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Single incisional approach for reconstruction of hypospadias and concomitant inguinal hernia

      Abstract

      Objective

      To demonstrate the feasibility, cosmetic outcome and therapeutic values of our single incisional approach in patients with both hypospadias and inguinal hernia (IH) in comparison with standard multiple incisional techniques.

      Materials and methods

      Sixty hypospadias-IH repairs were performed from February 2005 to February 2012. These patients were divided into two groups according to their age and hypospadias location. They were then separated randomly into multiple incision (MIG) and single incision (SIG) groups. Early and late complications were taken into consideration. Postoperative pain, need for analgesics, operative time, hospital stay and cosmetic results were recorded for further evaluation.

      Results

      Patients were followed up at 6-month intervals for up to 2 years postoperatively. Early and late complication rates were approximately the same in the two groups. 73.3% of patients in MIG and 96.6% in SIG attained an excellent cosmetic result according to two external surgeons. There was no case with poor cosmetic outcome in either group. More analgesic consumption was demanded in MIG patients.

      Conclusion

      This method of surgery is reproducible with better cosmetic outcome and a slightly shorter hospital stay. It could be a viable option in the management of children with hypospadias and concomitant IH. Negligible postoperative pain and short operative time are the other advantages.

      Keywords

      Abbreviations:

      IH (inguinal hernia), SIG (single incision group), MIG (multiple incision group), VAPS (visual analogue pain scale)

      Introduction

      Indirect inguinal hernia (IH) is one of the most common problems of pediatrics, and herniorrhaphy is one of the most frequent surgeries of infancy and childhood. The incidence of childhood hernia is between 0.8% and 4.4% in full-term babies and up to 30% in premature infants [
      • Harper R.G.A.
      • Sia C.
      Inguinal hernia: a common problem of premature infants weighing 1000 grams or less at birth.
      ]. The highest incidence of IH is in the first year of life, peaking at 1 month of age [
      • Harper R.G.A.
      • Sia C.
      Inguinal hernia: a common problem of premature infants weighing 1000 grams or less at birth.
      ,
      • Rowe M.
      • Clahvorthy H.
      The other side of the pediatric inguinal hernia.
      ]. Approximately 60% of IHs occur on the right, 30% on the left and 10% bilaterally [
      • Rowe M.
      • Clahvorthy H.
      The other side of the pediatric inguinal hernia.
      ]. The higher incidence of IH on the right side may be due to delayed testicular descent on this side, resulting in postponement of right processus vaginalis obliteration [
      • Gross R.
      The surgery of infancy and childhood.
      ]. Accordingly, patients who were present with left-sided IH are more likely to have the right-sided, as well. The most important concern, regarding infant hernias, is incarceration or strangulation of viscera, which creates an emergency situation requiring an operation within 2 h [
      • West K.W.
      • Bengston K.
      • Rescorla F.J.
      • Engle W.A.
      • Grosfeld J.
      Delayed surgical repair and ECMO improves survival in congenital diaphragmatic hernia.
      ]. Numerous studies have reported that laparoscopic herniorrhaphy has the ability to induce potential complications including testicular atrophy (0.2–1.49% of incidence) 4 weeks after surgery [
      • Saranga Bharathi R.
      • Arora M.
      • Baskaran V.
      Minimal access surgery of pediatric inguinal hernias: a review.
      ]. Hernia recurrence with prevalence of 0.8–3.8% [
      • Grosfeld J.L.
      • Minnick K.
      • Shedd F.
      • West K.W.
      • Rescorla F.J.
      • Vane D.W.
      Inguinal hernia in children: factors affecting recurrence in 62 cases.
      ], bleeding, wound infection, irritating scars, testicular ascent (1%) [
      • Surana R.
      • Puri P.
      Iatrogenic ascent of the testis: an under recognized complication of inguinal hernia operation in children.
      ], chronic pain, hemorrhage and damage of internal organs are among the most common complications of IH operation.
      Approximately, 15.7% of hypospadias patients were afflicted with concomitant IH in a nationwide study of Taiwan [
      • Huang W.Y.
      • Chen Y.F.
      • Guo Y.J.
      • Lan C.F.
      • Chang H.C.
      • Chen S.C.
      • et al.
      Epidemiology of hypospadias and treatment trends in Taiwan: a nationwide study.
      ]. By precise history taking and physical exam, the incidental findings will be more common. This combined situation can increase the risk of incarceration/strangulation (as a life-threatening complication of IH) in the postoperative period due to more risk of bladder spasm and increased intra-abdominal pressure [
      • Yegane R.A.
      • Kheirollahi A.R.
      • Bashashati M.
      • Rezaei N.
      • Tarrahi M.J.
      • Khoshdel J.A.
      The prevalence of penoscrotal abnormalities and inguinal hernia in elementary-school boys in the west of Iran.
      ]. Traditional surgical methods, have been used in order to explore the inguinal canal with a low complication rate [
      • Lau S.T.
      • Lee Y.H.
      • Caty M.G.
      Current management of hernias and hydroceles.
      ].
      Cosmetic details, appearance and postoperative discomfort are essential aspects to the patients with concomitant hypospadias and IH, so the application of a technique with less discomfort after the surgery would be beneficial. Due to the fact that pubertal growth can cause changes in cosmetic and functional outcomes after the hypospadias repair, long-term follow-up is essential.
      The present study was designed to investigate whether the one incision technique could be a more appropriate treatment for hypospadias and concomitant IH, and be used as an effective alternative to the previously applied two or three incision procedures.

