The goals of primary hypospadias repair include straightening the curvature of the penis, extending the meatus to the glans tip, and revising the abnormal prepuce by either circumcision or foreskin reconstruction to allow satisfactory cosmetic and functional results regarding urination and sexual function 1.
Modern approach in hypospadias repair is to preserve the urethral plate if possible 2. Given the relative simplicity of the operative concept for Snodgrass repair, low complication rate, and good cosmetic results in distal hypospadias, the tubularized incised plate procedure has been progressively applied to more proximal defects 3,4.
Although Snodgrass believes in the preservation of the plate as far as possible, he acknowledged that the urethral plate cannot be preserved in all cases of severe or proximal hypospadias 5,6.
The aim of the current study was to compare the final outcome for repair of severe hypospadias with moderate chordee using single-stage Snodgrass repair versus two-stage repair with dermal graft corporoplasty and to measure the degree of parent’s satisfaction for both procedures.
Patients and methods
A retrospective file review (after hospital administration approval) was performed for all cases of severe hypospadias during the period from February 2006 to February 2013 operated by a single surgeon.
Cases of severe hypospadias were defined as cases with proximal penile, penoscrotal, and scrotal. Moderate degree of chordee was defined as a chordee between 30 and 50° 7,8.
Exclusion criteria included cases with chordee more than 50°, perineal hypospadias, and cases in whom the chordee was corrected by division of the urethral plate.
The following data were collected: type of surgery, type of hypospadias, age at surgery, degree of chordee, postoperative complications, the duration to finish all the surgical procedures (including the surgical repair for postoperative complications), follow-up period, and parents’ satisfaction.
The data were analyzed and statistical significance was calculated using SPSS 17 (SPSS Inc., released 2008. SPSS Statistics for Windows, Version 17.0, Chicago, USA). The χ2-test and the t-test were used to test for statistical significant differences between the groups, and P value less than 0.05 was considered as statistically significant difference.
Parents’ satisfaction was measured using the answers to the degree of satisfaction for the final surgical outcome and cosmetic appearance, through a telephone call conducted by a social worker who was blinded to the performed surgical procedure. Excellent, very good, good, and poor were the answers given to the parents to choose from.
Dermal graft corporoplasty was used for the two-stage repair for chordee correction. The graft was harvested from the nonhairy inguinal skin area.
The first-stage surgical technique: After complete degloving of the penis, release of all the tethering tissues around the urethral plate was performed. Artificial erection was performed to measure the degree of residual chordee. If the chordee degree was between 30 and 50°, the urethral plate was divided at the maximum chordee angle and the urethral plate was separated proximally and distally from the corpus cavernosum.
Artificial erection was reperformed, if the chordee was less than 30°; a tabularized preputial flap was harvested from the inner surface of the prepuce to bridge the defect of the urethral plate; and the original urethral plate was tabularized proximally and distally then anastomosed to the preputial tube flap (those cases were excluded from the study).
If the degree of chordee was between 30 and 50° after urethral plate division, the tunica albuginea of the corpus cavernosum was excised at the angle of maximum curvature, taking great care not to injure the central corpus cavernosum artery, to achieve a straight penis. The defect of the corpus cavernosum was measured and the same size of the defect was replaced with a diamond-shape dermal graft.
The dermal graft was de-epithelialized completely then sutured in a water-tight continuous sutures manner, to the edges of the tunica albuginea, then artificial erection was performed to ensure absence of leak.
The preputial skin was incised as a Bayer’s flap; the inner layer of the prepuce was excised; and the outer preputial skin was moved ventrally to be sutured to the midline over the dermal graft and to the edges of the urethral plate. No extra skin was excised at this stage.
A Foley catheter was left in the meatus for 5 days and a compressive circular dressing was applied for the penis postoperatively.
The second-stage surgical technique: It was performed after 6–9 months from the first stage. An 8 mm width of the urethral plate was fashioned. Tubularization of the urethral plate was performed around 8-Fr urethral stent with 7/0 polyglactin two layers interrupted sutures; local flaps were created from the surrounding penile tissue to cover the sutures line of urethroplasty. The suprapubic midline fat deficiency was repaired by approximating the lateral suprapubic fat together in the midline. A suprapubic catheter was used for 12 days and the urethral stent was kept for 10 days postoperatively (Figs 1a–e and 2).
Tubularized incised plate Snodgrass urethroplasty was used for all cases of single-stage repair. The chordee was corrected using Nesbit’s dorsal plication procedure.
Urethral stent was inserted for 7 days postoperatively.
For single-stage repair, the degree of chordee was measured after complete degloving of the penile skin, excision of the fibrous tissues around the urethral plate, and mobilization of the splayed corpus spongiosum.
