Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication.

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Case report We report the case of a 2-year-old child who presented to us in 2019 complaining of a thin forceful stream, ballooning of the ventral aspect of the penis while voiding, and post-void dribbling. He has a history of undergoing a tabularised incised plate urethroplasty for distal penile hypospadias at 18-months-old. Ultrasound showed increased post-void residual volume and cystourethroscopy confirmed a urethral diverticulum extending from the subcorona to the base of the penis. The patient underwent partial excision of diverticulum, urethroplasty, and meatoplasty. He was followed-up 3 months later with complete resolution of his symptoms and a normal urinary stream with no urethral ballooning or dribbling. Conclusion Urethral diverticulum may present as a complication post hypospadias repair. Although it is rare, we believe that it is important for the patient’s parents to understand the possibility and know of the signs and symptoms in addition to attending regular outpatient clinic appointments in order to facilitate early management if needed. Furthermore, it is highly important for physicians to assess newborns for hypospadias before carrying out circumcision as it is a contraindication for the procedure. 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F1000Research 2024, 13 :222 ( https://doi.org/10.12688/f1000research.148191.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] Ammar Kheyami https://orcid.org/0000-0003-2133-8564 1 , Abdulla AlMuharraqi https://orcid.org/0009-0003-0805-6172 2 , Mahmood Abbas 1 , A.K Singhal 1 Ammar Kheyami https://orcid.org/0000-0003-2133-8564 1 , Abdulla AlMuharraqi https://orcid.org/0009-0003-0805-6172 2 , Mahmood Abbas 1 , A.K Singhal 1 PUBLISHED 27 Mar 2024 Author details Author details 1 Pediatric Surgery, Ibn Alnafees Hospital, Manama, Bahrain 2 General Practice, Manama Medical Center, Manama, Bahrain Ammar Kheyami Roles: Conceptualization, Investigation, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abdulla AlMuharraqi Roles: Conceptualization, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Mahmood Abbas Roles: Conceptualization, Investigation, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing A.K Singhal Roles: Conceptualization, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Abstract* Introduction A urethral diverticulum can be defined as a pocket that forms from the lining of the urethra and protrudes into the surrounding tissue, a condition which causes voiding dysfunction and may result as a rare complication of hypospadias repair surgery. Case report We report the case of a 2-year-old child who presented to us in 2019 complaining of a thin forceful stream, ballooning of the ventral aspect of the penis while voiding, and post-void dribbling. He has a history of undergoing a tabularised incised plate urethroplasty for distal penile hypospadias at 18-months-old. Ultrasound showed increased post-void residual volume and cystourethroscopy confirmed a urethral diverticulum extending from the subcorona to the base of the penis. The patient underwent partial excision of diverticulum, urethroplasty, and meatoplasty. He was followed-up 3 months later with complete resolution of his symptoms and a normal urinary stream with no urethral ballooning or dribbling. Conclusion Urethral diverticulum may present as a complication post hypospadias repair. Although it is rare, we believe that it is important for the patient’s parents to understand the possibility and know of the signs and symptoms in addition to attending regular outpatient clinic appointments in order to facilitate early management if needed. Furthermore, it is highly important for physicians to assess newborns for hypospadias before carrying out circumcision as it is a contraindication for the procedure. READ ALL READ LESS Keywords Urethra, diverticulum, hypospadias, circumcision. Corresponding Author(s) Abdulla AlMuharraqi ( [email protected] ) Close Corresponding author: Abdulla AlMuharraqi Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Kheyami A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Kheyami A, AlMuharraqi A, Abbas M and Singhal AK. Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.12688/f1000research.148191.1 ) First published: 27 Mar 2024, 13 :222 ( https://doi.org/10.12688/f1000research.148191.1 ) Latest published: 28 Jun 2024, 13 :222 ( https://doi.org/10.12688/f1000research.148191.2 )  There is a newer version of this article available. Suppress this message for one day. Introduction Urethral diverticulum - an out-pouching of the urethra into surrounding tissues - is an important but uncommon complication of hypospadias repair. 1 Studies suggest that it comprises 0.3% of postoperative complications and is mainly associated with proximal hypospadias. 