Hypospadias repair: a single centre experience

Preliminary Reference Interval for 5-Alpha Reductase in Normal Male Children and Its Association with Hypospadias

Background

5-alpha reductase (5-AR) enzyme is responsible for conversion of testosterone to dihydrotestosterone (DHT) in humans, which subserves various functions. The aim of the study was to establish a normal reference interval (RI) for blood levels of the enzyme 5-AR.

Methods

We conducted a prospective study on 150 boys, 75 of whom underwent circumcision for various benign conditions or for religious reasons (Group A/controls) and 75 suffering from hypospadias of variable severity (Group B/cases). The plasma levels of 5-AR were measured by enzyme-linked immunosorbent assay (ELISA) in all 150 boys and correlated with the severity of hypospadias.

Results

The 5-AR levels in Group A ranged from 14.6 to 17.3 ng/mL. The enzyme levels decreased in value with increasing severity of hypospadias in Group B (P-value <0.01 - statistically significant). The levels of the enzyme in this group ranged from 0.6 ng/mL (in the most severe variety of hypospadias) to 11.5 ng/mL (mild variety of hypospadias).

Conclusions

There is no record of RI values of 5-AR in the literature. The RI of 5-AR needs to be determined by conducting more studies globally. Its levels falls considerably with clinical severity of hypospadias, reinforcing the importance of the enzyme in the development of male external genitalia.

Clinical Profiles and Surgical Outcome of Hypospadias Repair at a Teaching Hospital in Ethiopia

BACKGROUND

Hypospadias repair is one of the commonest and challenging surgery done in pediatric age groups. This study was conducted to assess clinical profiles and surgical outcomes of hypospadias repair.

METHODS

A retrospective analysis of pediatric hypospadias repairs at St. Paul's hospital millennium medical college from September 2015 to August 2019 was conducted.

RESULTS

A total of 277 patients with hypospadias repair were investigated. The mean age was 3.7+/- 3.5 years (Range, 0.5-14 years) and only one-third (98,35.4%%) of patients were operated on in the recommended age group (6-18 months). Anterior/distal hypospadias was the commonest (123,44.4%) variant identified. The majority (176,63.5%) had chordee and 105(37.9%) were severe forms. Tubularized incised plate repair was the major (164,59.2%) surgical technique employed followed by staged urethroplasty (61,22%). Post-operative complications occurred in 135(48.7%) patients and the commonest was urethrocutanous fistula (95,34.3%). No significant correlation was found between the occurrence of these complications and factors such as age at repair, the severity of hypospadias, presence of concomitant urogenital anomaly, type of procedure and duration of urinary diversion. However, the presence of severe chordee (AOR=3.09; 95%CI 1.21-7.54; p=0.013) was an independent factor found to be associated with postoperative complications on multivariate analysis.

CONCLUSION

Higher rate of complications following hypospadias repair was observed in our study. Our study also demonstrated no significant advantage of any repair technique in reducing operative complications. Extensive preoperative evaluation, proper operative plan and regular follow-up of such patients is paramount for a better outcome.

Post-Hypospadias Repair Penile Score in Follow-Up Patients of Urethroplasty

Background: Hypospadias is described as the abnormal location of the urethral meatus upon the ventral surface of the penis with variable association with the abnormal development of the urethral spongiosum, ventral prepuce, and penile chordee. Numerous studies have utilized techniques like "Penile Perception Score (PPPS)," "Hypospadias Objective Scoring System (HOSE)," and "Hypospadias Objective Penile Evaluation Score (HOPE)" to evaluate the outcome after hypospadias repair, but there is a lack of evidence analyzing the utility of "Post-Hypospadias Repair Penile Score (PHRPS)." This study was carried out to assess PHRPS in children undergoing hypospadias repair.

Methodology: A prospective cohort study was conducted at the department of pediatric surgery, uni-II, The Children’s Hospital and University of Child Health Sciences, Lahore, Pakistan from November 2020 to December 2021. All male children aged up to 12 years and planning to undergo hypospadias repair during the study period were included. The PHRPS system was used to assess the outcomes of hypospadias repair. Qualitative data were represented as frequency and percentage, while mean and standard deviation (SD) were calculated for quantitative data.

Results: During this period, a total of 37 children were treated for hypospadias. The mean age of the patients at the time of repair was 8.2±3.6 years, ranging between 1.5 years and 12 years. Out of 37 patients, 14 (37.8%) had penoscrotal hypospadias, while 12 (32.4%) had distal penile hypospadias. In terms of acute post-surgery complications, edema was reported in 9 (24.3%), bleeding 1 (2.7%), and surgical site infection 1 (2.7), while all of these were successfully managed conservatively. Seven patients were lost to follow-up, so they were excluded from the final analysis. On the basis of PHRPS scoring, 17 (56.7%) patients had excellent outcomes, 2 (6.7%) had good outcomes, 8 (26.7%) had acceptable outcomes, and 3 (10.0%) had poor outcomes.

