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The influence of perioperative factors on primary severe hypospadias repair

Nature Reviews Urology volume 8, pages 198–206 (2011)Cite this article

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Abstract

Hypospadias is one of the most common congenital malformations of the male genitalia. Severe cases present with associated curvature greater than 30° and the meatus opening proximally to the penoscrotal junction. The perioperative management of patients with primary severe hypospadias is variable. Systematic evaluation of the upper urinary tract and the search for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias, and should be limited to severe cases with associated extraurinary malformations. Detection of a disorder of sex development is key for gender assignment and prognosis, but the identification of cases warranting a full work-up and the influence of such a diagnosis on the success of hypospadias repair is controversial. Preoperative hormonal stimulation allows for penile growth irrespective of the administration route. Associated morbidity is minimal, but its influence on the success of surgery is still unknown. An age of 6–18 months is generally recommended for surgery, but no trial data support this policy. Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery, whereas postoperative antibiotic prophylaxis and type of dressing have minimal impact on surgical success. Overall, most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined. Clinicians should be made aware of the evidence supporting any single intervention in order to standardize their management policies. We hope the issues outlined here will prompt researchers to design new studies to address the clinically relevant questions.

Key Points

  • Systematic evaluation of the upper urinary tract and investigation for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias

  • Diagnosis of a disorder of sex development is key, but the identification of cases warranting a full work-up and the influence of diagnosis on the success of surgery are controversial

  • Preoperative hormonal stimulation allows for penile growth irrespective of the administration route; associated morbidity is minimal, but its influence on the success of surgery is still unknown

  • An age of 6–18 months is generally recommended for surgery, but no trial data support this policy

  • Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery

  • Postoperative antibiotic prophylaxis and type of dressing have minimal impact on the success of surgery

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Figure 1: Primary severe hypospadias in a 12-month-old boy.
Figure 2: Enlarged prostatic utricle.
Figure 3: Second-layer coverage of the urethroplasty.
Figure 4: Compressive dressing after hyposapdias repair.

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References

  1. Baskin, L. S. & Ebbers, M. B. Hypospadias: anatomy, etiology, and technique. J. Pediatr. Surg. 41, 463–472 (2006).

    PubMed  Google Scholar 

  2. Castagnetti, M. & El-Ghoneimi, A. Surgical management of primary severe hypospadias in children: systematic 20-year review. J. Urol. 184, 1469–1474 (2010).

    PubMed  Google Scholar 

  3. Valla, J. S. et al. Single-stage correction of posterior hypospadias (178 cases). Comparison of three techniques: free skin graft, free bladder mucosal graft, transverse pedicle preputial graft. Eur. J. Pediatr. Surg. 1, 287–290 (1991).

    Article  CAS  PubMed  Google Scholar 

  4. Flack, C. E. & Walker, R. D. 3rd. Onlay-tube-onlay urethroplasty technique in primary perineal hypospadias surgery. J. Urol. 154, 837–839 (1995).

    Article  CAS  PubMed  Google Scholar 

  5. Fossum, M., Svensson, J., Kratz, G. & Nordenskjöld, A. Autologous in vitro cultured urothelium in hypospadias repair. J. Pediatr. Urol. 3, 10–18 (2007).

    Article  CAS  PubMed  Google Scholar 

  6. Hayashi, Y. et al. Neo-modified Koyanagi technique for the single-stage repair of proximal hypospadias. J. Pediatr. Urol. 3, 239–242 (2007).

    Article  PubMed  Google Scholar 

  7. Kajbafzadeh, A. M. et al. Proximal hypospadias with severe chordee: single stage repair using corporeal tunica vaginalis free graft. J. Urol. 178, 1036–1042 (2007).

    Article  PubMed  Google Scholar 

  8. Manzoni, G. A. & El-Ghoneimi, A. Posterior hypospadias. Dial. Pediatr. Urol. 29, 1–11 (2008).

    Google Scholar 

  9. Cerasaro, T. S., Brock, W. A. & Kaplan, G. W. Upper urinary tract anomalies associated with congenital hypospadias: is screening necessary? J. Urol. 135, 537–538 (1986).

