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25RESULTS OF SURGICAL TREATMENT OF HYPOSPADIA
IN BOYS
Yusupov А.Sh.1, Shamsiyev A.M.2, Pulatov P.A.3, Razin M.P.4, Sukhikh N.K.5, Baturov M.A.6
1Yusupov Abdurasulovich Shukhrat - MD, DSc, Associate Professor;
2Shamsiyev Azamat Muhitdinovich - MD, DSc, Professor; 3Pulatov Parviz Amriddinovich - Assistant, DEPARTMENT OF PEDIATRIC SURGERY, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN; 4Razin Maxim Petrovich - MD, PhD, Professor;
5Sukhikh Nikolay Konstantinovich - PhD, Associate Professor;
6Baturov Maxim Alexandrovich - Assistant Professor, DEPARTMENT OF PEDIATRIC SURGERY, KIROV STATE MEDICAL UNIVERSITY, KIROV
Abstract: under our supervision, there were 222 boys aged 2 years to 15 years who received inpatient treatment for anterior forms of hypospadias in the urology department of the 2nd SamMI clinic and Kirov SMU clinic in the period from 1999 to 2018. Patients, depending on the method of surgical correction, were divided into two groups: the control group consisted of 98 children treated during the period from 1997 to 2004, they underwent urethroplasty according to the Mathieu technique; the main group consisted of 124 patients who received treatment from 2005 to 2018. A modification of the urethroplasty technique developed by us and introduced into clinical practice by Mathieu has shown its effectiveness in the surgical treatment of anterior forms of hypospadias in children. Keywords: children, hypospadias, urethroplasty.
Relevance. Hypospadias in boys is a congenital malformation of the urethra and penis, which has not only a medical, but also a social aspect related to sexual function and the ability to create a family in adulthood. In boys with hypospadias, psychological discomfort develops quite early, and subsequently difficulties with sexual activity arise. In recent years, a significant increase in the prevalence of hypospadias has been noted. Currently, in some countries of Europe, this developmental anomaly occurs with a frequency of 1 accidental in 150-250 newborn boys [1, 3, 6].
Due to the relevance of this problem, indications for surgical methods of hypospadias treatment and requirements for their results have significantly changed. Previously, the main goal of the operation was to achieve a functional result, that is, the ability to urinate while standing and the ability to have sexual intercourse. Currently, in addition to a satisfactory functional state of the urethra, the task is to restore the normal anatomy of the penis and achieve a good cosmetic result [2].
Traditional methods of urethroplasty include the formation of urethral meatus at the level of the coronary sulcus. Then, the formation of the capitate of the urethra is the most difficult task of treatment, due to some anatomical features of the glans penis. Even with the use of modern techniques, a high incidence of postoperative complications is noted. With the correction of distal hypospadias, the frequency of repeated operations is from 5 to 23%. In the treatment of stem hypospadias, complications develop in 15-45% of patients [4]. Treatment of complications of surgical correction of hypospadias, as a rule, is a more difficult problem than primary intervention. Even with the closure of point skin-urethral fistulas, relapses are often observed [5]. Currently, there is also no single, universally recognized approach to surgical treatment, which leads to difficulties in choosing the optimal correction method [6].
The lack of a unified approach to surgical treatment, a significant frequency of postoperative complications and high social significance determine the urgency of this problem.
Aim. Improving the effectiveness of surgical treatment of hypospadias in children.
Material and research methods. Under our supervision, there were 222 boys aged 2 years to 15 years who received inpatient treatment for anterior forms of hypospadias in the urology department of the 2nd SamMI clinic and Kirov SMU clinic in the period from 1999 to 2018. Patients, depending on the method of surgical correction, were divided into two groups: the control group consisted of 98 children treated during the period from 1997 to 2004, they underwent urethroplasty according to the Mathieu technique; the main group consisted of 124 patients who received treatment from 2005 to 2018. Patients of the main group of urethral plastic surgery were performed according to our modification of the Mathieu method (certificate for rationalization proposal No. 1820 dated 05/17/2016, "A way to improve the results of surgical treatment of hypospadias in children").
Most patients underwent surgery before the age of 7 years - 133 (59.9%). In both groups, the age distribution was almost the same (Table 1). Most of the children were hospitalized from rural areas 175 (79.0%).