2 , 3 Factors predisposing to its formation include proximal defect, oversized neourethra, poorly supporting tissue covering urethroplasty, and distal urethral stricture. 2 , 3 We present a case of postoperative urethral diverticulum formation after distal hypospadias repair and discuss possible treatment options. Case report The child was one-month-old ( Figure 1 ) when referred to our centre in 2019 for review after undergoing Plastibell circumcision. On examination, he was circumcised with a hypospadiac meatus located at distal penile position ( Figure 2 ). Figure 1. A timeline of the patient’s presentations and the procedures he underwent. Figure 2. Ventral view of the penis (excessively circumcised with a distal penile patulous meatus). At 18 months of age, he underwent a tabularised incised plate urethroplasty at an external paediatric urology centre with an excellent outcome ( Figure 3 ). Figure 3. Ventral view of the penis after tabularised incised plate urethroplasty. One year later, he presented with typical signs and symptoms of a urethral diverticulum and meatal stenosis; thin forceful stream, ballooning of the ventral aspect of the penis during voiding, significant post-void dribbling, and need for manual emptying of the diverticulum ( Figure 4 ). Figure 4. Penis with urethral diverticulum. Ultrasound showed diffuse bladder wall thickening with significant post-void residual volume. Ascending urethrogram confirmed the diagnosis of meatal stenosis with proximal diverticulum ( Figure 5 ). Patient underwent cystourethroscopy which confirmed a diverticulum extending from the subcorona to the base of the penis. The diverticulum was opened through a ventral midline incision. A midline strip of 16 mm width of mucosa was preserved, and lateral mucosa was excised preserving the underlying dartos tissue ( Figure 6 ). Figure 5. Ascending urethrogram showing meatal narrowing (red arrow) and a proximal urethral diverticulum (yellow arrow). Figure 6. Ventral view of the penis during standard meatoplasty. The meatus was opened wider and stitches were taken at the margins. The urethroplasty was closed in two layers and was supported by double-breasted Dartos fascia. At the end of the procedure, standard meatoplasty was performed for meatal stenosis. Three months following repair, the child had a normal thick continuous stream with no post-void dribbling or ballooning of the urethra. Discussion Urethral diverticulum is an uncommon complication of hypospadias surgery which has several risk factors that could influence its incidence such as a large neourethra, inadequate supporting tissue post-urethroplasty, and a distal urethral stricture. 2 , 3 It can be diagnosed via clinical evaluation and confirmed with cystourethrography and cystoscopy. Partial excision of diverticulum and urethroplasty is an acceptable form of treatment for such cases, as the final aim is to restore a urethra with normal diameter and pressure that is also well supported with enough tissue and no distal obstruction. 2 , 4 In the presented case, the diagnosis of hypospadias was missed at birth and a circumcision was carried out though circumcision is contraindicated in these cases. This certainly requires more awareness since the repair of hypospadias in uncircumcised children is technically easier and has a better outcome. Additionally in this case, excessive circumcision resulted in a very wide meatus along with a severe deficiency in the ventral skin and the underlying supportive tissue which possibly complicated the repair and played an important role in the formation of the diverticulum. Meatal stenosis is another factor that predisposed to diverticulum formation in this child, and it was most likely a post-surgical complication as it can occur after any hypospadias surgery. Therefore, regular follow-up after hypospadias repair is of vital importance for early diagnosis and management of meatal stenosis. Conclusion Meatal stenosis and urethral diverticulum are amongst the possible complications of hypospadias repair. The repair of urethral diverticula is challenging, and the outcome depends on the creation of a well-supported and normal-sized urethra with no distal obstruction. Furthermore, parents should be educated about the signs and symptoms of meatal stenosis and the need for strict and regular follow-up to diagnose and manage any complication as early as possible. It is important to carefully examine the child for hypospadias before circumcision as it is contraindicated. Consent We discussed and explained to the patient’s father about the writing and publication of this case report. He had the opportunity to ask questions about everything related to this process, and understood that no identifying information related to the patient will be shared; Written informed consent for the publication of patient details and images was obtained from the patient’s father. Data availability All data underlying the results are available as part of the article and no additional source data are required. References 1. Crescenze IM, Goldman HB: Female Urethral Diverticulum: Current Diagnosis and Management. Curr. Urol. Rep. 2015; 16 : 71. PubMed Abstract | Publisher Full Text 2. Snodgrass W: Tubularized incised plate hypospadias repair: indications, technique, and complications. Urology. 