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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 313-317

Failed hypospadias repair: critical analysis of pediatric patients


1 Department of Urology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Menshawy General Hospital, Tanta, Egypt

Date of Submission23-Apr-2020
Date of Decision01-Jun-2020
Date of Acceptance07-Jun-2020
Date of Web Publication18-Apr-2022

Correspondence Address:
Abdelsalam A Aboelnoor
Department of Urology, Tala
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_120_20

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  Abstract 


Objective
To evaluate pediatric patients with anterior hypospadias without chordee who were planned for surgical repair.
Background
Failed hypospadias repair refers to any hypospadias repair associated with complications or causes patient dissatisfaction. It includes meatal stenosis, fistula, urethral stricture, and glans dehiscence.
Patients and methods
The study included 150 failed distal hypospadias repair patients. Patients were divided into two groups: previously failed hypospadias group (100 patients who were previously repaired (only one attempt of surgical repair) from June 2004 to October 2014) and de novo hypospadias group (50 patients). Their age ranged from 9 months to 6 years. Tubularized incised plate repair was applied for 87 cases, Mathieu technique for 20 cases, onlay technique for 13 cases, and meatal advancement and glanduloplasty incision for 30 cases. All 150 patients had undergone repair from October 2014 to October 2017 and were followed up for immediate and delayed complications.
Results
The incidences of meatal stenosis, fistula, neourethral stricture, and glanular dehiscence were 68, 50, 20, and 0%, respectively, in the previously failed hypospadias group compared with 82, 20, 16, and 16%, respectively, in the de novo hypospadias group. Our overall results showed that 87% of cases with shallow glanular groove had meatal stenosis, 51.3% of cases had neourethral stricture, 38.5% had fistula, and 15.4% had dehiscence.
Conclusion
The study showed a correlation between the glanular groove and the outcome of hypospadias repair, as the deeper the glanular groove, the lowest incidence of failed hypospadias repair.

Keywords: complications, failed hypospadias, fistula, glanular dehiscence, neourethral stricture


How to cite this article:
Selim MA, Aboelnoor AA, Abdelbaky TM, Soliman EH, Salman BM. Failed hypospadias repair: critical analysis of pediatric patients. Menoufia Med J 2022;35:313-7

How to cite this URL:
Selim MA, Aboelnoor AA, Abdelbaky TM, Soliman EH, Salman BM. Failed hypospadias repair: critical analysis of pediatric patients. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:313-7. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/313/343093




  Introduction Top


Hypospadias is one of the commonest congenital malformations with a prevalence of approximately one in 300 live male births [1]. Failed hypospadias repair is any hypospadias repair associated with complications or causes patient dissatisfaction [2].

Risk factors for failed hypospadias repair include factors related to hypospadias (severity of the condition, glanular groove, and characteristics of the urethral plate), patient's characteristics (age at surgery, endocrine environment, and wound healing), surgical procedure (surgical technique and surgeon experience), and postoperative management [3].

Complications of hypospadias repair are divided into early and late complications. Early complications include hemorrhage, edema, infection, catheter blockage, bladder spasm, and erection of the penis. Late complications include urethrocutaneous fistula, meatal stenosis, urethral stricture, and total glanular dehiscence [4]. The incidence of complications after distal hypospadias repair is about 3–21% [5].

The aim of this study was to evaluate patients with anterior penile hypospadias without chordee who were planned for surgical repair at the Urology Department of Menoufia University Hospital. Failure of repair in our study is defined as cases with distal hypospadias repair complicated with urethrocutaneous fistula, neourethral stricture, meatal stenosis, or total dehiscence.


  Patients and methods Top


The study protocol had been approved by the local ethical committee at Menoufia University hospitals. Written consent was taken from all the patients participated in the current study. The study included 150 patients with failed distal hypospadias repair. Patients were divided into two groups: previously failed hypospadias group [100 patients who were previously repaired (only one attempt of surgical repair) from June 2004 to October 2014] and de novo hypospadias group (50 patients). Their ages ranged from 9 months to 6 years.

The study included patients with distal hypospadias only (glandular, coronal, subcoronal, and anterior penile) who were planned for surgical repair. Cases with proximal hypospadias or with severe chordee and recurrent cases (more than one attempt of surgical repair) were excluded from the study.

