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 Table of Contents  
Year : 2016  |  Volume : 23  |  Issue : 1  |  Page : 21-24

Factors influencing waiting time in hypospadias repair surgery

1 Department of Surgery, Paediatric Surgery Unit, Lagos University Teaching Hospital, Idi-Araba, Nigeria
2 Department of Surgery, Paediatric Surgery Unit, Lagos University Teaching Hospital, Idi-Araba; Department of Surgery, Paediatric Surgery Unit, College of Medicine of the University of Lagos, Lagos, Nigeria

Date of Web Publication13-Apr-2016

Correspondence Address:
Adesoji O Ademuyiwa
Department of Surgery, Paediatric Surgery Unit, Lagos University Teaching Hospital, Idi-Araba; Department of Surgery, Paediatric Surgery Unit, College of Medicine of the University of Lagos, Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1117-1936.180152

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Aims: Hypospadias is a common congenital anomaly of the urethra and phallus, which is not life threatening. It is thus less prioritised in a resource-limited setting. The aim of this study was to evaluate the management of hypospadias by our paediatric surgery unit and determine the factors affecting the delay between presentation and surgical repair while proffering possible solutions to such delay in hypospadias repair surgery.
Patients and Methods: This was a retrospective review of all hypospadias repair surgeries carried out by our paediatric surgery unit over a 38-month period, evaluating the period between presentation and first surgery for each patient. Data were analysed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Released 2011, Armonk, NY, USA). Chi-square test was used to compare categorical variables and P ≤ 0.05 was considered significant.
Results: In 38 months, 47 operations for hypospadias were carried out on 42 boys. Thirty-seven patients (88.1%) had >3 months delay to surgery. The most frequent contributory factor to delay was unavailable theatre space (13 patients, 31%). Surgical outcome was good in only 16 patients (44%). Of the 16 patients with good outcome, 10 (63%) were operated between the ages of 2-4 years (P > 0.05).
Conclusions: Multiple factors are responsible for delays in carrying out hypospadias surgery in resource-limited environments, notably securing a functional operating theatre suite in the light of more urgent conditions. To combat these delays, we recommend having dedicated hypospadias repair sessions and surgeons dedicated to hypospadias repair. Hypospadias outreach camps are also proposed.

Keywords: Hypospadias, hypospadiology, waiting times

How to cite this article:
Idiodi-Thomas HO, Ademuyiwa AO, Elebute OA, Alakaloko FM, Bode CO. Factors influencing waiting time in hypospadias repair surgery. Niger Postgrad Med J 2016;23:21-4

How to cite this URL:
Idiodi-Thomas HO, Ademuyiwa AO, Elebute OA, Alakaloko FM, Bode CO. Factors influencing waiting time in hypospadias repair surgery. Niger Postgrad Med J [serial online] 2016 [cited 2022 Nov 29];23:21-4. Available from: https://www.npmj.org/text.asp?2016/23/1/21/180152

  Introduction Top

Hypospadias is a congenital anomaly of the phallus characterised by an ectopic ventral urethral meatus usually associated with ventral penile curvature of varying severity. [1] The repair of this anomaly is carried out by paediatric surgeons, urologists and sometimes, plastic surgeons. [2] However, Khan et al. [3] among others have advocated for the development of hypospadiology as a separate surgical subspeciality.

In resource-limited parts of Africa where there is already a dearth of specialist surgeons, super-specialisation in hypospadiology may not be feasible. Hence, depending on the centre and the scope of the paediatric surgeon's training, they may have to carry out all surgeries involving children including general, thoracic, abdominal and urologic procedures. Our paediatric surgery unit functions in this manner, but the paediatric urologic workload is however shared between the paediatric surgeons and urologists.

Since boys with hypospadias are in relative good health, they are the least prioritised in a setting of limited operating time and space, in deference to more emergent or urgent paediatric or adult surgeries. We present our experience in the management of hypospadias over a 38-month period with emphasis on the waiting times for surgery and possible strategies to reduce delays.

