) and proximal location (n=24; 77.4%). The median ventral curvature before degloving was 45 degrees (10-90). Twenty-eight and 3 patients underwent tubularized incised plate and 2-stage preputial flap repairs, respectively. Twenty-nine of 31 patients required cutback of the hypoplastic urethra. At the time of urethroplasty, 2 (6.5%), 7 (22.6%) and 22(70.9%) patients underwent distal, mid-shaft and proximal repairs, respectively. At a median follow-up of 30 months (14-50), 6 (19.4%) patients developed one or more complications (fistula=3; meatal stenosis=5). Conclusion Patients affected by this particular phenotype likely require non-distal hypospadias repair with possibly higher complication rate and should be treated by surgeons with expertise in complex hypospadias repair.

Left Amyand Hernia (AH) is a very rare form of inguinal hernia. It presents commonly as an incarcerated inguinal hernia and intraoperative diagnosis is usually the rule. This is a report of a 7 months old male infant presenting with bilateral inguinal hernia, including a complicated left AH, with associated mobile caecum and meatal stenosis. He had bilateral herniotomy, transhernial appendectomy and meatotomy and did well post-operatively. A comprehensive comparative review of all 35 reported cases of left AH in the literature was undertaken alongside this report.

To evaluate the intermediate outcomes of our institution’s experience with staged TPIF urethroplasty for proximal hypospadias repair. We retrospectively evaluated the medical records of patients who underwent repair of proximal hypospadias using staged TPIF urethroplasty at our hospital from 2011 to 2017. One hundred and two patients were included in the present study. The mean follow-up was 52.4 months (range 13–74 months). The mean age at the time of the first surgery was 13.5 months (range 11–65 months). There were two main types of initial complications including meatal stenosis in four (3.9%) and urethrocutaneous fistula in three (2.9%) patients after the first stage. Surgical complications were seen in 15 patients after second stage, including urethrocutaneous fistulas in 8 (7.8%), urethral strictures in 5 (4.9%), urethral diverticula in 2 (1.9%). Overall complication rates after second stage were 14.7%. The incidence of fistulas was lower in patients who underwent repair with a tunica vaginalis flap (1/29, 3.4%) than with the dartos fascia (7/73, 9.6%; p = 0.435). Our results show that staged TPIF urethroplasty is a viable and durable technique for primary severe proximal hypospadias. This procedure was associated with a 14.7% complication rate in the present study. Staged TPIF urethroplasty can reduce the incidence of urethral strictures and diverticula associated with the second stage.

To assess the consequence of tubularized incised plate urethroplasty on primary hypospadias repair. Total of 42 male patients underwent hypospadias repair in AL-Diwaniyah Teaching Hospital/Iraq. from April 2016 to April 2018. The levels of the hypospadias defect, age at operation, type of sutures and dressing, type of catheter and time of removal and complications were verified. Tubularized incised plate urethroplasty done for all patients and mean patients age at operation was 4.4 years (range 1 year to 8year). Postoperative follow up was 1 to 3 months. Generally, meatal stenosis, dehiscence due to infection and an urethrocutaneous fistula occurred in 3,2and 6 patients, respectively. T.I.P. urethroplasty has come to be the favourite surgical procedure of distal hypospadias cases at our hospital. The technique has a small number of complications in addition to prove success and adaptability that continue to increase its application.

Background: Hypospadias is the most common congenital malformation of penile shaft occurring in 1 per 300 male births; it is considered a common clinical problem as it causes not only functional problems but also psychological problems for parents. Objective: The objectives of this study is to review the result of TIP repair of distal penile hypospadias in terms of outcome and complications of stenting and unstenting the urethra. Patients and methods: As a prospective randomized study; this study has included patients with distal penile hypospadias operated with Snodgrass between year 2011-2018 and had divided to (group A) included 40 patients operated upon with stent preservation for a week (group B) was 20 patients with stent removed at the end of the operation. Results: Regarding group (A) the stent of 10 cases had slipped at the first 8 hour postoperative so they have been added to the count of (group B) and considered as unstented repair. It is clear here in our study that meatal stenosis rate were different from Snodgrass rate but were similar to other published studies. Other comparable items as fistula rate, urinary retention and hospital stay, were the same as published studies. Conclusion: It could tell that removing the catheter can reduce bladder spasm , urinary tract infections, and patient discomfort and improve the familiar compliance without increasing acute retention episodes and fistula rate, so that at least in some cases specially in distal types, leaving stent can be avoided.

Background: Options for urethroplasty in children with hypospadias can be classified as tubularizations of the urethral plate, skin flaps and grafts. Throughout the history of surgery for this condition flaps have been most commonly used, but in the past 10 years incision and tubularization of the urethral plate (tubularized incised-plate, TIP) has rapidly gained popularity for correcting distal, proximal and re-operative hypospadias. TIP potentially simplifies both decision-making and surgical technique, and has a low complication rate with better cosmetic results. However, careful attention to surgical details and awareness of contraindications to the procedure are needed to achieve optimal results.Aim of Study: Outcome of Snodgrass (Tabularized Incised Plate) in repair of primary distal hypospadias with narrow urethral plate.Patients and Methods: Twenty patients with primary distal and midpenile hypospadias were enrolled for repair with Snodgrass technique.Demographic data, hereditary relationship, urethral plate length and width, glans width, and intraoperative time were recorded and post-operative early and late complications were observed for parents and surgeon satisfaction.Results: Between the 20 patients, only three patients developed post-operative complication one was urethrocuta-neous fistula and two showed meatal stenosis with success rate 85%.Conclusion: Tubularized incised plate in repair of primary distal and midpenile hypospadias successfully fulfils all traditional hypospadias repair criteria. It offers a viable option in the management of primary hypospadias with a narrow urethral plate.

