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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 28-32

Hypospadias: 10 year review of outcome of treatment in pediatric urological practice


Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria

Date of Submission08-Sep-2014
Date of Acceptance18-Nov-2014
Date of Web Publication17-Feb-2015

Correspondence Address:
Ahmad Bello
Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna
Nigeria
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DOI: 10.4103/2384-5147.151571

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  Abstract 

Introduction: Hypospadias and its surgical correction is a challenging urologic discipline. Various surgical procedures for correction of this anomaly have evolved, in order to reduce complication rate and improve cosmetic outcome. The aim of this study is to review the complication rate and cosmetic outcome in patients who had hypospadias surgery at Ahmadu Bello University Teaching Hospital, Zaria. Patients and Methods: The case records and clinical appearance of 54 patients with hypospadias who had surgery between June1998 and June 2008 were reviewed. The effect of different variables on the overall complication rates were evaluated, including: the degree of chordee; the urethral meatal site after correction of any penile curvature; the age of the patient at surgery; the source of the neourethra; and tubularization of the flap. Result: The mean age of the patients was 1.97 (0.5-12) years. Most patients had their repair at 2 years of age. Twenty-six had distal hypospadias while twenty-eight were mid penile or proximal hypospadias. Distal hypospadias have a better outcome than proximal hypospadias. Onlay flaps have lower stricture and fistula compared with tubularized flaps. Repairs are done recently at earlier age with equal or better outcome. Conclusion: Skin flap procedures have had sufficiently extensive use to support the feasibility of a one-stage repair of different types of hypospadias. Snodgrass is gaining popularity in recent times, and more procedures are likely to evolve in order to improve cosmetic outcome.

Keywords: Complications, cosmetic outcome, hypospadias, surgery


How to cite this article:
Bello A, Hussaini MY, Kura MM, Muhammed A, Tijjani LA. Hypospadias: 10 year review of outcome of treatment in pediatric urological practice. Sub-Saharan Afr J Med 2015;2:28-32

How to cite this URL:
Bello A, Hussaini MY, Kura MM, Muhammed A, Tijjani LA. Hypospadias: 10 year review of outcome of treatment in pediatric urological practice. Sub-Saharan Afr J Med [serial online] 2015 [cited 2019 Oct 17];2:28-32. Available from: http://www.ssajm.org/text.asp?2015/2/1/28/151571


  Introduction Top


Hypospadias and its surgical correction was first described by Heliodor and Antyl (first, second and third centuries AD). [1] Various surgical procedures for correction of this anomaly have evolved, in order to reduce complication rate and improve cosmetic outcome. [2] Perhaps no surgical concern in history has inspired such widespread and varied opinion about management as has hypospadias surgery. Complications of hypospadias repair include bleeding/hematoma, meatal stenosis, urethrocutaneous fistula, urethral stricture, urethral diverticulum, wound infection, impaired healing, and breakdown of the repair. [3] When reoperation is indicated, complications such as meatal stenosis, urethrocutaneous fistula, and urethral stricture can be repaired expeditiously, with appropriate timing. However, more serious complications involving either partial or complete breakdown of the hypospadias repair may require a major reconstructive effort. The complication rate and cosmetic outcome are reviewed in these patients who had surgery for hypospadias in division of urology, Ahmadu Bello University teaching hospital Zaria.


  Patients and methods Top


The case records and clinical appearance of 54 patients with hypospadias who had surgery between June 1998 and June 2008 were reviewed. The preoperative characteristics, complication and cosmetic outcome were noted. The location of the meatus was noted from intraoperative records of the patients. Distal hypospadias were repaired by Denise Browne urethroplasty, Mathieu meatal-based flap or Snodgrass tubularized incised plate urethroplasty. Proximal hypospadias were repaired by inner preputial transverse island flap (Ducketts Jnr) alone or in combination with Snodgrass urethroplasty.

Any chordee was corrected by degloving the penis and ventral dissection carried out around or beneath the urethral plate. Adequate straightening was tested by artificial erection. Some patients had division of the urethral plate and dorsal plication of the tunica albuginea. Two patients had two-staged urethroplasty. The preoperative characteristics are as shown in [Table 1]. The neourethra was reconstructed over a stent of suitable diameter using full-thickness inverting sutures. Glanuloplasty and meatoplasty were performed to bring the meatus to the tip of the glans penis by either creating a subglanular tunnel or splitting and fashioning glanular triangular wings. The neourethra was covered by skin from the penile shaft; when there was insufficient skin, Byar's preputial flaps, and recently mucosal collars, were used. Polyglactin 5/0 and 6/0 sutures were used for the neourethra while 4/0 polyglactin rapid sutures were used for skin closure.
Table 1: The preoperative characteristic of 54 patients that had hypospadias repairs

