General considerations in hypospadias surgery

The Role of Postoperative Dressing in Hypospadias Surgery: A Systematic Review and Meta-analysis of the Pediatric Literature

This study aimed to describe the available dressings and their management in patients undergoing hypospadias repair and compare postoperative outcomes with and without dressing and between the different dressing types. A comprehensive electronic literature search of PubMed, Embase, and Cochrane Library was conducted to obtain studies, published in the period 1990 to 2021, reporting on the dressing used following hypospadias surgery. All information regarding the dressing was considered as primary endpoints, whereas surgical outcomes were assessed as secondary outcomes. Thirty-one studies containing 1,790 subjects undergoing hypospadias repair were included. Dressings were divided into three categories: nonadherent to the wound, adherent to the wound, and glue-based dressings. Most authors preferred to remove/change the dressing in the ward and the median time of removal/change was 6.56 postoperative days. The dressing removal appeared as the most frequent factor generating parental anxiety. The median rate of wound-related complications was 8.18%, of urethroplasty complications 9.08% and of reoperations 8.18%. Meta-analysis of outcomes showed higher risk of reoperations using conventional dressing, with no differences in urethroplasty and wound-related complications rates between conventional and glue-based dressings. Furthermore, the use of dressing reported increased risk of wound-related complications compared with no dressing, without significant differences regarding occurrence of urethroplasty complications and reoperations. The current evidence confirmed that there is no difference in outcomes of hypospadias repair depending on a certain dressing type. To date, surgeon's preference remains the main factor determining the choice for a specific dressing or for no dressing at all.

A meta-analysis: single or double dartos flap layer in tubularized incised plate urethroplasty to prevent urethrocutaneous fistula?

Backgrounds

Urethrocutaneous fistula is one of the most common complications after urethroplasty. This meta-analysis aims to evaluate the superiority of double dartos flap to single dartos flap in preventing fistula during tubularized incised plate urethroplasty (TIPU), which is one of the most frequently used operations for hypospadias.

Methods

We extracted clinical trials under the following included criteria: (1) children with TIPU; (2) a comparison of single and double flap layer; and (3) record of complications with the following excluded criteria: (1) non-comparison and (2) lack of data. Finally, 13 studies from PubMed, Cochrane Library, Scopus, and Embase have been investigated, with a total of 1,185 patients from 2005 to 2022. The quality assessment was conducted according to the Cochrane handbook and the Newcastle-Ottawa scale. A mixed-effect model was utilized to weigh the risk of fistula, phallic rotation, meatal stenosis, and wound dehiscence by the Review Manager V.5.4 software.

Results

The double dartos flap layer group excels in descending the risk of postoperative fistula [odds ratio (OR) = 9.56; 95% confidence interval (CI) (4.76, 19.22); P < 0.00001] and phallic rotation [OR = 31.26; 95% CI (9.60, 101.84); P < 0.00001], while there are no differences in the rate of meatal stenosis [OR = 1.49; 95% CI (0.73, 2.70); P = 0.31] and wound dehiscence [OR = 2.30; 95% CI (0.80, 6.63); P = 0.12].

Conclusions

The routine utility of a double dartos flap layer is recommended as a potential treatment during the tubularized incised plate urethroplasty.

Systematic Review Registration

identifier PROSPERO CRD42022366294.

Quantification of the Androgen and Estrogen Receptors in the Penile Tissues of Hypospadias in Comparison with Normal Children

INTRODUCTION

Hypospadias is a common congenital abnormality typified by a proximally placed ectopic urethral meatus along the ventral surface of the penis. Androgen receptor (AR) and estrogen receptor (ER) expression in the hypospadias tissues may be altered in hypospadias.

METHODOLOGY

We evaluated by immunohistochemistry the AR and ER expression in 75 tissues from hypospadias repair, and compared this expression to that of tissue from 75 patients undergoing circumcision. We also compared the intensity of AR and ER expression between different severities of hypospadias.

RESULTS

AR quantitative grading score decreased with severity of hypospadias, while the ER score increased as the hypospadias worsened, which was statistically significant (p-value <0.05).

CONCLUSION

The penile tissue AR expression is decreased and ER expression is increased with increasing severity of hypospadias.