      Patients and methods

      In this prospective/randomized study, we compared the outcomes of the single incision and two or three incision approaches in the simultaneous surgical treatment of hypospadias and IH.
      After institutional review board approval and obtaining informed consent, patients with hypospadias and concomitant IH were treated according to the algorithm depicted in Fig. 1. For distal and midshaft hypospadias we do not perform VCUG routinely, but only in the case of a history of voiding dysfunction (intermittency, painful urination, etc) and abnormal ultrasonography. However, in a child who presents with proximal hypospadias, we routinely perform VCUG in order to rule out reflux or the presence or absence of concomitant prostatic utricle or other congenital urethral anomalies. In children with depicted type I–III prostatic utricle on VCUG and proximal hypospadias, we initially proceed with endoscopic management of the prostatic utricle with hernia repair and the hypospadias reconstruction will be postponed. In a patient with a history of inguinal swelling, silk glove sign and hydrocele, further surgical correction is performed according to the diameter of the inguinal canal as demonstrated in the algorithm.
      Figure thumbnail gr1
      Figure 1Management of patients with concomitant inguinal hernia and distal hypospadias.
      Between February 2005 and February 2012, 1280 patients with different types of hypospadias were referred for further management. Of these, 60 patients (4.7%) presented with concomitant hypospadias and IH. The prevalence of different IH and hypospadias locations and the visual analogue pain scale (VAPS) after surgery are shown in Fig. 2. Patients with hypospadias (distal, proximal, midshaft and chordee) and concomitant IH (right, left and both) were matched according to their age and hypospadias location. These two groups were then divided randomly into single and multiple incisional groups (SIG/MIG). The mean age was 47.43 (4–128 months) and 38 (8–136 months) in MIG and SIG, respectively.
      Figure thumbnail gr2
      Figure 2(A) Hypospadias and inguinal hernia location; (B) comparison of VAPS scores during the first 28 days after surgery. Group A = MIG, Group B = SIG.
      In MIG, hernia repair was done based on classic inguinal low crease incision. The spermatic cord was delivered through the incision, outside the external ring. Then, the hernia sac was carefully dissected from adjacent structures and divided between hemostats. It was then freed proximally, as far as possible, where it was ligated with absorbable 4-0 polyglactin sutures. The distal portion of the hernia sac was left open to prevent hydrocele formation. Following the hernia repair, the skin of the penis was incised based on the selected technique with preservation of the urethral plate and the penis was degloved down to the penopubic and penoscrotal junction. Orthoplasty, urethroplasty and glanuloplasty were performed based on the meatal position and the chosen technique.
      In SIG, the skin of the penis was incised as in MIG. Then, the penis was degloved down to the penopubic and penoscrotal junction. The spermatic cord was approached via the lateral aspect of the degloved penis on each side. The spermatic cord was delivered through the incision, outside the external ring. The cremasteric muscles were separated to expose the hernia sac, which was located anteromedially to the vas and testicular vessels. The hernia sac was carefully dissected from adjacent structures, divided between hemostats and freed proximally, as described for MIG. After completing the procedure, orthoplasty, urethroplasty and glanuloplasty were performed based on the meatal position and chosen technique (TIP, MAGPI, BEAM or Mathieu). Reconstruction and straightening of the penis was meticulously performed in order to avoid any sexual dysfunction in adulthood (Fig. 3).
      Figure thumbnail gr3
      Figure 3Surgical procedure in a 2-year-old patient with concomitant hypospadias and right inguinal hernia undergoing the one incision technique.
      We do not prescribe narcotic agents as analgesics after the operation, but routinely at our center a caudal epidural block is applied using 0.25% bupivacaine, 0.5 ml/kg for all patients who undergo hypospadias surgery. The institutional review board approved the absence of analgesic treatment after the operation due to the fact that the epidural block usually controls the pain within 4–6 h postoperatively. Furthermore, as an adjunct to the caudal block in both groups, we managed bladder spasms (due to in-situ bladder catheter) with low dosage oral oxybutynin in selected cases according to patient demand. No further analgesic medication was applied for controlling the incisional pain in either group following the operation.
      Patients were followed up at 6-month intervals up to 2 years postoperatively. Hematoma and scrotal/penile edema were considered as early complications and hernia recurrence, testicular ascent, testis atrophy, fistula, urethral stricture and meatal stenosis as late complications. The cosmetic results were evaluated by two surgeons who were external to the study. The degree of satisfaction with cosmetic result was calculated according to a three-point scale (excellent, good and poor). In the present study, bleeding and wound infection within 2 weeks of surgery, visible scar with flared margins, and no visible scars (6 months postoperatively) were considered as poor, good and excellent cosmetic result, respectively. A VAPS was used for those patients who could describe their pain using this scale (21 patients in each group).
      Statistical analysis was performed using SPSS®, version 19. Categorical variables were compared using the chi-square test. VAPS was analysed in those old enough to be assessed by utilizing the independent sample t-test. Cosmesis was assessed independently by surgeons not involved with the cases and statistically analysed by Fisher exact test. Indication of statistical significance was accepted for P values less than 0.05.

