Hypospadias Objective Scoring Evaluation Research Articles

Modified Tubularised Incised Plate Urethroplasty (TIPU) with Dorsal Inlay Preputial Skin Graft: An Outcome Evaluation of 21 cases

There are different techniques of hypospadias repair, out of them TIPU is widely practiced and popular procedure. Here a midline incision is made over the urethral plate for widening of urethral lumen and creation of neomeatus. Meatal stenosis may subsequently develop at new meatus and it is the limitation of this procedure. In this study TIPU procedure is modified by applying preputial skin graft on incised urethral plate in dorsal inlay fashion and outcome is evaluated. In this prospective study total 21 patients with distal penile hypospadias underwent repair between 2016 and 2017. TIPU urethroplasty was done as usual along with application of a preputial skin graft on midline incised urethral plate. Tubularization was done over appropriate sized catheter and double layers bilateral Dartos flap was applied to cover the suture line. SPC catheterization was done in every patient. On 14th post-operative day urethral catheter was removed and on the same day if patient voids satisfactorily, SPC catheter was also removed. The outcome was evaluated according to the Hypospadias Objective Scoring Evaluation (HOSE) system. 95.23% of the patients achieved apical neomeatus and 90.47% of slit like meatal shape. Mild degree chordee and normal caliber urinary flow was in 9.5% and 95.23% of the patients respectively. 4.76% of the patients developed urethrocutaneous fistula. Dorsal inlay preputial skin grafting is a very simple and feasible technique to maximize the outcome of TIPU procedure. However, multicenter and high volume data are needed for its wide application.
 Bangladesh Med J. 2018 Jan; 47 (3): 9-12

Use of a Stent in Distal Hypospadias Repaired by Tubularized Incised Plate Urethroplasty: A Comparative Study

Purpose: We present our experience of stented and unstented distal hypospadias repaired by tubularized incised plate urethroplasty (TIPU). Patients and Methods: Data of 84 patients who were operated by TIPU method in 2 hospitals were retrospectively analyzed, and they were invited to be included in the study. Sixty-six patients agreed to participate in the study and were divided into 2 groups. Group 1 consisted of 38 boys operated in Sütçü İmam University Hospital on using a stent between 2015 and 2017. Group 2 consisted of 28 boys operated in Private Hospital of Megapark on without a stent between 2016 and 2017. The hypospadias objective scoring evaluation (HOSE) scale was used to compare the groups. Results: The median age was 2.81 years in group 1 and 1.95 years in group 2 (p = 0.243). The mean follow-up duration was 25.74 ± 4.62 and 24.5 ± 4.19 months in groups 1 and 2 respectively (p = 0.268). The HOSE scores were similar in both groups with comparable results (p = 0.622). Conclusions: No difference was observed between the groups in this study, regarding functional and cosmetic outcomes according to the HOSE score. However, the results should be supported by prospective studies with a sufficient number of patients.

Results of urethral plate preservation and use of vascular dartos flap in hypospadias repair

Background: Lower complication rates are observed if urethral plate (UP) is preserved and utilized for reparative surgery of hypospadias.Aim: This study aims to analyze our results of hypospadias repair by UP preservation, and using vascular dartos flap as interposition flap.Materials and Methods: prospective, cohort study of operated cases of hypospadias over 4.5 years' period. Data including age, diagnosis, preoperative testosterone administration, operation, postoperative complications, and assessment of outcome using hypospadias objective scoring evaluation (HOSE) system were collected. We preserved UP as far as possible, for urethral tube construction. We applied meatal advancement and glanuloplasty incorporated (MAGPI) for glanular/coronal hypospadias and tubularized incised plate urethroplasty (TIPU) (Snodgrass) for most other cases. Single dorsal vascular dartos-flap was transposed ventrally as interposition flap in TIPU. Single transurethral catheter 6F/8F size was employed as urethral stent as well as for bladder drainage. At the first review at 2 weeks after getting discharged, all patients underwent urethral calibration and first HOSE-score assessment. Maximum HOSE-score was 16 points and minimum 5.Results: A total of 111 patients with mean (range) age of 34.69 m (11 m– 123 m) were studied. TIPU (n = 49), MAGPI (n = 44), and others (n = 18) were the operations. There were 10 permanent complications; 9 following TIPU (7 (14.3%) single urethrocutaneous fistula (UCF), 1 torsion penis, 1 glans-dehiscence), and 1 following MAGPI (glans-dehiscence). Mean follow-up period was 15 m (range = 3–36 m). HOSE score ≥14 was achieved in 106 (95.5%) cases.Conclusion: The excellent result of MAGPI in our series is due to strict case selection and technical precision. UCF rate of 14.3% in TIPU can be due to the unselected nature of our cases which included small glans diameter and unfavorable UP characteristics.

