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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 665-670

Redo surgery in hypospadias


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of General Surgery, Shebin El Kom Teaching Hospital, Menoufia, Egypt

Date of Submission09-Jan-2019
Date of Decision11-Mar-2019
Date of Acceptance17-Mar-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Shiamaa M Kalama
Department of General Surgery, Shebin El Kom Teaching Hospital, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_19_19

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  Abstract 


Objective
The aim of this study was to determine and evaluate the types of complications and the best type of redo repair.
Background
Hypospadias surgery is characterized by a constant evolution. The surgeon should use the technique that is suitable for the patient and with which he is most conversant. The best operation for hypospadias correction is the operation that brings the best results.
Patients and methods
A prospective, randomized, controlled study was conducted during the period from July 2015 to October 2017 on 30 patients presented with crippled hypospadias to the outpatient clinic of Menoufia University Hospitals. All patients in the study presented with complication due to previously repaired hypospadias. The patients were divided into four groups: group A was operated upon with tubularized incised plate urethroplasty; group B was operated upon with Thiersch–Duplay; group C patients were operated upon with buccal mucosal graft; and group D patients were operated upon with one-stage or two-stage repair.
Results
Successful repair was done for 19 (63.3%) patients, complications occurred in 11 (36.6%) patients. The most common complications were urethrocutaneous fistula affecting six (20%) patients, meatal stenosis affecting four (13.3%) patients, urethral stricture affecting two (6.6%) patients, complete disruption affecting one (3.3%) patient, and donor site complication affecting one (3.3%) patient.
Conclusion
From this study, it seems that the repair depends on the type of hypospadias, presence or absence of chordee, condition of the nearby skin, and the experience of the surgeon.

Keywords: correction, hypospadias, repair, redo hypospadias, redo repair, surgeon


How to cite this article:
Lolah MA, Kishk TF, Sultan TA, Fakhry T, Kalama SM. Redo surgery in hypospadias. Menoufia Med J 2020;33:665-70

How to cite this URL:
Lolah MA, Kishk TF, Sultan TA, Fakhry T, Kalama SM. Redo surgery in hypospadias. Menoufia Med J [serial online] 2020 [cited 2020 Jul 16];33:665-70. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/665/287755




  Introduction Top


Hypospadias surgery is one of the most difficult areas in pediatric urology and has been characterized by a constant evolution[1]. Hypospadias is one of the most common urogenital anomalies occurring in three in 1000 births[2]. Reoperation for failed hypospadias has been considered to be a bothersome problem due to often lack of penile skin needed for urethroplasty and/or penile shaft skin coverage[3]. More than 300 methods were described for hypospadias correction. This is partly because of the wide spectrum of hypospadias presentations and partly because no single method that produces 100% satisfactory results. Surgeons may use one of the following tissues to form the neourethra[4]:

  1. Mobilization of the urethra.
  2. Skin distal to the meatus.
  3. Skin proximal to the meatus.
  4. Preputial skin.
  5. Combined prepuce and skin proximal to the meatus.
  6. Scrotal skin.
  7. Dorsal penile skin.
  8. Different grafts[4].


Commonly, operative failures result from wound infection, urine extravasation, hematoma, ischemia and necrosis of the flap/graft, errors in design, errors in technique, and repeated attempts of surgical repairs in these complicated cases[5].

The best type of redo repair depending on the location and size of the urethral meatus, the status of the urethral plate, genital skin, the severity of residual chordee, and the amount of scar tissue. This study aimed to determine and evaluate the types of complications and the best type of redo repair.


  Patients and Methods Top


A prospective, stratified, randomized, controlled study included 30 patients diagnosed having crippled hypospadias being hospitalized in the Surgical Department of Menoufia University Hospitals and El-Hussein University Hospital between July 2015 and October 2017. The patients were grouped according to presence or absence of healthy skin. Informed consent was obtained from all patients before inclusion in the study and it was approved by the Ethics Committee at El-Menoufia University.

Exclusion criteria

  1. Patients before 6 months from primary surgery
  2. Patients who refused to participate in the study
  3. Intersex patients.


