Functional & Objective Evaluation Of Hypospadias Repair Benedict Joshua, Dhruv Ghosh, Sanjeev Kumar, Alka Grewal, William Bhatti

Aim Functional and Objective Evaluation of Hypospadias Repair We audited the hypospadias repairs done in our department and evaluated them functionally as well as objectively

Methods Inclusion Criteria 6 months after hypospadias urethroplasty 2 month after urethrocutaneous fistula repair Toilet trained Toilet trained individuals who had at least a 6 month interval after urethroplasty or 2 months after a fistula repair were included

Methods Exclusion Criteria Not Toilet trained Active Urethrocutaneous fistula Symptomatic meatal stenosis Symptomatic urethral stricture Patients with an untreated urethrocutaneous fistula or symptomatic urethral obstruction were excluded

Methods Uroflowmetry Voided Volume Voiding Time Maximum Flow Rate Average Flow Rate Voiding Pattern Evaluation via Toguri’s Normogram1 Functional evaluation was done by Uroflowmetry in our Urodynamics laboratory and Toguri’s normogram used to classify obstructive or non obstructive flow 1. Toguri AG et al. Pediatric Uroflow Normograms. J Urol (1982);127:727 1982

Methods Hypospadias Objective Scoring Evaluation (HOSE)2 (Independent Investigator) Meatal Location Meatal Shape Urinary Stream Erection Fistula Max Score: 16 Acceptable Score ≥ 14 An independent investigator not involved in the management or surgery of these patients did the HOSE scoring by interviewing the patient or the primary caregiver 2. Holland AJA et al. HOSE: An Objective Scoring System For Evaluating The Results Of Hypospadias Surgery. BJU Int(2001);88:255

Materials 39 patients fulfilled all inclusion criteria Mean Age (At Surgery): 5.16 years (range: 1-24 yrs) Mean Age (At Evaluation): 8.5 years (range: 2-25 yrs) Mean Follow Up: 36.35 mths (range: 6-148mths) Amongst the patients who responded to our invitation for evaluation 39 fulfilled the inclusion-exclusion criteria. The demographic profile is presented here.

Materials Distal Hypospadias: 53.85% (n=21) Mid Penile Hypospadias: 17.95% (n=7) Proximal Hypospadias: 28.20% (n=11) Distal hypospadias repairs formed more than half the group

Qmax Significantly Better In Distal Repairs(p=0.03) Results Maximum Urine Flow Rate (Qmax) Normal:43.59% (n=17) Distal: 66.7% (n=14) Mid: 28.6% (n=2) Proximal: 9.1% (n=1) Obstructed: 43.59% (n=17) Distal: 23.8% (n=5) Mid: 57.1% (n=4) Proximal: 72.7% (n=8) Qmax Significantly Better In Distal Repairs(p=0.03) An equal number of patients showed a normal and an obstructed Qmax while the remainder were equivocal. Normal Qmax was seen in a significantly higher number of distal hypospadias repairs

Better Qave In Distal Repairs (p=ns) Results Average Flow Rate (Qave) Normal:17.9% (n=7) Distal: 28.6% (n=6) Mid: 14.3% (n=1) Proximal: 0% (n=0) Obstructed: 69.3% (n=27) Distal: 52.4% (n=11) Mid: 85.7% (n=6) Proximal: 90.9% (n=10) Better Qave In Distal Repairs (p=ns) The Qave was obstructive in a majority of our patients. A slightly better Qave was seen in distal repairs but this difference was not significant

Urine Flow Curve Less Obstructive In Distal Repair (p=ns) Results Urine Flow Patterns Normal:33.3% (n=13) Distal: 47.6% (n=10) Mid: 28.6% (n=2) Proximal: 9.1% (n=1) Obstructed: 66.7% (n=26) Distal: 52.4% (n=11) Mid: 71.4% (n=5) Proximal: 90.9% (n=10) Urine Flow Curve Less Obstructive In Distal Repair (p=ns) Again a majority of our patients demonstrated a obstructive urine flow curve. The urine flow curve was less obstructive in distal repairs but not significantly.

Qmax Appears to Improve With Time (p=ns) Results Follow Up v/s Qmax Less Than 2 Years Normal: 27.27% (n=6) Equivocal: 18.18% (n=4) Obstructed: 54.55% (n=12) More Than 2 Years Normal: 64.71% (n=11) Equivocal: 5.88% (n=1) Obstructed: 29.4% (n=5) Qmax Appears to Improve With Time (p=ns) Qmax seems to improve as time following repair elapses but there was no statistical significance of this improvement in our study

Improvement In Flow Pattern With Time (p=ns) Results Follow Up v/s Urine Flow Pattern ≤ 2 Years Normal: 22.7% (n=5) Obstructed: 77.3% (n=17) > 2 Years ≤ 5 Years Normal: 37.5% (n=3) Obstructed: 62.5% (n=5) > 5 Years Normal: 55.5% (n=5) Obstructed: 45.5% (n=4) Improvement In Flow Pattern With Time (p=ns) Urine flow patterns also gradually seem to improve with time but not significantly

Results Post Voidal Residual Volume Significant (>10% of FBC): 5.13% (n=2) Not Significant (<10% of FBC): 94.87% (n=37) Most Patients Voided To Completion Inspite Of Obstructive Flow Patterns & Rates While a majority of our patients showed obstructive flows and curves, they still managed to void to completion and only 2 children had a significant post voidal residue on ultrasound evaluation

Results Cystourethroscopy Patients With Abnormal Flow Rates & Patterns 6 Patients Consented All Patients Were Asymptomatic Cystourethroscopy Was Normal In All 6 6 children with abnormal flow patterns including the two with significant post voidal residue consented to cystoscopic evaluation. The cystourethroscopy was normal in all 6, raising the question as to what is contributing to the obstructive patterns.

Results HOSE Scoring Satisfactory: 71.79% (n=28) Distal: 85.7% (n=18) Mid: 85.7% (n=6) Proximal: 36.4% (n=4) Unsatisfactory: 28.21% (n=11) Distal: 14.3% (n=3) Mid: 14.3% (n=1) Proximal: 63.6% (n=7) Level Of Repair Significantly Related to Final Cosmetic Outcome (p=0.009) Our cosmetic outcomes were comparable to most series around the world with distal repairs having a significanltly better cosmetic result

Discussion Qmax Significantly Related To Level Of Repair Obstructive Flow Rates & Patterns Did Not Relate To Demonstrated Mechanical Obstruction What Causes The Obstructive Flow Rates And Patterns? Cosmetic Outcomes & Patient Satisfaction Related To Level Of Repair