STAGED AUTO GRAFT (STAG) REPAIR FOR PENOSCROTAL HYPOSPADIAS WITH VENTRAL CURVATURE GREATER THAN 30 DEGREES
Melissa McGrath, BASc, Smruthi Ramesh, BHSc, Kornelia Palczewski, BhSc, Luis H. Braga, MD,PhD.
McMaster University, Hamilton, ON, Canada.
BACKGROUND The gold standard technique for repair of scrotal/perineal hypospadias with severe ventral curvature (VC) has yet to be established. Herein, we describe our outcomes with the STAG technique and determine risk factors for complications in this severe subset of patients.
METHODS We selected patients with proximal defects(n=183) from a prospectively collected hypospadias database(2008-19-n=733). TIP/Byars flaps cases were excluded, leaving 57 who underwent STAG repair. Of these, 12 completed the 1ststage and 45 the 2ndstage with minimum 6-month follow-up. STAG repairs were performed using inner prepuce for primary cases and buccal mucosa for redos. VC was corrected by dividing the urethral plate in all cases and performing 2-3 transverse ventral corporotomiesądorsal plication. Preoperative testosterone stimulation (PTS) was administered for glans width <14mm (3-IM injections, 3-weeks apart). Age at each stage of repair, meatal location, degree of VC assessed before/after degloving with an artificial erection measured by eyeballing/photograph with an electronic app, anesthetic block (caudal/dorsal penile block), complications [urethrocutaneous fistula (UCF), glans dehiscence(GD), recurrent VC and graft contraction], and follow-up time. Primary outcome=overall complication rate. Recurrent VC was assessed by reflex erection during examination and/or parents reporting. Univariate and multivariable analyses of risk factors for complications were conducted.
RESULTS Median patient age at 1st and 2ndstage for those undergoing primary repair was 18.4 and 26.2months, respectively;mean follow-up was 33 months. Overall, 20/57(36%) patients had VC between 30-70° and 37(64%) >70° after degloving; 40/57(71%) boys received PHS(3 shots). Grafts took well in most cases with only 4(7%) contractions in all primary cases. Of these, 2 needed re-grafting and 2 are being stretched (vit. E). Median interval between stages was 8 months. Of the 45 patients who completed the 2ndstage, 37 were primary and 8 redo cases. Five of 37(13.5%) boys showed residual VC <30° at the 2ndstage, which was corrected by DP. Overall, complications occurred in 14/45(31%) patients. Of the 14 complications, 11 occurred after primary repairs (11/37-29.7%), with 7 UCFs and 4 GDs. Of the 8 redos, 2 developed UCF and 1 GD. All successful cases had the neomeatus located at the tip of the glans. None of the patients had recurrent curvature after a mean follow-up of 33months. Upon univariate analysis, PTS, type of anesthesia block and VC degree were not associated with a higher rate of complication post hypospadias repair.
CONCLUSIONS We have observed a lower complication rate for primary scrotal/perineal hypospadias repair using the STAG technique compared to what has been recently reported using other staged procedures (such as Byars flaps) or single stage operations. The majority of complications were UCFs, which can be easily managed. Only 7% of cases had graft contraction post-1ststage (requiring re-grafting) making it a 3-stage operation. Recurrent VC cases have yet to be documented after a mean follow-up of 2.5 years. Nevertheless, we recognize that this follow-up period is insufficient to fully assess recurrent VC, as patients need to be monitored until adolescence to reliably determine whether VC has reappeared.
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