All patients were subjected to:

  1. Adequate history taking, careful examination
  2. Routine laboratory investigations were performed including complete blood count, renal functions, liver enzymes, and prothrombin time and concentration
  3. Others if needed, for example, ascending cystourethrography, intravenous urogram, abdominal ultrasound etc.


    1. The choice of operative procedure was based on thorough evaluation of the condition and availability of healthy surrounding skin flaps. In cases with excessive scarring or when there is no available healthy surrounding skin flaps, free grafts (such as buccal mucosal grafts) will be used. According to the surgical procedure used, the patients were classified into four groups (A, B, C, D). An experienced surgeon team was made aware of the randomization performed for all the procedures.


The following scheme was used for the management of crippled hypospadias after correction of chordee if present:

  1. Healthy intact urethral plate – Tubularized incised plate (TIP) urethroplasty
  2. Redundant ventral penile skin – Thiersch–Duplay urethroplasty
  3. If there is no local healthy skin – buccal mucosal or free skin grafts
  4. If there is local healthy skin with posterior hypospadias – one-stage or two-stage hypospadias repair
  5. So according to this scheme our patients were classified into four groups (A, B, C, D):


Group A: Included patients who underwent TIP urethroplasty as they had a healthy intact urethral plate. Operative technique: skin incisions were made perpendicular to the tissues with a fine knife blade. Parallel longitudinal incisions were made deep into the glans tissue from the urethral meatus to the tip of the glans, defining an intervening urethral plate measuring 6–8 mm in width. This width may be increased up to 15 mm, depending on the patient's age and phallic size. A transverse incision proximal to the meatus was then marked and carried circumferentially and the penile shaft skin was degloved. Any suspicion of chordee should be evaluated at this point with an artificial erection. A longitudinal midline incision on the urethral plate was carried deeply, through the mucosal and sub-mucosal tissues of the urethral plate exposing the underlying corporal bodies. The incised urethral plate was tabularized without tension over a 6–8 Fr. silastic catheter. A 10 Fr. catheter may be used in older patients in whom a neourethra of larger luminal diameter is appropriate. Closure with a continuous single-layer 7–0 vicryl suture was used for neourethral closure.

Group B: Included patients who underwent (Thiersch–Duplay urethroplasty). One patient had a very redundant ventral penile skin and had Thiersch–Duplay directly. The other patient had first stage free skin graft from lateral remnant of the prepuce after correction of chordee and excision of fibrous tissue followed by Thiersch–Duplay urethroplasty 6 months.

Group C: Included patients who underwent buccal mucosal graft as they had no local healthy skin and long paucity of urethral defect (<5 cm) due to previous multiple failed repairs. The site of the meatus ranged from mid-penile to perineal.

Operative technique: In all cases, the penis was properly examined at the start of the procedure. Artificial erection was done to evaluate the degree of chordee if present. Care was taken to ensure removal of scared tissues and strictures of the urethra to allow for a vascularized graft bed. Correction of chordee was done if present. Buccal mucosal graft was taken from inner lower lip in four cases and inner cheek in eight cases. The inner cheek was used when the required graft exceeds 4 cm. The harvest site was marked carefully to avoid Stensen's duct opposite the upper second molar when harvesting from the inner cheek. Urethroplasty was performed using 7–0 vicryl continuous sutures with interrupted sutures at the ends. The tubed graft was anastomosed proximally to the native urethra and fixed to the corporal bodies to prevent kinking and shearing movement. The graft suture line was placed dorsally against the corpora to decrease the risk of fistula formation [Figure 1] and [Figure 2].
Figure 1: Epinephrine is injected submucosally.

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Figure 2: After first stage buccal mucosal graft.

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Group D: Technique of transverse preputial island flap hypospadias repair (one stage) is as follows. In the setting of scrotal or perineal hypospadias, severe curvature, and a small penis, we prefer to perform a two-stage repair. The second stage is performed 6 months or more after completion of the first stage. The primary goal of the second stage of the procedure is to create a neourethra that bridges the defect between the meatus and the tip of the penis.

