|Year : 2017 | Volume
| Issue : 4 | Page : 161-165
The use of autologous platelet-rich fibrin membrane in hypospadias surgery: a preliminary study
Ibrahim M El-Sayed, Walid A Moustafa, Enas A El-Zamarany, Mohamed S Sadaka
Plastic and Reconstructive Surgery Department, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||26-Apr-2017|
|Date of Acceptance||28-Aug-2017|
|Date of Web Publication||12-Mar-2018|
Ibrahim M El-Sayed
Plastic and Reconstructive Surgery Department, Faculty of Medicine, Tanta University, Shouber Road, El-Gharbia, Tanta
Background Hypospadias, a congenital anomaly with an incidence of 1/300, is a very challenging problem. Despite advances in hypospadias repair surgery, urethrocutaneous fistula remains a very common complication with a reported incidence varying from 4 to 28%. The use of an intermediate layer between the neourethra and the skin is one of the most important techniques used to reduce the likelihood of fistula formation and postoperative complications.
Aim The aim of this study was to evaluate the effect of platelet-rich fibrin membrane (PRF) on the success rate of tubularized incised plate (TIP) repair and its postoperative complications.
Patients and methods The study was carried out on 20 patients who were admitted to the Plastic and Reconstructive Surgery Department, Tanta University Hospitals, for hypospadias surgery throughout the period from the first of May 2015 to the end of April 2016. Urethroplasty was performed using the TIP technique. PRF membrane was applied and sutured over the sutured urethra as an intervening layer between the skin and neourethra. The perioperative course and postoperative complications were recorded.
Results Twenty patients were included in this study. Their mean age at surgery was 2.45 years (range: 1–4 years). No intraoperative complications were encountered. Glanular edema occurred in two patients. Wound infection occurred in one patient. None of the patients had hematoma, wound dehiscence, or flap necrosis. With a mean follow-up of 6 months, urethral fistula occurred in two patients.
Conclusion The PRF patch is a safe and efficient technique as an intermediate layer in TIP repair, and it helps to reduce the incidence of postoperative complications especially when healthy tissue is not available as an intervening layer.
Keywords: hypospadias, platelet-rich fibrin membrane, tubularized incised plate
|How to cite this article:|
El-Sayed IM, Moustafa WA, El-Zamarany EA, Sadaka MS. The use of autologous platelet-rich fibrin membrane in hypospadias surgery: a preliminary study. Tanta Med J 2017;45:161-5
|How to cite this URL:|
El-Sayed IM, Moustafa WA, El-Zamarany EA, Sadaka MS. The use of autologous platelet-rich fibrin membrane in hypospadias surgery: a preliminary study. Tanta Med J [serial online] 2017 [cited 2018 Mar 24];45:161-5. Available from: http://www.tdj.eg.net/text.asp?2017/45/4/161/227121
| Introduction|| |
Hypospadias is a common congenital anomaly that is occurs in 1/300 (0.3%) newborn children . It is characterized by an anomalous location of the ventral urethra. The presentations are distal (50%), middle (30%), and proximal (20%) .
Treatment for hypospadias is surgical, but there is technique that is recognized as the gold standard. This is because of the variability of results and the high frequency of complications .
Hypospadias continues to be a challenging problem. The current operative technique conceptualizes on a perfect single-stage repair of the malformation, functional excellence, and a cosmetically normal looking penis .
The most common complication occurring after hypospadias repair is urethrocutaneous fistula (UCF) with a reported incidence varying from 4 to 28% .
The use of an intermediate layer between the neourethra and the skin is one of the most important techniques used to reduce the likelihood of fistula formation .
Several coverage techniques have been described including local subcutaneous penile tissue, tunica vaginalis, dartos, and extragenital tissues. In addition to tissue flaps, fibrin sealants were introduced to prevent fistula formation . Kajbafzadeh et al.  proposed the use of fibrin sealant for UCF repair.
