By Christopher J. Long, MD
Hypospadias is a congenital malformation of the penis that affects many boys, occurring in up to 1 in 200 male births. Christopher J. Long, MD, an attending pediatric urologist in the Division of Urology at Children's Hospital of Philadelphia (CHOP), and his team were able to assess the impact of one complex variant in patients with distal hypospadias and its role on surgical outcomes. The yearlong research study was conducted with the help of a $25,000 Center for Outcomes Research in Surgery (CORES) grant, which promotes and supports studies that will help establish feasibility, infrastructure or pilot data.
How hypospadias presents in patients
Boys with hypospadias typically have a triad of manifestations, including:
- Incompletely formed foreskin
- A bent or curved penis (chordee)
- A urethral opening that presents at a lower location on the penis
The presentation of hypospadias at birth can be quite variable, with patients exhibiting a spectrum of degrees of chordee and the location of the urethral meatus. While some patients do not require surgical reconstruction, many boys undergo a procedure to straighten the penis and extend the urethra in continuity to the head of the penis. This is done to optimize the urinary and sexual function, and the cosmetic appearance.
Risk and surgical outcomes
Hypospadias surgery can be challenging, especially for patients with more complex anatomy. These patients can experience a complication after surgery up to 40% of the time, which can require additional procedures and lead to a less-than-optimal functional and cosmetic outcome. The best chance of success occurs with the first surgery, and we make every attempt to modify our approach, adapting it to the specific patient we are focusing on.
For this study, we specifically identified patients that had a narrow head of the penis and/or an unfavorable urethral groove within the head of the penis. These factors can have a negative effect on the repair with traditional techniques where the anatomy will increase the tension of the closure, potentially increasing the risk of the tissue separating and/or resulting in a narrow urethra after the repair. This can lead to higher pressure with urination and, in turn, increased risk for complication development. The published overall complication rate in patients with distal hypospadias ranges widely from 5-30%. Our overall complication rate ranges from 5-10% but a subset of our own patients with this more complex anatomy had a complication rate of 20%.
Our surgical approach
Our typical approach to surgical reconstruction utilizes the urethral tissue within the head of the penis, which is incised and then rolled closed with sutures to advance the urethra into a position within the head of the penis. We found that using this technique resulted in a higher complication rate. An alternative approach can be performed where a shallow groove or narrow head of the penis can be incised deeply within its back wall, then a skin graft can be placed within the ensuing gap, augmenting the urethra and glans into to a deeper, wider and more favorable form. With this different approach our complication rate significantly decreased from 20% to 3%. We think by creating this more natural groove for the reconstructed urethra, there is more room for the head of the penis to be closed over the urethra, resulting in a more natural appearance and flow pattern for urine to pass.
Improved clinical tools and patient benefits
To improve our outcomes at CHOP, we have created an extensive database that allows us to assess and quantify all elements of patient anatomy and surgical details. In addition, we have established a system that allows us to follow our patient outcomes in real time, a unique advantage compared to the traditional manual chart review, typically performed many years after surgery is performed. This database has provided us the opportunity to determine which factors have the most significant impact on our surgical outcomes rapidly enough that we can apply that information in clinical practice. For this grant, we identified this higher-risk anatomy, compared two alternative surgical approaches, then quantitated the method that most significantly improved outcomes.
To further reinforce our research findings with staff, we have created a nudge tool within our electronic medical record that appears once high-risk anatomy is documented on a patient. This nudge will reinforce to our surgical team that we need to consider the technical modifications that may result in better outcomes. This is another example of our efforts at standardizing patient assessments and personalizing patient care, altering treatment patterns to see significant improvements.
This research project and the subsequent nudge tool have led to considerable benefits for our patients, and we look forward to the next discovery to deepen our understanding of these complex variants.
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By Christopher J. Long, MD
Hypospadias is a congenital malformation of the penis that affects many boys, occurring in up to 1 in 200 male births. Christopher J. Long, MD, an attending pediatric urologist in the Division of Urology at Children's Hospital of Philadelphia (CHOP), and his team were able to assess the impact of one complex variant in patients with distal hypospadias and its role on surgical outcomes. The yearlong research study was conducted with the help of a $25,000 Center for Outcomes Research in Surgery (CORES) grant, which promotes and supports studies that will help establish feasibility, infrastructure or pilot data.
How hypospadias presents in patients
Boys with hypospadias typically have a triad of manifestations, including:
- Incompletely formed foreskin
- A bent or curved penis (chordee)
- A urethral opening that presents at a lower location on the penis
The presentation of hypospadias at birth can be quite variable, with patients exhibiting a spectrum of degrees of chordee and the location of the urethral meatus. While some patients do not require surgical reconstruction, many boys undergo a procedure to straighten the penis and extend the urethra in continuity to the head of the penis. This is done to optimize the urinary and sexual function, and the cosmetic appearance.
Risk and surgical outcomes
Hypospadias surgery can be challenging, especially for patients with more complex anatomy. These patients can experience a complication after surgery up to 40% of the time, which can require additional procedures and lead to a less-than-optimal functional and cosmetic outcome. The best chance of success occurs with the first surgery, and we make every attempt to modify our approach, adapting it to the specific patient we are focusing on.
For this study, we specifically identified patients that had a narrow head of the penis and/or an unfavorable urethral groove within the head of the penis. These factors can have a negative effect on the repair with traditional techniques where the anatomy will increase the tension of the closure, potentially increasing the risk of the tissue separating and/or resulting in a narrow urethra after the repair. This can lead to higher pressure with urination and, in turn, increased risk for complication development. The published overall complication rate in patients with distal hypospadias ranges widely from 5-30%. Our overall complication rate ranges from 5-10% but a subset of our own patients with this more complex anatomy had a complication rate of 20%.
Our surgical approach
Our typical approach to surgical reconstruction utilizes the urethral tissue within the head of the penis, which is incised and then rolled closed with sutures to advance the urethra into a position within the head of the penis. We found that using this technique resulted in a higher complication rate. An alternative approach can be performed where a shallow groove or narrow head of the penis can be incised deeply within its back wall, then a skin graft can be placed within the ensuing gap, augmenting the urethra and glans into to a deeper, wider and more favorable form. With this different approach our complication rate significantly decreased from 20% to 3%. We think by creating this more natural groove for the reconstructed urethra, there is more room for the head of the penis to be closed over the urethra, resulting in a more natural appearance and flow pattern for urine to pass.
Improved clinical tools and patient benefits
To improve our outcomes at CHOP, we have created an extensive database that allows us to assess and quantify all elements of patient anatomy and surgical details. In addition, we have established a system that allows us to follow our patient outcomes in real time, a unique advantage compared to the traditional manual chart review, typically performed many years after surgery is performed. This database has provided us the opportunity to determine which factors have the most significant impact on our surgical outcomes rapidly enough that we can apply that information in clinical practice. For this grant, we identified this higher-risk anatomy, compared two alternative surgical approaches, then quantitated the method that most significantly improved outcomes.
To further reinforce our research findings with staff, we have created a nudge tool within our electronic medical record that appears once high-risk anatomy is documented on a patient. This nudge will reinforce to our surgical team that we need to consider the technical modifications that may result in better outcomes. This is another example of our efforts at standardizing patient assessments and personalizing patient care, altering treatment patterns to see significant improvements.
This research project and the subsequent nudge tool have led to considerable benefits for our patients, and we look forward to the next discovery to deepen our understanding of these complex variants.
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