Abstract
Objective:
The functional outcome following hypospadias repair is as important as the cosmetic outcome. Currently, structured scoring systems, patient questionnaires and evaluations of photographs and uroflowmetry are used to assess the results of hypospadias repair. In the present study, we assessed the outcomes of two-stage hypospadias repair using Hypospadias Objective Scoring Evaluation-HOSE and measures of uroflowmetry.
Material and methods:
Over a period of eight years, from January 1997 to December 2004, 126 hypospadias patients were treated, 90 of these patients received two-stage repairs and 36 patients received single-stage repairs. HOSE questionnaire and uroflowmetry data were obtained to evaluate the long-term outcome of the two-stage hypospadias repairs.
Results:
The age at the time of assessment ranged from 8 to 23 years-old, with a mean follow-up time of 39.78 months. Thirty-five patients had proximal hypospadias, and 20 had distal hypospadias. Of the 55 patients who received complete two-stage hypospadias repair and agreed to participate in the study, nineteen patients had acceptable HOSE scores and 36 patients had non-acceptable scores. The uroflow rates of 43 of the subjects were below the fifth percentile in three patients, equivocal (between the 5th and 25th percentile) in four patients and above the 25th percentile in 36 patients.
Conclusion:
Two-stage repair is a suitable technique for all types of hypospadias with varying outcomes. HOSE and uroflowmetry are simple, easy, non-invasive and non-expensive tools for objectively assessing the long-term outcomes of hypospadias repair.
Keywords: Objective assessment of hypospadias repair, two-stage hypospadias repair
Introduction
Hypospadias is a common congenital anomaly affecting the penis that, either treated or untreated, can have functional, cosmetic and psychosexual consequences extending into adulthood.[1,2]
The techniques of hypospadias repair have been changing in recent years. Two-stage repair is now widely used for hypospadias repair, but excellent outcomes from single-stage repair have been recently reported.[3]
The assessment of the results of hypospadias repair remains problematic, as published studies have shown that a significant differences might exist between the judgment of patients and operating surgeons.[4]
Classically, the outcomes of hypospadias repair have been assessed by reoperation rate secondary to fistula, stenosis, diverticulum and residual penile curvature.[5]
Several attempts have been made to objectively assess outcomes using structured scoring systems (Hypospadias Objective Scoring Evaluation-HOSE and Pediatric Penile Perception Scoring-PPPS), patient questionnaires, photographic evaluation and uroflowmetry to assess voiding.[5–8]
In this study, we assessed the outcomes of two-stage hypospadias repair using the Hypospadias Objective Scoring Evaluation (HOSE) system and uroflowmetry. The HOSE is underused, although the use of such a system is recommended by others.[6,9,10]
The HOSE is a validated scoring system that incorporates the evaluation of meatal location and shape, urinary stream, straightness of erection, presence and complexity of urethral fistula.[6]
The minimum total score is 5, and the maximum total score is 16. The point score is graded as either acceptable or not. In the present study, a score of 14 to 16 was considered acceptable, and score a below 14 was considered not acceptable.
Material and methods
Over a period of eight years, from January 1997 to December 2004, a total of 126 referred patients underwent hypospadias repair in our surgical department. Ninety of them received two-stage repair, and 36 received single-stage repair.
After obtaining approval from the ethical committee of our university, either a phone call or an invitation letter was sent to 76 patients (84.4%) who had a completed two-stage hypospadias repair and whose medical records contained relevant data needed for the study. However, only 55 children and their parents agreed to give their consent for participation in the study. Table 1a, b lists the demographic data of the subjects, including race, age at time of study, age when first seen in the specialized clinic, type of hypospadias, associated anomalies and operative notes.
Table 1a.
Patient characteristics
| Characteristics | Number/Mean | SD/% |
|---|---|---|
| Race | ||
| Malay | 53 | 96.4 |
| Chinese | 1 | 1.8 |
| Siamese | z1 | 1.8 |
| Age | ||
| At the time of the study | 14.89 years (8–23 years-old) | 3.936 |
| When first seen | 9.165 years (1 month–17 years-old) | 4.512 |
| Type of hypospadias | ||
| Distal hypospadias | 20 | 36.4 |
| Glanular | 1 | 1.8 |
| Subcoronal | 7 | 12.7 |
| Distal penile | 12 | 21.8 |
| Proximal hypospadias | 35 | 63.6 |
| Proximal penile | 12 | 21.8 |
| Penoscrotal | 23 | 41.8 |
| Previous unsuccessful repair or circumcision before correction | ||
| Unsuccessful repair | 3 | 5.5 |
| Circumcised | 4 | 7.3 |
| Total associated anomalies | 10 | 18.2 |
| Undescended testis | 3 | 5.4 |
| Retractile testis | 1 | 1.8 |
| Bifid scrotum | 2 | 3.6 |
| Inguinal hernia | 3 | 5.4 |
| Hydrocele | 1 | 1.8 |
Table 1b.
