Hypospadias – the Surgical Treatment Performed in “ Grigore Alexandrescu ” Emergency Clinical Hospital for Children

Hypospadias represents one of the most frequent congenital anomalies, in 1 out of 300 male newborns, involving signifi cant biological and socioeconomical implications. The article aims to evaluate the patients admitted and treated for hypospadias. In addition, it offers an overview of the surgery for hypospadias. The cohort included 283 patients admitted and treated for hypospadias or one if its postoperative complications, from the fi rst of January 2013, until december 31st of 2012. The selection was made from the digital database of the hospital based on the diagnosis at the moment of discharge. The surgical techniques used to correct the malformations were analyzed, particularly, the methods for urethroplasty. Taking into consideration the total cohort, a variety of surgical techniques were used. The most frequent type of urethroplasty was the Snodgrass technique, which was used in 47.7% of the patients. The second one was the Mathieu operation which was applied in 18.7% of the patients. Both of them cover 67.8% of the pacients, including those cases who were treated using a combination of the two. Analyzing the data which was presented, the surgical procedures which were applied in this cohort were similar to the ones reccomended by international guidelines, and the inicidence of postoperative complications, depending on every type of hypospadias, was close to the one obtained by recent studies.


INTRODUCTION
Hypospadias represents one of the most frequent congenital anomalies, in 1 out of 300 male newborns, involving signifi cant biological and socioeconomical implications.Furthermore, recent studies show an increase in its incidence, even after ajusting it according to race, geographic region or socioeconomical status 3 .Th e same pattern was recorded by the EUROCAT study group, which was monitoring the statistical and epidemiological data regarding the congenital anomalies in Europe.One prospective study, which evaluated the incidence of the hypospadias in Holland (0.7%), demonstrated that it is more frequent than congenital heart anomalies (0.5%), which are considered to be the most frequent ones by the EUROCAT study group 5 .Th e article aims to evaluate the patients admitted and treated for hypospadias in the Clinical Emergency Hospital for Children "Grigore Alexandrescu, the First Pediatric Surgery Ward, along a period of two years, since the hospital adresses the regional as well as the national pathology.Another purpose of this paper is to off er an overview of the surgery for hypospadias.

MATERIALS AND METHODS
Th e cohort included 283 patients admitted and treated for hypospadias or one if its postoperative complications, from the fi rst of January 2013, until december 31 st of 2012.Th is period was chosen in order to collect suffi cient data regarding the long-term postoperative evolution.Th e patients were selected from the digital database of the hospital based on the diagnosis at the moment of discharge, according to the International Classifi cation of Diseases.Ultimately, the data was collected from the medical records and the registry books of operations.Th e limitations of the study were represented by retrospective manner of collecting the data and by the fact that the cohort cannot be considered a representative one since it was not reported to the total number of cases from the pediatric population.Regarding the postoperative complications, the surgical corrections of the recurrences performed in this hospital were the only ones included, so admissions to other centers of pediatric surgery cannot be precluded.Th e surgical techniques used to correct the malformations were analyzed, particularly, the methods for urethroplasty.Descriptive statistics were used in order to compare the methodoloy applied in the Clinical Emergency Hospital for Children "Grigore Alexandrescu", Bucharest, compared to international guidelines.

