MANAGEMENT OF DISTAL PENILE HYPOSPADIAS BY TUBULARIZED INCISED PLATE URETHROPLASTY- STUDY OF 30 CASES

1. Professor of Surgery, Central Medical College, Comilla. 2. Professor of Urology, Comilla Medical College, Comilla. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 30 June 2020 Final Accepted: 31 July 2020 Published: August 2020 Hypospadias is the result of failure of fusion of the urethral folds on the ventral aspect of the penis.It usually occur 1 in every 300 male children.Reconstruction of urethra in childhood is the only hope of cure. The aim of this study is to find out the outcome of tubularized incised plate urethroplasty for distal penile hypospadias and to show that this procedure will be end up in a better cosmetic appearance. This prospective study was conducted in Central Medical College Hospital, Comilla between July 2018 to June 2020 on 30 patients using Snodgrass technique of hypospadias surgery. All cases were consecutively selected. Data were processed and analysed using software SPSS (Statistical Package for social Sciences) version 11.5 and the test statistics used to analyse the data were descriptive statistics and Z-test for proportion. The variables studied were age, socioeconomic condition, post-operative complications, such as infection rate, urethrocutaneous fistula, meatal stenosis, wound dehiscence etc. & cosmatic outcome such as size of the meatus, shape of the glans studied.Satisfactory results were obtained in 21 (70%) patients and only 8 (26.67%) had urethrocutaneous fistula, 1(3.33%) had retrusive meatus and 7 (23.33%) had wound infection. The final outcome was evaluated based on urethrocutaneous fistula and cosmesis. Out of 30 patients, 21(70%) did not have urtethrocutaneous fistula and were cosmetically acceptable. Binomial test based on Z-approximation reveals that observed proportion of patients with satisfactory outcome was statistically significant (p = 0.05). This study concludes that Snodgrass urethroplasty has better cosmetic outcome. Thus we recommended it as the primary treatment for the children with distal hypospadias.

Hypospadias is the result of failure of fusion of the urethral folds on the ventral aspect of the penis.It usually occur 1 in every 300 male children.Reconstruction of urethra in childhood is the only hope of cure. The aim of this study is to find out the outcome of tubularized incised plate urethroplasty for distal penile hypospadias and to show that this procedure will be end up in a better cosmetic appearance. This prospective study was conducted in Central Medical College Hospital, Comilla between July 2018 to June 2020 on 30 patients using Snodgrass technique of hypospadias surgery. All cases were consecutively selected. Data were processed and analysed using software SPSS (Statistical Package for social Sciences) version 11.5 and the test statistics used to analyse the data were descriptive statistics and Z-test for proportion. The variables studied were age, socioeconomic condition, post-operative complications, such as infection rate, urethrocutaneous fistula, meatal stenosis, wound dehiscence etc. & cosmatic outcome such as size of the meatus, shape of the glans studied.Satisfactory results were obtained in 21 (70%) patients and only 8 (26.67%) had urethrocutaneous fistula, 1(3.33%) had retrusive meatus and 7 (23.33%) had wound infection. The final outcome was evaluated based on urethrocutaneous fistula and cosmesis. Out of 30 patients, 21(70%) did not have urtethrocutaneous fistula and were cosmetically acceptable. Binomial test based on Z-approximation reveals that observed proportion of patients with satisfactory outcome was statistically significant (p = 0.05). This study concludes that Snodgrass urethroplasty has better cosmetic outcome. Thus we recommended it as the primary treatment for the children with distal hypospadias. Hypospadias may be manifested classically as an association of three anatomical anomalies of the penis: (1) an abnormal ventral opening of the urethral meatus which can be located anywhere on the ventral aspect of the penis or in the perineum, (2) an abnormal ventral curvature of the penis (chordee), and (3) an abnormal distribution of the foreskin around the glans with the ventrally deficient hooded foreskin. The chordee and the hooded foreskin are common but not constant. Significant degree of chordee are present in about 35% of patients with hypospadias; the most common anomalies associated with hypospadias other than chordee and hooded foreskin, are undescended testes and inguinal hernia. A 9.3% of patients with hypospadias had an undescended testes 5 .
Hypospadias repair is technically difficult and the results are often far from optimal. Despite extensive advances in surgical technique, the use of fine materials, delicate instrument, proper tissue handling, advances in anesthesia, hypospadiac patients faces a lot of complications.
Of patients with hypospadias >80% have a meatus in coronal and subcoronal position 6 . Warren Snodgrass (1994) described a procedure for distal hypospadias repair with combination of incising urethral plate and a meatal based flap with a low complication rate and better cosmetic outcome 7 .
The aim of surgical repair is to provide a normal looking straight penis with vertically oriented meatal opening at the tip of the glans with good flow of urine.
Very few works have been done on hypospadias in Bangladesh. This problem requires to be studied more for its further development in our country. Thus we at Central Medical College Hospital in department of surgery started hypospadias surgery during the last few years. We are facing a lot of postoperative complications. Among them stent blockage, signs of infection, sloughing of skin flap, persistance of cordee, meatal stenosis, urethrocutaneous fistula are more marked and urethrocutaneous fistula is the most common complication.
To overcome our problems, we modified our surgical technique and suture material but still the result is not satisfactory. The aim of surgical repair is to provide a normal looking straight penis with meatal opening at the tip in a single-stage procedure and our previous experience showed that this could be achieved easily majority cases with distal hypoapadias by tubularized incised plate urethroplasty (Snodgrass procedure).

