Hypospadias Repair: Outcome and Objective Evaluation with Hypospadias Objective Scoring Evaluation (HOSE), Hypospadias Objective Penile Evaluation (HOPE) and Pediatric Penile Perception Score (PPPS) from Parents Perspective and Preference in COVID-19 Era Текст научной статьи по специальности «Клиническая медицина»

АНДРОЛОГИЯ ANDROLOGY

И ГЕНИТАЛЬНАЯ ХИРУРГИЯ AND GENITAL SURGERY JL 2 0 2 4

ТОМ 25 / VOL. 25

DOI 10.62968/2070-9781-2024-25-1-65-72

Hypospadias Repair: Outcome and Objective Evaluation with Hypospadias Objective Scoring Evaluation (HOSE), Hypospadias Objective Penile Evaluation (HOPE) and Pediatric Penile Perception Score (PPPS) from Parents Perspective and Preference in COVID-19 Era

MR Yusof 3, Khairul-Asri MG34, Ahmad Faiz NMG1, MZ Zakaria2, Mohamed Ashraf MD12

1 Urology Unit, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

2 Urology Unit, Department of Surgery, Hospital Universiti Sains Malaysia, Kelantan, Malaysia 3Department of Urology, Hospital Pengajar Universiti PUTRA Malaysia, Serdang, Malaysia

4Department of Urology, Faculty of Medicine and Health Sciences, Universiti PUTRA Malaysia Serdang, Malaysia

Address for

Correspondence: Dr Mohamad Ashraf bin Mohamad Daud, Urology Unit, Department of Surgery, Hospital Universiti Sains Malaysia, Kelantan, MALAYSIA E-mail: mashrafmdaud@gmail.com SUMMARY Introduction. Hypospadias is a common congenital abnormality. It may also be associated with other urogenital

tract abnormalities. Literature has described more than 300 techniques being used. An objective evaluation is useful for attending doctor and parents to ensure both understands detection of complication and to assess post operative satisfaction from both sides are similar. Thus study sought to assess the outcome of hypospadias repair with objective scoring evaluation from parents' perspective during COVID-19 era.

Methods. This was a retrospective study of all patient post-hypospadias repair in Urology Unit, Hospital Universiti Sains Malaysia from January 2020 to December 2022 during the Covid-19 period. All patient medical records were reviewed. Data analyzed for demographic, surgical treatment, complications, and objective evaluation with HOSE, HOPE and PPPS questionnaire and parents preferred questionnaire to be used using Microsoft Excel for Windows 2003 and qualitative variables were presented as frequencies and simple percentages.

Result. Hypospadias A total of 21 pediatric patients operated. The mean age during surgery was 7.2 years old. Distribution of glanular 6 patients, distal 3 patients and majority are proximal hypospadias with 12 patients (57.2%). Proximal hypospadias, 6 proximal penile and 6 penoscrotal. Single stage repair 18 patients and 2 patients had scrotoplasty performed a and 3 patients had two stage repairs. Majority of single stage surgery performed was TIP and two stage repairs done with >-

Bracka's technique. Overall mean follow-up time 16.78 month. Three patients had UCF with 14.3%. Questionnaire with "re

HOSE showed mean score 14.38. The HOPE questionnaire showed mean score of 54.71 and PPPS mean score was 10.2. Majority of parents preferred to use HOPE with 66.7% as compared to HOSE 14.3% and PPPS 19%.

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Discussion. This study has a small sample size possible due to very low rate for hypospadias in Malaysia and Covid-19 pandemic. Due to the pandemic, European Association of Urology recommended for repair before 18 months. However, if done after 2 years old showed significant predictor for complications. Validated questionnaires are useful and comparable to assess objectively both functional and patient satisfaction. However, HOPE might overestimate quality of cosmetic outcome compared with PPPS. Despite many available evaluation scoring systems were compared, reports show similar re

conclusions with none being more superior. -o

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Conclusion. Hypospadias requires complex surgery and complications are expected but should be within acceptable *

standards. In COVID-19 era, hypospadias repair had to be delayed and causes negative impact to patients. Despite many ^

various techniques available, surgeons experience and technique preference are very important. There is no evaluation ^

score more superior than another. It has its advantages and disadvantages. Parents satisfaction and functional outcome after repair should be routinely done for objective assessment.

BY 4.0

■ hose ■ hope ■ ppps Parents Preference Score

Keywords. Hypospadias, Repair, Outcome, Questionnaire

Introduction

Hypospadias is a common congenital abnormality affecting 1:300 live male births worldwide. However, the incidence is on the rise in recent years to 1:125 possible due to increasing environmental pollution or endocrine etiology. It has shown to have widespread variation at different parts of the world and numbers are increasing from year to year [1,2].