Double dartos flap layer in tubularized incised plate urethroplasty to prevent urethrocutaneous fistula in uncircumcised patients with distal hypospadias

Urethrocutaneous fistula may complicate hypospadias repair. We noticed that double-layered preputial dartos flaps added to tubularized incised plate urethroplasty can reduce the risk of urethrocutaneous fistula. The aim of this study was to compare the outcomes of tubularized incised plate urethroplasty with double-layered preputial dartos flaps to with single-layered local fascial flaps in preventing urethrocutaneous fistula. A retrospective cohort study was conducted between January 2017 and December 2020 at Jordan University Hospital (Amman, Jordan). Boys who were aged between 6 months and 5 years, diagnosed with distal hypospadias, and not circumcised were included. The primary outcome was the occurrence of urethrocutaneous fistula in patients who underwent tubularized incised plate urethroplasty with a double-layered fascial flap. The results showed a total of 163 boys with distal hypospadias; among them, 116 patients underwent tubularized incised plate urethroplasty with a single-layered fascial flap, and 47 underwent tubularized incised plate urethroplasty with a double-layered fascial flap. The development of urethrocutaneous fistula was higher in the group receiving tubularized incised plate urethroplasty with a single-layered fascial flap than in the group receiving tubularized incised plate urethroplasty with a double-layered fascial flap after 1 month, 6 months, and 12 months (6.9% vs 0, 10.3% vs 0, and 5.2% vs 0, respectively), and the difference after 6 months was statistically significant (P = 0.02).

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 &lt;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.

Effects of Caudal and Penile Blocks on the Complication Rates of Hypospadias Repair

Background:

The major influencing factors for complications during hypospadias repair are the original location of the meatus, previous urethral surgery, surgical technique, and surgeon’s experience. While the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.hile the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.

Aims:

To determine the effect of caudal block and penile block on complication rates of hypospadias repair in patients with subcoronal hypospadias.

Study Design:

Retrospective cross-sectional study.

Methods:

Data of children who underwent hypospadias repair between 2011 and 2019 in our clinic (n = 770) were reviewed retrospectively. Only patients with subcoronal hypospadias and who underwent tubularized incised plate urethroplasty, performed by the same two experienced surgeons (n = 279), were included in the study. The exclusion criteria were incomplete data and follow-up time shorter than 12 months. Data of 279 patients were analyzed. Patients were divided into two groups according to the analgesia type: caudal block (n = 95) and penile block (n = 184), and complication rates were compared between these groups.

Results:

The median age was 36 months in the caudal block group and 30 months in the penile block group (P = 0.390). The median follow-up times were 54 and 42.7 months in the caudal and penile block groups, respectively. Total complication rates did not differ significantly between the groups and were determined as 10.5% and 12.5% in the caudal and penile groups, respectively. Urethrocutaneous fistula rates were observed as 2.1% and 4.3% (p=0.50). None of the patients had penile chordee and no penile plication was performed in the whole group.

Conclusion:

This study shows that there is no increase in post-repair complications in patients with subcoronal hypospadias who underwent caudal block.

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.

Glans–urethral meatus–shaft score and penile parameters as preoperative assessment tools for hypospadias surgery outcome

Background

Our prospective study aims to assess if penile parameters and GMS score can predict the postoperative outcome of patients with hypospadias repaired with the TIP technique.

Methods

This prospective study included patients (6 months–11 years old) with coronal, distal or mid penile hypospadias who underwent Tubularized incised plate (TIP) urethroplasty technique from 2015 to 2017. All patients were assessed preoperatively using GMS score. GMS score included a scale for each component, with the more unfavorable characteristics assigned higher scores. Penile length, urethral plate length, and penoscrotal length were measured using a ruler. Glans width was measured by using a caliper ruler. Demographics and complications were assessed within 3 months of the procedure.

Results

There was a statistically significant difference between complicated and non-complicated patients regarding GMS score, glans width, penoscrotal length, penile length, and urethral plate length/penile length ratio. According to the ROC curve, the cutoff values for GMS score, glans width and penoscrotal length were 6, 14 mm and 5 cm, respectively. The area under the ROC curve for penile length and for urethral plate/penile length ratio was poor and so we could not get a specific cutoff value for either parameters. According to Stepwise logistic regression, the GMS score was the only significant independent parameter while controlling all the other factors. Any increase in the GMS score by one unit would increase the risk of complications 3 times.

Conclusion

GMS score and penile parameters are good predictors and complete each other in preoperative assessment for hypospadias patients. Patients with a high GMS score (above 6) have a higher risk of complication and patients with a Glans width of 14 mm or more and a penoscrotal length of 5 cm or more are associated with less risk of complication.

