Hypospadia repair

hypospadia repair: a

single centre experience…

@ mansoor khanPAPSCON 2015

HMC Plastic& recons.surgery

Plastic Surgery International, Volume 2014, Article ID 453039,

Introduction..

Hypospadia is the most common

urethral congenital anomaly..

affecting 1 : 300 live

male births with a

doubling of rates

since 1970

L. J. Paulozzi, J. D. Erickson, and R. J. Jackson, “Hypospadiastrends in two US

surveillance systems,” Pediatrics, vol. 100, no.5, pp. 831–834, 1997.

A lot have been achieved in terms

of establishing surgical protocols

and improvements of short term

results over the past 2 decades...

Hypospadialogist..?

Temperament 40–50

Six common techniques

G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by

whom?” BJU International,vol. 94, no. 8, pp. 1188–1195, 2004.

A. Bhat, “General considerations in hypospadias surgery,”Indian Journal of Urology, vol. 24, no. 2, pp. 188–194, 2008.

6-18 months 3-4 years

G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International, vol. 94, no. 8, pp. 1188–1195, 2004.

A. Bhat, “General considerations in hypospadias surgery,” Indian Journal of Urology, vol. 24, no. 2, pp. 188–194, 2008.

Atraumatic tech,

judicious cautery use,

tension free repair

with epithelial inversion,

buck’s water-proofing

straight penis,

slit-like meatus at glans’ tip,

urethra of uniform calibre

and adequate length,

symmetrical glans,

projectile stream and

normal erection

A. Bhat, “General considerations in hypospadias surgery,” Indian Journal of Urology, vol. 24, no. 2, pp. 188–194, 2008.

Chordee is quantified into

mild (10∘–20∘), moderate

(30∘–40∘), and severe

(>50∘)

R.A. Bologna, T. A. Noah, P. F.Nasrallah, andD. R.McMahon, “Chordee: varied opinions and treatments as documented in

a survey of the American Academy of Pediatrics, Section of Urology,” Urology, vol. 53, no. 3, pp. 608–612, 1999.A. Springer, W. Krois, and E. Horcher, “Trends in hypospadias surgery: results of a worldwide survey,” European Urology,

vol. 60, no. 6, pp. 1184–1189, 2011.

Wide urethral plate, adequate glans

cleft, without chordee can be tubularized by Zaonz’s GAP procedure

G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,vol. 94, no. 8, pp. 1188–1195, 2004.

Narrow & shallow urethral plate with

occasional bands needs Snodgrass’

TIP repairG.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,

vol. 94, no. 8, pp. 1188–1195, 2004.

for coronal/glanular

hypospadias modified meatal

advancement/MAGPI repair

inelastic urethral plate, conical glans

where midline incision is extended

beyond the distal limit of the glans

groove to achieve an apical meatus

needs Snod-graft repair (dorsal

inlay graft urethroplasty)


Bracka’s two-stage repair comes into play

when the chordee is corrected by urethral

plate transaction…


Removal of the stent at one week

1, 3 and 6 monthly and then yearly for

two years. For long term results patient is

followed up to mid-teen ageG.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,

vol. 94, no. 8, pp. 1188–1195, 2004.

To analyze the demographics,

protocols, techniques, complication

of hypospadias repair, and its effect

modifiers at our centre.

Material &

methods..?

2007 to 2011 at the

Plastic and Reconstructive Surgery

Hayatabad Medical Complex

Peshawar, Pakistan

Patients with co-morbidities (DM,

DSDs, coagulopathies) &

who were lost in the follow-up

Results stratification; two groups

Residents & fellow plastic

surgeons

Results..

428 patients (96.3% primary & 3.7%secondary

cases) fulfilled the inclusion

criteria

8.6% patientsHad positive family

history for hypospadias

Akin et al. & Abdelrahman et al.

observed positive family history in 26.5%

12% cases in their studies respectively.

family history may be

underreported due to social

stigma in our setup

Y. Akin, O. Ercan, B. Telatar, F. Tarhan, and S. Comert, “Hypospadias in Istanbul: incidence and risk factors,” PediatricsInternational, vol. 53, no. 5, pp. 754–760, 2011.

M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O. Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and

surgical review,” African Journal of Paediatric Surgery, vol. 8, no. 3, pp. 269–271, 2011.

