Category Archives: Hypospadias surgery

Hypospadias support, Hypospadias surgery

Chapter 3: Psychological Aspects of Hypospadias (part 2)

 

  1. Synthesis of the two studies

Paucity of literature  

According to the authors, in contrast to the abundance of literature on the medical side, very little scientific research has been carried out on the possible long-term psychological impact of hypospadias and surgery on the lives of the individuals concerned.

4.2. Offering professional psychological support

The studies carried out by the Swedish research team at the beginning of the 1980’s referred to several psychological, psychosocial and psychosexual  difficulties that can arise after hypospadias surgery. The authors highlighted the fact that the later development of boys operated on for hypospadias could be influenced by factors in the environment such as the reaction of parents and peers.

This team stressed the importance of psychological support which could be offered at an early stage to the parents of children with hypospadias and to the children themselves, in order to avoid adding a ‘psychological handicap’ (Berg et al., 1982, p. 411) to their ‘physical handicap’.

The series of studies produced by the Dutch research team also included a series of observations and conclusions concerning the psychological impact of hypospadias and its repercussions on psychosocial and psychosexual development. The authors remind us that, despite constant progress in this field, hypospadias surgery does not give a perfectly normal appearance to the penis (Mureau et al., 1997, 1995c). The majority of patients continued to perceive differences between the appearance of their own penis and that of others: they were more dissatisfied with the appearance of their penis, and had more often received comments about it; they were more self-conscious and embarrassed by the appearance of their genitals, which led to inhibitions in seeking out sexual relationships. They were also more inhibited in undressing in front of other people (e.g. in showers or communal changing rooms).

Mureau et al. (1995c) also included some comments on the importance of being able to offer psychological and/or professional sexual therapeutic support to both parents and the patients.

In conclusion, both series of studies show that although surgical treatment is effective in re-establishing varying degrees of functional and aesthetic normality to the penis, it is still always possible that emotional difficulties will persist.

4.3. Another risk factor: the secret of hypospadias

Other factors contribute to a patient’s capacity to face up to his hypospadias: as mentioned by the Dutch researchers, more often than not there is a lack of information and explanation from the medical community, for both parents and the patients themselves.

But the emotional consequences of a condition such as hypospadias are equally affected by a lack of discussion within the family. Thirty years ago, Robertson & Walker (1975) reported that that hypospadias was regarded, by the parents and the child, as ‘secret information’. The secret, in the context of hypospadias, referred to the existence of a penis which was not completely perfect; this situation was shared neither with friends, nor close relations, nor even in the bosom of the immediate family.

  1. A qualitative research project (United States, 1998)

The two series of studies already presented were quantitative in nature. As far as I know, there is no qualitative research published in journals. Nevertheless, I have located a doctoral thesis on the psychology of hypospadias (unpublished). I present here, broadly, why and how this research was carried out, and its results and implications.

5.1. The subjects investigated

Walker’s (1998) doctoral thesis aimed to thoroughly examine the psychological experience of living with hypospadias as an adult. Being affected personally by hypospadias, Walker knew that this condition and the related surgery had profoundly affected his existence during both childhood and adulthood; this experience of hypospadias was a powerful motivation to explore and so better understand the experience of others in the same situation. The objective of his research was to view the lives of men with hypospadias in a holistic manner (physical, psychological, creative and spiritual), so he could better understand the role which hypospadias had played in their lives. His approach acknowledges the whole person, as well as the deficiency.

5.2. Research method used

Walker (1998) used a qualitative research method. More precisely, this researcher adopted a method known as heuristic, an approach used in social science which requires the participation and involvement of the researcher at the center of the research. The direct experience of the researcher regarding the topic being investigated is one of the principal requirements of the heuristic method (Moustakas, 1990, cited in Walker, 1998). This researcher chose this approach since it allowed him to study the phenomenon of hypospadias while being personally affected by it.

5.3. Participants in the research

The participants in Walker’s (1998) research came from a support group for hypospadias which existed on the internet at the time. The researcher had himself been active in the support group and it was in this way that he gradually chose 5 participants affected by hypospadias [51]. The participants were aged between 23 and 47 years and came from different regions of the United States.

The medical characteristics of the participants at birth was varied. They ranged from penoscrotal hypospadias (posterior form), to balano-preputial hypospadias (anterior form). All except one participant, including the author, had experienced surgical repair (some more than once). The operations took place between the ages of 3 and 9.

