Primary vs secondary repairs using SIS grafting in proximal hypospadias and severe chordee
George Ransford, MD, Angela Mittel, MD, Mariaritta Salvitti, MD, George Wayne, MD, Miguel Gosalbez, MD, Miguel Castellan, MD, Kristin Kozakowski, MD, Andrew Labbie, MD, Rafael Gosalbez, MD.
Nicklaus Children's Hospital, Miami, FL, USA.
BACKGROUND: Severe chordee associated with proximal hypospadias requires complex reconstructions. Multiple reconstructive strategies are described in the literature, including small intestine submucosa (SIS) grafting for severe chordee with urethroplasty. This study reports outcomes and complications of primary vs secondary procedures in repairing proximal hypospadias with severe chordee using single ply SIS grafting.
METHODS: An IRB approved, retrospective chart review was performed. Patients who were included in the study had proximal hypospadias with severe chordee (>30-40 deg) from 2000 to 2015. 4 different surgeons performed procedures. All patients had SIS grafting for chordee repair, while the type of urethroplasty performed was at the surgeon’s discretion. All had artificial erection tests done in the OR. Associated conditions and post-operative complications were reviewed.
RESULTS: 94 patients underwent primary repair and 8 patients underwent secondary repair. In the primary repair group, 18 underwent a single stage procedure, 74 had a two stage, and 2 had a three stage procedure. The secondary repair group had 0 with a single stage, 6 had two stage, and 2 had three stage procedures. Median age at 1st stage of primary repair was 11 months and at secondary repair 116.5 months; 2nd stage primary repair and secondary repair ages were 20 months and 128 months, respectively. Overall complications of primary repair vs. secondary repair were comparable; 44% versus 50 % respectively, but not statistically significant. Fistulas developed in 16 (17%) in primary repair and 3 (37.5%) in secondary repair. Urethral diverticula developed in 10 patients (10.6%) undergoing primary repair and 0 patients undergoing a secondary repair. Preoperative testosterone was given to 34 (36%) of primary repair patients and 1 (12.5%) of secondary repair. 33 (35%) patients had undescended testes in the primary repair group and 3 (37.5%) in the secondary repair group. Scrotal abnormalities were noted in 24 (25.5%) of primary and 1 (12.5%) of secondary repairs. Chordee correction was required in 4 (4.3%) at second stage procedures, all in the primary repair group. Urethroplasty coverage used in primary repairs included tunica vaginalis 16 (17%), dartos (38%), or no coverage 42 (44%). In secondary repairs, tunica vaginalis was used in 2 (25%), dartos in 3 (37.5%), and no coverage in 3 (37.5%). There were 40 (42.5%) primary repairs that reported straight erections on follow-up and 54 (57.5%) lacked documentation. Six (75%) of the secondary repairs also had straight erections and 2 lacked documentation. No patients reported erectile dysfunction, whether primary or secondary repairs.
CONCLUSIONS: SIS grafting for repair of severe chordee in patients with proximal hypospadias is a viable option for repair. Overall complication rates are comparable to the reported literature, and only 4% of patients required further chordee correction after SIS grafting. This study reports the largest patient population undergoing SIS grafting for severe ventral chordee and proximal hypospadias.
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