Single center experience of primary hypospadias repair
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.153150
Introduction: Hypospadias is a complex congenital deformity which requires meticulous surgical technique. Several techniques have been advocated during the past 150 years to address chordee and construction of neourethra. This study highlights the surgical techniques and experience with primary hypospadias cases. Materials and Methods: A total of 65 patients aged ranges from 1 to 18 years underwent primary hypospadias repair at our center from August 2007 to December 2012. Exclusion criteria - previous surgical attempt or with incomplete follow-up. Patients with inadequate phallic size and age <12 years were administered injection testosterone (Testoviron) prior to the surgery. Patients with significant chordee underwent chordee correction followed by urethral reconstruction by either tubularized incised plate (TIP) or on-lay flap repair/dartos flap repair. In all the patients, infant feeding tube was kept per urethrally for 3 weeks and was removed between the post-operative day 18 th and 21 st day. Results: Out of 65 patients, 24 patients underwent TIP. A total of 41 patients underwent on-lay flap repair; of this six patients of midscrotal/perineal hypospadias underwent a combination of paraurethral skin and on-lay flap repair. Chordee correction was done in all the five cases of chordee without hypospadias (congenital short urethra) and dysplastic, transparent urethra repaired with on-lay flap repair. In our study, complications like flap necrosis and fistula were seen in 10 cases and other minor complications like superficial epidermal sloughing were seen in 13 cases which healed with epithelialization. Meatal stenosis was more commonly observed with TIP (four cases) and in two cases of on-lay repair. Conclusion: Historically, hypospadias surgery was regarded as non-rewarding surgical reconstruction due to higher complication and failure rates. For hypospadias, if planned properly, primary single stage repair; acceptable surgical success is an achievable target. Keywords: Chordee, hypospadias, tubularized incised plate
Hypospadias is defined as the spectrum of an abnormal ventral urethral meatus, an abnormal ventral penile curvature (chordee) and a deficiency of ventral preputial skin with enumerable permutations. It is one of the most common congenital anomalies seen in males with incidence being 1 in 150-300 male births. [1] Hypospadias is a congenital deformity which requires meticulous surgical planning and reconstruction. Several techniques have been advocated during the past 150 years to address chordee and construction of neourethra. The refashioning of the abnormally formed urethra offers a formidable problem in this field of art which is aptly described as hypospadiology. Culp and McRoberts [2] in 1968, very well stated that "It is the inalienable right of every boy to be a pointer instead of a sitter by the time he starts school and to write his name legibly in the snow." Traditionally, hypospadias reconstruction was multistage endeavor with a very high complication rates up to 30%. Multiply failed repairs carried ominous stigma of "hypospadias cripple." With this background, there was reasonable resistance among surgeons to venture in this field of reconstruction.
This prospective study was carried out in Department of Urology. A total of 65 patients aged 1-18 years (mean-3.5 years) underwent primary hypospadias repair at our center from August 2007 to December 2012. Institutional ethical committee clearance was taken prior to the commencement of the study. Written informed consent form was obtained from all the patients/parents before surgery. All patients with previous surgical attempt or with incomplete follow-up were not included in the study. Patients were categorized as per the anatomical location of urethral meatus [Table 1]. Patients with inadequate phallic size and age <12 years were administered injection testosterone (testoviron) prior to the surgery as three doses (50 mg for age <4 years and 100 mg for age >4 years) deep intramuscular (I/M) at 3 weeks interval. Patients with significant chordee underwent chordee correction followed by urethral reconstruction by either tubularized incised plate (TIP) or on-lay flap repair. Patients were given broad spectrum I/V antibiotics at the time of induction and continued up to post-operative day (POD) 5. Check dressing was done on POD 3 and POD 7 and the wound was left open thereafter. Due precaution were taken for detecting and treating infections if any. In all the patients, infant feeding tube (IFT) was kept per urethrally for 3 weeks and was removed between POD 18 th and 21 st day. Patients were followed up on a regular basis at 3 months, 6 months, and 1 year.
Surgical Protocol Pre-operative 1. Three doses of injection testosterone (testoviron) at 3 weekly interval to increase the phallic length and vascularity of flap provided us good vascularized dartos barrier flap. Intra-operative
Post-operative
Out of 65 patients, 24 patients underwent TIP. 41 patients underwent on-lay flap repair; of this six patients of midscrotal/perineal hypospadias underwent a combination of paraurethral skin and on-lay flap repair. Chordee correction was done in all the five cases of chordee without hypospadias (congenital short urethra) and dysplastic, transparent urethra repaired with on-lay flap repair. In our study, complications like flap necrosis was noted in two cases (4.8%) in on-lay repair group and fistula was seen in eight cases (19.5%), of which 2 fistula were noted in congenital short urethra cases. Other minor complication like superficial skin sloughing was seen in 13 cases which healed with epithelialization. Meatal stenosis was more commonly observed with TIP (4 cases, 16.7%) and but only in two cases (4.87%) of on-lay repair. Significant residual chordee was noted in three cases of proximal/perineal hypospadias which required correction. Total number of significant complications in TIP was noted in five cases of 24 (20.8%) and eight cases of 41 (19.5%) in on-lay group. Of these 13 patients, four cases of metal stenosis had fistula which healed with meatal dilatation and in on-lay repair group two patients had flap necrosis as well as fistula. Second surgery was required in three cases of significant residual chordee and two cases of flap necrosis. All the complications are summarized in [Table 2].
