Use of Double Pigtail Stent in Hypospadias Surgery

Abstract

Various types and materials of stents have been used for urinary diversion in hypospadias surgery. We evaluated whether double pigtail stents are superior to straight silicone stents.
We conducted a retrospective chart review of all patients who underwent hypospadias surgery with straight silicone or double pigtail stents between November 1997 and October 2005. Comparisons were made between the two groups specifically with regard to the complication rates.
A total of 86 patients were included. The complication rates in patients who received double pigtail stents were significantly reduced as compared with those who received straight silicon stents. There was less wound disruption associated with early stent dislodgement in the double pigtail group compared with the straight silicone group (3.2%vs. 17.4%, p< 0.05). The rate of urethrocutaneous fistula was also lower in the double pigtail stent group (12.7%vs. 30.4%). Subjectively, there was also improved patient comfort and parent anxiety in the double pigtail stent group.
Double pigtail stent is a suitable material for urinary diversion in hypospadias surgery. It not only reduces patient discomfort, but also decreases complication rates in hypospadias surgery.

Full text

28 ASIAN JOURNAL OF SURGERY VOL 34 • NO1 • JANUARY 2011
© 2011 Elsevier. All rights reserved.
Original ArticleOriginal Article
Use of Double Pigtail Stent in Hypospadias Surgery
Paul C.Y. Chang,1,2 Ming-Lun Yeh,1,3 Chun-Chih Chao1and Chi-Jen Chang,11Department of Pediatric Surgery,
Shin Kong Memorial Hospital, Taipei, ²Department of Pediatric Surgery, Fu-Jen Catholic University School of
Medicine, Hsinchuang, New Taipei City, and ³Department of Pediatric Surgery, E-Da Hospital, Kaohsiung, Taiwan.
OBJECTIVE: Various types and materials of stents have been used for urinary diversion in hypospadias
surgery. We evaluated whether double pigtail stents are superior to straight silicone stents.
METHODS: We conducted a retrospective chart review of all patients who underwent hypospadias surgery
with straight silicone or double pigtail stents between November 1997 and October 2005. Comparisons
were made between the two groups specifically with regard to the complication rates.
RESULTS: A total of 86 patients were included. The complication rates in patients who received double
pigtail stents were significantly reduced as compared with those who received straight silicon stents.
There was less wound disruption associated with early stent dislodgement in the double pigtail group
compared with the straight silicone group (3.2% vs. 17.4%, p<0.05). The rate of urethrocutaneous fistula
was also lower in the double pigtail stent group (12.7% vs. 30.4%). Subjectively, there was also improved
patient comfort and parent anxiety in the double pigtail stent group.
CONCLUSION: Double pigtail stent is a suitable material for urinary diversion in hypospadias surgery.
It not only reduces patient discomfort, but also decreases complication rates in hypospadias surgery.
[Asian J Surg 2011;34(1):28–31]
Key Words: double pigtail stent, hypospadias, straight silicone stent, urinary diversion
Introduction
Although the need for neo-urethral catheterization
remains controversial,1–4 urethral stenting following
hypospadias surgery offers the following advantages:
avoidance of obstruction secondary to postoperative
oedema; supporting repair and achieving urinary drainage;
and prevention of forceful urination with leakage through
suture lines. Various types and materials of stents have
been used for urinary diversion in hypospadias surgery.5
Traditionally, we have used simple straight silicone tubes
(FortuneMed, Corp., Taipei, Taiwan) for urethral stent-
ing, but since November 2001, we have changed to dou-
ble pigtail stents (Create Medic Co., Yokohama, Japan).
In this study, we evaluated whether double pigtail stents
are superior to straight silicone stents.
Patients and methods
We conducted a retrospective chart review of all patients
who underwent hypospadias surgery between November
1997 and October 2005. Patients with glandular hypo-
spadias were excluded, because no stents were used.
Information obtained included type of hypospadias,
surgical procedure performed, type of stent used, and
postoperative complications. The complications recorded
included early stent dislodgement, wound disruption,
meatal stenosis, urethral stricture, urethral diverticulum,
Address correspondence and reprint requests to Dr Ming-Lun Yeh, Department of Pediatric Surgery, E-Da Hospital,
1 E-Da Road, Yan-Chao District, Kaohsiung, Taiwan.
E-mail: paulcychang@gmail.com ●Received: May 3, 2010 ●Revised: Dec 1, 2010 ●Accepted: Jan 31, 2011

