Abstract
Hypospadias is a congenital anomaly in which due to the incomplete fusion of urethral folds the meatus opens on the ventral surface of the
penis. It is the most common congenital malformation of the urethra with the prevalence of 1 in 200-300 live male births. The late complications
of two stage AB repair of hypospadias are Urethrocutaneous fistula formation, urethral strictures, meatal stenosis and persistent chordee which
occur within 6 weeks after the 2nd stage of the procedure. The aim of the study is to determine the frequency of late complications of two staged
AB repair. The rationale of the study is that if the late complications rate of two staged AB repair comes out significantly lower than other studies
then it will help reconsider the existing guidelines of hypospadias surgery.
Material and methods
This study was conducted at Plastic and reconstructive unit Hayatabad Medical Complex Peshawar for the period of 24 months (from August
2011 to July 2013). The total sample size was 370 patients. More over this was a descriptive cross-sectional study in which non-probability
consecutive sampling technique was used.
Results
In this study mean age was 3 years with standard deviation ± 1.24. All the patients were male in which 28% patients had Urethrocutaneous
fistula, 8% patients had urethral structure. Frequency of complications among 370 patients was analyzed as late complications n=104(28%)
patients had Urethrocutaneous fistula, n=30(8%) patients had urethral stricture, n=44(12%) patients had meatal stenosis and n=19(5%)
patients had persistent chordee.
Conclusion
The most common late complication is Urethrocutaneous fistula and it can be reduced by adding a water proofing layer over the
urethroplasty, keeping the suture line of subsequent layers eccentric and meticulous tissue handling under loupe magnification.
Keywords
Hypospadias; Aivar Bracka; 2 staged hypospadias repair; Urethrocutaneous fistula
Introduction
Hypospadias is the common congenital anomaly of the penis with an
incidence of about 1 in 300 male live births [1]. Great variations exist
in the prevalence of hypospadias most likely because of differences in
genetics, environment, geography and in part to the differences in data
collection methods [2]. The dorsal aspect of the penis is most often
normal in hypospadias. Three associated anomalies classically found
in hypospadias are; an ectopic meatus, a ventral curvature of the penis
(chordee), and a defect of the ventral prepuce [3]. This chordee is due to
the differences in length of the ventral and the dorsal sides of the penis
known as corporocavernosal disproportion [4]. The urethral meatus is
positioned ectopically and lies somewhere proximal to the normal site at
the tip of glans ventrally. At least 70% of hypospadias is either glandular
or distal penile and rest are mid penile and more severe proximal type [5].
Histologically, the urethral plate consists of well-vascularized tissue with
large endothelial sinuses lined around an abortive urethral spongiosum
[6]. This leads to fibrosis and cicatrisation of urethral plate and at times
leads to chordee formation [7].
The most common associated anomalies are cryptorchidism (8% to
10%) and inguinal hernia (9% to 15%) [8,9]. The etiology of hypospadias
remains unknown with environmental exposure in the form of endocrine
disruptors, the most likely explanation for the worldwide increase in the
last three decades [3,10]. Interferences in the androgen metabolism, for
example, 5α-reductase deficit, defects of the androgen receptor, or gene
defects are possible etiological factors for hypospadia, that are only found
in <5% of the patients [8,11]. In patients with cryptorchidism or ambiguos
genitalia, karyotyping should be considered [12].
The sequential steps for the successful repair of hypospadias are
orthoplasty, urethroplasty, meatoplasty, glanuloplasty and prepucioplasty
[13]. More than 300 procedures described for hypospadias reconstruction
are evidence to both surgical ingenuity and dissatisfaction with the
resultant solutions [14]. Among the choice of procedures for distal
hypospadias is plate preservation procedures, like incised plate
urethroplasty (Snodgrass), glans approximation procedures and Mathieu
flip-flap repair, whereas for proximal hypospadias is extended application
of incised plate urethroplasty with (snodgraft) or without graft, various
flaps and graft urethroplasties, like Aivar Bracka in one or two stages [15].
Amongst the various methods reconstructing the hypospadic urethra,
the two stages Aivar Bracka repair, introduced in 1995, has gained steady
popularity worldwide during the last two decades fulfilling all the goals
of hypospadias repair [13,16]. It is now more frequently performed in
patients with inadequate urethral plate associated with moderate to severe
chordee [17]. In fact hypospadias surgery carries very high complication
rate even in experienced hands [18]. Complication rate depends on the
severity of the anomaly [19]. So far the commonest complication has been
fistula formation [17]. Urethral stricture, scarring, Chordee and painful
erection are other trades off from various surgical procedures [20].
The goals of hypospadias reconstruction is to create a straight penis that
is adequate for sexual intercourse, to reposition the urethral meatus to the
penile tip to allow the patient to void while standing, to create a neourethra
of adequate and uniform caliber and an aesthetically acceptable penis with
a slit like vertically located meatus [21,22]. Figure 1 shows a two staged
bracka repair. a – d is the first stage and e – h is the second stage (Figure 1).