Materials And Methods:-
This is an interventional type of prospective study. Patients of distal penile hypospadias (coronal, subcoronal, distal penile),age 2 years to 15 years with no history of pervious operation in the genital organ attending at above mentioned places for surgical correction.
Patients with distal hypospadias Age bellow 1 year and over 15 years, having glanular, mid penile & proximal variety of hypospadias, ambiguous genitalia and with other major surgical problems e.g. myelomeningocele, malignant disease were excluded. All guardian of the patients were given an explanation of the study and informed consents were obtained.Their knowledge and attitude about inclusion and exclusion criteria were assessed by talking interview using a standardized questionnaire.

Results:-
Total 30 cases were selected for clinical study, all patients were treated surgically by Snodgrass technique. All these 30 patients were followed up at 3 months and maximum up to 6 months. In the present series, following observations were noted.

Age distribution:
Patients who were between 3 to 15 years old were selected in the study. The mean age was found 7.5 years.

Socio-economic conditions:
In our study, we considered the socio-economic conditions of the hypospadias patients and the highest percentage of patients belonging to average families, constituting a number of 70%.

Consanguinity:
In this study one patient was detected as coming from consanguineous family.

Associated anomalies:
In our observations, associated hernia was two patients and only one patient presented with undescended testes.

Complications:
A) Urethrocutaneous fistula: Urine coming out other than neourethral orifice and opening found in and around the neourethral line. Urethrocutaneous fistula developed in 8 (26.67%) patients. B) Meatal stenosis: patients complaining of narrow stream and urethral opening found to be narrowed. Meatal stenosis developed in 4 (13.33%) patients. C) Unsatisfactory glans cosmesis: patients or patients parents are not satisfied with glans appearance and confirmed by examination. Glans appearance was unsatisfactory in 3 (10%) patients. D) Retrusive meatus: the newly constructed meatus was not in the place of penile tip as complained and examined.
Retrusive meatus developed in 1 (3.33%) patient. E) Sloughing of skin: the rotated flap skin was found to be blackened and sloughed. Sloughing of skin flap occurred in 3 (10%) patients. F) Deflected flow of urine: the urine flow was not oriented vertically or horizontally as noticed by patients and confirmed by observation. Deflected stream of urine noticed in 2 (6.67%) patients. G) Infection: discharge was noticed at operation site and confirmed by culture and sensitivity. Post-operative infection rate was present in 7 (23.33%) patients.   Table-10 shows the distribution of patient by final outcome. The final outcome was measured as satisfactory or unsatisfactory. Of the total 30 patients 70% exhibited satisfactory outcome in terms of no urethrocutaneous fistula and acceptable cosmetic appearance. Z-test demonstrates that observed proportion of is statistically significant (p = 0.05). liberally. In few cases injection pethidine was used through intramuscular route. The post-operative hospital stay was 7-10 days.