Individualized care for patients with intersex (differences of sex development): part 4/5.Considering the Ifs, Whens, and Whats regarding sexual-reproductive system surgery

Issues and concerns regarding surgery of the sexual-reproductive anatomy during infancy and early childhood are discussed using four actual examples. A case of a 46, XX infant with 21 hydroxylase deficiency congenital adrenal hyperplasia (CAH) with atypical (ambiguous) genitalia is discussed regarding timing and potential harms and benefits of surgery. We present the perspective of balancing the child's rights to bodily autonomy and right to an open future versus parents' decision making authority regarding what they perceive as their child's future best interests. The second case is a newborn with complete androgen insensitivity syndrome and we discuss the harms, benefits and timing of gonadectomy. The third case examines the physical and psychological impact of penile shaft hypospadias, raising the question of whether surgery is justified to prevent what may or may not be considered a permanent disability. The fourth case involves an adult woman with classic CAH, born with a urogenital sinus and clitoromegaly, who never had genital surgery and is now requesting vaginoplasty, but not clitoral reduction. The primary message of this article, as the previous articles in this series, is to encourage patient-family centered care that individualizes treatment guided by shared decision making.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in Indonesia

INTRODUCTION

Hypospadias is one of the most common congenital malformations with a worldwide increasing trend over the years. Despite advancements in hypospadias repair, complications still occur. One of the most common complications of hypospadias repair surgery is Urethrocutaneous fistula. Studies attempting to analyze the association between the complication and risk factors are always beneficial, especially for studies performed in different areas of the world. We hypothesize that several evaluated risk factors among Indonesian hypospadias patients could be associated with the occurrence of urethrocutaneous fistula after the repair procedure.

OBJECTIVE

To determine the risk factors associated with urethrocutaneous fistula after hypospadias repair surgery by collecting and analyzing data obtained from multiple centers in Indonesia.

MATERIALS AND METHODS

A nationwide, retrospective study with 12 hospitals in Indonesia of children with a diagnosis of hypospadias was conducted. The collected data, taken from patients admitted in 2018, from each center's medical records consisted of patient identity, repair technique used, neourethra length, percutaneous cystostomy, and splint size as independent variables speculated to be possible risk factors correlated to the presence of urethrocutaneous fistulae. Binomial logistic regression analysis was performed using SPSS 21.0 to determine the relationship between urethrocutaneous fistulae as a post-repair complication and possible risk factors.

RESULTS

We collected 591 hypospadias cases from 12 centers in 9 cities in Indonesia. Most patients came when they were already at the age of more than four years old (60.4%). The chordee-only and failed urethroplasty groups are excluded from the analysis as they are not classified as true hypospadias. Most repairs were performed by using the Tubular Incised Plate (TIP) with Thiersch-Duplay technique (44.16%). Most of the reconstructed neourethra are 2-3 cm in length (32.13%). The 8 Fr urethral splint (46.41%) was mostly used during the operation. Most surgeons decided not to perform cystostomy throughout the procedure (61.03%) based on personal preferences. Urethrocutaneous fistula was found in 80 patients (15.27%) out of the total patients who underwent the surgery. The binomial logistic regression analysis shows that age (OR = 1.398, p = 0.015), the decision to not perform cystostomy (OR = 2.963, p = 0.014), and splint size (OR = 1.243, p = 0.023) are significantly associated (p < 0.05) with the development of urethrocutaneous fistula.

CONCLUSION

Age and splint size are significant risk factors for urethrocutaneous fistula after hypospadias repair in Indonesia, whereas performing percutaneous cystostomy during the repair decreases the risk for urethrocutaneous fistula occurrence.

Outcome of urethral mobilization and advancement after anterior hypospadias surgery

Background

In hypospadias surgery, despite continued refinement of various surgical procedures, there is no completely satisfactory technique in terms of complications and cosmesis. In recent literature, urethral mobilization and advancement (UMA) is gaining popularity in the management of distal penile hypospadias with no or very low complication rate as compared to all other techniques. The aim of this study is to share our results by using UMA in the management of anterior hypospadias with or without chordae.

Results

A total of 60 patients of anterior hypospadias having the mean age 57.15 ± 38.73 months were included. The mean length of hospital stay was 2.83 ± 1.33 days. The only peroperative complication was urethral injury during urethral mobilization seen in one patient. The most common postoperative complication was hematoma seen in five (8.3%) cases. Two patients (3.3%) had retraction of urethra. One patient had wound infection. Stenosis was labeled in four (6.6%). At 3 months follow-up, 93.3% patients had slit-like meatus and good urinary stream.

