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Case report

Profile of hypospadias patients at Saiful Anwar General Hospital Malang

Profile of hypospadias patients at Saiful Anwar General Hospital Malang

Pradana Nurhadi1,&, Ryan Akhmad Adhi Saputra1


1Department of Urology, Medical Faculty, Brawijaya University Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia



&Corresponding author
Pradana Nurhadi, Department of Urology, Medical Faculty, Brawijaya University Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia




This study aimed to determine the profile of hypospadias patients in Saiful Anwar General Hospital. This study is a descriptive study with a retrospective cross-sectional approach, using data taken from medical records from January 2012 to December 2015. Thirty-four samples were taken from a population in the Urology Ward that met the inclusion criteria, using medical records as a measure of the study; data were analyzed using descriptive analysis. A total of 34 patients were evaluated and had corrective surgery. The mean age and body mass index at the time of surgery were 8.5 ± 6.2 years and 16.6 ± 12.7, respectively. Penoscrotal hypospadias was more common in 15 patients (44.1%), followed by scrotal in four patients (11.7%), proximal penile in three patients (8.8%), midshaft in three patients (8.8%), distal penile in three patients (8.8%), subcoronal in three patients (8.8%), and glandular in three patients (8.8%). Associated anomalies included maldescended testicles, bifid scrotum, and inguinal hernia in six (17.6%), two (5.8%), and one (2.9%) cases, respectively. Maldescended testicles were more common in penoscrotal hypospadias (85%). Operative techniques were single-stage procedures in 28 (85.3%) patients, consisting of a Snodgrass tubularized incised plate in 26 cases (76.4%), dorsal inlay preputial graft in two cases (5.8%), and Mathieu's perimeatal-based flap in one case (2.9%). Seventeen patients (50%) had multi-stage procedures. The most common post-operative complications were urethrocutaneous fistula, found in seven patients (20.5%). Penoscrotal hypospadias is the most numerous type of hypospadias, and the most common associated anomaly is maldescensus testis. The surgical technique most commonly used is one-stage urethroplasty with a tubularized incised plate. Aurethrocutaneous fistula is the most common complication of hypospadias repair.



Introduction    Down

Hypospadias is a congenital abnormality in boys caused by a delay in growth of the penis during fetal development, which makes the urethral opening more proximal to the glans penis; chordee also appears. Hypospadias surgical technique is a challenge for reconstruction surgeons, especially urologists, to create a new urethra while eliminating chordee and closing the defect in the ventral penile skin; it can achieve restored function and esthetics [1]. Hypospadias is characterized by a triad of anatomical abnormalities of the penis, namely: (1) the layout of the external urethral meatus is abnormal, on the ventral penis, ranging from the glans to the perineum; (2) curvature towards the ventral penis (chordee); (3) abnormal prepuce with hood on the dorsal penis, and deficiency on the ventral penis [1-3]. The prevalence of hypospadias is one case out of 300 live births in boys. The etiology of hypospadias is unknown, although 20-25% report no hereditary association [2, 4, 5]. Hereditary factors are also influential; when the father has hypospadias, the chance of children also having it is approximately 1-3% and approximately 9-17% of older siblings of the child have hypospadias [1]. The disorder is caused by endocrine imbalance, often associated with a decline in androgen and an increase in progesterone. The use of progestational hormones in early pregnancy is likely to be the cause. Pregnancy in older women could also be the cause, especially if the pregnancy is for a first child. Lately, more environmental factors have been suspected as the cause of hypospadias. It is associated with exposure of pregnant women to materials such as insecticides, medicines, and plants containing estrogen [5].



Patient and observation Up    Down

This research is a descriptive study with a cross-sectional retrospective approach, using data collected from medical records at Saiful Anwar General Hospital Malang from January 2012 to December 2015. Thirty-four samples meeting the inclusion criteria were analyzed using descriptive analysis. During the period January 2012 to December 2015, records were obtained for 34 hypospadias patients at the Saiful Anwar General Hospital Malang; their characteristics are shown in Table 1. Hypospadias patients' age during surgery at Saiful Anwar General Hospital Malang from January 2012 to December 2015 ranged from 1 to 33 years, with an average of 10.7 + 8.3 years; most were in the age range 6-10 years (13 patients, 38.2%), and only one (2.9%) was over 20 years old. Most patients with hypospadias had the penoscrotal type (15 patients, 15.1%). The second most prevalent was the scrotal type (four patients, 11.7%), followed by glandular, subcoronal, penile distal, mid-penile shaft, and proximal penile types (three patients each, 8.8%). A total of six patients (17.6%) had UDT as a comorbidity, while two (5.8%) had a bifid scrotum, and one (2.9%) had an inguinal hernia. Twenty-eight patients (82.3%) had a one-stage operation; only six patients (17.6%) underwent two-stage surgery, where urethroplasty was done at least 6 months after cordectomy. In this study, the surgical technique TIP was most widely used (26 patients, 76.4%), followed by engineering a preputial dorsal inlay graft in two patients (5.8%), and Mathieu's perimeatal-based flap in one patient (2.9%). Operative complications such as urethrocutaneous fistula were found in seven patients (20.5%).



