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Management of Proximal Hypospadias with 2-Stage Repair: 20 Year Experience
Erin R. McNamara, MD1, Anthony J. Schaeffer, MD MPH1, Catherine M. Seager, MD2, Ilina Rosoklija, MPH1, Alan B. Retik, MD1, David A. Diamond, MD1, Marc Cendron, MD1.
1Boston Children's Hospital, Boston, MA, USA, 2Cleveland Clinic, Cleveland, OH, USA.

Background: Proximal hypospadias repair can be approached by a 1- or 2-stage repair. In the latter, chordee is addressed prior to completing the urethroplasty in another operative setting. A recent systematic review of proximal hypospadias repair highlights the deficiency of studies that accurately report complications and outcomes. We report short- and long-term complications for the largest single center experience with proximal hypospadias treated with a 2-stage approach.
Methods: This was an IRB approved retrospective cohort study. Inclusion criteria included any patient with proximal hypospadias who underwent a planned multiple stage hypospadias repair from January 1992-December 2012. Demographics, preoperative management, operative technique and postoperative complications were reviewed.
Results: There were 134 patients included in this analysis. Patient demographics and preoperative characteristics are shown in Table 1.
First-stage characteristics: The median age at time of first surgery was 8.8 months [IQR 6.3-11.7]. Of the 134 patients, 50 (37.3%) were given testosterone prior to initial stage. The first-stage consisted of an orthoplasty and rotation of preputial skin to the ventrum in preparation for the second stage in 128 patients (95.5%). Maneuvers used for straightening (multiple in some patients) included degloving, urethral plate transection, dermis/other grafting and plication in 50%, 36.6%, 24.6% and 20.1%, respectively. Complications were encountered in 5 (3.7%) patients and were limited to surgical site infection (SSI) and wound breakdown.
Second/Third-Stage characteristics: The median age at time of second surgery was 17.1 months [IQR 14.2-20.3]. Median time between first- and second- stage was 8 months [IQR 6.9-9.2]. 34/134 (25.4%) were given testosterone prior to the final stage. The majority of patients had a Theirsch-Duplay urethroplasty (108/134, 80.6%), with Tubularized Incised Plate (20/134, 14.9%) being the second most common repair. Other procedures (bladder tube, buccal graft) were done in 6/134 (4.5%) patients. A urethral catheter or urethral stent were used in 35 (26.1%) and 91(67.9%) patients, respectively. Additional suprapubic drainage was utilized in 34 (25.4%) patients. Median length of drainage was 8 days [IQR 7-12]. Immediate post-operative complications were seen in 30/134 (22.4%) with the most common being glans dehiscence in 19/134 (14.2%), followed by UTI and SSI.
Follow-up: The median follow-up was 3.8 years (range: 1 month-21.7 years). Long-term complications were seen in 62/134 (46.3%) patients: fistula in 39(29.1%), meatal stenosis in 17(12.7%), stricture in 16(11.9%), diverticula in 12 (9%) and residual chordee in 3(2.2%). Reoperation was performed in 64/134 (47.8%) patients. In those that had additional surgeries, the median number of procedures was 2 [IQR 1-2.5]. Median time from urethroplasty to first surgical correction of complication was 14.9 months [IQR 6.7-30.8].
Conclusions: This data shows that a two-stage approach to proximal hypospadias is an alternative to one-stage procedures, with comparable outcomes. Complications are expected in almost half of these complex patients, with the most common being fistula. Further prospective studies are needed to ascertain which approach yields the best outcomes.

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