Complications after Hypospadias Correction: Prognostic Factors and Impact on Final Clinical Outcome.

The purpose of this study was to analyze the influence of patient and treatment characteristics on the occurrence of complications after hypospadias correction and the impact of complications on final clinical outcome. The study cohort consisted of 205 hypospadias patients who had surgery in the Medical Centre Leeuwarden (1996-2011). Patient and treatment characteristics were hypospadias severity (preoperative meatal location and chordee), number of planned surgeries, reconstruction technique, operation year, and patient's age at the time of surgery. The final clinical outcome was measured with the Hypospadias Objective Scoring Evaluation (HOSE) (maximum score = 16) and compared between patients with and without complications. Sixty-four patients (31%) had complications, most of which were fistulas (n = 40). An increased complication risk was seen in patients with severe hypospadias (preoperative proximal meatus or chordee), multistage reconstruction, reconstruction techniques other than Mathieu, and surgeries performed before 2005. Uncomplicated treatment resulted only in a marginally higher HOSE (15.7) compared with complicated treatment (15.4). Fistulas and multiple complications reduced clinical outcome more (15.3 and 14.9, respectively), while urinary tract infections, wound dehiscence, or prepuce related complications did not (16.0, 16.0, and 15.8, respectively). The complication risk after hypospadias correction is influenced by hypospadias severity and type and year of reconstruction. Certain, but not all complications diminish final clinical outcome.

Grafted tubularised incised-plate urethroplasty: An objective assessment of outcome with lessons learnt from surgical experience with 263 cases

ObjectiveSnodgrass urethroplasty remains the preferred technique in primary distal hypospadias but development of meatal stenosis often limits distal extension of the midline incision of the urethral plate (MIUP), which remains a limiting factor in reconstructing an apical neomeatus (NM). We here-in assess the cosmetic and functional outcome with distal extension of the MIUP in grafted tubularised incised-plate urethroplasty (G-TIP) repair. Patients and methodsThis prospective study included the surgical experience of 263 cases of primary hypospadias operated upon between 2012 and 2015. The G-TIP technique included standard steps of Snodgrass urethroplasty, including degloving and harvesting of glans wings, followed by MIUP that was extended distally beyond the margins of the urethral plate (UP) into the glans. The incised bed was grafted with a free preputial skin graft and fixed to the bed with polydioxanone 7-0 suture. The UP was tubularised and the suture line reinforced with a Dartos flap. The urethral catheter was removed at 7–10days after the repair and the outcome was assessed at follow-up using the Hypospadias Objective Scoring Evaluation (HOSE) system. ResultsAn apical NM was achieved in 96% of the patients with a 3.7% incidence of urethrocutaneous fistula. The presence of suture tracks and graft at the margins of the NM were seen in the initial 4% and 5% of cases, respectively. Acceptable cosmetic results, with objective HOSE scores of >14, were achieved in 96% of cases. ConclusionThe G-TIP repair is a straightforward and feasible technique facilitating reconstruction of an apical NM, with an optimum outcome based on HOSE scoring. However, multicentre data are needed for undertaking comparative analysis and to assess the universal applicability of this technique in primary hypospadias.

Assessment of postoperative outcomes of hypospadias repair with validated questionnaires

PurposeA standardized assessment for the optimal repair of hypospadias remains elusive. This study utilized validated questionnaires to assess the postoperative functional, cosmetic, and psychosocial outcomes of hypospadias repair. Materials and methods172 patients who underwent hypospadias repair under the care of a single surgeon were identified. 25 agreed for follow-up using the validated questionnaires of Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Scale (PPPS), and Pediatric Quality of Life Inventory (PedsQL™4.0). ResultsMean follow-up was 59months postoperatively (range 7–113months). Techniques used included tubularized incised plate urethroplasty, meatal advancement and glanuloplasty, and a 2-stage repair. 23 of 25 patients achieved a HOSE score of 14 or more (maximum of 16). The PPPS scores correlated with severity of the hypospadias. Those with glanular hypospadias (mean score=10) scored higher than those with coronal (mean score=9) and penile/penoscrotal hypospadias (mean score=7). There was no correlation between PedsQL™4.0 scores and the severity of hypospadias or procedure used. ConclusionValidated questionnaires revealed generally good functional, cosmetic, and early psychosocial outcomes after hypospadias repair. The use of validated questionnaires in routine follow-up sessions may facilitate objective assessment of both functional outcomes and patient satisfaction.

Long-Term Functional, Cosmetic and Sexual Outcomes of Hypospadias Correction Performed in Childhood

Objective: Hypospadias surgery, especially when performed early in life, may have a significant impact on the urinary and sexual functions in an adult. Because the literature is still limited, this paper assesses long-term functional, cosmetic and sexual results of hypospadias repair performed in childhood. Patients and Methods: The study includes 275 patients older than 12 years treated for a hypospadias by an Onlay, Mathieu, Duplay, or Duckett's technique between January 1990 and December 2000. Flowmetry results were retrospectively obtained from patients' charts. The Paediatric Penile Perception Score (PPPS), the Hypospadias Objective Scoring Evaluation (HOSE) and the IIEF-5 score (when older than 16 years old) questionnaires were used to assess cosmetic and sexual results. The PPPS is designed to assess both penile self-perception with regard to meatus, glans, skin and general appearance. The HOSE is a five-point scoring system designed to allow an objective appraisal of the outcome of hypospadias repair, based on evaluating meatal location, meatal shape, urinary stream, straightness of erection, and the presence and complexity of any complicating urethral fistula. Results: Q_max were within age-adjusted references, independent of the surgical technique, with median (range) Q_max of 18.8 ml/s (range 3-45, n = 136). Patients expressed a high satisfaction for every single item of the penile perception scale (PPPS), with mean values between 2 (satisfied) and 3 (very satisfied). Eighty-two percent were satisfied or very satisfied of the overall evaluation of penile appearance. Eighty-one percent of patients had a normal erectile function (IIEF-5 >22; n = 35/43). Conclusions: Taking into account the limitation of a small number of patients resulting from a low 21% questionnaire's response rate, the results of this study align with previous reports from the literature and confirms that hypospadias repair using standard techniques results in acceptable functional, cosmetic and sexual outcomes. This study highlights the need of developing a set of standard approved outcomes assessments tools for evaluating the long-term impact of hypospadias repair performed in infancy.

Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes

ObjectivesTo objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score. Patients and methodsIn a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3months after surgery, the flow pattern, maximum (Qmax), and mean urinary flow rate (Qave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system. ResultsThe native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5–14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3–24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3–14) years showed an abnormal Qmax below the fifth percentile in four (15%), with the Qave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13–16). Two patients had a small, single subcoronal fistula. ConclusionExtending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.

Objective Scoring Evaluation and Uroflowmetry Assessment of Two-Stage Hypospadias Repair: Single Center Experience

