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An Update of Current Practice in Hypospadias Surgery
EURSUP-730; No. of Pages 8 EUROPEAN UROLOGY SUPPLEMENTS XXX (2016) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
An Update of Current Practice in Hypospadias Surgery Alexander Springer a, Serdar Tekgul b, Ramnath Subramaniam c,* a
Department of Paediatric Surgery, Medical University of Vienna, Vienna, Austria; b Department of Paediatric Urology, Hacettepe University, Ankara, Turkey;
c
Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
Article info
Abstract
Keywords: Hypospadias Update Techniques Outcomes
Today, a multiple number of surgical techniques, modifications, and combinations of techniques are used to improve cosmetic and functional outcomes and to minimise the procedure burden for the patient. Nevertheless, controversy exists regarding the ideal management of hypospadias. This update is based on current literature following a systematic review using MEDLINE. # 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Leeds Teaching Hospitals NHS Trust, Level F, Martin Wing, Leeds General Infirmary, Leeds LS1 3EX, UK. Tel. +447818452603. E-mail address: [email protected] (R. Subramaniam).
1.
Introduction
Modern hypospadiology has considerably evolved since the 1980s but significant challenges remain like standardising the management with evidence-based protocols and the assessment of longer-term outcomes. The salient points from this update have been classified in terms of level of evidence and grade of recommendation as proposed by the Centre for Evidence Based Medicine [1] and shown in Table 1. Application of a structured analysis of the literature was not possible in many conditions due to a lack of well-designed studies. The limited availability of large randomised controlled trials—influenced also by the fact that a considerable number of treatment options relate to surgical interventions on a large spectrum of a congenital pathology—means this document is largely a consensus document. 2.
Why should hypospadias be corrected?
Hypospadias may implicate functional and cosmetic impairment. Indication for hypospadias surgery therefore includes the need for the correction of penile deviation and rotation, glans cleft and tilt, ectopic and stenotic urethral
meatus, hooded prepuce, penoscrotal transposition, and penile size. The ideal result of surgery is construction of a good calibre urethra with a slit-like urethral meatus at the tip of the glans and a straight penis. Voiding and sexual activity should not be impaired by hypospadias or its corrective procedure. Surgery should allow boys with hypospadias to grow up as self-confident young men with a normal body image. Long-term outcome and health-related quality of life is associated with the severity of hypospadias and the sequelae of surgery. Hypospadias is usually classified based on the anatomical location of the proximally displaced urethral orifice. This is clinically not relevant, does not relate well with the outcome, and pathology may significantly change after degloving of the skin. It is more common that hypospadias is classified as distal and proximal, where proximal cases are more severe. Patients with severe hypospadias and those with nonfavourable surgical outcomes are more likely to suffer a negative psychological impact than those with minor hypospadias and good surgical results. Therefore there is an argument for a new classification of hypospadias based on the cost-benefit ratio for the patient [2].
http://dx.doi.org/10.1016/j.eursup.2016.09.006 1569-9056/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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Table 1 – Summary of the Socie´te´ Internationale d’Urologie Current Best Practice Options in the management of hypospadias Topic Indication Classification
Documentation Further evaluation Timing
Androgens Mild hypospadias repair
Severe hypospadias repair
Foreskin reconstruction Urinary drainage Wound dressing Antibiotics
Comments
LE
GR
Substantial lack of long-term studies showing the effects of hypospadias surgery on cosmetic, functional, and psychological outcome. Recommendation on indication for hypospadias surgery is based on common sense. Meatal location is only one of many meaningful parameters including quality of tissues, curvature, size of glans, spongiosal division, and others. Classification of hypospadias is an evolving picture and at the moment there is not one objective classification that is universally accepted. Documentation of objective findings will help to establish prospective data bases and make future studies comparable. There is no consensus on objective penile assessment and documentation of preoperative findings. Routine evaluation of the upper urinary tract in an asymptomatic child with hypospadias is not recommended. In suspicion of DSD, further investigations according to current guidelines. It is recommended that hypospadias repair be performed in infancy or early childhood ideally when there is a trained paediatric anaesthetist available. Evidence concerning the ideal age of hypospadias repair is weak and confusing. Androgens are effective. There is neither consensus on the best type of androgen nor on the correct way of application and the potential side effects of androgens have not been studied thoroughly. TIP repair is the most commonly used technique for the repair of distal hypospadias with good evidence in literature. However, high quality randomised trials (follow up rate > 80% and long term follow-up) are missing. Therefore, personal experience, skill and surgical background will still play a major role in the choice of procedure (GR D). Two-stage repair is the most popular technique used in severe hypospadias. However, there is no consensus on the ideal technique and there is no evidence in the literature that there is a definitely superior technique in the correction of severe hypospadias. Comparison between series is complicated by the lack of reliability in reporting outcome, limited follow-up and failing to report long term outcome. Foreskin reconstruction can be offered in mild hypospadias repair.
3–5
B–D
3–5
C–D
3–5
B–D
3–5
B–D
3–5
B–D
2a–5
B–D
2a–5
B
3a–5
C
2a
B
2b–5
B–D
2b–5 1b
B–D B
No clear evidence can highlight advantages of one or another form of drainage although it seems logical to drain any reconstruction. No clear evidence can highlight advantages of one or another form of wound dressing. Until further evidence is available, prophylactic broad spectrum antibiotics will be the standard in hypospadias surgery. However, it is important to point out that prophylactic antibiotic versus no antibiotic in hypospadias repair should be subject for future controlled studies.
DSD = detrusor sphincter dyssynergia; GR = grade; LE = levels of evidence.
The position of the meatus allows standardised nomenclature and is thought to be a major prognostic factor for outcome [3]. Other more complex items (level of division of the corpus spongiosum, penile curvature, ventral hypoplasia, quality of urethral plate, etc.) should also be taken into account in the classification but they are much more difficult to assess reliably and objectively with validity [4,5]. 3.
When should hypospadias be corrected?
Based on expert opinion, it is better to perform surgery of the male genitalia between 6 mo and 18 mo of age [6,7]. This recommendation is based on surgical and anaesthetic considerations and the psychology of the infant male (cognitive development, genital awareness, emotional development, and psychosexual development). However, there is spare evidence regarding this and there are contradictory findings [8]. It is generally believed that early repair is associated with a lower complication rate, but again, there is inconsistency in literature. Last but not least, there are rising concerns by patient groups that esthetical genital surgeries in minor hypospadias without functional impairment should be postponed to an age where informed consent can be given by the patient himself [9]. 4.
Preoperative androgens?
Androgen stimulation has been used for a long time to enhance the size of the penis and to improve quality of tissues [10]. There are two randomised controlled trials
showing that preoperative androgen stimulation improves outcome (cosmesis and complication rate) [11,12]. There is no consensus on the best type of androgen, the application route, and correct way of application. Two recent systematic reviews and meta-analysis critically assess the effect of androgen stimulation on surgical outcomes but remained inconclusive [13,14]. It is a fact that androgens stimulate penile growth [15]; however, the real benefit in hypospadias surgery and long-term side effects of male sexual hormone application still needs to be defined. Perioperative antibiotics, urinary drainage, and 5. wound dressing For now, there is no consensus on the type of urinary drainage, stenting of the urethra, wound dressing, or the use of antibiotics. Each surgeon has his or her own preference. Urine can be drained using a transurethral catheter, transurethral dripping stent, or a suprapubic tube of various sizes. Most surgeons would agree that postoperative urinary diversion seems to reduce complications. However, in cases of distal hypospadias, some surgeons prefer no drainage at all [16–23]. With regards to urinary diversion, there is no clear evidence that wound dressing is of any benefit for surgical outcome. The rational for wound dressing seems clear: dry, safe, and clean immobilisation of the penis for a limited period of time to allow wound healing and minimise postoperative discomfort and there are many different products available: foam dressing (Cavicare), transparent film dressing (Tegaderm), simple
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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circular wound dressing, and indigenous home-made devices. However, two prospective randomised trials show no difference between postoperative dressing versus no postoperative dressing [24,25]. Most surgeons use prophylactic antibiotics in hypospadias repair but there is no consensus regarding when to administer what type of antibiotics for what period of time [26,27]. Evidence for prophylactic antibiotics in hypospadias management is very limited and there is still ongoing discussion if there is a real benefit in administering antibiotics [28–31]. 6.
Preferred technique for hyposopadias repair
Literally hundreds of techniques have been reported over the years. The choice of the technique mainly depends on the experience of the surgeon with the technique and his experience on different types of hypospadias. The surgeon should be able to define the anatomic components well, and choose and modify the technique according to the anatomy. Although common sense demands standardisation of procedures, many times there will be a need to make minor modifications in the technique which can only be done by dedicated surgeons at high-volume centres. The
use of magnification and microsurgical instruments, tissue handling with minimal trauma and fine suture material are essential. For now, the search for the ideal procedure for all hypospadias continues. An algorthim to the management of hypospadias is shown in Figure 1. 7.
Mild hypospadias repair
In the recent past, tubularised incided plate urethroplasty (TIP) repair has become the most popular technique for distal hypospadias repair worldwide [32–34]. Metaanalysis and systematic reviews of large retrospective cohort studies show that there is enough evidence to recommend the TIP repair as versatile, highly standardised, and a simple technique that provides favourable cosmetic and functional short- and long-term results with a reasonably low complication rate [35–38]. Since its introduction in 1994, TIP repair has evolved and consecutive modifications have significantly lowered the complication rates and it has come down to a fistula rate of 5.7% in primary mild hypospadias and a reoperation rate of 4.5%, respectively [39]. In particular, the fistula rate can be decreased by covering the urethroplasty with a
Hypospadias preoperative androgen application
Severe hypospadias
Mild hypospadias
No correction
TIP and others
Degloving erection test
Good urethral plate no ventral hypoplasia Mild chordee
Scarred tissue ventral hypoplasia severe chordee
TIP plication and other straightening techniques
Staged repair plication Ventral corporotomy
Fig. 1 – Algorthim of surgical management of hypospadias. TIP = tubularised incided plate urethroplasty.
