PEDURO 2011 II. National Pediatric Urology Congress

MJ Aboud

The Maternity and Child Teaching Hospital/Al-Qadisiya -Iraq Ministry of Health

Introduction: Great advances have been made in surgery for the correction of hypospadias. Proximal hypospadias remains the greatest challenge, but despite many innovations and much progress, surgery can fail. The new generation of paediatric surgeon has high ambitions in managing patients with hypospadias. More than 200 reconstructive procedures have been described for hypospadias repair. Despite large number of operative techniques for hypospadias repair, the complication rate is very high.

Objective  : To evaluate the factors that may influence the results of surgery after hypospadias repair at The Maternity and Child Teaching Hospital , pediatric surgery unit, Al-Qadisiya/ Iraq .

Patients & Methods: It was a retrospective observational study. Files of all patients who had Hypospadias repair were retrieved and analyzed with a view to identify the factors which may influence the results of surgery for Hypospadias. Patients with complete record available were included in the study, whereas those with incomplete data were excluded. Fortycases ( out of 115 cases of hypospadius ) of fistula, stricture, retrusive meatus, meatal stenosis, torsion, open distal urethra & urethral diverticula with combination of two or more, were managed by from 1st of January  2005 to the end of December 2009 . We looked at the number and type of initial and redo repairs they had. A minimum of at least 6 months was allowed to elapse between operations. To formulate an idea of the type of redo repair we would use, the clinical examination focused on the location and size of the urethral meatus, the status of the urethral plate and genital skin, the severity of residual chordee and the amount of scarring.

Results: There were 40 patients,aged 1–12 (mean 3.8) years, with failed hypospadias repairs. All operated on by the same surgeon, with a minimum of 12 months of follow-up.The initial severity of the hypospadias were as follows: perineal (2), penoscrotal (7), proximal shaft (4), mid-shaft (16), distal shaft (7), coronal (3) and mega-meatus (1). Of all the patients, 27 had 1 repair, 10 had 2 repairs and 3 had 3 repairs. The initial repairs comprised 13 tubularized island flaps (TIFs), 14 Snodgrass tubularized incised plate (TIP) techniques, 8 Mathieu repairs, 2 Meatal Advancement and GlanuloPlasty Incorporated (MAGPI) technique, 1 Pyramid, and 2 Thiersch-Duplay repair. Twenty-seven  of 40 patients had 1 redo operation, 9 had 2 redo operations, 3 had 3 redo operations and 1 had 4 redo operations, for a total of 58 redo operations. Of these, 34  were TIP techniques (58.6%), 8 were Mathieu (13.7%), 8 were TIF repairs (13.7%), 4 were onlay island flaps (6.8%) and 4 were buccal mucosal grafts (6.8%). Follow-up was 1–3 years (mean 1.5 yr). The final locations of urethral meatus included glans (29), corona (7), mid-shaft (3) and penoscrotal (1). Complications after redo surgery comprised 4 urethrocutaneous fistulae, 2 meatal stenoses, 1 urethral stricture and 3 dehiscences).

Conclusion: Surgical techniques for the repair of hypospadias are being developed continuously, implying that no single procedure is considered a panacea for hypospadias repair . Admittedly, it is difficult to follow patients for a long time, and it is even harder to predict who will have complications that will merit closer follow-up. Success in hypospadias surgery depends on good team work. Trained anesthetists allow early surgery with adequate postoperative pain relief. successful hypospadias surgery is minimal tissue handling, tension free reconstruction, the use of well vascularized tissue, knowledge of repairs are indicated and preservation of urethral plate. Using these principles, excellent cosmetic and functional results can be expected for treatment of hypospadias. All types of repair involve straightening the penis by removal of chordee.  The pediatric surgeon selects the appropriate operative procedure and carries it out with meticulous techniques. A good nursing team ensures a smooth recovery. Although single stage reconstruction carries a slightly higher complication rate, its advantages far outweigh that of the conventional staged approach .

MJ Aboud

The Maternity and Child Teaching Hospital/Al-Qadisiya -Iraq Ministry of Health