    Article  CAS  PubMed  Google Scholar 

  10. Davenport, M. & MacKinnon, A. E. The value of ultrasound screening of the upper urinary tract in hypospadias. Br. J. Urol. 62, 595–596 (1988).

    Article  CAS  PubMed  Google Scholar 

  11. Friedman, T. et al. Detection and incidence of anomalies associated with hypospadias. Pediatr. Nephrol. 23, 1809–1816 (2008).

    Article  PubMed  Google Scholar 

  12. Gupta, L., Sharma, S. & Gupta, D. K. Is there a need to do routine sonological, urodynamic study and cystourethroscopic evaluation of patients with simple hypospadias? Pediatr. Surg. Int. 26, 971–976 (2010).

    Article  PubMed  Google Scholar 

  13. Faundez, T., Chariatte, V. & Cachat, F. Urinary tract anomalies in children with hypospadias. Pediatr. Surg. Int. 26, 1237–1238 (2010).

    Article  PubMed  Google Scholar 

  14. Ciftci, A. O., Senocak, M. E., Büyükpamukçu, N. & Hiçsönmez, A. Abnormal prostatic utricle configuration in hypospadias and intersex patients. Eur. J. Pediatr. Surg. 9, 167–172 (1999).

    Article  CAS  PubMed  Google Scholar 

  15. Kojima, Y., Hayashi, Y., Maruyama, T., Sasaki, S. & Kohri, K. Comparison between ultrasonography and retrograde urethrography for detection of prostatic utricle associated with hypospadias. Urology 57, 1151–1155 (2001).

    Article  CAS  PubMed  Google Scholar 

  16. Chertin, B., Koulikov, D., Hadas-Halpern, I. & Farkas, A. Masculinizing genitoplasty in intersex patients. J. Urol. 174, 1683–1686 (2005).

    Article  CAS  PubMed  Google Scholar 

  17. Lee, P. A., Houk, C. P., Ahmed, S. F. & Hughes, I. A. Consensus statement on management of intersex disorders. International Consensus Conference on Intersex. Pediatrics 118, e488–e500 (2006).

    Article  PubMed  Google Scholar 

  18. Kaefer, M. et al. The incidence of intersexuality in children with cryptorchidism and hypospadias: stratification based on gonadal palpability and meatal position. J. Urol. 162, 1003–1006 (1999).

    Article  CAS  PubMed  Google Scholar 

  19. McAleer, I. M. & Kaplan, G. W. Is routine karyotyping necessary in the evaluation of hypospadias and cryptorchidism? J. Urol. 165, 2029–2031 (2001).

    Article  CAS  PubMed  Google Scholar 

  20. Cox, M. J., Coplen, D. E. & Austin, P. F. The incidence of disorders of sexual differentiation and chromosomal abnormalities of cryptorchidism and hypospadias stratified by meatal location. J. Urol. 180, 2649–2652 (2008).

    Article  PubMed  Google Scholar 

  21. Sircili, M. H. et al. Long-term surgical outcome of masculinizing genitoplasty in large cohort of patients with disorders of sex development. J. Urol. 184, 1122–1127 (2010).

    Article  PubMed  Google Scholar 

  22. Gupta, D., Bhardwaj, M., Sharma, S., Ammini, A. C. & Gupta, D. K. Long-term psychosocial adjustments, satisfaction related to gender and the family equations in disorders of sexual differentiation with male sex assignment. Pediatr. Surg. Int. 26, 955–958 (2010).

    Article  PubMed  Google Scholar 

  23. Bhat, A. Extended urethral mobilization in incised plate urethroplasty for severe hypospadias: a variation in technique to improve chordee correction. J. Urol. 178, 1031–1035 (2007).