Platelet-rich fibrin membrane (PRF) is an autologous source of growth factors. It is prepared from the sera of the patient. Transforming growth factor-β, vascular endothelial growth factor, and endothelial growth factor are the most common growth factors detected in PRF sample .
PRF enhances collagen synthesis and tissue repair and improves wound healing and angiogenesis; therefore, this autologous fibrin membrane could be used as an intermediate layer between the neourethra and the skin to reduce the incidence of fistula formation .
| Aim|| |
The aim of the study was to evaluate the effect of PRF on the success rate in tubularized incised plate (TIP) repair and its postoperative complications.
| Patients and methods|| |
After obtaining approval from the local ethical committee, we prospectively included 20 patients with anterior or mid penile hypospadias who were admitted to the Plastic and Reconstructive Surgery Department, Tanta University Hospitals, for hypospadias surgery throughout the period from the first of May 2015 to the end of April 2016.
Hypospadias repair was performed using the TIP technique. After examining under anesthesia and noting the meatal location, the technique was begun by placing a silk stay suture 4/0 with a round needle in the dorsal glans for traction of the penis, and an 8-Fr urethral catheter was inserted. To maintain a bloodless field, a tourniquet was applied at the base of the penis. An artificial erection was induced to ensure a straight penis.
A U-shaped incision was made extending beyond the edges of the urethral plate and 2 mm proximal to the original meatus. The glanular wings were created after making parallel longitudinal incisions to define the urethral plate and were dissected laterally for subsequent tension-free closure.
The edges of the urethral plate were gently elevated and retracted laterally with fine forceps. The urethral plate was then widened by a deep relaxing midline incision along its entire length from the meatus to the glans tip. The incision was carried deeply through the mucosal and submucosal tissue dividing all transverse webs and exposing the underlying corporal bodies.
Incised plate was then tubularized over an 8 Fr Nelaton’s urethral catheter. Continuous subcuticular 6–0 polyglactin suture was used to fashion the tube. Ten milliliter blood sample was obtained intraoperatively. Blood was collected without anticoagulant into a sterile plain glass tube and immediately centrifuged at 3000 rpm for 10 min, before completion of the urethroplasty.
After centrifugation, a fibrin clot was formed in the middle of the tube between the acellular plasma at the top and the red blood cells at the bottom ([Figure 1]). The clot was extracted from the tube and separated from red blood cells and gently compressed between two surgical swabs to obtain a soft and resistant membrane (PRF membrane) ([Figure 2] and [Figure 3]).
The entire procedure was performed under strict aseptic conditions. This autologous PRF membrane was applied over the urethroplasty and secured using a few 6–0 interrupted polyglactin sutures ([Figure 4]).
The skin was sutured over the patch using interrupted 6–0 polyglactin sutures ([Figure 5]). The glanular wings were symmetrically closed ventrally over the neourethra with 6–0 polyglactin sutures in two layers. The soft plastic 8 Fr urethral catheter was secured to the glans using the traction suture. The transurethral catheter was left in place for 5–7 days with a compressive dressing for a mean of 3 days.
All patients were scheduled to be examined in the outpatient clinic weekly for 3 weeks and then every month for 6 months postoperatively to assess the urethral meatus position and presence of UCF and other complications. Complications as well as cosmetic appearances were recorded in addition to parents’ satisfaction.
| Results|| |
The study was conducted on 20 patients with 16 anterior and four middle penile hypospadias. Their mean age at surgery was 2.45 years (range: 1–4 years). No intraoperative complications were encountered.
Early postoperative glanular edema occurred in two patients and was managed by antiedematous and anti-inflammatory medications.
Minor wound infection occurred in one patient and was managed by frequent dressing and intravenous antibiotic injection. None of the patients had hematoma, wound dehiscence, flap necrosis, or penile torsion.
UCF occurred in two patients, which was distal penile, and appeared after 2 weeks of surgery in the middle penile group. Closure of the fistula was done 6 months after the surgery.
