Repair of proximal hypospadias with single-stage (Duckett's method) or Bracka two-stage: a retrospective comparative cohort study

Abstract

Background: Surgical correction of proximal hypospadias is challenging. The complication rate of proximal hypospadias is still high, and the debate over its optimal treatment is ongoing. Duckett's method is a classic non-staging operation, and two-stage Bracka repair is an attractive alternative procedure. Herein, we retrospectively analyzed the effects of two surgical techniques on proximal hypospadias in order to reduce the complication rates of proximal hypospadias, and analyzed the various risk factors that cause complications.

Methods: This study retrospectively evaluated 94 consecutive patients who underwent repair of penoscrotal or proximal defects between 2015 and 2019. Patients were assigned to two groups: 46 patients were treated with Bracka and 48 with Duckett. Patient age at surgery, urethral meatus location, and postoperative complications were recorded. One-way analysis of variance (ANOVA) was used to analyze the length and curvature of the penis and the length of the urethral defect.

Results: There was no significant difference between the two groups in terms of age and type of hypospadias. In the Bracka group, there was 1 case (2.2%) of meatal stenosis after the first stage, which was restored with ureteral dilatation. After second-stage repair, a urethral fistula was noted in 4 cases (8.7%) and strictures in 2 cases (4.3%). In the Duckett group, urethral fistulas were noted in 8 cases (16.7%), strictures in 4 cases (8.3%), partial glans dehiscence in 4 cases (8.3%), and diverticulum in 1 case (2.1%) postoperatively. Compared with the Duckett group, the overall complication rate for Bracka repair was lower (35.4% vs. 13%, P=0.016). In addition, compared with the Duckett group, children with perineal hypospadias who were treated with the Bracka operation had fewer postoperative complications (100% vs. 13%, P=0.015). Risk factor analysis showed that the initial curvature of the penis, initial urethral defect, and degree of penile curvature after skin degloving were not correlated with complications. There was a significant correlation between urethral defects after correction of the chordee and urethral fistulas (P=0.019).

Conclusions: Compared with the Duckett procedure, the Bracka two-stage repair may be a safer and more reliable approach for proximal hypospadias in children. The Bracka two-stage repair should be used for perineal hypospadias. The larger the urethral defect after chordee correction, the greater the possibility of a postoperative urethral fistula.

Keywords: Bracka two-stage repair; Duckett procedure; children; proximal hypospadias.

Figure 1

Surgical procedures of Bracka two-stage repair. (A) Preoperative appearance of the penis; (B) the meatus was dropped back to the penile-scrotal junction, scrotum, or perineum; (C) created a Duplay urethra; (D) created a thin translucent skin strip; (E) the dorsal foreskin was transferred to both sides of the penis; (F) secured the skin strip to the prepared bed. Corrected the deformity of the bifid scrotum; (G) fixed the petroleum gauze properly to the ventral side of the penis; (H) covered the graft and anastomosis snugly with petroleum gauze; (I) new urethral plate; (J) tubularized the neourethral plate; (K) a protective dartos fascia flap or tunica vaginalis flap was placed over the entire suture line; (L) appearance of the penis after 2-staged operation.