Open catheter drainage after urethral surgery

Double versus single diaper technique after hypospadias repair, does it really matter?

INTRODUCTION

Double-diaper technique with an open-drainage catheter is a common practice after hypospadias repair. However, double-diapering may increase the burden of postoperative care and has not been compared to single-diapering with an open-drainage catheter.

OBJECTIVES

This study investigates whether the single-diaper technique is associated with inferior surgical outcomes compared to the double-diaper technique.

MATERIALS AND METHODS

A single surgeon database was retrospectively reviewed for patients who underwent hypospadias repair between 2013 and 2021. Patients who were lost to follow-up and those in whom the type of diaper care (single- or double-diaper) was not documented were excluded. Patients in the single-diaper technique received the same type of dressing and discharge instructions, as those in the double-diaper group, except for leaving the catheter freely draining into a single-diaper. Short-term complications including surgical site infection (SSI), urinary tract infection (UTI) and wound dehiscence, were the primary outcome; whereas the long-term urethroplasty complications (urethrocutaneous fistula and meatal stenosis) were secondary outcomes. Outcomes were analyzed according to the type of diaper care.

RESULTS

Among 323 patients reviewed, 219 patients met the inclusion criteria (72 patients in the double-diaper and 147 in the single-diaper group). Both study groups were similar regarding patient demographics, hypospadias characteristics and surgical technique. Looking at the primary outcomes, there was no statistically significant difference in SSI, UTI or wound dehiscence. For the secondary outcomes, the incidence of meatal stenosis (8.3 vs. 1.4%, p = 0.044), and fistula formation (15.3% vs 5.4%, p = 0.037) was significantly higher in the double-diaper than the single-diaper group, respectively (Table 2).

CONCLUSION

Single-diaper technique following hypospadias repair is not associated with increased risk of complications compared to double-diaper technique.

The influence of perioperative factors on primary severe hypospadias repair

Hypospadias is one of the most common congenital malformations of the male genitalia. Severe cases present with associated curvature greater than 30° and the meatus opening proximally to the penoscrotal junction. The perioperative management of patients with primary severe hypospadias is variable. Systematic evaluation of the upper urinary tract and the search for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias, and should be limited to severe cases with associated extraurinary malformations. Detection of a disorder of sex development is key for gender assignment and prognosis, but the identification of cases warranting a full work-up and the influence of such a diagnosis on the success of hypospadias repair is controversial. Preoperative hormonal stimulation allows for penile growth irrespective of the administration route. Associated morbidity is minimal, but its influence on the success of surgery is still unknown. An age of 6-18 months is generally recommended for surgery, but no trial data support this policy. Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery, whereas postoperative antibiotic prophylaxis and type of dressing have minimal impact on surgical success. Overall, most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined. Clinicians should be made aware of the evidence supporting any single intervention in order to standardize their management policies. We hope the issues outlined here will prompt researchers to design new studies to address the clinically relevant questions.

Hypospadias

Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position anywhere along the penile shaft, scrotum, or perineum. A spectrum of abnormalities, including ventral curvature of the penis (chordee), a hooded incomplete prepuce, and an abortive corpora spongiosum, are commonly associated with hypospadias. Advances in understanding of the causes of hypospadias and current approaches to the correction of hypospadias to provide a cosmetically and functionally satisfactory repair are the focus of this article.

Hypospadias

Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position anywhere along the penile shaft,scrotum, or perineum. Hypospadiology is an evolving and expanding discipline that remains at the forefront of pediatric surgical innovation. Although modern experiments have begun to yield a deeper understanding of the genetic, hormonal, and environmental basis of hypospadias, the quest for a surgical procedure that consistently results in a straight penis with a normally placed glanular meatus has challenged surgeons for over two centuries. This article focuses on the advances in the understanding of the etiology of hypospadias and the current approaches to the correction of hypospadias.

IS PROPHYLACTIC ANTIMICROBIAL TREATMENT NECESSARY AFTER HYPOSPADIAS REPAIR?

PURPOSE

We evaluate the complication rate after hypospadias repair with and without the use of antimicrobial prophylaxis.

MATERIALS AND METHODS

A total of 101 boys who underwent tubularized incised plate urethroplasty with urethral catheter placement during a 16-month period were randomly divided into group 1-52 treated with cephalexin from day 1 after surgery to 2 days after catheter removal and group 2-49 who did not receive prophylaxis. All children received cefonicid before surgery.

RESULTS

Average patient age was 2.3 years (range 11 months to 6.5 years). Hypospadias was coronal in 54 boys, penile in 33, glanular in 9 and penoscrotal in 5, the distribution of which was similar in both groups. Median time to urethral catheter removal was 8.6 days in group 1 and 8.3 in group 2. Overall bacteriuria was noted in 11 children in group 1 and 25 in group 2. The most common pathogen was Pseudomonas aeruginosa in group 1 and Klebsiella pneumoniae in group 2. Urethrocutaneous fistula developed in 3 boys in group 1 and 9 in group 2, meatal stenosis occurred in 1 boy in group 1 and 4 in group 2, and 1 boy in group 1 had meatal regression. Three boys in group 1 and 12 in group 2 had a complicated urinary tract infection (p <0.05). There was no difference in the number of surgical complications between boys for whom this was the first operation or a repeat hypospadias repair.

CONCLUSIONS

A broad-spectrum antibiotic is recommended before and antimicrobial prophylaxis after hypospadias repair. This protocol may decrease the risk of complicated urinary tract infections after surgery, and probably reduce meatal stenosis and urethrocutaneous rates.