Hypospadias Surgery. Clinical Aspects and Outcomes

Abstract

Abstract
Aim The aim of this thesis was to evaluate the treatment and follow-up of patients undergoing hypospadias surgery at the Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, in an attempt to improve the overall care of these patients. It also aimed to investigate the tissue properties of the urethral plate and deep chordee in hypospadias patients with significant ventral curvature of the penile shaft.
Methods Long term follow-up and patient reported outcomes in a cohort of 157 patients were investigated by chart review and a modified hypospadias functional outcome questionnaire. The hypospadias objective scoring evaluation (HOSE) system was used to objectify the results. In addition, 36 patients with secondary hypospadias repairs were analysed via chart review and 10 patients scheduled for orthoplasty during 2014–2015 consented to biopsy of the urethral plate and deep chordee during surgery.
Results HOSE analysis indicated that 86% of patients had satisfactory results after primary and secondary hypospadias repair. Overall fistula frequency was 11% after primary repair and post-pubertal follow-up. The HOSE analysis also showed that 82 to 92% of responding patients were neutral or more satisfied with their overall surgical outcomes, appearance, and urinary and sexual function and 90% of responders were satisfied or requested longer follow-up after surgery. In 22% of patients with salvage repairs, additional surgery was required because of complications or shortcomings after re-repairs per our treatment algorithm. All of the biopsy samples from the urethral plate and the deep chordee had similar tissue characteristics and the biopsies confirmed that chordee is a unique tissue entity. In addition, chronic inflammation, a finding not previously reported, was present in every biopsy specimen, with chronic inflammation in the urethral plate manifested as metaplasia in the form of urethritis cystica.
Conclusions Our findings show that the long-term, post-pubertal complication rate after hypospadias surgery is low and that a majority of patients have satisfactory results. Patient-reported outcomes indicated that the responding patients were satisfied with their overall long-term surgical/functional outcomes and with the long-term follow-up program. We also found that our treatment algorithm can be applied successfully in cases of secondary hypospadias repairs, provided local tissues are available for flap coverage. In these cases, it is of particular importance to treat all ventral curvature, secondary to chordee and ventral scarring. Thus, many secondary salvage procedures must be handled in two sessions to optimise safety and minimise postoperative complications. Finally, we also report previously undescribed chronic inflammatory activity in tissue samples from urethral plates and deep chordee in patients with hypospadias and ventral curvature, which suggests a possible dynamic feature in this unique tissue entity.

Abstract (Swedish)

Abstract
Aim The aim of this thesis was to evaluate the treatment and follow-up of patients undergoing hypospadias surgery at the Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, in an attempt to improve the overall care of these patients. It also aimed to investigate the tissue properties of the urethral plate and deep chordee in hypospadias patients with significant ventral curvature of the penile shaft.
Methods Long term follow-up and patient reported outcomes in a cohort of 157 patients were investigated by chart review and a modified hypospadias functional outcome questionnaire. The hypospadias objective scoring evaluation (HOSE) system was used to objectify the results. In addition, 36 patients with secondary hypospadias repairs were analysed via chart review and 10 patients scheduled for orthoplasty during 2014–2015 consented to biopsy of the urethral plate and deep chordee during surgery.
Results HOSE analysis indicated that 86% of patients had satisfactory results after primary and secondary hypospadias repair. Overall fistula frequency was 11% after primary repair and post-pubertal follow-up. The HOSE analysis also showed that 82 to 92% of responding patients were neutral or more satisfied with their overall surgical outcomes, appearance, and urinary and sexual function and 90% of responders were satisfied or requested longer follow-up after surgery. In 22% of patients with salvage repairs, additional surgery was required because of complications or shortcomings after re-repairs per our treatment algorithm. All of the biopsy samples from the urethral plate and the deep chordee had similar tissue characteristics and the biopsies confirmed that chordee is a unique tissue entity. In addition, chronic inflammation, a finding not previously reported, was present in every biopsy specimen, with chronic inflammation in the urethral plate manifested as metaplasia in the form of urethritis cystica.
Conclusions Our findings show that the long-term, post-pubertal complication rate after hypospadias surgery is low and that a majority of patients have satisfactory results. Patient-reported outcomes indicated that the responding patients were satisfied with their overall long-term surgical/functional outcomes and with the long-term follow-up program. We also found that our treatment algorithm can be applied successfully in cases of secondary hypospadias repairs, provided local tissues are available for flap coverage. In these cases, it is of particular importance to treat all ventral curvature, secondary to chordee and ventral scarring. Thus, many secondary salvage procedures must be handled in two sessions to optimise safety and minimise postoperative complications. Finally, we also report previously undescribed chronic inflammatory activity in tissue samples from urethral plates and deep chordee in patients with hypospadias and ventral curvature, which suggests a possible dynamic feature in this unique tissue entity.

• author: Nozohoor Ekmark, Ann
• supervisor: Henry Svensson; Emma Hansson; Einar Arnbjörnsson
• opponent: professor Nordensjöld, Agneta, Karolinska Institutet, Stockholm
• organization: Department of Clinical Sciences, Malmö; Surgery (research group); Pediatric surgery (research group)
• publishing date: 2017
• type: Thesis
• publication status: published
• subject: Medical and Health Sciences
• keywords: Hypospadias, hypospadias repair, hypospadias surgery, hypospadias, hypospadias repair, chordee
• pages: 102 pages
• defense location: KK-Aulan, Skånes Universitetssjukhus, Malmö
• defense date: 2017-03-16 13:00:00
• ISBN: 978-91-7619-410-2
• language: English
• LU publication?: yes
• additional info: ISSN: 1652-8220 Lund University, Faculty of Medicine Doctoral Dissertation Series 2017:29
• id: 57677aae-79f2-4804-92ca-3918a37ba74a
• date added to LUP: 2017-02-15 11:11:33
• date last changed: 2019-11-19 13:49:59