Distal hypospadias is the most common form of hypospadias. The Tubularized Incised Plate (TIP) repair is the standard surgical technique for this condition; however, complications such as fistula formation and meatal stenosis remain concerns. These complications are often influenced by the choice of intermediate tissue layer used to reinforce the neourethra. The traditional ventral dartos flap is effective but can be technically challenging and may result in a bulky tissue layer. Platelet-rich fibrin (PRF) is an autologous, growth factor-rich biological material that has shown promise in tissue regeneration and healing. It is easy to prepare intraoperatively and may serve as a biological reinforcement to reduce postoperative complications. This study aims to provide high-quality evidence comparing the effectiveness of PRF versus the ventral dartos flap in patients with distal hypospadias, specifically those with Grade 1 urethral defects and minimal penile curvature, using a stratified study population to ensure balanced groups.
This randomized controlled trial aims to compare the incidence of urethrocutaneous fistula at a minimum of 6 months postoperatively between two intermediate layers used in hypospadias repair: platelet-rich fibrin (PRF) membrane and ventral dartos flap. The study will also evaluate secondary outcomes, including rates of meatal stenosis, urethral stricture, other postoperative complications, and cosmetic outcomes assessed by standardized photographs and blinded expert scoring. Study Design and Setting: This prospective, multicenter, single-blinded randomized controlled trial will be conducted at centers in Tashkent, Uzbekistan, and Jakarta, Indonesia. A total of 140 patients (70 per group) will be enrolled, with randomization stratified by urethral plate score and center to ensure balanced groups. Participants: Children aged 6 months to 5 years with primary distal hypospadias (Grade 1, Abbas classification) or redo distal hypospadias (Grade 1, Abbas classification), with penile curvature less than 30° after degloving (measured as per Abbas, 2022), will be included. Exclusion criteria include previous hypospadias surgery, proximal hypospadias, penile curvature ≥30°, or syndromic anomalies/coagulopathies. Interventions: Participants will undergo tubularized incised plate (TIP) or glanuloplasty TIP (GTIP) urethroplasty performed by experienced pediatric urologists using standardized techniques. Group A: Application of autologous platelet-rich fibrin membrane over the neourethra. PRF will be prepared intraoperatively by drawing 10 mL of peripheral blood, centrifuging at 3000 rpm for 10 minutes, extracting the PRF clot, compressing it into a membrane, and securing it over the neourethra with absorbable sutures. Group B: Rotation of a ventral dartos flap over the neourethra. Intraoperative PRF Preparation: Blood will be collected into sterile glass tubes without anticoagulants, centrifuged immediately, and the PRF membrane prepared as described. The membrane will be placed over the neourethra before glans closure, secured laterally, and the skin closure completed in standard fashion. Stratification: Participants will be stratified based on urethral plate characteristics using a validated scoring system before randomization to ensure anatomical balance. Follow-Up: Patients will be assessed at 1, 3, and 6 months postoperatively for complications (fistula, stenosis, etc.), neomeatus function, and cosmetic appearance. Digital photographs will be evaluated by two blinded pediatric urologists, and cosmetic outcomes will be scored using the HOSE system. Data Management and Analysis: All data will be anonymized and stored securely. Statistical analysis will be performed using SPSS v22, applying appropriate tests for categorical and continuous variables, with multivariate regression if necessary.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
5
In this arm, a platelet-rich fibrin membrane will be prepared intraoperatively from the patient's blood using centrifugation. The prepared PRF membrane will then be applied directly over the neourethra following urethroplasty to promote healing and tissue regeneration.
Participants in this arm will undergo hypospadias repair with the application of a ventral dartos fascia flap. The procedure involves elevating a vascularized flap of ventral dartos fascia from the penile shaft, rotating it over the neourethra to provide additional tissue coverage and promote healing. This flap helps in reducing the risk of fistula formation and enhances vascular support to the neourethra. The surgical steps include dissecting the dartos fascia carefully, rotating it over the neourethral reconstruction, and securing it in place, followed by standard postoperative care and follow-up.
National Children's Medical Center
Tashkent, City, Uzbekistan
Hypospadias Cosmetic Score (HOSE)
Assessment Method: Standardized digital photographs taken at 6 months postoperatively. Evaluators: Two independent pediatric urologists blinded to treatment allocation will evaluate the photographs. Measurement Tool: Cosmetic outcome scored using the Hypospadias Objective Scoring Evaluation (HOSE) system or a similar validated scale. Units: HOSE score (range 5-10). Higher scores: Indicate better cosmetic outcomes.
Time frame: Follow-up evaluations will occur at 1, 3, and 6 months postoperatively.
Clinical examination for postoperative complications (fistula, stenosis, )
Assessment Method: Physical examination conducted by a trained clinician during follow-up visits at 1, 3, and 6 months post-surgery. Measurement Tools: Visual inspection and palpation for fistula or stenosis; documentation of findings in standardized case report forms. Units/Scoring: Presence or absence of complications (binary: yes/no). Interpretation: Higher occurrence indicates worse outcome.
Time frame: during follow-up visits at 1, 3, and 6 months post-surgery.
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