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In general, hemostasis was achieved mainly via a penile tourniquet. Edema was minimized by gentle tissue handling and by using stay sutures whenever required to avoid direct crushing of the tissue. The neourethra was routinely stented for 7-14 days. Urinary diversion was obtained by a soft urethral tube fixed to the glans with a suture or by a suprapubic catheter. Broad spectrum antibiotics, analgesics, and sedatives were administered to prevent infection, pain, bladder spasm and erections. A semi-concealed dressing was used. Patients were regularly followed: The protocol included questioning the parents, a clinical examination, calibration of the neourethral meatus, urine culture. Ascending urethrography was carried out when indicated. The outcome was evaluated by assessing the anatomical, functional and cosmetic results [Figure 1]. An excellent result was defined as a cosmetically and anatomically normal-looking penis able to direct a forceful urinary stream. A complication is defined as anatomical, functional or cosmetic outcome that require surgical intervention. A minor defect that would require no further management was considered a satisfactory outcome. The management was considered to have failed when there was a complication that required complete reconstruction.
Figure 1: (a) Perineal hypospadias with severe chordee, (b) first stage urethroplasty, (c) post second stage urethtroplasty, (d) subcoronal hypospadias without chordee, (e) post single stage urethroplasty (immediate postoperative) (f) postoperative outcome 3 months after surgery

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The effect of different variables on the overall complication rates were evaluated, including: The degree of chordee, that is, none or mild (corrected by skin release only) versus moderate to severe; the urethral meatal site after correction of any penile curvature, that is, distal (coronal, subcoronal or anterior penile) vs proximal (mid, posterior or penoscrotal); the age of the patient at surgery (<2 years vs. >2 years); the source of the neourethra, that is, meatal-based (Mathieu and vs. preputial island [onlay and Duckett] flaps; and tubularization of the flap, that is, not tubularized (Mathieu and Onlay) versus tubularized Duckett. The onlay flap procedure was also compared with Mathieu's, and with Duckett's repair. The Chi-square test was used to assess differences and they were considered statistically significant at P = 0.05.


  Result Top


Fifty-four patients records were analyzed. The mean age of the patients was 1.97 (0.5-12) years. Most patients had their repair at 2 years of age. Twenty-six had subcoronal hypospadias, six were penile, and sixteen penoscrotal and four were perineal. Twenty-six single-stage procedures for distal penile or coronal hypospadias without chordee were performed. Fourteen were Meatal Advancement Glanuloplasty (MAGPI) or Mathieu procedures. Twenty-eight patients had mid penile or proximal hypospadias and were repaired by transverse preputial onlay urethroplasty, Snodgrass or Duckett's procedure. Ten had combined Snodgrass and Duckett's urethroplasty. Fourteen patients had moderate to severe chordee. Four MAGPI were performed, and the results were satisfactory with no major complications. The only consistent problem was a redundancy of the ventral skin due to a reluctance to sacrifice enough of the prepuce.

At a mean (range) follow-up of 12 (6-32) months, the initial outcome was excellent in 38 (67%), satisfactory in 11 (10%) and complicated in 18 (20%) procedures. Patients with the satisfactory results had meatal retraction, meatal puckering or skin redundancy. The complications include fistulae in 5 (9.3%) patients, meatal stenosis in 4 (7.4%) patients, urethral strictures in 3 (5.6%) patients, residual chordee in 4 (7.3%) patients. Tubal abnormalities in 2 (3.7%) (One diverticulum and one urethral kink) and flap necrosis in 2 (3.7%). Most of the strictures and all the tubal abnormalities occurred after Duckett repairs. Of the 18 that developed complications 14 (25.9%) were corrected surgically while four were considered failures and will require reconstruction. This improved the success rate to 92%. The complications are shown in [Table 2] and the method of management in [Table 3].
Table 2: The postoperative characteristic and cosmetic outcome of 54 patients that had hypospadias repairs

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Table 3: Methods of managing complications