1999; 54 : 6–11. PubMed Abstract | Publisher Full Text 3. Snyder CL, Evangelidis A, Snyder RP, et al. : Management of urethral diverticulum complicating hypospadias repair. J. Pediatr. Urol. 2005; 1 : 81–83. PubMed Abstract | Publisher Full Text 4. Bote SM, Gite VA, Siddiqui AK, et al. : Acquired male urethral diverticulum: Report of two cases. Arch. Int. Surg. 2016; 6 : 54–56. Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 27 Mar 2024 ADD YOUR COMMENT Comment Author details Author details 1 Pediatric Surgery, Ibn Alnafees Hospital, Manama, Bahrain 2 General Practice, Manama Medical Center, Manama, Bahrain Ammar Kheyami Roles: Conceptualization, Investigation, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abdulla AlMuharraqi Roles: Conceptualization, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Mahmood Abbas Roles: Conceptualization, Investigation, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing A.K Singhal Roles: Conceptualization, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 28 Jun 2024, 13:222 https://doi.org/10.12688/f1000research.148191.2 version 1 Published: 27 Mar 2024, 13:222 https://doi.org/10.12688/f1000research.148191.1 Copyright © 2024 Kheyami A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Kheyami A, AlMuharraqi A, Abbas M and Singhal AK. Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.12688/f1000research.148191.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 27 Mar 2024 Views 0 Cite How to cite this report: Zouari M. Reviewer Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.162472.r261657 ) The direct URL for this report is: https://f1000research.com/articles/13-222/v1#referee-response-261657 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 Apr 2024 Mohamed Zouari , University of Sfax, Sfax, Tunisia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.162472.r261657 Urethral diverticula can be congenital or acquired; the most common cause of an acquired diverticulum in children is previous hypospadias repair. The reported incidence of diverticula formation after hypospadias repair is 0–21% [Radojicic ZI, et. al., 2004 (Ref 1)]. Factors ... Continue reading READ ALL Urethral diverticula can be congenital or acquired; the most common cause of an acquired diverticulum in children is previous hypospadias repair. The reported incidence of diverticula formation after hypospadias repair is 0–21% [Radojicic ZI, et. al., 2004 (Ref 1)]. Factors increasing the risk of diverticula include a proximal defect, use of poorly supported tissue for interposition grafting (e.g. bladder mucosa or tubularized pedicle grafts), and the presence of a distal stricture resulting in relative obstruction/higher outlet pressures [Horton CE, et. al., 1998 (Ref 2), Snyder CL, et. al., 2005 (Ref 3)]. In this article, the authors reported the case of a urethral diverticulum in a 2-year-old child circumcised at the neonatal age. This diverticulum occurred after of distal hypospadias repair as a complication of the TIP-technique. Although the article is interesting and the illustrations attractive, I believe that there are two major problems that need to be corrected. The first problem concerns Figure 1, which clearly shows a mega-meatus with an intact penis. The authors need to clarify whether or not this was an accidental circumcision, and on what grounds this assumption was made. There are no signs of scarring or trauma to the penis. The penile folds are well-defined, showing that the penis has not been damaged. My second problem concerns the English language, which needs revision. For example, I can identify the word "TUBULARIZED" which is written in the article "TABULARISED" several times. Other sentences use non-technical words such as "ballooning of the ventral aspect of the penis". In conclusion, this article is interesting since it highlights an uncommon complication of TIP-uretroplasty in children. This complication could lead to therapeutic challenges, for which there is still no consensus on management. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Radojicic ZI, Perovic SV, Djordjevic ML, Vukadinovic VM, et al.: 'Pseudospongioplasty' in the repair of a urethral diverticulum. BJU Int . 2004; 94 (1): 126-30 PubMed Abstract | Publisher Full Text 2. Horton CE, Horton CE: Complications of hypospadias surgery. Clin Plast Surg . 1988; 15 (3): 371-9 PubMed Abstract 3. Snyder CL, Evangelidis A, Snyder RP, Ostlie DJ, et al.: Management of urethral diverticulum complicating hypospadias repair. J Pediatr Urol . 