management of hypospadias repair complications скачать в хорошем качестве

management of hypospadias repair complications

Complications It is clear that repairs that are more proximal are associated with a greater incidence of complications. [43] Older age at surgery and low surgical experience have also been associated with poorer outcomes. A study from England by Wilkinson et al found that staged repairs were associated with higher complication rates and that high-volume centers had lower complication rates. [44] With longer follow-up, it is apparent that late complications can occur, and thus, most advocate continued evaluation through puberty. [45, 46, 47, 48] Immediate postoperative concerns Local edema and blood spotting can be expected early after repair and generally do not cause a significant problem. Postoperative bleeding rarely occurs and is usually controlled with a compressive dressing. Infrequently, reexploration may be required to evacuate a hematoma and to identify and treat the source of bleeding. Infection is a rare complication of hypospadias repair in the modern era. Skin preparation and perioperative antibiotics are generally used. Patients are often maintained on an antibiotic course until any stents are removed, though this has not clearly been shown to be beneficial. [49] Long-term issues Urethrocutaneous fistulization is a major concern in hypospadias repair. The rate of fistula formation is generally less than 10% for most single-stage repairs but rises with the severity of hypospadias, approaching 40% with complex reoperative efforts. Fistulas rarely close spontaneously and are repaired by using a multilayered closure with local skin flaps 6 months after the initial repair. After repair, fistulas recur in approximately 10% of patients. (See the image below.) Meatal stenosis, or narrowing of the urethral meatus, can occur. A urethral stent prevents any problems initially, but a fine-spraying urinary stream that is associated with straining to void may necessitate evaluation and possible surgical revision of the distal urethra.Urethral strictures may develop as a long-term complication of hypospadias repair. These are generally repaired operatively and may require incision, excision with reanastomosis, or patching with a graft or pedicled skin flap. Urethral diverticula may also form and are evidenced by ballooning of the urethra while voiding. A distal stricture may cause outflow obstruction and may result in a urethral diverticulum. Diverticula can form in the absence of distal obstruction and are generally associated with graft- or flap-type hypospadias repairs, which lack the subcutaneous and muscular support of native urethral tissue. The redundant urethral tissue is generally excised, and the urethra is tapered to an appropriate caliber. Hair-bearing skin is avoided in hypospadias reconstruction but was used in the past. When incorporated into the urethra, it may be problematic and can result in urinary tract infection (UTI) or stone formation at the time of puberty. This generally requires cystoscopic depilation using a laser or cautery device or, if severe, excision of hair-bearing skin and repeat hypospadias repair. Some surveys have suggested that milder forms of erectile dysfunction may be more common with more proximal hypospadias repairs. [50] This site is intended for healthcare professionals Complications It is clear that repairs that are more proximal are associated with a greater incidence of complications. [43] Older age at surgery and low surgical experience have also been associated with poorer outcomes. A study from England by Wilkinson et al found that staged repairs were associated with higher complication rates and that high-volume centers had lower complication rates. [44] With longer follow-up, it is apparent that late complications can occur, and thus, most advocate continued evaluation through puberty. [45, 46, 47, 48] Immediate postoperative concerns Local edema and blood spotting can be expected early after repair and generally do not cause a significant problem. Postoperative bleeding rarely occurs and is usually controlled with a compressive dressing. Infrequently, reexploration may be required to evacuate a hematoma and to identify and treat the source of bleeding. Infection is a rare complication of hypospadias repair in the modern era. Skin preparation and perioperative antibiotics are generally used. Patients are often maintained on an antibiotic course until any stents are removed, though this has not clearly been shown to be beneficial. [49] Long-term issues Urethrocutaneous fistulization is a major concern in hypospadias repair. The rate of fistula formation is generally less than 10% for most single-stage repairs but rises with the severity of hypospadias, approaching 40% with complex reoperative efforts. Fistulas rarely close spontaneously and are repaired by using a multilayered closure with local skin flaps 6 months after the initial repair. After repair, fistulas recur in approximately 10% of patients.