All patients were subjected to preoperative evaluation and clinical examination with focused local examination for the presence or absence of chordee, penile skin condition, and presence or absence of sufficient prepuce. The examination also included the site and shape of the meatus, urethral plate morphology and its diameter (hypoplastic or not), and glandular groove characteristics (deep, shallow, or flat).

All cases included in the study were done by only two experienced surgeons with good experience in hypospadias repair, and their results were nearly comparable. In all cases, standard techniques were used during operation with strict limited ischemia time if needed as the tourniquet was released after 20 min if it was used.

Tubularized incised plate (TIP) repair was applied for 87 cases, Mathieu technique for 20 cases, onlay technique for 13 cases, and meatal advancement and glanduloplasty incision for 30 cases. All 150 patients underwent repair from October 2014 to October 2017 and were followed up for immediate and delayed complications.

SPSS Inc. Released 2015. IBM SPSS statisics for windows, version 23, Armnok, NY: IBM Corp. Qualitative variables such as glandular characteristics and urethral plate criteria were described in frequencies. Continuous data such as age and width were described as mean and SD. χ2 test was used for categorical variables. The level of significance was considered statistically significant if P value is less than 0.05 and was highly statistically signification if P value is less than 0.01.


  Results Top


The mean age of the patients was 3.09 ± 1.37 years. In the previously failed hypospadias group, 68% of cases had meatal stenosis, 50% had urethrocutaneous fistula, 20% had neourethral stricture, and no cases had glandular dehiscence. In the de novo hypospadias group, 82% of cases had meatal stenosis, 20% of cases had glandular dehiscence, 16% of cases had urethrocutaneous fistula, and 16% of cases had neourethral stricture, as shown in [Figure 1].
Figure 1: Types of complications among the previously failed hypospadias group and in the denovo hypospadias group.

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The correlation between flat glandular groove and outcome of hypospadias repair showed that 80.8% of cases had meatal stenosis, 57.7% had urethrocutaneous fistula, 42.2% had neourethral stricture, and 3.8% had glandular dehiscence. The correlations between shallow glandular groove and outcome of hypospadias repair showed that 87% of cases had meatal stenosis, 51.3% of cases had neourethral stricture, 38.5% had urethrocutaneous fistula, and 15.4% had glandular dehiscence, as shown in [Table 1].
Table 1: Correlation between glandular characters and the outcome of hypospadias repair

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Finally, the correlation between deep glandular groove and outcome of hypospadias repair showed that 74% of cases had meatal stenosis, 47% had urethrocutaneous fistula, 36.5% had neourethral stricture, and 3.5% had glanular dehiscence, as shown in [Table 1].

Most cases of failed hypospadias were associated with narrow urethral plate diameter (6–8 mm). It was found that 13.1% of these cases had urethral plate stricture, 28.28% had urethrocutaneous fistula, 66.6% had meatal stenosis, and 3.9% had glandular dehiscence, as shown in [Table 2].
Table 2: Correlation between width of urethral plate and each type of failed hypospadias repair causes

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In our study, 85 (56%) patients had postoperative wound infection. All patients were treated with topical and systemic antibiotics, with resolution of the infection in 20 patients, whereas in the remaining 65 patients, the infection ended with failed hypospadias repair.

The effects of multiple factors such as urethral plate width, glandular groove, and infection on the outcome of hypospadias repair are shown in [Table 3].
Table 3: Effects of multiple factors on the outcome of hypospadias repair

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  Discussion Top


The aim of hypospadias repair is to create a straight penis with slit-like meatus at the tip of the gland with enough skin coverage, which enables the patient to urinate adequately and to have a penis with satisfactory cosmetic appearance. Multiple surgical operations have been used for treatment of hypospadias, which are based on the type and severity of hypospadias [6].

Literature-based research studies suggested that the age of patients with hypospadias repair starts from 6 months to preschool age. The mean age of repair in our study was 3.09 ± 1.37 years. Some evidence suggests that performing surgery at a younger age also decreases the risk of complications. In a series of 693 patients who underwent repair at age less than 12 months, there was a 3.4% complication rate, compared with 18.7% for patients who received surgery later in life [2].

