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SKRIPSI
DECEMBER 2017
THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR. WAHIDIN
SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 – JUNE 2017
PREVALENSI PASIEN HYPOSPADIA DI RSUP DR WAHIDIN SUDIROHUSODO,
MAKASSAR PERIODE JUNI 2016 – JUNI 2017
PREPARED BY:
AMALINA IZATI NUR BINTI IBRAHIM
NIM: C111 14 868
SUPERVISED BY:
DR. SACHRASWATY R. LAIDDING, SP. B, SpBP-RE(K)
MEDICAL EDUCATION COURSE
MEDICAL FACULTY
UNIVERSITAS HASANUDDIN
2017
HALAMAN PENGESAHAN
Telah disetujui untuk dilaksanakan
Judul Proposal Penelitian
THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR. WAHIDIN
SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 – JUNE 2017
Oleh :
AMALINA IZATI NUR BINTI IBRAHIM
C111 14 868
Makassar, 22 November 2017
Dosen Pembimbing,
dr. Sachraswaty R. Laidding, SpB, SpBP-RE (K)
NIP: 197601122006042001
DEPARTEMEN PENDIDIKAN KEDOKTERAN
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
2017
TELAH DISETUJUI UNTUK DICETAK DAN DIPERBANYAK
Skripsi dengan judul:
“THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR. WAHIDIN
SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 – JUNE 2017”
Makassar, 22 November 2017
Dosen Pembimbing
dr. Sachraswaty R. Laidding, SpB, SpBP-RE (K)
NIP: 197601122006042001
PANITIA SIDANG UJIAN SKRIPSI
FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
Skripsi dengan judul “THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR.
WAHIDIN SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 –
JUNE 2017”
telah disetujui, diperiksa dan dipertahankan di hadapan Tim Penguji Skripsi Departemen
Pendidikan Kedokteran
Fakultas Kedokteran Universitas Hasanuddin pada :
Hari / Tanggal : Rabu, 22 November 2017
Pukul : 2030 WITA
Tempat : Rumah Sakit Hikmah, Makassar
Pembimbing
dr. Sachraswaty R. Laidding, SpB, SpBP-RE (K)
NIP: 197601122006042001
Dr. A. J. Rieuwpassa, SpB, SpBP
NIP: 130222269
FOREWORD
Sincere praise and prayer are given to Allah SWT for His grace and mercy upon the
completion of this thesis as a requirement for completing the Thesis subject of the Medical
Faculty of Hasanuddin University, entitled “The Prevalences of Hypospadia Patient in RSUP
Dr. Wahidin Sudirohusodo, Makassar for the Periode of June 2016 – June 2017”.
The purpose of this research is done to show the prevalence and characteristic of
hypospadia patients that seek treatment at the referred hospital of Wahidin Sudirohusodo in
Makassar, South Sulawesi. With this research being done, it is hope that hypospadia is not taken
lightly and better procedures are being taken into account for a better management on
hypospadia patients.
The success in the completion of this thesis is not possible without the help from various
parties that gave guidance, moral assistance and cooperation towards any obstacles faced during
the whole procedure of the research. On this occasion, a sincere appreciation is given to:
1. Beloved parents, siblings and family member who have always been providing
encouragements, assistance and also guidance during the whole preparation of this thesis.
2. dr. Sachraswaty R. Laidding, Sp. B, SPBP-RE(K), as the supervisor who took time to
give guidance with sincerity and patience, from the moment of picking a topic for the
research to the proposal examination until the end of the final research examination.
3. Dr. A. J. Rieuwpassa, SpB, SpBP for taking time off from the busy schedule to be an
examiner during the proposal and final thesis examination, and dr. M. Asykar A.
Palinrungi, Sp. U for also taking the time to be an examiner during the proposal
examination and also giving advice and input in the process of writing and completing
the thesis.
4. The Dean, Vice Dean, Head of the Medical Education Unit (MEU), lecturers and staff
faculty of Medical faculty of Hasanuddin University that has helped and guided in
making this research.
5. Lecturers and all staffs of the plastic surgery department of medical faculty of
Hasanuddin University that has help giving guidance in writing this thesis.
6. Head of Medical Record Installation and all staff of RSUP Dr. Wahidin Sudirohusodo
Makassar that has helped in obtaining the medical record needed in this research.
7. My companion under the same supervisor Nur Nadhirah Iman, friends, fellow batchmates
that are undergoing the same process of completing the research thesis and multiple
individuals those names cannot be written for they are too many.
The realization that this thesis conducted is far from perfection so any form of criticism and
advice from any parties in order to improve this thesis is well appreciated. Hoping this thesis will
be any sort of help to any parties in the future.
Makassar, 22 December, 2017
Amalina Izati Nur Ibrahim
TABLE OF CONTENT
Title Page……………………………………………………………………………………….….I
Approval Page…………………………………………………………………………………….II
Foreword………………………………………………………………………………….………V
Table of Content………………………………………………………………………………..VII
List of Figures……………………………………………………………………………………IX
List of Tables……………………………………………………………………….…………….X
Abstract…………………………………………………………………………...…………….XI
Chapter 1. Introduction
1.1 Research Background…………………………………………………………………1
1.2 Summary of Study…………………………………………………………………….2
1.3 Objectives……………………………………………………………………………..3
Chapter 2. Literature Review
2.1 Literature Review…………………..…………………………………………………4
2.2 Theoretical Framework………………………………………………………………10
Chapter 3. Conceptual Framework
3.1 General Concept for the Manipulated Variable…………...…………………………11
3.2 The relationship pattern of the manipulated variable………………………..……....12
3.3 Operational definition and objective criteria…………………………...………....…13
Chapter 4. Research Method
4.1 Mode of Research……………………………………………………………………15
4.2 Location of Research………………………………………………………………...15
4.3 Population and Sample of Research…………………………………………………15
4.4 Sampling Method…………………………………………………………………….16
4.5 Presentation of Data………………………………………………………………….16
4.6 Work Method………………………………………………………………………...16
Chapter 5. Presentation of Data and Analysis of Data
Table 5.1 Age Distribution for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo
Makassar for the Period of June 2016 – June 2017…..………………………………….17
Table 5.2 Hypospadia Classification Parameter for Hypospadia Patient in RSUP DR.
