Hypospadiology: science and surgery

Hypospadias repair during adulthood: Case series

Purpose

We report our complications and success rate in adult hypospadias repair.

Patients and Methods

This was a retrospective study of patients aged ≥17 years who underwent hypospadias repair during 2006-2014. We analyzed two groups, one with primary repair and the other that had secondary repair after failed childhood hypospadias surgery. Outcome was compared between the two groups and among different surgical procedures. Descriptive statistics and Fisher's exact test were used and significance level was set at P < 0.05.

Results

Forty patients were included, of which 26 presented for a secondary repair and 14 for primary repair. The meatus was distal in 15 patients, mid-penile in 16, and penoscrotal in 9. The median age of patients at the time of surgery was 21 years (standard deviation [SD] =4, range 17-30). The median follow-up period was 37 months (SD = 8, range 5-75). In the primary repair group, the success rate was 71% (10/14), whereas in the secondary repair group, the success rate was 55% (14/26). The overall complication rate was 60%. Following a subsequent repair, the overall success rate reached 95% (38/40). There was no significant difference in success or complications between patients who presented with primary or secondary hypospadias or between methods of repair.

Conclusion

Delayed hypospadias repair in adults is associated with a high success rate of 95% with no difference between primary and secondary repair. Secondary repair however may require more than one procedure most of the time.

Comparison of variables affecting the surgical outcomes of tubularized incised plate urethroplasty in adult and pediatric hypospadias

INTRODUCTION

The American Academy of Pediatrics recommends operating on hypospadias between the ages of 6-12 months. Since most births in developed countries are conducted in a hospital, parents are likely to be well informed and counseled about the hypospadias. However, significant numbers of births in developing countries are still conducted at home, with illiteracy, poverty and ignorance often leading to late presentation at the hospital. Reported hypospadias-repair complication rates are higher in adults compared with those having surgery in childhood. The present study's objective was to evaluate the factors affecting surgical outcome in hypospadias patients undergoing tubularized and tubularized incised plate urethroplasty (TIPU) in adulthood compared with childhood.

MATERIALS AND METHODS

A prospective study of 60 adult patients >16 years, and 60 pediatric patients <5 years who underwent TIPU for primary hypospadias between May 2008 and May 2012. Patients were operated on by a single surgeon, under similar circumstances, and were pre-operatively examined to assess meatal location, chordee, and torsion; they were also examined intra-operatively for quality of spongiosum and urethral plate width. The outcomes were assessed by patient/parents for satisfaction regarding cosmesis, urinary stream and complications.

RESULTS

The age of the patients varied from 16 to 27 years, with a mean of 20.8 years in adults, and 6 months to 5 years, with a mean of 2.1 years, in children. The type of hypospadias, degree of curvature, quality of spongiosum and urethral plate width were comparable in both groups, but complication rates were higher in adults (16.7%) than in the pediatric (6.7%) group (Figure 1A-D). Meatal stenosis responded well to dilatation, but fistulae required revision surgery and had a cure rate of 100%. The median follow-up was 37 months in adults, and 39 months in children.

DISCUSSION

The higher complication rates in adults may be due to more frequent erections; increased susceptibility to infection along with relatively reduced vascularity lead to poor wound healing and increased complication rates. The limitation of the study was the small number of patients with mid and proximal hypospadias having lesser incidences in comparison with distal hypospadias. Adequate number of patients in these subgroups could have further strengthened the statistical correlation. Secondly, there was no objective criterion like uroflowmetry to assess urinary stream.

CONCLUSIONS

Complication rates were higher in adults undergoing TIPU compared with pediatric patients, which was also statistically significant in distal hypospadias. The important factors in surgical outcome were: severity of hypospadias, degree of curvature, quality of spongiosum, and urethral plate width.

Introducing the HOPE (Hypospadias Objective Penile Evaluation)-score: a validation study of an objective scoring system for evaluating cosmetic appearance in hypospadias patients

OBJECTIVE

To determine the reliability and internal validity of the Hypospadias Objective Penile Evaluation (HOPE)-score, a newly developed scoring system assessing the cosmetic outcome in hypospadias.