The failure of hypospadias repair occurs when the repair does not achieve the cosmetic and functional goals of a straight penis with normal shaped meatus at the tip of the penis and enables normal urinary and sexual function without complications [3].

Howe and Hanna [7] stated that repair of hypospadias was associated with multiple complications and failure. The common complications include meatal stenosis, urethrocutaneous fistula, neourethral stricture, total dehiscence of the gland, and persistent chordee. The failure of repair in our study was defined as any deviation from the smooth postoperative course with proper healing, leaving distal-situated functionally patent urethral meatus and capacious neourethral diameter [7].

Snodgrass et al. [8] reported that the median time for diagnosis of fistula, meatal stenosis, and neourethral stricture was 6 months and for glans dehiscence was 2 months.

When complications occurred, 64% were diagnosed by the first postoperative visit after TIP repair and 81% occurred during the first year after repair [9].

In our study, the median time for diagnosis of meatal stenosis was 6 months, 1.5 months for glans dehiscence, 5 months for fistula, and 1 year for neourethral stricture, which were nearly similar to Snodgrass and colleagues.

Neourethral stricture disease secondary to hypospadias is etiologically denoted as inflammatory stricture from prolonged catheterizations or neourethral stricture at the site of repair.

The true incidence of neourethral strictures is difficult to define because of a lack of series with long-term follow-up after hypospadias repair; however, neourethral strictures have been reported in some series to be the second most common complication of hypospadias repair in the pediatric population, with an incidence of 6.5% [10].

In our study, neourethral stricture was observed in 20 (13.1%) cases with narrow urethral plate (<8 mm) and in seven (4.6%) cases only with a wide urethral plate of more than 8 mm.

Our results were comparable to Snyder et al. [11], who reported neourethral stricture rate after hypospadias repair of 12% and also were comparable to Karabulut et al. [12] and Aboutaleb [13], who reported neourethral stricture rate after hypospadias repair of 12%.

In contrast, Eliçevik et al. [14] reported a lower incidence of neourethral stricture after hypospadias repair of only 1%.

On the contrary, Cimador et al. [2] reported a higher incidence of neourethral stricture of 72%. This could be explained by the fact that they included proximal and distal types of hypospadias.

Our study showed that cases with shallow glandular groove were associated with neourethral stricture in 61.3% of cases. Hypospadias repair for cases with flat glandular groove showed lower figures (42.3%), whereas cases with deep groove demonstrated only 7.5% new urethral strictures. This might be owing to the tight urethra associated with shallow glandular groove causes ischemia at the edges during repair with increased incidence of stricture formation.

Urethrocutaneous fistula was the second most common complication in our study after meatal stenosis. Fistula occurred in 58 (31.1%) of 150 cases. Most fistulae were associated with narrow urethral plate (28.28%), as shown in [Table 2]. Urethrocutaneous fistula cases were 57.7% in patients with flat glandular groove. Our study was comparable to Shapiro et al. [15], who reported urethrocutaneous fistula rate of 17%, and also comparable to Horton et al. [4] who reported urethrocutaneous fistula rate following hypospadias surgery to range between 15 and 45%.

In contrast to our study, the study by Aboutaleb [13] reported a fistula rate of 8%, as he included only cases with TIP repair. We also included cases of previous repair that might explains the higher urethrocutaneous fistula (31.3%) after hypospadias repair in our study.

Meatal stenosis was the most common complication in our study. It occurred alone or associated with urethrocutaneous fistula or with neourethral stricture. Our study showed that meatal stenosis was ∼68.2% in the previously failed hypospadias group and 82% in the de novo hypospadias group.

Meatal stenosis was common among cases with narrow urethral plate of less than 8 mm and among patients with shallow glandular groove.

The aforementioned results were different from those mentioned by Tarek et al. [3], Eliçevik et al. [14], and Karabulut et al. [12]. They reported a complication rate of 11.9, 5, and 4%, respectively. All of these previous studies included all cases of hypospadias repair (successful and failed), but in our study, we excluded successful cases and reoperated previously failed cases.

In our study, total glandular dehiscence after repair was 7%. These results were comparable with the studies done by Eliçevik et al. [14] and Snyder et al. [11]. They reported glandular dehiscence in 2 and 10%, respectively. However, Tarek et al. [3] reported a glandular dehiscence rate of 19.4%. This higher rate was owing to operation on failed hypospadias repair cases.