Wahidin Sudirohusodo Makassar for the Period June 2016 – June 2017……………….19
Table 5.3 Other Congenital Anomalies Parameter Associated with Hypospadia Patient in
RSUP Dr. Wahidin Sudirohusodo Makassar for the Period June 2016 – June 2017.…...21
Table 5.4 Treatment Parameter for Hypospadia Patient in RSUP Dr. Wahidin
Sudirohusodo Makassar for the Period June 2016 – June 2017………….………….…..23
Table 5.5 Post-Operative Complication for Hypospadia Patient in RSUP DR. Wahidin
Sudirohusodo Makassar for the Period June 2016 – June 2017.............................…….25
Chapter 6. Discussion
6.1 Age…………………………………………………………………………………...27
6.2 Classification…………………………………………………………………………28
6.3 Other Congenital Anomalies Associated……………………………………………29
6.4 Treatment…………………………………………………………………………….30
6.5 Post-Operative Complication………………………………………………………...30
Chapter 7. Conclusion and Suggestion
7.1 Conclusion…………………………………………………………………………...32
7.2 Suggestion……………………………………………………………………………33
References………………………………………………………………………………………..34
Appendices
LIST OF FIGURES
Diagram 1 : Classification of Hypospadia………………………………………………….…6
Graph 5.1 : Age Distribution for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo
Makassar for the Period of June 2016 – June
2017…..…………………………………………………….…………………….18
Graph 5.2 : Hypospadia Classification Parameter for Hypospadia Patient in RSUP DR.
Wahidin Sudirohusodo Makassar for the Period June 2016 – June
2017……………………………………………………………………...……….20
Graph 5.3 : Other Congenital Anomalies Parameter Associated with Hypospadia Patient in
RSUP Dr. Wahidin Sudirohusodo Makassar for the Period June 2016 – June
2017.……………………………………………………………………………...22
Graph 5.4 : Treatment Parameter for Hypospadia Patient in RSUP Dr. Wahidin
Sudirohusodo Makassar for the Period June 2016 – June
2017……………………………………………………………….………….…..24
Graph 5.5 : Post-Operative Complication for Hypospadia Patient in RSUP DR. Wahidin
Sudirohusodo Makassar for the Period June 2016 – June
2017...............................................................................................................…….26
LIST OF TABLES
Table 5.1 Age Distribution for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo
Makassar for the Period of June 2016 – June 2017…..………………………………………….17
Table 5.2 Hypospadia Classification Parameter for Hypospadia Patient in RSUP DR. Wahidin
Sudirohusodo Makassar for the Period June 2016 – June 2017………………………...……….19
Table 5.3 Other Congenital Anomalies Parameter Associated with Hypospadia Patient in RSUP
Dr. Wahidin Sudirohusodo Makassar for the Period June 2016 – June 2017…………………...21
Table 5.4 Treatment Parameter for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo
Makassar for the Period June 2016 – June 2017………….………………………………….…..23
Table 5.5 Post-Operative Complication for Hypospadia Patient in RSUP DR. Wahidin
Sudirohusodo Makassar for the Period June 2016 – June 2017...........................................…….25
SKRIPSI
MEDICAL FACULTY
HASANUDDIN UNIVERSITY
December 2017
Amalina Izati Nur Ibrahim (C111 14 868)
dr. Sachraswaty R. Laidding, SpB, SpBP-RE (K)
THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR. WAHIDIN
SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 – JUNE 2017
ABSTRACT
Background: Hypospadia is known to be one of the most common congenital urogenital defects
that occur in males. The incidence rate reported for hypospadia is approximately 1 in every 250-
300 births of male baby. Objective: The aim of this research is to gain information regarding the
prevalence of hypospadia patient that was treated at RSUP. DR. Wahidin Sudirohusodo,
Makassar within the period of June 2016 until June 2017. Method: The method used for this
research study is descriptive non-analytic study method where the entire research study will be
conducted in the manner of describing the prevalence and characteristic of hypospadia patient
from June 2016 until June 2017 based on the secondary data obtained from medical records. The
data collected will be utilized and presented in the form of statistic or table with further
elaboration on each respective data with respect to the objective of the research study using
Microsoft Excel. Sample: The sampling method used in this research is by total sampling.
Results: There were 34 cases of hypospadia presented and most patient present with hypospadia
is at age 0-10 years old (52.9%), with highest classification of posterior hypospadia (52.9%) and
highest other anomalies associated with hypospadia is undescended testis, and hernia ingualis
(5.9%). The highest treatment procedure received was the two-step repair procedure (73.5%) and
had the highest post-operative complication of urethrocutaneous fistula (20.6%). Conclusion:
Majority of the patients were of age 0-10 years old, with posterior hypospadia, highest number of
anomalies associated is undescended testis and hernia ingualis, received the two-step repair
procedure and faced urethrocutaneous as the post-operative complication.
Key Words: Hypospadia, prevalence, Makassar.