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waterproofing layer of dartos tissue [40–42]. There are many other techniques described with personal modifications. For example, Mathieu urethroplasty and its modifications are still popular procedures with excellent results [43]. Systematic reviews comparing the TIP repair and Mathieu repair show that no technique appears to be significantly superior over the other with similar fistula rates (3.4–3.6%), but there is a higher incidence of meatal stenosis in TIP (3.0% vs 0.6% in Mathieu) after 6–12 mo follow-up [44,45]. 8.
Severe hypospadias
Management of severe hypospadias is challenging and should only be offered in specialised centres with an adequate number of patients. Outcome is influenced by the presence of chordee (penile curvature), quality of the urethral plate, quality of ventral tissues, scrotal transposition, and last but not least the size of the penis. Over the years, large numbers of techniques have been described. In single centre studies, most of those techniques could provide favourable cosmetic and functional outcomes. In a recent 20-yr systematic review for surgical correction of severe hypospadias no approach appeared to be superior over the other [46]. Another systematic review comparing the transverse island flap technique and TIP show no major differences in clinical outcome [47]. However, both reviews indicated general problems of reporting data in hypospadiology: no clear definition of severe hypospadias, limited number of patients, limited follow-up, and no clear defined outcome measures. The authors therefore come to the conclusion that ‘‘these data have to be confirmed by more well-designed randomised controlled trials with high quality in the future’’ [47]. Today’ s surgical armamentarium in the management of hypospadias is huge and diverse, as shown in Table 2, with a clear international majority favouring a staged repair in complex hypospadias [32]. The two-stage repair, either using grafts or flaps, is a versatile technique when there is severe chordee, a small glans, and ventral scarring [48,49]. In two-stage repair, the operation starts with (ventral) degloving. The decision to sacrifice the urethral plate is key and is left until after artificial erection test. Chordee correction could take place in many ways after fibrous tissue is excised as much as
possible. Multiple transverse corporotomy incisions can be applied to lengthen the ventral aspect of the corpora cavernosa [50]. If necessary, dorsal plication with or without mobilisation of the neurovascular bundle can help to straighten the penis [51,52]. The dorsal midline incision minimises the risk of injury to the neurovascular bundle. More aggressive techniques like ventral corporal grafting are rarely needed and their long-term outcomes are doubtful [53]. The glans wings are mobilised extensively. Inner or outer preputial skin or buccal mucosa are the preferred graft materials. The graft is quilted onto the corpora. It is recommended to place tunica dartos flaps onto the corpora laterally as a bed providing an extensive amount of healthy tissue for the second-stage urethroplasty [54]. Appropriate urinary drainage and pressure wound dressing is crucial for a good outcome. Second-stage urethroplasty is performed by tubularisation of the graft with two further layers of tunica dartos to cover the urethroplasty. 9.
Follow-up and outcome
Long-term follow-up is of substantial importance. A recent systematic review showed that there is a significant lack in long-term data. Although there is a growing number of articles reporting reliable and valid data like inclusion and exclusion criteria, study design, primary and secondary outcome parameters, follow-up, a detailed description of the surgical procedure, and so on [55], quality of data is influenced by low follow-up periods and rates, heterogeneous patients and data, and a lack of validated questionnaires and control groups [56]. It has been criticised that follow-up periods—particularly in Northern America—are short [39], although some believe that most complications occur early after surgery [57]. However, there is evidence that the real number of complications is only to be assessed in long-term follow-up after puberty or even adulthood [58,59]. Although some current long-term studies have follow-up rates between 12.7%, 22.4%, and 56.2%, most outcome studies do not provide a follow-up rate or those lost to follow-up [60–62]. Table 3 shows long-term outcome studies from 2010 to 2015. Although the majority of patients do well after hypospadias repair there are reports
Table 2 – Most commonly performed techniques in the repair of severe hypospadias Name
Reference
Patel
[77]
2004
73
Duckett
Amukele
[78]
2004
265
Thiersch-Duplay
Obaidullah Djordjevic, Macedo
[79] [80,81]
2005 2008, 2011
1415 NA
Snodgrass Vepakomma
[82] [83]
2011 2013
26 24
Two stage repair Combinations, variations TIP Koyanagi
Hadidi
[84]
2014
63
BILAB
Yr
N
Generic name
Comments Preputial flap as transverse island tube or island onlay flap with longterm f/u of 14.2 yr. Very versatile technique with many modifications in literature, widely used. Long-term proven reliable technique, difficult with extensive chordee and low quality urethral plate. Two-stage repair very safe and applicable to all cases. Flaps, grafts, buccal mucosa, technically very challenging, techniques never gained popularity, short term follow-up. Suitable when no minor curvature and good quality of urethral plate. Based on a parameatal foreskin flap, many modifications since its introduction in 1983, technically challenging. Bilateral based preputial and penile skin flaps, generous blood supply.
f/u = follow-up; TIP = tubularised incided plate urethroplasty.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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Table 3 – Long-term outcome studies from 2010 to 2015 Name
Reference
Yr
N
Age at surgery (yr)
¨ rtqvist O
[85]
2015
167
Andersson
[86]
2015
Hueber
[87]
Fraumann
Age at FU (yr)
FU period (mo)
Fistula (%)
Curvature (%)
Stenosis (%)
4
34
29
16.4
23
5
40
3.6
15.2
11.6
5
15
22.5
2015
153
2.9
21/16/5
0/4/2
16/16/10
[61]
2014
13
1.2
21
20
7.5
38.5
7.5
Ekmark
[88]
2013
114
4.5–5
16
12
11
5.4
3.6
Aulagne
[62]
2010
27
3.3
25
33
18
26
Perera
[60]
2012
60
1.8
Ciancio
[89]
2015
20
5
Ruppen-Greff
[90]
2013
45
Chertin, Prat
[73,91]
2012, 2013
119
2.7
Adults
Robinson Kiss
[92] [59]
2012 2011
18 104
2.5
12.5 24–42
Jiao
[64]
2011
43
>10
11.3
33
28
26.2
10.5 20–30
21.6
Comments
Impaired cosmesis, shorter penis, more LUTS. Uroflow improves over time. Favourable outcomes (TIP/Mathieu/MAGPI). Satisfactory outcome, lower orgasmic function. Curvature can develop over time. Generally good outcomes.
Uroflow lower than controls, associated with previous chordee. Good cosmesis, no erectile dysfunction, low IPSS, penis shorter. HRQoL were not impaired among men. Good cosmetic results, mild erectile dysfunction, numerous techniques, high complication rates (0– 100%). Good flow and cosmesis. Less satisfaction with genital appearance, however healthy psychosexual development possible. Main complaint penile size and curvature, sexual function impaired.
FU = follow-up; HRQoL = health-related quality of life; IPSS = International Prostate Symptom Score; LUTS = lower urinary tract sysmptoms; MAGPI = meatal advancement and glanduloplasty; TIP = tubularised incided plate urethroplasty.
of adult reconstructive urologists trying to attract attention to the fact that some patients need redo surgery in adulthood. Table 4 shows the current series of hypospadias redo surgeries in adults. In literature, short-term and mid-term outcomes of hypospadias surgery seem favourable. However, the majority of these publications present single-centre and singlesurgeon retrospective case series with a limited follow-up period and a limited number of patients undergoing
follow-up [63]. Assessment of outcome includes: cosmesis, functional outcome (micturition and sexuality), and quality of psychosexual life. 9.1.
Cosmesis
Patients who had surgery for hypospadias may have a significant concern about penile appearance and penile size. Generally, a better cosmetic outcome is related to better
Table 4 – Series of hypospadias redo surgery in adults Name
Reference
Stein Myers Ching
[70] [93] [94]
Barbagli
[95]
Age at surgery (yr)
FU period (mo)
2014 2012 2011
39.7 38 37
15 (3–28) 7.4
163 50 55
2010
31
60.4
1176 (926 older than 16 yr)
n
Comments
54% erectile dysfunction. Difficult surgery, additional procedures common. Voiding problems 82%, UTI 36%, curvature 24%, BXO 13%, fistula 14%. 12% failure rate.
BXO = balanitis xerotica obliterans; FU = follow-up; UTI = urinary tract infection.
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sexual outcome [64]. There are several objective and validated scores to evaluate the outcome of hypospadias surgery (Hypospadias Objective Scoring Evaluation, Paediatric Penile Perception Score, Hypospadias Objective Penile Evaluation Score) [65–67]. For example, the Hypospadias Objective Penile Evaluation Score evaluates the position and shape, the shape of the glans, the penile skin, and curvature and torsion of the penis [65]. An independent person should ideally rate the outcome. Scoring is easy to apply, can be kept in the patients notes, and allow prospective evaluation. The International Disorders of Sex Development registry [68] and The Dutch (International) Hypospadias Study [65] are international databases for the allocation of prospective hypospadias patients. Every hypospadias surgeon is encouraged and invited to join such a database for personal audit and research purposes.
emotional relations, self-esteem, relationships, sex life, etc. The more severe the hypospadias, the less satisfactory the long-term outcome and as alluded to earlier, better cosmetic outcome is related to better sexual outcome [64]. In patients at risk, it seems important to provide meticulous transitional care where the paediatric patient is transferred into an adult urology service. Conflicts of interest The authors have nothing to disclose. References [1] Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-based Medicine—levels of evidence. 2009. http://www.cebm.net/ oxford-centre-evidence-based-medicine-levels-evidence-march-
9.2.