PATIENTS AND METHODS

The HOPE scoring system incorporates all surgically-correctable items: position of meatus, shape of meatus, shape of glans, shape of penile skin and penile axis. Objectivity was established with standardized photographs, anonymously coded patients, independent assessment by a panel, standards for a "normal" penile appearance, reference pictures and assessment of the degree of abnormality. A panel of 13 pediatric urologists completed 2 questionnaires, each consisting of 45 series of photographs, at an interval of at least 1 week. The inter-observer reliability, intra-observer reliability and internal validity were analyzed.

RESULTS

The correlation coefficients for the HOPE-score were as follows: intra-observer reliability 0.817, inter-observer reliability 0.790, "non-parametric" internal validity 0.849 and "parametric" internal validity 0.842. These values reflect good reproducibility, sufficient agreement among observers and a valid measurement of differences and similarities in cosmetic appearance.

CONCLUSIONS

The HOPE-score is the first scoring system that fulfills the criteria of a valid measurement tool: objectivity, reliability and validity. These favorable properties support its use as an objective outcome measure of the cosmetic result after hypospadias surgery.

Staged buccal mucosa urethroplasty in reoperative hypospadias

Introduction:

Repeated attempts at surgical repair of serious complications involving either the partial or complete breakdown of the hypospadias repair are less likely to succeed because the penis is densely scarred, or significantly shortened, and the skin over the penis is immobile and hypovascular. Buccal mucosa (BM) has become the preferred material for reconstruction, whenever a child with skin-deficient hypospadias needs reoperation. We report the results of our surgical experience with staged reoperation using BM, in the repair of hypospadias in children with complications after multiple failed repairs.

Materials and Methods:

Children needing reoperation for hypospadias underwent a staged repair using buccal mucosa. The complications were noted.

Results:

Twenty-one children aged 3 – 16 years underwent this staged repair during the period May 2000 – April 2010. Two of these 21 children had a failed first stage. One child developed a urethro-cutaneous fistula following the second stage, which was corrected in an additional stage.

Conclusions:

The use of the buccal mucosa graft for urethral reconstruction in a child with hypospadias, needing a reoperation, is a successful method, with a low incidence of complications.

Placental insufficiency in early gestation is associated with hypospadias

BACKGROUND AND PURPOSE

The association of growth retardation and hypospadias is well established. Fetal testosterone secretion is under the influence of placental human chorionic gonadotropin during first 14 weeks of gestation. We hypothesized that placental insufficiency may disrupt the supply of nutrients and human chorionic gonadotropin to the fetus leading to both growth retardation and hypospadias. To validate this hypothesis, we analyzed extremely low-birth-weight male infants with or without hypospadias for fetal growth parameters.

MATERIALS AND METHODS

One hundred four male newborn infants with birth body weight of less than 1500 g admitted to a neonatal intensive care unit over a 4-year period were retrospectively reviewed, recording the presence and type of hypospadias, fetal growth parameters, infant growth parameters at birth, placental weight, placental histopathology, cord information, and maternal morbidity. These data of patients with hypospadias were compared with those of controls.

RESULTS

Of the 104 extremely to very low-birth-weight male infants, 16 (15.3%) had hypospadias, and 10 (62.5%) of those had severe proximal hypospadias. Sixty-two controls who did not have hypospadias and whose body weight was less than 1500 g were identified. The incidence of hypospadias in full-term male birth in the hospital was 12 (0.30%) in 3959 births. Birth body weight and their SD for gestational age were lower in patients with hypospadias compared with those for controls (824 +/- 160 vs 1255 +/- 145 g). Placenta-to-fetal ratio (0.323 +/- 0.07 vs 0.229 +/- 0.03) and gestational age were significantly higher in the patients with hypospadias. Histopathologic study of the maternal placenta obtained from the patients with hypospadias revealed pronounced degenerative changes, infarction, and calcification, whereas these abnormalities were rare in controls.