Discussion Up    Down

The results show that 34 patients with hypospadias were treated at Saiful Anwar General Hospital from January 2012 to December 2015. Psychologically, hypospadias should be operated on before the child reaches school age, and it is mostly done before the age of 2 years. The ideal age for genital surgery is 6 weeks to 12 months. Based on research conducted by Weber et al. [6], psychologically significant differences were not found between patients operated on under the age of 18 months and those who had surgery at an age above 18 months. Penis length grows by 3mm per year between the ages of 5 months and 5 years, so that in the period before school, age is not a relevant factor for surgery [7]. In this study, the biggest group of patients was those who underwent surgery at between 6 and 10 years old (13 patients, 38.2%). According to some literature, approximately 20% of all patients with hypospadias have the penoscrotal type [3, 5]. In accordance with the literature, in this study, penoscrotal type accounted for 15 patients (15.1%). Comorbid disorders that can be found in cryptorchidism or hypospadias include undescended testicle, retractile testicle, upper urinary tract abnormalities, and intersex. An undescended testicle is found in 9% of all cases of hypospadias [4, 5]. In this research, undescended testicle was the most common comorbidity (six patients, 17.6%). Twenty-eight patients (82.3%) had one-stage surgery, and only six patients (17.6%) underwent two-stage surgery, where urethroplasty was performed at least 6 months after cordectomy. In some severe chordee cases, the urethral plate had to be eliminated. In this case, the best final result of surgery can be achieved through a gradual operation. The aim in the first stage of surgery is to straighten the penis through chordee correction. The second stage is to make a new urethra 6 months or more after the first stage of surgery [5].

Some literature mentions that the TIP surgical technique is used most often in both distal and proximal types of hypospadias. With preservation of the urethral plate, it is a very familiar technique used by the urologist. This TIP technique has complications in 13-16% of cases. In cases where the prepuce is insufficient, an onlay preputial island flap technique can be used, or if the urethral plate cannot be preserved, a tubularized preputial island flap can be used [1, 7]. In this study, the TIP surgical technique was most widely used (26 patients, 76.4%). Postoperative complications that often occur are divided into short-term (edema, hemorrhage, necrosis of the glans penis, wound dehiscence) and long-term (urethrocutaneous fistula, urethral opening stenosis, urethral stricture, torsion of the penis) complications. Aurethrocutaneous fistula is a complication that happens quite often. In general, fistula occurs in less than 10% of cases, but the risk of severe hypospadias fistula is approximately 40%. If there is poor vascularization, the surgical technique used to close the flap layer has to be sufficient for the blood flow, to ensure better vascularization [5]. Surgical complications in this study were known to be urethrocutaneous fistula in seven patients (20.5%). To avoid any complications, the surgical technique must be precise, well and carefully done, the appropriate suture selected, and good suture closure achieved. Postoperative antibiotics can be given to reduce the incidence of urinary tract infections [3]. Limitations of this study are mainly related to difficulty in finding patient medical records. Many patients' medical records were empty or hard to find, and some were incomplete.



Conclusion Up    Down

Hypospadias surgery was performed on 34 patients in Saiful Anwar General Hospital Malang from January 2012 to December 2015. The most common hypospadias comorbidity of patients in this study was UDT, found in six patients (17.6%). The urethroplasty technique most widely used in this study was a tubularized incised plate (76.4%). Other techniques used were dorsal inlay preputial graft (two patients, 5.8%) and Mathieu's preputial island flap on (one patient, 2.9%). In this study, the most common surgery complication was urethrocutaneous fistula, found in seven patients (20.5%).



Competing interests Up    Down

The authors declare no competing interests.



Authors’ contributions Up    Down

Pradana Nurhadi performed the study design and conception and Ryan Akhmad Adhi Saputra contributed to the editing and final approval of the article. All authors read and approved the final manuscript.



Table Up    Down

Table 1: characteristics of patients in Saiful Anwar General Hospital Malang from January 2012 to December 2015



References Up    Down

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  2. Siroky MB, Oates RD, Babayan RK. Handbook of Urology: diagnosis and therapy. Philadelphia, Lippincott Williams & Wilkins. 2004. Google Scholar

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