Single-layer Cytal® urinary bladder matrix is safe and effective for corporoplasty and fistula repair in complex proximal hypospadias: an initial experience
Kathy H. Huen, MD, Sarah A. Holzman, MD, Carol A. Davis-Dao, PhD, Zayn Suhale, BSc, Kai-Wen Chuang, MD, Heidi A. Stephany, MD, Elias J. Wehbi, MD, MS, Antoine E. Khoury, MD.
Children's Hospital of Orange County/ UC Irvine, Orange, CA, USA.
BACKGROUND: Tissue availability for grafts and flaps can pose a challenge in complex proximal hypospadias repairs. Small intestinal submucosa has demonstrated variable success as a pre-packaged graft. Single-layer Cytal™ matrix (ACell Inc, Columbia, MD) is a commercially available, acellular, non-crosslinked wound management scaffold derived from porcine bladder epithelial basement membrane and tunica propria, termed “urinary bladder matrix.” The genitourinary-derived graft material has been associated with excellent graft take and similar contraction rates when compared with buccal mucosal graft in adult patients undergoing complex substitution urethroplasty. We describe our initial experience using Cytal™ in pediatric patients undergoing corporoplasties or dorsal inlay grafts in hypospadias repair, and adjunct uses in wound healing of the penis or the urethra.
METHODS: This is a retrospective review of 13 patients with complex hypospadias repair in a single center of four surgeons between January 2020 and July 2021 with single-layer Cytal™. Chordee was measured with a goniometer.
RESULTS: Thirteen boys who underwent hypospadias repair were identified. Median age was 21.4 months (IQR 14.5-38.2). Mean follow up was 6.2 ± 4.7 months. Cytal™ was used for ventral corporal grafting in 9 boys undergoing either first stage of planned 2-stage hypospadias repair or 1-stage hypospadias repair with a double-faced transverse island preputial flap. Mean chordee in corporoplasties was 85 ± 56 degrees. Two had subsequent second-stage urethroplasties; 2 do not require any further surgery, and 5 are awaiting second stage repair. In 6 of 9 boys, tunica vaginalis flap was unavailable, most commonly due to concomitant undescended testes and inguinal hernias. Of the remaining 3, 1 patient had poor vascular supply to the tunica vaginalis flap, and Cytal™ was used between the flap and the vascular erectile tissue to stimulate tunica albuginea and vaginalis regeneration. All 9 patients had straight erections and no ventral corporal contractures on follow up by erection test (if second stage performed), parent history or physical exam.
Of the remaining 4 of 13 patients, 2 had Cytal™ as a dorsal inlay graft in second-stage hypospadias repair since there was no readily available autologous tissue. Meatuses were patent at follow up. One was a hypospadias cripple with 4 prior hypospadias operations, resulting in a urethrocutaneous fistula (UCF) 1 cm proximal to the mid-shaft meatal opening. This patient had poor vascularized tissue available for repair, therefore the urethroplasty was performed and Cytal™ was placed as a waterproofing second layer. The remaining patient had a wound dehiscence after a one-stage double-faced transverse island preputial flap hypospadias repair, resulting in a large UCF in the early postoperative period. Cytal™ was used as an onlay scaffold for tissue regeneration, with the resulting UCF now pinpoint.
CONCLUSIONS: Single-layer Cytal™ is safe, effective, and simple to use as graft material in hypospadias repairs when autologous tissue is unavailable without incurring additional donor site morbidity. Extended follow up is warranted to confirm results and assess durability.
| Patient# | Age at operation (months) | Prior hypospadias surgery (#) | Diagnosis/ indication | Concomitant conditions | Operation/ Procedure | Degree of chordee at operation | Cytal Use | Reason for Cytal | Outcome |
| 1 | 27 | 0 | Penoscrotal hypospadias | Bilateral UDT, Wolff Hirschhorn | Double-faced transverse preputial island flap one-stage hypospadias repair, R orchiopexy, RIHR | 60 | Corporoplasty | Bilateral UDT, no TV flap available | No residual chordee |
| 2 | 14 | 0 | Penoscrotal hypospadias | Bilateral UDT, Deny Drash, HTN, ESRD | First stage hypospadias repair, laparoscopic L one-stage orchiopexy, laparoscopic Mullerian remnant removal | 180 | Corporoplasty | L UDT, R TV flap not robust | No residual chordee |
| 3 | 75 | 3 | Hypospadias cripple, penoscrotal hypospadias | None | Re-do first stage hypospadias repair | Missing | Corporoplasty | Prior hypo repair used R TV flap, prior L IHR | No residual chordee |
| 4 | 38 | 1 | Penoscrotal hypospadias | Bilateral UDT | Urethroplasty, chordee correction,R orchiopexy, R IHR | 35 | Corporoplasty | Bilateral UDT, L TV used in prior repair | No residual chordee |
| 5 | 11 | 0 | Penoscrotal hypospadias | None | First stage hypospadias repair | 90 | Corporoplasty | n/a | No residual chordee |
| 6 | 14 | 0 | Perineal hypospadias | VSD | First stage hypospadias repair | 145 | Corporoplasty under L TV flap | L TV flap not robust | No residual chordee |
| 7 | 17 | 0 | Penoscrotal hypospadias | None | Double-faced transverse preputial island flap one-stage hypospadias repair | 45 | Corporoplasty | n/a | No residual chordee |
| 8 | 25 | 1 | Perineal hypospadias, residual chordee after prior first stage | Bilateral UDT | Re-do first stage hypospadias repair | Missing | Corporoplasty | Bilateral UDT | No residual chordee |
| 9 | 15 | 0 | Penoscrotal hypospadias | Mixed gonadal dysgenesis (descended gonads) | Double-faced transverse preputial island flap one-stage hypospadias repair, L testis biopsy | 45 | Laid on corpora after “fairy” cuts | n/a | No residual chordee |
| 10 | 44 | 3 | Penoscrotal hypospadias s/p redo first stage | None | Second stage hypospadias repair, dorsal inlay graft | n/a | Dorsal inlay graft | No readily available autologous tissue | Patent meatus |
| 11 | 21 | 1 (first stage) | Perineal hypospadias s/p first stage | None | Second stage hypospadias repair, dorsal inlay graft | n/a | Dorsal inlay graft | No readily available autologous tissue | Patent meatus |
| 12 | 11 | 1 | Urethrocutaneous fistula (active wound healing) after one-stage hypospadias repair | None | Cytal placement over wound separation | n/a | Wound breakdown | n/a | Urethrocutaneous fistula contracted, present |
| 13 | 162 | 4 | Hypospadias cripple, urethrocutaneous fistula | None | Urethrocutaneous fistula repair, one-stage urethroplasty | n/a | Waterproofing layer | Insufficient dartos for second layer | No recurrence urethrocutaneous fistula |
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