5.4. Some results

According to Walker (1998), the manner in which each participant reacted to surgery (from infancy to childhood) as well as to post-operative care from the family and the medical community, was different. However, this researcher was able to observe some common experiences among all the participants. Some of these experiences are presented here (see Walker, 1998, pp.97-100).

5.4.1. Lack of emotional support

One of the experiences common to all the participants was that they had not been emotionally supported by their families, nor had they benefited from any support from the medical profession. As children, they had been given little or no information, and no opportunities to talk about hypospadias.

5.4.2. Feeling different and keeping hypospadias a secret

All the participants said that they felt they were in some way ‘different’, partly as a result of the lack of information and discussion by the family and medical community. They also felt that they could not talk about this feeling of difference. This led them to hide their thoughts and feelings about this perceived difference, which engendered a kind of ‘secret life’ about the difference in their penis. This decision to ‘hide’ their difference intensified as they became adolescent, that is to say when their sexual awareness began to emerge.

5.4.3. Feelings of embarrassment

A common theme which stands out in the stories of the participants was feeling uncomfortable talking about sexuality. Equally it emerged that they were conscious of an uncertainty and embarrassment regarding their genital difference and their capacity to have normal sexual relations. The participants reported feeling sexually inadequate and anxious during their adolescence. Some of them had been stigmatized by comments from their peers about the appearance of their penis.

5.4.4. Shame and poor self-esteem

The participants reported having become timid and socially introverted during adolescence. It was also during this period that the first signs of ‘shame’ and a lowering of self-esteem became apparent [52].

5.4.5. Anxieties and fear of sexual intimacy

Having had different emotional and psychological experiences during adolescence due to hypospadias, each participant went through, in their own way, a ‘crisis’ on reaching adulthood. This crisis related to their sexual, personal and social identity. Their feelings of sexual inadequacy which emerged during adolescence, now evolved into a fear of sexual intimacy and difficulty in opening up emotionally and sexually towards their sexual partner. Moreover, they encountered difficulties in trusting others.

5.4.6. Solitude, isolation and mistrust   

Another experience commonly reported by the participants, as adults, was related to feeling alone and emotionally isolated. This led to their feelings of shame, difference and abnormality being further intensified.

5.4.7. Feelings of loss and incomplete masculinity

In response to their impression of being deficient with regard to their genitals, the participants felt that as men they were not totally complete. In some cases, they even developed a distorted body image. This affected their self-identity and self-worth.

5.4.8. Personal growth, acceptance of self and body

Despite difficult experiences, both emotional and psychological, in living with hypospadias, each of the participants described a process of personal recovery and psychological or even spiritual healing. These common experiences of recovery happened after experiencing an extreme level of physical and psychological suffering. This process of recuperation has been described as being a kind of ‘understanding of their experience of hypospadias’ which permitted them to live with their condition in a more effective way.

Each of the participants described, in his own manner, a way of learning to accept himself and accept his body. This kind of acceptance happened, for example, through: a helper or supporter from a spiritual program, different modes of therapy, or though a creative involvement in art and the use of a man’s imagination.

5.4.9. Support from other men with hypospadias

All the participants expressed an increased need to enter into contact with other men who had hypospadias, with the aims of finding mutual support, coming to a better self-acceptance, having an opportunity to reveal themselves (as having hypospadias), and telling their story to other men in a similar situation.

One of the topics most often raised by all the participants was the need to make parents – and the medical community involved with hypospadias – more conscious of the importance of offering psychological and emotional support at different developmental stages. This should include psychological support for parents, as well as for the young patients, but equally for adolescents and adults during their emotional and sexual development.

5.4.10. Hypospadias as a part of an overall life experience   

One last theme, but no less important, shared by all participants was coming to understand that hypospadias is only a part of their overall  experience. All had learned, in different ways, to extend their consciousness of being emotionally isolated with their experience of hypospadias (in which they were negatively focused on their ‘problem’) so that they finally understood they are part of a wider group of men who have hypospadias. To varying degrees this has enabled them to better accept their condition as being important but still only one part of their overall life experience.

5.5. Implications of the research

Walker’s research has brought out a number of implications. These are aimed both at professionals in the fields of mental health and medicine and at the family members of people with hypospadias (Walker, 1998, pp. 215-223)

5.5.1. Implications for professionals

Many participants expressed their appreciation at receiving, at certain moments in their life, professional support which helped them learn to live with hypospadias as a medical condition. However, it was not easy for them to find such help, partly because of the lack of mental health services specializing in this condition. Even in health centers and hospitals, no service existed to support the psychological problems associated with hypospadias [53]. The author recommended that new studies be carried out, and that both medical and mental health professionals be trained so that hospital services specializing in the surgical correction of hypospadias have the possibility of offering an educational and psychological support service, as well as guidance to patients and their parents, as a central part of the overall treatment for this condition (Walker, 1998, pp. 215-216).