Hypospadias described with presence of abnormal urethral location at the ventral region, hooded foreskin and ventral penile chordee. It may also be associated with other urogenital tract abnormalities such as bifid scrotum, inguinal hernia, cryptorchidism, pelvi-ureteric junction obstruction, vesico-ureteric reflux, or renal agenesis [3,4,5,6].

Many classifications have been used throughout the years. Commonly used are classified by Duckett's and latest by Hadidi in 2018. Hadidi classifies hypospadias into four which are Glanular, Penile, Proximal and Perineal

(Figure 1). Classification is to grade the severity of Hypospadias and complexity of surgery as more proximal towards perineal indicates more complexity and high likely would require two stage repairs [7].

Throughout the years many surgical techniques have been described to give the best outcome. This surgical technique follows these principles to ensure good outcome in functional and cosmetic appearance. First to correct penile chordee (orthoplasty), second to reconstruct urethra (urethroplasty) and third to reconstruct glans penis (glansoplasty) [8]. Literature has described more than 300 techniques being used. Surgical techniques such as Tubularised Incised Plate (TIP), Meatal Advancement and Glanuloplasty (MAGPI), Thiersch Duplay, Mathieu Procedure, Onlay Island Flap (OIF) or Two stage surgery with Buccal Mucosa Graft or Preputial Graft are the few too mention. The most preferred technique used is TIP by Snodgrass for distal hypospadias and two stage surgery for proximal hypospadias.

Kaufmann Schaefer Avellan

1386 1950 1975

Grade I Glanular Glanuiar

Grade II Penile Penile

Grade III

Grade iV Perineal Penoperineai Perineal Perineal wfo Bulb

Duckett 1996

Hadidi 2004

Hadidi 2018

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Glanular Sub-coronai Distal penile

Mid shaft Proximal penile Penoscrotal Mid scrotal

Perineal

Glanular Glanuiar

Proximal

Penile

Proximal

Perineal

Figure 1: Hypospadias Classification

АНДРОЛОГИЯ ANDROLOGY

И ГЕНИТАЛЬНАЯ ХИРУРГИЯ AND GENITAL SURGERY

Post operatively it is important to follow-up patients because early and late complications can occur. It is important to educate parents to monitor post operatively at home. An objective evaluation is useful for attending doctor and parents to ensure both understands detection of complication and to assess post operative satisfaction from both sides are similar. Hence, the use of Hypospadias Objective Scoring Evaluation (HOSE), Hypospadias Objective Penile Evaluation (HOPE) and Pediatric Penile Perception Score (PPPS) questionnaire in our hospital during follow-up.

Patients and Methods

A retrospective study of all patients with hypospadias repair done in Hospital Universiti Sains Malaysia from January 2020 to December 2022. All cases were done by a single Consultant Urologist. All patient medical records were reviewed. Data analyzed for demographic, surgical treatment, complications, and objective evaluation with HOSE, HOPE and PPPS questionnaire and parents preferred questionnaire to

Most of our patients had a single stage repair with 18 patients and 2 patients had scrotoplasty performed and 3 patients had two stage repairs. Majority of single stage surgery performed was TIP and two stage repair was done

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be used using Microsoft Excel for Windows 2003 and qualitative variables were presented as frequencies and simple percentages.

Results

A total of 21 pediatric patients was operated for hypospadias during the Covid-19 period. Despite due to lockdown and quarantine we manage to operate on 21 cases but follow up were difficult due to factors above. The mean age during time of surgery was 7.2 years old (Figure 2).

Our patients were classified according to Hadidi 2014 as glanular, distal and proximal hypospadias. Glanular showed 6 patients with 28.5%, distal 3 patients with 14.3% and majority are proximal hypospadias with 12 patients and 57.2% (Figure 3). Total from proximal hypospadias, 6 were proximal penile and 6 penoscrotal. All patients had hooded penis and patients with chordee were 38%. Other associated anomalies were two patients with bifid scrotum and one patient with inguinal hernia.

with Bracka's technique. We use PDS 5/0 suture for all our patients and urinary catheter used were pediatric feeding tube size 4-6 Fr. Wound inspection done at day 5 and catheter removed on day 7 after surgery (Figure 4).

3,5 3 2,5 2 1,5 1

0,5

I I I I I I I I I I I M I I

0 1 YEAR 9 MON 2 3 4 5 6 7 8 9 10 12 13 14 15 17

YEARS YEARS YEARS YEARS YEARS YEARS YEARS YEARSYEARS YEARS YEARS YEARS YEARS YEARS

TH

■ NO. OF PATIENTS 1 1 2 1 1 1 2 2 1 1 1 3 1 2 1

Figure 2. Patients age during time of surgery

Figure 3. Types of Hypospadias

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SINGLE STAGE

0 2 4 6 8 10 12 14 16 18 20

SINGLE STAGE TWO STAGE

■ Ряд! 18 3

Figure 4. Type of Stage Repair

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АНДРОЛОГИЯ ANDROLOGY

И ГЕНИТАЛЬНАЯ ХИРУРГИЯ AND GENITAL SURGERY

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During the Covid-19 phase, patients follow up was difficult due to many restrictions. Overall mean follow-up time were 16.78 month. We had 3 patients with complications and no death were recorded. All three patients had UCF with 14.3% which was detected during follow up. We had one patient with severe chordee required repair and 4 patients with minimal chordee that does not require repair.