SKRIPSI
FAKULTAS KEDOKTERAN
UNIVEERSITAS HASANUDDIN
Desember 2017
Amalina Izati Nur Ibrahim (C111 14 868)
dr. Sachraswaty R. Laidding, SpB, SpBP-RE (K)
PREVALENSI PASIEN HYPOSPADIA DI RSUP DR. WAHIDIN SUDIROHUSODO,
MAKASSAR UNTUK PERIODE JUNI 2016 - JUNI 2017
ABSTRAK
Latar Belakang: Hypospadia merupakan satu kelainan kongenital urogenial yang paling umum
terjadi pada pria. Tingkat kejadian yang dilaporkan untuk hipospadia adalah sekitar 1 dari setiap
250-300 kelahiran bayi laki-laki. Tujuan: Tujuan dari penelitian ini adalah untuk mendapatkan
informasi tentang prevalensi hipospadia yang dirawat di RSUP. DR. Wahidin Sudirohusodo,
Makassar dalam kurun waktu dari Juni 2016 sampai Juni 2017. Metode: Metode yang digunakan
dalam penelitian ini adalah metode prevalensi dan karakteristik hipospadia dari bulan Juni 2016
sampai Juni 2017 berdasarkan data sekunder yang diperoleh dari rekam medis. Data yang
terkumpul akan digunakan dalam bentuk statistik atau tabel dengan penjelasan yang lebih lanjut
dari Microsoft Excel. Sampel: Metode pengambilan sampel yang digunakan dalam penelitian ini
adalah dengan total sampling. Hasil: Terdapat 34 kasus hipospadia dan kebanyakan pasien
dengan hipospadia berada pada usia 0-10 tahun (52,9%), dengan klasifikasi tertinggi adalah
hipospadia posterior (52,9%) dan anomali tertinggi lainnya yang terkait dengan hypospadia
adalah testis yang tidak turun, dan ingualis hernia (5,9%). Prosedur perawatan tertinggi adalah
prosedur perbaikan dua tahap (73,5%) dan memiliki komplikasi pascaoperasi tertinggi yaitu
fistula urethrocutaneous (20,6%). Kesimpulan: Mayoritas pasien hipospadia berusia 0-10 tahun,
dengan hipospadia posterior, jumlah anomali tertinggi yang terkait dengan testis yang tidak turun
dan hernia ingualis, menerima prosedur perbaikan dua tahap dan menghadapi urethrocutaneous
sebagai komplikasi pasca operasi.
Kata Kunci: Hipospadia, prevalensi, Makassar.
CHAPTER 1
INTRODUCTION
1.1 RESEARCH BACKGROUND
Hypospadia is known to be one of the most common congenital urogenital defects that
occur in males (Al-Salem A.H, 2014). Hypospadia occurs due to abnormal development of the
urethral spongiosum, ventral preputium, and penile chordee (Nugroho T. D, Duarsa G. W, 2016).
This condition is described where the urethral meatus is abnormally located from its normal site,
which is located at the top end of the glans penis but along the urethral groove that includes the
glanular, scrotal and even the perineal (Maritska Z, 2015). The incidence rate reported for
hypospadia is approximately 1 in every 250-300 births of male baby (Risa, A. et al, 2017). A
research was conducted in the urology sub division in the hospital of M Djamil located in
Padang, Indonesia stating that there was increase rate of urethroplasty action in cases of
hypospadia from 15 cases in the year of 2009-2011 to 65 cases in the year of 2011-2014 (Praja
H, et al, 2017).
Studies shows that the reasons used for treating hypospadia patients are due to improper
urinary flow or other inconvenient urinary symptoms, possible infertility due to difficulty in
deposition of sperm, complication during intercourse as a result of ventral curvature of the penis,
and unsatisfied penile appearance that leads to delayed sexual development. Those are the
probability that those reasons may become a concern in untreated hypospadia patients (Schlomer
B. et al 2014). According to the Urology Committee of the American Academy of Pediatrics, the
optimal psychological age for someone to undergo genitalia surgery is below six month of age or
at the age of four years old (Duarsa G. W, Nugroho T. D, 2016)
Based on the Urology Committee of the American Academy of Pediatrics, within the
sixth month of age or by the age of four years old is the optimal psychological age for the
surgery of the genitalia. Based on the size of the penis, in the age of three months it is considered
sufficient enough for a surgery to be done with the help of a magnifier. With the intention of
doing early intervention, doctors are trying to do hypospadia repair on children at the age of four
to eight months old which is better for psychological and emotional state. The main purpose for
the hypospadia repair is to obtain a nearly normal cosmetic and functional results and the
decision for the technique used is based on the type of hypospadia, the penile curvature, and the
quality of the surrounding tissues (Duarsa G. W, Nugroho T. D, 2016).
1.2 SUMMARY OF STUDY
Based on the background of the research study mentioned above, a study will be
conducted regarding the prevalence of hypospadia patient that was treated at RSUP. DR.
Wahidin Sudirohusodo, Makassar within the time frame of June 2016 until June 2017.
1.3 OBJECTIVES
1.3.1 General Objective
To gain information regarding the prevalence of hypospadia patient that was treated at
RSUP. DR. Wahidin Sudirohusodo, Makassar within the period of June 2016 until June
2017.
1.3.2 Specific Objective
1. To study the prevalence of hypospadia patient according to age
2. To study the prevalence of hypospadia patient according to classification
3. To study the prevalence of hypospadia patient with other congenital anomalies
4. To study the prevalence of hypospadia patient according to treatment
5. To study the prevalence of hypospadia patient according to postoperative complication
CHAPTER 2
LITERATURE REVIEW
Hypospadia is one of the most common congenital anomalies and also one of the most
frequent male genital malformations. The word hypospadia is originally taken from two Greek
words hypo and spadon which means below and hole, crack or gutter respectively. According to
definition taken from the Greek word, it means that the meatus of the urethra is below the
intended hole of the urethra, which was suppose to be at the tip of the glans penis. The urethral
meatus located in this case can be anywhere along the urethral groove, whether glanular, scrotal,
or perinal (Maritska Z, 2015). The severity of the hypospadia varies on the location of the
meatus, the farther the meatus is to the tip of the penis the severe the case of hypospadia it is
(Schlomer. B, 2014).
The main idea that causes the occurrence of hypospadia is due to the arrest or incorrect
normal development of the urethra during various stage of the embryonic development, which is
within the 9 till 13 weeks of gestation (Al-Salem, 2017). The etiology for hypospadia is known
to be multifactorial, which includes genetic, endocrine disruptors, environmental influences and
other miscellaneous risk factors such as multiple birth, small gestation age, maternal age and
smoking parents (Maritska Z, 2015). There have been maternal-placental factors that have been
identified that enhance the probability of hypospadia, such as maternal hypertension,
prematurity, preeclampsia, preexisting maternal diabetes and many more. The influence of the
maternal dietary nutrients and medication has also been proven to contribute to the prevalence of
hypospadia, such as low consumption of organic food during pregnancy and also hormone
containing contraceptives during embryonal life. Though the pathophysiology of how this
condition occurs, there are studies that show that congenital penile malformation is somehow
connected to the microscopic organization of the smooth muscle fibre of the dartos tissue
(Fahmy, 2016).
