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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 10-15

Outcome of anterior hypospadias repair: A single center experience


1 Department of Paediatric Surgery, Kempegowda Institute of Medical Sciences and Research Institute, Bangalore, Karnataka, India
2 Department of Surgery, Kempegowda Institute of Medical Sciences and Research Institute, Bangalore, Karnataka, India

Date of Web Publication14-Mar-2019

Correspondence Address:
Dr. S Pramod
Department of Paediatric Surgery, Kempegowda Institute of Medical Sciences and Research Institute, Bangalore - 560 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_17_18

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  Abstract 


Background: Hypospadias is a common congenital condition affecting the male phallus. It is characterized by abnormal opening of the urethra on the ventral aspect of the penis with ventral curvature of the phallus (chordee). Various surgical techniques have been described in the treatment of hypospadias. Evaluate the surgical outcome of anterior hypospadias repair including different procedures used to repair distal hypospadias. A retrospective observational study conducted by the Department of Pediatric Surgery, Kempegowda institute of medical sciences hospital, Bangalore from January 2014 to January 2018 over a period of 4 years.
Patients and Methods: All children with anterior hypospadias were included in the study. Children underwent either meatal advancement and glanuloplasty (MAGPI) or Snodgrass urethroplasty depending on the type of hypospadias. On follow–up, children were evaluated for complications. Chi square test was used to test for relationships between categorical variables.
Results: Fifty children were included in the study. Age ranges of children were between 9 months to 14 years. Coronal hypospadias was the most common variety (32%). Chordee, undescended testis, inguinal hernia, and penile torsion were observed in 44%, 4%, 6%, and 4%, respectively. On preoperative ultrasonography, renal anomalies were observed in 4 (8%) children. Out of 50 children, 25 underwent MAGPI and remaining 25 underwent Snodgrass repair. Postoperative complication was seen in nine children (18%). Most common complication was urethral fistula seen in five (10%) children followed-by meatal stenosis. Of these nine children with complication, only three children required resurgery.
Conclusion: Distal hypospadias is uncommonly associated with renal anomaly, which was once again reiterated in our study. Undescended testis and inguinal hernia were the most common associated anomalies with distal hypospadias. MAGPI is choice in case of glanular and coronal hypospadias with minimal chordee. Snodgrass technique is excellent choice in subcoronal and distal penile hypospadias with chordee.

Keywords: Anterior hypospadias, meatal advancement and glanuloplasty, Snodgrass


How to cite this article:
Pramod S, Prakash GS. Outcome of anterior hypospadias repair: A single center experience. Arch Int Surg 2018;8:10-5

How to cite this URL:
Pramod S, Prakash GS. Outcome of anterior hypospadias repair: A single center experience. Arch Int Surg [serial online] 2018 [cited 2019 Jul 22];8:10-5. Available from: http://www.archintsurg.org/text.asp?2018/8/1/10/254140




  Introduction Top


Hypospadias is the common congenital condition affecting male external genitalia.[1],[2] Hypospadias is derived from Greek terms hypo meaning under and spadon meaning rent or fissure. Hypospadiology was a term coined by Duckett in 1995.[3] Hypospadias is characterized by three anomalies of the penis (1) a ventrally located meatus, proximal to its normal position anywhere between the glans and the perineum; (2) ventral curvature of the penis (chordee); and (3) the dorsal preputial hood with a ventral deficit of the prepuce.[2],[4]

Recent evidence suggests an increase in incidence and severity of hypospadias in the last 30 years.[5],[6],[7],[8] This may be because of multiple factors including exogenous hormone usage (estrogen)[9] and environmental pollutants.[10] Various classifications of hypospadias have been mentioned and published in literature. Hypospadias is classified depending on the site of opening of the urethral meatus. If the urethral meatus is on the glans penis, at the corona, subcoronal, or distal penile, it is termed as distal or anterior hypospadias. Distal hypospadias is the most common variety. It accounts for 70%-80% of all hypospadias. Mid-shaft hypospadias accounts for 15%–20% of cases.[11] Posterior proximal forms are rare.[12]

In history, the first attempted hypospadias surgery was by Alexandrian surgeons Heliodorus and Antyllus during the first century A.D.[13] Since then, more than 300 techniques for hypospadias surgery have been documented. The goal of surgery is focused on functional and cosmetic outcomes. The functional outcome is measured by the ability to void while in standing and to allow effective coitus in adulthood. The procedures can be broadly classified as tubularization techniques, advancement techniques, and use of flaps or grafts.[14] In the present study, two techniques employed were Snodgrass (tubularized incised plate) urethroplasty and meatal advancement and glanuloplasty (MAGPI).

Tubularized incised plate is according to the principle of urethral plate tubularization, which was earlier known as Thiersch-Duplay repair.[15],[16] In cases of inadequate width of the urethral plate, alternative procedures such as Mathieu urethroplasty (flip-flap technique) or vascularized island flap were performed. In 1994, Snodgrass popularized the technique of urethral plate incision, tubularization, and secondary dorsal healing for hypospadias repair.[17]

Duckett in 1981 described MAGPI for distal hypospadias repair.[18] The two common complication of MAGPI are meatal regression and meatal stenosis.

