Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes

In this article, we present the current approach to hypospadias, a review of the classification, preoperative evaluation, and factors that enable decision-making during surgery. We will then discuss patient-reported outcomes, evaluating the patients\u27 and parents\u27 perspectives regarding hypospadias repair

Urethro-cutaneous fistula after hypospadia repair: a single institution study

Urethro-cutaneous fistula (UCF) is one of the most frequently seen complications of hypospadias surgery requiring reoperation; it occurs with an incidence of between 4% and 28%. Risk factors associated with the development of UCF can be classified as preoperative, intraoperative or postoperative. The aim of this study was to determine the association of perioperative risk factors and the development of urethrocutaneous fistula after hypospadias repair. A retrospective review of patients who had undergone hypospadias repair at Kenyatta National Hospital between 2013 and 2017 was conducted. 114 patient records were retrieved. The incidence of UCF was 47%. Risk factors that were significantly associated with UCF are hypospadias type (p=0.028), lack of a protective intermediate layer (p=0.002), and presence of postoperative complications (p=0.001). Age at surgery, suture material, type of repair and use of catheter/stents were not significant factors. Multivariate analysis showed wound infection and meatal stenosis as the most significant factors associated with UCF development.Keywords: Hypospadias, Urethro-cutaneous fistula, Risk factors, Wound infection, Meatal stenosi

Quality of Hypospadias Surgery in a High Volume Hospital: Review of Short to Medium-Term Outcomes after Snodgrass Hypospadias Repair

OBJECTIVES The study aimed to review short-term and medium-term outcomes of Snodgrass repair from one-year to two-year follow-up. METHODOLOGY It’s a retrospective review of 114 patients (secondary data) with distal penile hypospadias without curvature who underwent Snodgrass repair performed by a single surgeon in the department of Urology, Lady Reading Hospital Peshawar from March 2021 to March 2022. Hypospadias objective score Evaluation (HOSE) was used for functional and cosmetic outcomes. RESULTSThe mean age at the time of presentation for surgery was 3 years. The mean documented follow-up was 13 months (2-23 months). 51% (58) of patients presented with coronal hypospadias, followed by sub-coronal, distal and glanular hypospadias. Overall complication rate was 10%. Three patients developed a total breakdown of their wounds that needed further staged procedures. Meatal stenosis was noted in three patients requiring meatal dilatation, and another two came back with non-obliterative strictures. One had gentle dilatation, and the other underwent an optical urethrotomy. The rest of the four patients developed urethrocutanoeus fistulae (UCF), ultimately getting repaired 6 months postoperatively. Good cosmetic and functional results were achieved in 93% of cases (HOSE score of 14 or above). CONCLUSION This study shows that Snodgrass repair is the best option for mainly correcting distal penile and midshaft hypospadias and has an acceptably low complication rate with better short to medium-term outcomes

Parental Perspectives on Decision-making about Hypospadias Surgery

Introduction Many parents who choose hypospadias repair for their son experience decisional conflict and regret. The utilization of a shared decision-making process may address the issue of decisional conflict and regret in hypospadias repair by engaging both parents and physicians in decision-making. Objective The objective of this study was to develop a theoretical framework of the parental decision-making process about hypospadias surgery to inform the development of a decision aid. Study Design We conducted semi-structured interviews with parents of children with hypospadias to explore their role as proxy-decision-makers, inquiring about their emotions/concerns, informational needs and external/internal influences. We conducted interviews until no new themes were identified, analyzing them iteratively using open, axial and selective coding. The iterative approach entails a cyclical process of conducting interviews and analyzing transcripts while the data collection process is ongoing. This allows the researcher to make adjustments to the interview guide as necessary based on preliminary data analysis in order to explore themes that emerge from early interviews with parents. We used grounded theory methods to develop an explanation of the surgical decision-making process. Results We interviewed 16 mothers and 1 father of 7 preoperative and 9 postoperative patients (n=16) with distal (8) and proximal (8) meatal locations. We identified four stages of the surgical decision-making process: 1) processing the diagnosis, 2) synthesizing information, 3) processing emotions and concerns and 4) finalizing the decision (Extended Summary Figure). We identified core concepts in each stage of the decision-making process. Primary concerns included anxiety/fear about the child not waking up from anesthesia and their inability to be present in the operating room. Parents incorporated information from the Internet, medical providers and their social network as they sought to relieve confusion and anxiety while building trust/confidence in their child’s surgeon. Discussion The findings of this study contribute to our understanding of decision-making about hypospadias surgery as a complex and multi-faceted process. The overall small sample size is typical and expected for qualitative research studies. The primary limitation of the study, however, is the underrepresentation of fathers, minorities and same-sex couples. Conclusions This study provides an initial framework of the parental decision-making process for hypospadias surgery that will inform the development of a decision aid. In future stages of decision aid development, we will focus on recruitment of fathers, minorities and same-sex couples in order to enrich the perspectives of our work