      Results

      No intraoperative complications were reported in this series of patients. Mean operative time for distal, proximal, midshaft and chordee hypospadias repair with one or two hernia sacs is shown in Table 1, A.
      Table 1(A) Comparing the mean operative time between MIG and SIG groups (mean ± SD). (B) The frequency of postoperative complications in each group. (C) Evaluation of cosmetic results by two external surgeons.
      A
      Operative time in MIG (min) (mean ± SD)Operative time in SIG (min) (mean ± SD)
      Distal hypospadiasUnilateral hernia75.3 ± 270 ± 1
      Bilateral hernia105.5 ± 190.4 ± 4
      Midshaft hypospadiasUnilateral hernia90 ± 382.2 ± 1
      Bilateral hernia130 ± 2110.1 ± 3
      Proximal hypospadiasUnilateral hernia195.8 ± 2185.4 ± 4
      Bilateral hernia210.6 ± 4190.1 ± 3
      Chordee hypospadiasUnilateral hernia119.9 ± 3114.3 ± 2
      Bilateral hernia148.7 ± 1132 ± 1
      B
      ComplicationsSIG (n = 30)MIG (n = 30)P value
      Scrotal discoloration34ns (0.69)
      Penile skin edema75ns (0.52)
      Mild scrotal edema33ns (1.00)
      Hernia recurrence00ns (0.00)
      Testis atrophy00ns (0.00)
      Fistula32ns (0.64)
      Urethral stricture01ns (0.32)
      Total breakdown00ns (0.00)
      Meatal stenosis23ns (0.64)
      C
      SIGMIGCosmetic results
      29 (96.66%)22 (73.33%)Excellent (no visible scar)
      1 (3.33%)8 (26.66%)Good (visible scars with flared margins)
      0%0%Poor (bleeding and wound infection)
      The prevalence of immediate postoperative complications in the two groups was similar (81% and 83.3%) (Table 1, B). None of these minor complications (swelling and bruising) needed any postoperative intervention before resolving in all the patients of both groups.
      In this study, no meaningful difference was detected in postoperative complications between the two groups, while cosmetic results (with regard to inguinal scar) were significantly better in SIG, after a minimum follow-up of 6 months. Twenty-two of 30 (73.3%) patients in MIG achieved excellent cosmetic results versus 29 of 30 patients (96.6%) in SIG (Table 1, C). There was no case with poor cosmetic outcome in either group.
      The VAPS of the 21 patients in each group, immediately after the operation, was 56 and 45 out of 100 in MIG and SIG, respectively. Statistical analysis of these results showed no significant difference (P = 0.10). Patients in SIG experienced less acute pain, while the pain for MIG patients was more severe with a greater demand for analgesics.
      A negligible diminution in duration of hospital stay (P = 0.10) was detected in patients undergoing the single incision procedure. Additionally, parents of the SIG group were more satisfied with postoperative outcomes (hospital stay and patient discomfort at home as a result of pain or other complications).
      In summary, fewer complications, and better cosmetic and rehabilitation outcomes can be attained safely by this new approach, which was initially performed by a senior surgeon (AMK). This procedure is nowadays a routine part of our teaching program in selected cases.