None of the patients had postoperative meatal stenosis, meatal retraction, or urethral stricture.
The final urethral meatus was cosmetically acceptable with good urethral stream in the successful cases.
| Discussion|| |
For hypospadias repair to be considered successful, it should fulfill the following criteria: a vertical slit-like glandular meatus, a conically shaped glans, a straight penis during erection, good skin coverage, and a normal position of the scrotum in relation to the penis .
The success rate of urethral repair can be improved by correction of distal urethral obstruction, tension-free anastomosis, closure with absorbable suture material, and a well-vascularized intermediate layer between urethral and skin closures .
UCF still remains a common complication in spite of the advances in hypospadias repair and the application of the above recommendations . Surgical techniques with nontraditional tissue adherents, such as fibrin sealants, can promote healing and decrease the incidence of UCF formation .
Autologous fibrin membrane can be used to provide an interposition layer during hypospadias repair . PRF has several advantages over other fibrin sealants: it can be easily obtained intraoperatively, has no cost, preparation method is simple, and no biochemical blood handling is required. It is obtained from the blood of the patient and prepared during the operation using a simple centrifugation method. Therefore, the risk of allergic reactions, infections, and harm of high fibrinogen concentration are eliminated .
There are two reports in the literature discussing the use of PRF in hypospadias. Guinot et al.  studied the use of autologous PRF membrane for urethroplasty coverage in distal hypospadias surgery, whereas Soyer et al.  studied the use of autologous PRF in urethrocutaneous fistula repair.
In our study, 20 boys with primary anterior or mid penile hypospadias were operated using TIP repair with the addition of an autologous PRF for urethroplasty coverage as an intermediate layer between the neourethra and the skin.
The rates of glanular edema and hematoma incidence were 5 and 0%, respectively, in our study, whereas those were 0% in Guinot et al.’s  study; and the rates were 13 and 5% using spongioplasty with dorsal dartos flap  and 12 and 5% with fibrin glue as an intermediate layer .
In our series, incidence of infection was 5%, whereas it was 0% in Guinot et al.’s  study; incidence of infection was 13.79%  and 5.71%  with the use of tunica vaginalis flap as an intermediate layer.
Similar to our study, Guinot et al.  reported no cases of skin dehiscence, whereas it was 4.6% with ventral subcutaneous flap , 4% with spongioplasty , and 13% with fibrin glue . No cases of flap necrosis occurred in our series, whereas it was 6.7% with fibrin glue as an intermediate layer .
The incidence of UCF in our study was 10%, whereas it was 6% in another PRF urethroplasty study ; it was 9% with the use of the ventral-based dartos flap wrapping technique , 10.34% with the use of tunica vaginalis flap , and 10% with fibrin glue .
The interposition of an intermediate layer between the urethroplasty and skin is an important step in surgical repair of hypospadias. The use of an autologous PRF membrane seems to be a safe covering technique.
The procedure is quick and has low risk of early postoperative complications such as edema, hematoma, infection, wound dehiscence, and flap necrosis. Two of our 20 patients had a UCF (10%), and this is comparable with the results of other techniques of neourethra coverage.
In this preliminary study, the feasibility and safety of using PRF as an intermediate layer for hypospadias surgery is showed; it should be considered a viable and alternative technique to other conventional coverage techniques especially in some redo cases without suitable foreskin, in circumcised hypospadias, and in cases that do not have a healthy dartos tissue or when tunica vaginalis is no longer available due to testicular operation.
| Conclusion|| |
The use of an autologous PRF patch as an intermediate layer in hypospadias surgery is a safe technique. The procedure is quick and straightforward and has a low risk of postoperative complications such as hematoma, edema, wound infection, wound dehiscence, and flap necrosis.
PRF decreases the incidence of UCF formation with no superiority over other coverage techniques.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gopal SC, Gangopadhyay AN, Mohan TV, Upadhyaya VD, Pandey A, Upadhyaya A et al.
Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair. J Pediatr Surg 2008; 43:1869–1872.
