Authored by Diaa-Eldin Taha*
Abstract
Objective: To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate in addition to granular width and configuration.
Materials and methods: The study was a prospective evaluation of patients operated for hypospadias. The urethral plate width (UPW) and glans width (GW) of the patients were measured preoperatively using standard calipers. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair. All patients were managed via the same technique using Snodgrass tabularized incised plate repair (TIP). All operations were performed by a single surgeon. All intaoperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meat us at the tip of the glans with no stenosis, fistula or diverticulum.
Results: All 38 patients were evaluated at 6 months and 1 year follows up. The mean age at surgery was 4.5 ± 2.1 years. Overall, the mean ± SD of UPW was 10.92 ± 1.24 mm. a 24 patients (61.5 %) (Group A) had a urethral plate width of less than 8 mm while 14 patients (35.9 %) (group B) had a urethral plate width greater or equal to 8 mm. the mean ± SD of GW was 9.52 ± 1.56 mm. Success was documented in 36/38 patients (94.3%). The only complication was Fistula in two patients (6.7 %), glans dehiscence in three patients (10%). Success rate was not statistically different in correlation of UPW and GW (p=0.5). The only statistically significant difference between all patients was a longer operative time in the patients with deficient urethral plate compared to others with adequate urethral plate (p= 0.005). The urinary stream was straight in 32 boys and sprayed in 6. Overall, mean ± SD HOPE score was 39.1 ± 8.83. A significant correlation found between the cosmetic outcome of the two groups and HOPE score (p = 0.06).
Conclusion: The pre-incision urethral plate width and granular width was not correlated with the TIP outcome. A better HOPE score is associated with wide urethral plate.
Keywords: Hypospadias; Urethral plate; Tabularized incised plate repair (TIP); Hypospadias objective penile evaluation
Introduction
Dating the final 2 decades, tabularized incised plate procedure (TIP) for repair of distal penile hypospadias is the foremost common method at numerous institutions. In any case, a few downsides counting metal and/or neourethral stenosis and the require for standard urethral dilatation have been recorded [1]. The preservation of the urethral plate and the increase in the surface area with healthy epithelium give better outcome [2] TIP is a procedure that is more dependent on urethral plate quality in comparison with other surgical procedures. The plate quality is generally regarded as one of the intrinsic risk factors influencing the outcomes of hypospadias repairs. However, there is currently no clear agreement on the evaluation of the urethral plate [3].The urethral plate width was classified based on an arbitrary 8-mm cutoff value, while groove depth was graded as deep, moderate and shallow. However, is the arbitrary value of 8 mm suitable for all penis sizes? [4]. Generally, urethral plate width increases with penis size, as the patient grows. It might be more appropriate to evaluate urethral plate quality with a parameter scaled with penis size. In recent years, Glans–Urethral Meat us–Shaft score was proposed to classify the severity of hypospadias, providing a concise method for evaluating urethral plate quality [4,5]. There is a debate regarding the effect of UPW and GW on the postoperative complications post TIP surgery. Some reports have found that urethral plate (UP) widths <8 mm before TIP incision increased urethroplasty complications [6]. While, The UP width before incision did not increase urethroplasty complications [7-9]. Glans size does not correlate with age in patients with hypospadias between 3 and 24 months old, supporting the decision to operate as early as 3 months in some centers [10]. Small glans size, defined as width <14 mm, is an independent risk factor for urethrocutanous fistula [8]. To address this void, we aimed to answer a question, Is the UPW and GW are a controlling factors for hypospadias outcome as regard the functional and cosmetic outcome?
Materials and Methods
After approval from Institutional Review Board, we conducted a prospective study that was carried out in Urology department in kafr el sheikh university, between November 2018 and November 2019. A total of 60 children diagnosed with distal penile hypospadias were included. Inclusion criteria were, distal penile hypospadias, primary, uncircumcised, and no or mild chordee (less than 30°), aged < 10 years, No associated syndromes and boys able and willing to comply with follow up schedule. We excluded boys who were recurrent, circumcised, with severe chordee. written consent with detailed description of the operation and expected complications was explained and signed from the parents. All operations were performed by single pediatric urologists. Preoperative IV antibiotic prophylaxis was given. A circumferential sub coronal incision is made proximal to the hypospadiac urethral meat us. The penis is degloved. A bilateral longitudinal incision was made along the urethral plate to prepare the granular wings. The flap was obtained from the inner dartos muscle and sutured overlying the incision line with 6/0 vicryl. The flap width and length were differing in every case according to the location of the meat us, urethral plate characteristics and depth of the midline incision. Urethroplasty was performed using 6/0 Vicryl continuous subcuticular then interrupted sutures and 2nd layer cover using dartos fascia flap. Granular approximation was done with 6/0 Vicryl. 8F stent was kept for 7-10 days. All patients were routinely followed up for cosmetic and functional results at 3 months intervals. By routine examination of the external genitalia, evaluation of the voiding symptoms, uroflowmetery study was performed if possible and it was repeated when the voided volume was insufficient or when the result was inconsistent with the physical examination and history. Overall acceptable cosmetic appearance of the penis was decided according to the slit like appearance of the neo-meat us, the straight position of the penis and this cosmetic aspect was judged by an independent blinded observer. Hypospadias Objective Penile Evaluation (HOPE) is considered a valuable tool for assessing the outcome [11].
Statistical Analysis
Statistical analysis was performed with IBM Statistical Package for Social Sciences. IBM SPSS Statistics for Windows (version 22.0. Armonk, NY) was used to evaluate multiple steps. Significance level was set to p < 0.05. Internal consistency reliability was tested using Cronbach’s α, and test-retest reliability was assessed with the Wilcox on signed rank test. For concurrent external validity, Spearman rank correlation was used. For values > 0.70, it was assumed that there was sufficient consistency and reliability.
Results
1. All 30 patients were evaluated at 1 year of follow up. Mean age at surgery was 4.5 ± 2.1 years.
2. Of the 30 patients who had their distal hypospadias repaired using TIP, seven patients (23.3 %) had glanular hypospadias, nine patients (30 %) had coronal hypospadias and 14 patients (46.7 %) had distal penile hypospadias (Table 1).
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