Hypothesis / aims of study
In our part of the world, many patients present with hypospadias in adult age, where results are often poor and associated with increased complications. Undoubtedly, patients with primary hypospadias should undergo repair between 6 and 12months of age, as recommended by the American Academy of Pediatrics. Nevertheless, in developing countries like India with such a high rate of illiteracy and ignorance, many patients seek attention in adulthood. Complications of hypospadias surgery are more in the later age than in children. Adult hypospadias repair is associated with a longer healing time, higher risk of infections due to hair growth in the penile area, more pain, and bleeding due to nighttime erections. Understanding the risk factors associated with the complications of hypospadias surgery among adults may help in achieving better outcomes. This study was conducted to assess the late complications of single-stage hypospadias surgery in adults.
Study design, materials and methods
A prospective observational study was conducted at the Department of Urology & Renal Transplant of a tertiary care hospital from February 2018 to August 2019 after approval from the Institutional Ethical Committee [No. 262 (35/2018)]. All hypospadias patients >12years of age were included in this study, and a written informed consent was obtained. Hypospadias cripples (>2 failed hypospadias surgeries), patients with previous unsuccessful repair in the last 12 months, and those undergoing staged repair were excluded from this study. All patients were operated on by a single experienced surgeon, who had an experience of more than 100 hypospadias surgeries. The type of surgery to be performed was decided based on various factors like urethral plate width and degree of chordee, location of hypospadias, glans width, etc.
Relevant predictive factors such as history of previous hypospadias surgery and local examination findings were obtained. Necessary investigations including uroflowmetry were done with optional studies such as RGU/ MCU and cystoscopy when required. Appropriate surgery was performed for each patient, and intraoperative factors such as degree of chordee and spongiofibrosis were noted. Late (after 1 month) complications were studied. Patients were assessed clinically at 1, 3, and 6 months postoperatively and with uroflowmetry. Successful surgery was defined as any patient having all three parameters at 6 months of follow-up: (a) cosmetic—meatal opening in the glans, (b) clinical—clinically satisfied patient voiding well, and (c) investigative—flow on uroflowmetry >12 mL s. Data analyzed using SPSS version 21.0 (IBM SPSS Corp.; Armonk, NY, USA).
Results
50 patients with hypospadias (primary and secondary) were reported during the study period. Of these, 31 patients were enrolled in this study, while 19 patients were excluded (nine crippled hypospadias, seven underwent staged repair, and three refused surgery). Of the 31 patients enrolled, 12 (38.7%) patients had a history of previous hypospadias surgery, while 19 (61.29%) patients were naive. Distributions of pre-operative and Intra-operative parameters are given in Tables 1 and 2.
At the 6month follow-up, urethrocutaneous fistula, glans dehiscence, and urethral stricture were present in eight (25.8%), five (16.12%), and four (14.89%) patients, respectively. Patients were divided into two groups: Group A—patients with complications (n = 17) and Group B—patients without complications (n = 14). Group A had less mean glans width (16.17 mm vs. 19.21 mm) and less mean urethral plate width (5.94 mm vs. 7.35 mm) compared to patients of Group B (statistically significant). There were more patients with poorly developed spongiosum (57.89% vs. 42.11%), history of previous surgery (83.33% vs. 16.67%), and flat urethral plate (76.47% vs. 23.53%) in Group A (statistically significant). The mean stretched penile length (7.88 cm vs. 8 cm), chordee, type of hypospadias, presence of penile torsion, presence of scrotal transposition, type of surgery, and barrier used were comparable between the two groups.
Interpretation of results
On univariate logistic regression analysis, parameters comprising glans width (P < .0001), urethral plate shape (P = .011), urethral plate width (P = .005), and history of surgery (P = .018) were found to be significantly associated with post-surgery complications.
With an increase in glans width and urethral plate width by one unit, risk of post-surgery complications decreased by 98.9% and 77.5%, respectively. On the other hand, patients with a history of surgery and flat urethral plate had significantly higher chances of post-surgery complications with odds ratio of 8.571 and 8.125, respectively.
Furthermore, on multivariate logistic regression analysis, glans width (P < .0001) was the only parameter found to be significantly associated with post-surgery complications. On increasing the glans width by one unit, risk of post-surgery complications decreased by 80.3% with an adjusted odds ratio of 0.197.
Concluding message
Several factors are associated with significant complications in adult hypospadias single stage repair. Small glans width, flat urethral plate, small urethral plate width, history of previous failed repair, and poorly developed spongiosum were found to be significant on univariate analysis, whereas glans width was the only significant factor on multivariate analysis.
Our study was limited by a small sample size and short-term follow-up of patients. This study being an observational study is prone for observer bias.