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Maher et al. Hypospadias: an algorithm for repair

plate is incised vertically with horizontal extensions at rate specific to one stage and two stage procedures
the meatus; and glans flaps are raised. A full thickness was 5.3% (n = 3) and 13% (n = 6) respectively. Other
skin graft is harvested from the inner surface of the late complications included, altered urine stream 0.9%
dorsally hooded prepuce, its dimensions are not (n = 1) and urethral stricture 0.9% (n = 1) [Figure 4]. No
routinely measured, and however, the overall width complications related to bleeding were encountered.
of the urethral plate and skin graft should be at least Re-operation was required for 2 patients with wound
12 mm. The donor is closed primarily using rapidly dehiscence and 9 patients with fistula.
dissolving polyglactin 7-0 suture (Vicryl Rapide-
Ethicon). The skin graft is secured to the defect DISCUSSION
created using polyglactin 7-0 sutures (Vicryl-Ethicon).
The same suture material is used to quilt the skin graft. Many techniques and modifications have been
Polypropylene 6-0 sutures (Prolene-Ethicon) are used described for the repair of hypospadias, yet there
to secure the non-adhesive bolster dressing applied has been no general consensus on a specific
to the skin graft. A size 6 Fr silicone Foley’s catheter procedure for a given subset of hypospadias meatal
is inserted at this stage. The average time for the first positions or morphology. Prat et al. published a
[3]
stage is 45 min. series that covered three decades including 820
patients, highlighting different techniques and overall
The second stage is performed for the patient 6 results. They performed meatal advancement and
months after the first stage, where the graft has glanduloplasty (MAGPI), TIP, two stage procedures,
healed completely and the tissues have become onlay tabularised island flap, yet with a high incidence
soft and supple. The second stage is identical to the of complications. We employ the use of a simple
one stage repair, where by the lateral incisions are double-armed algorithm ending in two procedures,
performed at the edge of the full thickness skin grafts. which we feel are adequate to address treatment of
The average time taken is similar to the one stage hypospadias.
repairs: 60-75 min.
The algorithm [Figure 5] disregards the meatal
RESULTS position, and addresses other morphological findings;
chordee, adequacy of the urethral plate, glans cleft,
A total of 102 patients were operated upon between and presence of a urethral bar. A similar algorithm
2009 and 2013. Inclusion criteria included primary was utilised by Coleman et al., whereby they used
[4]
hypospadias in the paediatric population. Exclusion
criteria, was 1 adult with delayed presentation of
primary hypospadias, and 5 cases of phimosis,
thought to have concealed hypospadias, treated with
circumcision only. Of the 102 patients, 56 underwent a
one stage procedure while 46 underwent a two stage
procedure. Mean age at presentation was 22 weeks ±
29.75 (SD). The mean age at surgery was 25 months
± 11.56 (SD).

Of the 102 cases, 41.2% (n = 42) were subcoronal,
20.6% (n = 21) coronal, 13.7% (n = 14) glandular, 1% Figure 3: Hypospadias subtypes (%)
(n = 1) terminal, 11.8% (n = 12) distal shaft, 2.9% (n =
3) mid-shaft, 3.9% (n = 4) proximal shaft, and 4.9% (n
= 5) penoscrotal [Figure 3].

Early complications were those encountered within
6 weeks of the operative procedure, whilst any
complication encountered after that period would be
classed as a late complication. Early complication rate
was 4.9% (n = 5) and they included dislodged/snapped
catheters 1.9% (n = 2), wound dehiscence and infection
2.9% (n = 3). Overall late complication rate was 10.7%
(n = 11). The most common complication was urethro-
cutaneous fistula occurring in 8.8% (n = 9). The fistula Figure 4: Complication rate (%)
Plastic and Aesthetic Research ¦ Volume 4 ¦ April 27, 2017 67