5.5.2. Implications for family members  

The participants constantly described feelings of not having been supported by their family members, and this had an impact on their experience of hypospadias. According to the author, it was vital to be able to create a climate of openness, support and communication in the heart of the family (Walker, 1998, p. 121). In this way, children could feel more free to ask questions and express their anxieties. Parents should be able to educate, guide and listen actively to their child. One of the ways to achieve, according to the author, would be to create a specialized guidance service for parents so that they themselves may explore their own anxieties, hopes and fears. Finally, as well professional support, it would be extremely beneficial for parents to be able to access support groups for men and boys with hypospadias (p.122).

Hypospadias surgery

Chapter 2: Hypospadias and Surgery (part 3)

Chapter 2 Continued (part 3)

  1. Conclusion

The understanding of the etiology and the surgical treatment of hypospadias (or hypospadiology), remain two very active fields in medical research and literature.

Hundreds of surgical procedures developed over a century and half bear witness to the interest of surgeons, and more recently pediatric urologists, in this condition.  One of the principle objectives of surgery for hypospadias has always been to improve the functional aspects of the penis: to permit urination standing up and satisfactory sexual relationships.

For several years now, specialists in this surgery have also tried to give the penis an appearance which comes as close as possible to the aesthetic norm.  This is realized in those techniques which allow the creation of a urethral meatus in a terminal position and also result in a penis of a circumcised appearance.

Another important change concerns the required age for surgical treatment. Current practice is to advise that the operation should take place as soon as possible in order to avoid emotional consequences of awareness of a congenital deficiency and the experience of surgery.

In the same context, it’s now seen as important that the parents accompany the child during the pre- and post-operative processes. Another principle objective is to prepare the parents for the child’s surgery, giving them information on surgical procedures, the duration of hospitalization, the possible complications and the required post-operative care.

A review of the medical literature shows that hypospadias is much studied from a surgical position, but research on the psychological, psychosocial and psychosexual effects of hypospadias and its surgery is very much less represented in the literature. This is the subject of the next chapter.

Footnotes to text of Chapter 2

[21] It is notable that only a small number of publications have dealt with the physical consequences of unoperated hypospadias, regarding sexuality and reproduction as an adult (see, for example, Moudouni, Tazi, Nouri et al., 2001; Viville, 1993).

[22] In simple cases of hypospadias, an aesthetic correction should only be planned after first discussing the psychological aspects linked to hypospadias as well as clarification of any functional difficulties.

[23] The earliest forms of treatment date back to the !st and 2nd centuries BC, when surgeons amputated the penis at the level of the meatus and cauterized the wound with a hot iron! (De Sy & Hoebeke, 1996; Smith, 1997; Zaontz & Packer, 1997).

[24] I cite in this regard the use of scrotal skin (Cecil, 1932, cited by Horton & Devine, 1972), vesicle mucosa (Marshall & Spellman, 1955, cited by Coleman, 1981) or even skin from the penis (Denis Browne, 1949, cited by Gearhart & Witherington, 1979) to carry out urethroplasty.

[25] In fact, according to Paparel et al. (2001), replacement of the missing urethra using different skin grafts often produced unsatisfactory results and too high a number of repetitive operations (repetitive failures). This period was known as the ‘dark age of hypospadias surgery‘, since so many ‘disasters’ occurred!

[26] The reason for waiting was mainly ‘strategic’: surgeons had to have a reserve of skin sufficient to carry out reconstruction of the urethra. This did not happen until the age of around 3 years, or even later (AAP, 1975).

[27] When reconstructions in multiple stages were the rule (AAP, 1975), these were usually separated at intervals of 6 to 12 months, and children stayed in hospital a number of days (between 5 to 14 days) after each operation; very often rooms for parents to stay in were not provided. According to the AAP (1996), the need for several days of post-operative hospitalization is tending to be replaced by outpatient procedures, permitting patients to go home the same day. If a stay is required, many pediatric centers take care to minimize the separation time and offer rooms adapted to allow for this.

