|Year : 2019 | Volume
| Issue : 2 | Page : 539-543
Evaluation of different techniques in the management of crippled hypospadias
Tamer A Sultan1, Mohammed H Abdel-Satar1, Kareem M Ouda2
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Submission||17-Dec-2017|
|Date of Acceptance||27-Feb-2018|
|Date of Web Publication||25-Jun-2019|
Kareem M Ouda
Source of Support: None, Conflict of Interest: None
To evaluate and compare different modalities that used in the management of different complications that we face in cases of crippled hypospadias.
Hypospadias is one of the most common congenital deformities in humans. It has many causes and its repair is a challenging topic of urogenital reconstructive surgery. Many different techniques are currently being used.
Patients and methods
This was a randomized prospective study which included 30 patients with crippled hypospadias who presented to Menoufia University Hospital and who were classified into three groups: group A patients underwent tubularized incised plate (TIP) urethroplasty; group B patients underwent Thiersch–Duplay urethroplasty and group C patients underwent buccal mucosal graft.
The age of the cases at the time of repair ranged between 2 and 14 (8.55 ± 2.3) years. The most common postoperative complications in the whole groups were urethrocutaneous fistula (13.3%), followed by meatal stenosis (6.7%), while urethral stricture and donor site complications were the rarest encountered in only one (3.3%) case.
There is no single applicable technique for hypospadias repair, if the urethral plate is healthy we can repair with TIP, if we have available nearby penile or preputial skin we use Duplay graft. Moreover buccal mucosa could be used in rest crinkled hypospadias.
Keywords: allograft, diverticulum, hypospadias, testosterone, urethra
|How to cite this article:|
Sultan TA, Abdel-Satar MH, Ouda KM. Evaluation of different techniques in the management of crippled hypospadias. Menoufia Med J 2019;32:539-43
|How to cite this URL:|
Sultan TA, Abdel-Satar MH, Ouda KM. Evaluation of different techniques in the management of crippled hypospadias. Menoufia Med J [serial online] 2019 [cited 2020 Feb 27];32:539-43. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/539/260936
| Introduction|| |
Hypospadias is one of the most common congenital deformities in humans. Its incidence varies between 1:1000 and 1:100 births. The etiology is not fully understood, but there are theories involving testosterone deficiency, multifactorial causes, genetic predisposition, tissue remodeling, and others,.
Hypospadias repair is a challenging topic of urogenital reconstructive surgery, and many different techniques are currently being used.
Proximal hypospadias, being identified in 20% of cases, has a higher incidence of complications. Various surgical techniques have been used to repair proximal hypospadias, including tubularized incised plate and onlay island flap urethroplasty. Urethral plate (UP) mobilization and dorsal plication have been used to correct penile curvature of hypospadias with chordee,.
The surgical repair of primary hypospadias in childhood may result in late postoperative complications involving the external urinary meatus (stenosis and retrusive meatus), the urethra (stricture, fistula, and diverticulum), the corpora cavernosa (penile curvature, torsion, or deformity), the preputial skin or the genitalia. The main causes of these late surgical complications are poorly executed procedures, postoperative infection, wound dehiscence, urine extravasation, hematoma, or ischemia or necrosis of transplanted tissues.
The term 'crippled hypospadias' has been coined for individuals with remaining functional complications after multiple attempts at hypospadias repair. This term, however, is somewhat pejorative and should probably be avoided in contemporary discussion of this problem. Men have a very heavy burden of psychological problems related to the complications of failed hypospadias repair.
The choice of an optimal method depends on anatomical factors; one of the main challenges in surgery for crippled hypospadias is the correction of severe ventral curvatures, especially in cases where only a dorsal plication is not sufficient to straighten the penis shaft, and ventral lengthening of the corpus cavernosum is necessary. A number of tissues have been used as grafts to restore corpora integrity after corporotomy; the main ones are the tunica vaginalis flap, the dermal allograft, and the porcine intestinal submucosa.
Patients who develop strictures after hypospadias repair as a child pose particular problems for stricture repair. Repairs on these individuals are difficult because of scarring, immobility, inflammation, poor blood supply, as well as penile and urethral shortening from earlier surgery.
The aim of this study was to evaluate and compare different modalities that are used in the management of different complications that we face in cases of crippled hypospadias.
| Patients and Methods|| |
All parents of the patients were given full information about the operation that will be done for their infants, its benefits, and any harms entailed. An oral consent was taken from the parents of patients who agreed to participate in the study.
This was a randomized prospective study which included 30 patients with crippled hypospadias who presented to Menoufia University Hospital. Their ages ranged between 6 months and 14 years.
All patients were subjected to a detailed history taking including the type of hypospadias, the previous operations done for repair, the follow-up period for these operative techniques, medical examination 'general and local examination' carried out for all patients, and the choice of operative procedure depended on thorough evaluation of the condition and availability of healthy surrounding skin flaps.
