Objective Scoring Evaluation and Uroflowmetry Assessment of Two-Stage Hypospadias Repair : Single Center Experience

Background: Hypospadias is a common congenital anomaly affecting the penis, two-stage repair becoming more interesting in era of tubularized –incised urethral plate (TIP). Functional outcome of hypospadias repair either single or two stage is as important as cosmetic outcome. In contemporary series , structured scoring systems (Hypospadias Objective Scoring Evaluation-HOSE and Pediatric Penile Perception Scoring -PPPS), evaluation of photographs and uroflowmetry, were used to assess results of hypospadias repair. Objectives: We have assessed outcomes of two-stage hypospadias repair using Hypospadias Objective Scoring Evaluation(HOSE) and uroflowmetry. Material and Methods: Over a period of eight years, from January 1997 to December 2004, One hundred and twenty six hypospadias patients were treated, ninety of them had two-stage repair and36 single-stage repairs. The HOSE questionnaire and uroflowmetry were obtained to evaluate the long term outcome of two –stage hypospadias repair. Results: The age at time of assessment ranged from 8 to 23 year-old, with mean follow up of 39.78months. Thrifty five patients had proximal hypospadias and 20 had distal varieties of hypospadias. Operations performed were 37 Bracka?s and 18 Byar?s procedures. Of the 55 patients had complete two stage hypospadias repair and agree to participate in the study , Nineteen patients had acceptable HOSE and 36 had non-acceptable score. Uroflow rates of 43 subjects were below the fifth centile in three patients ,equivocal (between 5th and 25th centile ) in four patients and above 25 th centile in 36 subjects. Conclusion: Two –stage repair is a suitable technique for all types of hypospadias with versatile outcomes. HOSE and uroflowmetry are simple, easy, non invasive and non expensive tools to assess long term outcomes objectively.


Introduction
Hypospadias is a common congenital anomaly affecting the penis, that either treated or untreated can have functional, cosmetic and psychosexual consequences extending into adulthood 1, 2 .
Indeed the current concept of hypospadias repair have been change, two-stage repair was widely used for hypospadias repair; although excellent outcome of single stage repair have been reported 3 .
Assessment of result of hypospadias repair is still an issue of discussion, as the published studies have shown that a significant difference might be existing between patients and operating surgeon judgments 4 .Classically, outcomes of hypospadias repair have been assessed by reoperation rate secondary to fistula, stenosis, diverticulum and residual penile curvature 5 .
Recently attempts have been made to assess outcomes objectively using structured scoring systems (HOSE and PPPS), evaluation of photographs and uroflowmetry to assess voiding 5, 6, 7 .
In this study, we have assessed outcomes of twostage hypospadias repair using Hypospadias Objective Scoring Evaluation (HOSE) and uroflowmetry .HOSE is underused, although the use of such a system is recommended by others 6, 8, 9 .
The HOSE is a validated scoring system that incorporates evaluation of meatal location and shape, urinary stream, straightness of erection , presence and complexity of urethral fistula 6 .

Material And Methods
Over a period of eight years, from January 1997 to December 2004, a total of 126 patients underwent hypospadias repair in our surgical department, ninety of them had two-stage repair and 36 single-stage repair.
After obtaining approval from ethical committee in our university, either phone call or invitation letter sent to 76 patients (84.4%) whom completed twostage repair hypospadias and their medical records contained relevant data needed for the study; However only 55 children and their parents agreed to participate in the study.

Discussion
The last decade have witness on increasing the incidence of hypospadias worldwide demanding increasing in hypospadias surgery.Generally Bracka?s and Byar?s operation are the most common operations performed in our departments, as both operations can be used to treat all types of hypospadias, from subcoronal to penoscrotal in agreement with others 13, 14 .
Today, the repairs are performed during first year of life; although some advised assessment throughout of puberty ,as pubertal growth can change the final cosmetic and functional aspect of corrected penis 15 .
In this retrospective study, majority of our patients presented between 10 and 15 year-old , in agreement with other local studies where the age of patient first seen ranged from neonate to 26 years 14 .
Thus the age at surgery mostly depends on the age when first seen at surgical outpatient clinic.If they were referred early, the first-stage repair was performed at age of 3 to 4years, when they were toilet trained, not wearing diapers and the phallus is of acceptable size to make the surgery more feasi-ble in the agreement with Arshad A.R. 14 .
The second -staged repair was usually performed 6-12 months later, thus they complete two-stage repair and any subsequent surgery before the school age.The published data showed there are more than 300 surgical techniques to correct hypospadias resulting in various outcome measures.
The HOSE questionnaire is a validated objective outcome assessment with a very low inter-observer error and good inter-observer correlation.Nineteen patients (34.5%) of our subjects had an acceptable HOSE with a total score of 14 to 16 and 36 patients (65.5%) had unacceptable outcome with total score of thirteen and below, It is difficult to compare our HOSE score with others as the majority of published studies using this method to assess the outcome of anterior hypospadias repair.The meatal location, shape and fistula are easy to be assessed objectively by assessor, However the main drawback of HOSE for us, arises when the straightness of penis and evaluating of urinary stream to assess objectively , as to witness the child or adult voiding or to induce erection is out of Asian norm especially in our culture, even though Holland et al stated that erection was gauged after an erection witnessed by assessor or based on parental evaluation.
The studies investigated micturition of repaired urethral are few, those that did not generally studied the micturition after straightforward distal hypospadias repair 16 .
The urethral stricture is a well recognized complication of urethral reconstruction with unknown long-term consequences of asymptomatic stenosis after hypospadias repair 17 .
The measures available to assess the reconstructed urethra include direct observation of urinary stream, voiding cystourethrogram and uroflowmetry 18 .
Rynja et al showed that there was a discrepancy between subjective and objective parameters of urinary function both in hypospadias patients and in control group 15 .
The average flow rate and Q max in hypospadias patient need to be interpreted by a nomogram as they are increase with age of patient and volume of the bladder 10 .
Hypospadias surgery is still a demanding procedure; there are many factors that may influence the outcome of hypospadias repair, type of hypospadias, age at repair, duration of time between first and second stage, technique of repair and personal experiences with cumulative success rate ranging from 37% to 77%, with greater than 95% after third revision 19, 20 .
The reported overall complication rate from

Limitations of The Study
Small non randomized sample size and disappointing overall result , probably reflects the learning curve associated with the severe type of hypospadias in our study.

Conclusion
Two -stage hypospadias repair is a suitable technique for all types of hypospadias with versatile outcomes .HOSE and uroflowmetry are simple, non-invasive, and non-expensive and easy to assess long term outcomes objectively.

Table I
The Q-max and voided volume were considered to be normal if > 25 th percentile, equivocal if between 5-25 th percentile range and obstructed if <5 th percentile.Objective Scoring Evaluation and Uroflowmetry Assessment of Two-Stage Hypospadias Repair: Single Center Experience

Table 3 a: Characteristics of the uroflowmetry pattern in patients with distal hypospadias who completed two-stage repair (15 patients)
surgery is 5-40%, wound infection, haematuria, penile skin blister, and suprapubic catheter, all of them are minor and can be treated conservatively, furthermore fistula, meatal stenosis, wide meatal opening and urethral stricture 20, 21 .Overall 19 (34.5%) of our subjects had an acceptable score and 36 patients (83.7%) of them had Q max more than 25 th centile on Kajbaafzadeh nomogram and Q max below 5 th centile in three patients (one urethral stricture and two meatal stenosis).