  Patients and Methods Top

A retrospective review of all hypospadias surgeries performed in the paediatric surgery unit of our hospital over a total period of 38 months using theatre records, surgeon log entry books and clinical case notes was done. Data obtained included total number of surgeries carried out in the period, total number of hypospadias surgery done, age at patient's first presentation and at surgery for hypospadias, factors responsible for delayed hypospadias surgery, intra-operative details on the type of hypospadias, use of pre-operative hormonal treatment, type of repair done, acute complications and outcome.

The duration of delay (from presentation to first hypospadias surgery) was calculated for each patient to the nearest month.

Type of hypospadias was determined using Duckett's classification (1996). [4] Clinical and cosmetic outcome was described as poor if a consideration for redo-urethroplasty was being entertained at the first post-operative clinic visit (2-4 weeks post-operatively).

Data were analysed using IBM SPSS Statistics for Windows, Version 20.0, (IBM Corp., Released 2011, Armonk, NY, USA). Chi-square test was used to compare categorical variables and P ≤ 0.05 was considered significant.

  Results Top

A total of 1219 surgical operations were carried out by the paediatric surgery team in the period under review, of which 47 (3.9%) operations were for hypospadias. Forty-two patients were operated, 5 (11.9%) of whom had two hypospadias-related surgeries within the period under review. The age range at first presentation to our unit was 1 day to 10 years with a mean of 28 ± 6 months. The boys' age at the first surgery for hypospadias ranged from 2 to 11 years with a median at 4 years [Table 1].
Table 1: Demographic data of the patients ge at presentation, age at surgery, delay factor and duration of delay

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The delay period between presentation and surgery as well as contributory factors to delay are presented in [Table 1]. Thirty-seven (88.1%) patients experienced over 3 months delay between presentation and eventual surgery. The most frequent contributory factors to delay were unavailable theatre space and small penile size (31% and 23.8%, respectively).

Three patients in the study period had pre-operative hormonal treatment. They were all above 4 years at first presentation and had small penile sizes for age.

The most common types of hypospadias operated were subcoronal (45.2%) and distal penile (33.3%) accounting for 78.5% of cases [Table 2].
Table 2: Types of hypospadias operated

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The most common surgical procedure was the tubularised incised plate urethroplasty offered to 31 patients (73.8%). [Figure 1] and [Figure 2] are selected perioperative pictures.
Figure 1: Photograph of subcoronal hypospadias just before repair

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Figure 2: Immediate post-repair photograph for Figure 1

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Clinical and cosmetic outcome was good in 16 patients (44%) and poor in 20 patients (56%). Ten (63%) of the 16 patients with good outcome were operated between the ages of 2-4 years (P = 0.2). Sixteen (80%) of the 20 patients with poor outcome (and at risk for redo surgery) had acute complications within the first post-operative week while on admission (P = 0.02). This is represented in [Table 3].
Table 3: Comparison of age at surgery to outcome and post-operative acute complications and outcome

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  Discussion Top

The predominant reason for delay in commencing surgical correction of hypospadias in our series was unavailability of theatre space/slots or elective operating time. Because of the insufficient number of operating suites in our centre, surgical specialities have been placed on an elective operating schedule. With a single day a week for elective surgical cases, there is a tendency to favour performing operations that are emergent or urgent. A patient with an anterior hypospadias, who is otherwise physically healthy, cannot effectively compete for limited theatre operating space with another patient with an abdominal malignancy or even a patient on colostomy awaiting definitive posterior sagittal anorectoplasty. This trend, however, becomes a vicious cycle leading to fewer hypospadias repair being performed and resulting in diminishing surgeon's willingness, exposure and skills. Another factor that further reduces the available operating time and space is a spill over of emergency cases into elective theatre time coupled with the limitation of insufficient anaesthetists and perioperative nurses to man multiple suites running concurrently. Closely related to these factors is the apparent lack of super-specialists such as hypospadiologists. Although this is not listed as a cause of delay, the availability of such specialist(s) will require the theatre management to create an additional operating list which can drastically reduce the waiting time in this peculiar group of patients. Olajide et al. [5] in their study in Ile-Ife, Nigeria, also expressed the challenge of having one theatre space per week, with further crippling limitations, namely industrial actions by public health workers, poor electricity supply and non-availability of operating materials. These are problems which resonate with many surgeons practicing in resource-limited countries, especially in Africa.