The following scheme was used for differentiating the types of procedures used for the management of hypospadias after correction of chordee. In cases of healthy intact UP, we used TIP urethroplasty. In cases of redundant ventral penile skin, we used Thiersch–Duplay urethroplasty. In cases with excessive scarring or if there were no available healthy surrounding skin flaps, free grafts 'such as buccal mucosal grafts' were used. In cases with no local healthy skin, buccal mucosal or free skin grafts were used, and in cases with no local healthy skin with long paucity urethral defect, a combination of more than one technique was used.
According to the surgical procedure used, the patients of the study (30 patients) were classified into three groups: group A patients underwent TIP urethroplasty, group B patients underwent Thiersch–Duplay urethroplasty, and group C patients underwent buccal mucosal graft.
All patients were followed up in the outpatient clinic as follows: patients were examined every week during the first month and every 2 weeks for 5 months.
The items of assessment included, the force and caliber of the urinary stream, degree of postoperative edema, presence of complications, and evaluation of late results 3–6 months postoperatively.
Using the standard statistical tests, the two groups for qualitative data will be compared.
| Results|| |
The age of the majority of cases at the time of repair ranged between 2 and 14 years with a mean age of 8.55 ± 2.3 years, nine (30%) patients were between 2 and 4 years with a mean of 3.2 ± 1.1 (group A), in eight (26.7%) patients their age ranged between 4 and 6 years with a mean of 5.4 ± 2.2 years (group B), in 13 (43.3%) patients the age ranged between 6 and 8 years 7.3 ± 3.1 years (group C), and the statistical analysis showed that there was no significant difference between the groups regarding the age of the patient (P = 0.061, 0.073 and 0.057, respectively) [Table 1].
Four of our patients (4/30, 13.3%) had only one previous operation, 11 (11/30, 36.7%) patients had two previous operative interference, while 15 (15/30, 50%) patients had three or more previous operative interference [Table 2].
|Table 2: Distribution of cases according to the number of previous operations|
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In our study; four (4/30, 13.3%) patients had a mild degree of fibrous chordee, in three cases (3/30, 10%) there was a moderate degree of fibrous chordee, while one (1/30, 3.3%) patient had a severe fibrous chordee that was corrected by excision of the fibrous tissue only before urethroplasty. It should be noted that out of the studied cases only one case had a lateral remnant of the prepuce and used as free skin graft followed by Thiersch–Duplay urethroplasty 6 months later.
Twenty of our studied cases (20/30, 66.6%) encountered early postoperative complications, the most common postoperative complications in the whole group was urethrocutaneous fistula (6/30, 20%), followed by infection (5/30, 16.7%), edema (4/30, 13.3%), hematuria (2/30, 6.7%) while hemorrhage, retention, and complete failure were the rarest early postoperative complications encountered in only one (1/30, 3.3%) case [Table 3].
|Table 3: Early (within the first 2 weeks postoperatively) complications encountered during follow-up of the studied groups|
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The total number of complicated cases in group A was six (6/30, 20%); in group B were four (4/30, 13.3%), while early postoperative complications were encountered in 10 (10/30, 33.3%) cases of group C [Table 3].
Eight (8/30, 26.6%) of our studied cases encountered late postoperative complications; the most common postoperative complications in the whole group was urethrocutaneous fistula (4/30, 13.3%), followed by meatal stenosis (2/30, 6.7%), while urethral stricture and donor site complications were the rarest late postoperative complications encountered in only one (1/30, 3.3%) case [Table 4].
|Table 4: Late (> 2 weeks and ≤6 months postoperatively) complications encountered during follow-up of the studied groups|
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The total number of late complication in group A was two (2/30, 6.7%) cases; in group B no cases were encountered (0/30, 0.0%) while late postoperative complications were encountered in six (6/30, 20%) cases of group C [Table 4].
| Discussion|| |
The surgical approach to failed hypospadias repair is mainly focused on urethral reconstruction and rarely on problems involving the corpora cavernosa or the complete resurfacing of the genitalia.
After the creation of a neourethra in a 'hypospadias cripple', resurfacing the penis with healthy skin is a significant challenge because the local tissue is often scarred and unusable. Many authors had experience with various strategies to resurface the penis in hypospadias cripples.
In our study, the age of the patients ranged from 6 months to 14 years. The age of the majority of cases at the time of repair ranged between 2 and 14 years with a mean age of 8.55 ± 2.3 years. Barbagli et al. in their study on 1176 patients found that the age of the patients ranged between 1 and 12 years which was in agreement with our study.
In our study, patients underwent previous operations for correction of hypospadias ranged from one time to three or more times. Nerli et al. reported in their study that their patients underwent previous operations from 2 to 5 times, which was in agreement with our results. Gill et al. showed in their study on crippled hypospadias had previously undergone multiple (3–16) procedures which is in contradict with our results. Mousavi et al. in their study found that the age at operation ranged 7–34 months with previous operations of 1–5 times which was in agreement with our results.
In our study, fibrous chordee of various degrees was present and corrected before urethroplasty. The risk of complications such as fistula, infection, and residual penile curvature in hypospadias surgery is relatively high even though perfect surgeries are performed correction of the complications with secondary surgeries which are still challenging especially in patients with scarred, inadequate penile tissue.
