Hypospadias Surgery: A High Complication Rate & Satisfied Patients

Introduction

‘The quest for perfection in hypospadias surgery must continue’ ¹

Hypospadias is a common anomaly. The etiology is not known. Various theories have been proposed (like vascular problems, α-reducatase deficiency, androgen/androgen receptors deficiency), and multiple factors may be involved.² In women infection and in men cosmesis and function dictate surgery.³

Surgery is technically demanding, and the results may be less than satisfactory.⁴ Complications include fistula formation, meatal stenosis, stricture and others. Fistula is common. Proximal hypospadias are more commonly associated with chordee and postoperative complications.⁵ Failure traditionally meant complications requiring re-operation. The importance of cosmetic outcomes is increasing and some centers of excellence have started reporting cosmetic shortfalls as complications.⁶ A staged approach or a single-stage procedure may be used. Many procedures are available and new modifications are evolving which means none is ideal. The quest for an operative procedure with persistently excellent results and minimal complications is still needed.¹

We are using a single stage repair and we believed our complication rate to be high. We therefore designed this study to evaluate our results and to report our experience.

MATERIAL and Methods

This study was conducted at General Surgery Unit B, Ayub Medical College & Hospital Complex, Abbottabad.

Patients undergoing urethral plate elevation and onlay preputial flap repair for Hypospadias from April 1997 to April 2003 were included in this observational study. Children aged 2 ½ years or older were offered surgery. Parents of younger children were advised to wait. Children with suspected inter-sex problems and those where preputial skin was not available, were excluded.

Hypospadias was graded as distal, penile shaft and peno-scrotal. The presence of chordee and quality or urethral plate was noted.

Chordee was categorized as mild, moderate and severe. Chordee was categorized as mild (visible only on erection), moderate (demonstrable without erection), and severe (bent penis bringing tip of glans onto ventral surface).

Table was split in the center, and head was tilted down to improve operative field and reduce blood loss.

Preputial onlay-flap with mobilization of the urethral plate was used. Fibrous tissue anchoring urethral plate to corpora cavernosa was excised. Artificial erection was used to confirm straightening. Tourniquet was not applied; direct pressure was used and haemostasis secured with bipolar cautery.

Anastomosis was performed with 6/0 PDS II on round-bodied needle under antibiotic cover (Cefuroxime). Naso-gastric tube was used as catheter.

Patients stayed on the ward for 7 days. Dressing was changed at 48 hours, and thereafter daily. Follow-up was scheduled one week after discharge (when catheter was removed), and in 6 months.

Cosmetic results were graded as good, satisfactory or unsatisfactory. The overall cosmetic assessment was subjective, although slit-like meatus at end of glans, mucosal collar and bending were considered.⁵ Complications were graded as minor and major. Major complications required longer hospital stay or/and secondary surgical procedure, and included fistula, meatal stenosis, premature tube dislodgment, epidermal sloughing, residual chordee, torsion penis and a knotted tube requiring suprapubic removal. Minor complications included chest & wound infections and blood transfusions.

Results

One hundred and ninety-six patients with hypospadias presented to the consultation clinic during this six-year period. One hundred and forty-seven (75%) were advised to come back later. Fourteen patients were operated before the routine 2 ½ years. Seven patients were excluded because foreskin was not available. Seven patients were lost to follow-up and were excluded. Four patients with inter-sex were also not included. One hundred patients were included in the study,

Results are tabulated in tables 1-7.

Out of 17 patients (17%) with fistula, five had meatal narrowing and were put on regular dilatation. None healed - all required re-surgery. Fistula healed in 9 patients. Six patients were operated after a delay of 7 to 9 months and 2 healed. In 11 patients fistula was operated immediately on identification and 7 healed.

Eight patients (8%) had residual chordee - six barely noticeable and 2 moderate. The two with moderate residual chordee had peno-scrotal hypospadias and fibrosed urethral plates.

Seven patients (7%) developing meatal stenosis were recognized after removal of catheter - five also had leak. Meatal stenosis responded to urethral dilatation - fistula did not.

Three patients (3%) had accidental dislodgment of catheter. One tube dislodged on 2^nd post operative day was replaced under general anaesthesia. Two tubes were dislodged on 6^th and 7^th post-op days were replaced on the ward.

Two patients (2%) had bluish discolouration and sloughing of the epidermis. Basal layers were intact. It regenerated.

One retained tube (1%) was removed transvesically. It had a knot inside the bladder!

Minor complications included chest and superficial wound infections and blood transfusions.

Table 1: Age at initial presentation (n=196)

Age at initial presentation
Age	No. of patients	%
1-7 days	49	25 %
8 days to 3 months	69	35 %
3 months to 2.5 years	29	15 %
>2.5 years	49	25 %
Total	196	100 %

Table 2: Age at operation (n=100)

Age group	Age	No.
	19 Months	1	Total
	20 Months	6	14
<2 ½ Years	21 Months	4
	22 Months	1
	24 Months	2
2.5–3 Years		51	51
> 3 Years	3 – 5 Years	16	35
	5 – 10 Years	6
	11 Years	3
	13 Years	2
	16 Years	4
	17 Years	2
	18 Years	1
	24 Years	1
	Grand Total	100	100

Table 3: Categorization of Hypospadias (n=100)

Hypospadias	Chordee				Urethral Plate
Hypospadias	-	+	++	+++	-	+
Distal n=30	10	13	7	-	10	20
Penile Shaft n=52	23	13	12	4	12	40
Peno-scrotal n=18	1	4	4	9	3 +5*	10
	34	30	23	13	30	70
Total n=100	34	66			30	70

Legend:

Chordee: + mild, ++ moderate, +++ severe.

Urethral Plate: + well developed, - poorly developed

* Urethral plate contributing

significantly to the chordee

Table 4: Site of Fistula (n=17)

Site of Fistula	No.	%
Junction of neo-urethra with urethra	12	12/17 = 71%
Complete Disruption	3 + 5*	8/17 = 47%
Corona	2	2/17 = 12%

* in these patients, the fistula started at junction of neo-urethra with the urethra and then proceeded to become complete disruption

Table 5: Major complications (n=63)

Complications	No. (%)	2^nd op.	Extra Stay	Resolved	Residual problem
Fistula	17 (17%)	17(100%)	17(100%)	9 (53%)	8 (47%)
Meatal Stenosis	7 (7%)	7 (100%)	7*	7 (100%)	-
Tube dislodgment	3 (3%)	3 (100%)	-	3 (100%)	-
Epidermal sloughing	2 (2%)	- (0%)	2 days	2 (100%)	-
Residual Chordee	2 (2%)	- (0%)	-	-	2**
Knotted tube	1 (1%)	1 (100%)	-	1 (100%)	-
Torsion penis	1 (1%)	- (0%)	-	-	**
Total	33/100 (33%)	27/33*** (82%)	25/33, (76%)	22/33 (67%)	11/33 (33%)

* Multiple procedures without admission

** Parents fully satisfied: did not agree to second medically indicated procedure!

*** Out of 33 major complications, 27 required 2^nd surgery, 25 stayed longer, 22 resolved and 11 still need further treatment.\

Complications	No. of patients (%)	2^nd op./ longer stay	Residual problem
Wound infection	15 (15%)	-	-
Chest Infection	14 (14%)	-	-
Blood transfusion	02 (2%)	-	-

Irfan U. Khattak, Mohammad Akbar, Mohammad Nawaz, Ali Al-Saleh, Bakhmal Noor, Zia-ur-Rehman

Age at initial presentation

Age

Total

Table 2: Age at operation (n=100)

Hypospadias

Chordee

Complications

Total