Snodgrass W, Bush N C
PARC Urology, 5680 Frisco Square Blvd, Suite 2300, Frisco, TX 75034, USA.
PARC Urology, 5680 Frisco Square Blvd, Suite 2300, Frisco, TX 75034, USA.
J Pediatr Urol. 2017 Jun;13(3):289.e1-289.e6. doi: 10.1016/j.jpurol.2016.11.012. Epub 2016 Dec 7.
The primary aim of this report was to compare urethroplasty complications for primary distal and proximal repairs with those after 1, 2, 3, and 4 or more re-operations.
Prospectively collected data on consecutive hypospadias repairs (tubularized incised plate (TIP), inlay, two-stage graft) from 2000 to 2015 were reviewed. Isolated fistula closures were excluded. Extracted information included patient age, meatal location, repair type, primary vs. re-operative surgery, number of prior operations, any testosterone use, glans width, and urethroplasty complications. Pre-operative testosterone stimulation was used during the study period until 2012. Initially, it was given for a subjectively small-appearing glans, but from 2008 to 2012 use was determined by glans width <14 mm. Patients initially managed elsewhere were queried for any testosterone treatment. The number of prior operations was determined by patient history and confirmed by review of records. Calibrations, dilations, cystoscopies, and/or isolated skin revisions were not considered as prior urethroplasty operations. Multiple logistic regression was performed for all patients, and for the subset of patients undergoing re-operation, using stepwise regression for the following potential risk factors: meatal location (distal vs. midshaft/proximal), number of prior surgeries (0, 1, 2, 3, ≥4), pre-operative testosterone use (yes/no), small glans (<14 vs. ≥14), surgery type (TIP, inlay and two-stage graft), and age (continuous in months), with P-values <0.05 considered statistically significant.
In contrast to the 135/1085 (12%) complication rate in patients undergoing primary distal and proximal TIP repair, re-operative urethroplasty complications occurred in 61/191 (32%) TIP, 16/46 (35%) inlay, and 49/124 (40%) two-stage repairs, P<0.0001. Data regarding testosterone use was available for 1490 (96%) patients. A total of 139 received therapy, of which 65 (46%) had urethroplasty complications vs. 229 of 1351 (16%) without treatment, P = 0.0001. Logistic regression in 1536 patients demonstrated that each prior surgery increased the odds of subsequent urethroplasty complications 1.5-fold (OR 1.51, 95% CI 1.25-1.83), along with small glans <14 mm (OR 2.40, 95% CI 1.48-3.87), mid/proximal meatal location (OR 2.54, 95% CI 1.65-3.92), and use of pre-operative testosterone (OR 2.57, 95% CI 1.53-4.31); age and surgery type did not increase odds (AUC = 0.739).
Urethroplasty complications doubled in people undergoing a second hypospadias urethroplasty compared with those undergoing primary repair. This risk increased to 40% with three or more re-operations. Logistic regression demonstrates that each surgery increases the odds for additional complications 1.5-fold. Mid/proximal meatal location, small glans <14 mm, and use of pre-operative testosterone also significantly increase odds for complications. These observations support the theory that previously operated tissues have less robust vascularity than assumed in a primary repair, and suggest additional adjunctive therapies are needed to improve wound healing in re-operations. The finding that even a single re-operative urethroplasty has twice the risk for additional complications vs. a primary repair emphasizes the need for hypospadias surgeons to 'get it right the first time'. The fact that 40% of the re-operative urethroplasties in this series followed distal repairs emphasizes that there is no 'minor' hypospadias.
A single re-operative hypospadias urethroplasty has twice the risk for additional complications vs. the primary repair, which increases to 40% with three or more re-operations. These results support a theory that vascularity of penile tissues decreases with successive operations, and suggest the need for treatments to improve vascularity. The higher risk for complications during re-operative urethroplasties also emphasizes the need to get the initial repair correct.
本报告的主要目的是比较初次远端和近端尿道下裂修复术与1次、2次、3次及4次或更多次再次手术术后的尿道成形术并发症。
回顾性分析2000年至2015年连续行尿道下裂修复术（管状切开板修复术（TIP）、镶嵌修复术、两期移植修复术）患者的前瞻性收集数据。排除单纯性瘘管闭合术。提取的信息包括患者年龄、尿道口位置、修复类型、初次手术与再次手术、既往手术次数、是否使用睾酮、龟头宽度及尿道成形术并发症。在研究期间直至2012年使用术前睾酮刺激。最初，对于外观主观较小的龟头给予该治疗，但从2008年至2012年，根据龟头宽度<14mm确定使用情况。询问最初在其他地方接受治疗的患者是否接受过任何睾酮治疗。既往手术次数根据患者病史确定，并通过病历审查确认。校准、扩张、膀胱镜检查和/或单纯皮肤修复不视为既往尿道成形术手术。对所有患者以及再次手术患者亚组进行多因素逻辑回归分析，对以下潜在危险因素采用逐步回归分析：尿道口位置（远端与阴茎体中部/近端）、既往手术次数（0次、1次、2次、3次、≥4次）、术前是否使用睾酮（是/否）、小龟头（<14mm与≥14mm）、手术类型（TIP、镶嵌修复术和两期移植修复术）及年龄（以月为单位的连续变量），P值<0.05被认为具有统计学意义。
与初次远端和近端TIP修复术患者135/1085（12%）的并发症发生率相比，再次尿道成形术并发症发生率在TIP修复术中为61/191（32%），镶嵌修复术中为16/46（35%），两期修复术中为49/124（40%），P<0.0001。1490例（96%）患者有关于睾酮使用的数据。共有139例接受治疗，其中65例（46%）发生尿道成形术并发症，而未接受治疗的1351例中有229例（16%）发生并发症，P = 0.0001。对1536例患者进行逻辑回归分析表明，每次既往手术会使后续尿道成形术并发症的几率增加1.5倍（OR 1.51，95%CI 1.25 - 1.83），同时小龟头<14mm（OR 2.40，95%CI 1.48 - 3.87）、阴茎体中部/近端尿道口位置（OR 2.54，95%CI 1.65 - 3.92）及术前使用睾酮（OR 2.57，95%CI 1.53 - 4.31）也会增加并发症几率；年龄和手术类型未增加并发症几率（AUC = 0.739）。
与初次尿道下裂尿道成形术患者相比，再次行尿道下裂尿道成形术患者的并发症发生率翻倍。三次或更多次再次手术时，该风险增至40%。逻辑回归分析表明，每次手术会使额外并发症的几率增加1.5倍。阴茎体中部/近端尿道口位置、小龟头<14mm及术前使用睾酮也会显著增加并发症几率。这些观察结果支持以下理论，即先前手术过的组织的血管生成能力不如初次修复时所设想的那样强大，并表明需要额外的辅助治疗来改善再次手术时的伤口愈合。单次再次尿道成形术发生额外并发症的风险是初次修复的两倍这一发现强调了尿道下裂外科医生“一次做对”的必要性。本系列中40%的再次尿道成形术是在远端修复术后进行的，这一事实强调了不存在“轻微”尿道下裂。
单次再次尿道下裂尿道成形术发生额外并发症的风险是初次修复的两倍，三次或更多次再次手术时该风险增至40%。这些结果支持阴茎组织血管生成能力随连续手术而降低的理论，并表明需要进行改善血管生成的治疗。再次尿道成形术期间较高的并发症风险也强调了初次修复正确的必要性。
