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Assessment of Urinary Stream after Repair of Anterior Hypospadias by Meatoplasty and Glanuloplasty
0022-534 7/85/1341-0100$02.00/0 Vol. 134, July
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1985 by The Williams & Wilkins Co.
ASSESSMENT OF URINARY STREAM AFTER REPAIR OF ANTERIOR HYPOSPADIAS BY MEATOPLASTY AND GLANULOPLASTY R. D. H. MACMILLAN, B. M. CHURCHILL* AND R. F. GILMOUR From the Division of Urology (Department of Surgery), The Hospital for Sick Children, Toronto, Ontario, Canada
ABSTRACT Voiding function was studied after repair of anterior hypospadias in 44 boys using Duckett's technique of meatoplasty and glanuloplasty. Assessment of the urinary stream was done in 2 ways. At least 6 weeks postoperatively a uroflow measurement using a DISA rotating disk machine was done. Peak flow was compared to previously prepared normal values in a large group of normal boys. Then, a high speed picture of the stream was taken using electronic video photography at the time of peak flow. Of the boys 42 had normal flow rates and 40 had acceptable stream patterns. The only complication was meatal stenosis in 2 cases. There were no fistulas. Although the primary indication for correction of anterior hypospadias is cosmetic, it is essential that function not be sacrificed to achieve this end. This study indicates that voiding function is maintained after hypospadias repair with meatoplasty and glanuloplasty. were from 2 to 15 years old, with the majority (33) being less than 5 years old. One surgeon (B. M. C.) performed the MAGPI repair in all cases after documentation (with photography) of the distal meatal position and absence of significant chordee (less than 15 degrees), using saline-simulated erections if indicated. Postoperatively, 30 patients had indwelling urethral catheters (usually a No. 8 feeding tube) for 48 to 72 hours and a 3-inch wide compressive dressing of elastic gauze. Usually, a 12-hour period of cooling with cotton gauze soaked with iced saline was used before catheter removal. The boys were discharged from the
Many surgeons have been reluctant in the past to offer reconstructive surgery for boys with anterior or first degree hypospadias. Correction was denied for a variety of reasons: the indication is purely cosmetic, the complication rate can be high, and many of the procedures described are technically demanding and require fine instrumentation. More recently, Duckett reported superb cosmetic results and a low complication rate with the revolutionary technique of meatoplasty and glanuloplasty (MAGPI).' Most important of all, his excellent original results have been reproduced by surgeons across the country. 2
B
BS· 0,92 rn2·1.42 m2 AGE GROUP: BY, 14Y
35
35
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35
1
30
30
~I°[ I l
50
+-'--,---,----,---r--~~~~~
O .
0
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®
®
D
B
D
B
a
VOLUME VOIDED (cc)
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®
®
D
B
D
B
100
150 200 250 300 VOLUME VOIDED (cc)
350
400
450
G
VOLUME VOIDED (cc)
FIG. 1. Grafhs of standard flow rate curves. A, body surface area less than 0.92 m. 2 in boys (36) 3 to 7 years old. B, body surface area from 0.92 to 1.42 m. in boys (7) 8 to 14 years old. C, body surface area greater than 1.42 m. 2 in patients (1) 15 to 21 years old.
However, the price of such cosmetic perfection in terms of functional aspects of the penis has not yet been determined. In this study we completed a detailed assessment of micturition in a large series of boys after MAG PI hypospadias repair in an effort to answer this question. MATERIALS AND METHODS
A total of 44 boys with anterior hypospadias presented to our hospital for treatment between 1979 and 1983. The patients Accepted for publication February 13, 1985. Read at annual meeting of American Urological Association, New Orleans, Louisiana, May 6-10, 1984. * Requests for reprints: Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada M5G 1X8. 100
hospital once they began voiding freely. Initial followup was 6 weeks postoperatively, at which time an objective assessment of the urinary stream was made. A flow rate was obtained using a D ISA* rotating disk uroflow machine, and a high speed picture of the stream was taken at the moment of peak flow using electronic video photography. Peak flow rate in cubic centimeters per second was compared to a series of standard flow rate curves prepared previously by our urodynamics laboratory. To establish the standard rates peak flow rates were plotted against voiding volume for more than 250 normal boys and confidence limits of 80, 90 and 95 per cent were established based on body surface area. In addition, the photographs of the urinary stream were compared to those taken of the normal boys. * Dantec Electronics, Denmark.
