|Year : 2021 | Volume
| Issue : 3 | Page : 170-174
Appraisal of hypospadias repair at University of Nigeria Teaching Hospital Enugu
Ijeoma Chioma Obianyo, Christopher Chim Amah, Nene Elsie Obianyo
Sub-Department of Paediatric Surgery, College of Medicine, University of Nigeria, Ituku/Ozalla Campus, Nigeria
|Date of Submission||29-May-2020|
|Date of Decision||11-Jul-2020|
|Date of Acceptance||30-Jan-2021|
|Date of Web Publication||20-Apr-2021|
Ijeoma Chioma Obianyo
Sub-Department of Paediatric Surgery, College of Medicine, University of Nigeria, Ituku/Ozalla Campus.
Source of Support: None, Conflict of Interest: None
Background: Hypospadias repair is one of the most common urologic surgeries performed in male children. Various surgical repairs and modifications of existing ones have evolved over the past decades. Notable among them is the Snodgrass tubularized incised plate (TIP) procedure. We document an appraisal of hypospadias repair performed at the University of Nigeria Teaching Hospital (UNTH) Enugu within a period of 6 years. Aim: The aim of this article is to determine the common presentations, repair, and outcome of hypospadias at UNTH. Materials and Methods: This is a retrospective study. Case notes of all patients who had surgeries for hypospadias between January 2013 and January 2019 were retrieved and data extracted. The data were analyzed using SPSS version 23. Results: Sixty-one operations were carried out on 51 patients within the 6-year period. The ages of the patients at the time of surgery ranged from 6 months to 27 years with a median age of 3 ± 4.9 years. The most frequent type was coronal hypospadias occurring in 25 patients (41%). The rarest forms were perineal hypospadias and proximal penile hypospadias seen in one patient (1.6%) each. Five patients (8.2%) each were seen with failed hypospadias repair and urethrocutaneous fistula. Fifty-four (88.5%) were single-stage operations and 7 (11.5%) were staged procedures. The most common surgery performed was Snodgrass TIP urethroplasty done in 38 patients (62.3%). Thirty-six patients (59%) had no complication, whereas 25 (41%) had complications. The common complications were urethrocutaneous fistula in 14 patients (23%) and surgical site infection in five patients (8.2%). Conclusion: Snodgrass TIP was noted to have a good outcome for the repair of hypospadias in UNTH.
Keywords: Hypospadias, Snodgrass tubularized incised plate (TIP)
|How to cite this article:|
Obianyo IC, Amah CC, Obianyo NE. Appraisal of hypospadias repair at University of Nigeria Teaching Hospital Enugu. Int J Med Health Dev 2021;26:170-4
|How to cite this URL:|
Obianyo IC, Amah CC, Obianyo NE. Appraisal of hypospadias repair at University of Nigeria Teaching Hospital Enugu. Int J Med Health Dev [serial online] 2021 [cited 2021 May 11];26:170-4. Available from: https://www.ijmhdev.com/text.asp?2021/26/3/170/313948
| Introduction|| |
Hypospadias is a union of four anatomical anomalies, namely, an abnormal ventral opening of the external urethral meatus, a deficiency of a segment of the ventral wall of urethra which leaves a urethral plate distal to the anomalous meatus, a ventral curvature of the penis called chordee, and a ventral deficiency of the prepuce that leaves a dorsal hood. Hypospadias occurs as a result of an arrest in the fusion of the urethral folds. The etiology is multifactorial. It is classified anatomically into glanular, coronal, distal penile, mid penile, proximal penile, penoscrotal, interscrotal, and perineal hypospadias.
Hypospadias repair is a delicate and complex reconstructive procedure. It is one of the most common urologic surgeries performed in children. The aim of repair is to achieve a functional and cosmetically acceptable penis, i.e. a straight penis on erection, a neo-meatus at the tip of the glans penis, a straight stream at urination, and a normal-looking penis. This is achieved by correction of chordee and reconstruction of the missing urethra and reconstruction of the ventrum of the penis, glans, and meatus.
Numerous procedures have been described by various surgeons. In fact, more than 300 types of repairs have been described in medical literature. The tubularized incised plate (TIP) procedure was introduced in 1994 by Warren T. Snodgrass. This procedure in a nutshell consists of excision of the chordee with preservation of the urethral plate, midline incision of the urethral plate, tubularization of the urethral plate, and covering of the ventrum. A major advantage of this procedure is the incision of the urethral plate before tubularization. TIP is currently the most common type of repair for hypospadias at University of Nigeria Teaching Hospital (UNTH) Enugu. The aim of this retrospective study, therefore, is to document and evaluate our experience with this procedure.
| Materials and Methods|| |
This is a retrospective study of patients who had surgery for hypospadias in the 6-year period between January 2013 and January 2019. The case notes of these patients were retrieved, and data regarding the age of the patient at the time of surgery, class of hypospadias, type of surgery, and outcome were extracted. The data were computed into Statistical Package for Social Sciences (SPSS) version 23 software and analyzed. χ2 and T-tests were used to test for significance, and a p-value of ≤0.005 was considered statistically significant.
| Results|| |
Sixty-one operations were carried out on 51 patients within this period. The ages of the patients at time of surgery ranged from 6 months to 27 years. Median age was 3 ± 4.9 years but the age with the highest frequency was 2 years accounting for 16.4% of the patients [Figure 1].