Figure1: (a,b,c,d) Stage 1 Aiver Bracka Repair
a: stay sutures and incision on the urethral plate
b: dissection of the urethral plate and release of chordee
c: Full thickness graft being secured
d: graft secured with tie over dressing
e: second stage, degloving of penile shaft
f: urethroplasty and water proofing layer being elevated
g & h: completed stage 2.
The purpose of this study is to determine our rate of late complications
with this technique. Efforts will be made to improve the surgical technique
and to minimize late complications further, thereby reducing the number
of subsequent surgeries.
Methods
This study was carried out in the Plastic and reconstructive unit of
Hayatabad Medical Complex, Peshawar, Pakistan from August 2011 to
July 2013.
A total number of 370 patients were included in the study. The inclusion
criteria was set to include all male patients of any age group Presenting
hypospadias associated with chordee along with narrow urethral plate
and the exclusion criteria was set to exclude all previously operated
cases or hypospadias cripples and coronal and glanular hypospadias
without significant chordee along with wide urethral plate. Patients with
ambiguous genitalia diagnosed by clinical examination with the findings
of genitalia which could not be assigned to either sex were also excluded
from the study.
All male patients with hypospadias (diagnosed by clinical findings of
meatal opening on the ventral surface of the penis) fulfilling the inclusion
criteria was enrolled from Out-patients’ department and referral from
other departments. An informed consent was taken from all the patients
after explaining the study protocol. After detailed clinical history and
physical examination, all the hypospadias patients were subjected to two
staged AB repair by plastic and reconstructive surgeons (with at least 5
years post-fellowship experience in hypospadias repair). In the first stage
chordee (abnormal ventral curvature due to fibrosis) was released with
sharp dissection and the wound was covered with inner preputial full
thickness skin graft to provide the deficient urethral plate. The 2nd stage
was performed after 6 months in which the grafted area of the penis was
tabularized over a silicon urinary catheter with Polygalactone 6-0 suture.
The catheter was removed on 7th post-operative day.
All the patients was observed for late complication in the corresponding
follow-up visits on every week in the first month, and then every 3rd week
till the end of 6th post operation month operative month to detect any
late complications like Urethrocutaneous fistula, meatal stenosis, urethral
strictures, persistent chordee.
The exclusion criteria had strictly followed to exclude confounders and
bias in the results.
Results
This study was conducted at plastic and reconstructive unit Hayatabad
Medical Complex, Peshawar in which a total of 370 patients were observed
to find the frequency of common complication after two stage AB repair
of hypospadias surgery and the results were analyzed as :
Age distribution among the patients was analyzed as most of the
patients n=296(80%) were in age range 3-7 years followed by n=67(18%)
patients were in age range 8-15 years and n=7(2%) patients were in age
range 15-20 years.Mean age was 3 years with standard deviation ± 1.24
(Table 1).
Table 1: Age Distribution (n=370)
Duration of surgery of in our patients was analyzed as n=340(92%)
patients were operated in less than 60 minutes while n=30(8%) patients
operated in more than 60 minutes.Mean duration of surgery was
30minutes with standard deviation ± 2.41 (Table 2).
Table 2: Duration of Surgery (n=370)
Frequency of complications among 370 patients was analyzed as late
complications n=104(28%) patients had Urethrocutaneous, n=30(8%)
patients had urethral stricture, n=44(12%) patients had meatal stenosis
and n=19(5%) patients had Persistent chordee (Table 3).
Table 3: Complications (n=370)
Association of complications with age distribution was analyzed as in
130 cases of edema, 109 patients were in age range 3-7 years, 18 patients
were in age range 8-15 years and 3 patients were in age range 15-20 years.
In 104 cases of Urethrocutaneous, 88 patients were in age range 3-7 years,
14 patients were in age range 8-15 years and 2 patients were in age range
15-20 years. In 30 cases of urethral stricture, 26 patients were in age range
3-7 years and 4 patients were in age range 8-15 years. In 44 cases of meatal
stenosis, 39 patients were in age range 3-7 years, 5 patients were in age
range 8-15 years. In 19 cases of persistent chordee, 18 patients were in age
range 3-7 years, 2 patients were in age range 8-15 years (Table 4).
Table 4: Association of Complications in Age Group (n=370)
Association of complications with duration of surgery was analyzed as
in 104 cases of Urethrocutaneous fistula,97 patients were operated in <
1 hour and 7 patients were operated in > 1 hours. In 30 cases of urethral
stricture, 29 patients were operated in < 1 hour and 1 patient was operated
in > 1 hours. In 44 cases of meatal stenosis, 42 patients were operated in <
1 hour and 2 patients were operated in > 1 hours. In 19 cases of persistent
chordee all the 19 patients were operated in < 1 hour (Table 5).
Table 5: Association of Complications in Duration of Surgery (n=370)
Discussion
The AivarBracka (two stage) repair is a simple technical innovation
that has revolutionized hypospadias surgery. In 2000, Rick wood et al.