Functional outcome
2009/. [2] Springer A, Spinoit AF, Nappo S, et al. Current best practice options
Functional outcomes are just beginning to be reported in literature. A recent systematic review recommends a uroflow study after toilet training. Children with obstructed flow parameters or borderline flows should be followed until adulthood. However, the significance of this advice remains uncertain [69]. In an Australian study of long-term follow-up, urinary flow rates were significantly lower compared with age-matched controls but still fell within the normal range without significant association with lower urinary tract symptoms and poor urinary flow. However, severe chordee preoperatively seems to be a significant risk factor for poor urinary flow [60]. Therefore, in adults following hypospadias surgery it may be necessary to have a repeated close look at urinary flow, postvoid residuals, symptoms of lower urinary tract symptoms, or other urinary signs. In most of the cases sexual function, strength and duration of erection, problems with ejaculation (spraying, dribbling, retrograde ejaculation, and premature ejaculation), and masturbation are not impaired. However, depending on the severity of chordee, ventral hypoplasia, type and length of urethroplasty, burden of surgery, and other factors, there may be concerns for the patient and there are standardised assessment scores available to objectively rate those concerns (International Prostate Symptom Score, International index of erectile function, and Sexual Summary Score) [63]. A certain prevalence of erectile dysfunction hypospadias patients has been reported [70].
in the management of hypospadias. In: DeVries CR, Nijman JM, editors. Congenital anomalies in children—A joint SIU-ICUD International Consultation. Montreal: Socie´te´ Internationale d’Urologie; 2014. p. 52–78. [3] Spinoit AF, Poelaert F, Van Praet C, Groen LA, Van Laecke E, Hoebeke P. Grade of hypospadias is the only factor predicting for reintervention after primary hypospadias repair: A multivariate analysis from a cohort of 474 patients. J Pediatr Urol 2015;11:, 70.e1-6. [4] Hadidi AT. Classification of hypospadias. In: Hadidi AT, Azmy AF, editors. Hypospadias surgery. Heidelberg: Springer; 2004. p. 79–83. [5] Mouriquand PD, Mure PY. Current concepts in hypospadiology. BJU Int 2004;93(Suppl 3):26–34. [6] Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia. American Academy of Pediatrics. Pediatrics 1996;97:590-4. [7] Tekgu¨l S, Riedmiller H, Gerharz E, et al. Guidelines on Paediatric Urology of the EAU. 2013. https://uroweb.org/wp-content/uploads/ 24_Paediatric_Urology.pdf. [8] Weber DM, Schonbucher VB, Gobet R, Gerber A, Landolt MA. Is there an ideal age for hypospadias repair? A pilot study. J Pediatr Urol 2009;5:345–50. [9] Springer A, Baskin L. Timing of hypospadias repair in patients with disorders of sex development. In: Hiort O, Ahmed SF, editors. Understanding differences and disorders of sex development. Basel: Karger; 2014. p. 197–202. [10] Malik RD, Liu DB. Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias. J Pediatr Urol 2014;10:840–3. [11] Asgari SA, Safarinejad MR, Poorreza F, Safaei Asl A, Mansour Ghanaie M, Shahab E. The effect of parenteral testosterone administration prior to hypospadias surgery: a prospective, random-
9.3.
Psychosexual outcome
ised, and controlled study. J Pediatr Urol 2015;11:143.e1-6. [12] Kaya C, Bektic J, Radmayr C, Schwentner C, Bartsch G, Oswald J. The
Psychosexual well-being is far more difficult to evaluate. There are only a few studies assessing long-term psychosexual adjustment and sexual function, healthrelated quality of life, and quality of sexual life without or matched with control groups. These data are very limited and controversial [62,64,71–76]. Generally speaking, hypospadias patients should do well in adulthood in all regards (cosmesis, function, and psychology), but there can be significant issues, like impaired capacity for social and
efficacy of dihydrotestosterone transdermal gel before primary hypospadias surgery: a prospective, controlled, randomized study. J Urol 2008;179:684–8. [13] Wright I, Cole E, Farrokhyar F, Pemberton J, Lorenzo AJ, Braga LH. Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review. J Urol 2013;190:652–9. [14] Netto JM, Ferrarez CE, Schindler Leal AA, Tucci Jr S, Gomes CA, Barroso Jr U. Hormone therapy in hypospadias surgery: a systematic review. J Pediatr Urol 2013;9:971–9.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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7
[15] Nerli RB, Koura A, Prabha V, Reddy M. Comparison of topical versus
[37] Sarhan OM, El-Hefnawy AS, Hafez AT, Elsherbiny MT, Dawaba ME,
parenteral testosterone in children with microphallic hypospadias.
Ghali AM. Factors affecting outcome of tubularized incised plate
Pediatr Surg Int 2009;25:57–9. [16] Radwan M, Soliman MG, Tawfik A, Abo-Elenen M, El-Benday M. Does the type of urinary diversion affect the result of distal hypospadias repair? A prospective randomised trial. Ther Adv Urol 2012;4:161–5. [17] Xu N, Xue XY, Wei Y, et al. Outcome analysis of tubularized incised plate repair in hypospadias: is a catheter necessary? Urol Int 2013;90:354–7. [18] Ritch CR, Murphy AM, Woldu SL, Reiley EA, Hensle TW. Overnight urethral stenting after tubularised incised plate urethroplasty for distal hypospadias. Pediatr Surg Int 2010;26:639–42. [19] Hardwicke J, Jones E, Wilson-Jones N. Optimisation of silicone urinary catheters for hypospadias repair. J Pediatr Urol 2010;6: 385–8. [20] Lorenz C, Schmedding A, Leutner A, Kolb H. Prolonged stenting does not prevent obstruction after TIP repair when the glans was deeply incised. Eur J Pediatr Surg 2004;14:322–7. [21] Leclair MD, Camby C, Battisti S, Renaud G, Plattner V, Heloury Y.
(TIP) urethroplasty: single-center experience with 500 cases. J Pediatr Urol 2009;5:378–82. [38] Snodgrass WT, Bush N, Cost N. Tubularised incised plate hypospadias repair for distal hypospadias. J Pediatr Urol 2010;6:408–13. [39] Pfistermuller KL, McArdle AJ, Cuckow PM. Meta-analysis of complication rates of the tubularized incised plate (TIP) repair. J Pediatr Urol 2015;11:54–9. [40] Yigiter M, Yildiz A, Oral A, Salman AB. A comparative study to evaluate the effect of double dartos flaps in primary hypospadias repair: no fistula anymore. Int Urol Nephrol 2010;42:985–90. [41] Djordjevic ML, Perovic SV, Vukadinovic VM. Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair. BJU Int 2005;95:1303–9. [42] Cimador M, Pensabene M, Sergio M, Catalano P, de Grazia E. Coverage of urethroplasty in pediatric hypospadias: randomised comparison between different flaps. Int J Urol 2013;20:1000–5. [43] Hadidi AT. The slit-like adjusted Mathieu technique for distal hypospadias. J Pediatr Surg 2012;47:617–23.
Unstented tubularized incised plate urethroplasty combined with
[44] Wilkinson DJ, Farrelly P, Kenny SE. Outcomes in distal hypospadias:
foreskin reconstruction for distal hypospadias. Eur Urol 2004;46:
a systematic review of the Mathieu and tubularised incised plate
526–30. [22] Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypospadias dilemmas: a round table. J Pediatr Urol 2011;7:145–57. [23] Castagnetti M, El-Ghoneimi A. The influence of perioperative factors on primary severe hypospadias repair. Nat Rev Urol 2011;8:198–206. [24] McLorie G, Joyner B, Herz D, et al. A prospective randomized clinical trial to evaluate methods of postoperative care of hypospadias. J Urol 2001;165:1669–72. [25] Van Savage JG, Palanca LG, Slaughenhoupt BL. A prospective ran-
repairs. J Pediatr Urol 2012;8:307–12. [45] Wang F, Xu Y, Zhong H. Systematic review and meta-analysis of studies comparing the perimeatal-based flap and tubularized incised-plate techniques for primary hypospadias repair. Pediatr Surg Int 2013;29:811–21. [46] Castagnetti M, El-Ghoneimi A. Surgical management of primary severe hypospadias in children: systematic 20-year review. J Urol 2010;184:1469–74. [47] Xiao D, Nie X, Wang W, et al. Comparison of transverse island flap onlay and tubularized incised-plate urethroplasties for primary
domised trial of dressings versus no dressings for hypospadias
proximal hypospadias: a systematic review and meta-analysis.
repair. J Urol 2000;164:981–3.
PLoS One 2014;9:e106917.
[26] Hsieh MH, Wildenfels P, Gonzales Jr ET. Surgical antibiotic practices
[48] McNamara ER, Schaeffer AJ, Logvinenko T, et al. Management of
among pediatric urologists in the United States. J Pediatr Urol
proximal hypospadias with 2-stage repair: 20 year experience. J
2011;7:192–7. [27] Springer A. The use of antibiotics in hypospadias surgery. Results from an international survey. Unpublished data. 2013. [28] Lee YC, Huang CH, Chou YH, Lin CY, Wu WJ. Outcome of hypospa-
Urol 2015;194:1080–5. [49] Bracka A. The role of two-stage repair in modern hypospadiology. Indian J Urol 2008;24:210–8. [50] Snodgrass W, Prieto J. Straightening ventral curvature while pre-
dias reoperation based on preoperative antimicrobial prophylaxis.
serving the urethral plate in proximal hypospadias repair. J Urol
Kaohsiung J Med Sci 2005;21:351–7.
2009;182:1720–5.
[29] Meir DB, Livne PM. Is prophylactic antimicrobial treatment necessary after hypospadias repair? J Urol 2004;171:2621–2. [30] Baillargeon E, Duan K, Brzezinski A, Jednak R, El-Sherbiny M. The role of preoperative prophylactic antibiotics in hypospadias repair. Can Urol Assoc J 2014;8:236–40.