A3SESSiv1EI\fT OF URII'~ARY 3TREAtv1 AFTER REPAIR OF Ar'\TERIOR I-IYPOSPADIA.8 RESULTS
The cosmetic result was excellent in 43 cases. In the remain ing patient a small ventral flap was present at initial followup but it improved without further treatment and 1 year postoperatively the appearance was acceptable. Meatal stenosis, which was the only complication, developed in 2 patients, one of whom required a meatotomy, while the other responded to several urethral dilations. There were no urethral fistulas. The uroflow measurements were obtained in all 44 boys. Postoperative comparison with the normal values indicated that the flow rates were within the 95 per cent confidence limits of the standard curves in 42 boys and the 80 per cent confidence limits in 36 (fig. 1). In 25 boys flow rates obtained again between 6 months and 2 years postoperatively correlated well with the assessment at 6 weeks. Photographs of the urinary stream at the time of peak flow using high speed video photography were taken as a permanent record of the stream. In normal boys the stream consists of a series of symmetrical and evenly spaced drops in a single line with no turbulence or fanning. Of the 43 boys for whom postoperative photographs were taken 15 had the normal pattern (fig. 2). In 23 others a single straight stream was present but the
FIG. 2. Normal stream pattern. Drops are of equal size, evenly spaced and in straight line. Stream characteristics were enhanced artistically to facilitate reproduction.
101
pattern was laminar and fanning. A smooth stream fanned out from the meatus of these boys and the drop pattern formed out much further (fig. 3, A). The fanning pattern tended to occur in patients with a more proximal meatus who had required a large advancement and had a correspondingly larger meatus. The stream was functionally quite acceptable in these patients. A turbulent flow pattern was seen in 2 boys. Scattered irregular drops spread out from the meatus (fig. 3, B). One patient had excess ventral tissue and, possibly, the abnormal stream was related to prominence of glans tissue adjacent to the meatus. This stream was functionally poor. In 3 patients the stream pattern was stenotic, with fine, small irregular drops (fig. 3, C). Subsequently, 2 of these patients required treatment for meatal stenosis. The flow rate in these 2 cases also was below normal and in the remaining case it was in the borderline low-normal range. In summary, in the vast majority of the patients the photographs of the stream demonstrated a satisfactory if not entirely normal pattern and the uroflow measurements were normal. Abnormal uroflow studies often were the first indication of a problem with the repair in the few boys who did have a complication. DISCUSSION
Although a great variety of procedures have been devised to manage anterior hypospadias, the major controversy has related to the necessity for surgery at all. Functionally, these boys have a normal penis, although the meatus is not at the end of the glans. However, the appearance of the penis is distinctly abnormal and this alone causes significant parental concern. The parents of children with hypospadias are more anxious about the maleness of their child than about the proposed surgery. Questions about the ability to have normal sexual relations or children are asked frequently. The children themselves demonstrate considerable anxiety, particularly in the postoperative period when unusually aggressive behavior often is seen. 3 In adults there is some evidence that sexual and social development in the hypospadiac patient may be retarded slightly and that over-all sexual activity is lower than average. 4 Although it seems logical that there would be some adverse psychological effect of having an imperfect penis, many surgeons believe that this aspect has been over emphasized. 5 Be that as it may, parents are increasingly insistent that correction be performed. Interestingly enough, Duckett collected a series of 14 patients with anterior hypospadias whose fathers had the same problem left uncorrected.' Although none of the fathers was willing to undergo correction in adulthood, they all wished that they had been more normal while growing up and, therefore, wanted their sons to have the benefit of an early hypospadias repair. The MAG PI procedure is reserved for with a meatus in the distal location (that is glandular, coronal or subcoronal) without significant chordee. The advancement possible usually
I
B
-+---+-------)f----+-----+-+-
d
I
'
0
FIG. 3. A, laminar fa_nni?f!" pattern-;-smooth stream spreads out from meatus and drop pattern forms out much further. B, turbulent patternscattered drop J?attern 1s v!s.1ble startmg from meatus and fans out usually. C, stenotic pattern-drops are small. Stream characteristics were enhanced artistically to facilitate reproduction.