[28] MAGPI: Meatal Advancement and Glanuloplasty Incorporated. A surgical procedure consisting of opening the glans by a longitudinal incision, then vertically suturing the two sides.  This maneuver creates a flattening of the glans and repositioning of the urethral meatus to the level of the glans apex (Sheldon & Duckett, 1987).

[29] In fact, many authors have confirmed a regression or secondary recoil of the meatus after using MAGPI (Paparel et al., 2001).

[30] GAP : Glans Approximation Procedure. This technique pulls the sides of the glans together.  Its indication is limited to hypospadias where the meatus is wide and deep (Gites et al., 1998).

[31] The principle of this intervention is to use the elasticity of the urethra to bring it forward into a good position on the apex of the glans (Atala, 2002).

[32] Tubularization: creation of a new urethral canal (or neo-urethra) by rolling the tissue around a urethral catheter and suturing it in the form of a tube (Wilcox & Ransley, 2000).

[33] Embryologically, the urethral plate creates the penile urethra. In the case of a hypospadic penis, the urethral plate represents an important anatomic entity: it is a smooth urethral mucosa of variable dimensions which extends from the hypospadic meatus as far as the glans (Perovic et al., 1999). Anatomical studies have demonstrated that its use works well in the fabrication of a neo-urethra: this structure is free from hair, is richly vascularised and nerve-free, and it possesses good muscular and connective tissue components (Erol, Baskin, Li & Liu, 2001).

[34] TIP: Tubularized Incised Plate Urethroplasty.

[35] Mathieu’s technique (1932) was for a good part of the 20th century considered a model technique in repairing anterior hypospadias (the limit of its use is median hypospadias). Its method is as follows: a piece of skin, taken in advance from the ventral side of the penis, is freed, moved forward and stitched between the flanks of the urethral canal to create a new conduit (Ravasse, Petit & Delmas, 2000).

[36] The technique, the preputial pedicle flap is more often known as the ‘Onlay-Island Flap’. Its general principle is as follows: a flap of preputial skin is dissected and moved onto an isolated pedicle in the subcutaneous tissue of the dorsal side of the penis.  It is then turned over onto the ventral side and sutured as a patch on the urethral canal to constitute a new canal as far as the glans apex (De Sy, 1996b). See also: Braz J Urol, 26: 621-629, 2000 online at http://www.brazjurol.com.br/novembro/Baskin_621_629.htm

[37] This technique, better known as ‘Tubularized Transverse Preputial Island Flap’, is employed when the urethral plate has had to be dissected to straighten the penis. It utilizes the inner portion of the foreskin, retaining its own blood supply. The remaining outer portion of foreskin resurfaces the front of the penis. (See also: Hayashi et al., 2003).

[38] Buccal mucosa: mucosa taken in advance from either the inside of the cheek or from the inside upper lip.

[39] I note here that certain new techniques such as GRAP (Glanular Reconstruction and Preputioplasty) (Gray & Boston, 2003), allow a combined reconstruction of the glans and the prepuce (preputioplasty) in the case of anterior hypospadias repair. Reconstruction of the prepuce may be carried out for many reasons: aesthetic, personal convenience or even cultural (Bruézière, 1996 ; Klijn, Dik & de Jong, 2001).

[40] In English medical literature this term is known as ‘hypospadias cripples’ (Stecker, Horton, Devine & McCraw, 1981).

[41] These numerous operations are the result of an accumulation of technical faults, traumatic dissections, use of poorly vascularised skin, bad sutures or even post-operative infections (Paparel et al., 2001).

Hypospadias surgery

Chapter 2: Hypospadias and Surgery (part 2)

Chapter 2 Continued (Part 2)

6 Some technical aspects of hypospadiology

 

Progressively and over the course of time, surgeons and pediatric urologists have developed an impressive number of techniques for repairing the various forms of hypospadias. When considered globally, it is estimated that more than 300 techniques (including variations) for the correction of hypospadias have been described in literature (Arap & Mitre, 2000).

6.1. Correction of chordee 

The choice of of a urethroplasty technique is made after correction of chordee (De Sy, 1996a). Different techniques for normalizing the penis have been described (see Baskin, Duckett & Lue, 1996 ; Hayashi, Kojima, Mizuno et al., 2002). The presence of chordee is generally more easily visible when the penis is erect rather than flaccid, and in young infants this is tested by an artificial erection induced by an injection of physiological serum (Wese et al., 1994). The artificial erection test allows a judgment to be made about the extent of straightening and the length of the operation (Baskin et al., 1996 ; Hayashi et al., 2002).