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[Table 4] shows the effect of different variables on the outcome. The age of the patient at time of repair had no significant effect, but the complications were more in patients with proximal hypospadias and in those where the urethral plate was transected. Meatal-based flaps had a lower complication than preputial flaps. However, there was no significant difference in complication rates between onlay and mathieu repairs. The rate of urethrocutaneous fistulae was significantly higher in Mathieu compared to onlay procedures. There was a higher tendency to perform Duckett's repair in proximal hypospadias and in those with severe chordee. The complication rate was higher after Duckett's repair 30% than the onlay procedure 8%. Similarly the incidence of meatal stenosis, fistulae, strictures and tubal abnormalities were significantly higher after Duckett than after onlay procedure. No difference in the occurrence of flap necrosis between the two types of repair. The Snodgrass procedure had the lowest fistulae rate as a complication rate when compared to Denise brown, onlay and Duckett's procedures but no significant difference in rate of stricture occurrence. The overall cosmetic appearance was better in distal hypospadias (88%) compared with penile (74%) and perineal (55%) hypospadias. The overall appearance was excellent (100%) in the staged procedures.
Table 4: Impact of different factors on the complication rates

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  Discussion Top


Hypospadias surgery has developed so that the present standard of care is to undertake outpatient surgery in most patients. [4],[5] The expected treatment is to produce a normal-looking penis, with the meatus at the tip, in a one-stage operation in 80-90% of patients with hypospadias. Historically, the outcome of hypospadias repair has been assessed by the need for reoperation (typically for fistula, stenosis, diverticulum and bleeding). The goal of the present study is to assess the outcome not only on the complication rate but also in terms of the cosmetic appearance. The present series of 52 one-stage repairs of different types of mild to severe hypospadias confirms that this technique is reliable and durable in achieving the current goals of treatment. Compared with a recent series of two-stage repairs, where the success rate was 78-86%, [6] the current technique, with a final success rate of 92% at a mean of 1.3 surgical procedures, can be used safely even in cases of severe hypospadias, offering potentially lower costs and less psychological anxiety. In contrast to free skin grafts, that had complication rates of up to 69%, [7],[8] the initial success rate of skin flaps repairs in this study was 76%. This is similar to what was reported by others [9],[10] that whenever possible skin flaps are better than free graft. The success largely depends on the length of the flap in relation to the volume of the vascular pedicle.

In patients with proximal hypospadias with severe chordee, the urethral plate was transected. However, recent work [11],[12] showed that the urethral plate contribute little to penile curvature. In patients who had a transaction of the urethral plate, the neourethra loses its stability, and they may develop complications such as urethral diverticulum, malalighnment and stricture at anastomotic site. [13],[14] The meatal-based flaps have no defined pedicle [15],[16] compared to preputial flaps but in this study they appeared to be more successful than preputial flaps. This could as a result of tubularization in most of the preputial flaps. However this is a retrospective study, thus the conclusion could not be easily drawn, there is a need of randomization to eliminate or reduce selection bias.

It appears that there was an obvious indication to perform the onlay procedure in more severe types of hypospadias but the Mathieu procedure had a higher complication rate, indicating that the onlay procedure is more applicable for the repair of different types of hypospadias, and with a more reliable outcome. In the current series, the tubularized form of the Duckett's flap resulted in a significantly higher complication rate than the onlay repair. Although there was a tendency to perform Duckett's repair in cases with more severe chordee, with increasing experience even severe curvatures could be corrected by dissection beneath the urethral plate, with no transection. [2] As in the present results, others noted fewer complications after onlay repair, which has led to an increasing preference for onlay over tubularized repair, [13],[14]

In this study all patients had assessment of the cosmetic appearance some had in addition had photography before the surgery, immediately after and at 3-6 months after surgery.

There are few reports that documented the outcome based on the appearance of the penis after surgery. [17],[18] Photographic analysis may be used for an unbiased assessment of the outcome of the reconstruction. As hypospadias surgery becomes more refined, it is critical that the outcome is defined more accurately and objectively. The photographs/clinical appearance can be scores using four criteria that is, overall appearance, mucosal collar, and meatal location and configuration; other variables could also be evaluated. [17],[18] The mucosal collar is a well-established standard in hypospadias surgery, with the goal being to recreate the appearance of a circumcised penis. [19],[20] The location of meatus is also a standard that is well established as an outcome variable in hypospadias surgery. Historically, it was acceptable to have the meatus on the distal aspect of the penis. [21] Presently, the norm is a terminal meatus on the ventral-distal aspect of the glans. The configuration of the meatus can also be assessed critically, with a normal penis having slit like meatus after the surgery [Figure 1]. The cosmetic outcome is better in the staged procedure 98% and least in the patient with perineal hypospadias 62%.


  Conclusion Top


Skin flap procedures have had sufficiently extensive use to support the feasibility of a one-stage repair of different types of hypospadias. In this study, and in comparison with Mathieu's repair, the onlay island preputial flap has a wider applicability in different types of hypospadias, including those with distal urethral hypoplasia or with chordee, with no increased risk of complications.