Preoperatively, parents were fully explained the pros and cons of both procedures; parent’s informed consent was obtained for both procedures in all cases. Selection of the type of the procedure was performed in a random manner (a group of parents preferred to perform a single stage if possible for social reasons; other groups of parents preferred to get the best cosmetic results).
All cases received a single preoperative dose of amoxicillin/clavulanic acid and continued postoperatively as well as enema on the night of surgery. Oxybutynin (2.5 mg) twice daily was given postoperatively until the stent was removed.
Follow-up visits included calibration of the urethra at 2 weeks, 1 month, 2 months, and 3 months postoperatively, then every 3 months for 1 year to exclude any urethral or meatal stenosis.
During the study period, 52 patients were operated for severe hypospadias and 39 patients were found to have a moderate degree of chordee, and their data were included in the study.
The mean age at surgery for single-stage repair was 18 months versus 21 months for the two-stage group; the type of surgery and the mean degree of chordee are shown in Table 1.
The duration for completion of all the surgical procedures was 10 and 18 months in the single-stage and two-stage groups, respectively (Table 2).
In all, 87 and 83% of the parents in single-stage versus two-stage repair, respectively, were accessible for a telephone questionnaire for the degree of satisfaction (Table 3).
Follow-up period for both procedures ranged from 15 to 36 months.
There is some reluctance to use dermal grafts for augmenting the tunica albuginea to correct severe forms of chordee. The main concern is that, by violating the integrity of the tunica albuginea, venous leakage could presumably ensue and result in erectile dysfunction 9.
In 1983, Kogan et al. 10 and in 1998 Lindgren et al.11 suggested an interpositional dermal grafting in patients with persisting severe chordee of ∼30° or more after conventional techniques, especially when the penis was short. The results of this technique were satisfactory without postoperative erectile dysfunctions.
Caesar and Caldamone 12 and Gershbaum et al.13 reported better results for dermal graft than tunica vaginalis graft for chordee correction with severe hypospadias.
There were no statistically significant differences in the mean age at surgery, degree of chordee, and type of hypospadias between single-stage versus two-stage repair.
There was statistically significant less time for the single-stage repair compared with the two-stage repair for the duration required to finish all the surgical procedures.
Incidence of postoperative urethral fistula was 27 versus 12.5% for single-stage and two-stage repair, respectively. The higher incidence of fistula in the single-stage repair may be attributed to the aggressive dissection around the urethral plate to release the chordee as much as possible, which is not required in the two-stage repair.
Meatal stenosis was not encountered in the two-stage repair versus 13% in single-stage repair. There was one case (7%) of complete repair dehiscence in the single-stage repair, which was due to trauma on the third postoperative day.
There was statistically significant less incidence of total postoperative complications in the two-stage versus single-stage repair.
Ozturk et al.14 reviewed their 15-year experience with one-stage repairs and have come to a similar conclusion that severe chordee and proximal hypospadias are associated with higher complication rates.
Snodgrass and Lorenzo 15 reported 33 patients who had severe hypospadias in which they were operated using his technique with dorsal plication. He reported an incidence of 21% fistula, 6% complete repair dehiscence, and 3% meatal stenosis with a total complication rate of 33%.
Parents’ degree of satisfaction posthypospadias repair is very rarely highlighted in the pediatric surgery literatures, although it is a very good landmark for the cosmetic appearance of the procedure used from the parents’ point of view. Pope et al.16 showed an excellent parents’ satisfaction with the use of dermal graft to correct the chordee in severe hypospadias. Snodgrass et al.17 used a standardized questionnaire to parents and operating surgeon to determine their opinion regarding outcomes from tubularized incised plate hypospadias repair.
Telephone questionnaire for parents’ satisfaction for both types of repair was conducted after completing all the surgical procedures including postoperative complications.
There were statistically significantly more parents’ satisfaction for the two-stage versus single-stage repair. This result of parents’ satisfaction indicates that the main concern for parents of hypospadias children is the cosmetic appearance regardless of the time required to reach this target.
The current study was a retrospective experience with no standardized patient selection, with small number of patients, and the questionnaire used for parents’ satisfaction is not a validated questionnaire. For the above drawbacks of the study, giving the small numbers of this type of hypospadias, a prospective multi-institutional study should be conducted in the future. A validated questionnaire to measure the parents’/patient satisfaction and the patients’ quality of life, especially after puberty, should be a scope of future studies.
Repair of severe hypospadias with moderate chordee using two-stage dermal graft corporoplasty was associated with statistically significant less postoperative complications and more parent’s satisfaction than single-stage Snodgrass urethroplasty repair in our current study.
Conflicts of interest
There are no conflicts of interest.
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