Operative data
| Data | Number/Mean (n=55) | %/SD |
|---|---|---|
| Operative technique | ||
| Bracka’s | 37 | 67.3 |
| Byars’ | 18 | 32.7 |
| Post-operative urinary catheter | ||
| Continuous bladder drainage | 37 | 67.3 |
| Suprapubic catheter/urethral stent | 18 | 32.7 |
| Length of urethral catheter/stent | ||
| First-stage | 5.75 (4–10 days) | 1.336 |
| Second-stage | 6.15 (3–9 days) | 1.508 |
| Length of hospital stay | ||
| First-stage | 7.25 (5–29 days) | 3.351 |
| Second-stage | 7.93 (4–18 days) | 2.300 |
| Age at time of repair | ||
| First-stage | 10.15 years (3–17 years-old) | 3.768 |
| Second-stage | 11.36 years (4–18 years-old) | 3.776 |
| Duration of time bet. first and second-stage | 14.55 months (7–29 months) | 4.682 |
| Redo (revision) surgery | ||
| Re-do first and second-stage Bracka’s repair (penoscrotal, wound breakdown with fistula) | 1 | 1.8 |
| Revision surgery (wide meatal opening at coronal) | 1 | 1.8 |
| Post-operative follow-up | 39.78 months (8–80 months) | 19.057 |
Upon arrival at the outpatient clinic, each patient was supplied with a copious amount of diluted juice. At the same time, the patient and/or parents were interviewed, and at this stage, the subjects were examined based on the HOSE questionnaire (Table 2).
Table 2.
HOSE: Hypospadias objective scoring evaluation
| 1 | Meatal location | Score |
| 1.1 | Distal glanular | 4 |
| 1.2 | Proximal glanular | 3 |
| 1.3 | Coronal | 2 |
| 1.4 | Penile shaft | 1 |
| 2 | Meatal shape | |
| 2.1 | Vertical slit | 2 |
| 2.2 | Circular | 1 |
| 3 | Urinary stream | |
| 3.1 | Single stream | 2 |
| 3.2 | Spray | 1 |
| 4 | Erection | |
| 4.1 | Straight | 4 |
| 4.2 | Mild angulation (<10) | 3 |
| 4.3 | Moderate angulation (>10 but <45) | 2 |
| 4.4 | Severe angulation (>45) | 1 |
| 5 | Fistula | |
| 5.1 | None | 4 |
| 5.2 | Single-subcoronal | 3 |
| 5.3 | Proximal-subcoronal | 2 |
| 5.4 | Multiple or complex | 1 |
| Total score | /16 |
After an appropriate time, the patients (who did not have fistula and could void voluntary) were asked to perform uroflowmetry in private (Urocap-11TM) (Laborie medical technologie corp, Mississauga, Ontario L4V 1X1 Canada).
The parameters measured were the peak flow, voiding time, flow time, time to peak flow and voided volume. The peak flow (Q-max) and voided volume (vv) results were expressed as percentiles and interpreted according to a Kajbafzadeh nomogram (Figure 1).[11]
Figure 1.
Uroflowmetry nomogram for maximum urine flow rates in boys (7–14)
Q-max and voided volume were considered to be normal if they were >25th percentile, equivocal if they were between the 5–25th percentile range and obstructed if they were <5th percentile.
Results
Fifty-three Malay patients, one Chinese patient and one Siamese patient with different types of hypospadias underwent 37 Bracka’s and 18 Byars’ procedures that were performed by three surgeons in a similar manner to the original descriptions. The mean follow-up period was 39.78 months (range of 8–80 months).[12,13]
The mean age at the first repair stage was 10.12 years (range 3–17 years-old) and at the second stage was 11.36 years (range 4–18 year-old). The age at time of assessment ranged from 8 to 23 years-old.
The mean of the duration between the first and second repair stage was 14.55 months (range 7–29) months. Thirty-five patients had proximal hypospadias, and 20 patients had distal hypospadias.
Of the 55 patients who received complete two-stage hypospadias repair, 13 had single urethrocutaneous fistula, 4 had multiple urethrocutaneous fistula, two patients had meatal stenosis, one patient had urethral stricture and one patient had wide meatal opening.
The HOSE outcome data were obtained for all subjects (55), and 19 patients had an acceptable score and 36 had a non-acceptable score (Table 3). The uroflow rates were obtained for 43 subjects (78.2%) who either did not have primary fistula (38) or underwent successful fistula repair (6) and could void volitionally.
Table 3.