    Article  PubMed  Google Scholar 

  24. Moursy, E. E. Outcome of proximal hypospadias repair using three different techniques. J. Pediatr. Urol. 6, 45–53 (2010).

    Article  PubMed  Google Scholar 

  25. Arena, F. et al. Surgical correction of penoscrotal transposition associated with hypospadias and bifid scrotum: our experience of two-stage repair. J. Pediatr. Urol. 1, 289–294 (2005).

    Article  CAS  PubMed  Google Scholar 

  26. Djordjevic, M. L. et al. Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias. Urology 71, 821–825 (2008).

    Article  PubMed  Google Scholar 

  27. Aoki, K., Fujimoto, K., Yoshida, K., Hirao, Y. & Ueoka, K. One-stage repair of severe hypospadias using modified tubularized transverse preputial island flap with V-incision suture. J. Pediatr. Urol. 4, 438–441 (2008).

    Article  PubMed  Google Scholar 

  28. Retik, A. B. et al. Management of severe hypospadias with a 2-stage repair. J. Urol. 152, 749–751 (1994).

    Article  CAS  PubMed  Google Scholar 

  29. Emir, H., Jayanthi, V. R., Nitahara, K. & Danismend, N. & Koff. S. A. Modification of the Koyanagi technique for the single stage repair of proximal hypospadias. J. Urol. 164, 973–975 (2000).

    Article  CAS  PubMed  Google Scholar 

  30. Barroso, U. Jr, Jednak, R., Spencer Barthold, J. & González, R. Further experience with the double onlay preputial flap for hypospadias repair. J. Urol. 164, 998–1001 (2000).

    Article  PubMed  Google Scholar 

  31. Gershbaum, M. D., Stock, J. A. & Hanna, M. K. A case for 2-stage repair of perineoscrotal hypospadias with severe chordee. J. Urol. 168, 1727–1728 (2002).

    Article  PubMed  Google Scholar 

  32. Snodgrass, W. & Yucel S. Tubularized incised plate for mid shaft and proximal hypospadias repair. J. Urol. 177, 698–702 (2007).

    Article  PubMed  Google Scholar 

  33. Braga, L. H. et al. Comparative analysis of tubularized incised plate versus onlay island flap urethroplasty for penoscrotal hypospadias. J. Urol. 178, 1451–1456 (2007).

    Article  PubMed  Google Scholar 

  34. Hadidi, A. T. Lateral-based flap: a single stage urethral reconstruction for proximal hypospadias. J. Pediatr. Surg. 44, 797–801 (2009).

    Article  PubMed  Google Scholar 

  35. Snodgrass, W. & Prieto, J. Straightening ventral curvature while preserving the urethral plate in proximal hypospadias repair. J. Urol. 182, 1720–1725 (2009).

    Article  PubMed  Google Scholar 

  36. Catti, M., Lottmann, H., Babloyan, S., Lortat-Jacob, S. & Mouriquand, P. Original Koyanagi urethroplasty versus modified Hayashi technique: outcome in 57 patients. J. Pediatr. Urol. 5, 300–306 (2009).

    Article  PubMed  Google Scholar 

  37. Sakakibara, N., Nonomura, K., Koyanagi, T. & Imanaka, K. Use of testosterone ointment before hypospadias repair. Urol. Int. 47, 40–43 (1991).

    Article  CAS  PubMed  Google Scholar 

  38. Koff, S. A. & Jayanthi, V. R. Preoperative treatment with human chorionic gonadotropin in infancy decreases the severity of proximal hypospadias and chordee. J. Urol. 162, 1435–1439 (1999).

    Article  CAS  PubMed  Google Scholar 

  39. Luo, C. C., Lin, J. N., Chiu, C. H. & Lo, F. S. Use of parenteral testosterone prior to hypospadias surgery. Pediatr. Surg. Int. 19, 82–84 (2003).