Objective To compare the outcome and complication rate of the platelet-rich plasma applied as a coverage layer and dartos flap layer during primary repair of distal hypospadias. Methods A prospective randomized study was carried out comprising 180 boys (age range 12-65 months) from October 2011 to December 2016 at Al-Azhar University Hospitals, Cairo, Egypt. A single surgeon carried out all urethroplasty. Patients were randomly divided into two groups: group A (tubularized incised plate urethroplasty with platelet-rich plasma coverage layer) and group B (ventral dartos flap). Complication rates were compared between two groups. Results There was a significant difference in the occurrence of complications between the two groups. A total of 36 (20%) complications were recorded in 26 patients, just 12 (13.3%) reported in group A, but 24 (26.7%) complications were reported in group B. Urethrocutaneous fistula was observed in nine patients (10%) in group A, and 12 (13.3%) in group B. Partial glans dehiscence occurred in one patient in group A, and four patients in group B. No patient in group A had a superficial wound infection, compared with six patients in group B. One case of meatal stenosis and urethral stricture was recorded in each group, all of which were managed conservatively. The resultant urinary stream was single and good in 154 patients of both groups. Conclusions Platelet-rich plasma sheet might be considered as an alternative coverage layer for distal hypospadias repair, especially in the absence of a healthy layer.

Objective To correct all types of glanular/subcoronal hypospadias, we performed surgery named the distal urethroplasty and glanuloplasty procedure (DUG procedure). We analyzed cases that we have experienced. Methods A vertical incision with the meatal margin was made in the 12 o'clock direction, with the margin of the external urethral meatus as the center. By this meatoplasty according to Heineke-Mikulicz principle, we changed all type of glanular/subcoronal hypospadias to the hypospadias with wide meatus and wide glans. And then Thiersh-Duplay procedure was performed. Results Consecutive 24 underwent modified DUG procedure. The mean age at the time of surgery was 19.0 ± 11.9 months and the mean preoperative glans width was 13 ± 1.5 mm. The external urethral meatus was located glanular in 13 and subcoronal in 11. Hypoplastic urethra (HU) was observed in 7. Skin chordee in 10, penile torsion in 6 and meatal stenosis in 10 were observed. The mean surgical duration was 106 ± 25.4 minutes and the mean postoperative observation period was 40.5 ± 26.2 months. All patients with preoperative skin chordee, penile torsion, and meatal stenosis were improved postoperatively, and in all cases, apart from the patient with meatal regression with longest HU from glanular to distal penile, the slit-like shape of the external urethral meatus was achieved. Conclusion DUG procedure can be used for any type of glanular/subcoronal hypospadias but care should be taken not to indicate too aggressively for glanular/subcoronal hypospadias accompanying long HU to distal penile shaft.

Objective The study assesses the surgical outcomes in boys with lower urinary tract symptoms (LUTS) and symptomatic meatal urethral stenosis. Methods This retrospective cohort study was conducted from July 2014 till December 2015. Thirty-two boys (aged 4–12 years) with Lower Urinary Tract Symptoms were examined for the presence of urethral meatus stenosis. The collected data were statistically analysed using Univariate and Multivariate analyses. Results A significant improvement of urinary stream, urgency incontinence, urgency, and frequency were found after using an objective assessment tool with p-value ≤ 0.001. The assessment of surgical outcomes, following uncomplicated meatoplasty with objective noninvasive uroflowmetry, has been reported in the pediatric population. Conclusion It highlighted the importance of urethral meatal stenosis diagnosis in boys with lower urinary tract symptoms. The novel contribution was made by assessing surgical outcomes following meatoplasty. However, further research is needed with larger sample cohorts.

Introduction: Hypospadias is a common congenital anomaly in which the urethral opening is on the ventral surface of the penis, often associated with ventral curvature of penis (chordee). Many techniques have been descried in the literature for the repair of hypospadias with variable results. This study aimed at outcome following Snodgrass repair in distal hypospadias by a single Urologist. Methods: This was a retrospective study conducted at Department of Urology, Birat Medical College from December 2017 to January 2019 during which 16 patients with distal hypospadias underwent primary repair using Snodgrass technique. Results: Mean age was 5.12 years and duration of operation was 136.25 minutes. About 56.25% of cases were subcoronal and 43.25% were coronal. Chordee of

Introduction: Partial penectomy is one of the common organ preserving procedures for penile malignancies and certain benign conditions. Partial penectomy causes psychosexual morbidity to the patient. Dorsal spatulation of urethra is classically done while performing the procedure, it carries risk of meatal stenosis along with compromised cosmesis. Several complex neoglans reconstructive techniques exist to prevent stenosis and improve cosmetic outcomes. We hereby describe outcomes of a simple and reproducible modification of the procedure by ventral spatulation of the urethra. Materials and method: An analysis of 31 partial penectomies from May 2016 to June 2019 using a ventral spatulation technique was done. Patients were followed up for an average of 1 year to look for meatal stenosis, the morphological appearance of residual stump and psychosexual well-being. Results: None of the patient had meatal stenosis on follow up. All patients had a satisfactory cosmetic outcome, scoring 6 or more on ANA scale. Seventeen patients reported “satisfied”, six scored “highly satisfied “and eight were “harmonic” with the outcome. Out of 31, significant patients (20) were sexually active with most of them “equally satisfied or dissatisfied” or “very much satisfied.” Conclusion: Used uncommonly, ventral spatulation of urethra is a simple, reproducible and less time consuming alternative, which avoids the chances of meatal stenosis and gives good cosmetic results with psychological benefits to patients.