Is there an ideal age for hypospadias repair? A pilot study

OBJECTIVE: To assess whether repairing hypospadias before or after 18 months affects psychological adjustment, health-related quality of life (HRQoL) and surgical outcome. PATIENTS AND METHODS: Seventy-seven boys aged 6-17 years were assigned to one of two groups, according to whether they had a hypospadias repair before or after the age of 18 months. The surgical outcome was assessed using the pediatric penile perception score by non-involved urologists. A psychologist interviewed the patients to assess HRQoL and gender-role behavior. The child's psychological adjustment was assessed with a questionnaire for parents. RESULTS: The surgical outcome and complication rate were not significantly different between groups. A covariance analysis of HRQoL, gender-role behavior and psychological adjustment as a function of age at the last operation with current age as covariant was performed, but differences did not reach significance. CONCLUSION: This study does not provide evidence to support recommendations concerning the ideal age for hypospadias repair. In the absence of evidence of a benefit of early surgery, anesthesia-related risk factors must be considered when operating in very early infancy. Large, prospective studies, measuring surgical and psychological outcome with similar instruments to those presented may reveal whether there is a true ideal age for hypospadias surgery

Hypospadias Surgery. Clinical Aspects and Outcomes

AbstractAim The aim of this thesis was to evaluate the treatment and follow-up of patients undergoing hypospadias surgery at the Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, in an attempt to improve the overall care of these patients. It also aimed to investigate the tissue properties of the urethral plate and deep chordee in hypospadias patients with significant ventral curvature of the penile shaft.Methods Long term follow-up and patient reported outcomes in a cohort of 157 patients were investigated by chart review and a modified hypospadias functional outcome questionnaire. The hypospadias objective scoring evaluation (HOSE) system was used to objectify the results. In addition, 36 patients with secondary hypospadias repairs were analysed via chart review and 10 patients scheduled for orthoplasty during 2014–2015 consented to biopsy of the urethral plate and deep chordee during surgery.Results HOSE analysis indicated that 86% of patients had satisfactory results after primary and secondary hypospadias repair. Overall fistula frequency was 11% after primary repair and post-pubertal follow-up. The HOSE analysis also showed that 82 to 92% of responding patients were neutral or more satisfied with their overall surgical outcomes, appearance, and urinary and sexual function and 90% of responders were satisfied or requested longer follow-up after surgery. In 22% of patients with salvage repairs, additional surgery was required because of complications or shortcomings after re-repairs per our treatment algorithm. All of the biopsy samples from the urethral plate and the deep chordee had similar tissue characteristics and the biopsies confirmed that chordee is a unique tissue entity. In addition, chronic inflammation, a finding not previously reported, was present in every biopsy specimen, with chronic inflammation in the urethral plate manifested as metaplasia in the form of urethritis cystica.Conclusions Our findings show that the long-term, post-pubertal complication rate after hypospadias surgery is low and that a majority of patients have satisfactory results. Patient-reported outcomes indicated that the responding patients were satisfied with their overall long-term surgical/functional outcomes and with the long-term follow-up program. We also found that our treatment algorithm can be applied successfully in cases of secondary hypospadias repairs, provided local tissues are available for flap coverage. In these cases, it is of particular importance to treat all ventral curvature, secondary to chordee and ventral scarring. Thus, many secondary salvage procedures must be handled in two sessions to optimise safety and minimise postoperative complications. Finally, we also report previously undescribed chronic inflammatory activity in tissue samples from urethral plates and deep chordee in patients with hypospadias and ventral curvature, which suggests a possible dynamic feature in this unique tissue entity