    Article  CAS  PubMed  Google Scholar 

  40. Chalapathi, G. et al. Testosterone therapy in microphallic hypospadias: topical or parenteral? J. Pediatr. Surg. 38, 221–223 (2003).

    Article  CAS  PubMed  Google Scholar 

  41. Nerli, R. B., Koura, A., Prabha, V. & Reddy, M. Comparison of topical versus parenteral testosterone in children with microphallic hypospadias. Pediatr. Surg. Int. 25, 57–59 (2009).

    Article  CAS  PubMed  Google Scholar 

  42. Ishii, T., Hayashi, M., Suwanai, A., Amano, N. & Hasegawa, T. The effect of intramuscular testosterone enanthate treatment on stretched penile length in prepubertal boys with hypospadias. Urology 76, 97–100 (2010).

    Article  PubMed  Google Scholar 

  43. Gorduza, D. B. et al. Does androgen stimulation prior to hypospadias surgery increase the rate of healing complications? A preliminary report. J. Pediatr. Urol. doi: 10.1016/j.jpurol.2010.05.003.

  44. Davits, R. J., van den Aker, E. S., Scholtmeijer, R. J., de Muinck Keizer-Schrama, S. M. & Nijman, R. J. Effect of parenteral testosterone therapy on penile development in boys with hypospadias. Br. J. Urol. 71, 593–595 (1993).

    Article  CAS  PubMed  Google Scholar 

  45. Kaya, C. et al. The efficacy of dihydrotestosterone transdermal gel before primary hypospadias surgery: a prospective, controlled, randomized study. J. Urol. 179, 684–688 (2008).

    Article  CAS  PubMed  Google Scholar 

  46. DeFoor, W. & Wacksman, J. Results of single staged hypospadias surgery to repair penoscrotal hypospadias with bifid scrotum or penoscrotal transposition. J. Urol. 170, 1585–1588 (2003).

    Article  PubMed  Google Scholar 

  47. Kuyumcuoglu, U., Eryildirim, B., Faydaci, G., Tarhan, F. & Ozgül, A. The comparison of belt-fuqua and “TIPU” techniques in proximal penile hypospadias cases: retrospective analysis of 65 cases. Int. Urol. Nephrol. 41, 755–759 (2009).

    Article  PubMed  Google Scholar 

  48. No authors listed. 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 97, 590–594 (1996).

  49. Alalami, A. A., Ayoub, C. M. & Baraka, A. S. Laryngospasm: review of different prevention and treatment modalities. Paediatr. Anaesth. 18, 281–288 (2008).

    Article  PubMed  Google Scholar 

  50. Hayashi, Y., Kojima, Y., Mizuno, K., Nakane, A. & Kohri, K. The modified Koyanagi repair for severe proximal hypospadias. BJU Int. 87, 235–238 (2001).

    Article  CAS  PubMed  Google Scholar 

  51. Hensle, T. W., Tennenbaum, S. Y., Reiley, E. A. & Pollard, J. Hypospadias repair in adults: adventures and misadventures. J. Urol. 165, 77–79 (2001).

    Article  CAS  PubMed  Google Scholar 

  52. Jones, B. C., O'Brien, M., Chase, J., Southwell, B. R. & Hutson, J. M. Early hypospadias surgery may lead to a better long-term psychosexual outcome. J. Urol. 182, 1744–1749 (2009).

    Article  PubMed  Google Scholar 

  53. Weber, D. M., Schonbucher, V. B., Gobet, R., Gerber, A. & Landolt, M. A. Is there an ideal age for hypospadias repair? A pilot study. J. Pediatr. Urol. 5, 345–350 (2009).

    Article  CAS  PubMed  Google Scholar 

  54. Hayashi, Y. et al. Scrotal dartos flap for the prevention of the urethrocutaneous fistula on hypospadias urethroplasty. Int. J. Urol. 12, 280–283 (2005).