[51] Nesbit RM. Operation for correction of distal penile ventral curvature with or without hypospadias. Trans Am Assoc Genitourin Surg 1966;58:12–4. [52] Baskin LS, Duckett JW. Dorsal tunica albuginea plication for hypospadias curvature. J Urol 1994;151:1668–71.
[31] Kanaroglou N, Wehbi E, Alotay A, et al. Is there a role for prophy-
[53] Braga LH, Pippi Salle JL, Dave S, Bagli DJ, Lorenzo AJ, Khoury AE.
lactic antibiotics after stented hypospadias repair? J Urol 2013;190:
Outcome analysis of severe chordee correction using tunica vagi-
1535–9. [32] Springer A, Krois W, Horcher E. Trends in hypospadias surgery: results of a worldwide survey. Eur Urol 2011;60:1184–9. [33] Cook A, Khoury AE, Neville C, Bagli DJ, Farhat WA, Pippi Salle JL. A multicentre evaluation of technical preferences for primary hypospadias repair. J Urol 2005;174:2354–7, discussion 7. [34] Steven L, Cherian A, Yankovic F, Mathur A, Kulkarni M, Cuckow P. Current practice in paediatric hypospadias surgery; a specialist survey. J Pediatr Urol 2013;9:1126–30. [35] Braga LH, Lorenzo AJ, Salle JL. Tubularised incised plate urethroplasty for distal hypospadias: a literature review. Indian J Urol 2008;24:219–25. [36] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularised incised plate hypospadias repair: results of a multicenter experience. J Urol 1996;156:839–41.
nalis as a flap in boys with proximal hypospadias. J Urol 2007;178:1693–7, discussion 7. [54] Springer A, Subramaniam R. Split dorsal dartos flap transposed ventrally as a bed for preputial skin graft in primary staged hypospadias repair. Urology 2012;79:939–42. [55] Snodgrass W. Hypospadias reporting—how good is the literature? J Urol 2010;184:1255–6. [56] Rynja SP, de Jong TP, Bosch JL, de Kort LM. Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood. J Pediatr Urol 2011;7:504–15. [57] Snodgrass W, Villanueva C, Bush NC. Duration of follow-up to diagnose hypospadias urethroplasty complications. J Pediatr Urol 2014;10:208–11. [58] Spinoit AF, Poelaert F, Groen LA, Van Laecke E, Hoebeke P. Hypospadias repair at a tertiary care center: long-term followup is
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
EURSUP-730; No. of Pages 8 8
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mandatory to determine the real complication rate. J Urol 2013;189:2276–81. [59] Kiss A, Sulya B, Szasz AM, et al. Long-term psychological and sexual outcomes of severe penile hypospadias repair. J Sex Med 2011; 8:1529–39.
[78] Amukele SA, Weiser AC, Stock JA, Hanna MK. Results of 265 consecutive proximal hypospadias repairs using the Thiersch-Duplay principle. J Urol 2004;172:2382–3. [79] Obaidullah, Aslam M. Ten-year review of hypospadias surgery from a single centre. Br J Plast Surg 2005;58:780–9.
[60] Perera M, Jones B, O’Brien M, Hutson JM. Long-term urethral func-
[80] Djordjevic ML, Majstorovic M, Stanojevic D, et al. One-stage repair
tion measured by uroflowmetry after hypospadias surgery: com-
of severe hypospadias using combined buccal mucosa graft and
parison with an age matched control. J Urol 2012;188:1457–62. [61] Fraumann SA, Stephany HA, Clayton DB, et al. Long-term follow-up
longitudinal dorsal skin flap. Eur J Pediatr Surg 2008;18:427–30. [81] Macedo Jr A, Liguori R, Ottoni SL, et al. Long-term results with a one-
of children who underwent severe hypospadias repair using an
stage complex primary hypospadias repair strategy (the three-in-
online survey with validated questionnaires. J Pediatr Urol 2014;
one technique). J Pediatr Urol 2011;7:299–304.
10:446–50. [62] Aulagne MB, Harper L, de Napoli-Cocci S, Bondonny JM, Dobremez E. Long-term outcome of severe hypospadias. J Pediatr Urol 2010;6:469–72. [63] Springer A. Assessment of outcome in hypospadias surgery—a review. Front Pediatr 2014;2:2. [64] Jiao C, Wu R, Xu X, Yu Q. Long-term outcome of penile appearance and sexual function after hypospadias repairs: situation and relation. Int Urol Nephrol 2011;43:47–54. [65] van der Toorn F, de Jong TP, de Gier RP, et al. Introducing the HOPE (Hypospadias Objective Penile Evaluation)-score: a validation study of an objective scoring system for evaluating cosmetic
[82] Snodgrass W, Bush N. Tubularised incised plate proximal hypospadias repair: continued evolution and extended applications. J Pediatr Urol 2011;7:2–9. [83] Vepakomma D, Alladi A, Ramareddy RS, Akhtar T. Modified koyanagi repair for severe hypospadias. J Indian Assoc Pediatr Surg 2013;18:96–9. [84] Hadidi AT. Perineal hypospadias: the Bilateral Based (BILAB) skin flap technique. J Pediatr Surg 2014;49:218–23. [85] Ortqvist L, Fossum M, Andersson M, et al. Long-term follow-up of men born with hypospadias: urological and cosmetic results. J Urol 2015;193:975–81. [86] Andersson M, Doroszkiewicz M, Arfwidsson C, Abrahamsson K,
appearance in hypospadias patients. J Pediatr Urol 2013;9:
Sillen U, Holmdahl G. Normalised urinary flow at puberty after
1006–16.
Tubularised Incised Plate (TIP) urethroplasty of hypospadias in
[66] Holland AJ, Smith GH, Ross FI, Cass DT. HOSE: an objective scoring system for evaluating the results of hypospadias surgery. BJU Int 2001;88:255–8. [67] Weber DM, Schonbucher VB, Landolt MA, Gobet R. The Pediatric Penile Perception Score: an instrument for patient self-assessment and surgeon evaluation after hypospadias repair. J Urol 2008; 180:1080–4, discussion 4. [68] Network I-D. I-DSD Network. 2014. http://gtr.rcuk.ac.uk/projects? ref=G1100236. [69] Gonzalez R, Ludwikowski BM. Importance of urinary flow studies
childhood. J Urol 2015;194:1407–13. [87] Hueber PA, Antczak C, Abdo A, Franc-Guimond J, Barrieras D, Houle AM. Long-term functional outcomes of distal hypospadias repair: a single center retrospective comparative study of TIPs, Mathieu, and MAGPI. J Pediatr Urol 2015;11:68.e1-7. [88] Ekmark AN, Svensson H, Arnbjornsson E, Hansson E. Postpubertal examination after hypospadias repair is necessary to evaluate the success of the primary reconstruction. Eur J Pediatr Surg 2013;23:304–11. [89] Ciancio F, Lo Russo G, Innocenti A, Portincasa A, Parisi D, Mondaini
after hypospadias repair: a systematic review. Int J Urol 2011;18:
N. Penile length is a very important factor for cosmesis, function
757–61.
and psychosexual development in patients affected by hypospadi-
[70] Stein DM, Gonzalez CM, Barbagli G, Cimino S, Madonia M, Sansalone S. Erectile function in men with failed hypospadias repair. Arch Esp Urol 2014;67:152–6. [71] Bubanj TB, Perovic SV, Milicevic RM, Jovcic SB, Marjanovic ZO, Djordjevic MM. Sexual behavior and sexual function of adults after
as: results from a long-term longitudinal cohort study. Int J Immunopathol Pharmacol 2015;28:421–5. [90] Ruppen-Greeff NK, Weber DM, Gobet R, Landolt MA. Health-related quality of life in men with corrected hypospadias: an explorative study. J Pediatr Urol 2013;9:551–8.
hypospadias surgery: a comparative study. J Urol 2004;171:1876–9.
[91] Prat D, Natasha A, Polak A, et al. Surgical outcome of different types
[72] Rynja SP, Wouters GA, Van Schaijk M, Kok ET, De Jong TP, De Kort
of primary hypospadias repair during three decades in a single
LM. Long-term followup of hypospadias: functional and cosmetic results. J Urol 2009;182:1736–43. [73] Chertin B, Natsheh A, Ben-Zion I, et al. Objective and subjective
center. Urology 2012;79:1350–3. [92] Robinson AJ, Harry LE, Stevenson JH. Assessment of long term function following hypospadias reconstruction: do flow rates, flow
sexual outcomes in adult patients after hypospadias repair per-
quality and cosmesis improve with time? Results from the modified
formed in childhood. J Urol 2013;190:1556–60.
Bretteville technique. J Plast Reconstr Aesthet Surg 2013;66:120–5.
[74] Svensson J, Berg R, Berg G. Operated hypospadiacs: late follow-up.
[93] Myers JB, McAninch JW, Erickson BA, Breyer BN. Treatment of
Social, sexual, and psychological adaptation. J Pediatr Surg
adults with complications from previous hypospadias surgery. J
1981;16:134–5. [75] Mieusset R, Soulie M. Hypospadias: psychosocial, sexual, and reproductive consequences in adult life. J Androl 2005;26:163–8. [76] Singh JC, Jayanthi VR, Gopalakrishnan G. Effect of hypospadias on sexual function and reproduction. Indian J Urol 2008;24:249–52. [77] Patel RP, Shukla AR, Snyder 3rd HM. The island tube and island
Urol 2012;188:459–63. [94] Ching CB, Wood HM, Ross JH, Gao T, Angermeier KW. The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system. BJU Int 2011;107:1142–6. [95] Barbagli G, Perovic S, Djinovic R, Sansalone S, Lazzeri M. Retrospec-
onlay hypospadias repairs offer excellent long-term outcomes: a
tive descriptive analysis of 1176 patients with failed hypospadias
14-year followup. J Urol 2004;172:1717–9, discussion 9.
repair. J Urol 2010;183:207–11.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
available at www.sciencedirect.com journal homepage: www.europeanurology.com
An Update of Current Practice in Hypospadias Surgery Alexander Springer a, Serdar Tekgul b, Ramnath Subramaniam c,* a
Department of Paediatric Surgery, Medical University of Vienna, Vienna, Austria; b Department of Paediatric Urology, Hacettepe University, Ankara, Turkey;
c
Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
Article info
Abstract
Keywords: Hypospadias Update Techniques Outcomes
Today, a multiple number of surgical techniques, modifications, and combinations of techniques are used to improve cosmetic and functional outcomes and to minimise the procedure burden for the patient. Nevertheless, controversy exists regarding the ideal management of hypospadias. This update is based on current literature following a systematic review using MEDLINE. # 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Leeds Teaching Hospitals NHS Trust, Level F, Martin Wing, Leeds General Infirmary, Leeds LS1 3EX, UK. Tel. +447818452603. E-mail address: [email protected] (R. Subramaniam).