      Discussion

      Hypospadias can be accompanied by other congenital abnormalities of the genital organs or dysmorphic syndromes [
      • Cerasaro T.
      • Brock W.
      • Kaplan G.
      Upper urinary tract anomalies associated with congenital hypospadias: Is screening necessary?.
      ]. The prevalence of this common male external genital anomaly is 0.2–4.1 in 1000 live births [
      • Kallgn B.
      • Bertollini R.
      • Castilla E.
      • Czeizel A.
      • Knudsen L.B.
      • Martinez Frias M.L.
      • et al.
      A joint international study on the epidemiology of hypospadias.
      ]. An increase in hypospadias occurrence over specific time periods in different areas, such as Scandinavian countries, USA, England and Italy, has been reported [
      • Matlai P.
      • Beral V.
      Trends in congenital malformations of external genitalia.
      ]. Although it is usually presented as an isolated anomaly, associated urogenital abnormalities can occur with a prevalence of approximately 7–9% [
      • Fallon B.
      • Devine Jr., C.
      • Horton C.
      Congenital anomalies associated with hypospadias.
      ]. Cryptorchidism, IH, upper urinary tract abnormalities and anorectal malformation are among the most common coexistent urogenital anomalies [
      • Meizner I.
      • Mashiach R.
      • Shalev J.
      • Efrat Z.
      • Feldberg D.
      The ‘tulip sign’: a sonographic clue for in utero diagnosis of severe hypospadias.
      ].
      According to several studies, the prevalence of IH is 1–4% in children [
      • Chung K.L.Y.
      • Leung M.W.Y.
      • Chao N.S.Y.
      • Wong B.P.Y.
      • Kwok W.K.
      • Liu K.K.W.
      Laparoscopic repair on asymptomatic contralateral patent processus vaginalis in children with unilateral inguinal hernia: a centre experience and review of the literature.
      ]. Nearly 0.8–4.4% of congenital indirect IHs occur in childhood and they are more prevalent in boys [
      • Brandt M.L.
      Pediatric hernias.
      ]. Up to 15% of all surgical procedures in infants and children are related to IH repair [
      • Lloyd D.A.
      • Rintala R.
      Inguinal hernia and hydrocele.
      ]. The hernias are usually asymptomatic; however, in every child with hypospadias, the inguino-scrotal region must be examined meticulously in supine position and undressed. The examiner will then be able to observe potential inguinal asymmetry or an obvious mass. If no visible mass is present, then the older child should be examined in standing position with Valsalva maneuver. The infant will be examined during straining or crying in order to enable the examiner to determine the presence or absence of an inguinal/scrotal swelling. The most obvious part of physical examination is the hernial mass, which will emerge through the external inguinal ring, lateral to the pubic tubercle, and enlarge with increased intra-abdominal pressure. IH can also be diagnosed by examining the inguinal region for non-palpable or non-visualized inguinal/scrotal swelling by looking for the “silk glove sign” (SGS) or palpating the processus vaginalis over the pubic tubercle. A positive SGS indicates possible IH [
      • Gross R.
      The surgery of infancy and childhood.
      ]. The specificity of diagnosis by SGS was reported as high as 97.3% and the accuracy of this repeated and careful examination is about 91% [
      • Luo C.
      • Chao H.
      Prevention of unnecessary contralateral exploration using the silk glove sign (SGS) in pediatric patients with unilateral inguinal hernia.
      ]. Furthermore, in the presence of a positive SGS, measurement of inguinal canal diameter by ultrasonography can be considered as a highly accurate and non-invasive test for the detection of non-bulging IH. Ultrasonography not only shows the herniated viscera or open processus vaginalis and hydrocele but also measures the inguinal canal and the size of the spermatic cord. The diameter of the inguinal canal being more than 4 mm at any age is one of the supplementary findings (95%) for diagnosis of IH [
      • Chen K.C.
      • Chu C.C.
      • Chou T.Y.
      • Wu C.J.
      Ultrasonography for inguinal hernias in boys.
      ]. In our patients, if communicating hydrocele, clinical hernia or positive SGS was observed, the patient underwent ultrasonography. In the U/S examination, if the canal diameter was more than 4 mm, and taking into account the child's age (patent processus vaginalis), we decided to perform concomitant hypospadias and IH repair.
      There are several postoperative complications associated with hypospadias surgery, such as urethrocutaneous fistula, urethral diverticulum formation, wound dehiscence, meatal stenosis, hematoma and urethral stricture. The incidence of complications following hypospadias surgery is 6%–30%, depending on the severity of the abnormality and surgeon's expertise [
      • Bhat A.
      • Mandal A.K.
      Acute postoperative complications of hypospadias repair.
      ,
      • Metzelder M.L.
      • Kuebler J.
      • Glueer S.
      • Suempelmann R.
      • Ure B.