    Article  PubMed  Google Scholar 

  55. Telfer, J. R., Quaba, A. A., Kwai Ben, I. & Peddi, N. C. An investigation into the role of waterproofing in a two-stage hypospadias repair. Br. J. Plast. Surg. 51, 542–546 (1998).

    Article  CAS  PubMed  Google Scholar 

  56. Chuang, J. H. & Shieh, C. S. Two-layer versus one-layer closure in transverse island flap repair of posterior hypospadias. J. Pediatr. Surg. 30, 739–742 (1995).

    Article  CAS  PubMed  Google Scholar 

  57. Gopal, S. C. et al. Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair. J. Pediatr. Surg. 43, 1869–1872 (2008).

    Article  PubMed  Google Scholar 

  58. Savanelli, A., Esposito, C. & Settimi, A. A prospective randomized comparative study on the use of ventral subcutaneous flap to prevent fistulas in the Snodgrass repair for distal hypospadias. World J. Urol. 25, 641–645 (2007).

    Article  PubMed  Google Scholar 

  59. Demirbilek, S., Kanmaz, T., Aydin, G. & Yücesan, S. Outcomes of one-stage techniques for proximal hypospadias repair. Urology 58, 267–270 (2001).

    Article  CAS  PubMed  Google Scholar 

  60. Sugita, Y., Tanikaze, S., Yoshino, K. & Yamamichi, F. Severe hypospadias repair with meatal based paracoronal skin flap: the modified Koyanagi repair. J. Urol. 166, 1051–1053 (2001).

    Article  CAS  PubMed  Google Scholar 

  61. Sugar, E. C. & Firlit, C. F. Urinary prophylaxis and postoperative care of children at home with an indwelling catheter after hypospadias repair. Urology 32, 418–420 (1988).

    Article  CAS  PubMed  Google Scholar 

  62. Montagnino, B. A., Gonzales, E. T. Jr & Roth, D. R. Open catheter drainage after urethral surgery. J. Urol. 140, 1250–1252 (1988).

    Article  CAS  PubMed  Google Scholar 

  63. Ben Meir, D. & Livne, P. M. Is prophylactic antimicrobial treatment necessary after hypospadias repair? J. Urol. 171, 2621–2622 (2004).

    Article  Google Scholar 

  64. Demirbilek, S. & Atayurt, H. F. One-stage hypospadias repair with stent or suprapubic diversion: which is better? J. Pediatr. Surg. 32, 1711–1712 (1997).

    Article  CAS  PubMed  Google Scholar 

  65. Cilento, B. G. Jr, Stock, J. A. & Kaplan, G. W. Pantaloon spica cast: an effective method for postoperative immobilization after free graft hypospadias repair. J. Urol. 157, 1882–1883 (1997).

    Article  PubMed  Google Scholar 

  66. McLorie, G. et al. A prospective randomized clinical trial to evaluate methods of postoperative care of hypospadias. J. Urol. 165, 1669–1672 (2001).

    Article  CAS  PubMed  Google Scholar 

  67. Van Savage, J. G., Palanca, L. G. & Slaughenhoupt, B. L. A prospective randomized trial of dressings versus no dressings for hypospadias repair. J. Urol. 164, 981–983 (2000).

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Oncological and Surgical Sciences, Section of Pediatric Urology, Urology Unit, University Hospital of Padova, Monoblocco Ospedaliero, Via Giustiniani 2, 35128, Padua, Italy

    Marco Castagnetti

  2. Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, University of Paris VII, René Diderot, 48 Boulevard Serurier, 75019, Paris, France

    Alaa El-Ghoneimi

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M. Castagnetti and A. El-Ghoneimi contributed equally to the researching of data, discussion of content, writing the article and reviewing the manuscript before submission

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Correspondence to Marco Castagnetti.

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Castagnetti, M., El-Ghoneimi, A. The influence of perioperative factors on primary severe hypospadias repair. Nat Rev Urol 8, 198–206 (2011). https://doi.org/10.1038/nrurol.2011.24

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