Hypospadia is defined by three major anatomical defects that include ectopic urethral
meatus, abnormal foreskin that shows irregular penile raphe and dorsal hood, and chordee that
during erection shows congenital bend in the penis (Baskin, L. 2004). The main anomaly seen in
cases of hypospadia is the failure of the midline perineal mesenchyme to grow ventrally to cover
the urethral plate that causes the ectopic urethral meatus. Incomplete morphogenesis is the most
common embryological defect that causes the arrest of the urethra opening at or near the coronal
groove of the glans. When the opening is located more proximal on the penile shaft, it suggests a
more severe defect in the androgenic action. Some hypospadia patient may show abnormal
foreskin that shows irregular penile raphe may be explained by the failure of androgen-
dependent growth of the ventral penile mesenchyme, this leaves a wedge-shaped defect in the
ventral prepuce with absent of frenulum. While chordee, it is present in most patients but its
related to the severity of the hypospadia. It is usually present in patients with perineal or scrotal
anomalies, this maybe because it showed feminine development of the phallus with possible
testicular dysplasia and/or abnormal function of androgens (Hutson, J. M., Penington, E. C.,
2004)
Hypospadia is classified by the ectopic location of the urethral meatus, which can be
divided as anterior or distal hypospadia, middle or mid-penile hypospadia, and posterior or
proximal hypospadia. Anterior hypospadia is described when the urethral meatus is located at the
glandular, the meatus on the ventral surface of the glans penis;corona, the meatus in the
balonopenile furrow; or at the distal, which is in the distal third of the penile shaft. The second
category, middle or mid-penile hypospadia is when the urethral meatus is located aligning the
middle third of the penile shaft. The posterior hypospadia extends through the one third proximal
end of the penile shaft to the perineum, at the base of the shaft; scrotal, on the scrotum; and
perineal, behind the scrotum. The severity of the hypospadia is usually present with the
downward curvature of the chordee or penile curvature (Baskin, L. 2004).
Diagram 1 Classification of hypospadia
The symptoms shown on hypospadia patients are usually that they urinate downwards
instead of outwards and away from the body and causing wetness of the clothes and shoes, other
than that it may also lead to difficulty in depositing sperm and causing possible infertility, and if
it isn’t properly corrected, during adulthood, it may be a complication during intercourse due to
its ventral curvature of the penis and delayed sexual development because of its unsatisfied
penile appearance. In a certain case of severe hypospadia, which is usually the proximal type, it
is more likely to have an additional congenital anomaly. The most common urogenital anomaly
linked with hypospadia are cryptorchidism (undescended testis) and inguinal hernias. Patients
that has both hypospadia and undescended testis has a chance of having and underlying disorder
of sexual development (DSD). DSD has a higher risk of happening to those with proximal
hypospadia. DSD is shown with approximately 30% of patients with unilateral or bilateral
undescended testis with hypospadia, but increases 50% with patients with non-palpable testis. A
number of cases of hypospadia has also shown an anomaly with low-grade vesicoureteral reflux.
Any anomalies related with upper urinary tract anomalies are rarely present (Duarsa G. W,
Nugroho T. D, 2016).
Based on the Urology Committee of the American Academy of Pediatrics, within the
sixth month of age or by the age of four years old is the optimal psychological age for the
surgery of the genitalia. Based on the size of the penis, in the age of three months it is considered
sufficient enough for a surgery to be done with the help of a magnifier. With the intention of
doing early intervention, doctors are trying to do hypospadia repair on children at the age of four
to eight months old which is better for psychological and emotional state. There are no ideal
techniques that can be applied to repair all types of hypospadia. The main purpose for the
hypospadia repair is to obtain a nearly normal cosmetic and functional results and the decision
for the technique used is based on the type of hypospadia, the penile curvature, and the quality of
the surrounding tissues (Duarsa G. W, Nugroho T. D, 2016). Where else the main point for the
operation for correcting the hypospadia is making a new opening on the tip of the penis. After
the tempo of healing, most boys will have normal functions and appearance of the penis. The
type of surgery needed to fix hypospadia depends on several points which include the position of
the meatus and also the amount of foreskin (Mohamed, S. A, 2015).
The technique used to repair hypospadia should consider the type of hypospadia, the
penile curvature and the surrounding tissues. The operative steps includes degloving of the penis,
straightening the penile (chordectomy), reconstruction of the urethra, providing a good
vascularization coverage for the urethroplasty, reconstruction of the glans (glansplasty) and
create a circumcised penile appearance by doing a cosmetic skin coverage. At the end of the
surgery to repair hypospadia is to check the intravesical position of the bladder catheter and to
apply the proper wound dressing (Snodgrass, W. T, 2006)
There are several techniques to repair hypospadia, and the one used in this research is the
one-step and two-step operation. In relevancy, the one-step operation is usually used because it
spares the urethral plate and it is the ideal approach for the hypospadia repair. However, a two-
step approach is more ideal in most proximal cases of hypospadia when the urethra is located at
the scrotal or the perineal area, or cases with severe chordee and small penis (Duarsa G. W,
Nugroho T. D, 2016). In the one-step procedure in repairing hypospadia, the chordee is repaired
by chordectomy along urethroplasty, a method that tabularized perpucial flaps. Buccal grafts are
frequently used in the one-step procedure as a ventral patches or tube, though risk factor for
complication increases in approximately 50% of the cases due to irregular revascularization. For
the two-step procedure, the chordee is repaired during the first stage and followed by the
urethroplasty, and glansplasty are repaired after the first step has completely healed. The second
stage is usually performed prior 6-12 months after the first stage procedure (Al-Salem, 2017).