In the present study, the surgical outcomes of distal hypospadias repair were analyzed. The postoperative complication and their management were also analyzed. The relationship of type of suture material to the surgical outcome was studied.


  Patients and Methods Top


This was a retrospective study conducted by the department of Pediatric Surgery, Kempegowda institute of medical sciences hospital, Bangalore from January 2014 to January 2018. All children with distal or anterior hypospadias were included in the study. Children with previous surgery were excluded from the study. The demographic data of children were tabulated. All children underwent routine blood investigation and ultrasonography of the renal system before surgery. On the day of surgery the children received intravenous antibiotics (cephalosporin and amikacin) 1 h prior to surgery. The children underwent either MAGPI or Snodgrass repair depending on the site and mobility of meatus.

Meatal Advancement and Glanuloplasty

The first step is application of traction suture to the glans with polypropylene 3/0 suture. Bladder is catheterized with a adequate size infant feeding tube. A circumferential sub-coronal incision is made proximal to the native urethral meatus. The penile shaft skin is degloved up to the penoscrotal junction. This step in most of the cases corrects the ventral chordee. A longitudinal incision is made from the native urethral meatus to the tip of the glans. The incision is closed transversely by Heineke-Mikulicz method to advance the meatus to the tipoff glans. Finally, degloved penile skin is sutured to the mucosa.

Snodgrass

The penile skin is degloved by a circumferential subcoronal incision. This incision is done 2 mm proximal to the urethral native meatus. At the lateral margins of the urethral plate, an U shaped incision is done. The glans wings are raised at this point. The urethral plate is incised in the midline. Following this, the urethral plate is tubularized over a adequate size infant feeding tube using absorbable suture. The sutures used were polyglactin 910 or polydioxanone. The dartos flap is transported from dorsal aspect either by button hole technique or from the sides. The dartos flap acts as a second layer of cover to the urethral tube. Later the glans wings are approximated in the midline. The degloved penile skin is sutured to the mucosa completing the procedure.

Catheters used in our study were infant feeding tubes of varying sizes (6 French to 10 French) depending on the age of the child. Postoperatively, all the children received intravenous antibiotics for a duration of 3–5 days. Bladder spasm caused by the indwelling catheter was treated with anticholinergic drug oxybutynin. The need of oxybutynin for bladder spasm was recorded. All children were given paracetamol suppository for pain relief initially and latter oral combination of combiflam. To prevent straining, all children were started on laxatives from postoperative day 1. All children underwent first dressing on postoperative day 4. The duration of catheterization and duration of stay in hospital were recorded. The children were followed-up for a period of 6 months to 4 years. On follow-up, children were evaluated for complications (edema, meatal stenosis, fistula, wound breakdown, and glans dehiscence).


  Results Top


Fifty children with anterior hypospadias were included in the study. The age ranges of children were between 9 months and 14 years. The distribution of age is depicted in [Table 1]. Most of the hypospadias were diagnosed at birth, only in 6 cases, it was noticed later in life. Coronal hypospadias (32%) was the most common variety [Table 2]. Chordee, undescended testis, inguinal hernia, and penile torsion were observed in 44%, 4%, 6%, and 4% of cases, respectively [Table 3]. On preoperative ultrasonography of the abdomen, renal anomalies were observed in 4 (8%) children.
Table 1: Age distribution of the children

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Table 2: Type of anterior hypospadias

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Table 3: Associated anomalies with hypospadias

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Out of 50 children, 25 underwent MAGPI and remaining 25 underwent Snodgrass repair. The mean duration of surgery in MAGPI was 56.8 min and in Snodgrass was 92.25 min. Postoperatively, 21 children required anticholinergics for bladder spasm. In remaining 29 children, only NSAIDs were sufficient. The mean duration of catheterization was 7.76 and 12.92 days in MAGPI and Snodgrass, respectively. The mean duration of stay in MAGPI was 8 days and in Snodgrass was 13 days [Table 4].
Table 4: Comparison between MAGPI and Snodgrass

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Postoperative complication was seen in nine children (18%). Most common complication was urethral fistula seen in five (10%) children. Out of these five children, three children required resurgery (i.e., fistula closure) and remaining two children were managed conservatively with urethral dilatation. The children in whom fistula closed spontaneously were of smaller size (<5 mm) with a patent neourethra. Next common complication was meatal stenosis seen in four (8%) children. All the children with meatal stenosis were managed conservatively with urethral dilatation [Table 5]. Overall, out of the 50 children who underwent surgery, only 3 (6.66%) required resurgery.
Table 5: Complication and position of meatus

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In 24 children, polyglactin 910 sutures were used, and in 26 children, polydioxanone sutures were used. The complication was more in children where polyglactin 910 suture (33.2%) was used [Table 6] but not statistically significant.
Table 6: Comparison among suture material