In addition, the onlay island preputial flap anastomosed to an intact urethral plate has a better outcome than the Duckett's tubularized preputial flap with transection of the urethral plate. This improved outcome is obtained.

 
  References Top

1.
Hauben DJ. The history of hypospadias. Acta Chir Plast 1984;26:196-9.  Back to cited text no. 1
[PUBMED]    
2.
Ghali AM. Hypospadias repair by skin flaps: A comparison of onlay preputial island flaps with either Mathieu's meatal-based or Duckett's tubularized preputial flaps. BJU Int 1999;83:1032-8.  Back to cited text no. 2
    
3.
Duckett JW Jr, Kaplan GW, Woodard JR, Devine CJ Jr. Panel: Complications of hypospadias repair. Urol Clin North Am 1980;7:443-54.  Back to cited text no. 3
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4.
Baskin LS. Hypospadias and urethral development. J Urol 2000;163:951-6.  Back to cited text no. 4
    
5.
Duckett J, Baskin L. Hypospadias. In: Gillenwater J, Grayhack J, Howards S, Duckett J, editors. Adult and Paediatrics Urology. St Louis: Mosby; 1996.  Back to cited text no. 5
    
6.
Bracka A. A versatile two-stage hypospadias repair. Br J Plast Surg 1995;48:345-52.  Back to cited text no. 6
    
7.
Redman JF. Experience with 60 consecutive hypospadias repairs using the Horton-Devine techniques. J Urol 1983;129:115-8.  Back to cited text no. 7
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8.
Woodard JR, Cleveland R. Application of Horton-Devine principles to the repair of hypospadias. J Urol 1982;127:1155-8.  Back to cited text no. 8
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9.
Barraza MA, Roth DR, Terry WJ, Livne PM, Gonzales ET Jr. One-stage reconstruction of moderately severe hypospadias. J Urol 1987;137:714-5.  Back to cited text no. 9
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10.
Duckett JW. The current hype in hypospadiology. Br J Urol 1995;76 Suppl 3:1-7.  Back to cited text no. 10
    
11.
Hollowell JG, Keating MA, Snyder HM 3 rd , Duckett JW. Preservation of the urethral plate in hypospadias repair: Extended applications and further experience with the onlay island flap urethroplasty. J Urol 1990;143:98-100.  Back to cited text no. 11
    
12.
Mollard P, Castagnola C. Hypospadias: The release of chordee without dividing the urethral plate and onlay island flap (92 cases). J Urol 1994;152:1238-40.  Back to cited text no. 12
    
13.
Wiener JS, Sutherland RW, Roth DR, Gonzales ET Jr. Comparison of onlay and tubularized island flaps of inner preputial skin for the repair of proximal hypospadias. J Urol 1997;158:1172-4.  Back to cited text no. 13
    
14.
Mouriquand PD, Persad R, Sharma S. Hypospadias repair: Current principles and procedures. Br J Urol 1995;76 Suppl 3:9-22.  Back to cited text no. 14
    
15.
Duckett JW. Hypospadias. In: Walsh PC, Retick AB, Stamey TA, Vaughan ED, editors. Campbell's Urology. 6 th ed. Philadelphia: Saunders; 1992. p. 1893-910.  Back to cited text no. 15
    
16.
Duckett JW, Snow BW. Hypospadias repair. In: Mundy AR, editor. Urology. Current Operative Surgery. London: Bailliere Tindall, Saunders; 1988. p. 119-39.  Back to cited text no. 16
    
17.
Baskin L. Hypospadias: A critical analysis of cosmetic outcomes using photography. BJU Int 2001;87:534-9.  Back to cited text no. 17
    
18.
van der Toorn F, de Jong TP, de Gier RP, Callewaert PR, van der Horst EH, Steffens MG, et al. Introducing the HOPE (Hypospadias Objective Penile Evaluation)-score: A validation study of an objective scoring system for evaluating cosmetic appearance in hypospadias patients. J Pediatr Urol 2013;9:1006-16.  Back to cited text no. 18
    
19.
Firlit CF. The mucosal collar in hypospadias surgery. J Urol 1987;137:80-2.  Back to cited text no. 19
[PUBMED]    
20.
Weber DM, Landolt MA, Gobet R, Kalisch M, Greeff NK. The Penile Perception Score: An instrument enabling evaluation by surgeons and patient self-assessment after hypospadias repair. J Urol 2013;189:189-93.  Back to cited text no. 20
    
21.
Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.  Back to cited text no. 21
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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