The two-stage technique allows more anatomic reconstruction compared to one stage complete
replacement technique that uses tubes from foreskins or penile skin flaps. The skin flaps can be
used from the local penile tissues from the healthy dorsal side of the penis. Though, higher rates
of complication are observed in this technique due to internal problems such as vascularization
problem, possible retraction, flap necrosis and many more. With that, many surgeons avoid the
complication by using free tissue grafts compared to flaps (Fahmy, M 2016).
Complications after postoperative can be observed on the first few days to months after
the surgery has successfully performed, but nevertheless long-term follow up is necessary. Acute
complications occur 7-10 days after the operation that needs proper assessment and management.
Any mismanagement of the complication may lead to failure in the procedure and also higher
risk of complication afterwards. Acute complication includes bleeding, bruising, wound
dehiscence, flap or graft necrosis, urinary tract infection and urinary tract obstruction
(.Mohamed, S. A, 201). They have been also reported delayed complications that occur months
after the surgery that shows urethral fistula and recurrent curvature of the penis after puberty
happened. Postoperative assessments may include observed voiding and post-void residue
assessments or formal uroflowmetry. Common complication that happens postoperative
hypospadia repair may include urethrocutaneous fistula, meatal stenosis, urethral stenosis,
recurrent penile curvature, erectile dysfunction and many more. Any complication faced
postoperative of hypospadia surgery can be performed after 4 – 6 months after healing (Keays,
M. A, Dave, S 2017)
Theoretical Framework
Hypospadia
Etiology
Arrest or incorrect normal development
of the urethra in embryonic
development
Genetic
Endocrine disruptors
Environment influences
Multiple birth
Small gestation age
Maternal age
Smoking parents
Maternal-placental factors
o Maternal hypertensioion
o Preeclampsia
o Preexisting maternal
diabetes
Maternal dietary nutrients and
medication
o Low consumption of
organic food
o Hormones containing
contraceptives
Classification
Anterior or distal hypospadia
Middle or mid-penile hypospadia
Posterior or proximal hypospadia
Symptoms
Urinate downwards
Difficulty in depositing sperm
causing infertility
During adulthood, during
intercourse
Surgical technique used for hypospadia
treatment
One-step procedure
Two-step procedure
Complications postoperative
Urethral fistula
Recurrent curvature of penis after
puberty
Meatal stenosis
Urethral stenosis
Congenital Anomalies Associated
Cryptorchidism (undescended
testis)
Inguinal hernias
Middle or mid-penile hypospadia
CHAPTER 3
CONCEPTUAL FRAMEWORK
3.1 General concept for the manipulated variable
The research study conducted will be divided into two variables which is the dependent
variables; the prevalence of hypospadia patients and the independent variables; age,
classification and treatment.
List of the manipulated variables:
- Age
- Classification
- Congenital Anomalies Associated
- Treatment
- Postoperative complication
3.2 The relationship pattern of the manipulated variable.
The relationship between the manipulated variable and the prevalence of Hypospadia
patients
Remarks:
= Independent variable
= In-between variable
= Dependent variable
Host factor
- Age
Hypospadia
Clinical symptoms
Classification
Postoperative complications
Surgical treatment
Anomalies Associated
3.3 Operational definition and objective criteria
3.3.1 Age
Age is the time of life a person had lives from the moment they were born until
they seek medical attention and been diagnose with the disease as stated in the
medical records.
Objective criteria based on WHO (World Health Ogranization)
1. Childhood 0 – 10 years
2. Adolescent 11 – 19 years
3. Young adult 20 – 40 years
4. Adult 41 – 65 years
5. Elderly > 65 years
3.3.2 Classification
Classification is groups of categories divided according to the position of the
ectopic meatus of the urethra
1. Anterior or distal hypospadia
2. Middle or mid-penile hypospadia
3. Posterior or proximal hypospadia
3.3.3 Congenital Anomalies Associated
Congenital anomalies are defined as structural or functional anomalies found
together with hypospadia that occur during intrauterine life.
1. Cryptorchidism (undescended testis)
2. Inguinal hernias
3.3.3 Treatment
Treatment is the act of seeking cure once the medical problem has started
1. One-step procedure
2. Two-step procedure
3.3.4 Postoperative complication
Complication is the problem faced by the patient after the repair operation.
1. Urethrocutaneous fistula
2. Meatal stenosis
3. Urethral stenosis
4. Recurrent penile curvature
CHAPTER 4
RESEARCH METHOD
4.1 MODE OF RESEARCH
The method used for this research study is descriptive non-analytic study method where
the entire research study will be conducted in the manner of describing the prevalence
and characteristic of hypospadia patient based on the secondary data obtained from
medical records
4.2 LOCATION OF RESEARCH
The location of research will be taken place in the surgical department of at RSUP. DR.
Wahidin Sudirohusodo, Makassar.
4.3 POPULATION AND SAMPLE OF RESEARCH
The target population and samples used for this research study will be patient that has
received treatment in RSUP. DR. Wahidin Sudirohusodo, Makassar within the period of
June 2016 until June 2017, either as in inpatient or outpatient.
4.4 SAMPLING METHOD
The sampling method used in this research is by total sampling, where the sample taken
is same as the population. The secondary data obtained from the written information of
the patient found in the medical record in RSUP. DR. Wahidin sudirohusodo, Makassar
during the month of June 2016 till June 2017. The medical records used must meet the
specific criteria and incomplete and damaged medical records will not be included in the
research.
4.5 PRESENTATION OF DATA
The data collected for this research study will be utilized and presented in the form of
statistic or table with further elaboration on each respective data with respect to the
objective of the research study using Microsoft Excel.
4.6 WORK METHOD
Obtain ethical approval from the Hasanuddin University Medical Faculty Ethics Committee.
Collect the data of hypospadia patients from the medical records of the surgery department of RSUP. DR. Wahidin sudirohusodo,
Makassar.