During follow up three questionnaires were used to assess parents understanding and satisfaction after surgery. We have used HOSE, HOPE and PPPS as it is widely used worldwide. Questionnaire were filled up by parents. Questionnaire with HOSE showed mean score 14.38.

The HOPE questionnaire showed mean score of 54.71 with lowest score 43 and highest score 60 points. The PPPS has 4 criteria using Likert scale and total score given by parents (Table 1). This mean score of PPPS was 10.2. (Figure 5).

Scale Penile Appearance

0 points Very dissatisfied

1 points Dissatisfied

2 points Satisfied

3 points Very satisfied

Table 1. Likert scale

PPPS

■NO. 4 3 5 3 6

Figure 4. HOSE, HOPE and PPPS score

After completing all three questionnaire parents gave their input as which questionnaire would be suggested to be used for future parents as standard post operative

follow up care. Majority of parents preferred the HOPE 66.7% as compared to HOSE 14.3% and PPPS 19% (Figure 6).

■ HOSE ■ HOPE ■ PPPS

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Figure 6. Parents Preference Score

Discussion

Hypospadias was described by AD Celsius and Galen as early as in the first and second century. It is a disease that requires complex surgery and many techniques has been described but none being more superior than the other. The main principles to allow voiding in standing position with single good flow, able to achieve normal coitus and insemination, and acceptable penile cosmesis. Hence, it is important to be done correctly during the initial surgery by expert surgeons. This is to ensure good psychological, emotional and sexual well-being [9].

Throughout the world despite being a common disease detected after delivery it varies in different countries. In Malaysia, a retrospective study collected over 15 years by Arshad in 2005 showed 115 patients with majority 76% had proximal hypospadias. Malaysia is classified as very low rate for hypospadias with 0.6/10,000 birth as compared to extremely high-rate of 464/10,000 births in Denmark by A Springer et al in 2016. Asian population has more proximal hypospadias as compared to western countries with distal hypospadias. Hence, our patients and Arshad et al had majority with proximal hypospadias [10,11,12]. Hypospadias surgery in our country is also performed by Pediatrics Surgery and Plastic and Reconstructive surgery. Unfortunately, we do not have a national database from all specialty to evaluate and analyze the numbers and outcome.

Since the COVID-19 pandemic outbreak, standard of care had to be modified. Due to restriction movements, many patients were unable to come to hospital. As compared to the year before pandemic, Wei et al reported 62.86% fewer patients in China had hospital visits and underwent pediatric operations. Patient triage had to be re-modeled to adapt during COVID-19 pandemic to channel resources for more urgent cases. Elective and nonurgent cases had to be rescheduled and this causes delay in treatment. This however is not feasible and causes negative "E impact to patients despite recommendation for repair a before 18 months by European Association of Urology.

Garnier et al found that hypospadias repair age more than ¡2 2 years old was a significant predictor for complications. As the pandemic becomes more stable, hospitals re-opens

0 for elective and non-urgent cases and delaying surgery will ^ be avoided [13,14,15,16].

£ Majority of our patients had TIP performed. Only 3

™ patients had two stage surgery with Bracka's technique

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^ for proximal hypospadias. The TIP by Snodgrass has x successful repair in distal hypospadias. This technique

1 has also been used for proximal hypospadias. However, re

i Snodgrass and Lorenzo reported high complication rates. ^ We have performed TIP as primary option for distal and ^ proximal hypospadias and showed good outcome with low complication rates. Although our numbers are low and not yet comparable with other large data. Edhi Hapsari et al

and Rynja SP et al used TIP as the preferred technique for proximal hypospadias. This is because of its flexibility for medial until distal type of hypospadias and require only single stage surgery [17,18,19,20].

Despite many techniques described, complications will occur. Common complications are Urethrocutaneous Fistula (UCF), meatal stenosis, urethral stricture, urethral diverticulum, glans dehiscence, wound breakdown, penile torsion, or unfavorable cosmetic outcome requiring re-do surgery. The most common complication from hypospadias repair surgery is UCF. The incidence ranges from 6.2 to 38.8% and mostly being between 10 to 20%. Our study showed complication rates within the acceptable range with 14.3% in 3 patients underwent TIP technique. Most UCF heals spontaneously within 3 months. All of our 3 patients with UCF had to undergone fistula repair after failed conservative treatment [21].