RESULTS AND DISCUSSIONS
At the time of admission, the patients were in two possible situations concerning the surgical history of this condition.Th e group of patients who did not undergo surgical treatment for hypospadias was called the "naive" group, while the rest of the patients were included in the group of "previous surgical corrections".Th e surgical treatment of each of the three components of the penile anatomy involved in this congenital anomaly was included: the type of urethroplasty, dorsal penile defl ection and glanuloplasty.Th e types of urethroplasty in both groups are presented in Table 1.
Taking into consideration the total cohort, a variety of surgical techniques were used.Th e most frequent type of urethroplasty was the Snodgrass technique, which was used in 47,7% of the patients.Th e second one was the Mathieu operation which was applied in 18,7% of the patients.Both of them cover 67.8% of the pacients, including those cases who were treated using a combination of the two.One small group of patients, meaning 24 cases, did not require any type of urethroplasy, 10 of them belonging to the "naive" group, while the rest of them underwent at least one type of surgical treatment in the past.Congenital penile curvature (chordee without hypospadias) was diagnosed in 7 patients from the "naive" group, while the other 3 required glanuloplasties.Th e patients from the other group who did not undergo any type of urethroplasty required additional correction of the penile curvature (23.8%) or glanuloplasty (76.2%).Th e international and Mathieu 6,7,8 .In this cohort, the most frequently used surgical technique for this type of hypospadias was meatoplasty, in 38% of the cases (Figure 1).Th e preference for this option could be explained by the high location of the urethral orifi ce, very close to the tip of the glans, which allowed a satisfactory correction by this method alone.Th e following ones were the Snodgrass technique (27%) and MAGPI (22%).
For the treatment of distal hypospadias, the European Associacion of Urology reccomends using the urethral plate as a reference point in the surgical treat-ment.Th e reccomended techniques in the fi rst step of treatment are Tiersch -Duplay, when the urethral plate is large enough to allow the tubularization, or the Snodrass technique, when it is short.Th e Mathieu technique is mentioned as another possibility, although other guidelines mention it as a preferable option, next to Snodgrass and Onlay urethroplasties 6,7,8 .With regards to this cohort, distal hipospadias was treated by the Snodrass and Mathieu procedures in 50% of the cases, and 21,5% respectively (Figure 2).Th e Onlay procedure was never used, and the Duplay urethroplasy was applied in 2 patients (1.63%).Th e Leveuf -Godard procedure was used more often compared to other centers, which could be explained by the expertise of the surgeons in this particular method.
Most of the articles which analyze the efi ciency of urethroplasties present the results obtained mostly after the Snodgrass, Mathieu or Onlay procedures, which proves the variable use of these procedures.Th e reccomendations for the correction of the proximal hypospadias are also based on keeping the urethral plate and using it as often as possible in reconstructing the future urethra 9 .Th e preff ered techniques are Snodgrass and Onlay.When the penile curvature cannot be corrected by preserving the urethral plate, the Koyanagi procedure is reccomended or the two-steps urethroplasty.Analyzing the distribution of the surgical techniques in the category of proximal hypospadias which did not require the incision of the urethral plate and with no previous surgical corrections, most of the cases benefi ted from the Mathieu (16.3%) and Snodgrass procedures (53%) (Figure 3).Regarding the proximal hypospadias, the Onlay procedure was not used.Th e  not require additional surgical corrections, the effi ciency in curing this condition being remarcable, since the medical literature reports small rates of recurrences 13,14 .Urethral complications occured in 16.82% of the cases who were treated for distal hypospadias, while recent studies report rates varying from 6.2-7% up to 21.8% 18 .Th ese complications consisted of urethral fi stulas, urethral stenosis or unsatisfying cosmetic result which required additional corrections.Th e highest rate of complications occured in the treatment of proximal hypospadias (44.18%), the value being situated in the interval obtained by a metaanalysys which compared the onlay and Snodgrass procedures in proximal hypospadias, the rate of complications varying between 13.54% 20 and 60% 21 .

CONCLUSIONS
Analyzing the data which was presented, the surgical procedures which were applied in this cohort were similar to the ones reccomended by international guidelines, except for certain particularities: for the correction of glandular hypospadias, there was a higher rate of other procedures, whereas in case of distal hypospadias, the regeneral reccomendation of preserving and including the urethral plate during the process of urethroplasty was widely used.One distinguishable aspect is the usage of the Leveuf -Godard technique, compared to the international guidelines.Regarding the correction of the proximal hypospadias, there was a tendency in preserving the urethral plate, the Snodgrass procedure being mostly used, followed by the Mathieu technique.When the incision of the urethral plate was necessary, group with previous surgical corrections was treated mostly by the Snodgrass technique 11 .
When the penial curvature was severe, it required the inicision of the urethral plate, so the two-steps procedure was applied, with Byars fl aps used in order to substitute the urethral plate.Proximal fl ap of the urinary meatus was used in 2 cases of proximal hypospadias and 2 of distal hypospadias.Th ese 4 cases sum up 1.41% incidence of severe penile curvature, which is small compared to the one cited in recent studies 10 .Despite the fact that the attention was focused primarily on the types of urethroplasty, the correction of the other anatomical components involved were not excluded.Consequently, the correction of the penile curvature was obtained by releasing the skin from the fi brous adhesions created along the penile body and it was manatory in 29.68% of the cases from the entire cohort.Taking into consideration the fact that only 4 cases required the incision of the urethral plate, and that midline dorsal plication was neccesary in only one patient, the incidence of severe penile curvature represents 1.76% of the cases.Similar incidence rates were found in other studies which focused their research on this aspect 11 .Th e glanuloplasty consisted of the ventral transposition of the skin and the longitudinal suture of the glans, circumcision, Byars fl aps, or other methods which were adapted to the particularities of the patients, especially those with previous surgical corrections.Th e overall rate of circumcisions was small (1.27%), taking into consideration the fact that most of the surgeouns prefer this method in most of the cases 12 .
Concerning postoperative complications, patients undergoing treatment for glandular hypospadias did operative complications are concerned, the incidence according to every type of hypospadias corresponds to the one cited by recent reseach, which emphasizes the benefi t of the treatment.the two-steps urethroplasty using the Byars fl aps was the preferred method.As a particularity, there was a limited use of skin or oral mucosa grafts for the correction of proximal or distal hypospadias.As fas as post-

Figure 2 .
Figure 2. Surgical Techniques Used in Distal Hypospadias According to the Patient's Medical History.

Figure 3 .
Figure 3. Surgical Techniques Used in Proximal Hypospadias According to the Patients' History.

Table 1 .
Types of urethroplasties or other surgical corrections involving the urethra treatment guidelines present diff erent reccomendations depending on the type of hypospadias and the shape of the glans.Th e surgical techniques reccomended for the correction of the glanular hypospadias are MAGPI (Meatoplasy and Glanuloplasty), GAP (Glans Approximation Procedure), TIP (Tubularised Incised Plate)