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Case series: long term experience with different types of hypospadias and its correction by single stage procedure
Abstract and Figures
Background: Hypospadias is a relatively common congenital defect of the male external genitalia. It is present in approximately 1 in 250 male newborns. Hypospadias, in boys, is defined as an association of three anomalies of the penis: an abnormal ventral opening of the urethral meatus that may be located anywhere from the ventral aspect of the glans penis to the perineum, an abnormal ventral curvature of the penis (chordee), and an abnormal distribution of foreskin with a “hood” present dorsally and deficient foreskin ventrally.Methods: In this study author operated 250 cases of Hypospadias of different types in different age groups during (1992-2017) using MAGPI for glandular, TIP and Flip-flap procedure for distal penile and Ducket Onlay Flap technique for Proximal penile, penoscrotal and perineal Hypospadias. Complicated / Failed Hypospadias was repaired by Trap door technique or Byer’s double tube technique.Results: After the primary repair of Hypospadias fistula was found in 4.5% of patients. Post-operative haemorrhage was seen in 3.2% of patients. Flap Necrosis was found in 8% of patients after Mathieu’s Flip- Flap technique. The success rate of Complicated Hypospadias was quite satisfactory and Meatal Stenosis was seen in 10% of the cases. Over All study has shown superior cosmetic results and one stage repair is cost effective, satisfactory and less psychologically affecting the parents and the patients.Conclusions: MAGPI and its different modifications in the repair for Glandular and Flip-flap or TIP for distal penile in cases of mild or no chordee. Proximal Penile has sufficient Chordee and can be corrected by dorsal plication and urethroplasty by Ducket’s Onlay flap technique. The cost-effectiveness due to single stage repair and its cosmetic results and there least complications prove the efficacy of this protocol. Single stage repair is also beneficial for developing countries like India where the follow-up compliance in the rural patients is extremely poor.
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Introduction
The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair.
Methods
We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002–2012) for relevant articles, using the terms ‘proximal hypospadias’, ‘posterior hypospadias’ ‘single stage’, ‘multiple stage’, and ‘complications’. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate.
Results and conclusions
The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.
There are many techniques of harvesting vascularized skin flaps from penile skin for hypospadias repairs. Here, we review our experience with the use of longitudinal dorsal island flap (LDIF) for mid- and proximal hypospadias repairs and to assess the results and complications of onlay and tubularized repairs.
We retrospectively reviewed the data of all children with hypospadias operated by a single surgeon using the LDIF technique. The severity of hypospadias, technique, complications, and follow-up were assessed.
Over a 9.4-year period, 102 children (mean age 4.2 years, range 6 months to 11 years) were operated for primary hypospadias using the LDIF technique. All children had poorly formed urethral plates and hence were considered unsuitable for tubularized incised plate repair. The hypospadias was classified as midpenile, proximal penile/penoscrotal or perineal in 29, 64, and 9 children respectively. Onlay LDIF repair was done in 85 children, while in 17 children, tubularized LDIF repair was performed. At a mean follow-up of 1.8 years, complications occurred in 12 (12%) children. Complications were more common after tubularized repairs than onlay repairs (24% vs. 9.5%). All glans dehiscences occurred after onlay repairs, while meatal stenosis and diverticulum occurred after tubularized repairs. No child had urethral stenosis after onlay repair, and uroflow studies in 16 children demonstrated normal curves and flow rates.
We report the use of LDIF for single-stage mid and proximal hypospadias repair with good success and an acceptable complication rate. Onlay repairs had fewer complications than tubularized repairs. Our results indicate that the specific advantages and versatility of LDIF make it a good option to consider in cases of hypospadias with poorly developed urethral plates where onlay or substitution urethroplasty is indicated.
A technique is described for correction of distal hypospadias with minimal chordee by tubularizing the urethral plate. The key step is deep longitudinal incision of the plate, which allows for tubularization without the need for additional flaps. The resultant neourethra is functionally adequate and an excellent cosmetic result with a vertically oriented meatus is achieved. A total of 16 boys underwent the procedure with no case of meatal stenosis or fistula occurring during a median followup of 22 months.
We evaluated one-stage hypospadias repairs in providing a normal looking penis with a normal functioning urethra. Also we looked critically at the effects of the severity of hypospadias, the type of repair and the experience of the surgeon on the outcome. Materials and
From 1987 to 1996 we performed 578 primary hypospadias repairs. The type and surgical results as well as the effects of certain variables on outcome were reviewed retrospectively.
