Surgical repair techniques in hypospadias with unfavorable urethral plate: A systematic review and network meta-analysis.

Introduction: Hypospadias is one of the most common urogenital malformations in male newborns. Numerous techniques exist for repairing hypospadias, including urethral advancement, tubularized incised plate (TIP), flaps, and graft-tubularized incised plate (GTIP). However, it remains unclear which approach is optimal in cases with an unfavourable urethral plate.

Objective: This systematic review and network meta-analysis compares efficacy, complication rates, and patient outcomes of the various surgical procedures used to repair hypospadias with an unfavorable urethral plate.

Study design: Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA) guidelines were used to conduct a search of PubMed, Cochrane Library, Embase, and Science Direct databases up to May 4, 2024. Studies were rigorously screened and evaluated using Cochrane Risk of Bias 2.0. A random-effects meta-analysis was conducted using R-Studio to combine effect estimates. Included were peer-reviewed publications of randomized controlled trials, prospective cohort studies, and retrospective studies involving male patients diagnosed with hypospadias and "unfavorable urethral plate".

Results and discussion: A total of 20 studies representing n = 1483 patients were included, screened, and displayed low risk of bias. Four studies were included in the network meta-analysis. Narrow meatus were found to be more prevalent in TIP urethroplasty, while glans dehiscence was less common with flaps. Additionally, TIPs and GTIP displayed lower incidence of diverticulum compared to flaps. The network meta-analysis indicated no significant differences between the three procedures in terms of fistula complication (Flap [OR 0.41; 95 % CI 0.11-1.50] and GTIP [OR 0.52; 95 % CI 0.17-1.57]). GTIP procedures were associated with fewer overall complications (OR 0.37; 95 % CI [0.19-0.75]).

Conclusion: Flap and GTIP techniques may display lower complication rates than TIP in cases of unfavorable urethral plate, with modest superiority of the GTIP approach. Flap and GTIP techniques may therefore be optimal for repairing hypospadias in cases of unfavorable urethral plate, although high-quality comparative studies are needed to confirm this finding.