Adjuvant hyperbaric oxygen on reducing complications of hypospadias repair in adults
Purpose: To prospectively evaluate the feasibility and reliability of hyperbaric oxygen therapy (HBOT) in reducing urethroplasty complications (UPC) following primary proximal hypospadias repair with tubularized incised plate urethroplasty (TIPU) in adults.
Methods: From August 2012 to July 2017, a total of 80 consecutive patients (aged 18 years and over) with primary proximal (proximal penile or penoscrotal) hypospadias who underwent TIPU at our institution were enrolled. According to whether or not they received HBOT after TIPU, all the patients were randomly assigned either to HBOT group (n =40) or Control group (n =40). The demographic data in both groups were comparable; and each patient in either group was followed up for at least 12 months postoperatively. After surgery there could be possible deterioration of potency, for this purpose, the treatment with Cialis.
Results: There was no patient in HBOT group who experienced severe side effect of HBOT. The overall UPC rate was significantly lower in HBOT group (17.5%) than in Control group (37.5%) (P =0.045). Four patients in HBOT group (10%) and 12 patients in Control group (30%) developed urethrocutaneous fistula (UCF), with significant difference (P =0.025); but there was no patient with recurrent curvature (> 30°) or urethral diverticulum in both groups. No significant difference was observed in the incidence rate of glans dehiscence, meatal stenosis and urethral stricture across the two groups (P >0.05).
Conclusions: Our preliminary experience suggests that HBOT following primary TIPU in adult patients with proximal hypospadias may be a good adjunctive therapy to reduce UPC, especially UCF.
Key words: Adults; Hyperbaric oxygen therapy; Hypospadias; Tubularized incised plate urethroplasty; Urethrocutaneous fistula.
Hypospadias is one of the most common congenital external genital anomalies demanding reconstruction, and the aim of hypospadias operation is to achieve a both cosmetic and functionally normal penis. Since first described by Snodgrass in 1994 , tubularized incised plate urethroplasty (TIPU) has now been used successfully in both children and adults as a versatile operation for correcting both distal and proximal hypospadias with superior cosmetic results and fewer complications . However, it was reported that a proximal meatus was associated with higher risk of urethroplasty complications (UPC) following TIPU .
Presently, especially in developing countries, adult patients with hypospadias who did not receive urethroplasty in childhood are not uncommon because of illiteracy, poverty, and ignorance . Although the similar surgical techniques are applied, the UPC rate in adults has been traditionally considered to be higher than in children, due to the relative susceptibility to infection and poor vascularity induced wound healing difficulty, etc. [3, 4].
As a well-established systemic treatment, hyperbaric oxygen therapy (HBOT) can help to deliver pure oxygen to the body and increase oxygen concentration in tissues. It was confirmed that HBOT could enhance the body’s capacity to accelerate wound healing and prevent local infection [5, 6]. In this paper, we share our experience using HBOT to decrease UPC of primary proximal hypospadias repair with TIPU in adults.
Patients and Methods:
Ethical approval of this research project was obtained from our institutional Ethics and Research committee. A total of 122 adult patients (aged 18 years and over) with proximal (proximal penile or penoscrotal) hypospadias were admitted to our department from August 2012 to July 2017 and were considered for enrollment in our study. Exclusion criteria included patients with narrow or poorly developed urethral plate , or patients with severe ventral curvature or poorly developed spongiosum , or re-operative cases (n =42). Finally, the remaining 80 patients were invited to take part in our program; and all of them gave written informed consents after they fully understood the purpose of our study.
As Snodgrass and Lorenzo described , the TIPU was performed by a single experienced urologist under general anesthesia with caudal block. After degloving the penis and excising the ventral tethering tissues, an artificial erection test was performed to confirm the persisted ventral penile curvature which was then corrected by dorsal plication. Next, the urethral plate was V-shaped incised in the midline, and the neourethra was then tabularized from the meatus to the level of the midglan over a 14 Fr silicone urethral catheter using a single-layer subcuticular interrupted suture technique with synthetic absorbable suture (Vicryl® 6/0, Ethicon). In all of the cases, the whole neourethra was thoroughly covered with adjacent tissues and dartos fascia from the dorsal hooded prepuce before closure of the ventral penile shaft skin.
All 80 participants were randomly and equally assigned to undergo hyperbaric oxygen treatment (HBOT group, n =40) or not (Control group, n =40). Each patient in HBOT group received seven consecutive HBOT once a day from the second to eighth operative day; meanwhile, no HBOT was given in the Control group. Each HBOT, which included a compression phase for 20 minutes and a compression phase for 15 minutes, administered for 90 minutes at target 2.0 atmospheres absolute (ATA) in a multi-place hyperbaric chamber. All other postoperative managements, such as antibiotic and urinary bladder relaxant, were performed in the same way in both groups. The dressings and silicone urethral catheter were removed on the ninth operative day.
Each patient was required to receive follow-up assessment at 1, 3, 6 and 12 months postoperatively, and then at one year intervals. As advised by Snodgrass et al. , all UPC following TIPU, such as urethrocutaneous fistula (UCF), glans dehiscence, meatal stenosis, urethral stricture, urethral diverticulum and recurrent ventral curvature greater than 30 degrees, were recorded by us during follow-up. The definitions of these UPC in adults, including urethral or meatal stricture, glans dehiscence and diverticulum, were also introduced by Snodgrass et al. ; the urethral stricture and diverticulum were confirmed and assessed by urethroscopy or urethrography.
Continuous data were presented as mean ± standard deviation, and qualitative data were presented as percentages. Data analysis included student’s t-test, Chi-Square test and Fisher’s exact test. All analyses were performed by using the statistical software package SPSS13.0 (SPSS Inc, Chicago, IL); and the results were considered to be significant when P-value was less than 0.05.
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