Conclusion: The PHRPS is a new but simple objective tool, facilitating surgical audit and balanced evaluation of the outcomes of traditional and innovative procedures. The outcome of hypospadias repair was generally found to be good.

Dorsal midline incision: A versatile technique for correction of meatal stenosis during hypospadias repair

Objectives:

To our knowledge, the incidence of congenital meatal abnormalities associated with hypospadias varies from 9.6% to 31%, of which meatal stenosis is the most common, affecting 9.1–16.7% of patients. Traditionally, meatal stenosis has been dealt with by meatal dilatation, although ventral meatotomy until the normal urethra is encountered has also been used. Here, we report the outcome of a technique where, during hypospadias repair, a dorsal midline incision was performed instead of a ventral urethral incision, starting at the narrow meatus and subsequently extending proximally to treat the meatal stenosis.

Methods:

Patients having distal hypospadias with meatal stenosis were included in this study. In this technique, a dorsal midline incision was extended until normal calibre urethra was encountered. Patients with chordee >15°, proximal hypospadias, redo cases, glans width <14 mm, where separation of the skin from the underlying urethra was not possible and with a follow-up of less than three months were excluded from the study. A total of 73 patients were operated on using this technique. Results were assessed with regards to urethrocutaneous fistula (UCF) and stricture formation.

Results:

Five (6.85%) patients developed UCF: one (5%) in the subcoronal group, two (8.0%) in the distal penile group and two (14.3%) in the mid-penile hypospadias group. Postoperatively, only one patient had meatal stenosis.

Conclusion:

We think hypospadiac meatal stenosis is best treated by a dorsal midline incision, as it does not lead to a proximal shift of the meatus, and this defect heals by re-epithelisation without significant scarring, which in turn decreases the possibility of UCF. That is why the fistula rate in our study was 6.85%, which is lower than in various published series.

Common Practice of Hypospadias Management by Pediatric Urologists in Indonesia: A Multi-center Descriptive Study from Referral Hospitals

BACKGROUND:

Hypospadias is the second most common congenital anomalies among human congenital disabilities. There are over 300 surgery techniques being introduced to treat hypospadias. The successful of hypospadias repair is assessed by several outcomes as well as complications following surgery.

AIM:

This study aims to show the multicenter hypospadias data in Indonesia descriptively.

METHODS:

All the data were compiled based on questionnaires, which were distributed to Indonesian pediatric urologists. The questionnaire includes several questions containing demographic aspect, preferred techniques being used, and complications being found regarding hypospadias repair.

RESULTS:

Eighteen Indonesian pediatric urologists from 12 centres involved in this study. The data were collected from June – September 2018 based on the surgeon’s experience throughout 2017. From 591 cases based on the returned questionnaire, penile-type hypospadias was the most common type of hypospadias being treated (35.7%) followed by penoscrotal (28.9%) and scrotal-type (12.9%). Moderate severity of chordee was mostly seen among all cases (40.6%). Tubularised incised plate (TIP), + Thiersch Duplay, was the most common technique being used to treat hypospadias (44.3%), followed by onlay island preputial flap (14.9%) and two-stage technique (14%). The incidence of urethrocutaneous fistulae in this study was 13.9%.

CONCLUSION:

This study showed how Indonesian pediatric urologists dealt with hypospadias cases. TIP + Thiersch Duplay procedure being the preferred technique used by most participants and the rate of urethrocutaneous fistulae as one of the complications was comparable with previous studies.

Hypospadias Repair in Ethiopia: A Five Year Review

Background

Hypospadias repair is one of the problematic issues in pediatric surgery. As a result of the multiple complications following the procedure, a variety of techniques have been used and newer methods continue to emerge. There is still controversy regarding the best method of repair. We aimed to determine the outcome of surgery and factors contributing to unfavorable outcomes in children with hypospadias.

Materials and Methods

This is a retrospective review undertaken from September 2009 to August 2014. The research was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. All children who underwent hypospadias repair and had regular follow-up were included in the study.