Background: Hypospadias is a common congenital anomaly affecting the penis, two-stage repair becoming more interesting in era of tubularized –incised urethral plate (TIP). Functional outcome of hypospadias repair either single or two stage is as important as cosmetic outcome. In contemporary series , structured scoring systems (Hypospadias Objective Scoring Evaluation-HOSE and Pediatric Penile Perception Scoring -PPPS), evaluation of photographs and uroflowmetry, were used to assess results of hypospadias repair. Objectives: We have assessed outcomes of two-stage hypospadias repair using Hypospadias Objective Scoring Evaluation(HOSE) and uroflowmetry. Material and Methods: Over a period of eight years, from January 1997 to December 2004, One hundred and twenty six hypospadias patients were treated, ninety of them had two-stage repair and36 single-stage repairs. The HOSE questionnaire and uroflowmetry were obtained to evaluate the long term outcome of two –stage hypospadias repair. Results: The age at time of assessment ranged from 8 to 23 year-old, with mean follow up of 39.78months. Thrifty five patients had proximal hypospadias and 20 had distal varieties of hypospadias. Operations performed were 37 Bracka?s and 18 Byar?s procedures. Of the 55 patients had complete two stage hypospadias repair and agree to participate in the study , Nineteen patients had acceptable HOSE and 36 had non-acceptable score. Uroflow rates of 43 subjects were below the fifth centile in three patients ,equivocal (between 5th and 25th centile ) in four patients and above 25th centile in 36 subjects. Conclusion: Two –stage repair is a suitable technique for all types of hypospadias with versatile outcomes. HOSE and uroflowmetry are simple, easy, non invasive and non expensive tools to assess long term outcomes objectively. Bangladesh Journal of Medical Science Vol. 12 No. 02 April’13 Page 133-139 DOI: http://dx.doi.org/10.3329/bjms.v12i2.14940

Postpubertal Examination after Hypospadias Repair Is Necessary to Evaluate the Success of the Primary Reconstruction

Hypospadias is one of the most common congenital anomalies. There are many studies describing successful initial repair, but there are few studies examining long-term result. The aims of this study were to evaluate our patients that have been reconstructed for hypospadias and undergone final clinical examination after puberty and to assess how long clinical follow-up time is warranted after hypospadias repair. A standard protocol, with visits at ages 7, 10, 13 and a final clinical examination at the age of 16, was followed. To objectify our long-term functional and aesthetic results, Hypospadias Objective Scoring Evaluation (HOSE) was used. A total of 114 boys reconstructed between 1989 and 2009 had undergone final clinical examination. Seventy-nine were classified as degree I, 25 as degree II, 6 degree III, 3 as degree IV, and 1 boy could not be classified retrospectively. Sixty-seven boys were operated on in stages according to Byars, 25 according to Mathieu, and 14 according to Scuderi. Only eight patients needed release of chordee and realignment of skin. Ten boys needed closure of fistulas and strictures had to be operated on in four cases. At the concluding visit, 86% of the patients had an excellent result according to the total HOSE score. It was noted that six patients had developed an incurvation between the prepubertal and postpubertal checkup. It is important that the boys are followed according to a planned standardized protocol until they have passed puberty as incurvation may occur during puberty.

Foreskin reconstruction and preservation of a thin distal urethra: a challenge in tubularized incised plate urethroplasty

The aim of this retrospective study was to evaluate the functional and cosmetic outcome of tubularized incised plate urethroplasty (TIPU) with preputial reconstruction and preservation of a thin distal urethra when applicable. The records of 64 boys with hypospadias, who underwent TIPU between 2000 and 2007 were analyzed. 33 (52%) underwent foreskin reconstruction and a thin distal urethra was preserved and incorporated in 19 (30%) patients. The Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), and uroflowmetry were evaluated in 55 boys (86%) after a mean of 4.8 years. All patients had a vertically oriented meatus. The overall rate of fistula occurrence was 9% and of wound dehiscence, 5%. Among 33 preputial reconstructions, two (6%) patients had dehiscence and three (9%) had a fistula. No cases of stricture or stenosis occurred. There were significantly more complications with reconstruction of the foreskin (p = 0.012) and preservation of a thin distal urethra (p = 0.021). Uroflowmetry was normal in 76% of patients. PPPS and HOSE revealed excellent results. TIPU produces excellent cosmetic and functional results with few complications; complications are more common after foreskin reconstruction and use of a thin distal urethra.