Table 1. Age distribution of patients
Patients age 3-6 years total 7-14 years over 14 years old Total
Control group 61(45.9%) 34(41.5%) 3(42.8%) 98(44.14%)
Main group 72(54.1%) 48(58.5%) 4(57.2%) 124(55.86%)
Total 133(59.9%) 82(36.9%) 7(3.2%) 222(100%)
To achieve the goal of the study, the following research methods were applied to all patients admitted to inpatient treatment, allowing to obtain a comprehensive description of the studied groups of patients and substantiate the relevant recommendations. When studying the history data, special attention was paid to the initial manifestations of the disease. The complexity of any reconstructive surgery on the urethra, in particular hypospadias, and its favorable outcome are directly dependent on its form, the extent of the urethra deficiency, the degree of its obstruction, the nature of the changes in paraurethral tissues. All patients underwent measurements of the penis size, length and diameter in cm. To exclude a urinary tract infection, a general urine test was mandatory for all patients. When leukocyturia was detected, uroseptics were always prescribed and an additional examination was carried out in the future - mainly ultrasound sonography (US) and, according to indications, excretory urography. Of all the patients observed, only one patient was diagnosed with left-sided hydronephrosis of the first degree.
In the majority of examined patients of both groups, the distal-stem form of hypospadias 196 prevailed (88.3%). The ratio in the groups was almost the same (Table 2).
Table 2. Hypospadias Forms
Hypospadias Forms Control group Main group Total
Distal stem 80 (81.6%) 116 (93.5%) 196 (88.3%)
Crown 18 (18.4%) 8 (6.5%) 26 (11.7%)
Total 98(44.2%) 124 (55.8%) 222 (100%)
Of the other forms in the control group, the coronary form of hypospadias was more common in 18 (18.4%), in the main group in 8 (6.5%) patients.
Results and its discussion. After a complete clinical and laboratory examination, all patients were operated on as planned. One of the main factors for a successful outcome after urethroplasty is the use of one or another suture material. In the control group, vitalon was mainly used in 42 patients and polyamide in 20, the main preference was given to PDS in 43 patients and polyamide in 21. All patients had a urinary catheter installed during the operation, which was removed depending on the appearance of independent urination in the patient past the catheter. Basically, the catheter was removed 3-6 days after surgery. It should be noted that in the control group the catheter was removed 5-6 days after surgery, in the main group 3-4 days.
One of the important indicators of the effectiveness of urethroplasty is the development of certain complications in the postoperative period (Table 3).
Table 3. Complications identified in the early postoperative period
Complications Control Group (n = 98) The main group (n = 124)
Fistula 19 (19.4%) 12 (9.7%)
infiltrate 1 (1.0%) -
urethritis - 1 (0.8%)
suture inconsistency 4 (4.1%) 2 (1.6%)
Total 24 (24.4%) 15 (12.1%)
In the control group, various complications were revealed in 24.4% of all operated patients, more often in the form of fistulas - 19 (19.4%), in 4 patients there was a discrepancy of sutures. In the main group, the number of complications significantly decreased and was observed only in 15 patients, which amounted to 12.1%, of which 12 children developed fistula, which resolved independently after 6 months, and one patient had a urethritis clinic that was stopped by conservative measures. The study of the long-term results of urethral repair in hypospadias is an objective criterion for assessing the effectiveness of surgical treatment of patients. A follow-up examination was conducted for 114 (51.35%) patients of both groups: in 58 (59.2%) patients of the control group and 56 (45.2%) children of the main group in the period from 6 months to 7 years. Long-term results of treatment of patients were assessed as good, satisfactory and unsatisfactory (Table 4).
The results were considered good for those children who did not show complaints after the operation, the general physical condition corresponded to their age, the soft and painless postoperative scar does not rise above the surface of the skin, the act of urination is not disturbed and does not cause concern, the appearance of the penis satisfies the patient. Good long-term results were found in 38 (65.5%) patients in the control group and 46 (82.1%) patients in the main group.
Table 4. Long-Term Urethroplasty Results
Results Control Group (n = 58) The main group (n = 56)
good 38 (65.5%) 46 (82.1%)
satisfactory 13 (22.4%) 7 (12.5%)
unsatisfactory 7 (12.1%) 3 (5.4%)
Total 58 (100%) 56 (100%)
The results were considered satisfactory in those cases where patients complained of periodic dysuric disorders, moderate pain on palpation in the postoperative scar area, which remained soft, not fused with surrounding tissues, was noted. Satisfactory results were obtained in 22.4% of patients from the control group, in the main it decreased to 12.5%.
Unsatisfactory results were considered when patients complained of frequent dysuric disorders, postoperative coarse scars fused to the underlying tissues, towering above the
surface of the skin and deforming the penis. Complications in the form of fistula development or retraction of the meatus were also noted. When analyzing the results of treatment in the long-term period, a decrease in unsatisfactory results is also noted from 12.1% of the control to 5.4% of the main group. Thus, the proposed modification of urethroplasty according to Mathieu has shown its effectiveness, which is confirmed by the analysis of both immediate and long-term treatment results.
Conclusions. 1. A modification of the urethroplasty technique developed by us and introduced into clinical practice by Mathieu has shown its effectiveness in the surgical treatment of anterior forms of hypospadias in children. 2. An analysis of the immediate and long-term results of treatment showed that complications in the early postoperative period decreased from 24.4% to 12.1%, and good long-term results improved from 65.5% to 82.1%.
References
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