Repair of Distal hypospadias with foreskin reconstruction provides a better anatomical penile appearance with a Favorable OutcomeHisham Hussein, MD & Ashraf Abdel Aal MD*Departments of General Surgery & Urology, Faculty of Medicine, Benha UniversityAbstractTo evaluate the short-term surgical and cosmetic outcome of hypospadias repair using tubularized incised plate urethroplasty (TIPU) with foreskin reconstruction (FSR) in children with distal hypospadias, 50 children with distal hypospadias were categorized according to parental preference either to have TIPU only or to have TIPU with FSR and to be circumcised one-month later. Mothers were trained for the frequent postoperative meatal dilatation and preputial retraction. Patients were followed-up weekly for one-month for the occurrence of complications related to either urethroplasty or FSR. Parents' satisfaction concerning the cosmetic appearance of the penis after FSR and prior to circumcision was inquired. Eleven children had glandular and 39 had coronal hypospadias; 30 children had TIPU and FSR, and 20 children had TIPU only. Five patients (10%);3 had TIPU only and 2 had TIPU & FSR required redo surgery for repairof urethrocutaneous fistula. Only 3 patients who had FSR developed phimosis but was not hampering meatal dilatation. One patient had FSRgapping and was readmitted for circumcision at 2 weeks after surgery.Two patients in TIPU group required removal of redundant skin. Parents of all patients had FSR were highly satisfied by the appearance of the penis after surgery and liked regaining of its normal anatomical appearance. TIPU and FSR is a simple and safe procedure for distal hypospadias repair with minimal morbidities and a higher satisfaction rate for both children and parents; so, if the objective of distal hypospadias surgery is to restore a penis with anappearance as normal as possible, prepuce reconstruction should constitute a key element of the final result. Keywords: Distal hypospadias, TIPU, Foreskin reconstruction

IntroductionHypospadias is a common developmental disorder of the

urogenital tract, occurring in approximately 1 in 125 live male births. Defined as an atypical urethral opening anywhere along the shaft of the penis, scrotum, or perineum, hypospadias is often associated with a deficient prepuce and chordee. Hypospadias usually occurs as an isolated defect, butcan be part of a recognized syndrome or associated with other genital anomalies, (1).

Hypospadias constitute major challenges both functional and psychological, parents may be aware about both, however, the psychological impact on the child was great especially if

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hypospadias was not repaired till school age. In communities where circumcision was conducted for religious or traditional requirements and in these communities where circumcision was prohibited for religious requirements, the presence of normally appearing complete circumferential prepuce is mandatory and this is the main source for the psychological burden, (2, 3).

Few studies have evaluated the outcome of preputialreconstruction; Haseebuddin & Brandes, (4) analyzed the role ofprepuce preservation in various penile disorders like peniledegloving procedures, phimosis or hypospadias repair, and alsopenile cancer resection, and found that there is no clearevidence that debilitating and persistent preputial lymphedemawill develop after a prepuce-sparing penile deglovingprocedure.

The current study aimed to evaluate the surgical andcosmetic outcome of hypospadias repair with foreskin reconstruction in children with distal hypospadias

Patients & MethodsAfter obtaining approval of the study protocol from the

Local Ethical Authority; the present study was conducted at Departments of General Surgery and Urology, Benha University Hospital and included 50 children with distal hypospadias assigned for tubularized incised plate urethroplasty (TIPU) with or without foreskin reconstruction (FSR). Patients' grouping was dependent on the parents wishes after explanationof the operative details and the probable advantages of FSR and the need for another setting for circumcision, then all parents signed a written fully informed consent.

The enrolled children had been submitted for general examination for other anomalies with special concern to the urogenital tract, and preoperative laboratory workup. Patientswho had urinary or respiratory tract infection were postponed till become fit. All surgeries were conducted as inpatient procedures under general endotracheal anesthesia. A single dose of third generation cephalosporin (50 mg/kg body weight) started with the induction of anesthesia and continued for thefirst 24h post-operatively. After completion of TIPU, 2 stay sutures were applied at the tip of the prepuce on both sides to allow maximal stretching of the prepuce, (Fig. 1a), a planewas opened at the mucocutaneous junction of both side-edges ofthe stretched prepuce and mucosa was fully dissected from the skin so as to create an inner mucosal flaps, (Fig. 2b) that had been sutured in the midline without tension enveloping theglans using 5/0 absorbable (Vicryl) suture material, (Fig.

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1c,d&e). Then, the outer skin flaps were closed as a separate layer for completion of prepuce reconstruction, (Fig. 1f) using 5/0 absorbable (Vicryl) suture material. After completion of reconstruction, retraction of the foreskin was tested so as to avoid prepuce stenosis, (Fig. 1g&h).