Objective long-term evaluation after distal hypospadias repair using the meatal mobilization technique

Meatal mobilization (MEMO) by distal urethral preparation has been demonstrated to be an efficient surgical technique for the correction of distal hypospadias offering excellent short-term success rates. This study objectively evaluates individual patient satisfaction using a validated score in the long term. A total of 218 patients who underwent hypospadias repair using the MEMO technique was identified. Of these, 104 (mean age at time of surgery 4.9 years, range 2-28 years) had a minimum follow-up of 5 years and were eligible for the study. They were investigated by physical examination and self-assessment. An objective evaluation using the validated Hypospadias Objective Scoring Evaluation (HOSE) was done in all patients. Mean follow-up was 6.3 (range 5-8) years. Ninety-nine patients participated in the investigation, an overall survey response rate of 95.2%. One urethrocutaneous fistula occurred, but no cases of stenosis were noted. One patient developed a mild penile deviation during the postoperative follow-up. Ninety-three out of 99 patients reached the maximum of 16 points (median 15, range 12-16) on the HOSE symptom score. The MEMO technique demonstrates a surgical success rate of 97% after 2 years. Even in the long-term follow-up of a mean 6.3 years objective outcome data and individual patient satisfaction were excellent. MEMO is a reliable and versatile method for distal hypospadias repair, as reflected by high patient satisfaction.

Long-term outcome of severe hypospadias

To evaluate, from the patient's point of view, long-term urinary and sexual outcome of surgery for severe hypospadias. Patients treated for severe posterior hypospadias during childhood and now aged 20-35 years were included. Outcome was evaluated using the Hypospadias Objective Scoring Evaluation and our own quality of life questionnaire. Of 48 patients, 13 were lost to follow up. The questionnaire was thus sent to 35 patients of whom 27 agreed to answer (77% response rate). Fifteen presented proximal and 12 scrotal hypospadias. Average age at surgery was 3.3 years and the children underwent an average of 3.7 procedures. There were 40% early complications, and 59% late complications, including 33% fistulae and 26% stenosis. At present, 70% of patients have an apical meatus, 82% have a straight penis, 37% present difficulty initiating voiding, and one patient has a persistent fistula; 74% say their penis looks abnormal, either because of the absence of foreskin, penis size or scarring. Sexual and global satisfaction rates, determined using a visual analogue scale, are respectively 68% and 63%. Satisfaction is statistically correlated to the presence of early complications or stenosis, but not fistula. It decreases if the patient thinks his penis is not normal, even if the anatomical result is good. Urinary and sexual outcome is good for most patients though the results are variable. Satisfaction seems more affected by subjective feelings than the anatomical result.

Early Hypospadias Surgery May Lead to a Better Long-Term Psychosexual Outcome

We evaluated long-term outcomes in boys treated for hypospadias at Royal Children's Hospital, Melbourne. Boys who underwent hypospadias surgery were reviewed at ages 13 to 15 years. Surgical results were evaluated using the Hypospadias Objective Scoring Evaluation. Lower urinary tract function was assessed using uroflowmetry and symptom questionnaire. Self-report surveys measured quality of life, patient satisfaction, memory of surgery, psychosexual outcomes and parent satisfaction with care. By Hypospadias Objective Scoring Evaluation score 80% of patients had an excellent surgical outcome. Two independent reviewers assessed lower urinary tract function as normal in 82% and 86% of cases, respectively. Quality of life scores were comparable to published values in normal children. Parents rated the institution highly. Overall 90% and 81% of boys were satisfied with the body and genital appearance, respectively. Those dissatisfied with genital appearance had poorer psychosexual outcomes than satisfied patients. When surgery was completed before age 5 years, boys had no perioperative memories. An association was found between no recollection of surgery and satisfaction with body appearance. Objective surgical and functional outcomes are excellent after early surgery. Post-repair quality of life is comparable to published data on normal children. Parents are pleased with care. Most boys are satisfied with the body and genital appearance. However, those dissatisfied with genital appearance must be identified in the interest of psychosexual development. The association between no recollection of treatment and satisfaction with body appearance suggests that surgery should be completed before age 5 years when possible to allow the development of good body image in adolescence.