European Journal of Cardiovascular Medicine

Hypospadias is a congenital malformation characterized by an ectopically placed meatus on the ventral side of the penis or scrotum, a cleaved foreskin and sometimes a penile curvature1. It is a multifactorial disease, caused by both genetic and environmental factors. The birth prevalence is 1/125 boys born, which is why hypospadias is one of the most common congenital malformations². The malformation is a midline anomaly and can be of varying severity, usually divided into degrees, according to where the meatus is situated. The more proximal, the more complex the anomaly, and more complex cases may also present with curvature of the penis. The proximal hypospadias account for up to 30% of all cases of hypospadias. In the mildest forms, the sign of a midline anomaly might be the cleaved foreskin exposing meatus in or near the correct location. In these boys, physical symptoms are rare. ^3-7 In distal hypospadias the meatus is sometimes narrow which influences urinary flow by obstruction. The result of a conservative approach, when it comes to function and appearance, could only be evaluated after puberty, but it could be expected that a pronounced curvature of the penis might interfere with penetrating intercourse. While the treatment is surgical there is as yet a lack of consensus of opinion on the ideal treatment of hypospadias, and complications resulting from surgery are common. Treatment consists of surgery to achieve a cosmetically normally looking penis with the meatus located on the tip of the glans without curvature, and with a future normal sexual function.

With the aim of introducing the subject of hypospadias, a background containing a short historical view, epidemiology, etiology, normal and abnormal sex development as well as clinical features, management and outcome measures of hypospadias will follow.

AIM & OBJECTIVES OF THE STUDY

The aim of this study, to assess in term of OBJECTIVE and FUNCTIONAL variants following surgical correction of Proximal hypospadias.

 OBJECTIVE ASSESSMENT

Using HOSE (HYPOSPADIAS OBJECTIVE SCORING EVALUATION) system.

Retrograde urethrogram Ultra sound KUB

FUNCTIONAL ASSESSMENT

Using Uroflowmetry.

STUDY DESIGN:

Observational Prospective & Retrospective (3 years Retrospective & 2 years Prospective study).

SAMPLE SIZE: 50 cases.

STUDY DURATION: The study period is for two years.

SAMPLING TECHNIQUE:

• Clinical examination to diagnose proximal Hypospadias was be done, Assessment of degree of chordee following which two staged repair was be planned
• Stage 1: for chordee correction, after 6 months
• Stage 2: for definitive Urethroplasty was performed and followed up till 2 years from date of
• Surgical site inspection was done on Post operative day 5 and post operative day 10
• Catheter was removed on 10^th POD and urine stream was
• Cases without fistula underwent Retrograde urethrogram (RGU) after 2 months of stage II
• Cases without fistula underwent UROFLOWMETRY after 3 months of stage II

INCLUSION CRITERIA:

• Children who underwent surgery for proximal hypospadias in last three years and who are in regular follow up at Department of Paediatric surgery, Niloufer hospital .
• All children with proximal hypospadias who

UNDERWENT STAGED REPAIR during study period at Department of Paediatric surgery, Niloufer  Hospital.

EXCLUSION CRITERIA:

• Children with other forms of
• Children with hormone deficiency / DSD
• Children who underwent single stage repair for proximal hypospadias
• Children without toilet
• Children / parents not willing to participate or give consent to be subjects of

Table 1. AT STAGE 1

Stage 1 correction/ chordee / ventral curvature, all cases underwent stage 1 correction at a mean age of 2years 4 months, the mean stretch penile length at the time of stage 1 correction was 2.8cms, few cases were preoperatively given 1-3 doses of Inj. Testosterone.

Status of degree of chordee at clinical presentation in our subjects was mild in 7, moderate in 33 and severe in 10 suggesting proximal hypospadias is more associated with moderate to severe degrees of chordee. 22% (11) of our subjects had meatus at proximal penile level and 78% (39) of them had meatus at penoscrotal level.

8 cases had associated penoscrotal transposition which were addressed in the later part of follow-up.7 cases had undescended testis of which 6 were unilateral palpable testis and one had bilateral palpable testis for which karyotyping evaluation was done. 3 cases had inguinal hernia, 1 case had encysted hydrocele which were simultaneously operated during stage 1 procedure.

Table 2. AT STAGE 2

At stage 2 correction mean age was 5 years 1 month, the mean stretch penile length at the time of stage 2 correction was 3.3cms, 3 cases had residual chordee after stage 1 correction of which underwent redo chordee correction. Post chordee correction, 11 cases who had proximal penile meatus displaced proximally to penoscrotal level.

