Hypospadia repair
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Transcript of Hypospadia repair
hypospadia repair: a
single centre experience…
@ mansoor khanPAPSCON 2015
HMC Plastic& recons.surgery
Plastic Surgery International, Volume 2014, Article ID 453039,
Introduction..
Hypospadia is the most common
urethral congenital anomaly..
affecting 1 : 300 live
male births with a
doubling of rates
since 1970
L. J. Paulozzi, J. D. Erickson, and R. J. Jackson, “Hypospadiastrends in two US
surveillance systems,” Pediatrics, vol. 100, no.5, pp. 831–834, 1997.
A lot have been achieved in terms
of establishing surgical protocols
and improvements of short term
results over the past 2 decades...
Hypospadialogist..?
Temperament 40–50
Six common techniques
G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by
whom?” BJU International,vol. 94, no. 8, pp. 1188–1195, 2004.
A. Bhat, “General considerations in hypospadias surgery,”Indian Journal of Urology, vol. 24, no. 2, pp. 188–194, 2008.
6-18 months 3-4 years
G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International, vol. 94, no. 8, pp. 1188–1195, 2004.
A. Bhat, “General considerations in hypospadias surgery,” Indian Journal of Urology, vol. 24, no. 2, pp. 188–194, 2008.
Atraumatic tech,
judicious cautery use,
tension free repair
with epithelial inversion,
buck’s water-proofing
straight penis,
slit-like meatus at glans’ tip,
urethra of uniform calibre
and adequate length,
symmetrical glans,
projectile stream and
normal erection
A. Bhat, “General considerations in hypospadias surgery,” Indian Journal of Urology, vol. 24, no. 2, pp. 188–194, 2008.
Chordee is quantified into
mild (10∘–20∘), moderate
(30∘–40∘), and severe
(>50∘)
R.A. Bologna, T. A. Noah, P. F.Nasrallah, andD. R.McMahon, “Chordee: varied opinions and treatments as documented in
a survey of the American Academy of Pediatrics, Section of Urology,” Urology, vol. 53, no. 3, pp. 608–612, 1999.A. Springer, W. Krois, and E. Horcher, “Trends in hypospadias surgery: results of a worldwide survey,” European Urology,
vol. 60, no. 6, pp. 1184–1189, 2011.
Wide urethral plate, adequate glans
cleft, without chordee can be tubularized by Zaonz’s GAP procedure
G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,vol. 94, no. 8, pp. 1188–1195, 2004.
Narrow & shallow urethral plate with
occasional bands needs Snodgrass’
TIP repairG.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,
vol. 94, no. 8, pp. 1188–1195, 2004.
for coronal/glanular
hypospadias modified meatal
advancement/MAGPI repair
inelastic urethral plate, conical glans
where midline incision is extended
beyond the distal limit of the glans
groove to achieve an apical meatus
needs Snod-graft repair (dorsal
inlay graft urethroplasty)
G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,vol. 94, no. 8, pp. 1188–1195, 2004.
Bracka’s two-stage repair comes into play
when the chordee is corrected by urethral
plate transaction…
G.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,vol. 94, no. 8, pp. 1188–1195, 2004.
Removal of the stent at one week
1, 3 and 6 monthly and then yearly for
two years. For long term results patient is
followed up to mid-teen ageG.Manzoni, A. Bracka,E.Palminteri, andG.Marrocco, “Hypospadias surgery: when, what and by whom?” BJU International,
vol. 94, no. 8, pp. 1188–1195, 2004.
To analyze the demographics,
protocols, techniques, complication
of hypospadias repair, and its effect
modifiers at our centre.
Material &
methods..?
2007 to 2011 at the
Plastic and Reconstructive Surgery
Hayatabad Medical Complex
Peshawar, Pakistan
Patients with co-morbidities (DM,
DSDs, coagulopathies) &
who were lost in the follow-up
Results stratification; two groups
Residents & fellow plastic
surgeons
Results..
428 patients (96.3% primary & 3.7%secondary
cases) fulfilled the inclusion
criteria
8.6% patientsHad positive family
history for hypospadias
Akin et al. & Abdelrahman et al.
observed positive family history in 26.5%
12% cases in their studies respectively.
family history may be
underreported due to social
stigma in our setup
Y. Akin, O. Ercan, B. Telatar, F. Tarhan, and S. Comert, “Hypospadias in Istanbul: incidence and risk factors,” PediatricsInternational, vol. 53, no. 5, pp. 754–760, 2011.
M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O. Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and
surgical review,” African Journal of Paediatric Surgery, vol. 8, no. 3, pp. 269–271, 2011.