6.2. Urethroplasty

According to De Sy (1996a), the choice of a particular urethroplasty technique is dependent on physical factors present (e.g., chordee, location and appearance of the urethral meatus, the shape and size of the glans, the quality of ventral skin covering the urethra, length of the urethral plate, quantity of preputial skin available). For Wilcox and Ransley (2000), the available techniques can be synthesized into four large groups.

The techniques for advancing the urethra refer to processes of adjusting the distal extremity of the penis, used in repairing anterior forms of hypospadias, without associated chordee.  One of the most popular techniques of urethral advancement was the ‘meatal advancement and glanuloplasty incorporated’  or MAGPI [28], which appeared in the 1980s (Sheldon & Duckett, 1987).

However, the aesthetic results of surgical repair of hypospadias by MAGPI are mixed [29], and pediatric urologists are tending to abandon this technique (Paparel et al., 2001). Other techniques have been proposed for repair of anterior forms of hypospadias, such as the ‘glans approximation procedure’ or GAP [30] (Zaontz, 1988, cited by Gittes, Snyder & Murphy, 1998). There is also a technique known as ‘mobilization of the urethra with advancement’ [31]
(Koff, 1981, cited in Atala, 2002).

The techniques known as tubularization [32] of the urethral plate [33] were described by the pioneers of hypospadias surgery almost a century and a half ago (Duplay, 1874). Somewhat forgotten, they were only rediscovered in the 1980s and then widely popularized during the 1990s (Wilcox & Ransley, 2000).

The general principle of these techniques is, as their name indicates, to use the urethral plate, which, once preserved, can be tubularized upon itself as far as the tip of the glans (Bouhafs, Mege, Dubois et al., 2002 ; Mege, Pelizzo, Dubois et al., 1999).

As the urethral plate is too narrow for tubularisation, a method introduced by Snodgrass (1994) overcomes this limitation: a longitudinal incision along its whole length causes the urethral plate to broaden and it can then be tubularized.

The Snodgrass technique, first used for the repair of anterior hypospadias, was later extended to posterior forms (Cendron & Ellsworth, 1999 ; Snodgrass, 1999 ; Snodgrass & Lorenzo, 2002a ; Sugarman, Trevett & Malone, 1999). The urethroplasty technique of ‘tubularized incised plate urethroplasty’ or TIP [34] is nowadays one of the most popular in surgical repair of hypospadias (Cheng, Vemulapalli, Kropp et al., 2002 ; Snodgrass & Nguyen, 2002b).

The techniques known as ‘vascularised flaps’ consist of the creation of a new urethral tube using various flaps of skin taken directly from the penis. I should mention here the Mathieu technique [35] (modified) for repair of anterior hypospadias (Hoebeke, Boemers & De Jong, 1996 ; Ravasse, Petit & Delmas, 2000).

Other techniques have been proposed when chordee is present, for example ‘transversal preputial pedicle flap’ [36] for the repair of both anterior and median hypospadias (Duckett, 1981, cited in De Sy, 1996b), and also the technique known as ‘tubular transversal preputial pedicle flap’ [37], a technique for complete replacement of the urethra, used for repair of posterior hypospadias (Duckett, 1980, cited in Hayashi, Kojima, Nakane et al., 2003).

The techniques using free grafts from elsewhere on the body, popular throughout a large part of the twentieth century, are no longer recommended except in a minority of cases: extreme posterior forms (e.g., perineal) (Ferro et al, 2002 ; Meyer et al., 2002), and multi-operated hypospadias where the skin from the penis (e.g., preputial skin) is no longer useable (van der Werff & van der Meulen, 2000).

However, I would add that certain current techniques make increasing use of the buccal mucosa [38] for making grafts (Caldamone, Edstrom, Koyle et al., 1998; Hensle, Kearney & Bingham, 2002).

6.3. Reconstruction of the ventral side of the penis

The third stage of surgery refers to reconstruction of the ventral side of the penis (Paparel et al., 2001). This final stage is usually incorporated within current urethroplasty techniques [39]. Reconstruction is carried out by means of three surgical techniques.  I mention them here, without going into details:

–       remodeling of the urethral meatus (meatoplasty) and the ventral side of the glans (glanuloplasty)

–       reconstruction of the mucous collar around the glans.  This is a technique which gives the penis an appearance very close to that of a normal circumcised penis (Kolligian & Firlit, 2000)

–       a correctly vascularised cutaneous covering

  1. Possible complications

Although the objectives of hypospadias repair aim to obtain a penis with normal functions of urination, erection and appearance, it is well known that there are a number of possible complications related to this type of surgery (Paparel et al., 2001; Wilcox & Ransley, 2000). Here is an outline of some of them.