and urethrocutaneous fistula. Comparisons were made
between the patients who received straight silicone stents
and double pigtail stents. Statistical analysis was per-
formed by Student’s ttests.
All patients were operated under general anaesthesia
and endotracheal intubation. We adhered to general princi-
ples of plastic surgery, such as magnifying loupes and fine
instruments. Fine 6/0 and 7/0 monofilament absorbable
sutures were used. For both groups, the stent was placed
into the bladder and sutured with 5-0 Prolene to the glans
of the penis to prevent migration. For the straight silicone
stent group, 6 French, 15-cm-long pleated stents were
used, with the free end protruding for several millimetres
outside the urethral meatus. For the double pigtail stent
group, 4.8 French, 16-cm-long stents were used, with their
free end fashioned into a circle to prevent further inward
migration (Figure 1). All wounds were cared for in an
open fashion, with application of antibiotic ointment,
without wound cover, and the urine dripped continu-
ously into the diaper. In both groups, the stents were left
in situ for 7–10 days. Patient comfort and parental satis-
faction were recorded subjectively on a chart during
follow-up clinic visits.
Results
A total of 86 patients were included. Between November
1997 and October 2001, 23 patients who underwent
hypospadias surgery received straight silicone stents.
Between November 2001 and October 2005, 63 patients
received double pigtail stents. All patients were operated
on by the senior author (MLY). Both the double pigtail
and straight silicon stent groups were operated on at
a similar age (30 months vs. 29 months). The average
hospital stay was 3 days for both groups. Fine 7/0 mono-
filament absorbable polyglyconate sutures (Maxon) were
used for urethroplasty and 6/0 for preputioplasty. Oral
cefadroxil was prescribed for 3 days postoperatively
for all patients. Stents were kept between 7–10 days
postoperatively.
Both groups had similar distribution of types of hypo-
spadias. Forty-three patients in the double pigtail stent
group and 15 in the straight silicon stent group had distal
type hypospadias, which included coronal and subcoro-
nal types (68.3% vs. 65.3%, p>0.05). Eleven patients in the
double pigtail stent group and four in the straight silicon
stent group had middle type hypospadias, which included
proximal, mid-shaft and distal penile types (17.5% vs.
17.4%, p>0.05). Nine patients in the double pigtail stent
group and four in the straight silicon stent group had
proximal type hypospadias, which included penoscrotal,
scrotal and perineal types (14.3% vs. 17.4%, p>0.05). The
glandular type hypospadias were excluded, because no
stents were used in these patients.
For distal type hypospadias, the Snodgrass tabularized
incised plate procedure was performed. For the middle
type hypospadias, the Mathieu meatal-based flap proce-
dure was performed. For the proximal type hypospadias,
the Duckett’s onlay preputial island flap procedure was
performed.
There was no incidence of meatal stenosis, urethral
stricture or urethral diverticulum formation in either
group. Early stent dislodgement and wound disruption
occurred in four patients (17.4%) in the straight silicone
stent group, compared with two patients (3.2%) in the
double pigtail stent group. Urethrocutaneous fistula
occurred in seven patients (30.4%) in the straight silicone
stent group, and in eight patients (12.7%) in the double
pigtail stent group. Subjectively, there was less patient dis-
comfort and pain in the double pigtail stent group.
Parents of children in the double pigtail stent group were
less anxious about stent care compared with parents of
children in the straight silicon stent group.
Discussion
Hypospadias is a common congenital condition; however,
there are about 200 surgical procedures that have been
described in the literature, which represent evolving new
■ DOUBLE PIGTAIL STENT IN HYPOSPADIAS SURGERY ■
ASIAN JOURNAL OF SURGERY VOL 34 • NO1 • JANUARY 2011 29
Figure 1. Photograph of a patient showing the outer portion of
the double pigtail stent.

and modified techniques in an attempt to reduce com-
plications.6The complications of hypospadias surgery
depend on the severity of the disease, presence of chordee,
quality of the urethral plate, experience of the surgeon,
use of urinary diversion and dressing, as well as other non-
surgical factors.7Published rates of urethral fistula range
between 5% and 23%.8–10 The rate of complications with the
Snodgrass procedure can reach 17%.11 Complication rates
for Mathieu repair range between 3% and 12%.12 For more
severe hypospadias, the Duckett’s onlay island flap is asso-
ciated with fistula formation in up to 44% of patients.13,14
In our series, the complication rates of meatal stenosis and
urethral stricture were much lower than those reported in
the literature. However, in our straight silicon stent group,
the fistula rate was slightly higher than average. This could
have resulted from the fact that there were fewer patients
included in that period. In the double pigtail stent group,
the fistula rate was within the reported range.
Various reports have debated whether stenting is
necessary.15,16 Different institutions use different types of
stents. Some are specified in their publications, others
simply have mentioned their size; probably representing
what is available at that institution. Double pigtail stents
have been designed specifically as ureteral stents that
lodge easily between the kidney and urinary bladder. We
attempted to improve our surgical results by using its
specific quality as a urethral stent.
From our experience, we noted that double pigtail
stents are superior to straight silicone stents. There was
no increased incidence of meatal stenosis or urethral stric-
ture, even when a smaller stent was used (6 Fr vs. 4.2 Fr).
There was no incidence of bladder irritation that required
treatment with oxybutynin. The spectrum of complica-
tions between the double pigtail and strain silicone stent
groups remained the same. The incidence of stent-related
wound dehiscence was significantly reduced for the double
pigtail group compared with the straight silicone group
(3.2% vs. 17.4%). The incidence of urethrocutaneous fistula
was also significantly reduced for the double pigtail
group compared with the straight silicone group (12.7%
vs. 30.4%). In addition, there was also subjective improve-
ment in patient comfort in the double pigtail stent group.
On the contrary, most of the patients with the straight
silicone stent in place were more irritable until the tube
was removed.
There were several limitations in this study. As a retro-
spective study, the evidence was not as strong as that with
a prospective randomized trial. However, because of the
initial experience of patient comfort and parental satis-
faction, our clinical acumen steered us away from con-
ducting a randomized trial, and we used historical controls
instead. We propose several possible mechanisms by
which double pigtail stents are superior to straight sili-
cone stents. First, the double pigtail stent is softer and has
a low-friction polymer surface. It causes less tissue trauma,
results in better wound healing and less patient discom-
fort than the straight silicone stent. Second, the fenestra-
tions of the double pigtail stent allow debris and exudate
to be washed away from the site of repair, thus promoting
wound healing.16–18 Third, the actual curvature of the
double pigtail stent prevents migration inwards and out-
wards. The curvature on the bladder side and its blunt tip
also cause less irritation and discomfort than does the
straight silicone stent. Lastly, the diameter of the double
pigtail stent is smaller than that of the straight silicone
stent, which could explain why less discomfort was
reported with the double pigtail stent.
It is our conclusion that double pigtail stent is suitable
for urinary diversion in hypospadias surgery. It reduces
patient discomfort and complications, such as fistula for-
mation, in hypospadias surgery.
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