Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
J Pediatr Urol. 2021 Apr;17(2):225.e1-225.e8. doi: 10.1016/j.jpurol.2020.12.008. Epub 2020 Dec 11.
Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars' flaps.
A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with <6 months follow-up and incomplete operative reports were excluded. Risk of complications (fistula, dehiscence, diverticulum, meatal stenosis, stricture) were evaluated following urethroplasty and stratified by first-stage repair technique. As technique refinements have been made since 2012, comparisons between two temporal subgroups (those who underwent repair in 2007-2012 and in 2013-2017) were made.
78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4-128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14-0.65) and inlay grafts (HR 0.32; 95% CI 0.11-0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars' flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p = 0.001), but differences in complication rates by first-stage technique were not statistically significant.
In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars' flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising.
Approach to the first stage of two-stage repairs affects outcomes. Pedicled preputial flaps and inlay grafts were associated with lower complication risks than Byars' flaps. Refinement of technique and patient selection may have resulted in fewer complications in the short term. However, long-term follow-up is needed.
近端尿道下裂修复仍然具有挑战性。我们对两阶段近端尿道下裂修复的第一阶段的方法已经从使用 Byars 皮瓣演变为在解剖上合适的病例中使用包皮内植入物移植物，以及在更复杂的修复中使用带蒂包皮瓣。我们回顾了我们的结果，并假设植入物和带蒂包皮瓣与 Byars 皮瓣相比，并发症风险较低。
这是一项来自 2007 年至 2017 年的连续两阶段、原发性近端尿道下裂修复的单机构回顾性队列研究。排除了随访时间<6 个月和手术报告不完整的患者。根据尿道成形术评估并发症（瘘管、裂开、憩室、尿道口狭窄、狭窄）的风险，并按第一阶段修复技术分层。由于自 2012 年以来已经进行了技术改进，因此对两个时间亚组（2007-2012 年和 2013-2017 年接受修复的患者）进行了比较。
78 名患者符合纳入标准。总体并发症发生率为 47%（总结表）。尿道成形术后的中位随访时间为 25.4 个月（范围 6.4-128.5 个月）。带蒂包皮瓣（风险比 [HR] 0.30；95%置信区间 [CI] 0.14-0.65）和植入物（HR 0.32；95%CI 0.11-0.95）与 Byars 皮瓣相比，并发症风险较低（总结表）。Kaplan-Meier 分析显示，Byars 皮瓣的并发症中位时间明显短于植入物（40.6 个月）和带蒂包皮瓣（79.2 个月）。时间亚组比较显示，总体并发症发生率从 70%降至 31%（p=0.001），但第一阶段技术的并发症发生率差异无统计学意义。
在我们的队列中，使用 Byars 皮瓣的修复并发症发生率最高，这与我们的观察结果一致，即从 Byars 皮瓣形成的尿道缺乏适当的支撑，并且活动过度和不规则。为了克服这些缺点，我们对两阶段近端尿道下裂修复的方法进行了修改，使用植入物和带蒂包皮瓣缝合到下面的 corporal 体，以优化尿道板的稳定性。我们的初步结果很有希望。
两阶段修复的第一阶段方法会影响结果。带蒂包皮瓣和植入物与 Byars 皮瓣相比，并发症风险较低。技术改进和患者选择可能导致短期并发症减少。然而，需要长期随访。