Postoperative management

All cases were stented and a suprapubic catheter was left for 2 weeks. Postoperative antibiotics and analgesia were given for 2 weeks. A subcutaneous suction drain was left for 12 h, adjacent to the neourethra, to prevent hematoma formation and a compressive dressing was used. The tip of the glans was covered all time with an antibiotic ointment to prevent dryness and encrustation. The dressing was removed after 7 days and changed every 2 days with lavage of the neourethra using an antibiotic solution (gentamycin and crystalline penicillin) through the urethral stent. Older children were instructed to minimize their activity to assure graft immobilization. Amyl nitrate was also used in older children in the postoperative period to control erections. A clear liquid diet was given initially which rapidly advanced to a soft and then regular diet. Meatal dilatation was used after catheter removal for up to 6 months to avoid stenosis. The patient was instructed for follow-up visits once weekly in the first month, once monthly in the following 6 months, and then every 3 months for 1 year.

Discharge criteria

Were met once the patient became generally well, no complications occurred, and if any complications had happened, the patients were discharged after proper management of it.

Statistical analysis

All data were collected, tabulated, and statistically analyzed using SPSS 22.0 for Windows (SPSS Inc., Chicago, Illinois, USA) and for all the analysis a P value less than 0.05 was considered statistically significant, and highly significant if the P value is less than 0.001.

Analysis of variance (χ2-test) was used to analyze the differences among groups.


  Results Top


Results show distribution of the studied cases according to the site of the meatus ([Table 1] and [Figure 3].
Table 1: Distribution of the studied cases according to site of the meatus

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Figure 3: Distribution of the studied cases according to the site of the meatus.

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It is quite evident that the most common postoperative complications in all groups were urethrocutaneous fistula followed by infection. Complete failure was the rarest early postoperative complication in this study as shown in [Table 2] and [Figure 4]. It is clear that the most common late complication in all groups was the urethra-cutaneous fistula (20%): six (20%) patients one in group A and three in group C and two in group D developed small urethrocutaneous fistula [Figure 5].
Table 2: Comparison between the studied groups as regards late complications (>2 weeks and ≤6 months postoperatively) developed during the follow-up

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Figure 4: Comparison between the studied groups as regards late complications (>2 weeks and ≤6 months postoperatively) developed during the follow-up.

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Figure 5: Urethrocutaneous fistula.

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Successful repair was done on 19 (63.3%) patients, total complications in 11 (36.6%) patients such as fistula in six (20%), meatal stenosis in two (6.6%), urethral stricture in two (6.6%), and complete failure in one (3.3%) ([Table 3] and [Figure 6].
Table 3: Comparison between the studied groups as regards the results of repair

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Figure 6: Comparison between the studied groups as regards the results of repair.

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  Discussion Top


Complications occurs following hypospadias repair are commonly due to persistent chordee, fibrous patches, scarred tissues, irregular skin happened after multiple surgical interventions, and multiple fistulae partly covered by skin bridges. An incorrect diagnosis, ignorance of the principles of this fine surgery, and a poor follow-up are usually responsible. Neglected chordee, missed intersex, traumatizing dissection, inappropriate urine drainage, and infection are the main causes of such complications[6]. We should adapt the procedure to specific anatomy encountered. It is also necessary for the surgeons to know their individual results. A simple spreadsheet listing patient name, meatal location, surgical procedure done, primary versus reoperative repair, and complications is sufficient to inform a surgeon of his or her results. It is clear that working as a surgical team of two experienced hypoapadiologists will reduce the incidence of complications[7].

Patients included in this study were categorized into four groups (A, B, C, and D) according to the characters mentioned before.

Group A

Group A included seven (23.3%) patients who underwent TIP urethroplasty as they had a good urethral plate. Hypospadias results from incomplete fusion of the urethral folds. The TIP repair demonstrates that the tissue which should have completed urethral development is largely preserved in the urethral plate[7]. The Snodgrass repair is ideal for repair following failed Mathieu, Onlay-island flap, and tubularization procedures[7]. Only one (14.2%) patient in this group developed urethra-cutaneous fistula that was successfully repaired later. This finding runs parallel with those reported by Luo and Lin[8] who operated upon six patients with complicated and repeated hypospadias using TIP urethroplasty. A small fistula developed in one (16.6%) child and mild meatal retraction in another one. Also Joseph[9] documented that tabularized incised plate urethroplasty has become the preferred technique of TIP urethroplasty.