For patients presenting to us in infancy, another major cause of delay is the penile size. In the absence of adequate fine instruments, appropriate and affordable suturing materials for delicate surgery and magnifying loupes for the team, we routinely plan to operate on our hypospadias patients in the 2 nd or 3 years of life to allow for adequate phallic growth. However, a study by Tomova et al. [6] on 6200 boys in Bulgaria showed only mild gradual increase in penile length and circumference averaging about 0.7 cm and 0.4 cm, respectively, from birth to 4 years (using their 50 th percentile for age results), with the maximum penile growth occurring after puberty. Recommendations from the section of urology of the American academy of Paediatrics suggest that the optimum time for elective surgery on the genitalia is either in the second 6 months of life or sometimes during the 4 th year to avoid 'that difficult uncooperative behavioural phase of child development between 18 months and 3 years'. [2],[7],[8]

While pre-operative hormonal enhancement with testosterone injections and creams has been recommended, [2] we utilise this option sparingly due to recurrent delays and cancellation of scheduled surgery on elective operating days due to unfavourable theatre logistics such as lack of oxygen or anaesthetic gases, no theatre suite due to on-going emergencies, no sterile drapes or surgical instruments resulting from malfunction of the sterilising unit or simply no electricity on the morning of the surgery. Thus, over a 38-month period, only three patients received monthly pre-operative intramuscular injections of testosterone to appreciably increase phallic size before surgery. We feel this cautious attitude will reduce the risk of giving pre-operative supplementation that is not followed immediately with planned surgery, which is common in our peculiar setting.

Unlike the finding by Olajide et al. where financial constraints were a major contributory factor to delayed repair, only 5 (11.9%) of our patients had this challenge; our cost of US $400-500 in Lagos being comparable to that in Ile-Ife. [5] It appears that our long delays may have helped in this regard by giving care givers enough time to raise the necessary funds.

Other less frequent delay factors identified include co-morbid disease in the hypospadias patient, industrial actions by various cadres of Nigerian health workers, government-declared public holidays, maternal pregnancy/illness and others.

Most of our patients were offered the tubularised incised plate urethroplasty which can be attributed to the large proportion of anterior hypospadias in our review (78.5%), but which also reflects an attempt by the individual surgeons in our team to improve skill in one relatively versatile technique in spite of our low hypospadias surgery rate.

Sixty-four percent of patients had acute complications, the most common of which was urethrocutaneous fistulae [Table 4]. This is high considering recent literature with complication rates ranging 7-50%. [9],[10],[11],[12],[13],[14],[15],[16] This again is a reflection of our low hypospadias repair volume. Our centre is one of the two major hospitals that cater for hypospadias patients in Lagos and some other parts of Nigeria. Our challenge in meeting the internationally accepted minimum of 40-50 hypospadias repairs per annum [2] does not lie with patient availability, but with the multiple delay factors already alluded to. Due to low long-term follow-up rates and the limitation of this study being retrospective, we chose to classify our outcome based on a 2-4-week subjective clinical assessment of need for eventual re-operation at the first surgical outpatient visit. A shortfall of this approach is that patients with acute complications are mostly classed as poor outcome irrespective of their response to conservative management (essentially serial meatal dilation with or without general anaesthesia and wound care). It was thus not surprising to have poor outcomes in 56% of patients considering the high complication rate. In fact, subjecting our data on complications and outcome to statistical analysis yielded P = 0.02, which was statistically significant. Most of the patients with good outcome were operated on within the ages of 2-4 years, but this relationship was not statistically significant. Irrespective of this statistical conclusion, authors are of the opinion that the delay periods as presented are not acceptable.
Table 4: Post - operative acute complications and outcome

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  Conclusions/Recommendations Top

We recommend that there should be a dedicated day for hypospadias surgery. This ensures that between three and four hypospadias repairs are performed in a month thus reducing the waiting period for surgery.