Baskin LS, Ebbers MB. Hypospadias: anatomy, etiology, and technique. J Pediatr Surg 2006; 41:463–472.
Cooper CS, Snyder HM. Pediatric reconstructive surgery. Curr Opin Urol 2000; 10:195–199.
Lundquist R, Holmstrøm K, Clausen C, Jørgensen B, Karlsmark T. Characteristics of an autologous leukocyte and platelet-rich fibrin patch intended for the treatment of recalcitrant wounds. Wound Repair Regen 2013; 21:66–76.
Guinot A, Arnaud A, Azzis O, Habonimana E, Jasienski S, Frémond B. Preliminary experience with the use of an autologous platelet-rich fibrin membrane for urethroplasty coverage in distal hypospadias surgery. J Pediatr Urol 2014; 10:300–305.
Hosseini J, Kaviani A, Mohammadhosseini M, Rezaei A, Rezaei I, Javanmard B. Fistula repair after hypospadias surgery using buccal mucosal graft. Urol J 2009; 6:19–22.
Kajbafzadeh AM, Abolghasemi H, Eshghi P, Alizadeh F, Elmi A, Shafaattalab S, Mohseni MJ. Single-donor fibrin sealant for repair of urethrocutaneous fistulae following multiple hypospadias and epispadias repairs. J Pediatr Urol 2011; 7:422–427.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL et al.
Platelet-rich fibrin (PRF): a second-generation platelets concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101:56–60.
Soyer T, Ayva Ş, Boybeyi Ö, Aslan MK, Çakmak M. The effect of platelet rich fibrin on growth factor levels in urethral repair. J Pediatr Surg 2013; 48:2545–2549.
Shankar KR, Losty PD, Hopper M, Wong L, Rickwood AM. Outcome of hypospadias fistula repair. BJU Int 2002; 89:103–105.
Yachia D. Surgical anatomy of the penis and scrotum. In: Yachia D, editor. Text atlas of penile surgery. CRC Press; 2007. pp. 1–7.
Ambriz-Gonzalez G, Velazquez-Ramirez GA, García-González JL, de León-Gómez JM, Muciño-Hernández MI, González-Ojeda A et al.
Use of fibrin sealant in hypospadias surgical repair reduces the frequency of postoperative complications. Urol Int 2007; 78:37–41.
Soyer T, Çakmak M, Aslan MK, Şenyücel MF, Kisa Ü. Use of autologous platelet rich fibrin in urethracutaneous fistula repair: preliminary report. Int Wound J 2013; 10:345–347.
Bhat A, Singla M, Bhat M, Sabharwal K, Kumar V, Upadhayay R et al.
Comparison of results of TIPU repair for hypospadias with ‘spongioplasty alone’ and ‘spongioplasty with dorsal dartos flap’. Open J Urol 2014; 4:41–48.
Tabassi KT, Mohammadi S. Tunica vaginalis flap as a second layer for tubularized incised plate urethroplasty. Urol J 2010; 7:254–257.
Hamid R, Baba AA, Shera A, Ahmad S. Tunica vaginalis flap following ‘tubularised incised plate’ urethroplasty to prevent urethrocutaneous fistula. Indian J Plast Surg 2015; 48:187–191.
] [Full text]
Savanelli A, Esposito C, Settimi A. A prospective randomized comparative study on the use of ventral subcutaneous flap to prevent fistulas in the Snodgrass repair for distal hypospadias. World J Urol 2007; 25:641–645.
Dodat H, Landry JL, Szwarc C, Culem S, Murat FJ, Dubois R. Spongioplasty and separation of the corpora cavernosa for hypospadias repair. BJU Int 2003; 91:528–531.
Hayashi Y, Kojima Y, Nakane A, Kurokawa S, Tozawa K, Kohri K. Ventral based dartos flap for the prevention of the urethrocutaneous fistula urethroplasty. Int J Urol 2007; 14:725–728.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]