7.1. Urethral fistulas 

One of the more commonly encountered complications after hypospadias surgery is the urethral fistula.  Characterized by an outflowing of urine at the site of the repair on the ventral side of the penis, a urethral fistula is at least an annoyance during urination (Dubois, Pellizo, Nasser et al., 1998). This complication can occur during the first six months following the operation or even several years later.  Sometimes, fistulas close themselves spontaneously. However, if this complication persists, it is possible to operate again, according to the severity of the situation (e.g. size of the fistula, multiple fistulas) (Elbakry, 2001; Shankar, Losty, Hopper et al., 2002). Some fistulas which are more complex to close than others require specific surgical procedures (Richter, Pinto, Stock & Hanna, 2003).

7.2. Stenosis of the urethral meatus

A second complication is stenosis of the urethral meatus. Rarer than fistulas, stenoses consist of a shrinking of the urethral meatus, which lessens the stream of urine during urination (Ellsworth et al., 1999). This complication can lead to serious problems due to the difficulty of completely emptying the bladder (e.g. damage to the upper urinary tract, urinary infections).  A stenosis can be treated manually by dilatation with the help of a catheter or surgically (a meatotomy) (Wilcox & Ransley, 2000).

7.3. Persistent chordee

A third complication refers to the persistence of chordee. In general, this complication is due to its inadequate correction at the time of the first operation. This complication is becoming less frequent thanks to the development of new surgical techniques in orthoplasty and the potential to check the straightening of the penis throughout the surgery (Wilcox & Ransley, 2000).

7.4. Unsatisfactory aesthetic results 

A fourth complication relates to disappointing aesthetic results. The aesthetic quality of the repair can, for example, be compromised by the presence of irregular suture points or an excess of skin on the ventral side of the glans (Paparel et al., 2001). The aesthetic objective (to give the patient a penis with as near normal an appearance as possible) can be also be subject to other complications.

Even after surgery, the urethral meatus may be situated below the apex of the glans or may have a circular form instead of a vertical orientation (slit) (Holland, Smith, Ross & Cass, 2001). With the aim of evaluating the aesthetic results of repair operations, some pediatric urologists have, for example, put forward a ‘system of objective analysis’, using photographic negatives taken at different moments of the intervention (just before, just after and between three months and one year afterwards) (Baskin, 2001).

7.5. Multiple failures

A fifth complication refers to multiple failures in operations carried out on what some authors have called hypospadias ‘cripples’ [40] or ‘disasters’ (Paparel et al., 2001). This terminology refers to boys or men who, even if they have been operated on several times [41], still suffer major functional or aesthetic problems (e.g., badly scarred tissue, persistent chordee or fistulas, stenosis of the meatus) (van der Werff & van der Meulen, 2000).

  1. Pre-admission and post-operative care

Given that the candidate population for hypospadias surgery is composed mostly of young children, the parents should benefit from a variety of information before giving their consent to the operation to be performed on their child (Ellsworth et al., 1999).

The information given out before admission is notably related to the surgical procedures and their objectives, risks and complications associated with such procedures and the duration of hospitalization. Pre-admission information also concerns post-surgical care (Sanders, 2002).

Parents should be informed that a catheter will probably be left in place for several days following the operation, to drain the urine from the bladder (Mondet, Johanet, Larroquet et al., 1999). They should also know that after the operation the penis will be covered in a specialized dressing, the application of which is recommended for several reasons: to keep the penis stabilized, to allow for the best possible healing of tissues, to ensure sterility of the wound, to reduce the risk of bleeding by keeping a moderated pressure, and to maintain the catheter in the correct position (Searles & Mackinnon, 2001).

Continued here.

Hypospadias information, Hypospadias surgery

Chapter 2: Hypospadias and Surgery (part 1)

Chapter 2: Hypospadias and Surgery (part 1)

  1. Introduction

This second chapter is dedicated to exploring medical treatment. We shall look at the physical issues which are taken into account in the decision to operate and I shall describe briefly the necessary objectives and principles of surgery.

After a review of the history of surgery for hypospadias, I shall move on to the question of the appropriate age for surgery, where I will try to show that changes have taken place in this field in recent years.  I will present a few surgical techniques in use today, and cite some complications inherent in this type of surgery.  Finally, I will touch briefly on several elements concerning pre-admission and post-operative care.