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  Discussion Top


The incidence of hypospadias is about 8.2 per 1000 live male births.[19] In the last 30 years, there is an increase in the prevalence of hypospadias.[5],[6],[7],[8] The aim of hypospadias surgery is to obtain a functional and cosmetically normal penis. Surgery for hypospadias remains one of the most challenging problems in pediatric urology. More than 300 different surgical techniques have been described in the treatment of hypospadias. This gives testimony to both surgical ingenuity in dealing with hypospadias and the dissatisfaction among previous procedure.[20]

The median age of presentation in our study was 4 years with a range of 9 months to 14 years. With the improvement in pediatric anesthesia and microsurgical techniques, children at younger age can be operated without increased risk.[21] After analyzing various factors such as sexual orientation, genital awareness, and separation anxiety Schultz and co-workers advised repair between 8 and 14 months.[22] Manley and Epstein also observed disturbing behavioral changes in boys undergoing hypospadias repair between the ages of 2 and 6 years. Following the above finding, they reduced the age to 10–18 months. By doing this, they noted improvement emotionally and psychologically compared to the older age group. Boys undergoing staged hypospadias repair, did significantly better psychologically with one stage repair at age 6 months compared to those undergoing two stage repair at age 3 years.[23] At present, the recommended age of surgery is between 6 and18 months.[24]

The most common associated anomalies with hypospadias are undescended testes and inguinal hernia. Cryptorchidism is present in 7%–-9% of the patients.[25],[26],[27] In our study, 4% of the children had associated undescended testis. Hernia is seen in 9%–16% of the children with hypospadias.[25],[26],[27] Only 6% of the children in our study had associated hernia. In anterior hypospadias, John M Gatt Andrew J reported undescended testis in 4.8% children and inguinal hernia in 7.1% children.[28]

The type of surgery depends on the position of meatus, mobility of the urethra, penile curvature, and thickness of periurethral tissue.[29] The MAGPI was devised by Duckett in 1981. The MAGPI technique provides reliable, reproducible technique for reconfiguring meatus and glans without the use of catheter and very low morbidity rate. The limiting factors for MAGPI are distal chordee, fibrotic urethral meatus, glandular tilt, or thin periurethral tissue.[30] Meatal regression and meatal stenosis are the two common complications in MAGPI. The reported incidence of complication in MAGPI ranges from 1.2% to 10%.[31],[32] The significant meatal regression was seen by Hastie et al.[33] In our study, we had two children (8%) with meatal stenosis. These two children were treated with urethral calibration. None of them required resurgery. Complication in MAGPI was attributed to poor case selection, severe chordee, and more proximally placed meatus. Hence, case selection is very important to reduce complication rate.

The two frequent complications seen with Snodgrass repair are urethrocutaneous fistula and meatal stenosis. Complication rate in Snodgrass repair range from 2% to 18%.[34],[35] In our study, complication was seen in 18% of the children. Complication included urethrocutaneous fistula and meatal stenosis.

In our series, urethrocutaneous fistula was the most common complication seen in 10% of the children. In the literature, the median fistula rate was 5%, ranging from 0% to 16% among the 54 case series reviewed.[36],[37],[38] The factors influencing fistula formation was studied by Waterman.[39] He found that technique of primary repair was important, and there was no difference between stent versus non-stent and age of child at the time of surgery. Two sites vulnerable to fistula are the sub-coronal area and the penoscrotal junction. Various factors responsible for urethrocutaneous fistula are improper mobilization of the flap during dissection, some degree of meatal stenosis, and pressure necrosis due to tight dressing.

In our series, out of the five children with fistula, three of them had fistula at subcoronal region. Three children required resurgery for fistula closure and the remaining two children fistula closed by regular urethral dilatation.

Next common complication was meatal stenosis. Meatal stenosis was seen in 8% of the cases, which was treated by regular meatal dilatation. It is believed that the reason for meatal stenosis is technical related. It occurs if the tubularization of the urethral plate is done too far distally. Ideally, it is good to create an appropriate sized oval shaped meatus. Technical modifications to reduce meatal stenosis are formation of wide and oval neomeatus, eversion of the neomeatus, restrictive midline incision distally, postoperative bougienage of the neourethra, skin grafting, or buccal mucosal grafting.

Study done by EL-Mahourky found that polydioxanone (PDS) reacts with urine causing chemical reaction increasing the chance of fistula and complication.[40] However, Ulman et al. found that the occurrence of fistula was high in children who underwent urethroplasty with vicryl compared to PDS.[41] In our study, there was no significant difference in the incidence of complication with respect to the suture material.

Long-term follow-up is required to access the pattern of urine flow in children who have undergone urethroplasty I.


  Conclusion Top


Distal hypospadias is common congenital condition. Distal hypospadias is uncommonly associated with renal anomaly, which was once again reiterated in our study. Undescended testis and inguinal hernia were the most common associated anomalies with distal hypospadias. MAGPI is choice in case of glanular and coronal hypospadias with minimal chordee. The Snodgrass technique is excellent choice in subcoronal and distal penile hypospadias with chordee. The complication rates in our study were comparable to other similar studies. The common complication observed after anterior hypospadias repair in our study was urethrocutaneous fistula.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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