Outcome of hypospadias repair according to HOSE
| HOSE variable | (HOSE) Score | Number of patients (%) (n=55) |
|---|---|---|
| Meatal location | ||
| Tip of glans | 4 | 17 (30.9) |
| Proximal glans | 3 | 16 (29.1) |
| Coronal | 2 | 20 (36.4) |
| Penile shaft | 1 | 2 (3.6) |
| Meatal shape | ||
| Vertical slit | 2 | 12 (21.8) |
| Circular | 1 | 43 (78.2) |
| Urinary stream | ||
| Single stream | 2 | 55 (90.9) |
| Spray | 1 | 5 (9.1) |
| Erection | ||
| Straight | 4 | 20 (36.4) |
| Mild angulation | 3 | 29 (52.7) |
| Moderate angulation | 2 | 6 (10.9) |
| Severe angulation | 1 | 0 (0) |
| Fistula | ||
| None | 4 | 44* (80) |
| Single proximal | 3 | 2 (3.6) |
| Single distal | 2 | 8 (14.5) |
| Multiple or complex | 1 | 1 (1.8) |
Thirty-eight patients had no primary fistula, and 6 patients had successful fistula repair.
However, there was one 8-year-old patient who did not have any fistula but was not able to volitionally void.
Table 4a, b lists the characteristics of the uroflowmetry patterns in patients with distal and proximal hypospadias who completed two-stage repair. Three patients (7%) presented an obstructed pattern, 4 patients (9.3%) were equivocal and 36 patients (83.7%) were considered normal.
Table 4a.
Characteristics of the uroflowmetry pattern in patients with distal hypospadias who completed two-stage repair (15 patients)
| Patients | Age (year) | Voided volume (mL) | Q-max (mL/s) | Percentile (result) |
|---|---|---|---|---|
| 1 | 15 | 217 | 19 | >25 |
| 2 | 18 | 248 | 21 | >25 |
| 3 | 15 | 182 | 18 | >25 |
| 4 | 10 | 119 | 11 | >25 |
| 5 | 18 | 304 | 16 | 10–25(E) |
| 6 | 15 | 219 | 21 | >25 |
| 7 | 21 | 414 | 16 | >25 |
| 8 | 19 | 327 | 25 | >25 |
| 9 | 19 | 188 | 6 | <5(O) |
| 10 | 19 | 272 | 17 | >25 |
| 11 | 14 | 167 | 17 | >25 |
| 12 | 14 | 185 | 18 | >25 |
| 13 | 22 | 278 | 9 | <5(O) |
| 14 | 12 | 130 | 14 | >25 |
| 15 | 12 | 118 | 11 | >25 |
N.B. (a) >25th percentile, normal flow; 5–25th percentile, equivocal obstruction (E); <5th percentile, obstructed flow (O)
Table 4b.
Characteristics of the uroflowmetry pattern in patients with proximal hypospadias who completed two-stage repair (28 patients)
| Patients | Age (year) | Voided volume (mL) | Q-max (mL/s) | Percentile (result) |
|---|---|---|---|---|
| 1 | 15 | 192 | 19 | >25 |
| 2 | 9 | 97 | 13 | >25 |
| 3 | 8 | 82 | 11 | >25 |
| 4 | 17 | 215 | 15 | 5–25(E) |
| 5 | 9 | 106 | 12 | >25 |
| 6 | 16 | 184 | 18 | >25 |
| 7 | 16 | 225 | 14 | 5–25(E) |
| 8 | 11 | 113 | 12 | >25 |
| 9 | 9 | 94 | 11 | >25 |
| 10 | 18 | 164 | 26 | >25 |
| 11 | 11 | 106 | 12 | >25 |
| 12 | 15 | 174 | 16 | >25 |
| 13 | 18 | 236 | 20 | >25 |
| 14 | 15 | 213 | 27 | >25 |
| 15 | 15 | 186 | 17 | >25 |
| 16 | 18 | 176 | 18 | >25 |
| 17 | 9 | 98 | 12 | >25 |
| 18 | 22 | 156 | 23 | >25 |
| 19 | 23 | 179 | 7 | <5(O) |
| 20 | 17 | 259 | 30 | >25 |
| 21 | 10 | 116 | 11 | >25 |
| 22 | 14 | 131 | 15 | >25 |
| 23 | 16 | 256 | 21 | >25 |
| 24 | 13 | 164 | 15 | >25 |
| 25 | 10 | 101 | 12 | >25 |
| 26 | 12 | 133 | 11 | 5–25(E) |
| 27 | 10 | 89 | 10 | >25 |
| 28 | 10 | 114 | 13 | >25 |
N.B.(a). >25th percentile, normal flow; 5–25th percentile, equivocal obstruction (E); <5th percentile; obstructed flow (O)
Of the obstructed patients, one had urethral stricture and two had meatal stenosis. Those with equivocal uroflowmetry required further workup to clarify the cause.