544 single-stage hypospadias repairs have been followed up for a mean of 19 months (range 12-49). They included: MAGPI (92), ARAP (78), Mathieu (205), Mustarde (12), Duckett's tubularized preputial flap (142) and Onlay preputial flap (15). Despite an initial overall complication rate of 19%, the final success rate was 96%, after a mean of 1.3 procedures. Complications included fistula in 48 (9%) cases, meatal stenosis or retraction in 28 (5%), residual chordee in 17 (3%), stricture in 14 (2.5%), tubal abnormality in 10 (2%), and flap necrosis in 9 (2%). Complication rates were significantly higher (p < 0.05) when the meatus was proximal, the degree of chordee was moderate or severe and in the early series. Complication rates were also significantly higher with flap procedures and when the urethral plate was resected. Cosmetic defects occurred mainly with meatal advancement procedures.
A repertoire of different types of single stage procedures has allowed the successful treatment of most hypospadias cases presenting to one surgeon. Complication rates increases with the severity of hypospadias or transection of the urethral plate. A cumulative experience allows for better results via a proper selection of the procedure and a perfection of a few techniques.
The repair of hypospadias is among the most difficult problems in urology, as it demands the construction of a well-functioning urethra and a good cosmetic appearance. We performed a retrospective analysis of 422 cases subjected to one-stage anterior hypospadias repair between 1982 and 1999 in our clinic and investigated the effects of factors like degree of hypospadias, surgical technique, and the surgeon's experience on outcome. The operations used were MAGPI (91), urethral advancement (10), Mathieu (260), modified Allen-Spence (50), onlay island flap (5), and double-faced island flap (6) procedures. The early complication rate was 18%, while the final success rate following secondary interventions was 95%. The complications included fistula formation in 49 cases (12%), flap necrosis in 12 (3%), meatal problems in 12 (3%), residual chordee in 4 (1%), and urethral stricture in 1 (<1%). Complication rates were significantly higher if the meatus was proximal or there was severe chordee and in the first 6 years of the study. The flap procedures were associated with a higher complication rate. It is concluded that one-stage procedures are successful in the repair of anterior hypospadias in experienced hands with proper patient selection.
Tubularized incised plate urethroplasty has now been successfully applied to all varieties of hypospadias. Given this versatility and the good cosmetic outcomes, the operation has achieved widespread popularity. We review important technical aspects of the repair.
Key steps include preservation of the urethral plate during correction of the ventral curvature, midline incision of the plate for urethroplasty, and subsequent glansplasty. Lessons learned from personal and published experiences are emphasized.
Tubularized incised plate urethroplasty is currently one of the most popular techniques for hypospadias repair. Attention to important surgical details is needed to obtain optimal functional and cosmetic results.
Hypospadias is repaired by paediatric surgeons, paediatric urologists, adult reconstructive urologists and plastic surgeons. This review is unique in representing all four specialities, to provide a unified policy on the management of hypospadias. The surgeon of whichever speciality should have a dedicated interest in this challenging work, ideally having an annual volume of at least 40-50 cases. The ideal time for primary repair is at 6-12 months old, although when this is not practicable there is another opportunity at 3-4 years old. A surgical protocol is presented which emphasises both functional and cosmetic refinement. Using a logical progression of a very few related procedures allows the reliable correction of almost any hypospadias deformity. A one-stage repair is used when the urethral plate does not require transection and its axial integrity can be maintained. Occasionally, when the plate is of adequate width and depth, it can be tubularized directly using the second stage of the two-stage repair. When (usually) the urethral plate is not adequately developed and requires augmentation before it can be tubularized, then that second-stage procedure is modified by adding a dorsal releasing incision +/- a graft (alias Snodgrass and 'Snodgraft' procedures). The two-stage repair offers the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. From available evidence this protocol combines excellent function and cosmesis with optimum reliability. Nevertheless, it would be complacent to assume that these gratifying results will be maintained into adult life. We therefore recommend that there is still a need for active follow-up through to genital maturity.
We evaluated the outcome of postpubertal patients who underwent 1-stage hypospadias repair before onset of puberty with at least 10 years of followup.
A total of 2,053 patients underwent surgical repair of hypospadias between January 1981 and May 2004 at our hospital. We evaluated patients who are now at least 18 years old and who underwent 1-stage hypospadias repair. Data were collected in regard to familial incidence, age at operation, operative technique, complications and followup of at least 10 years. Evaluation was subdivided based on operative procedure.
A total of 126 patients were included in the study. The familial incidence was 7.9% of cases and an associated undescended testis was seen in 9.5%. There were 62 cases with no complications. At least 1 complication was seen in 64 cases, including infection in 3, tissue necrosis in the operative area in 3, wound dehiscence in 6, fistula in 29, meatal stenosis in 15, urethral stenosis in 10, cosmetic dissatisfaction in 16 and other in 2.
Even in the hands of the experienced pediatric urologists the complication rate after hypospadias repair remains high, with an average of 54% at long-term followup. Our results clearly showed that additional complications can present after long-term followup (a first complication can present after more than 5 years with the longest interval being 14 years). Therefore, final outcome of hypospadias surgery can only be evaluated once the patient has reached adulthood. The results seem to depend on the severity of the abnormality, reflected in the complication distribution rather than operative technique.