Conclusion

We found that UMA technique had good functional as well as excellent cosmetic outcome, so the technique can be adopted for anterior hypospadias correction.

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.

Management of hypospadias in Saudi Arabia: A national survey

Introduction:

Hypospadias is one of the most common congenital anomalies of the penis. Different methods of hypospadias management are described in the literature. We try in this study to evaluate the national trends and to compare them with international practices.

Materials and Methods:

A multiple choice survey was distributed among a sample of national practitioners using a weblink between September and December 2017. It included questions about participants demographics, number of cases operated on per year, perioperative care and preferences, long-term follow-up, and complications. Data were analyzed and compared with international practices.

Results:

Results of 47 practitioners were evaluated and analyzed in this study. The majority of the participants were pediatric urologists (48.9%) and from the central province (44.7%). Most of the participants prefer to operate on patients between the ages of 1 and 2 years (48.9%) and operate at ≥20 cases per year (76.6%). Tubularized incised plate (TIP) is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for proximal cases. All participants use a form of a second layer and a stent for their repairs. The majority reported an overall complication rate of ≤10% for distal penile hypospadias (76.1%) and >10% for proximal penile cases (59.6%).

Conclusion:

This study helped us identify national trends in hypospadias management, which were comparable to the international trends. TIP repair is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for more complex proximal variants. Although data in this study come from reports of personal experience, it can serve as a backbone for the future prospective studies on this topic.

Psychological Aspects of Androgen Insensitivity Syndrome: Two Cases Illustrating Therapeutical Challenges

Androgen Insensitivity Syndrome (AIS) and its heterogeneous phenotypes comprise the pieces of a challenging clinical problem. The lack of standardized guidelines results in controversies regarding the proper diagnostic and therapeutic approach, including the time and type of intervention. Due to its variable phenotype, AIS is not diagnosed at the proper age that would allow optimal psychological and medical support to the patient. Therapeutic approaches are not established, mainly due to the rarity of the disease. In addition, various social and ethical consequences may emerge. The aim of this double case report is to outline the difficulties that may rise during diagnostic, therapeutic, and psychological approach of AIS, especially concerning the handling of the relatives' reaction.

Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study

This study aimed to assess the association between caudal block and postoperative complications after tubularised incised plate urethroplasty. The medical records of 388 paediatric patients who underwent urethroplasty at a tertiary medical centre were analysed retrospectively. Among the 342 patients included, 216 patients received a caudal block and 72 (21.1%) patients suffered surgical complications. The number of patients having surgical complications was significantly greater among patients who received a caudal block than among patients who did not receive a caudal block (53 (24.5%) versus 19 (15.1%), respectively, p = 0.04). Based on multivariate logistic regression analysis, duration of surgery, caudal block and hypospadias types were independent risk factors for the surgical complications. Patients with caudal block had an odds ratio of 2.1 (95% CI, 1.14-3.81, p = 0.018) for the development of postoperative complications compared with patients without caudal block. This analysis demonstrates that caudal block is associated with surgical complications after tubularised incised plate urethroplasty.

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.

Hypospadias repair and outcome in Abuja, Nigeria: A 5-year single-centre experience

BACKGROUND

To determine the outcome of hypospadias repair in children.

PATIENTS AND METHODS

This was a retrospective study of all patients with hypospadias managed at the University of Abuja Teaching Hospital, Abuja, Nigeria from January 2009 to December 2013.

RESULTS

Twenty-four cases of hypospadias had corrective surgery during the 5-year period under review. Seventy-five percent of the patients (n = 18) were seen after the 1 st year of life. There were two peaks of ages at corrective repair; 45.8% between age 1 and 3 years and 29.1% between age 5 and 10 years. The average age at time of surgery was 44.9 months. Distal hypospadias were more common (58.4%), followed by glanular (20.8%) and proximal (20.8%) hypospadias. Associated anomalies included chordee, maldescended testicles and inguinal hernia in 20.8%, 4.1% and 8.3% cases, respectively. Operative techniques were single-stage procedures in 79.1% of patients consisting of simple circumcision in two cases (10.5%), Mathieu's peri-meatal based flap in four cases (21%), meatal advancement and glanuloplasty incorporated in three cases (16%) and Snodgrass tubularised incised urethral plate tubularised incised plate in 10 cases (52.5%). The remaining 20.9% (n = 5) had multi-staged procedures. The most common post-operative complications were urethrocutenous fistula in nine patients (33.3%) and metal stenosis in 3 patients (12.5%).

