Two-stage repair in hypospadias

Abstract

We provide the reader with a nonsystematic review concerning the use of the two-stage approach in hypospadias repairs. A one-stage approach using the tubularized incised plate urethroplasty is a well-standardized approach for the most cases of hypospadias. Nevertheless, in some primary severe cases, in most hypospadias failures and in selected patients with balanitis xerotica obliterans a two-stage approach is preferable. During the first stage the penis is straightened, if necessary and the urethral plate is substituted with a graft of either genital (prepuce) or extragenital origin (oral mucosa or postauricular skin). During the second stage, performed around 6 months later, urethroplasty is accomplished by graft tubulization. Graft take is generally excellent, with only few cases requiring an additional inlay patch at second stage due to graft contracture. A staged approach allows for both excellent cosmetic results and a low morbidity including an overall 6% fistula rate and 2% stricture rate. Complications usually occur in the first year after the second stage and are higher in secondary repairs. Complications tend to decrease as experience increases and use of additional waterproofing layers contributes to reduce the fistula rate significantly. Long-term cosmetic results are excellent, but voiding and ejaculatory problems may occur in as much as 40% of cases if a long urethral tube is constructed. The procedure has a step learning curve but because of its technical simplicity does not require to be confined only to highly specialized centers.

Evaluation of the Extent of Primary Buccal Mucosal Graft Contracture in Augmentation Urethroplasty for Stricture Urethra: A Prospective Observational Study at a Tertiary Healthcare Centre

“…The incidence of graft contracture in BMG urethroplasty varies from 3 to 22.5% in various studies [ 13 – 18 ]. Oral mucosal grafts are also used in the ocular reconstructive surgeries [ 19 ].…”

The Bracka two-stage repair for severe proximal hypospadias: A single center experience

“…A retraction of 20% of grafted area usually occurs between stages; therefore harvesting a graft slightly larger than required is recommended. [ 14 ] We harvested and quilted a larger graft than required and thereby we could avoid the adverse effects of graft contraction. We achieved 100% graft take as were the results of others.…”

“…[ 17 ] reported a 63% fistula rate in cases operated without and a 4.5% rate in those operated with such an additional layer. The initial higher fistula rate might be due to learning curve of a new technique[ 7 14 ] and we attribute our initial higher fistula rate to the phenomenon of learning curve. Out of 8 patients who developed fistula 5 were spontaneously closed with regular meatal dilatation under anesthesia at interval of 3 weeks for 3-5 sessions and similarly 2 fistulae spontaneously closed in study by Ferro et al .…”

Single-Stage Versus Two-Stage Urethroplasty for Hypospadias

“…In some cases, the urethral plate may be undeveloped and unsuitable for inclusion in the urethroplasty, even though it does not contribute to the curvature. A phased approach might be beneficial for all instances that require a urethral plate substitution (Haxhirexha KN et al, 2008;Keays & Dave, 2017;Steven et al, 2013). Recently, there have been technical advancements in the two-staged reconstructive procedure, specifically aimed at implementing a more assertive correction of chordee.…”

“…There have been extended indications for single-stage repairs to manage the discomfort and potential hazards associated with a subsequent treatment, as well as the customary six-month waiting period between stages (Babu & Chandrasekharam, 2021;Dason et al, 2014;Hoy et al, 2019). However, the two-stage repair is currently experiencing a resurgence in popularity due to its ability to simultaneously decrease morbidity and enhance cosmesis in the treatment of the most severe types of hypospadias (Haxhirexha KN et al, 2008).…”