Increase in number of patients for

hypospadia repair was observed

during the study period with

the highest (24.1%) patients

presented in 2011

1.87% and 34.6% patients were operated in 1-2 years,

3–5 year age windows while the rest presented in ≥6 years of age

lack of public awareness

about the conditions and

financial restraints

74.3% of the hypospadias wereassociated with chordee with mild degree being the most

common (51.4%)

Similar results were observed by different authors

M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O. Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and surgical review,” African Journal of Paediatric Surgery, vol. 8, no. 3, pp. 269–271, 2011.

Meatal stenosis was observed

in 9.1%, cryptorchidism in 2.8%

cases. 2.1% cases were

associated with inguinal hernias

positive relationship between

hypospadias and cryptorchidism is

reported in 7.3% 14.7% 20% cases

by different authors

Y. Akin, O. Ercan, B. Telatar, F. Tarhan, and S. Comert, “Hypospadias in Istanbul: incidence and risk factors,” Pediatrics International, vol. 53, no. 5, pp. 754–760, 2011.

M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O.Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and surgical review,” African Journal of Paediatric Surgery, vol. 8, no. 3, pp. 269–271, 2011.

W.-H. Wu, J.-H. Chuang, Y.-C. Ting, S.-Y. Lee, and C.-S. Hsieh, “Developmental anomalies and disabilities associated with hypospadias,” Journal of Urology, vol. 168, no. 1, pp. 229–232, 2002.

Two-stage (Bracka) repair

was the most common procedure

performed in 76.2% of cases.

In 46.4% cases without

chordee, two-stage repair was

performed for narrow urethral

plate and incomplete glans cleft

In most of the centres worldwide single

stage repairs are the most common

procedure

The reasons for high number of two-stage

repairs in our centre are relative low

expertise/lack of knowledge about the

indications of single-stage procedures

& relative short learning curve for

two-stage repair

M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and surgical review,” African Journal of Paediatric Surgery, vol. 8, no.3, pp. 269–271, 2011.

D. Prat, A. Natasha, A. Polak et al., “Surgical outcome of different types of primary hypospadias repair during three decades in a single center,” Urology, vol. 79, no. 6, pp. 1350–1354, 2012.

acute complications

edema (28.3%), bleeding (4.4%),

surgical site infection 4.2%,

wound dehiscence (4.2%), and

partial graft (1.4%) loss,

late complicationsUCF 26.6% (corrected frequency)

(Excluding 31.33% closed spontaneously)50.6% were managed by single surgical

procedure

specialists UCF rate was 23.32%

residents UCF 33.10%(𝑃-value of 0.0374)

Bhat et al. review of pubMedUCF & edema were the most common

Similar frequencies of UCF were reported by Chung et al. Huang et al. reported 14.6% UCF

11.5% in series of TIP repair by Bush et al. Snodgrass et al. observed UCF of 10%-33% for patients

undergoing TIP with different suture techniques.

Our relatively high UCF lack of routine use of microvascular

instruments & magnificationBhat et al. “Acute postoperative complications of hypospadias repair,” Indian Journal of Urology, 2008.

J. W. Chung et al. “Risk factors for the development of urethrocutaneous fistula after hypospadias repair: a retrospective study,” Korean Journal of Urology, 2012.L. Huang et al. “Tubularized incised plate urethroplasty for hypospadias in children,” Zhongguo Xiu Fu Chong JianWai Ke Za Zhi, 2006.

N. C. Bush, W. Snodgrass et al “Age does not impact risk for urethroplasty complications after tubularized incised plate repair of hypospadias in prepubertal boys,” Journal of Pediatric Urology, 2013.

W. Snodgrass “Tubularized incised plate for mid shaft and proximal hypospadias repair,” Journal of Urology, 2007.

learning curve Horowitz et al. had the same

observations in his work

M. Horowitz and E. Salzhauer, “The “learning curve” in hypospadias surgery,” BJU International,

2006.

complications ratestwo-stage repair 66.9%

single-stage repair 44.1% (𝑃-value of 0.0001)

no significant difference

In the UCF frequencies

subjecting the patient 2 surgeries (different levels of expertise),

prolongs psychological stress in the most

vulnerable stage of life,

cumulative donor site morbidity

long term resultsvoiding, sexual function, ejaculation,

psychosexual adjustment &

self-appraisal

Surgical technique

for hypospadia

repair..?Lets have a quick look..

A

C’C

B’B

Conclusion..?

revision of existing

institutional

guidelines

mandatory use of

magnification

increasing the

threshold for two-

stage Bracka’s

repair by revising

its indications

expertise

development in

single-stage repairs

Regular audit

should be

performed.

culture of casual

hypospadias

surgery should be

abandoned

thanksPlastic and Reconstructive unit

HMC, Peshawar

Hypospadia repair

Health & Medicine

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