The medical records must meet certain criteria
The data is then gathered, interpreted, and presented in the research
CHAPTER 5
PRESENTATION OF DATA AND ANALYSIS OF DATA
This research has been conducted by obtaining secondary data from the written
information of hypospadia patients found in the medical record in RSUP DR. Wahidin
Sudirohusodo medical record during the period of June 2016 till June 2017. The number of
sample used was based on the total sample the hospital had within the period of June 2016 – June
2017, which was 34 samples. From the medical record, the information on age, classification,
other congenital anomalies, treatment and post-operative complication was jotted down. The data
obtain was then processed using Microsoft Excel. The processed data are presented in the form
of tables and graphs followed by explanation on them.
5.1 Age Distribution for Hypospadia Patient
Table 5.1 Age distribution for hypospadia patient in RSUP Dr. Wahidin Sudirohusodo
Makassar for the Period of June 2016 – June 2017
Age Total (n) Percentage (%)
0 - 10 years 18 52.9
11 - 19 years 13 38.2
20 -40 years 3 8.8
41 - 65 years 0 0.0
> 65 years 0 0.0
Total 34 100
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar.
Graph 5.1 Age distribution for hypospadia patient in RSUP Dr. Wahidin Sudirohusodo
Makassar for the Period of June 2016 – June 2017
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar.
Table 5.1 shows the age distribution from the patient population, it is divided into 6
different age groups of 0 – 10 (childhood), 11 – 19 (adolescent), 20 – 40 (young adult), 41 – 65
(adult), and above 65 (elderly). The most dominant age group among the patient was in the age
group of 0 – 10 with summation of 18 patients and the percentage of 52.9%. Next would be the
age group of 11 – 1 9 that has 13 patients and holds 38.2%. And lastly, the least amount of
patients is in the age group of 20 – 40 with the amount of 3 patients with a distribution of 8.8%.
For the age group of 41-65 and above 65, there were no noted patients present.
0
10
20
30
40
50
60
0 - 10 years 11 - 19 years 20 -40 years
Age Distribution
Age Distribution
5.2 Classification Parameter for Hypospadia Patient
Table 5.2 Hypospadia classification parameter for hypospadia patient in RSUP DR.
Wahidin Sudirohusodo Makassar for the period June 2016 – June 2017.
Classification Total Percentage (%)
Anterior 8 23.5
Middle 8 23.5
Posterior 18 52.9
Total 34 100
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar.
Table 5.2 shows the classifications for the patients with hypospadia that are distributed into
groups of anterior, middle and posterior hypospadia. The number of people with posterior
hypsopadia holds the highest number with 18 patients and a percentage of 52.9%. This is then
followed by the middle and anterior hypospadia that have similar number of patient with a
distribution of 8 people and a percentage of 23.5%.
Graph 5.2 Classification distributions for hypospadia patient in RSUP Dr. Wahidin
Sudirohusodo Makassar for the Period of June 2016 – June 2017
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar
5.3 Other Congenital Anomalies Parameter Associated with Hypospadia Patient
0
10
20
30
40
50
60
Anterior Middle Posterior
Classification Distribution
Percentage (%)
Table 5.3 Other congenital anomalies parameter associated with hypospadia patient in
RSUP Dr. Wahidin Sudirohusodo Makassar for the period June 2016 – June 2017.
Anomalies Associated Total Percentage (%)
Hypospadia 29 85.3
Hypospadia + Undescended testis 2 5.9
Hypospadia + Undescended testis +
Hernia Ingualis Lateralis 2 5.9
Hypospadia + Micropenis 1 2.9
Total 34 100.0
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar
Table 5.3 shows the distribution of patient of hypospadia with other congenital anomalies.
Patients with only hypospadia and without any other congenital anomalies are more than half the
data which is 29 people with a percentage of 85.3 %. Patients with hypospadia and congenital
anomalies of undescended testis are noted with only 2 patients with a percentage of 5.9%. The
amount of patients with hypospadia and undescended testis with additional of hernia ingualis
lateral has the similar number with patients with hypospadia and undescended testis with a total
of 2 patients, which is 5.9%. The least number of patients with any congenital anomalies
associated with hypospadia is hypospadia with micropenis with a total of only 1 patient with the
percentage of 2.9%.
Graph 5.3 Distribution of other anomalies associated with hypospadia patient in RSUP Dr.
Wahidin Sudirohusodo Makassar for the Period of June 2016 – June 2017
0
10
20
30
40
50
60
70
80
90
Hypospadia Hypospadia +Undescended testis
Hypospadia +Undescended testis +
Hernia IngualisLateralis
Hypospadia +Micropenis
Anomalies Associated
Percentage (%)
5.4 Treatment Parameter for Hypospadia Patient
Table 5.4 Treatment parameter for Hypospadia patient in RSUP Dr. Wahidin
Sudirohusodo Makassar for the period June 2016 – June 2017.
Treatment Total Percentage (%)
One-step Procedure 9 26.5
Two-step Procedure 25 73.5
Total 34 100.0
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar
Table 5.4 shows the data for the treatment received by the hypospadia patients. Based on the
table, more than 50% of the patient received the two-step procedure compared to the one-step
procedure. 25 patients with the percentage of 73.5% received the two-step procedure compared
to the patients with the one-step procedure was only 9 patients contributing 26.5%.
Graph 5.4 Distribution of treatment for hypospadia patient in RSUP Dr. Wahidin
Sudirohusodo Makassar for the Period of June 2016 – June 2017
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar
0
10
20
30
40
50
60
70
80
One-step Procedure Two-step Procedure
Treatment
Percentage (%)
Table 5.5 Post-operative complication for hypospadia patient in RSUP DR. Wahidin
Sudirohusodo Makassar for the period June 2016 – June 2017
Post-operative complication Total Percentage (%)
Bleeding 2 5.9
Urethracutaneous Fistula 7 20.6
Urethracutaneous Fistula + infection 2 5.9
Infection + Necrosis + Urine retention 1 2.9
Urine retention + Urethra stricture 1 2.9
No Complication 21 61.8
Total 34 100
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar
Table 5.5 show the distribution on the post-operative complication faced the the hypospadia
patients. Based on the table, most of the patient did not face any complication. 21 out of 34
patients in this research did not face any complication, contributing to 61.8% of the data. This is
then followed by 7 patients with a percentage of 20.6% that faced the complication of
urethrocutaneous fistula. Patients that faced the complication of urethrocutaneous fistula with
additional complication of infection were totaled of 2 patients that contribute 5.9%. Bleeding
complication has the same number of patient as the urethrocutaneous fistula with infection,
which were 2 patients with the percentage of 5.9%. The least number of post-operative
complications was both patient that had a sign of infection, necrosis that was associated with
urethra retention and urine retention due to urethra stricture. Both of those post-operative
complications had one patient with the percentage 2.9% each.