Results

A total of 202 boys aged less than 13 years were assessed. Most surgeries (80.3%) were performed in children older than 18 months. Transverse incised plate urethroplasty (TIP) was frequently performed for distal hypospadias (71.2 %), while transverse ventral preputal flap (TVPF) was the most common procedure done for proximal hypospadias (62.8 %). Overall success rate for first surgery was 55.9 %. There was a high rate of major post-operative complications (44.1%) of which urethrocutaneous fistula (UCF) was the most common (31.2%) followed by meatal stenosis and glans breakdown (7.4 % each). These complications were found to be higher in those who were operated at a later age and those with proximal hypospadias (p=0.03 and p=0.01 respectively). There was also a significant difference among the type of procedures with TIP and TVPF having the least complications (p<0.01).

Conclusion

From our experience, we found TIP a relatively safe and reliable method of repair for distal hypospadias while TVPF single stage repair was superior in the proximal ones. The high rate of complications in our institution was associated with higher burden of severe hypospadias and older age at surgery.

The risk factors of Urethrocutaneous fistula after hypospadias surgery in the youth population

Background

The current research aims to evaluate the risk factors of urethrocutaneous fistula after hypospadias surgery among the youth in China.

Methods

One hundred twenty hypospadias patients were enrolled in our study. All of them were defined as Tanner 4 or 5. The information collected from the participants include age, urethral operation history, urinary comorbidities before operation, urine test before operation, body temperature before and after operation, type of surgical repair, chordee degree, urethral defect length and whether received vesicostomy after surgery or not. Independent t test, chi-square test and multivariate logistic regression were performed to evaluate the risk factor of urethrocutaneous fistula.

Results

Among the enrolled patients, 39 patients (32.5%) developed urethrocutaneous fistula after hypospadias repair. Our result showed significant association between the group with urethrocutaneous fistula and the group without urethrocutaneous fistula with respect to age, pyuria before operation, urethral defect length and the urethral operation history. The following logistic regression showed that urethral defect length and the urethral operation history were the risk factors of urethrocutaneous fistula.

Conclusions

Urethral defect length and urethral operation history should be taken into consideration before undergoing hypospadias surgery since our study discovered that the risk of developing urethrocutaneous fistula after hypospadias repair is associated with urethral defect length and urethral operation history. Age, surgical procedure, type of surgical repair, chordee degree and other factors were not obviously related to the development of urethrocutaneous fistula.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0366-z) contains supplementary material, which is available to authorized users.

Genetic Polymorphism in the RYR1 C6487T Is Associated with Severity of Hypospadias in Chinese Han Children

Objective

Hypospadias is a common congenital malformation of the male external genitalia. Most cases have an unknown etiology, which is probably a mix of monogenic and multifactorial forms, implicating both genetic and environmental factors. Ryanodine receptor 1 (RYR1) mutations are a common cause of congenital diseases associated with both dominant and recessive inheritance in humans. Herein, we evaluated the correlations of RYR1 C6487T polymorphism with the risk and severity of hypospadias.

Methods

263 congenital hypospadias children and 312 healthy children were recruited. The polymorphism of RYR1 C6487T in the peripheral blood was detected by polymerase chain reaction-restriction fragment length polymorphism, and different genotypes and allelic genes were analyzed to explore their associations with the risk of congenital hypospadias.

Results

The distribution frequencies of CC/CT/TT genotypes and two alleles (C and T) at RYR1 C6487T showed significant differences between the case and control groups (P < 0.05). The frequency of C allele in the case and control groups was 46.95% and 54.94%, respectively, and of T allele was 53.05% and 45.06% (P < 0.05). In addition, the distribution frequency of CC/CT/TT genotypes exhibited significant difference between patients with mild hypospadias and those with moderate or severe hypospadias (all P > 0.05), suggesting that RYR1 C6487T polymorphism is correlated with the severity of congenital hypospadias (X² = 13.722, P = 0.001).

Conclusion

Our study demonstrated that RYR1 C6487T polymorphism might be associated with an increased risk of congenital hypospadias in Chinese Han children. Our findings highlight the heterogeneous nature of hypospadias genetic susceptibility.

URETHROCUTANEOUS FISTULA FOLLOWING SNODGRASS VERSUS TWO STAGE AIVAR BRACKA REPAIR OF DISTAL PENILE HYPOSPADIAS IN MALE CHILDREN: A RANDOMIZED CONTROL TRIAL