[23] published his result of 367 cases. He advocates a modern two stage
terminalising repair that could produce an even caliber hairless neourethra
with a vertically slit meatus and glans configuration. Not only did
the result proved to be more sophisticated than with the available single
stage methods, but also the surgery was relatively straightforward, reliable
and reproducible [23].
The majority of clinicians across KPK, Pakistan, use the AivarBracka
two stage repair (88%), Snodgrass (43%) or MAGPI (43%) [24]. Aslam
et al. [24] in a 10-year review, highlight the advantages of the Bracka two
stage repair in treating broad spectrum of pathologies with good outcome.
They highlight the advantages of a normal looking slit like meatus (unlike
MAGPI), ability to deal with chordee, scarless ventral surface and its
universal application (unlike Snodgrass), and hence requiring surgeons to
master only one technique [24].
There are several reasons for the great popularity of this technique,
including its technical simplicity, and its great versatility and excellent
cosmetic results. Furthermore, being uniquely versatile it could be used
as a universal repair for almost all types of hypospadias deformity. For a
resident plastic surgeon dealing with a still modest number of hypospadias
patients, being able to master one straight forward principle of repair and
produce refined results in a broad spectrum of primary and re-operative
problems is undoubtedly appealing [19].
In fact, hypospadias surgery carries very high complication rate even in
experienced hands [19]. Complication rate depends on the severity of the
anomaly. Our study shows that the incidence of hypospadias was found
more in age range 3-7 years as 80% patients were found in the same age
group. Secondly, most of the patients (92%) were operated in less than 60
minutes. Similar results were found in study done by Aslam et al. [17] in
which most of the patients (90%) was in the age range 3-9 years.
Our study shows that the most occurring complication was
Urethrocutaneous fistula which was found in 28% patients followed by
meatal stenosis which was found in 12% patients, urethral stricture was
found in 8% patients, Persistentchordee was found in 5% patients. Similar
results were quoted by another study done by Aslam et al. [17] in which
Urethrocutaneous was the leading risk factor found in 33% patients,
meatal stenosis was found in 10% patients, urethral stricture was found in
7% patients, Persistent chordee was found in 3% patients.
Complications are common after hypospadias repair, ranging from
fistulae to complete loss of the neo-urethra requiring total reconstruction
[20]. Even in experienced hands, hypospadias repairis associated with the
development of Urethrocutaneous fistulae. The Snodgrass technique is a
simple technical innovation that has revolutionized hypospadias surgery.
There are several reasons for this great popularity, including its technical
simplicity, and its great versatility and excellent cosmetic results. Rick
Wood et al. [23] in 1991 and reported the results of treatment of 367
patients with distal hypospadias, in whom an overall complication rate
of 7% was found.
In the current study the mean age was 3 years with SD+1.24 which is
comparable with 4.21} 4.4 years shown by Tabassi et al. [25] in their study
from Iran and contrary to 22.72} 7.75 months by Al-Saied et al. [26] in
their study from Saudi Arabia.
The location of the hypospadias in our study (48.5% had distal penile
hypospadias while 24.2% had coronal hypospadias) is similar to the
results reported by Tabassi et al. [25] (distal penile in 59% cases). The main
complication of hypospadias repair in this series is Urethrocutaneous
fistula which is found in 28% cases. Dodson et al. [27] reported fistula
rate of 50% in their study which higher than the current study. Braga et
al. [28] reported fistula formation rate of 14% which is lower than our
study. Fistula formation has multifactorial etiology i.e. surgical technique,
delicate tissue handling, patients, age, type of hypospadias defect, surgeon
experience, waterproof urethroplasty coverage, and concomitant foreskin
reconstruction. In our study the fistula rate was slightly higher because of
the learning curve.
The meatal abnormally was noted in 12% cases in this series which
comparable with 10.34% reported by Tabassi et al. [25] Other studies have
shown frequency of meatal abnormalities (stenosis) from 6-20%.
In our study the fistula rate was found significantly lower when
performed in age group above 5 years which may be due to the
adequatephallus size. The late complications frequencies were found
higher when the operation time was higher than 60 min.
TIPS (Snodgrass) and snodgraft procedure employ the preservation
of urethral plate as an important part of the neo-urethra formation
with favorable outcomes [15]. However, it has the inherited problem of
limited application and is applied in some coronal and distal hypospadias
with mild to moderate chordee [20]. Also the problems of fish mouth
appearance and stenosis of urinary meatus make the repair less favorable
[20]. A technique to repair hypospadias with universal applicability in
most variants would be appealing.
Conclusion
The current study conclude that post-operative Urethrocutaneous
fistula is the main complication of hypospadias repair, its rate is
significantly lower in age group above 5 years and the complication
frequency increases when the operation time is less than 60 min.
Snodgrass repair has acceptable complications rates in the hypospadias
repair. Further multi-centre studies are suggested to confirm the results
in our setup.