Single-step
correction of hypospadia using hemostatic plate
Alchinbaev M.K., Kussymzhanov S.M., Kabdoldin
K.N., Toktabayanov B.G., Abzalbekov A.Z.
Background
Study of the results of surgical correction of hypospadia using
urethroplasty, in accordance to data of domestic and foreign authors, shown
that the therapeutic issue for this malformation is still not solved, as
various failures during post-operative period approximate to 10-50%. The most common
complications after urethroplasty are urethral fistulas, which occur almost in
all urethroplasty types. The local tissue ischemia with following necrosis,
artificial urethra marginal disadaptation, rough suture material, tissue injury
by surgical instruments, infection, inadequate post-operative urinary derivation,
inappropriate dressing application etc., could be assigned to urethral fissures
causes.
Study
objective. Main objective of our study was to improve the surgical treatment results
in hypospadia pediatric patients using single-step correction.
Study
tasks:
1.
To develop the methods and improvement
of the single-step correction of hypospadia technique
2.
Analysis of the results of single-step
treatment of hypospadia
Study
material and methods
The
results of examination and treatment collected from 40 pediatric patients aged
from 1 to 15 years, who underwent single-step correction of hypospadia and haemostatic
plate application, were taken as a basis.
For correction of hypospadia in
children the following surgical techniques were used: Dupley, Ñ.W.Snodgrass, Duckett, and MAGPI.
Table
3. Distribution of patients underwent surgery by hypospadia type according to
age.
|
Age, years |
Clinical types of hypospadia |
Total |
||
|
Glandular |
Mid-shaft |
Mid-scrotal |
||
|
1-3 |
1 |
5 |
3 |
9 (22,5%) |
|
4-7 |
2 |
7 |
2 |
11 (27,5%) |
|
8-12 |
3 |
8 |
6 |
17 (42,5%) |
|
13-15 |
- |
2 |
1 |
3 (7,5%) |
|
Total (%) |
6 (15%) |
22 (55%) |
12 (30%) |
40 (100%) |
Using
one out of mentioned above techniques we were successful in single-step elimination
of glandular, mid-shaft, and in some instances, mid-scrotal types of
hypospadia, in dependence on plastic material reserve. The main principle of all
single-step techniques used in the clinical practice, is a complete denuding of
penile cavernous bodies, which allows to more careful resection of the bridle,
skin dysplasia degree assessment, and preparation of plastic material reserve
for main and final stages of the surgery – urethroplasty and penile closure.
Table 5.
Distribution
of patients underwent surgery by hypospadia type according to surgical approach
|
|
Clinical types of hypospadia |
Total (%) |
||
|
Glandular |
Mid-shaft |
Mid-scrotal |
||
|
W. Snodgrass |
|
11 |
|
13 (32,5%) |
|
Duckett |
|
|
5 |
5 (12,5%) |
|
MAGPI |
6 |
|
|
6 (15%) |
|
Dupley |
|
18 |
|
16 (40%) |
|
Total: |
6 (15%) |
29 (72,5%) |
5 (12,5%) |
40 (100%) |
Considering the high incidence of post-operative complications we
have improved the surgical approach in hypospadia using application of haemostatic
plate onto sutures of the formed urethra. The technique of urethra formation by
Snodgrass was used as prototype.
Surgical technique:
Penile
balanus is taken at catgut holder, chordal lamina is dissected longitudinally,
with dissection of the external orifice of the urethra approaching penile balanus,
providing sufficient plastic material.
The subcutaneous
fascia formation technique: four holders are applied onto the internal preputial
leaflet by such a way, that in transversal direction the length of strained part
was 5-6 cm. Using assigned lines the flap is exsected together with
subcutaneous fatty tissue, with attempts to not alter the vascularization of
the skin form penile dorsal surface.