Group B

Group B included two (6.6%) patients who underwent Thiersch–Duplay. The first patient (patient no. 1) had a free skin graft from the remnants of preputial skin followed after 6 months by Thiersch–Duplay and the other one had penoscrotal hypospadias with redundant ventral penile skin. Both patients had a second layer from the surrounding penile fascia before skin closure with good results in both patients.

Richard and Gary[10] reported that they treated 10 patients who had failed hypospadias repairs via a second- stage procedure by a varied combination of split-thickness mesh graft urethroplasty and tunica vaginalis flap. No strictures or fistulas occurred in eight patients and two patients needed a second-stage repair after successful stage 1 placement of graft.

Group C

Group 3 included 13 (43.3%) patients who were repaired using buccal mucosal graft as they have no local skin with long urethral defect. Five out of the 13 patients developed complications. The overall complication rate was 38.4%. Urethra-cutaneous fistula was encountered in three (23%) patients and corrected surgically by simple closure while urethral stricture was encountered in one (7.6%) patient, meatal stenosis in another one (7.6%) patient and were successfully managed by meatoplasty.

Buccal mucosa has advantages over both skin and bladder grafts. The thick epithelial layer, abundant elastic fibers, less tendency to shrink, and favorable imbibition properties make it more suitable for neourethral reconstruction[11].

Thirty patients with complex hypospadias were treated by Michael and Wu[12] using buccal mucosal graft and complications were encountered in 17 out of 30 (57%) cases. The most common complications encountered in this series were stricture represented by seven (23.3%) patients followed by meatal stenosis in five (16.6%) patients, fistula in two (6.6%) patients, and complete graft breakdown in one (3.3%) patient.

Group D

Group D included eight (26.6%) patients who underwent one-stage or two-stage hypospadias repair as they had a very long urethral defect. Postoperative complications were encountered in five out of eight patients with a complication rate of 62.5%. Two (25%) patients developed urethra-cutaneous fistula which were successfully repaired later by a simple closure. One (12.5%) patient had complete failure due to severe infection, and another one (12.5) patient developed meatal stenosis that was successfully managed by meatoplasty. Also, one (12.5%) patient developed urethral stricture that required surgical repair later. Snodgrass and Elmore[13] reported a slightly lower success rate with 88% of complete graft uptake in secondary repairs. The overall complication rate in this study was 36.6% nearly similar to the 40% reported by Keating and Duckett[14], 31% by Devine and Horton's[15], 43% by Redman[16], 43% by Rober et al.[17], and 39% by Weber et al.[18] by using different techniques for the management of recurrent cases.

Opinions about the best operative technique for patients with posterior hypospadias with no urethral plate had varied, in using either one stage or two stages. The surgical principle is aiming at multiple goals including orthoplasty, urethroplasty, glanuloplasty, meatoplasty, scrotoplasty, and skin coverage with circumcision or preputial reconstruction. All these steps can be performed in a single or staged operation. The technique should be tailored according to each individual case. Reoperation is accompanied with a higher complication rate. However, in redo cases to improve the results, the selection of appropriate treatment modality and customization of techniques for each patient cannot be overemphasized. So, each case should be evaluated individually preoperatively as regards the type of complication (stenosis, fistula, complete failure, degree of fibrosis, availability of the surrounding healthy skin, choice of the technique to be used, etc.) and a senior surgeon is a must in performing such operations to get the best results. Also to improve success, a 6-month delay before any secondary surgical attempt, inversion of the urethral mucosa, avoidance of any overlapping suture lines, urinary diversion proximal to the repair site for 5–14 days, usage of thin absorbable suture materials, and using magnifying loops are the main criteria that should be fulfilled for a satisfactory hypospadias repair[19].