102
MACMILLAN, CHURCHILL AND GILMOUR
is limited to 1 cm. so that other procedures are necessary for more proximal hypospadias. A MAGPI also can be used as a final stage of multistaged hypospadias repairs to get the meatus out to the glans. The complication rate has been low in most series. Duckett's own experience of more than 200 MAG PI repairs demonstrated only 1 fistula and no other significant problems. 1 This compares dramatically with the 10 to 20 per cent fistula rate quoted for the Horton-Devine flip-flap procedure or the Ombredanne procedure.6 Meatal stenosis also is a significant problem with these repairs. Simpler procedures, such as the Allen-Spence repair or Belman's urethral advancement, have much lower complication rates but the cosmetic results are not as good as with the MAG PI or the more complex repairs. 7 Until recently, the price of perfection in the management of anterior hypospadias was significantly high. However, with the advent of the MAG PI repair, which virtually guarantees perfect cosmetic results and fully preserves micturitional function, all boys with distal hypospadias should be offered early surgical correction.
REFERENCES
1. Duckett, J. W.: MAGPI (meatoplasty and glanuloplasty): a procedure for subcoronal hypospadias. Urol. Clin. N. Amer., 8: 513, 1981. 2. Shapiro, S. R.: Complications of hypospadias repair. J. Urol., 131: 518, 1984. 3. Robertson, M. and Walker, D.: Psychological factors in hypospadias repair. J. Urol., 113: 698, 1975. 4. Berg, R., Svensson, J. and Astrom, G.: Social and sexual adjustment of men operated for hypospadias during childhood: a controlled study. J. Urol., 125: 313, 1981. 5. Williams, D. I.: Urology in Childhood. Berlin: Springer-Verlag, pp. 104-107, 1958. 6. Mills, C., McGovern, J., Mininberg, D., Coleman, J., Muecke, E. and Vaughan, E. D., Jr.: An analysis of different techniques for distal hypospadias repair: the price of perfection. J. Urol., 125: 701, 1981. 7. Allen, T. D. and Spence, H. M.: The surgical treatment of coronal hypospadias and related problems. J. Urol., 100: 504, 1968.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1985 by The Williams & Wilkins Co.
ASSESSMENT OF URINARY STREAM AFTER REPAIR OF ANTERIOR HYPOSPADIAS BY MEATOPLASTY AND GLANULOPLASTY R. D. H. MACMILLAN, B. M. CHURCHILL* AND R. F. GILMOUR From the Division of Urology (Department of Surgery), The Hospital for Sick Children, Toronto, Ontario, Canada
ABSTRACT Voiding function was studied after repair of anterior hypospadias in 44 boys using Duckett's technique of meatoplasty and glanuloplasty. Assessment of the urinary stream was done in 2 ways. At least 6 weeks postoperatively a uroflow measurement using a DISA rotating disk machine was done. Peak flow was compared to previously prepared normal values in a large group of normal boys. Then, a high speed picture of the stream was taken using electronic video photography at the time of peak flow. Of the boys 42 had normal flow rates and 40 had acceptable stream patterns. The only complication was meatal stenosis in 2 cases. There were no fistulas. Although the primary indication for correction of anterior hypospadias is cosmetic, it is essential that function not be sacrificed to achieve this end. This study indicates that voiding function is maintained after hypospadias repair with meatoplasty and glanuloplasty. were from 2 to 15 years old, with the majority (33) being less than 5 years old. One surgeon (B. M. C.) performed the MAGPI repair in all cases after documentation (with photography) of the distal meatal position and absence of significant chordee (less than 15 degrees), using saline-simulated erections if indicated. Postoperatively, 30 patients had indwelling urethral catheters (usually a No. 8 feeding tube) for 48 to 72 hours and a 3-inch wide compressive dressing of elastic gauze. Usually, a 12-hour period of cooling with cotton gauze soaked with iced saline was used before catheter removal. The boys were discharged from the
Many surgeons have been reluctant in the past to offer reconstructive surgery for boys with anterior or first degree hypospadias. Correction was denied for a variety of reasons: the indication is purely cosmetic, the complication rate can be high, and many of the procedures described are technically demanding and require fine instrumentation. More recently, Duckett reported superb cosmetic results and a low complication rate with the revolutionary technique of meatoplasty and glanuloplasty (MAGPI).' Most important of all, his excellent original results have been reproduced by surgeons across the country. 2
B
BS· 0,92 rn2·1.42 m2 AGE GROUP: BY, 14Y
35
35
lr/ 19()%80%
35
1
30
30
~I°[ I l
50
+-'--,---,----,---r--~~~~~
O .