Background: Hypospadias is the most common congenital malformation of the urethra with the prevalence of 1 in 200-300 live male births. The objective of this trial was to compare the frequency of urethrocutaneous fistula between Snodgrass and two staged Aivar Bracka repair of distal penile hypospadias in male children. Material & Methods: This RCT was conducted in Department of Plastic & Reconstructive Surgery, Hayatabad Medical Complex, Peshawar, Pakistan from 1st June 2013 to 31st May 2014. 64 male patients were randomly allocated to two surgical procedures, 32 to experimental (Snodgrass) group and 32 to control (two stage Aivar Bracka) group. Age in years, age groups and presence of urethrocutaneous fistula were variables. Age in years was analyzed by mean, SD and range and other variables by count and percentage. McNemar chi-square test was applied to see the significance of difference between the experimental and control groups in terms of frequency of urethrocutaneous fistula at alpha 0.05. Results: Mean age in experimental (Snodgross) group was 6.74 years±1.26 & in control (Aivar Bracka) group 6.71 years ±1.29. The urethrocutaneous fistula was present in three (9.38%, 80% CI 2.77-15.99%) cases in experimental (Snodgross) group and in six (18.75%, 80% CI 9.91-27.59%) cases in control (Aivar Bracka) group. McNemar chi-square test showed no significant difference between the experimental and control groups in terms of frequency of urethrocutaneous fistula. Conclusion: The results are comparable for Snodgrass repair and two stage Aivar Bracka repair for distal penile hypospadias in male children in terms of frequency of urethrocutaneous fistula in our population.

The use of latex foley catheter in repair of hypospadias the most common seen congenital penile anomaly

OBJECTIVE

Hypospadias is the most common congenital penile anomaly occurring in 1/300 live births. Various surgery techniques are used in repair of hypospadias. Infant and children with hypospadias are usually admitted to emergency services by worried their parents for the first time. TIP urethroplasty is widely used in the repair of hypospadias, but the use of urethral catheters is still a matter for discussion. Herein, we described our experiences with the use of an unsutured latex foley catheter placed in the glans for 24 to 48 hours.

METHODS

A retrospective chart review was performed on 38 patients who underwent Tubularized incised plate (TIP) hypospadias repair from 2009 to 2011. Of these, 35 patients who had two-way latex Foley catheters placed for 24 h to 48 hands were followed for at least 12 month.

RESULTS

Excellent cosmetic results were obtained in all patients. Urinary tract infection developed in two patients (5.7%). one patient (2.8%) who had mild urethral repair breakdown was repaired in the office environment.

CONCLUSION

We observed very low complication rates in application of a two-way latex Foley catheter in hypospadias surgery and found that this method can be used safely. Moreover, the catheter can be used for traction purposes during the procedure. At the end of the 24 to 48 h period, removal of the two-way latex urethral catheter with balloon does not harm the urethral repair. To reach a definite conclusion, larger studies are needed.

Soft tissue interposition is effective for protecting the neourethra during hypospadias surgery and preventing postoperative urethrocutaneous fistula: a single surgeon's experience of 243 cases

PURPOSE

Soft tissue interposition (STI) during hypospadias repair (HR) purportedly prevents postoperative urethrocutaneous fistula (PUF) by supporting the neourethra. We report our experience.

METHODS

Data from 243 hypospadias patients treated by a single surgeon from 1997 to 2014 by urethroplasty (UP) with STI (n = 229; UP + STI) and UP without STI (n = 14; UP-STI) were collated prospectively and compared for incidence of PUF. Re-operative UP were excluded.

RESULTS

Hypospadias was distal (n = 55), mid-shaft (n = 59), proximal/penoscrotal (n = 109), scrotal (n = 15), and perineal (n = 5). UP was single-staged in 86, multi-staged in 157; mean age at UP was 3.1 ± 2.4 years. Soft tissue used for STI was prepucial inner dartos fascia (inner dartos: n = 88), ventral dartos fascia (ventral dartos: n = 15), pedicled external spermatic fascia (ESF: n = 84), adipose tissue surrounding the spermatic cord (pericordal: n = 9), scrotal adipose tissue (n = 8), or a combination of tissues (combined: n = 25). Mean follow-up was 6.4 ± 4.6 (range 0.6-16.8) years. Overall incidence of PUF was 10/243 (4.1 %); 7/229 (3.1 %) for UP + STI and 3/14 (21.4 %) in UP-STI (p < 0.05); incidence versus type of hypospadias was 1/55 for distal (1.8 %), 3/59 for mid-shaft (5.1 %), 5/109 for proximal/penoscrotal (4.6 %), 0/15 for scrotal (0 %), and 1/5 for perineal (20 %); incidence versus type of STI was 7/88 for inner dartos, 0/15 for ventral dartos, 0/84 for ESF, 0/9 for pericordal adipose tissue, 0/8 for scrotal adipose tissue, and 0/25 for combined. All PUF were repaired successfully. Satisfaction with penile cosmesis was acceptable (10.3 %) or good (89.7 %) without any testicular complications or scrotal deformity.

CONCLUSION

STI, especially ESF, would appear to effectively prevent PUF in HR.