1.
Introduction
Modern hypospadiology has considerably evolved since the 1980s but significant challenges remain like standardising the management with evidence-based protocols and the assessment of longer-term outcomes. The salient points from this update have been classified in terms of level of evidence and grade of recommendation as proposed by the Centre for Evidence Based Medicine [1] and shown in Table 1. Application of a structured analysis of the literature was not possible in many conditions due to a lack of well-designed studies. The limited availability of large randomised controlled trials—influenced also by the fact that a considerable number of treatment options relate to surgical interventions on a large spectrum of a congenital pathology—means this document is largely a consensus document. 2.
Why should hypospadias be corrected?
Hypospadias may implicate functional and cosmetic impairment. Indication for hypospadias surgery therefore includes the need for the correction of penile deviation and rotation, glans cleft and tilt, ectopic and stenotic urethral
meatus, hooded prepuce, penoscrotal transposition, and penile size. The ideal result of surgery is construction of a good calibre urethra with a slit-like urethral meatus at the tip of the glans and a straight penis. Voiding and sexual activity should not be impaired by hypospadias or its corrective procedure. Surgery should allow boys with hypospadias to grow up as self-confident young men with a normal body image. Long-term outcome and health-related quality of life is associated with the severity of hypospadias and the sequelae of surgery. Hypospadias is usually classified based on the anatomical location of the proximally displaced urethral orifice. This is clinically not relevant, does not relate well with the outcome, and pathology may significantly change after degloving of the skin. It is more common that hypospadias is classified as distal and proximal, where proximal cases are more severe. Patients with severe hypospadias and those with nonfavourable surgical outcomes are more likely to suffer a negative psychological impact than those with minor hypospadias and good surgical results. Therefore there is an argument for a new classification of hypospadias based on the cost-benefit ratio for the patient [2].
http://dx.doi.org/10.1016/j.eursup.2016.09.006 1569-9056/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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Table 1 – Summary of the Socie´te´ Internationale d’Urologie Current Best Practice Options in the management of hypospadias Topic Indication Classification
Documentation Further evaluation Timing
Androgens Mild hypospadias repair
Severe hypospadias repair
Foreskin reconstruction Urinary drainage Wound dressing Antibiotics
Comments
LE
GR
Substantial lack of long-term studies showing the effects of hypospadias surgery on cosmetic, functional, and psychological outcome. Recommendation on indication for hypospadias surgery is based on common sense. Meatal location is only one of many meaningful parameters including quality of tissues, curvature, size of glans, spongiosal division, and others. Classification of hypospadias is an evolving picture and at the moment there is not one objective classification that is universally accepted. Documentation of objective findings will help to establish prospective data bases and make future studies comparable. There is no consensus on objective penile assessment and documentation of preoperative findings. Routine evaluation of the upper urinary tract in an asymptomatic child with hypospadias is not recommended. In suspicion of DSD, further investigations according to current guidelines. It is recommended that hypospadias repair be performed in infancy or early childhood ideally when there is a trained paediatric anaesthetist available. Evidence concerning the ideal age of hypospadias repair is weak and confusing. Androgens are effective. There is neither consensus on the best type of androgen nor on the correct way of application and the potential side effects of androgens have not been studied thoroughly. TIP repair is the most commonly used technique for the repair of distal hypospadias with good evidence in literature. However, high quality randomised trials (follow up rate > 80% and long term follow-up) are missing. Therefore, personal experience, skill and surgical background will still play a major role in the choice of procedure (GR D). Two-stage repair is the most popular technique used in severe hypospadias. However, there is no consensus on the ideal technique and there is no evidence in the literature that there is a definitely superior technique in the correction of severe hypospadias. Comparison between series is complicated by the lack of reliability in reporting outcome, limited follow-up and failing to report long term outcome. Foreskin reconstruction can be offered in mild hypospadias repair.
3–5
B–D
3–5
C–D
3–5
B–D
3–5
B–D
3–5
B–D
2a–5
B–D
2a–5
B
3a–5
C
2a
B
2b–5
B–D
2b–5 1b
B–D B
No clear evidence can highlight advantages of one or another form of drainage although it seems logical to drain any reconstruction. No clear evidence can highlight advantages of one or another form of wound dressing. Until further evidence is available, prophylactic broad spectrum antibiotics will be the standard in hypospadias surgery. However, it is important to point out that prophylactic antibiotic versus no antibiotic in hypospadias repair should be subject for future controlled studies.
DSD = detrusor sphincter dyssynergia; GR = grade; LE = levels of evidence.
The position of the meatus allows standardised nomenclature and is thought to be a major prognostic factor for outcome [3]. Other more complex items (level of division of the corpus spongiosum, penile curvature, ventral hypoplasia, quality of urethral plate, etc.) should also be taken into account in the classification but they are much more difficult to assess reliably and objectively with validity [4,5]. 3.
When should hypospadias be corrected?
Based on expert opinion, it is better to perform surgery of the male genitalia between 6 mo and 18 mo of age [6,7]. This recommendation is based on surgical and anaesthetic considerations and the psychology of the infant male (cognitive development, genital awareness, emotional development, and psychosexual development). However, there is spare evidence regarding this and there are contradictory findings [8]. It is generally believed that early repair is associated with a lower complication rate, but again, there is inconsistency in literature. Last but not least, there are rising concerns by patient groups that esthetical genital surgeries in minor hypospadias without functional impairment should be postponed to an age where informed consent can be given by the patient himself [9]. 4.
Preoperative androgens?
Androgen stimulation has been used for a long time to enhance the size of the penis and to improve quality of tissues [10]. There are two randomised controlled trials
showing that preoperative androgen stimulation improves outcome (cosmesis and complication rate) [11,12]. There is no consensus on the best type of androgen, the application route, and correct way of application. Two recent systematic reviews and meta-analysis critically assess the effect of androgen stimulation on surgical outcomes but remained inconclusive [13,14]. It is a fact that androgens stimulate penile growth [15]; however, the real benefit in hypospadias surgery and long-term side effects of male sexual hormone application still needs to be defined. Perioperative antibiotics, urinary drainage, and 5. wound dressing For now, there is no consensus on the type of urinary drainage, stenting of the urethra, wound dressing, or the use of antibiotics. Each surgeon has his or her own preference. Urine can be drained using a transurethral catheter, transurethral dripping stent, or a suprapubic tube of various sizes. Most surgeons would agree that postoperative urinary diversion seems to reduce complications. However, in cases of distal hypospadias, some surgeons prefer no drainage at all [16–23]. With regards to urinary diversion, there is no clear evidence that wound dressing is of any benefit for surgical outcome. The rational for wound dressing seems clear: dry, safe, and clean immobilisation of the penis for a limited period of time to allow wound healing and minimise postoperative discomfort and there are many different products available: foam dressing (Cavicare), transparent film dressing (Tegaderm), simple
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circular wound dressing, and indigenous home-made devices. However, two prospective randomised trials show no difference between postoperative dressing versus no postoperative dressing [24,25]. Most surgeons use prophylactic antibiotics in hypospadias repair but there is no consensus regarding when to administer what type of antibiotics for what period of time [26,27]. Evidence for prophylactic antibiotics in hypospadias management is very limited and there is still ongoing discussion if there is a real benefit in administering antibiotics [28–31]. 6.
Preferred technique for hyposopadias repair
Literally hundreds of techniques have been reported over the years. The choice of the technique mainly depends on the experience of the surgeon with the technique and his experience on different types of hypospadias. The surgeon should be able to define the anatomic components well, and choose and modify the technique according to the anatomy. Although common sense demands standardisation of procedures, many times there will be a need to make minor modifications in the technique which can only be done by dedicated surgeons at high-volume centres. The
use of magnification and microsurgical instruments, tissue handling with minimal trauma and fine suture material are essential. For now, the search for the ideal procedure for all hypospadias continues. An algorthim to the management of hypospadias is shown in Figure 1. 7.
Mild hypospadias repair
In the recent past, tubularised incided plate urethroplasty (TIP) repair has become the most popular technique for distal hypospadias repair worldwide [32–34]. Metaanalysis and systematic reviews of large retrospective cohort studies show that there is enough evidence to recommend the TIP repair as versatile, highly standardised, and a simple technique that provides favourable cosmetic and functional short- and long-term results with a reasonably low complication rate [35–38]. Since its introduction in 1994, TIP repair has evolved and consecutive modifications have significantly lowered the complication rates and it has come down to a fistula rate of 5.7% in primary mild hypospadias and a reoperation rate of 4.5%, respectively [39]. In particular, the fistula rate can be decreased by covering the urethroplasty with a
Hypospadias preoperative androgen application
Severe hypospadias
Mild hypospadias
No correction
TIP and others
Degloving erection test
Good urethral plate no ventral hypoplasia Mild chordee
Scarred tissue ventral hypoplasia severe chordee
TIP plication and other straightening techniques
Staged repair plication Ventral corporotomy
Fig. 1 – Algorthim of surgical management of hypospadias. TIP = tubularised incided plate urethroplasty.