Graph 5.5 Distribution of post-operative complication for hypospadia patient in RSUP Dr.
Wahidin Sudirohusodo Makassar for the Period of June 2016 – June 2017
Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar
0 10 20 30 40 50 60 70
Bleeding
Urethracutaneous Fistula
Urethracutaneous Fistula + infection
Infection + Necrosis + Urine retention
Urine retention + Urethra stricture
No Complication
Post-operative Complication
Percentage (%)
CHAPTER 6
DISCUSSION
This research was conducted for almost two months in order to investigate the prevalence
of hypospadia patients that was treated in RSUP Dr. Wahidin Sudirohusodo Makassar from the
period of June 2016 until June 2017. After prior screening of the data and taking the total sample
that fulfills the criteria and variable, a total of 34 data was selected. In this research, the
prevalence of hypospadia patients are based on the variables of age, classification, congenital
anomalies associated with the hypospadia, treatment and post-operative complication. All the
data collected was tabulated and briefly explained.
5.1 AGE
Research done by the Urology Committee of the American Academy of
Pediatrics, within the sixth month of age or by the age of four years old is the optimal
psychological age for the surgery of the genitalia. Where else based on the size of the
penis, in the age of three months it is considered sufficient enough for a surgery to be
done with the help of a magnifier. Based on this research that was conducted on the
patients with hypospadia at RSUP Dr. Wahidin Sudirohusodo Makassar within the
month period of June 2016 until June 2017 and can be seen on table 5.1, the age group
of 0 – 10 years old has the most number of patients in the research. The number of
patients in the age group of 0 – 10 years old is 18 people (52.9%). The result of this
study has similar outcome with the research conducted by Yu-Fen Chen (2013) at
Kang-Ning Junior College of Medical care and management in Taiwan where 60.6% of
their subject has hypospadia repair after the optimal age of 18 month but decreases to
12.4 % after the age of 60 months (Chen, 2013). A similar case is also seen in Khan
(2014) research in Hayatabad Medical Complex, where a total of 428 patients with age
ranging from one to 40 years with mean age of 8.12 are presented for hypospadia repair
(Khan, 2014). Early correction for hypospadia has shown to have advantages such as
easier to handle post-operative care due to good restraint for hygienic purposes,
decrease possibility of catheter dislodgement, less pain control needed, lesser amount of
emotional disturbance faced post-operative, and might improve bonding between parent
and infant (Chen, 2013).
5.2 CLASSIFICATION
Hypospadia is classified by the ectopic location of the urethral meatus, which can be
divided as anterior or distal hypospadia, middle or mid-penile hypospadia, and posterior
or proximal hypospadia (Baskin, L. 2004). In this research that was conducted, it has
been found that the most classification group among the three classifications is the
posterior type of hypospadia that shows 18 out of 34 subject of the research with
posterior hypospadia with a percentage of 52.9%. The outcome of this research saying
that the posterior hypospadia among the other classification has the highest number of
patients resembles the research conducted by Wang-Hseng Wu (2002) at Chang Gung
Children’s Hospital, China where from 356 patients, 234 (65.7) were classified as
posterior hypospadia, showing majority of the patients were facing posterior hypospadia
(Wu, 2002). The possibility why the posterior hypospadia has a higher prevalence than
other classification is because the hospital done for the research is known to be a referred
hospital where severed cases are referred and handled. For the less severe cases of
hypospadia, any hospital without specialization can also handle this case causing the
prevalence for the anterior and middle hypospadia to be less.
5.3 OTHER CONGENITAL ANOMALIES ASSOCIATED
In a certain case of severe hypospadia, it is more likely to have an additional congenital
anomaly. The most common urogenital anomaly linked with hypospadia are
cryptorchidism (undescended testis) and inguinal hernias (Duarsa G. W, Nugroho T. D,
2016). This may be due to the abnormal occurrence during the 8 week of gestation where
the external genitalia development under the influence of testosterone. Testosterones are
converted to dihydrotesterone that acts locally to change the external genetalia into a
masculine (Al-Salem, A. H., 2017). According to the data acquired from the sample in this
research, only 5 out of 34 patients had other congenital anomalies associated with
hypospadia. Two of the patients had hypospadia with undescended testis, and another two
had hypospadia with undescended testis with additional hernia ingualis lateralis, with both
categories giving a percentage of 5.9%. The end result of this research is synchronized with
the research performed by Yu-Fen Chen (2013) at Kang-Ning Junior College of Medical
care and management in Taiwan where the common anomalies associated with hypospadia
were inguinal hernia with 11 patients (12.4%) and undescended testis with 8 patients (9%).
5.4 TREATMENT
There are many reported ways on treatments for hypospadia repair, but the main concept is
using the one-step or two-step procedure. One-step procedure is mainly used because it
spared the urethral plate and reduces cost, hospital stay and anesthetic risk. Where else the
two-step procedure is the most ideal for the proximal case of hypospadia, severe case of
chordee or micropenis and gives an anatomic satisfactory outcome (Duarsa G. W, Nugroho
T. D, 2016) (Dason, 2014). The outcome of this research shows that more than half the
number of patients had the two-step procedure for hypospadia repair, which was a total of
25 patients (73.5%), and the one-step procedure only had 9 patients (26.5%). Due to the
majority classification of hypospadia is the posterior type, its leads to the majority
prevalence for the two-step procedure to occur. This result is supported by Khan (2014)
where his subject of total 428 cases, a total of 326 patients (76.2%) were treated with the
two-step procedure, while 20.8% with total of 89 patients were treated with the one-step
procedure (Khan, 2014).