Post-operative final outcome:
In the present study average age of the patients was 7.58 years. We have found that most of the patients presented to the hospital at their 3-7 years of age which were comparable to other studies 8 . No conclusive data have been sorted out on the timing of presentation of hypospadias. Schultz and Colleagues 9 pointed out that an ideal time for hypospadias repair should be age 6-18 months to minimize the emotional effect of this traumatic insult. Our observation is that parents of this group of anomaly usually like to treat the problem before school going age.
Children from average families constituted 21(70%) was the highest sufferer followed by the poor class 7(23.33%) and the least was in rich class 2(6.67%), which was comparable to another study. Majority (70%) of the hypospadias patients was rural residents whose monthly family income was found to range from 5000 -10000 Tks. This finding contrasts with findings of Masud (1998), Alam (2000) and Haque (2005) who reported preponderance of poor patients in their studies (65%, 60% and 75% respectively). Only one patient has had the history consanguinity (3.33%). Although genetic factors is the etiology of hypospadias are certainly indicated by the higher incidence of the anomaly in the first-degree relatives of hypospadias patients 10 .
The abnormal location of the meatus and the tendency towards meatal stenosis results in a ventrally deflected and splayed stream of urine in hypospadias. Mild to moderate or severe form of meatal stenosis may be associated with any variety of hypospadias in our study. Over half (53.33%) had meatal stenosis ranging from mild to moderate grade which is consistent with the findings (60%) of Haque (2005).
Nine to thirteen percent hypospadias are associated with hernia and undescended testis, with higher incidence when the meatus is more proximal in location 12 , in this study two (6.67%) patient has associated hernia and one (3.33%) has undescended testis.
The operative procedure performed in our patients was Snodgrass procedure. For all cases, we followed the principles of plastic surgery regarding fine instruments and fine suture materials along with precise and delicate tissue handling.
All patients were operated under general anaesthesia. Skin hooks were used to prevent over handling of the tissues. We preferred 5/0 Polyglycolic acid suture material with a continuous running suture for constructing the neourethra and chromic 5/0 catgut suture for the skin. Hemostasis was maintained by tourniquet for 20 to 30 minutes duration and by using a low current diathermy.
Urinary diversion was provided by means of placing a feeding tube (6Fr, 7Fr, 8Fr etc.) in the neourethra and sutured to the glans and attached to thigh by micropore to prevent traction injury. The outer sheath of 3cc disposable syringe was interposed between feeding tube and urobag. A compression dressing was applied with gouge soaked with povidon iodin to provide immobilization with prevention of hematoma and oedema. Although distal hypospadias repair can be performed without a stent, the complication rate is lower when a stent is left indwelling for 3 to 6 days 13 .
In our study mean operation time consumed was 93 minutes. In original study by Snow et al., (1995) 14 additional 15-20 minutes of operative time is mentioned.
Urethrocutaneous fistula was developed in 8 (26.67%) patients. It was 34.38%, 33.33% and 23.3% in different studies in of Bangladesh (Masud, 1998;Alam, 2000;Haque, 2005). Urethrocutaneous fistulas are likely to remain an inherent risk of hypospadias repair for many years afterward. The result from failure of healing at some points along the neourathral suture line and can range from pin point to large enough for all voided urine to exit at this point. Fistulas may be associated with stenosis or distal stricture. Occasionally, small fistulas seen early postoperatively may close spontaneously. No attempt should be made to close the fistula for 6 months. To avoid