All patients were hospitalized for a period of 7 days under cover of an oral antibiotics, close follow-up and careful observation of the urinary catheter. During this period mothers were trained for the frequent preputial retraction to guard against the development of phimosis. Patients were followed-up weekly for one month and meatal dilatation was started two weeks after surgery using the tip of the medical thermometer to prevent the occurrence of urethroplasty complications; especially meatal stenosis. Thosehad FSR were observed for wound dehiscence, gapping prepuce, and the occurrence of phimosis, and they were prescribed localsteroid cream to be applied on the tip of the new prepuce to prevent phimosis and aid for easier retraction. One-month after surgery, patients who had FSR were readmitted for circumcision using the dissection method under light inhalational mask anesthesia,(Fig.2).

Parents' satisfaction concerning the cosmetic appearance of the penis after FSR and prior to circumcision was inquired using a satisfaction score: highly satisfactory, satisfactory and unsatisfactory.

Fig.1a; Fig1b;

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Fig1c; Fig.1d;

Fig.1e; Fig.1f;

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2

3b 1d

Fig.1g Fig.1h;Fig. (1): shows operative details for FSR after completion of TIPU

Fig. (2): shows penile appearance at 1-month later to TIPU and FSR after circumcision

ResultsThrough 2-year duration, 50 children with mean age of

3.3±1.5; range: 6 months-5 years were recruited in the study.Eleven children had glandular and 39 had coronal hypospadias. Thirty patients had TIPU and FSR, while parents of the other

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5b

20 children insisted on TIPU only. All children had smooth intraoperative course without complications. There was a non-significant difference between both groups as regards age, level of hypospadias or operative time, (Table 1).

Table (1): Children and operative data

TIPU only TIPU & FSR TotalNumber (%) 20 (40%) 30 (60%) 50 (100%)Age (years) 3.1±1.6

(0.5-5)3.4±1.5 (1-

5)3.3±1.5(0.5-5)

Level of hypospadias

Glandular

4 (20%) 7 (23.3%) 11 (22%)

Coronal 16 (80%) 23 (76.7%) 39 (78%)Operative time (min) 76.2±19.5

(45-115)81±19.8 (40-100)

79.1±19.6 (40-115)

Five children (10%); 3 who had TIPU only and 2 who had TIPU & FSR required redo surgery for repair of urethrocutaneous fistula. No patient had phimosis and only 3 children had FSR developed prepuce stenosis but was not hampering meatal dilatation. One patient had FSR gapping and was readmitted for circumcision at 2 weeks after surgery. Two children in TIPU group required removal of redundant skin, (Table 2, Fig. 2). Parents of all children had FSR were highlysatisfied by the appearance of the penis after surgery and liked regaining of its normal anatomical appearance.

Table (2): Postoperative complications

Complications TIPU only(n═20)

TIPU & FSR(n═30)

Total (n═50)

Urethrocutaneous fistula

3 (15%) 2 (6.7%) 5 (10%)

Phimosis 0 0 0Prepuce stenosis 0 3 (10%) 3 (6%)FSR gapping 0 1 (3.3%) 1 (2%)Redundant skin 2 (10%) 0 2 (4%)Total 5 (25%) 6 (20%) 11 (22%)

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Fig. (2): The frequency of postoperative com plications in patients categorized according to the procedure undertaken

0

5

10

15

20

25

30

35

TIPU & FSR TIPU

Patie

nts

0

1

2

3

4

5

6

7

Complica

tions

Total Com plications

DiscussionFrom the ethical point of view and being a Moslem country

where circumcision is a religious demand, all parents had consented to choice between one-stage repair of hypospadias and foreskin excision to achieve circumcised appearance or to undergo preliminary hypospadias repair and circumcision one-month later and parents' preference was the basis for childrengrouping.

All children, irrespective of foreskin management, underwent TIPU procedure and all had smooth intraoperative course without complications. The prophylactic frequent meataldilatation prevented postoperative stenosis and the prophylactic application of steroid cream to the opening of the reconstructed prepuce allowed easy retraction and so the ability for meatal dilatation. The success of these prophylactic measures supported that previously reported by Searles & MacKinnon, (5) who found dilatation of the urethral meatus can be taught successfully to boys or their families athome, thus avoiding repeated hospital attendance and often general anesthesia for dilatation of developing meatal phimosis and by Suoub et al., (6) who found initial retraction of

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the foreskin after prepuce reconstruction was successful in 15of 21 patients (71.4%) operated upon, while five of the remaining six (28.6%) who failed initial retraction responded to steroid cream, an outcome which indicated the success of prophylactic regimen as only 3 patients (10%) had prepuce stenosis but was not hampering meatal dilatation.