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waterproofing layer of dartos tissue [40–42]. There are many other techniques described with personal modifications. For example, Mathieu urethroplasty and its modifications are still popular procedures with excellent results [43]. Systematic reviews comparing the TIP repair and Mathieu repair show that no technique appears to be significantly superior over the other with similar fistula rates (3.4–3.6%), but there is a higher incidence of meatal stenosis in TIP (3.0% vs 0.6% in Mathieu) after 6–12 mo follow-up [44,45]. 8.
Severe hypospadias
Management of severe hypospadias is challenging and should only be offered in specialised centres with an adequate number of patients. Outcome is influenced by the presence of chordee (penile curvature), quality of the urethral plate, quality of ventral tissues, scrotal transposition, and last but not least the size of the penis. Over the years, large numbers of techniques have been described. In single centre studies, most of those techniques could provide favourable cosmetic and functional outcomes. In a recent 20-yr systematic review for surgical correction of severe hypospadias no approach appeared to be superior over the other [46]. Another systematic review comparing the transverse island flap technique and TIP show no major differences in clinical outcome [47]. However, both reviews indicated general problems of reporting data in hypospadiology: no clear definition of severe hypospadias, limited number of patients, limited follow-up, and no clear defined outcome measures. The authors therefore come to the conclusion that ‘‘these data have to be confirmed by more well-designed randomised controlled trials with high quality in the future’’ [47]. Today’ s surgical armamentarium in the management of hypospadias is huge and diverse, as shown in Table 2, with a clear international majority favouring a staged repair in complex hypospadias [32]. The two-stage repair, either using grafts or flaps, is a versatile technique when there is severe chordee, a small glans, and ventral scarring [48,49]. In two-stage repair, the operation starts with (ventral) degloving. The decision to sacrifice the urethral plate is key and is left until after artificial erection test. Chordee correction could take place in many ways after fibrous tissue is excised as much as
possible. Multiple transverse corporotomy incisions can be applied to lengthen the ventral aspect of the corpora cavernosa [50]. If necessary, dorsal plication with or without mobilisation of the neurovascular bundle can help to straighten the penis [51,52]. The dorsal midline incision minimises the risk of injury to the neurovascular bundle. More aggressive techniques like ventral corporal grafting are rarely needed and their long-term outcomes are doubtful [53]. The glans wings are mobilised extensively. Inner or outer preputial skin or buccal mucosa are the preferred graft materials. The graft is quilted onto the corpora. It is recommended to place tunica dartos flaps onto the corpora laterally as a bed providing an extensive amount of healthy tissue for the second-stage urethroplasty [54]. Appropriate urinary drainage and pressure wound dressing is crucial for a good outcome. Second-stage urethroplasty is performed by tubularisation of the graft with two further layers of tunica dartos to cover the urethroplasty. 9.
Follow-up and outcome
Long-term follow-up is of substantial importance. A recent systematic review showed that there is a significant lack in long-term data. Although there is a growing number of articles reporting reliable and valid data like inclusion and exclusion criteria, study design, primary and secondary outcome parameters, follow-up, a detailed description of the surgical procedure, and so on [55], quality of data is influenced by low follow-up periods and rates, heterogeneous patients and data, and a lack of validated questionnaires and control groups [56]. It has been criticised that follow-up periods—particularly in Northern America—are short [39], although some believe that most complications occur early after surgery [57]. However, there is evidence that the real number of complications is only to be assessed in long-term follow-up after puberty or even adulthood [58,59]. Although some current long-term studies have follow-up rates between 12.7%, 22.4%, and 56.2%, most outcome studies do not provide a follow-up rate or those lost to follow-up [60–62]. Table 3 shows long-term outcome studies from 2010 to 2015. Although the majority of patients do well after hypospadias repair there are reports
Table 2 – Most commonly performed techniques in the repair of severe hypospadias Name
Reference
Patel
[77]
2004
73
Duckett
Amukele
[78]
2004
265
Thiersch-Duplay
Obaidullah Djordjevic, Macedo
[79] [80,81]
2005 2008, 2011
1415 NA
Snodgrass Vepakomma
[82] [83]
2011 2013
26 24
Two stage repair Combinations, variations TIP Koyanagi
Hadidi
[84]
2014
63
BILAB
Yr
N
Generic name
Comments Preputial flap as transverse island tube or island onlay flap with longterm f/u of 14.2 yr. Very versatile technique with many modifications in literature, widely used. Long-term proven reliable technique, difficult with extensive chordee and low quality urethral plate. Two-stage repair very safe and applicable to all cases. Flaps, grafts, buccal mucosa, technically very challenging, techniques never gained popularity, short term follow-up. Suitable when no minor curvature and good quality of urethral plate. Based on a parameatal foreskin flap, many modifications since its introduction in 1983, technically challenging. Bilateral based preputial and penile skin flaps, generous blood supply.
f/u = follow-up; TIP = tubularised incided plate urethroplasty.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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Table 3 – Long-term outcome studies from 2010 to 2015 Name
Reference
Yr
N
Age at surgery (yr)
¨ rtqvist O
[85]
2015
167
Andersson
[86]
2015
Hueber
[87]
Fraumann
Age at FU (yr)
FU period (mo)
Fistula (%)
Curvature (%)
Stenosis (%)
4
34
29
16.4
23
5
40
3.6
15.2
11.6
5
15
22.5
2015
153
2.9
21/16/5
0/4/2
16/16/10
[61]
2014
13
1.2
21
20
7.5
38.5
7.5
Ekmark
[88]
2013
114
4.5–5
16
12
11
5.4
3.6
Aulagne
[62]
2010
27
3.3
25
33
18
26
Perera
[60]
2012
60
1.8
Ciancio
[89]
2015
20
5
Ruppen-Greff
[90]
2013
45
Chertin, Prat
[73,91]
2012, 2013
119
2.7
Adults
Robinson Kiss
[92] [59]
2012 2011
18 104
2.5
12.5 24–42
Jiao
[64]
2011
43
>10
11.3
33
28
26.2
10.5 20–30
21.6
Comments
Impaired cosmesis, shorter penis, more LUTS. Uroflow improves over time. Favourable outcomes (TIP/Mathieu/MAGPI). Satisfactory outcome, lower orgasmic function. Curvature can develop over time. Generally good outcomes.
Uroflow lower than controls, associated with previous chordee. Good cosmesis, no erectile dysfunction, low IPSS, penis shorter. HRQoL were not impaired among men. Good cosmetic results, mild erectile dysfunction, numerous techniques, high complication rates (0– 100%). Good flow and cosmesis. Less satisfaction with genital appearance, however healthy psychosexual development possible. Main complaint penile size and curvature, sexual function impaired.
FU = follow-up; HRQoL = health-related quality of life; IPSS = International Prostate Symptom Score; LUTS = lower urinary tract sysmptoms; MAGPI = meatal advancement and glanduloplasty; TIP = tubularised incided plate urethroplasty.
of adult reconstructive urologists trying to attract attention to the fact that some patients need redo surgery in adulthood. Table 4 shows the current series of hypospadias redo surgeries in adults. In literature, short-term and mid-term outcomes of hypospadias surgery seem favourable. However, the majority of these publications present single-centre and singlesurgeon retrospective case series with a limited follow-up period and a limited number of patients undergoing
follow-up [63]. Assessment of outcome includes: cosmesis, functional outcome (micturition and sexuality), and quality of psychosexual life. 9.1.
Cosmesis
Patients who had surgery for hypospadias may have a significant concern about penile appearance and penile size. Generally, a better cosmetic outcome is related to better
Table 4 – Series of hypospadias redo surgery in adults Name
Reference
Stein Myers Ching
[70] [93] [94]
Barbagli
[95]
Age at surgery (yr)
FU period (mo)
2014 2012 2011
39.7 38 37
15 (3–28) 7.4
163 50 55
2010
31
60.4
1176 (926 older than 16 yr)
n
Comments
54% erectile dysfunction. Difficult surgery, additional procedures common. Voiding problems 82%, UTI 36%, curvature 24%, BXO 13%, fistula 14%. 12% failure rate.
BXO = balanitis xerotica obliterans; FU = follow-up; UTI = urinary tract infection.
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sexual outcome [64]. There are several objective and validated scores to evaluate the outcome of hypospadias surgery (Hypospadias Objective Scoring Evaluation, Paediatric Penile Perception Score, Hypospadias Objective Penile Evaluation Score) [65–67]. For example, the Hypospadias Objective Penile Evaluation Score evaluates the position and shape, the shape of the glans, the penile skin, and curvature and torsion of the penis [65]. An independent person should ideally rate the outcome. Scoring is easy to apply, can be kept in the patients notes, and allow prospective evaluation. The International Disorders of Sex Development registry [68] and The Dutch (International) Hypospadias Study [65] are international databases for the allocation of prospective hypospadias patients. Every hypospadias surgeon is encouraged and invited to join such a database for personal audit and research purposes.
emotional relations, self-esteem, relationships, sex life, etc. The more severe the hypospadias, the less satisfactory the long-term outcome and as alluded to earlier, better cosmetic outcome is related to better sexual outcome [64]. In patients at risk, it seems important to provide meticulous transitional care where the paediatric patient is transferred into an adult urology service. Conflicts of interest The authors have nothing to disclose. References [1] Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-based Medicine—levels of evidence. 2009. http://www.cebm.net/ oxford-centre-evidence-based-medicine-levels-evidence-march-
9.2.
Functional outcome
2009/. [2] Springer A, Spinoit AF, Nappo S, et al. Current best practice options
Functional outcomes are just beginning to be reported in literature. A recent systematic review recommends a uroflow study after toilet training. Children with obstructed flow parameters or borderline flows should be followed until adulthood. However, the significance of this advice remains uncertain [69]. In an Australian study of long-term follow-up, urinary flow rates were significantly lower compared with age-matched controls but still fell within the normal range without significant association with lower urinary tract symptoms and poor urinary flow. However, severe chordee preoperatively seems to be a significant risk factor for poor urinary flow [60]. Therefore, in adults following hypospadias surgery it may be necessary to have a repeated close look at urinary flow, postvoid residuals, symptoms of lower urinary tract symptoms, or other urinary signs. In most of the cases sexual function, strength and duration of erection, problems with ejaculation (spraying, dribbling, retrograde ejaculation, and premature ejaculation), and masturbation are not impaired. However, depending on the severity of chordee, ventral hypoplasia, type and length of urethroplasty, burden of surgery, and other factors, there may be concerns for the patient and there are standardised assessment scores available to objectively rate those concerns (International Prostate Symptom Score, International index of erectile function, and Sexual Summary Score) [63]. A certain prevalence of erectile dysfunction hypospadias patients has been reported [70].
in the management of hypospadias. In: DeVries CR, Nijman JM, editors. Congenital anomalies in children—A joint SIU-ICUD International Consultation. Montreal: Socie´te´ Internationale d’Urologie; 2014. p. 52–78. [3] Spinoit AF, Poelaert F, Van Praet C, Groen LA, Van Laecke E, Hoebeke P. Grade of hypospadias is the only factor predicting for reintervention after primary hypospadias repair: A multivariate analysis from a cohort of 474 patients. J Pediatr Urol 2015;11:, 70.e1-6. [4] Hadidi AT. Classification of hypospadias. In: Hadidi AT, Azmy AF, editors. Hypospadias surgery. Heidelberg: Springer; 2004. p. 79–83. [5] Mouriquand PD, Mure PY. Current concepts in hypospadiology. BJU Int 2004;93(Suppl 3):26–34. [6] Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia. American Academy of Pediatrics. Pediatrics 1996;97:590-4. [7] Tekgu¨l S, Riedmiller H, Gerharz E, et al. Guidelines on Paediatric Urology of the EAU. 2013. https://uroweb.org/wp-content/uploads/ 24_Paediatric_Urology.pdf. [8] Weber DM, Schonbucher VB, Gobet R, Gerber A, Landolt MA. Is there an ideal age for hypospadias repair? A pilot study. J Pediatr Urol 2009;5:345–50. [9] Springer A, Baskin L. Timing of hypospadias repair in patients with disorders of sex development. In: Hiort O, Ahmed SF, editors. Understanding differences and disorders of sex development. Basel: Karger; 2014. p. 197–202. [10] Malik RD, Liu DB. Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias. J Pediatr Urol 2014;10:840–3. [11] Asgari SA, Safarinejad MR, Poorreza F, Safaei Asl A, Mansour Ghanaie M, Shahab E. The effect of parenteral testosterone administration prior to hypospadias surgery: a prospective, random-
9.3.
Psychosexual outcome
ised, and controlled study. J Pediatr Urol 2015;11:143.e1-6. [12] Kaya C, Bektic J, Radmayr C, Schwentner C, Bartsch G, Oswald J. The
Psychosexual well-being is far more difficult to evaluate. There are only a few studies assessing long-term psychosexual adjustment and sexual function, healthrelated quality of life, and quality of sexual life without or matched with control groups. These data are very limited and controversial [62,64,71–76]. Generally speaking, hypospadias patients should do well in adulthood in all regards (cosmesis, function, and psychology), but there can be significant issues, like impaired capacity for social and
efficacy of dihydrotestosterone transdermal gel before primary hypospadias surgery: a prospective, controlled, randomized study. J Urol 2008;179:684–8. [13] Wright I, Cole E, Farrokhyar F, Pemberton J, Lorenzo AJ, Braga LH. Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review. J Urol 2013;190:652–9. [14] Netto JM, Ferrarez CE, Schindler Leal AA, Tucci Jr S, Gomes CA, Barroso Jr U. Hormone therapy in hypospadias surgery: a systematic review. J Pediatr Urol 2013;9:971–9.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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7
[15] Nerli RB, Koura A, Prabha V, Reddy M. Comparison of topical versus
[37] Sarhan OM, El-Hefnawy AS, Hafez AT, Elsherbiny MT, Dawaba ME,
parenteral testosterone in children with microphallic hypospadias.
Ghali AM. Factors affecting outcome of tubularized incised plate
Pediatr Surg Int 2009;25:57–9. [16] Radwan M, Soliman MG, Tawfik A, Abo-Elenen M, El-Benday M. Does the type of urinary diversion affect the result of distal hypospadias repair? A prospective randomised trial. Ther Adv Urol 2012;4:161–5. [17] Xu N, Xue XY, Wei Y, et al. Outcome analysis of tubularized incised plate repair in hypospadias: is a catheter necessary? Urol Int 2013;90:354–7. [18] Ritch CR, Murphy AM, Woldu SL, Reiley EA, Hensle TW. Overnight urethral stenting after tubularised incised plate urethroplasty for distal hypospadias. Pediatr Surg Int 2010;26:639–42. [19] Hardwicke J, Jones E, Wilson-Jones N. Optimisation of silicone urinary catheters for hypospadias repair. J Pediatr Urol 2010;6: 385–8. [20] Lorenz C, Schmedding A, Leutner A, Kolb H. Prolonged stenting does not prevent obstruction after TIP repair when the glans was deeply incised. Eur J Pediatr Surg 2004;14:322–7. [21] Leclair MD, Camby C, Battisti S, Renaud G, Plattner V, Heloury Y.
(TIP) urethroplasty: single-center experience with 500 cases. J Pediatr Urol 2009;5:378–82. [38] Snodgrass WT, Bush N, Cost N. Tubularised incised plate hypospadias repair for distal hypospadias. J Pediatr Urol 2010;6:408–13. [39] Pfistermuller KL, McArdle AJ, Cuckow PM. Meta-analysis of complication rates of the tubularized incised plate (TIP) repair. J Pediatr Urol 2015;11:54–9. [40] Yigiter M, Yildiz A, Oral A, Salman AB. A comparative study to evaluate the effect of double dartos flaps in primary hypospadias repair: no fistula anymore. Int Urol Nephrol 2010;42:985–90. [41] Djordjevic ML, Perovic SV, Vukadinovic VM. Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair. BJU Int 2005;95:1303–9. [42] Cimador M, Pensabene M, Sergio M, Catalano P, de Grazia E. Coverage of urethroplasty in pediatric hypospadias: randomised comparison between different flaps. Int J Urol 2013;20:1000–5. [43] Hadidi AT. The slit-like adjusted Mathieu technique for distal hypospadias. J Pediatr Surg 2012;47:617–23.
Unstented tubularized incised plate urethroplasty combined with
[44] Wilkinson DJ, Farrelly P, Kenny SE. Outcomes in distal hypospadias:
foreskin reconstruction for distal hypospadias. Eur Urol 2004;46:
a systematic review of the Mathieu and tubularised incised plate
526–30. [22] Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypospadias dilemmas: a round table. J Pediatr Urol 2011;7:145–57. [23] Castagnetti M, El-Ghoneimi A. The influence of perioperative factors on primary severe hypospadias repair. Nat Rev Urol 2011;8:198–206. [24] McLorie G, Joyner B, Herz D, et al. A prospective randomized clinical trial to evaluate methods of postoperative care of hypospadias. J Urol 2001;165:1669–72. [25] Van Savage JG, Palanca LG, Slaughenhoupt BL. A prospective ran-
repairs. J Pediatr Urol 2012;8:307–12. [45] Wang F, Xu Y, Zhong H. Systematic review and meta-analysis of studies comparing the perimeatal-based flap and tubularized incised-plate techniques for primary hypospadias repair. Pediatr Surg Int 2013;29:811–21. [46] Castagnetti M, El-Ghoneimi A. Surgical management of primary severe hypospadias in children: systematic 20-year review. J Urol 2010;184:1469–74. [47] Xiao D, Nie X, Wang W, et al. Comparison of transverse island flap onlay and tubularized incised-plate urethroplasties for primary
domised trial of dressings versus no dressings for hypospadias
proximal hypospadias: a systematic review and meta-analysis.
repair. J Urol 2000;164:981–3.
PLoS One 2014;9:e106917.
[26] Hsieh MH, Wildenfels P, Gonzales Jr ET. Surgical antibiotic practices
[48] McNamara ER, Schaeffer AJ, Logvinenko T, et al. Management of
among pediatric urologists in the United States. J Pediatr Urol
proximal hypospadias with 2-stage repair: 20 year experience. J
2011;7:192–7. [27] Springer A. The use of antibiotics in hypospadias surgery. Results from an international survey. Unpublished data. 2013. [28] Lee YC, Huang CH, Chou YH, Lin CY, Wu WJ. Outcome of hypospa-
Urol 2015;194:1080–5. [49] Bracka A. The role of two-stage repair in modern hypospadiology. Indian J Urol 2008;24:210–8. [50] Snodgrass W, Prieto J. Straightening ventral curvature while pre-
dias reoperation based on preoperative antimicrobial prophylaxis.
serving the urethral plate in proximal hypospadias repair. J Urol
Kaohsiung J Med Sci 2005;21:351–7.
2009;182:1720–5.
[29] Meir DB, Livne PM. Is prophylactic antimicrobial treatment necessary after hypospadias repair? J Urol 2004;171:2621–2. [30] Baillargeon E, Duan K, Brzezinski A, Jednak R, El-Sherbiny M. The role of preoperative prophylactic antibiotics in hypospadias repair. Can Urol Assoc J 2014;8:236–40.
[51] Nesbit RM. Operation for correction of distal penile ventral curvature with or without hypospadias. Trans Am Assoc Genitourin Surg 1966;58:12–4. [52] Baskin LS, Duckett JW. Dorsal tunica albuginea plication for hypospadias curvature. J Urol 1994;151:1668–71.
