Thursday, January 3, 2013

Primary Severe Hypospadias: Comparison of Reoperation Rates, and Parental Perception of Urinary Symptoms and Cosmetic Outcomes Among 4 Repairs


Abstract 

Purpose

We compared complication rates, urinary symptoms and cosmetic outcomes, as perceived by parents, among patients undergoing one of four repairs for proximal hypospadias associated with curvature.

Patients and Methods

Ninety-three patients were operated between 2004 and 2010. Repairs included the tubularised incised plate (n=26) or the onlay island flap urethroplasty (n=31) in cases requiring no urethral plate (UP) transection, whereas the onlay island flap on albuginea (n=18) or the 2-stage repair (n=18) in those requiring UP transection.
Complications were assessed by chart review. A customized questionnaire and the Pediatric Penile Perception Score (PPPS) were administered to parents to evaluate their perception of urinary symptoms and cosmetic outcomes, respectively.

Results

After a median (range) follow-up of 4.5 (2.2-8.4) years, complications developed in 21 (23%) patients without any difference among the procedures, or between cases requiring and not requiring UP transection.
Parents of 75 (80%) patients participated in the survey, without difference among repairs (p=0.35). Reported urinary symptoms were not different among repairs. On PPPS, the only difference concerned the question about penile length (p=0.03), which score was significantly better in the techniques requiring UP transection (p=0.05). The 2-stage repair had significantly better scores in the question about penile length and overall PPPS than all the other techniques.

Conclusions

Overall complication rates were comparable among repairs and did not increase after UP transection. Urinary symptoms, as reported by parents, were comparable among the procedures. Perceived penile length was significantly better after UP transection. The 2-stage repair yielded the best cosmetic results.



By Will Boggs, MD
NEW YORK (Reuters Health) - Complication rates and urinary symptoms are similar with four different techniques for repairing primary severe hypospadias, a new study shows.
"The ideal approach strictly depends on the intraoperative findings," Dr. Marco Castagnetti from University Hospital of Padova, Italy told Reuters Health. "If urethral plate transection can be avoided, I generally opt تختار for a TIP (tubularized incised plate) repair unless I am unhappy with the urethral plate (too narrow). When urethral plate transection is deemed necessary, then I would prefer a two-stage approach, but the choice depends also on parental preference."
Dr. Castagnetti and colleagues compared complication rates, urinary symptoms, and cosmetic outcomes (as perceived by parents) in 93 patients with primary proximal hypospadias repaired by one of four techniques. When urethral plate transection was not required for straightening, 26 patients had TIP and 31 had onlay preputial island flap (OIF) urethroplasty. When urethral plate transection was needed, 18 patients had an onlay island flap on albuginea (OIFA) and 18 had a two-stage repair.
Complication rates ranged from 16% for OIF to 27% for TIP but did not differ significantly by technique, according to a November 13th online report in The Journal of Urology.
Urinary symptoms included post-void dribbling (32%), abnormal micturition frequency (25%), deflected stream (16%), hesitation (9%), weak stream (9%), urinary tract infection (8%), and straining to void (3%). Their prevalence was similar after the different procedures.
Parental impression of penile length was significantly better for the two-stage repair compared with all of the other techniques, as was parental impression of penile axis. The two-stage repair also had a significantly higher Pediatric Penile Perception Score.
"Overlying attempts at preserving the urethral plate continuity are unnecessary, and rather than insisting in the use of procedures that shorten the dorsal aspect of the penis, in cases with curvature greater than 30 degrees after ventral dissection, it is better to embark on urethral plate transection," Dr. Castagnetti said. "This does not compromise the results of surgery as previously thought."
"I would be even less keen to preserve the urethral plate in patients with a small penis, as in these cases one should avoid as much as possible to shorten the penis," Dr. Castagnetti said. "Patients with a short penis are best suited for a two-stage repair."
He cautioned, "It is important to remember that the two-stage procedure could become multistage," as 30% to 75% of cases involve additional procedures. "This is an issue and parents should be informed," he added.

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