Table 3. Operative data

In our study all children underwent Byar’s two staged repair, 48 cases were kept on continuous bladder drainage using feeding tube. one case had urinary retention in early post operative hours managed by placing suprapubic catheter, in another case due to long length and tension tubularization suprapubic catheter was placed intraoperatively.

Length of catheter drainage following stage 1 correction was 9.1 days, prolonged catheter drainage was instituted for cases with surgical site infection, devascularised byars flaps. Following stage 2 correction mean length of catheter drainage was 10.6 days.

Post operative follow up revealed fistula rate of 30% (15 cases) in our study of 4 cases required revision urethroplasty in view of complex or multiple fistulas. Rest 11 cases underwent simple fistula closure in follow-up.

Table 4. Hypospadias Objective Scoring Evaluation

Fig 1. Hose Scores in our Study:

Table 5. Meatal Location

After stage 2 correction meatal position in our study , 52% children had meatus at glanular level 22% at coronal level. 6% ( 3 cases) had neo meatus at tip of glans.

Table 6. Meatal Shape

Meatus shape post urethroplasty , 78% had a vertical slit like meatus with wide caliber 22% had circular meatus with narrow caliber meatus 70% had single stream from neo meatus, 30% cases had spraying stream which are most common associated distal fistula.

Table 7. Erection

Post stage 2 correction 6 cases had residual chordee , 5 had mild degree and 1 had moderate degree which was of skin level chordee.

Table 8. Fistula

Fistula rate in our study is 30% , fistula ranging from simple fistula to complex type , most fistulas in our study were of complex/ multiple types. 4 out 10 cases with multiple fistulas had to undergo revision urethroplasty.

Table 9. Post operative Assesment Tool

As per our study protocol all cases were assessed with ultrasound KUB of which 3 cases had post voidue residue more than 30ml , these were associated with stenotic meatus. None of cases had significant bladder wall changes or Hydronephrosis.

Retrograde urethrogram was done in cases without fistula of which 2 cases had stricture at proximal penile level which were under serial calibration during follow up .

Uroflowmetry done 3 months following urethroplasty measuring max flow rate (Qmax), voiding time 58% of children had peak flow rate under acceptable curve (5^th- 25^th centile).

Over the last decade, there has been an increasing incidence of hypospadias worldwide, demanding an accompanying increase in hypospadias surgery. Generally, Byars’ and Bracka’s operations are the most common operations performed in our institution. We restricted to Byars technique for our study.

In this study, the majority of our patients presented between 02 and 11 years-old, the age at surgery mostly depended on the age when the patient was first seen at the surgical Outpatient. The second-stage repair was usually performed after 6-12 months. Thus, the patients completed two-stage repair and any subsequent surgery before they were of school age.

The HOSE criteria used in the study is a validated, objective outcome assessment with a very low inter-observer error and good inter-observer correlation. Seventy-four(74%) of our study children had an acceptable HOSE outcome with a total score of 14 to 16, and 13 (26%) had an unacceptable outcome with a total score of thirteen or below. The meatal location, shape and fistula are easy to objectively assess, but the main drawback of the HOSE in our study arose in relation to the necessity of objective evaluation of the straightness of the penis and urinary stream. There are few studies that have investigated the micturition of repaired urethral, and those few have not generally studied micturition after straightforward distal hypospadias repair.⁸ Urethral stricture is a well-recognized complication of urethral reconstruction with unknown long-term consequences of asymptomatic stenosis after hypospadias repair.⁹

The measures available to assess the reconstructed urethra include direct observation of the urinary stream, voiding cystourethrogram and uroflowmetry.¹⁰ Rynja et al.¹¹ demonstrated that there was a discrepancy between the subjective and objective parameters of urinary function, both in hypospadias patients and in controls. The average flow rate and Q max in hypospadias patients need to be interpreted using a nomogram, as these parameters increase with the age of patient and volume of the bladder.

The reported overall complication rate from hypospadias surgery is ranges between 5-40%. The complications include wound infection, hematuria, penile skin blister, and suprapubic catheter, all of which are minor and can be treated conservatively. Furthermore, fistula, meatal stenosis, wide meatal opening and urethral stricture have also been observe^12,13

Our study drawbacks being small non-randomized sample size , short follow up results, which are most likely reflect the learning curve associated with the severe type of hypospadias seen in our patients.

In conclusion, two-stage hypospadias repair is a suitable technique for proximal penile hypospadias and produces a variety of outcomes. HOSE and uroflowmetry are simple, non- invasive, non-expensive and easy methods to objectively assess the long-term outcomes of hypospadias repair.

Conflict of Interest: None

Funding Support: Nil

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