Increase in number of patients for
hypospadia repair was observed
during the study period with
the highest (24.1%) patients
presented in 2011
1.87% and 34.6% patients were operated in 1-2 years,
3–5 year age windows while the rest presented in ≥6 years of age
lack of public awareness
about the conditions and
financial restraints
74.3% of the hypospadias wereassociated with chordee with mild degree being the most
common (51.4%)
Similar results were observed by different authors
M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O. Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and surgical review,” African Journal of Paediatric Surgery, vol. 8, no. 3, pp. 269–271, 2011.
Meatal stenosis was observed
in 9.1%, cryptorchidism in 2.8%
cases. 2.1% cases were
associated with inguinal hernias
positive relationship between
hypospadias and cryptorchidism is
reported in 7.3% 14.7% 20% cases
by different authors
Y. Akin, O. Ercan, B. Telatar, F. Tarhan, and S. Comert, “Hypospadias in Istanbul: incidence and risk factors,” Pediatrics International, vol. 53, no. 5, pp. 754–760, 2011.
M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O.Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and surgical review,” African Journal of Paediatric Surgery, vol. 8, no. 3, pp. 269–271, 2011.
W.-H. Wu, J.-H. Chuang, Y.-C. Ting, S.-Y. Lee, and C.-S. Hsieh, “Developmental anomalies and disabilities associated with hypospadias,” Journal of Urology, vol. 168, no. 1, pp. 229–232, 2002.
Two-stage (Bracka) repair
was the most common procedure
performed in 76.2% of cases.
In 46.4% cases without
chordee, two-stage repair was
performed for narrow urethral
plate and incomplete glans cleft
In most of the centres worldwide single
stage repairs are the most common
procedure
The reasons for high number of two-stage
repairs in our centre are relative low
expertise/lack of knowledge about the
indications of single-stage procedures
& relative short learning curve for
two-stage repair
M. Y. H. Abdelrahman, I. A. Abdeljaleel, E.Mohamed, A.-T. O Bagadi, andO. E. M. Khair, “Hypospadias in Sudan, clinical and surgical review,” African Journal of Paediatric Surgery, vol. 8, no.3, pp. 269–271, 2011.
D. Prat, A. Natasha, A. Polak et al., “Surgical outcome of different types of primary hypospadias repair during three decades in a single center,” Urology, vol. 79, no. 6, pp. 1350–1354, 2012.
acute complications
edema (28.3%), bleeding (4.4%),
surgical site infection 4.2%,
wound dehiscence (4.2%), and
partial graft (1.4%) loss,
late complicationsUCF 26.6% (corrected frequency)
(Excluding 31.33% closed spontaneously)50.6% were managed by single surgical
procedure
specialists UCF rate was 23.32%
residents UCF 33.10%(𝑃-value of 0.0374)
Bhat et al. review of pubMedUCF & edema were the most common
Similar frequencies of UCF were reported by Chung et al. Huang et al. reported 14.6% UCF
11.5% in series of TIP repair by Bush et al. Snodgrass et al. observed UCF of 10%-33% for patients
undergoing TIP with different suture techniques.
Our relatively high UCF lack of routine use of microvascular
instruments & magnificationBhat et al. “Acute postoperative complications of hypospadias repair,” Indian Journal of Urology, 2008.
J. W. Chung et al. “Risk factors for the development of urethrocutaneous fistula after hypospadias repair: a retrospective study,” Korean Journal of Urology, 2012.L. Huang et al. “Tubularized incised plate urethroplasty for hypospadias in children,” Zhongguo Xiu Fu Chong JianWai Ke Za Zhi, 2006.
N. C. Bush, W. Snodgrass et al “Age does not impact risk for urethroplasty complications after tubularized incised plate repair of hypospadias in prepubertal boys,” Journal of Pediatric Urology, 2013.
W. Snodgrass “Tubularized incised plate for mid shaft and proximal hypospadias repair,” Journal of Urology, 2007.
learning curve Horowitz et al. had the same
observations in his work
M. Horowitz and E. Salzhauer, “The “learning curve” in hypospadias surgery,” BJU International,
2006.
complications ratestwo-stage repair 66.9%
single-stage repair 44.1% (𝑃-value of 0.0001)
no significant difference
In the UCF frequencies
subjecting the patient 2 surgeries (different levels of expertise),
prolongs psychological stress in the most
vulnerable stage of life,
cumulative donor site morbidity
long term resultsvoiding, sexual function, ejaculation,
psychosexual adjustment &
self-appraisal
Surgical technique
for hypospadia
repair..?Lets have a quick look..
A
C’C
B’B
A
C’C
B’B
Conclusion..?
revision of existing
institutional
guidelines
mandatory use of
magnification
increasing the
threshold for two-
stage Bracka’s
repair by revising
its indications
expertise
development in
single-stage repairs
Regular audit
should be
performed.
culture of casual
hypospadias
surgery should be
abandoned
thanksPlastic and Reconstructive unit
HMC, Peshawar