  Conclusion Top


The overall analysis of failed hypospadias cases showed that the deep the glanular groove and the wider the urethral plate diameter, the lowest the incidence of meatal stenosis, urethrocutaneous fistula, and neourethral stricture. In contrast, with flat glandular groove and narrow urethral plate diameter, there is increased incidence of meatal stenosis, urethrocutaneous fistula, neourethral stricture, and glandular dehiscence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Retik A, Borer JG. Hypospadias, In: Retik AB, Vaughan ED, Wein AJ, et al., editors. Campbell's urology. 8th ed. Philadelphia: Saunders; 2002. p. 652248–652333.  Back to cited text no. 1
    
2.
Cimador M, Vallasciani S, Manzoni G, Rigamonti W, De Grazia E, Castagnetti M. Failed hypospadias in paediatric patients. Nat Rev Urol 2013; 10:657.  Back to cited text no. 2
    
3.
Tarek AG, Mohammed AZ, Osama M. Reoperative urethroplasty after failed hypospadias repair. Med J Cairo Univ 2019; 87:3325–3332.  Back to cited text no. 3
    
4.
Horton CE, Devine CJ, Adamson JE, Carraway JH. Hypospadias, epispadias and extrophy of the bladder. Smith's plastic surgery. 5th ed. Philadelphia, New York: LippincottRaven Publishers; 1997. 1101–1110.  Back to cited text no. 4
    
5.
Oswald J, Körner I, Riccabona M. Comparison of the perimeatal based flap Mathieu and the tabularized incisedplate urethroplasty (Snodgrass) in primary distal hypospadias. BJU Int 2000; 85:725–727.  Back to cited text no. 5
    
6.
Snodgrass W, Bush NC. Re-operative urethroplasty after failed hypospadias repair: how prior surgery impacts risk for additional complications. J Pediatr Urol 2017; 13:289-e1.  Back to cited text no. 6
    
7.
Howe AS, Hanna MK. Management of 220 adolescents and adults with complications of hypospadias repairs during childhood. Asian J Urol 2017; 4:14–17.  Back to cited text no. 7
    
8.
Snodgrass W, Villanueva C, Bush NC. Duration of follow-up to diagnose hypospadias urethroplasty complications. J Pediatr Urol 2014; 10:208–211.  Back to cited text no. 8
    
9.
ElSherbiny MT, Hafez AT, Dawaba MS, Shorrab AA, Bazeed MA. Comprehensive analysis of tabularized incisedplate urethroplasty in primary and reoperative hypospadias. BJU Int 2004; 93:1057–1061.  Back to cited text no. 9
    
10.
Borer JG, Bauer SB, Peters CA, Diamond DA, Atala A, Cilento BG, et al. Tabularized incised plate urethroplasty: expanded use in primary and repeat surgery for hypospadias. J Urol 2001; 165:581–585.  Back to cited text no. 10
    
11.
Snyder CL, Evangelidis A, Hansen G, Peter SD, Ostlie DJ, Gatti JM, et al. Management of complications after hypospadias repair. Urology 2005; 65:782–785.  Back to cited text no. 11
    
12.
Karabulut A, Sunay M, Erdem K, Emir L, Erol D. Retrospective analysis of the results obtained by using Mathieu and TIP urethroplasty techniques in recurrent hypospadias repairs. J Pediatr Urol 2008; 4:359–363.  Back to cited text no. 12
    
13.
Aboutaleb H. Role of the urethral plate characters in the success of tabularized incised plate urethroplasty. Indian J Plastic Surg 2014; 47:221–237.  Back to cited text no. 13
    
14.
Eliçevik M, Tireli G, Demirali O, Ünal M, Sander S. Tabularized incised plate urethroplasty for hypospadias reoperations in 100 patients. Int Urol Nephrol 2007; 39:823–827.  Back to cited text no. 14
    
15.
Shapiro SR. Fistula repair. In: Ehrlich RM, Alter GJ, (editors). Reconstructive and plastic surgery of the external genitalia. Philadelphia: Saunders; 1999:132–136.  Back to cited text no. 15
    


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  [Table 1], [Table 2], [Table 3]



 

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