2005; 1 (2): 81-3 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pediatric surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Zouari M. Reviewer Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.162472.r261657 ) The direct URL for this report is: https://f1000research.com/articles/13-222/v1#referee-response-261657 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 28 Jun 2024 Abdulla AlMuharraqi , General Practice, Manama Medical Center, Manama, Bahrain 28 Jun 2024 Author Response Dear Dr. Mohamed, Thank you for your review and invaluable comments. Spelling corrections have been made as per your advice. In regards to your comment concerning Figure 1, ... Continue reading Dear Dr. Mohamed, Thank you for your review and invaluable comments. Spelling corrections have been made as per your advice. In regards to your comment concerning Figure 1, when we discussed the case with the General Practitioner who performed the circumcision, they explained that in their opinion it was a mild case of hypospadias and that the foreskin was intact. However, after the procedure the patient presented with the findings described in the manuscript. Kind regards, Dr. Abdulla Al-Muharraqi Dear Dr. Mohamed, Thank you for your review and invaluable comments. Spelling corrections have been made as per your advice. In regards to your comment concerning Figure 1, when we discussed the case with the General Practitioner who performed the circumcision, they explained that in their opinion it was a mild case of hypospadias and that the foreskin was intact. However, after the procedure the patient presented with the findings described in the manuscript. Kind regards, Dr. Abdulla Al-Muharraqi Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 28 Jun 2024 Abdulla AlMuharraqi , General Practice, Manama Medical Center, Manama, Bahrain 28 Jun 2024 Author Response Dear Dr. Mohamed, Thank you for your review and invaluable comments. Spelling corrections have been made as per your advice. In regards to your comment concerning Figure 1, ... Continue reading Dear Dr. Mohamed, Thank you for your review and invaluable comments. Spelling corrections have been made as per your advice. In regards to your comment concerning Figure 1, when we discussed the case with the General Practitioner who performed the circumcision, they explained that in their opinion it was a mild case of hypospadias and that the foreskin was intact. However, after the procedure the patient presented with the findings described in the manuscript. Kind regards, Dr. Abdulla Al-Muharraqi Dear Dr. Mohamed, Thank you for your review and invaluable comments. Spelling corrections have been made as per your advice. In regards to your comment concerning Figure 1, when we discussed the case with the General Practitioner who performed the circumcision, they explained that in their opinion it was a mild case of hypospadias and that the foreskin was intact. However, after the procedure the patient presented with the findings described in the manuscript. Kind regards, Dr. Abdulla Al-Muharraqi Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Wirmer J. Reviewer Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.162472.r261654 ) The direct URL for this report is: https://f1000research.com/articles/13-222/v1#referee-response-261654 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 05 Apr 2024 Johannes Wirmer , Sana Klinikum, Offenbach, Germany Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.162472.r261654 The Report describes a case of urethral diverticulum after tubularized-inzised plate repair (TIP) of a distal Hypospadias. The Hypospadias repair was performed at the age of 18 month, but had a circumcision as a newborn. From the picture taken before ... Continue reading READ ALL The Report describes a case of urethral diverticulum after tubularized-inzised plate repair (TIP) of a distal Hypospadias. The Hypospadias repair was performed at the age of 18 month, but had a circumcision as a newborn. From the picture taken before the hypospadias repair, he most likely had a MIP-Hypospadias (megameatus intact prepuce). The here described developement of an urethral diverticulum after repair of distal hypospadias is an important complication of the TIP-technique. Even though it has been described before ( Lee H, et al., 2006) [Ref 1], the common assumption is still that it mainly occurs after flap urethroplasty. This article is an important contribution to drawing attention to the complications of tip correction. Small suggestions for corrections would be: Title: Case Report: Urethral Diverticulum after TIP-Repair of distal hypospadias: a not so uncommon complication In addition, tabularized incised plate urethroplasty is mentioned several times throughout the text, where it should correctly be called TUBULARIZED plate urethroplasty. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Lee H, Han S: Surgical Correction of Post-hypospadias Repair Urethral Diverticulum and Stricture using Rotational Flap. Korean Journal of Urology . 2006; 47 (11). Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Hypospadiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Wirmer J. Reviewer Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.162472.r261654 ) The direct URL for this report is: https://f1000research.com/articles/13-222/v1#referee-response-261654 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 28 Jun 2024 Abdulla AlMuharraqi , General Practice, Manama Medical Center, Manama, Bahrain 28 Jun 2024 Author Response Dear Dr. Johannes, Thank you for your review and invaluable comments. Changes have been made as per your suggestions. Kind regards, Dr. Abdulla Al-Muharraqi Competing Interests: No competing interests were disclosed. Dear Dr. Johannes, Thank you for your review and invaluable comments. Changes have been made as per your suggestions. Kind regards, Dr. Abdulla Al-Muharraqi Dear Dr. Johannes, Thank you for your review and invaluable comments. Changes have been made as per your suggestions. Kind regards, Dr. Abdulla Al-Muharraqi Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 28 Jun 2024 Abdulla AlMuharraqi , General Practice, Manama Medical Center, Manama, Bahrain 28 Jun 2024 Author Response Dear Dr. Johannes, Thank you for your review and invaluable comments. Changes have been made as per your suggestions. Kind regards, Dr. Abdulla Al-Muharraqi Competing Interests: No competing interests were disclosed. Dear Dr. Johannes, Thank you for your review and invaluable comments. Changes have been made as per your suggestions. Kind regards, Dr. Abdulla Al-Muharraqi Dear Dr. Johannes, Thank you for your review and invaluable comments. Changes have been made as per your suggestions. Kind regards, Dr. Abdulla Al-Muharraqi Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 27 Mar 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 28 Jun 24 read read Version 1 27 Mar 24 read read Johannes Wirmer , Sana Klinikum, Offenbach, Germany Mohamed Zouari , University of Sfax, Sfax, Tunisia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Zouari M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 08 Jul 2024 | for Version 2 Mohamed Zouari , University of Sfax, Sfax, Tunisia 0 Views copyright © 2024 Zouari M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors reported a case of postoperative urethral diverticulum following distal hypospadias repair in a child and discussed treatment options of this rare condition. The authors have responded to all comments and made the required corrections. I recommend accepting the manuscript for indexing in its present form. Competing Interests No competing interests were disclosed. Reviewer Expertise Pediatric surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Zouari M. Peer Review Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.168132.r296925) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-222/v2#referee-response-296925 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Wirmer J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 04 Jul 2024 | for Version 2 Johannes Wirmer , Sana Klinikum, Offenbach, Germany 0 Views copyright © 2024 Wirmer J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have no further suggestions Competing Interests No competing interests were disclosed. Reviewer Expertise Hypospadiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Wirmer J. Peer Review Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.168132.r296926) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-222/v2#referee-response-296926 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Zouari M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Apr 2024 | for Version 1 Mohamed Zouari , University of Sfax, Sfax, Tunisia 0 Views copyright © 2024 Zouari M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Urethral diverticula can be congenital or acquired; the most common cause of an acquired diverticulum in children is previous hypospadias repair. The reported incidence of diverticula formation after hypospadias repair is 0–21% [Radojicic ZI, et. al., 2004 (Ref 1)]. Factors increasing the risk of diverticula include a proximal defect, use of poorly supported tissue for interposition grafting (e.g. bladder mucosa or tubularized pedicle grafts), and the presence of a distal stricture resulting in relative obstruction/higher outlet pressures [Horton CE, et. al., 1998 (Ref 2), Snyder CL, et. al., 2005 (Ref 3)]. In this article, the authors reported the case of a urethral diverticulum in a 2-year-old child circumcised at the neonatal age. This diverticulum occurred after of distal hypospadias repair as a complication of the TIP-technique. Although the