CONCLUSIONS

Our results show that hypospadia repair is froth with attendant high complications in our setting.

Common conditions in pediatric surgery

Primary care physicians are generally the first contacts of the parents of children with any disease. Management protocols and methods of the surgical conditions in children have undergone changes over time and the aim of this review is to update the knowledge base of clinicians. New technologies like laparoscopy and endoscopic surgery are available for management. The optimal treatment of any surgical condition requires that appropriate procedure is performed at the optimal time by a pediatric surgeon who is best trained for management of these conditions.

Hypospadias repair: a single centre experience

Objectives. To determine the demographics and analyze the management and factors influencing the postoperative complications of hypospadias repair. Settings. Hayatabad Medical Complex Peshawar, Pakistan, from January 2007 to December 2011. Material and Methods. All male patients presenting with hypospadias irrespective of their ages were included in the study. The data were acquired from the hospital's database and analyzed with Statistical Package for Social Sciences (SPSS). Results. A total of 428 patients with mean age of 8.12 ± 5.04 SD presented for hypospadias repair. Midpenile hypospadias were the most common. Chordee, meatal abnormalities, cryptorchidism, and inguinal hernias were observed in 74.3%, 9.6%, 2.8%, and 2.1% cases, respectively. Two-stage (Bracka) and TIP (tubularized incised urethral plate) repairs were performed in 76.2% and 20.8% of cases, respectively. The most common complications were edema and urethrocutaneous fistula (UCF). The complications were significantly lower in the hands of specialists than residents (P-value = 0.0086). The two-stage hypospadias repair resulted in higher complications frequency than single-stage repair (P value = 0.0001). Conclusion. Hypospadias surgery has a long learning curve because it requires a great deal of temperament, surgical skill and acquaintance with magnifications. Single-stage repair should be encouraged wherever applicable due to its lower postoperative complications.

Age of patient is a risk factor for urethrocutaneous fistula in hypospadias surgery

OBJECTIVE

There is still much debate regarding the effect that age at hypospadias operation has on the rate of complications. The aim of this study was to evaluate whether patient age is a risk factor for surgical complications when using the tubularized incised plate (TIP) urethroplasty technique.

METHODS

Between 2005 and 2011, 307 pediatric patients with distal or mid-penile hypospadias underwent the TIP procedure. Demographic and surgical data were evaluated.

RESULTS

The complications recorded across all age groups were: fistula, meatal stenosis, glans dehiscence and urethral stenosis. Fistula was the most frequent complication in 10-14 year olds compared to the younger patient groups, and this difference was statistically significant.

CONCLUSION

Age and surgical technique should be taken into consideration when planning hypospadias surgery, since the complication rate increases with patient age. The TIP technique is a safe procedure with a low rate of fistula formation in distal and mid-penile hypospadias repair for patients of any age during the prepubertal period.

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.

Management of urethrocutaneous fistula after hypospadias surgery - An experience of thirty-five cases

Introduction:

The commonest complication following hypospadias repair is occurrence of urethrocutaneous fistula. The smaller fistulas (<2 mm) are easier to close with a simple closure whereas larger ones (>2 mm) with good vascular surrounding skin require a local skin flap closure for avoiding overlapping suture lines. For the recurrent/larger fistulas with impaired local surrounding skin - incidence of recurrence is significantly reduced by providing a waterproofing interposition layer.

Aims:

To study the effect of size, location, number of fistulas and surrounding tissues in selecting the procedure and its outcome. To identify various factors involved in the recurrence and to formulate a management in the cases where recurrence has occurred.

Patients and Methods:

This study of 35 cases of urethrocutaneous fistula repair was done from July 2006 to May 2009 to achieve better results in fistula management following hypospadias surgery.

Statistical analysis used:

X² test and Fisher's exact test.

Results:

The overall success rate for fistula repair at first attempt was 89% with success rates for simple closure, layered closure and closure with waterproofing layer being 77%,89% and 100%, respectively. The second attempt success rate at fistula repair for simple closure and closure with waterproofing layer were 33% and 100%, respectively. At third attempt the two recurrent fistulas were managed by simple closure with a waterproofing interposition layer with no recurrence. All the waterproofing procedures in this study had a success rate of 100%.

Conclusions:

The treatment plan for a fistula must be individualized based on variables which has an effect on the outcome of repair and to an extent dictates the type of repair to be performed. The significantly improved success rates with the addition of a waterproofing layer suggests the use of this interposition layer should be done at the earliest available opportunity to prevent a reccurence rather than to reserve it for future options.