  Conclusion Top


From this study, it seems that there is no single universally applicable technique for repairing all types of hypospadias, but the repair of hypospadias especially crippled cases depends on the type of hypospadias, presence or absence of chordee, condition of nearby skin, and the experience of the surgeon.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baccala AA Jr, Detore N, Ross J. Modified tubularized incised urethroplasty (Snodgrass) for hypospadias repair. Urology 2005;66:1305–6.  Back to cited text no. 1
    
2.
Mouriquand P, Mure P. Hypospadias. In Puri, ME Hollwarth (eds)Pediatric surgery, Springer Surgery Atlas Series. Springer-Verlag. Berlin. Heidelberg. New York, 2007. p. 529–542.  Back to cited text no. 2
    
3.
Marrocco G, Vallasciani S, Fiocca G, Calisti A. Hypospadias surgery: a 10-year review. Pediatr Surg Int 2004; 20 :200–203.  Back to cited text no. 3
    
4.
Paulozzi L, Erickson D. Hypospadias trends in two US surveillance systems. Pediatrics 2006; 100 :831–834.  Back to cited text no. 4
    
5.
Barbagli A, Angelis B, Palminteri A, Lazzeri M. Failed hypospadias repair presenting in adults. Eur Urol J 2006; 49 :220–240.  Back to cited text no. 5
    
6.
Mouriquand P, Persad R, Sharma S. Hypospadias repair: current principles and procedures. Br J Urol 2006; 76 :9–22.  Back to cited text no. 6
    
7.
Snodgrass W, Bush N. Primary hypospadias repair techniques: a review of the evidence. Urol Ann 2016; 8 :403–408.  Back to cited text no. 7
    
8.
Luo CC, Lin JN. Repair of hypospadias complication using TIP. J Ped Surg 1999; 34 :1665–1667.  Back to cited text no. 8
    
9.
Joseph G. Tubularized incised plate urothroplasty used in 1ry and repeat surgery for hypospadias. J Urol 2012; 165 :581–585.  Back to cited text no. 9
    
10.
Richard M, Gary A. Split-thickness skin graft urethroplasty and tunica vaginalis flaps for failed hypospadias repairs. J Urol 2012; 155 :131–134.  Back to cited text no. 10
    
11.
Duckett J, Coplen D, Ewalt D. Buccal mucosa in urethral replacement. J Urol 2012; 153 :1660–1663.  Back to cited text no. 11
    
12.
Michael JM, Wu HY. Buccal mucosal grafts: lessons learned from an 8 year experience. J Urol 2001; 166 :1459–1461.  Back to cited text no. 12
    
13.
Snodgrass W, Elmore J. Initial experience with staged buccal graft (Bracka) hypospadias reoperations. J Urol 2004; 172 :1720–1724.  Back to cited text no. 13
    
14.
Keating M, Duckett J. Hypospadiology. In: Whitfield HN, Hendry WF, Kirly RS, Duckett JW, editors. Textbook of genitourinary s urgery. 2nd ed. Hoboken, New Jersey, United State: Blackwell Science Ltd; 1998. p. 319.  Back to cited text no. 14
    
15.
Devine C, Horton C. Hypospadias repair. J Urol 1977; 118 :188.  Back to cited text no. 15
    
16.
Redman J. Experience with 60 consecutive hypospadias repairs using the Horton–Devine techniques. J Urol 1987; 129 :115–118.  Back to cited text no. 16
    
17.
Rober P, Perlmutter A, Reitelman C. Experience with 81, 1-stage hypospadias repairs with free graft urethroplasties. J Urol 1990; 144 :526–529.  Back to cited text no. 17
    
18.
Weber D, Schonbucher V, Gobet R, Gerber A, Landolt M. Is there an ideal age for hypospadias repair? A pilot study. J Pediatr Urol 2009; 5 :345–350.  Back to cited text no. 18
    
19.
Latifoǧlu O, Yavuzer R, Unal S, Cavuşoǧlu T, Atabay K. Surgical treatment of urethral fistulas following hypospadias repair. Ann Plast Surg 2000; 44 :381–386.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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