Postoperative urethrocutaneous fistula being the only hypospadias repair related complication and was reported in 5 patients (10%). This figure was in line with Cakan et al., (7) whoreported a frequency of fistula of 11% after TIPU. However, patients had TIPU & FSR showed lower frequency of postoperative fistula and this could be attributed to the coverage effect of prepuce after its reconstruction providing a new layer for protection that patients in the other group had missed. In support of such assumption, Thompson et al., (8) retrospectively studied a cohort of 11 children who underwent urethral repair and adjunctive full thickness inguinal skin grafts due to circumcision injuries (4 patients), traumatic urethral injury (1) or congenital lymphangiectasis (1), or forcongenital hypospadias with previous failed surgery (5) and reported only urethrocutaneous fistula and concluded that the use of full thickness inguinal skin grafts to resurface the penis is useful and justifies consideration in appropriately selected patients. However, the procedure applied in the current study was advantageous in dependence on the already preserved blood supply of the prepuce, while Thompson et al., (8) depended on neovascularization of the onlay graft. Also, Suoub et al., (6) compared the outcome of distal hypospadias repair with FSR but without dartos flap coverage versus repairwithout FSR but with dartos flap coverage and found no statistical difference in outcome between the two techniques, particularly regarding fistula complication. The complication particular to FSR, namely initial failure of foreskin retraction, responds adequately to steroid cream application.

Moreover, 2 patients had TIPU only required circumcision redo for excision of redundant skin with a 10% frequency of second setting for a complication not related to hypospadias repair, while only one patient (3.3%) in the other group required circumcision prior to the predetermined time, thus parents could not spare the second setting in these two children.

Parents' satisfaction by regaining the normal anatomical appearance of the penis in the early cases motivated for completion of the studied cases and this was the target of both patients especial in our Oriental community that respected the presence of prepuce that to be circumcised.

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The obtained results regarding the outcome of TIPU and FSR agreed with that reported in literature; Cimador et al., (9) assessed the risks related to preputial reconstruction and itsrelevance for parents of children undergoing hypospadias repair compared to those underwent circumcision and found no statistical differences in urethral complications between the two groups; urethral or meatal strictures occurred in 6.9% and7.4%, fistula in 5% and 3.7%, respectively and preputial reconstruction dehiscence and phimosis as specific complications of this procedure occurred in 3.7% and 6.2% of cases. Snodgrass et al., (10) reported their experience from 4 institutions in the reconstruction of the foreskin during penile surgery and reported that among 49 hypospadias repairs 2 patients had dehiscence of the reconstructed foreskin, with development of a urethral fistula in one and concluded that FSR in association with penile surgery can be performed safelyand with a low complication rate. Bhatti et al., (11) retrospectively analyzed the results of preputial reconstruction combined with hypospadias repair in 35 patientsand found 28 (80%) patients had an anatomically normal penis with a normal retractable foreskin, while 3 (8.25%) had complication of the reconstructed foreskin and 4 (10.4%) had complications with the reconstructed urethra in four (10.4%) and on follow up parents were generally satisfied with the results.

Also, Shimada et al., (12) evaluated the short-term results of FSR associated with hypospadias repair and reported fistulain 2 patients and mild stenosis of the glandular urethra in one patient and complications related to FSR included dehiscence of the ventral foreskin in 2 patients, but in all cases parents were well satisfied with the reconstructed prepuce. Leclair et al., (13) evaluated the morbidities of the context of distal hypospadias repair surgery, prepuce reconstruction as an alternative to circumcision and reported partial or complete disunion of the reconstructed prepuce in 18 (6%) cases, mainly early in the authors' experience, and in9 occurred in a more general context of failure of hypospadiasrepair surgery, secondary phimosis was observed in 40 cases, 12 months after the operation and topical corticosteroids (betamethasone 1.0% cream) allowed normal foreskin retraction in 85% of cases and concluded that prepuce reconstruction performed in the context of distal hypospadias repair surgery is responsible for a low rate of specific morbidity. Papouis et al., (14) investigated the risk of simultaneous repair of distal hypospadias and preputioplasty in one operation and its relevance to the clinical, functional and cosmetic outcomes

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and reported urethral or meatal stricture in 3.8%, fistulas appeared in 6.4%, phimosis appeared in 3.8% and foreskin dehiscence in 2.5% and concluded that preputioplasty together with distal hypospadias repair is feasible without risking thesuccess of the main operation and guaranties a satisfactory cosmetic appearance.

It could be concluded that TIPU and FSR is a safe procedure for distal hypospadias repair with minimal morbidities and a higher satisfaction rate for both children and parents and achieved the cultural target. So, if the objective of distal hypospadias surgery is to restore a penis with an appearance as normal as possible, prepuce reconstruction should constitute a key element of the final result.

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10. Snodgrass, W.T., Koyle, M.A., Baskin, L.S., Caldamone, A.A.: Foreskin preservation in penile surgery. J Urol., 2006; 176(2):711-4.

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12. Shimada, K., Matsumoto, F., Matsui, F., Takano, S.: Prepuce-sparing hypospadias repair with tubularized incised plate urethroplasty. Int J Urol., 2008; 15(8):720-3.

13. Leclair, M.D., Benyoucef, N., Houry, Y.: Morbidity of foreskin reconstruction in distal hypospadias repair surgery. Prog Urol., 2008; 18(7):475-9.

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