article is interesting and the illustrations attractive, I believe that there are two major problems that need to be corrected. The first problem concerns Figure 1, which clearly shows a mega-meatus with an intact penis. The authors need to clarify whether or not this was an accidental circumcision, and on what grounds this assumption was made. There are no signs of scarring or trauma to the penis. The penile folds are well-defined, showing that the penis has not been damaged. My second problem concerns the English language, which needs revision. For example, I can identify the word "TUBULARIZED" which is written in the article "TABULARISED" several times. Other sentences use non-technical words such as "ballooning of the ventral aspect of the penis". In conclusion, this article is interesting since it highlights an uncommon complication of TIP-uretroplasty in children. This complication could lead to therapeutic challenges, for which there is still no consensus on management. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Radojicic ZI, Perovic SV, Djordjevic ML, Vukadinovic VM, et al.: 'Pseudospongioplasty' in the repair of a urethral diverticulum. BJU Int . 2004; 94 (1): 126-30 PubMed Abstract | Publisher Full Text 2. Horton CE, Horton CE: Complications of hypospadias surgery. Clin Plast Surg . 1988; 15 (3): 371-9 PubMed Abstract 3. Snyder CL, Evangelidis A, Snyder RP, Ostlie DJ, et al.: Management of urethral diverticulum complicating hypospadias repair. J Pediatr Urol . 2005; 1 (2): 81-3 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Pediatric surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 28 Jun 2024 Abdulla AlMuharraqi, General Practice, Manama Medical Center, Manama, Bahrain Dear Dr. Mohamed, Thank you for your review and invaluable comments. Spelling corrections have been made as per your advice. In regards to your comment concerning Figure 1, when we discussed the case with the General Practitioner who performed the circumcision, they explained that in their opinion it was a mild case of hypospadias and that the foreskin was intact. However, after the procedure the patient presented with the findings described in the manuscript. Kind regards, Dr. Abdulla Al-Muharraqi View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Zouari M. Peer Review Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.162472.r261657) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-222/v1#referee-response-261657 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Wirmer J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 05 Apr 2024 | for Version 1 Johannes Wirmer , Sana Klinikum, Offenbach, Germany 0 Views copyright © 2024 Wirmer J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The Report describes a case of urethral diverticulum after tubularized-inzised plate repair (TIP) of a distal Hypospadias. The Hypospadias repair was performed at the age of 18 month, but had a circumcision as a newborn. From the picture taken before the hypospadias repair, he most likely had a MIP-Hypospadias (megameatus intact prepuce). The here described developement of an urethral diverticulum after repair of distal hypospadias is an important complication of the TIP-technique. Even though it has been described before ( Lee H, et al., 2006) [Ref 1], the common assumption is still that it mainly occurs after flap urethroplasty. This article is an important contribution to drawing attention to the complications of tip correction. Small suggestions for corrections would be: Title: Case Report: Urethral Diverticulum after TIP-Repair of distal hypospadias: a not so uncommon complication In addition, tabularized incised plate urethroplasty is mentioned several times throughout the text, where it should correctly be called TUBULARIZED plate urethroplasty. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Lee H, Han S: Surgical Correction of Post-hypospadias Repair Urethral Diverticulum and Stricture using Rotational Flap. Korean Journal of Urology . 2006; 47 (11). Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Hypospadiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 28 Jun 2024 Abdulla AlMuharraqi, General Practice, Manama Medical Center, Manama, Bahrain Dear Dr. Johannes, Thank you for your review and invaluable comments. Changes have been made as per your suggestions. Kind regards, Dr. Abdulla Al-Muharraqi View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Wirmer J. Peer Review Report For: Case Report: Urethral Diverticulum after Distal Hypospadias Repair: An Uncommon Complication. [version 1; peer review: 2 approved with reservations] . F1000Research 2024, 13 :222 ( https://doi.org/10.5256/f1000research.162472.r261654) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-222/v1#referee-response-261654 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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