      • Petersen C.
      Penile block is associated with less urinary retention than caudal anesthesia in distal hypospadia repair in children.
      ].
      In order to prevent the occurrence of strangulation, which can lead to the loss of the testis or part of the intestine, especially in infants of 0–6 months with IH, surgery should be performed urgently. Furthermore, early recurrence of IH was reported in 1.9% of patients due to inadequate technique [
      • De Lange D.
      • Kreeft M.
      • Van Ramshorst G.
      • Aufenacker T.
      • Rauwerda J.
      • Simons M.
      Inguinal hernia surgery in the Netherlands: are patients treated according to the guidelines?.
      ]. The risk of recurrence from the application of inguinal exploration after the treatment of IH is more than 2–3% in boys younger than 1 year, which may be detected during adolescence [
      • Montupet P.
      • Esposito C.
      Laparoscopic treatment of congenital inguinal hernia in children.
      ,
      • Spurbeck W.
      • Prasad R.
      • Lobe T.
      Two-year experience with minimally invasive herniorrhaphy in children.
      ].
      Searching through the literature, we found no classical reports with specific focus on concomitant repair of hernia and hypospadias. However, a similar technique was previously described by the Seattle group in their review of open minimally invasive surgery with promising results [
      • Hidalgo-Tamola J.
      • Shnorhavorian M.
      • Koyle M.A.
      “Open” minimally invasive surgery in pediatric urology.
      ]. Regarding the frequency of concomitant occurrence of these conditions, an attempt to have a less invasive procedure in one session seems logical. In many cases of severe hypospadias, extensive dissection and degloving inherent to hypospadias surgery for correcting penile curvature exposes the testis and spermatic cords to the surgical field. Therefore, the idea of simultaneous surgery with a single approach does not seem far from the mind. In cases of distal hypospadias, an extra effort in degloving and dissecting to deliver the cord into the surgical field must be made. However, the dissection does not seem excessive and also the complication rate does not seem to rise. Moreover, this dissection has the advantage of detection and correction of associated chordee, which is often an obligatory part of hypospadias repair. On the other hand, by the application of this approach, operation time decreases significantly; especially in bilateral IH as compared with other procedures. In this study we tried to employ a unique approach for the given patients by utilizing a single incision technique in children with both hypospadias and IH, which can be applied for a broad range of hypospadias defects encompassing both proximal and distal cases in order to minimize surgical trauma and improve the cosmetic outcome. The purpose of no incision herniorrhaphy during hypospadias reconstruction is to decrease the risks of bleeding, organ impairment and derive the best cosmetic results. In the present procedure, it is suggested that the distal portion of the hernia sac may be left open to prevent hydrocele formation. It can also be used as a second layer coverage for hypospadias repair, the results of which are under further investigation.
      The inability of the nine younger patients to verbally communicate their pain score, the small numbers of cases meaning low statistical power, and late referral for correction are among the limitations of the present study. The highlighted advantage of this technique is its reproducibility in different hands, which makes it universally applicable, while representing a minimal invasion principle without any impairment in surgical results. More investigations with a larger number of patients are required to evaluate the benefits and disadvantages of this technique.

      Conclusion

      This study describes the correction of hypospadias and IH simultaneously. The single incisional approach introduces less discomfort and shorter surgical duration without an increase in complication rate, as compared to other studies in the literature. It has the potential to be used extensively owing to the satisfactory cosmetic and functional results, and its simplicity. However, more investigations are needed to validate the superiority of this approach.

      Conflict of interest/funding

      None.

      Disclosure

      None of the authors has direct or indirect commercial financial incentive associating with publishing the article and does not have any conflict of interest, and signed the Disclosure Form.

      Acknowledgement

      We highly appreciate Mr. Majid Kajbafzadeh at the School of Population and Public Health, Faculty of Medicine University of British Columbia, Vancouver, Canada for his valuable final linguistic revision of the manuscript and Miss Farnaz Bayat for her artistic illustrations.

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        Acute postoperative complications of hypospadias repair.
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