Frequency of types of hypospadias
The most frequent type seen was coronal hypospadias, occurring in 25 patients (41%), followed by glanular hypospadias in 7 patients (11.5%) and distal penile hypospadias in 6 patients (9.8%). The rarest forms were perineal hypospadias and proximal penile hypospadias seen in one patient (1.6%) each. Five patients (8.2%) each were seen with failed hypospadias repair and urethrocutaneous fistula [Table 1] and [Figure 2].
Type of surgery
Fifty-four (88.5%) were single-stage operations and 7 (11.5%) were staged procedures in patients with proximal hypospadias in association with male intersex, and those that had re-do repairs. The most common surgery performed was Snodgrass TIP urethroplasty done in 38 patients (62.3%) [Table 2].
Thirty-six patients (59%) had no complication whereas 25 (41%) had complications. The most common complications were urethrocutaneous fistula in 14 patients (23%) and surgical site infection in five patients (8.2%) [Figure 3].
| Discussion|| |
The acceptable age for repair of hypospadias is 6–18 months, with a trend toward earlier intervention based on anesthetic safety, genital awareness, and prevention of psychological embarrassment in the child., The age at repair in our institution was higher and significantly different. This is not an uncommon finding in Nigeria. Bello et al., in a review of hypospadias in Zaria, found that the mean age of patients at the time of surgery was 2 years. Similarly, Olajide et al. in Ile-Ife noted that even though majority of the patients presented within the first year of life, most of the repairs were done in the second, third, and fourth years of life. Our reason for the increased age at repair is mainly due to late presentation for surgery and anesthetic safety for an elective procedure in our environment. A pilot study done by Weber et al. found that there was no significant difference in psychological adjustment in patients who had surgery done before or after 18 months.
Our finding that coronal hypospadias is the most common type is in keeping with the publications of Nwako and Gatti.
Snodgrass TIP is the most frequent surgery performed for hypospadias repair at UNTH. The patients who had other surgeries were either part of a re-do for failed repair or staged repair in association with male intersex or had modified circumcision for glanular hypospadias. Idiodi-Thomas et al. in Lagos stated that TIP was the most common surgical procedure offered in 73.8% of their patients. Similarly, Aisuodionoe-Shadrach et al. in their experience in Abuja also cited Snodgrass as the most common surgery done on their patients accounting for 52.5% of the cases. In contrast, Olajide et al. in Ile-Ife reported preputial island flap and Mathieu’s peri-meatal based flap as the most common surgeries performed in their center on 43.1% and 31.4% of the patients, respectively.
Our rate of post-operative urethrocutaneous fistula has markedly reduced with TIP urethroplasty and the modification of adding a Dartos layer between the neo-urethra and skin. In a clinical review of the Snodgrass hypospadias repair, Holland et al. also reported high success rate with this modification. Similarly, Hombalkar et al. reported favorable outcomes in their case series of Snodgrass hypospadias repair citing relative simplicity of the operative concept, low complication rate, and good cosmetic result.
| Conclusion|| |
Snodgrass TIP urethroplasty has proven to be successful in UNTH over the years. As more modifications and techniques arise, we hope to build on the framework already in existence to further improve our success.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agugua-Obianyo NEN Short notes on hypospadias. In: Agugua-Obianyo NEN, editor. An atlas of paediatric surgery in the tropics (AAPS). Enugu: Immaculate Publications Ltd; 2013. pp. 194-201. ISBN: 978-036-567-2.
van der Horst HJR, de Wall LL Erratum to: Hypospadias, all there is to know. Eur J Pediatr 2017;176:1443.
Gatti JM Hypospadias. Available from: http://www.emedicine.medscape.com. Updated June 16, 2019. [Last accessed on 2019 Aug 15].
Snodgrass W Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.
Snodgrass WT Snodgrass technique for hypospadias repair. BJU Int 2005;95:683-93.
Bello A, Hussaini MY, Kura MM, Muhammed A, Tijjani LA Hypospadias: 10 year review of outcome of treatment in pediatric urological practice. Sub-Saharan Afr J Med 2015;2:28-32.
Olajide AO, Sowande AO, Salako AA, Olajide FO, Adejuyigbe O Challenges of surgical repair of hypospadias in Ile-Ife, Nigeria. Afr J Urol 2009;15:96-102.
Weber DM, Schonbucher VB, Gobet R, Gerber A, Landolt MA Is there an ideal age for hypospadias repair? A pilot study. J Pediatr Urol 2009;5:345-50.
Nwako F A combined one-stage urethroplasty in the treatment of hypospadias. J Pediatr Surg 1974;9:467-70.
Idiodi-Thomas HO, Ademuyiwa AO, Elebute OA, Alakaloko FM, Bode CO Factors influencing waiting time in hypospadias repair surgery. Niger Postgrad Med J 2016;23: 21-4.
Aisuodionoe-Shadrach OI, Atim T, Eniola BS, Ohemu AA Hypospadias repair and outcome in Abuja, Nigeria: A 5-year single-centre experience. Afr J Paediatr Surg 2015;12: 41-4.
Holland AJA, Smith GHH, Cass DT Clinical review of the ‘Snodgrass’ hypospadias repair. Aust NZ J Surg 2000;70:597-600.
Hombalkar NN, Gurav PD, Dhandore PD, Parmar RR SNODGRASS procedure—A versatile technique for various types of hypospadias repair. J Krishna Inst Med Sci Univ 2013;2:116-22.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]