PEDIATRIC UROLOGY

Quality assessment of hypospadias repair with emphasis on techniques used and experience of pediatric urologic surgeons
Chrzan R, Dik P, Klijn AJ, de Jong TP.
Department of Pediatric Urology, University Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
Urology. 2007; 70:148-52

• Objectives: To assess outcomes in hypospadias repair at our institution, as compared with the literature, with repair technique and surgeon considered as risk factors.
• Methods: The results of 299 primary hypospadias corrections were analyzed. All procedures were performed by three experienced pediatric urologists. Mean patient age at operation was 16.3 months. Follow-up was between 6 months and 5.5 years. Distal hypospadias repair was carried out in 242 patients, with tubularized incised plate reconstruction in 100 patients, advancement in 128, and the Mathieu technique in 14.
• Results: During follow-up, complications occurred overall in 93 patients (31%). For distal hypospadias complications occurred in 59 patients (24%). The most common findings for distal hypospadias were urethral fistulas (14.4%). The complication rate depended on the severity of the anomaly (0 glanular, 28% pericoronal, and 63% proximal) and the chosen technique (16% advancement technique versus 60% tubular techniques). We found statistically significant differences in complication rates between operating surgeons.
• Conclusions: Complications after hypospadias surgery are frequent. They are multifactorial and depend mainly on the type of the anomaly, the chosen technique, and the experience of the surgeon. More studies are needed to obtain an internationally accepted quality indicator for the outcome of hypospadias repair.
  
  
• Editorial Comment
  These authors reviewed 299 primary hypospadias repairs over a five year period with a special emphasis on the technique used and the experience of the pediatric urologic surgeon, with a mean follow up of 29 months and with a very critical eye for complications. The mean age of surgery was 16.3 months.
  Tubularized incised plate technique was used in 133 patients and advancement techniques not requiring sutures in the urethra were used in 128 patients with 38 patients having miscellaneous techniques. Prophylactic antibiotics were given. Stenting was left to the choice of the individual surgeons. All procedures were performed with loupe magnification.
  The groups were analyzed according to technique used and with respect to the three operating pediatric urologic surgeons. All glanular hypospadias patients did uniformly well. 93 patients, or 31% of the patients had a complication after surgery. 7% have recurrent problems that required more than one surgical intervention. 18% were fistulas, partial dehiscence of the wound or glans resulting in meatal retraction was 7.4% and urethral stenosis was 2%. Complication rates were higher the further away from the tip of the penis that the hypospadias meatus was, which is not surprising. Advancement techniques had a complication rate of 16%, while tubular reconstructions had a complication rate of 56%. Tubularized incised plate urethroplasties had a complication rate of 27%. When tubularized incised plate was used for hypospadias on the shaft of the penis, the complication rate was 66% and when it was used for distal hypospadias, it was 35%.
  The pediatric urologist who had the most experience had a statistically significant better success rate for hypospadias repairs than the pediatric urologist with the least experience. 24% complication rate was noted in the hands of the most experienced surgeon and 40% complication rate in the least experienced surgeon.
  At first glance this manuscript seems to have a high complication rate, however all patients that had a single-staged hypospadias reconstruction were included and complication rates are higher in the studies that include all patients rather than those that deal with a single technique. The authors should be congratulated on their attention to the detail of the complications and their honest reporting.
  Of note for students of hypospadias, when the tubularized incised plate urethroplasty was used for mild hypospadias, it was very successful, however when it was extended to more severe hypospadias patients it was not.
  It has always been my belief that hypospadias complications are directly proportional to the length of the repair and this study seems to validate that relationship also. There is some speculation in the study about the learning curve, since the newest member of the faculty member had a higher complication rate than those who had been there for 5 and 14 years. In some respects, it is encouraging to note that within 5 years the experience seems adequate to have very good results.

Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA