Hypospadias: Evaluation of Therapeutic Outcomes and Sexual Function in Adulthood in a University Hospital Setting

Background: Hypospadias is a congenital malformation resulting from hypoplasia of the tissues forming the ventral face of the penis. It is associated to variable degrees with an ectopic urethral meatus, a penis curvature and a sapper’s apron foreskin [1]. The incidence of this malformation varies from country to country. It is estimated at 1/300 male births in France and 0.26/ 1000 in Mexico [1]. In Senegal, the prevalence of this malformation is unknown. Hypospadias surgery has improved significantly in recent years due to a better understanding of the anatomy on the one hand and the improvement of the instruments used during surgery on the other (suture material, surgical magnification, urethral catheter of suitable size). In sub-Saharan Africa and particularly in Senegal, hypospadias surgery remains a challenge due to the unavailability of adequate equipment (lack of microsurgical instruments and surgical loupes). Objective: To evaluate the outcomes of the treatment of hypospadias by the different surgical techniques used in our center as well as their sexual function in adulthood. Patients and Methods: This is a retrospective study, including all patients operated for hypospadias between January 2009 and December 2017 in Urology-Andrology department of Aristide Le Dantec hospital. The studied parameters were: frequency, age, clinical and therapeutic aspects, and their sexual function in adulthood after treatment. The outcomes of the treatment were judged good or poor depending of the quality of penile straightening, the aesthetic appearance of the penis, the posiHow to cite this paper: Diaw, E.H.M., Ndiaye, M., Sow, O., Ndiath, A., Sarr, A., Fall, B., Sine, B., Traore, A., Ndong, A., Ze Ondo, C., Thiam, A., Gaye, O., Ndour, N.S., Thiam, N.M., Sow, Y., Diao, B., Fall, P.A. and Ndoye, A.K. (2020) Hypospadias: Evaluation of Therapeutic Outcomes and Sexual Function in Adulthood in a University Hospital Setting. Open Journal of Urology, 10, 245-252. https://doi.org/10.4236/oju.2020.109029 Received: August 10, 2020 Accepted: September 21, 2020 Published: September 24, 2020 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/


Introduction
Hypospadias is a urogenital malformation resulting from hypoplasia of the tissues forming the ventral face of the penis. It is associated to variable degrees with at an ectopic meatus urethral on the ventral side of the penis, a penile curvature and a foreskin in the form of a sapper's apron [1]. This is the second most common malformation in males [2]. Duckett's anatomo-clinical classification was used, distinguishing according to seat meatus hypospadias: the anterior forms (balanic, balano-penile and anterior penile), the middle form and the posterior forms (posterior penile, scrotal and perineal). The location is anterior, median and posterior respectively in 50%, 20% and 30% of cases [3]. Several surgical techniques were described, justifying the interest in the constant search for effective techniques with the least possible morbidity. Surgery is the standard treatment for hypospadias and several surgical techniques had described in the literature [1] [2] [4]. There are currently more than 400 surgical procedures and their variants without any of it being ideal for the correction of hypospadias. These techniques can be in single or two surgical steps and the choice will depend on the type of hypospadias. Single surgical steps such as the MAGPI, Duplay, Mathieu, Onlay, Duckett techniques adopted in our center seem to be more suitable in our developing countries where the cost of surgery remains inaccessible for the majority of patients. In our context, hypospadias surgery remains a challenge because of several factors interfering with the results. According to Diallo [4] and Diao [5] treatment of hypospadias is fraught with complications due to the conditions in which this type of surgery is performed in our country. The improvement of our outcomes is not only through the training of pediatric urologists

Patients and Methods
This is a retrospective, descriptive, and single-center study evaluating the out-

Results
Fifty-five patients were included during the study period. The annual incidence was more frequent in 2017 with a percentgae of 23.6% (n = 13). The median age was 6 years (P25 = 2.8 and P75 = 13 years). Forty-four patients were brought in for consultation by their parents. Prior hypospadias accounted for 74% (n = 41) of patients. Associated malformations were micropenis 10.9% (n = 6), cryptorchidism 3.6% (n = 2), persistence of the peritoneal-vaginal duct 3.6% (n = 2) and right renal agenesis 1.8% (n = 1). The karyotype performed in 3 patients was normal. All patients were treated with a single surgical step. Adhesion release (36.4% (n = 20)) was the most commonly used types of repair (Table 1). Duplay-Snodgrass urethroplasty was the most commonly used urethroplasty technique (41.8% (n = 23)) ( Table 2). The mean duration of postoperative drainage    Table 2. Eleven patients were concerned for the evaluation of the sexuality.
Four patients were unreachable and four other patients refused the investigation.
After a mean delay of 53 ± 26 months (with extremes of two and 10 years) for the three patients who accepted the survey, the sexual function was rated best in one patient (score 12) and average in the other two (score 9 each).

Discussion
Hypospadias is a congenital urogenital malformation frequently encountered in our daily practice. Surgery is the treatment of choice but it exist several problems related to the surgical technique or its postoperative complications. Hypospadias surgery can be performed at any age, however, most authors recommend surgery between 6 -18 months [6]. In 1996, the American Academy of Pediatrics also recommended that elective surgery of the male external genitalia be performed at this age, after the first phase of penis growth [7]. A delay in the consultation was noted in our study with a median age of 6 years (P25 = 2.8 and P75 = 13 years). This median age observed shows an improvement of this delay in consultation compared to other African studies, in particular those of Diallo AB et al. [4] in Guinea Conakry and Diao B et al. [5] in Senegal who reported a mean  [18]. The evaluation of hypospadias surgery provides valuable information on the outcome, helps decision-making, improves performance and quality of care [19]. Several instruments aimed at measuring the satisfaction of patients with hypospadias were identified in the literature. Among them, the hypospadias objective assessment score, the pediatric penile perception score, the genital perception scale. However, most of these scores assess the postoperative cosmetic aspect and not the sexuality and the psychosocial sequelae [19]. We tried in our study to assess sexuality after treatment in adulthood. Among the 3 patients who accepted the survey about sexual function, one was married without children. Indeed, this small number of participating patients is a limit of this evaluation, and it was impossible to draw a conclusion. In the literature, the evaluation of sexual function in adulthood remains difficult because of its subjectivity [20]. It is necessary to study the fertility, ejaculation quality, sperm parameters and hormonal profile of these patients with a larger cohort in order to draw conclusions.

Conclusion
Urethroplasty according to Duplay Snodgrass was the most technique using in our studies with a satisfactory rate of good outcome. The complication rate observed was related to several factors, including the lack of adequate surgical equipment. The evaluation of the sexual function remained subjective in our study due the low rate of participant.