0
BO
®
®
D
B
D
B
a
VOLUME VOIDED (cc)
BO
®
®
D
B
D
B
100
150 200 250 300 VOLUME VOIDED (cc)
350
400
450
G
VOLUME VOIDED (cc)
FIG. 1. Grafhs of standard flow rate curves. A, body surface area less than 0.92 m. 2 in boys (36) 3 to 7 years old. B, body surface area from 0.92 to 1.42 m. in boys (7) 8 to 14 years old. C, body surface area greater than 1.42 m. 2 in patients (1) 15 to 21 years old.
However, the price of such cosmetic perfection in terms of functional aspects of the penis has not yet been determined. In this study we completed a detailed assessment of micturition in a large series of boys after MAG PI hypospadias repair in an effort to answer this question. MATERIALS AND METHODS
A total of 44 boys with anterior hypospadias presented to our hospital for treatment between 1979 and 1983. The patients Accepted for publication February 13, 1985. Read at annual meeting of American Urological Association, New Orleans, Louisiana, May 6-10, 1984. * Requests for reprints: Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada M5G 1X8. 100
hospital once they began voiding freely. Initial followup was 6 weeks postoperatively, at which time an objective assessment of the urinary stream was made. A flow rate was obtained using a D ISA* rotating disk uroflow machine, and a high speed picture of the stream was taken at the moment of peak flow using electronic video photography. Peak flow rate in cubic centimeters per second was compared to a series of standard flow rate curves prepared previously by our urodynamics laboratory. To establish the standard rates peak flow rates were plotted against voiding volume for more than 250 normal boys and confidence limits of 80, 90 and 95 per cent were established based on body surface area. In addition, the photographs of the urinary stream were compared to those taken of the normal boys. * Dantec Electronics, Denmark.
A3SESSiv1EI\fT OF URII'~ARY 3TREAtv1 AFTER REPAIR OF Ar'\TERIOR I-IYPOSPADIA.8 RESULTS
The cosmetic result was excellent in 43 cases. In the remain ing patient a small ventral flap was present at initial followup but it improved without further treatment and 1 year postoperatively the appearance was acceptable. Meatal stenosis, which was the only complication, developed in 2 patients, one of whom required a meatotomy, while the other responded to several urethral dilations. There were no urethral fistulas. The uroflow measurements were obtained in all 44 boys. Postoperative comparison with the normal values indicated that the flow rates were within the 95 per cent confidence limits of the standard curves in 42 boys and the 80 per cent confidence limits in 36 (fig. 1). In 25 boys flow rates obtained again between 6 months and 2 years postoperatively correlated well with the assessment at 6 weeks. Photographs of the urinary stream at the time of peak flow using high speed video photography were taken as a permanent record of the stream. In normal boys the stream consists of a series of symmetrical and evenly spaced drops in a single line with no turbulence or fanning. Of the 43 boys for whom postoperative photographs were taken 15 had the normal pattern (fig. 2). In 23 others a single straight stream was present but the
FIG. 2. Normal stream pattern. Drops are of equal size, evenly spaced and in straight line. Stream characteristics were enhanced artistically to facilitate reproduction.