Using thin scissors the flap is separated together with subcutaneous fatty
tissue from the external preputial leaflet with direction to penile base, and therefore, forming the vascularised
pedicle. Generally, the vessels in the pedicle, are well seen. It is essential
during the separation of internal and external preputial leaflets to preserve
their supplying vessels. Ischemic
flap margins are resected. The resulting flap on supplying pedicle is transferred
onto ventral surface, and then the hemostatic plate is applied onto sutures aiming
hemostasis and strengthening. A plate, which is preliminarily moisturized by
physiological saline, is placed onto the suture region, pressed using dry towelette
for 5 minutes. After this the towelette is accurately removed, and the control
of hemostasis and adhesion quality is performed. Nodular vicrylic sutures are
applied onto the skin.
Correction of the
anterior hypospadia type with hypospadia meatus location on penile glance and
in the region of coronary sulcus was performed using MAGPI technique.
11 patients with
mid-shaft form underwent surgical intervention according to W.Snodgrass technique using haemostatic plate, of them in 1 child the
urethral fissure was formed, and in 1child the urethral suture line disruption occurred.
Duckett
method
was used for single-step
correction of mid-scrotal and mid-shaft hypospadia type. We used this technique
even in severe hypospadia types with significant skin deficit. 5 patients underwent
surgical intervention using this technique, 4 patients were discharged with
complete recovery, of them in 1 child urethral stenosis occurred in the
anastomosis region, which was eliminated using bougienage. Surgical intervention
using Dupley technique was performed in 18 patients, of them urethral fissure
occurred in 2, and wound margins diastase, eliminated surgically in 6 months,
in 1.
Table
6. characteristics of complications after single-step urethroplasty
|
Correction
methods |
Stenosis |
Fissure |
Pyogenesis and
wound margins diastase |
Urethral suture line
disruption |
|
W. Snodgrass |
|
1 |
|
1- |
|
Duckett |
1 |
|
|
|
|
MAGPI |
- |
1 |
- |
|
|
Dupley |
- |
2 |
- |
1 |
|
Total: |
1(2,5%) |
4 (12,5%) |
|
2 ( 5%) |
Transurethral deprivation was conducted for 3-14 days
according to surgical technique. After surgery by MAGPI urinary derivation was performed
for 3-4 days, after surgery by Snodgrass – for 7-10 days, and after Duckett
technique – for 10-14 days. After finishing the surgery and toilet of the penis
with jodonate 3%, a compressive towelette moisturized by vegetable oil was
applied. Compression dressing was applied for the period from 4 to 7 days,
thereafter the dressing change was performed with preliminary moisturizing of
the latter by furacillin solution. Thereafter the dressing change was performed
daily.
Antibacterial
therapy in post-operative period was conducted using oral sulfanilamide drugs
(trimethsulphate, sulphatrim, etc) for 6-7 days with following transition to
uro-antiseptic drugs for 10-14 days.
Conclusion
Thus, an analysis was performed concerning various surgical techniques
for treatment and prophylaxis of post-operative complications in hypospadia pediatric
patients with developing the criteria of correction techniques efficacy, allows
to conclusion that good results were achieved using techniques MAGPI,
Duckett, Duplay, in combination with decutanization of the penis, and single-step
surgery by Snodgrass. Using the haemostatic plate during both single-step or
staged surgical correction of hypospadia is a prospective technique, and
requires following studies.
Implemented single-step
techniques for correction of hypospadia allows to elimination of developmental
malformation at earlier time (from 1 year) almost in any type of this
malformation.
Correction of hypospadia by
single-step plastic techniques using haemostatic plate decreased the incidence
of post-operative complications from 40.86% to 20%, and number of repeated
hospital admissions and general anesthesia 3-fold. Skin of the dorsal penile
surface and preputial sack used for artificial urethra formation possesses
optimum features for favorable healing. Using thin atraumatic suture material
(polydioxanone or vecryl 6/0-7/0) allows to better healing of the artificial
urethra.
Transurethral urinary
derivation is effective for post-operative urine derivation. It is necessary to
use compression dressing in early post-operative period for 4-7 days, which
prevents tissue edema and allows to optimum healing of the formed urethra. Bladder
drainage using urethral catheter is reasonable after urethroplasty for the
period from 7 to 10 days.
Post-operative use of
sulphanilamide drugs is sufficient and effective preventive means for
post-operative inflammation.