In our study, the commonly encountered early postoperative complications were urethrocutaneous fistula, infection, edema, hematuria, hemorrhage, retention, and complete failure. Nerli et al. reported in their study that the most common early postoperative complications of hypospadias repair included bleeding, hematoma, meatal stenosis, urethrocutaneous fistula, urethral stricture, urethral diverticulum, wound infection, impaired healing, and breakdown of the repair which was in agreement with our results.
In our study, the complication rate in group A was 20%; in group B 13.3%, while in group C it was 33.3%. Mousavi et al. in their study reported that Yang et al. studied complications in patients without UP manipulation and reported that there were no complications in this group compared with the 41.2% occurrence of complications, mostly fistula, in patients with a history of TIP urethroplasty which is in contradict to our study. Chen et al. found in their study that complications included urethrocutaneous fistulas, urethral strictures, and urethral diverticulum which coincidence with our results. It has been concluded that the use of the transverse preputial island flap can decrease complications associated with the second stage and significantly improve the success rate.
In our study, late postoperative complications commonly encountered were urethrocutaneous fistula, meatal stenosis, urethral stricture, and complications of the donor site which were the rarest late postoperative complications. Barbagli et al. reported in their study that the cause of late complications are poorly executed procedures, postoperative infection, wound dehiscence, urine extravasation, hematoma, or ischemia or necrosis of transplanted tissues which coincide with what we found in our study.
The total number of late complications in group A was 6.7%; in group B no complications were encountered, while in group C it was 20%. The success rate for the whole group was 73.4%. Leslie et al. found in their study using buccal mucosal graft a success rate of 66% without any donor side complications which coincide with our results. While it contradicts with our study, Barbagli et al. found a higher success rate using buccal mucosa (82%). Mousavi et al. reported in their study that Nguyen et al. and Eliçevik et al. emphasized that TIP urethroplasty technique is the best for repair of recurrent hypospadias if the UP has not been excised.
| Conclusion|| |
There is no single applicable technique for hypospadias repair, if the UP is healthy we can repair with TIP, if we have available nearby penile or preputial skin we use Duplay graft. Moreover buccal mucosa could be used in rest crinkled hypospadias.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stanasel I, Le HK, Bilgutay A, Roth DR, Gonzales ET Jr, Janzen N, et al
. Complications following staged hypospadias repair using transposed preputial skin flaps. J Urol 2015; 194
Mattos RM, Araújo SRR, Quitzan JG, Leslie B, Bacelar H, Parizi JLG, et al
. Can a graft be placed over a flap in complex hypospadias surgery? an experimental study in rabbits. Int Braz J Urol 2016; 42
Orkiszewski M. A standardized classification of hypospadias. J Pediatr Urol 2012; 8
Zheng DC, Yao HJ, Cai ZK, Da J, Chen Q, Chen YB, et al
. Two stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single center experience. Asian J Androl 2015; 17
Long CJ, Canning DA. Proximal hypospadias: we aren't always keeping our promises. F1000Res 2016; 5
Barbagli G, Sansalone S, Djinovic R, Lazzeri M. Surgical repair of late complications in patients having undergone primary hypospadias repair during childhood: a new perspective. Adv Urol 2012; 2012
Kiss A, Sulya B. Long-term psychological and sexual outcomes of severe penile hypospadias repair. J Sex Med 2011; 8
Hampson LA, McAninch JW, Breyer BN. Male urethral strictures and their management. Nat Rev Urol 2014; 11
Fam MM, Hanna MK. Resurfacing the penis of complex hypospadias repair 'hypospadias cripples'. J Urol2017; 197 (Pt 2)
Nerli RB, Neelagund SE, Guntaka A, Patil S, Hiremath SC, Jali SM, et al
. Staged buccal mucosa urethroplasty in reoperative hypospadias. Indian J Urol 2011; 27
Gill NA, Hameed A. Management of hypospadias cripples with two-staged Bracka's technique. J Plast Reconstr Aesthet Surg 2011; 64
Mousavi SA, Aarabi M. Tubularized incised plate urethroplasty for hypospadias reoperation: a review and meta-analysis. Int Braz J Urol2014; 40
Cakmak M, Gollu G, Kucuk G, Bahadir B. Rapid intraoperative tissue expansion with Foley catheter in a challenging cripple Hypospadias. Int Braz J Urol 2015; 41
Yang SS, Chen SC, Hsieh CH, Chen YT. Reoperative Snodgrass procedure. J Urol 2001; 166
Chen C, Yang TQ, Chen JB, Sun N, Zhang WP. The effect of staged transverse preputial island flap urethroplasty for proximal hypospadias with severe chordee. J Urol 2016; 196
Leslie B, Lorenzo AJ, Figueroa V. Critical outcome analysis of staged buccal mucosa graft urethroplasty for prior failed hypospadias repair in children. J Urol 2011; 185
Nguyen MT, Snodgrass WT. Tubularized incised plate hypospadias reoperation. J Urol 2004; 171
:2404–2406; [discussion 2406].
Elicevik M, Tireli G, Demirali O, Unal M, Sander S. Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients. Int Urol Nephrol2007; 39
[Table 1], [Table 2], [Table 3], [Table 4]