Failure of urogenital fold development or failure of its distal closure to a variable extent leads to hypospadias. The extent of the closure determines the position of the urethral orifice. Hypospadias has multifactorial etiology. It results from incomplete embryologic development; as a result of:
Occasionally, this could be a manifestation of disorder of sex development like testicular feminizing syndrome/5-alpha reductase deficiency. [3] Another postulate for hypospadias is delayed maturation of hypothalamic-pituitary-testicular axis. Familial hypospadias is seen in 7% cases, which may be due to genetic defects like CYP17 gene suppression. Certain environmental factors such as insecticides, pharmaceuticals, and metal cans used in canned foods industry are coated internally with plastics rich in estrogenic substances are responsible for rising trend of hypospadias world-wide. [4],[5],[6],[7] Maternal exposure to progestin as in assisted reproductive technique has a higher incidence of hypospadias. Maternal dietary deficiency of meat and fish may also result in a four-fold increase in hypospadias cases. [8],[9],[10],[11] The early description of hypospadias surgery was dated back during the second half of 19 th century by Thiersch and Duplay. [12] Since then, hundreds of techniques have evolved, mostly to answer the challenge of creating a functional neourethra. In the coronal and subcoronal (distal) hypospadias group, there is a change in the trend of using TIP approach as against to buried skin strip principle of Denis Browne. [13] In 1994, Snodgrass popularized the concept of urethral plate incision with subsequent tubularization and secondary dorsal healing for primary hypospadias repair. Creevy has proposed that "urethral plate," the strip of epithelium overlying fibrous remnants of the malformed corpus spongiosum, contribute to penile curvature. And hence, transection of the urethral plate was advocated when chordee persisted after the penis was degloved. Many authors have challenged this theory, noting that chordee is usually not improved by transecting the urethral plate. Many authors believe that deeply grooved and wide urethral plate may have less chances of metal stenosis when compared to flat and narrow urethral plate. [14],[15],[16] TIP procedure, which was originally developed to target distal hypospadias repair, recently demonstrated its effectiveness in proximal hypospadias as well. [17] Since, the TIP procedure does not use skin flaps, previous circumcision or hypospadias repair is not a limitation. In our study, 24 patients of distal and milder forms of hypospadias underwent TIP. The urethral plate is always preserved in our cases of TIP. In all our cases of TIP, urethral plate was incised in the midline, vertically to widen it sufficiently for tubularization. It was independent of the finding whether, the urethral plate was flat or grooved. In all the cases, chordee correction was achieved by completely degloving the penis, excision of fibrous, dysplastic tissue. In addition, Nesbit's plication was done whenever needed. In our TIP series, five patients had complications like fistula (three cases, 12.5%) and meatal stenosis (four cases, 16.7%). Two patients had meatal stenosis with fistula. Fistula healed following meatal dilatation on follow-up. Mustafa [18] in his study had overall complication rate as 33.4% (fistula-25%, meatal stenosis-8.4%). Similarly in yet another large study of 324 cases, Eliçevik et al. had reported 23% overall complications (fistula-15% and metal stenosis-7%). [19] Other series have shown comparable rate of metal stenosis, ranging from 6% to 20% and fistula rate ranging from 0% to 16%, respectively. [20] In our study, out of 41 on-lay repairs, eight patients had major complications. Three cases of proximal hypospadias had significant residual chordee requiring a second surgery. Five patients had fistula, two of these were cases of chordee without hypospadias repaired by de-epithelialized dartos flap and two cases had proximal fistula with distal flap necrosis. Other two cases had coronal fistula with metal stenosis which healed spontaneously after metal dilatation. Overall, 20% patients had complications in our study which is much below than the published literature. In another study by Prat et al., which included 820 hypospadias cases at a single center, the average complication rate was 28.7% (TIP-33.7% and on-lay flap-48.5%). [12] which is quite high as reported in the literature. Authors have cited residents performing the surgery as the reason for higher complication rates.
Hypospadias surgery was always regarded as non-rewarding surgical reconstruction; due to higher complication rate and repeated failures. Terminology of "hypospadias cripple" was used in literature for repeated failed cases. As is true for any other reconstruction, for hypospadias also, properly performed primary repair does always yield the best results. With better knowledge of penile anatomy, vascularity and barrier dartos flap, the overall success has significantly increased. With TIP repair as popularized by Snodgras and On-lay repair as proposed by Duckett et al., hypospadias repair has become rewarding having minimal significant complications. The key to success in this study was adherence to the predefined surgical protocol which resulted in minimal complications and better outcome.
The authors wish to express their gratitude to The Dean, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Center, Pune for allowing us to use the hospital records of the patients and other materials in the preparation of this study.
[Table 1], [Table 2]
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