CONCLUSIONS

The significant association between the occurrence of hypospadias and early growth retardation with higher placenta-to-fetal ratio and placental abnormalities suggest that placental dysfunction in early gestation may play an important role in the development of hypospadias.

Home dressing removal following hypospadias repair

Hypospadias is a common congenital abnormality that is increasing in incidence. There are many articles describing different surgical techniques and the merits of different dressings following hypospadias surgery. This article describes postoperative nursing management in collaboration with each family following surgery. Listening to the wishes of parents identified ways in which improvements could be made to the patient journey. The involvement of parents in decision-making has been at the heart of developments in the care of boys who have hypospadias repair. A review of nursing care in combination with partnerships with paediatric community nursing teams has enabled the additional benefit of developing a home dressing removal service following hypospadias repair.

Abnormal urine flow in boys with distal hypospadias before and after correction

PURPOSE

We established the urine flow rate and the effect of surgical correction on that rate in patients with hypospadias.

MATERIALS AND METHODS

The urine flow rate, voided volume and residual urine were measured using an ultrasound flow probe and bladder scan in boys with distal hypospadias before operative correction in 42 with a mean age of 16 months, 3 and 9 months after operative correction in 28 and 11, respectively, and in a control group of 51 boys 0 to 3 years old (mean age 11 months). Long-term flow data were obtained retrospectively from the records of 63 patients with hypospadias 1 to 10 years after operation.

RESULTS

Of the controls 37% had mainly intermittent and sometimes fractionated flows, 4% had a plateau phase flow and 59% had mainly bell-shaped flow curves. The average maximum flow rate +/- SD was 6.8 +/- 4.1 ml per second and maximum flow rate/voided volume was 0.26 +/- 0.11 l per second. Of the boys with distal hypospadias 76% produced intermittent flows (fractionated in the majority) before correction. After correction this percent decreased to 50%. The average maximum flow rate was 7.5 +/- 2.5 ml per second before correction, and 6.6 +/- 2.8 and 7.2 +/- 1.8 ml per second 3 and 9 months after operation, respectively. Average maximum flow rate/voided volume was 0.22 +/- 0.12 l per second before, and 0.16 +/- 0.09 and 0.16 +/- 0.09 l per second 3 and 9 months after operation, respectively. In the long-term group maximum flow rate/voided volume was 0.13 +/- 0.11 l per second. The number of patients voiding with a plateau phase increased from 6% before to 13% and 17% after correction, respectively. An obstructive pattern was also observed in 41% of the long-term followup group.

CONCLUSIONS

An intermittent flow pattern is common in 0 to 3-year-old boys. It appears to be more common and more pronounced or fractionated in boys with distal hypospadias at the same ages. In relation to voided volume patients with hypospadias already produce an abnormally low urine flow rate before correction and even more so thereafter in the short and intermediate term. The corrective procedure increases the occurrence of flows with an obstructive pattern.

Failed hypospadias repair presenting in adults

OBJECTIVES

To evaluate the results of one-stage and multistage urethroplasty in adults with complications following multiple failed hypospadias repairs.

METHODS

Sixty adults underwent reconstructive surgery of the following complications after hypospadias repair: stricture (34), residual hypospadias (26), fistula (18), meatal stenosis (11), penile curvature (9), hair (4), diverticula (2), and stone (1). A total of 36% of the patients had one complication and 64% had two or more complications. Twenty-nine patients underwent one-stage repair with buccal or skin grafts or direct repair, and 31 underwent multistage repairs with buccal or skin grafts.

RESULTS

Mean follow-up was 33.8 mo. Of the 60 cases, 45 (75%) had a final successful outcome and 15 (25%) failed. One-stage repair provided 24 (82.7%) successes and 5 (17.3%) failures. Multistage repair provided 21 (67.7%) successes and 10 (32.3%) failures. Buccal mucosa grafts provided 81% of success in one-stage procedures and 82.3% in multistage procedures. Penile skin grafts provided 80% of success in one-stage procedures and 50% in multistage procedures.

CONCLUSIONS

Adults with complications following childhood hypospadias repair are still a difficult population to treat with a high failure rate for reoperative surgery.