5.5 POST-OPERATIVE COMPLICATION
Literatures that have been studied shows that any acute post-operative
complication that occurs in hyospadia patients are very thin. Though there are articles
saying that complication that occurs are only one or two but never all together at once.
Common complication includes bleeding, fistula, skin necrosis and wound infection
(Bhat, 2008). The study sample on this research shows that after the hypospadia repair,
a total of 21 patients (61.8%) did not face any complication of any kind. But among the
patients that faced any sort of complication, the highest would be the urethrocutaneous
fistula. This research shows that 7 patients (20.6%) had urethrocutaneous fistula.
Another 2 patients with a percentage of 5.9% showed a complication of
urethrocutaneous fistula with additional complication of infection around the surgery
location. The outcome of this research are similar as the on conducted by Idiodi-
Thomas (2016), where 64% of his patients had acute complication of urethrocutaneous
fistula, and based on Srivastava (2011) where urethrocutaneous fistula formation is
among the common complication with incidence reported of 4 – 25% after the
hypospadia repair. Though there are no evident that shows the causes of
urethrocutaneous fistula, but there are probably an error that occurs in the technique
with inadequate inversion of the mucosa, inadequate layers of closure, ischaemic tissue
or overlapping of suture line that leads to a suture line leak (Srivastava, 2011).
CHAPTER 7
CONCLUSION AND SUGGESTION
7.1 CONCLUSION
After performing data analysis and also discussing the distribution of the data collected on the
prevalence of hypospadia patients in RSUP Dr. Wahidin Sudirohusodo, Makassar for a year
period from June 2016 until June 2017, a conclusion can be made that:
1. The distribution for most patients presented with hypospadia at the hospital is within the
age group of 0 until 10 years old.
2. Most of the patient presented with hypospadia is mostly presented with posterior or
proximal hypospadia.
3. Undescended testis and hernia ingualis lateralis are the most common congenital
anomalies associated with hyspospadia.
4. The treatment procedure most surgeons take to repair hypospadia is the two-step
procedure.
5. The common post-operative complication featured in hypospadia patient is
urethrocutaneous fistula.
7.2 SUGGESTION
After the research has been conducted on the prevalence of hypospadia patient that was
treated at RSUP Dr. Wahidin Sudirohusodo during a year period of June 2016 until June
2017, suggestion that made on form of:
1. For primary prevention, it is important to do health promotion to the people on the
risk factor that may cause hypospadia such as smoking parents, preeclampsia,
preexisting maternal diabetes and many more.
2. It is suggested to the parents of a newborn son and the health care provider to check
the condition of the penis of the baby, and to detect any anomalies to the penis. Once
any anomalies are detected, the health care provider is obligated to educate the
parents on the anomalies and when to come for further testing and treatment.
3. It is expected for the public, especially male, that feels like there are any anomalies
that can be seen at their private part to get it looked at by the doctor and to get it
treated.
4. It is hoped from the health institution by filling the medical record data with more
complete and better system of rules and hopes that the result of this research can be
used as one of the information sources for a deeper research on the characteristic of
hypospadia with more variables and for a longer period of time
5. This suggestion is addressed to the educational institution in hoping that this research
can be used as a reference to the next researcher.
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APPENDIX
APPEND1X 1 – MASTER DATAOF HYPOSPADIA PATIENTS
no. Age Classification Treatment Procedure
Anomalies
Associated
Post-operative
Complication
1 2 Posterior Chordectomy two-step Bleeding
2 2 Middle
Chordectomy
Urethroplasty
Orchidopexy sinistra one-step
Hypospadia
Undescended testis Bleeding
3 5 Posterior Chordectomy two-step
Hypospadia
Micropenis
4 9 Posterior Urethroplasty two-step
Urethrocutaneous
fistula
5 13 Posterior Urethroplasty two-step
Urethrocutaneous
fistula
6 11 Anterior
Chordectomy
Glansplasty two-step
7 1 Middle
Chordectomy
Urethroplasty two-step
8 18 Middle Urethroplasty two-step
9 14 Anterior
Chordectomy
Urethroplasty one-step
10 5 Posterior
Chordectomy
Urethroplasty one-step
11 4 Middle Urethroplasty two-step
12 8 Posterior Urethroplasty two-step
13 4 Posterior Urethroplasty two-step
14 12 Middle Urethroplasty two-step
15 19 Posterior
Chordectomy
Urethroplasty one-step
16 5 Anterior
Chordectomy
Urethroplasty one-step
Urethrocutaneous
fistula
17 13 Posterior Urethroplasty two-step
Urethrocutaneous
fistula
18 4 Middle Urethroplasty two-step
Urine retention
Urethra stricture
19 6 Anterior Urethroplasty one-step
20 3 Posterior Urethroplasty two-step
Hypospadia
Undescended testis
Hernia ingualis
lateralis
21 4 Posterior Urethroplasty two-step
Infection
Necrosis
Urine retention
22 34 Posterior
Chordectomy
Urethroplasty one-step
23 6 Anterior
Chordectomy
Urethroplasty two-step
24 4 Middle
Chordectomy
Urethroplasty two-step
25 2 Posterior
Chordectomy
Urethroplasty one-step
26 15 Posterior Urethroplasty two-step
Urethrocutaneous
fistula
27 11 Middle
Chordectomy
Urethroplasty one-step
Urethrocutaneous
fistula
28 12 Posterior Urethroplasty two-step
Urethrocutaneous
fistula
Infection
29 22 Anterior Chordectomy two-step
30 5 Anterior Urethroplasty two-step
Hypospadia
Undescended testis
Hernia ingualis
lateralis
31 13 Posterior
Chordectomy
Urethroplasty
Granuloplasty
Meatoplasty two-step
Hypospadia
Undescended testis
32 21 Posterior Urethroplasty two-step
33 12 Anterior Urethroplasty two-step
Urethrocutaneous
fistula
34 14 Posterior Urethroplasty two-step
Urethrocutaneous
fistula
infection