Discussion
Over the last decade, there has been an increasing incidence of hypospadias worldwide, demanding an accompanying increase in hypospadias surgery. Generally, Bracka’s and Byars’ operations are the most common operations performed in our departments, as both operations can be used to treat all types of hypospadias, from subcoronal to penoscrotal. This view is supported by other reports in the literature.[14,15]
Currently, the repairs are performed during the first year of life, although some clinicians have advised an assessment throughout puberty, as pubertal growth can change the final cosmetic and functional aspect of the corrected penis.[16]
In this retrospective study, the majority of our patients presented between 10 and 15 years-old, which is in agreement with other local studies where the age of the patient when first seen ranged from immediately post-birth to 26 years.[15] Thus, the age at surgery mostly depended on the age when the patient was first seen at the surgical outpatient clinic. If the patients were referred early, the first-stage repair was performed at an age of 3 to 4 years, when the patients were toilet trained, not wearing diapers and the phallus was of acceptable size to make the surgery more feasible. This surgical pattern is in the agreement with the findings of Arshad.[15]
The second-stage repair was usually performed after 6–12 months. Thus, the patients completed two-stage repair and any subsequent surgery before they were of school age. The published data indicate there are more than 300 surgical techniques to correct hypospadias. As a result, there are various outcome measures. The HOSE questionnaire is a validated, objective outcome assessment with a very low inter-observer error and good inter-observer correlation. Nineteen (34.5%) of our subjects had an acceptable HOSE outcome with a total score of 14 to 16, and 36 patients (65.5%) had an unacceptable outcome with a total score of thirteen or below. It is difficult to compare our HOSE scores with others, as the majority of published studies that have used this method to assess the outcome of anterior hypospadias repair.
The meatal location, shape and fistula are easy to objectively assess, but the main drawback of the HOSE in our study arose in relation to the necessity of objective evaluation of the straightness of the penis and urinary stream. Witnessing a child or adult voiding or inducing erection is beyond normal Asian cultural norms, especially in Malaysia. However, Holland et al.[6] stated that erection can be gauged after an erection is witnessed by an assessor or can be based on parental evaluation.
There are few studies that have investigated the micturition of repaired urethral, and those few have not generally studied micturition after straightforward distal hypospadias repair.[17] Urethral stricture is a well-recognized complication of urethral reconstruction with unknown long-term consequences of asymptomatic stenosis after hypospadias repair.[18]
The measures available to assess the reconstructed urethra include direct observation of the urinary stream, voiding cystourethrogram and uroflowmetry.[19]
Rynja et al.[16] demonstrated that there was a discrepancy between the subjective and objective parameters of urinary function, both in hypospadias patients and in controls. The average flow rate and Q max in hypospadias patients need to be interpreted using a nomogram, as these parameters increase with the age of patient and volume of the bladder.[11]
Hypospadias surgery remains a demanding procedure. There are many factors that may influence the outcome of hypospadias repair, including the type of hypospadias, age at repair, duration of time between first and second stage, repair technique and personal experiences. These varying factors produce cumulative success rates ranging from 37% to 77%, with the rate rising to higher than 95% after the addition of a third repair stage.[20,21]
The reported overall complication rate from hypospadias surgery is ranges between 5–40%. The complications include wound infection, hematuria, penile skin blister, and suprapubic catheter, all of which are minor and can be treated conservatively. Furthermore, fistula, meatal stenosis, wide meatal opening and urethral stricture have also been observed.[21,22]
Overall 19 (34.5%) of our subjects had an acceptable HOSE score; 36 patients (83.7%) of our patients had a Q max more than the 25th percentile on a Kajbafzadeh nomogram, and three patients had a Q max below the 5th percentile (one case of urethral stricture and two cases of meatal stenosis). Our disappointing overall results and the small non-randomized sample size most likely reflect the learning curve associated with the severe type of hypospadias seen in our patients.
In conclusion, two-stage hypospadias repair is a suitable technique for all types of hypospadias and produces a variety of outcomes. HOSE and uroflowmetry are simple, non-invasive, non-expensive and easy methods to objectively assess the long-term outcomes of hypospadias repair.
Footnotes
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - N.S.H., S.B.A.S.; Design - N.S.H.; Supervision - M.N.G.; Materials - N.S.H., S.B.A.S., M.A., M.N.G.; Data Collection and/or Processing - N.S.H., S.B.A.S.; Analysis and/or Interpretation - N.S.H., S.B.A.S., M.A., M.N.G.; Literature Review - N.S.H., S.B.A.S.; Writer - N.S.H.; Critical Review - N.S.H., M.N.G.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
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