101
pattern was laminar and fanning. A smooth stream fanned out from the meatus of these boys and the drop pattern formed out much further (fig. 3, A). The fanning pattern tended to occur in patients with a more proximal meatus who had required a large advancement and had a correspondingly larger meatus. The stream was functionally quite acceptable in these patients. A turbulent flow pattern was seen in 2 boys. Scattered irregular drops spread out from the meatus (fig. 3, B). One patient had excess ventral tissue and, possibly, the abnormal stream was related to prominence of glans tissue adjacent to the meatus. This stream was functionally poor. In 3 patients the stream pattern was stenotic, with fine, small irregular drops (fig. 3, C). Subsequently, 2 of these patients required treatment for meatal stenosis. The flow rate in these 2 cases also was below normal and in the remaining case it was in the borderline low-normal range. In summary, in the vast majority of the patients the photographs of the stream demonstrated a satisfactory if not entirely normal pattern and the uroflow measurements were normal. Abnormal uroflow studies often were the first indication of a problem with the repair in the few boys who did have a complication. DISCUSSION
Although a great variety of procedures have been devised to manage anterior hypospadias, the major controversy has related to the necessity for surgery at all. Functionally, these boys have a normal penis, although the meatus is not at the end of the glans. However, the appearance of the penis is distinctly abnormal and this alone causes significant parental concern. The parents of children with hypospadias are more anxious about the maleness of their child than about the proposed surgery. Questions about the ability to have normal sexual relations or children are asked frequently. The children themselves demonstrate considerable anxiety, particularly in the postoperative period when unusually aggressive behavior often is seen. 3 In adults there is some evidence that sexual and social development in the hypospadiac patient may be retarded slightly and that over-all sexual activity is lower than average. 4 Although it seems logical that there would be some adverse psychological effect of having an imperfect penis, many surgeons believe that this aspect has been over emphasized. 5 Be that as it may, parents are increasingly insistent that correction be performed. Interestingly enough, Duckett collected a series of 14 patients with anterior hypospadias whose fathers had the same problem left uncorrected.' Although none of the fathers was willing to undergo correction in adulthood, they all wished that they had been more normal while growing up and, therefore, wanted their sons to have the benefit of an early hypospadias repair. The MAG PI procedure is reserved for with a meatus in the distal location (that is glandular, coronal or subcoronal) without significant chordee. The advancement possible usually
I
B
-+---+-------)f----+-----+-+-
d
I
'
0
FIG. 3. A, laminar fa_nni?f!" pattern-;-smooth stream spreads out from meatus and drop pattern forms out much further. B, turbulent patternscattered drop J?attern 1s v!s.1ble startmg from meatus and fans out usually. C, stenotic pattern-drops are small. Stream characteristics were enhanced artistically to facilitate reproduction.
102
MACMILLAN, CHURCHILL AND GILMOUR
is limited to 1 cm. so that other procedures are necessary for more proximal hypospadias. A MAGPI also can be used as a final stage of multistaged hypospadias repairs to get the meatus out to the glans. The complication rate has been low in most series. Duckett's own experience of more than 200 MAG PI repairs demonstrated only 1 fistula and no other significant problems. 1 This compares dramatically with the 10 to 20 per cent fistula rate quoted for the Horton-Devine flip-flap procedure or the Ombredanne procedure.6 Meatal stenosis also is a significant problem with these repairs. Simpler procedures, such as the Allen-Spence repair or Belman's urethral advancement, have much lower complication rates but the cosmetic results are not as good as with the MAG PI or the more complex repairs. 7 Until recently, the price of perfection in the management of anterior hypospadias was significantly high. However, with the advent of the MAG PI repair, which virtually guarantees perfect cosmetic results and fully preserves micturitional function, all boys with distal hypospadias should be offered early surgical correction.
REFERENCES
1. Duckett, J. W.: MAGPI (meatoplasty and glanuloplasty): a procedure for subcoronal hypospadias. Urol. Clin. N. Amer., 8: 513, 1981. 2. Shapiro, S. R.: Complications of hypospadias repair. J. Urol., 131: 518, 1984. 3. Robertson, M. and Walker, D.: Psychological factors in hypospadias repair. J. Urol., 113: 698, 1975. 4. Berg, R., Svensson, J. and Astrom, G.: Social and sexual adjustment of men operated for hypospadias during childhood: a controlled study. J. Urol., 125: 313, 1981. 5. Williams, D. I.: Urology in Childhood. Berlin: Springer-Verlag, pp. 104-107, 1958. 6. Mills, C., McGovern, J., Mininberg, D., Coleman, J., Muecke, E. and Vaughan, E. D., Jr.: An analysis of different techniques for distal hypospadias repair: the price of perfection. J. Urol., 125: 701, 1981. 7. Allen, T. D. and Spence, H. M.: The surgical treatment of coronal hypospadias and related problems. J. Urol., 100: 504, 1968.