[31] Kanaroglou N, Wehbi E, Alotay A, et al. Is there a role for prophy-
[53] Braga LH, Pippi Salle JL, Dave S, Bagli DJ, Lorenzo AJ, Khoury AE.
lactic antibiotics after stented hypospadias repair? J Urol 2013;190:
Outcome analysis of severe chordee correction using tunica vagi-
1535–9. [32] Springer A, Krois W, Horcher E. Trends in hypospadias surgery: results of a worldwide survey. Eur Urol 2011;60:1184–9. [33] Cook A, Khoury AE, Neville C, Bagli DJ, Farhat WA, Pippi Salle JL. A multicentre evaluation of technical preferences for primary hypospadias repair. J Urol 2005;174:2354–7, discussion 7. [34] Steven L, Cherian A, Yankovic F, Mathur A, Kulkarni M, Cuckow P. Current practice in paediatric hypospadias surgery; a specialist survey. J Pediatr Urol 2013;9:1126–30. [35] Braga LH, Lorenzo AJ, Salle JL. Tubularised incised plate urethroplasty for distal hypospadias: a literature review. Indian J Urol 2008;24:219–25. [36] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularised incised plate hypospadias repair: results of a multicenter experience. J Urol 1996;156:839–41.
nalis as a flap in boys with proximal hypospadias. J Urol 2007;178:1693–7, discussion 7. [54] Springer A, Subramaniam R. Split dorsal dartos flap transposed ventrally as a bed for preputial skin graft in primary staged hypospadias repair. Urology 2012;79:939–42. [55] Snodgrass W. Hypospadias reporting—how good is the literature? J Urol 2010;184:1255–6. [56] Rynja SP, de Jong TP, Bosch JL, de Kort LM. Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood. J Pediatr Urol 2011;7:504–15. [57] Snodgrass W, Villanueva C, Bush NC. Duration of follow-up to diagnose hypospadias urethroplasty complications. J Pediatr Urol 2014;10:208–11. [58] Spinoit AF, Poelaert F, Groen LA, Van Laecke E, Hoebeke P. Hypospadias repair at a tertiary care center: long-term followup is
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006
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EUROPEAN UROLOGY SUPPLEMENTS XXX (2016) XXX–XXX
mandatory to determine the real complication rate. J Urol 2013;189:2276–81. [59] Kiss A, Sulya B, Szasz AM, et al. Long-term psychological and sexual outcomes of severe penile hypospadias repair. J Sex Med 2011; 8:1529–39.
[78] Amukele SA, Weiser AC, Stock JA, Hanna MK. Results of 265 consecutive proximal hypospadias repairs using the Thiersch-Duplay principle. J Urol 2004;172:2382–3. [79] Obaidullah, Aslam M. Ten-year review of hypospadias surgery from a single centre. Br J Plast Surg 2005;58:780–9.
[60] Perera M, Jones B, O’Brien M, Hutson JM. Long-term urethral func-
[80] Djordjevic ML, Majstorovic M, Stanojevic D, et al. One-stage repair
tion measured by uroflowmetry after hypospadias surgery: com-
of severe hypospadias using combined buccal mucosa graft and
parison with an age matched control. J Urol 2012;188:1457–62. [61] Fraumann SA, Stephany HA, Clayton DB, et al. Long-term follow-up
longitudinal dorsal skin flap. Eur J Pediatr Surg 2008;18:427–30. [81] Macedo Jr A, Liguori R, Ottoni SL, et al. Long-term results with a one-
of children who underwent severe hypospadias repair using an
stage complex primary hypospadias repair strategy (the three-in-
online survey with validated questionnaires. J Pediatr Urol 2014;
one technique). J Pediatr Urol 2011;7:299–304.
10:446–50. [62] Aulagne MB, Harper L, de Napoli-Cocci S, Bondonny JM, Dobremez E. Long-term outcome of severe hypospadias. J Pediatr Urol 2010;6:469–72. [63] Springer A. Assessment of outcome in hypospadias surgery—a review. Front Pediatr 2014;2:2. [64] Jiao C, Wu R, Xu X, Yu Q. Long-term outcome of penile appearance and sexual function after hypospadias repairs: situation and relation. Int Urol Nephrol 2011;43:47–54. [65] van der Toorn F, de Jong TP, de Gier RP, et al. Introducing the HOPE (Hypospadias Objective Penile Evaluation)-score: a validation study of an objective scoring system for evaluating cosmetic
[82] Snodgrass W, Bush N. Tubularised incised plate proximal hypospadias repair: continued evolution and extended applications. J Pediatr Urol 2011;7:2–9. [83] Vepakomma D, Alladi A, Ramareddy RS, Akhtar T. Modified koyanagi repair for severe hypospadias. J Indian Assoc Pediatr Surg 2013;18:96–9. [84] Hadidi AT. Perineal hypospadias: the Bilateral Based (BILAB) skin flap technique. J Pediatr Surg 2014;49:218–23. [85] Ortqvist L, Fossum M, Andersson M, et al. Long-term follow-up of men born with hypospadias: urological and cosmetic results. J Urol 2015;193:975–81. [86] Andersson M, Doroszkiewicz M, Arfwidsson C, Abrahamsson K,
appearance in hypospadias patients. J Pediatr Urol 2013;9:
Sillen U, Holmdahl G. Normalised urinary flow at puberty after
1006–16.
Tubularised Incised Plate (TIP) urethroplasty of hypospadias in
[66] Holland AJ, Smith GH, Ross FI, Cass DT. HOSE: an objective scoring system for evaluating the results of hypospadias surgery. BJU Int 2001;88:255–8. [67] Weber DM, Schonbucher VB, Landolt MA, Gobet R. The Pediatric Penile Perception Score: an instrument for patient self-assessment and surgeon evaluation after hypospadias repair. J Urol 2008; 180:1080–4, discussion 4. [68] Network I-D. I-DSD Network. 2014. http://gtr.rcuk.ac.uk/projects? ref=G1100236. [69] Gonzalez R, Ludwikowski BM. Importance of urinary flow studies
childhood. J Urol 2015;194:1407–13. [87] Hueber PA, Antczak C, Abdo A, Franc-Guimond J, Barrieras D, Houle AM. Long-term functional outcomes of distal hypospadias repair: a single center retrospective comparative study of TIPs, Mathieu, and MAGPI. J Pediatr Urol 2015;11:68.e1-7. [88] Ekmark AN, Svensson H, Arnbjornsson E, Hansson E. Postpubertal examination after hypospadias repair is necessary to evaluate the success of the primary reconstruction. Eur J Pediatr Surg 2013;23:304–11. [89] Ciancio F, Lo Russo G, Innocenti A, Portincasa A, Parisi D, Mondaini
after hypospadias repair: a systematic review. Int J Urol 2011;18:
N. Penile length is a very important factor for cosmesis, function
757–61.
and psychosexual development in patients affected by hypospadi-
[70] Stein DM, Gonzalez CM, Barbagli G, Cimino S, Madonia M, Sansalone S. Erectile function in men with failed hypospadias repair. Arch Esp Urol 2014;67:152–6. [71] Bubanj TB, Perovic SV, Milicevic RM, Jovcic SB, Marjanovic ZO, Djordjevic MM. Sexual behavior and sexual function of adults after
as: results from a long-term longitudinal cohort study. Int J Immunopathol Pharmacol 2015;28:421–5. [90] Ruppen-Greeff NK, Weber DM, Gobet R, Landolt MA. Health-related quality of life in men with corrected hypospadias: an explorative study. J Pediatr Urol 2013;9:551–8.
hypospadias surgery: a comparative study. J Urol 2004;171:1876–9.
[91] Prat D, Natasha A, Polak A, et al. Surgical outcome of different types
[72] Rynja SP, Wouters GA, Van Schaijk M, Kok ET, De Jong TP, De Kort
of primary hypospadias repair during three decades in a single
LM. Long-term followup of hypospadias: functional and cosmetic results. J Urol 2009;182:1736–43. [73] Chertin B, Natsheh A, Ben-Zion I, et al. Objective and subjective
center. Urology 2012;79:1350–3. [92] Robinson AJ, Harry LE, Stevenson JH. Assessment of long term function following hypospadias reconstruction: do flow rates, flow
sexual outcomes in adult patients after hypospadias repair per-
quality and cosmesis improve with time? Results from the modified
formed in childhood. J Urol 2013;190:1556–60.
Bretteville technique. J Plast Reconstr Aesthet Surg 2013;66:120–5.
[74] Svensson J, Berg R, Berg G. Operated hypospadiacs: late follow-up.
[93] Myers JB, McAninch JW, Erickson BA, Breyer BN. Treatment of
Social, sexual, and psychological adaptation. J Pediatr Surg
adults with complications from previous hypospadias surgery. J
1981;16:134–5. [75] Mieusset R, Soulie M. Hypospadias: psychosocial, sexual, and reproductive consequences in adult life. J Androl 2005;26:163–8. [76] Singh JC, Jayanthi VR, Gopalakrishnan G. Effect of hypospadias on sexual function and reproduction. Indian J Urol 2008;24:249–52. [77] Patel RP, Shukla AR, Snyder 3rd HM. The island tube and island
Urol 2012;188:459–63. [94] Ching CB, Wood HM, Ross JH, Gao T, Angermeier KW. The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system. BJU Int 2011;107:1142–6. [95] Barbagli G, Perovic S, Djinovic R, Sansalone S, Lazzeri M. Retrospec-
onlay hypospadias repairs offer excellent long-term outcomes: a
tive descriptive analysis of 1176 patients with failed hypospadias
14-year followup. J Urol 2004;172:1717–9, discussion 9.
repair. J Urol 2010;183:207–11.
Please cite this article in press as: Springer A, et al. An Update of Current Practice in Hypospadias Surgery. Eur Urol Suppl (2016), http://dx.doi.org/10.1016/j.eursup.2016.09.006