It is important to have an agreement between evaluation of outcomes from surgeon and parent side. A standard evaluation questionnaire can be used to assess the outcome cosmetically and functionally. NS Hussein reported hypospadias repair in Kelantan, Malaysia using HOSE and Uroflowmetry in 2013. Both evaluation score was simple, non-invasive and non-expensive. Since then, many objective evaluations score has been used but not standardized. In this study we used three questionnaires for evaluation assessment and seek opinion from parents' as which evaluation score would be preferred for future parents to use Three questionnaires used were HOSE, HOPE and PPPS [22,23].

The HOSE questionnaire introduced by Holland et al 2001 showed little inter-observer variations between surgeon, nurse and one of child parents. A score of 14 or more was suggested by the authors to infer an acceptable outcome with the meatus at least at the proximal glans, a single urinary stream and only moderate angulation of the penile shaft [23]. Our study showed 16 from 21 patients with score more than 14 with means score of 14.38. Majority were satisfied with the outcome after repair. Parents commented this evaluation score is simple and easy to be understood.

Later in 2008, Weber et al published regarding PPPS and subsequently used in adults as well. We had 14 patients with score of more than 10, majority of parents are satisfied with outcome of the repair. Abdullah El-Debeiky et al and Syed Adeel Ahmed and Syed Zafar Zaidi used PPPS as an evaluation tool in their study. They highly recommend usage of PPPS to be used as an evaluation assessment. However, to further improve it is suggested for a multicenter clinical trial [23,24,25]. PPPS is a simpler version of evaluation score with criteria without images involved. However, our patients' parents had difficulty to gauge satisfaction and were unable to compare criteria's from very dissatisfied to very satisfied.

AHДPOЛOГИЯ ANDROLOGY

И ГEHИTAЛЬHAЯ ХИРУРГИЯ AND GENITAL SURGERY

In 2013, Van der Toorn et al introduced HOPE and showed a high degree of reproducibility. It has been prospectively validated and use in Netherlands with images. Parents can refer to the images in this questionnaire to aid in scoring. Our study showed good cosmetic outcome in majority of our patients. However, this study does not include complication of spraying of urine and urethrocutaneous fistula. It is a more cosmesis evaluation score rather than functional evaluation.

Among this three-evaluation score, literature showed no scoring system to be more superior than the other, hence our intention to know from this study which questionnaire can be used for our future patients from parents' perspective [26].

Data collected from this study showed from three questionnaires used most of patients chose HOPE as the suitable and recommended to be used for future patients. It is more detailed with images to aid better understanding for patients to use. The HOSE study was the second choice as parents said it is simpler to be understood but not detailed enough as HOPE. Third questionnaire PPPS had the least favorable choice as there were no images or diagram to explain to compare. A. Springer

Conclusion

Hypospadias requires complex surgery and complications are expected but should be within acceptable standards. In COVID-19 era, hypospadias repair had to be delayed and causes negative impact to patients. Despite many various techniques available,

1TOM 25 I VOL. 25 2 0 2 4

in 2014 reported the advantages and disadvantages of the evaluation scoring system available (Table 2). Liu M.M.Y. et al and Haid et al reported a comparative study between scoring system after hypospadias repair. Validated questionnaires are useful and comparable to assess objectively both functional and patient satisfaction. HOPE might overestimate quality of cosmetic outcome compared with PPPS [27,28,29,30]. Despite many available evaluation scoring systems were compared, reports show similar conclusions with none being more superior.

The disadvantage of this study is the small sample size. This probably due to Malaysia being very low rate for hypospadias. Another factor is because it was during the Covid-19 pandemic, our operating time were limited and patient follow-up were difficult due to the Restriction Movement Order. Another limitation, it was only done in a single center and single unit. We were unable to include data from other unit specialty in our hospital. In the future, more patients including from other units performing hypospadias repair should be included. A multicenter data collection would give a better overall numbers and outcomes if able to be done.

surgeons experience and technique preference are very important. There is no evaluation score more superior than another. It has its advantages and disadvantages. Parents satisfaction and functional outcome after repair should be routinely done for objective assessment.

Score Item Advantage Disadvantage

•Meatal location •Meatal shape •Inter-observer reliability tested •Limited items • No general appearance

HOSE • Urinary stream •Erection/curvature • Fistula • No penis size

HOPE • Position meatus • Meatal shape • Shape of glans • Shape of skin •Penile torsion • Erection/curvature • Reference picture, implemented into prospective database •Time consuming

PPPS • Length of penis • Position shape and meatus • Glandular shape «Erection/curvature • General appearance • High inter-rater reliability • Validated for surgeon and patient • Inherent subjective assessment

Table 2. Advantage and disadvantage evaluation scoring system

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R E F E R E N C E S

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