  1. Consequences of hypospadias

2.1. Functional problems

Medical practitioners believe that hypospadias runs the risk of a number of adverse physical consequences if it is not treated surgically (Bukowski & Zeman, 2001 ; De Sy & Hoebeke, 1996). Surgical intervention is generally recommended for posterior and median forms of hypospadias as well as distal forms presenting an associated pathology (e.g., chordee).

The existence of functional problems related to urination, sexuality and reproduction, has often been reported in the  literature (Arap & Mitre ; Baskin, 2000 ; Zaontz & Packer, 1997). For example, misplacement of the urethral meatus can alter the direction of the stream of urine: depending on the anatomical condition, the stream of urine tends to deviate backwards, making it more difficult to urinate standing up.  In posterior forms, deviation may be such that the individual has to sit down to urinate.

On attaining adolescence or adulthood [21], the presence of chordee may hinder sexual activity (e.g., through pain during intercourse). In adulthood, fathering a child may potentially be made more difficult if, due to the location of his urethral meatus, a man’s ejaculation takes place lower down the vagina, reducing the chances of semen reaching far enough into the vagina for insemination. 

2.2. Aesthetic repercussions 

To the three difficulties mentioned above (urination, sexual activity, fatherhood) must be added a fourth, which refers to problems of an aesthetic nature. The appearance of a hypospadic penis may be rather different to that of a ‘normal’ penis (Baskin, 2000; Sheldon & Duckett, 1987).

The external aspect of a penis with hypospadias must be taken into account during the clinical examination, even if there are no physical difficulties with the stream of urine or chordee [22] (Zaontz & Packer, 1997).

  1. Objectives and principles of hypospadias surgery

3.1. Objectives of surgery

Surgical treatment aims to re-establish the functions (urination, erection) and anatomy of the genito-urinary organ, rendering it as similar as possible to a ‘normal’ penis (Wese et al., 1994). The objectives are to obtain, at the end of the operation, various functional and aesthetic characteristics  (Zaontz & Packer, 1997):

–       a straight penis (in erection)

–       a urethral meatus situated, if possible, at the end of the glans

–       urination with a straight, well-aimed stream

–       a penis of aesthetically normal appearance

The straightening of the penis is carried out to permit the individual to have satisfactory sexual relationships later on.  The creation of a urethral meatus as close as possible to the glans, or even at the tip, using new procedures, is designed to make it possible to urinate standing up, without misdirection of the stream of urine. The position of the newly created urinary meatus also permits insemination for reproduction. Finally, the objective is also to render the penis as close as possible to ‘normal’ in appearance.

3.2. Principles of surgery

According to Paparel et al. (2001), the current approach to hypospadias is governed by three fundamental principles which should, if possible, be dealt with at the same stage (Paparel et al., 2001); they are:

–       correction of chordee

–       reconstruction of the missing piece of urethra (urethroplasty)

–       reconstruction of the ventral side of the penis

Before going into any further detail on the techniques currently utilized by pediatric urologists specializing in the surgical approach to hypospadias – known as ‘hypospadiology’ (Sheldon & Duckett, 1987) – I will briefly review the history of surgery for hypospadias as well as providing an overview of the main changes which have taken place regarding opinions about the best age for the operation.

  1.  Surgery for hypospadias: an historical view

Surgical treatment for hypospadias has long represented  ‘a great challenge’ (Perovic, Scepanovic, Vukadinovic et al., 2000; Macedo & Srougi, 1998), for generation of surgeons and pediatric urologists, and it is very likely to remain so in the future.

While different types of surgical treatment have been mentioned over the centuries [23], the ‘modern principles’ of surgery for hypospadias were only described for the first time during the 19th century and beginning of the 20th century, in Europe, by German and French surgeons (e.g., Dieffenbach, 1936 et Tiersh, 1869 ; Duplay, 1874 ; Novè Josserand, 1897 ; Ombrédanne, 1923 ; Mathieu, 1932) (Smith, 1997). Moreover, the techniques in use today mainly stem from modifications based on discoveries made by the pioneers of this surgery (Santanelli, 2002).

The surgical procedures in existence during the 20th century have been divided into two main types: multi–stage reconstructive techniques and single stage reconstructive techniques.

In multi-stage procedures, a first operation was necessary to correct the chordee.  Urethroplasty only took place afterwards, necessitating one or more operations (Horton & Devine, 1972). These procedures, used during the major part of the last century, and which used multiple skin grafts [24] as substitute material for the urethroplasty thus lengthening the time taken for the operation, are not in use today [25].

In the field of surgery for hypospadias, as stressed by Babut (1996, p. 64), ‘the ideas are evolving and certain principles have been abandoned’. If some surgeons still make use of multi-stage techniques, these are no longer likely except in very severe cases (Ferro, Zaccara, Spagnoli & al., 2002 ; Gershbaum, Stock & Hanna, 2002).

The single stage procedures are surgical procedures which permit correction of chordee and urethroplasty in one and the same operation. These procedures, mostly using penile skin (skin from the penis or prepuce), were introduced during the 1960s, then popularized around the 1980s (Lottman, 1998). They have never ceased to be remodeled and subtly improved (Belman, 1997). In the last few years, hypospadias repair has seen unprecedented evolution. Reconstruction work, originally purely functional, has today combined with aesthetic repair work of increasing finesse  (see for example, Hoebeke, De Kuyper et Van Laeke, 2002).

  1.  The preferred age for surgery

5.1. Changes in the timing

Initially, surgical reconstructions for hypospadias were practiced during later childhood, or even postponed to early adolescence (Ellsworth et al., 1999). It was only around the second half of the 19th century that certain north American surgeons proposed that the operations be carried out before children entered primary school, to permit them to urinate standing up in the boys’ toilets (Culp, 1951, cited in Mills, McGovern, Coleman et al., 1981).

The idea of operating on boys born with hypospadias before they started school spread throughout the USA where it became accepted practice at the end of the 1970s (Hodgson, 1981). At that time, according to the American Academy of Pediatrics (AAP), technical considerations remained of prime importance (American Academy of Pediatrics 1975) [26].

At the beginning of the 1980s, two publications appeared concerning the technical possibilities of starting to operate on very young children (Belman & Kass, 1982 ; Manley & Epstein, 1981). As technical changes reduced the possible age of surgery, an awareness began to develop about the psychological implications of surgery at such a young age. For example, in the mid-1970s, Robertson and Walker (1975) were able to observe that the child candidates for hypospadias surgery, and their parents, could be anxious regarding the surgical procedures used or regarding the condition of hypospadias itself (Robertson & Walker, 1975).

And at the end of the decade, Lepore and Kesler (1979) described a specific pattern of negative behavior in a group of children who had just been operated upon. The authors alerted the medical community to the danger to the children’s psychological health caused by genital surgery around the age of three years.

Around the same time, the publication of an article by Schultz, Klykylo and Wacksman (1983) contributed further to revision of the timing of the operation. These authors primarily emphasized the fact that the psychological impact of hypospadias, or a repair operation, varied according to age. According to a review of the literature at that time, Shultz et al. (1983) suggested – with regard to emotional and cognitive development and the emergence of self-image and sexual identity – that surgical interventions should be practiced during the first year of the child’s life.

They also stated that it should be arranged so that parent-child separation during hospitalization was minimized and that parental accompaniment should be encouraged, with the aim of reassuring parents and allowing them to express their anxieties, worries or feelings of guilt, emotions which are often present.

The issues of a psychological order tackled thirty years ago by Shultz et al. (1983), as well as those concerning technological advances in the domain of ‘hypospadiology’, were reprised in a more recent article from the American Academy of Pediatrics (AAP) (American Academy of Pediatrics, 1996).

According to the AAP (1996), it has become technically possible (e.g., using optical magnifiers, micro-instruments, delicate materials and sutures, and with progress in anesthesia) to operate on almost all forms of hypospadias in very young children while minimizing not only the time spent in hospital and the amount of separation from parents [27], but also the number of operations required (e.g., by using single stage procedures).

According to the AAP (1996), because emotional and cognitive development and body image can be profoundly affected both by the genital condition and the experience of surgery, the ‘best’ time to operate is between 6 and 12 months of age.

5.2. Current practice

Current practice, in north America, is to carry out this type of surgical intervention between the ages of 6 and 18 months (AAP, 2000). However, there is still no true consensus on this question internationally.  In France, for example, some surgeons prefer to wait until the child is one or two years old (Paparel et al., 2001). Overall, however, the tendency is to operate increasingly early, with as few operations as possible and in as limited a time period as possible, with the aim of diminishing the psychological impact of both the hypospadias and the experience of surgery  (Arap & Mitre, 2000; Baskin, 2000; Paparel et al., 2001).

Continued here.