Despite the dearth of specialist surgeons in our sub region, there is a need for general paediatric surgeons to identify areas for subspecialisation such as hypospadiology, as this will lead to increased levels of skills and expertise necessary for the desired improved surgical treatment outcomes.

Another measure we propose is regional surgery outreach camps for hypospadias repairs. At predetermined periods during the year, surgeons with special interests and sufficient experience in hypospadias repair come together to operate on these patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Baskin LS. Hypospadias. In: Coran AG, Adzick NS, Krummel TM, Laberge JM, Shamberger RC, Caldamone AA, editors. Paediatric Surgery. 7 th ed. Philadelphia: Elseiver-Saunders; 2012. p. 1531-53.  Back to cited text no. 1
Manzoni G, Bracka A, Palminteri E, Marrocco G. Hypospadias surgery: When, what and by whom? BJU Int 2004;94:1188-95.  Back to cited text no. 2
Khan M, Majeed A, Hayat W, Ullah H, Naz S, Shah SA, et al. Hypospadias repair: A single centre experience. Plast Surg Int 2014;2014:453039.  Back to cited text no. 3
Hadidi AT. Classification of hypospadias. In: Hadidi AT, Azmy AF, editors. Hypospadias Surgery: An Illustrated Guide. 1 st ed. Berlin: Springer-Verlag; 2004. p. 80.  Back to cited text no. 4
Olajide AO, Sowande AO, Salako AA, Olajide FO, Adejuyigbe A. Challenges of surgical repair of hypospadias in Ile Ife, Nigeria. Afr J Urol 2009;15:96-102.  Back to cited text no. 5
Tomova A, Deepinder F, Robeva R, Lalabonova H, Kumanov P, Agarwal A. Growth and development of male external genitalia: A cross-sectional study of 6200 males aged 0 to 19 years. Arch Pediatr Adolesc Med 2010;164:1152-7.  Back to cited text no. 6
Kelalis P, Bunge R, Barkin M, Perlmutter AD, Friedman DB, Work HH, et al. The timing of elective surgery on the genitalia of male children with particular reference to undescended testes and hypospadias. Pediatrics 1975;56:479-83.  Back to cited text no. 7
Lepore AG, Kesler RW. Behavior of children undergoing hypospadias repair. J Urol 1979;122:68-70.  Back to cited text no. 8
Winberg H, Westbacke G, Ekmark AN, Anderberg M, Arnbjörnsson E. The complication rate after hypospadias repair and correlated pre-operative symptoms. Open J Urol 2014;4:155-62.  Back to cited text no. 9
Snodgrass WT, Koyle MA, Baskin LS, Caldamone AA. Foreskin preservation in penile surgery. J Urol 2006;176:711-4.  Back to cited text no. 10
Aslam R, Campbell K, Wharton S, Bracka A. Medium to long term results following single stage Snodgrass hypospadias repair. J Plast Reconstr Aesthet Surg 2013;66:1591-5.  Back to cited text no. 11
Spinoit AF, Poelaert F, Groen LA, Van Laecke E, Hoebeke P. Hypospadias repair at a tertiary care center: Long-term followup is mandatory to determine the real complication rate. J Urol 2013;189:2276-81.  Back to cited text no. 12
Prat D, Natasha A, Polak A, Koulikov D, Prat O, Zilberman M, et al. Surgical outcome of different types of primary hypospadias repair during three decades in a single center. Urology 2012;79:1350-3.  Back to cited text no. 13
Elganainy EO, Abdelsalam YM, Gadelmoula MM, Shalaby MM. Combined Mathieu and Snodgrass urethroplasty for hypospadias repair: A prospective randomized study. Int J Urol 2010;17:661-5.  Back to cited text no. 14
Sarhan O, Saad M, Helmy T, Hafez A. Effect of suturing technique and urethral plate characteristics on complication rate following hypospadias repair: A prospective randomized study. J Urol 2009;182:682-5.  Back to cited text no. 15
Aisuodionoe-Shadrach OI, Atim T, Eniola BS, Ohemu AA. Hypospadias repair and outcome in Abuja, Nigeria: A 5-year single-centre experience. Afr J Paediatr Surg 2015;12:41-4.  Back to cited text no. 16
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]

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