Association between extra-genital congenital anomalies and hypospadias outcome

Extra-genital congenital anomalies are often present in cases of hypospadias, but it is unclear whether they have an association with the outcome of hypospadias surgery. The aim of this study was to review all hypospadias cases that had surgery between 2009 and 2015 at a single centre and identify clinical determinants of the surgical outcome. An extra-genital congenital anomaly was reported in 139 (22%) boys and 62 (10%) had more than 1 anomaly. Of the 626 boys, 54 (9%), including 44 with proximal hypospadias, had endocrine as well as limited genetic evaluation. Of these, 10 (19%) had a biochemical evidence of hypogonadism and 5 (9%) had a molecular genetic abnormality. At least 1 complication was reported in 167 (27%) patients, with 20% of complications (most frequently fistula) occurring after 2 years of surgery. The severity of hypospadias and the existence of other anomalies were clinical factors that were independently associated with an increased risk of complications (p < 0.001). In conclusion, complications following surgery are more likely in those cases that are proximal or who have additional extra-genital anomalies. To understand the biological basis of these complications, there is a greater need to understand the aetiology of such cases

Adult Urethral Stricture Disease after Childhood Hypospadias Repair

Background. Adult patients with urethral stricture after childhood hypospadias surgeries are infrequently discussed in the literature. We report our experience in treating such patients. Materials and Methods. A retrospective chart review was performed. From 2002 through 2007, nine consecutive adult patients who had current urethral stricture and had undergone childhood hypospadias surgeries were included. All adult urethral strictures were managed by a single surgeon. Results. Mean patient age was 38.9 years old. The lag time of urethral stricture presentation ranged from 25 to 57 years after primary hypospadias surgery, with an average of 36 years. Stricture length ranged from 1 to 17 cm (mean: 10.3 cm). Open graft-based urethroplasties were performed in 4/9 cases. Salvage perineal urethrostomy was performed in 2/9 cases. Another 3 cases chose to undergo repeat urethrotomy or dilatations—none of these patients was cured by such treatment. Complications included one urethrostomy stenosis and one urinary tract infection. Conclusion. Urethral stricture may occur decades after initial hypospadias surgery. It can be the most severe form of anterior urethral stricture, and may eventually require salvage treatment such as a perineal urethrostomy. Patients undergoing hypospadias surgery should receive lifelong follow-up protocol to detect latent urethral strictures

Effect of Preoperative Hormonal Therapy in Hypospadias Surgery: Evaluation of the current practice at the Pediatric surgery Clinic, Clinical Center University of Sarajevo

Introduction:The most common congenital abnormality of the penis is hypospadias. Although the main treatment is surgical; hormone therapy with dihydrotestosterone is also used.Materials and Methods: This randomized clinical trial was carried out between January 2012 and December 2017 on 79 children with hypospadias (in the Clinic of Pediatric Surgery, Clinical Centre University of Sarajevo). Their mean age was 38.2±2.8 months. GroupI included 36 children whom were treated with 2.5% dihydrotestosterone gel which was applied twice a day to the penile shaft and glans for one month prior to surgery. GroupII included 43 children whom did not receive any treatment preoperatively.Results: Mean age of patients in group I was 37.3±6.3 months and in groupII it was 39.1±5.9 months which were comparable. Complications occurring postoperatively were: urethrocutaneous fistula in 6 patients (13.9%) in group II, versus 1 patient (2.7%) in group I. There were 2 patients with meatalstenosis in group II (4.7%), and 3 (8.3%) in group I. Finally, there was a significant difference (p<0.05) between the overall reoperation rates between groups (p<0.05).Conclusion: Pretreatment with 2.5% dihydrotestosterone transdermal gel before hypospadias repair is beneficial in decreasing complication rates