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ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 6  |  Page : 713-717
 

An objective assessment and comparison of the cosmetic outcome: Parental perspective after tubularized incised plate urethroplasty with foreskin reconstruction and circumcision


Pediatric Surgery Unit, Ashish Hospital and Research Centre, Jabalpur, Madhya Pradesh, India

Date of Submission11-Apr-2022
Date of Decision22-Aug-2022
Date of Acceptance14-Sep-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Pradyumna Pan
Pediatric Surgery Unit, Ashish Hospital and Research Centre, Jabalpur - 482 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_51_22

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   Abstract 


Aim: We aimed to evaluate the parents' view of the cosmetic outcome after hypospadias surgery.
Materials and Methods: Between January 2017 and December 2020, 70 patients aged between 2 and 7 years underwent surgical correction of hypospadias. Group 1 had 35 patients (coronal: 6, distal: 19, and mid-penile: 10) assigned for tubularized incised plate urethroplasty (TIPU) with modified foreskin reconstruction. Group 2 had 35 patients (coronal: 4, distal: 22, and mid-penile: 9) assigned for TIPU and circumcision. Parents were assessed with the Pediatric Penile Perception Score (PPPS).
Results: Parent satisfaction for the position and shape of the urethral opening, shape of the glans, penile skin, and length exhibited no statistically relevant difference between the group. Parent satisfaction with the appearance of the genitals in Group 1 was relatively high 2.60 ± 0.55, as compared to Group 2 1.77 ± 0.49 which is statistically significant (P < 0.00028).
Conclusion: Our experience shows good early cosmetic results of foreskin reconstruction and high parental satisfaction. Foreskin reconstruction should constitute a key element of the final result to restore a penis with an appearance as normal as possible.


Keywords: Cosmetic outcome, hypospadias, parents, pediatric penile perception score


How to cite this article:
Pan P. An objective assessment and comparison of the cosmetic outcome: Parental perspective after tubularized incised plate urethroplasty with foreskin reconstruction and circumcision. J Indian Assoc Pediatr Surg 2022;27:713-7

How to cite this URL:
Pan P. An objective assessment and comparison of the cosmetic outcome: Parental perspective after tubularized incised plate urethroplasty with foreskin reconstruction and circumcision. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Dec 7];27:713-7. Available from: https://www.jiaps.com/text.asp?2022/27/6/713/360963





   Introduction Top


Hypospadias is a common urogenital congenital anomaly, occurring in approximately 1 in 125 live male births.[1] The goal of hypospadias surgery is to reconstruct a penis that is both functional and cosmetically normal. However, where circumcision is unusual, the concept of cosmetic normalcy varies widely among patients, surgeons, and cultures. In Asian countries and the Hispanic populations, due to their religious feelings, parents of many hypospadias patients demand prepuce be saved.[2] Preputial reconstruction (PR) is a procedure that achieves a near-normal appearance of the hypospadias penis. PR can be achieved in the majority of distal and selected mid-penile hypospadias. Surgical results have improved and there are fewer functional postoperative problems. As a result, the quality of cosmetic results is becoming increasingly important. Cosmesis remains an important aspect in averting the future psychological stress of malformation. The perception of a good-looking penis is a subjective issue. The parents are often less satisfied than surgeons with the overall genital appearance, emphasizing the importance of asking about parent satisfaction. Several standardized and prospectively validated score systems for assessing cosmetic results after hypospadias correction have been presented in recent years. Weber et al.[3] proposed the Pediatric Penile Perception Score (PPPS) for patients and parents. It allows parents to evaluate the perception of their child's genitalia after the operation.[3]

The purpose of this study was to assess and compare the parental satisfaction for corrective appearance in patients undergoing modified foreskin reconstruction versus circumcision with tubularized incised plate urethroplasty (TIPU) for distal and mid-penile hypospadias using the PPPS.


   Materials and Methods Top


A prospective comparative study was conducted to determine the cosmetic success, as assessed by parents of the child undergoing distal and mid-penile tubularized incised plate urethroplasty with modified foreskin repair compared to those who underwent circumcision. After obtaining approval from the ethical committee of the hospital, parents were asked to assess their child's genitalia with the PPPS questionnaire at a routine clinic visit 12 months after their last procedure. The cohort consisted of 70 children with distal and mid-penile hypospadias who underwent treatment from January 2017 to December 2020 in a tertiary level referral pediatric surgery and urology unit. Inclusion criteria were patients aged between 2 and 7 years with coronal, distal, and mid-penile hypospadias who had a primary repair. Exclusion criteria were patients with narrow urethral plate, chordee >30°, proximal hypospadias, the presence of torsion, previous circumcision, and children from Muslim faith. The child who had complications after the operation, such as urethral fistula, glans dehiscence, and meatal stenosis, was not included in this study.

Group 1 had 35 patients (coronal: 6, distal: 19, and mid-penile: 10) assigned for TIPU with modified foreskin reconstruction. Group 2 had 35 patients (coronal: 4, distal: 22, and mid-penile: 9) assigned for TIPU and circumcision. All procedures were done by a single surgeon and the same surgical team.

Urethroplasty and glansplasty were the same for both groups. In both groups, the ventral dartos flap was used as a barrier layer between the neourethral tube and skin. In Group 1, the modified technique of foreskin reconstruction was done.[4] In Group 2, the prepuce was excised and skin edges closed with interrupted subepithelial 6-0 Vicyrl. Postoperative care was similar in both groups. Both groups were subjected to the same follow-up.

The PPPS questionnaire asked the parents to assess five different cosmetic aspects of the male genitalia: penile length, position, and shape of the urethral meatus, the shape of the glans, penile skin, and general appearance of the penis. Each one was rated with a number score indicating very satisfied (3), satisfied (2), dissatisfied (1), and very dissatisfied (0) [Appendix 1]. The original PPPS scoring system included a penile axis. Since the parents evaluated the esthetic aspect of the genitals and the penile axis cannot be evaluated in the flaccid penis, it was not included in this study. The questionnaires from these two groups were analyzed and compared, as assessed by caregivers.




   Results Top


A total number of 70 patients were enrolled in the study after hypospadias surgery. Most parents expressed a high satisfaction for every single item of the Penile Perception Scale, with mean values between 2 (satisfied) and 3 (very satisfied) shown in [Table 1] and [Table 2]. When assessing individual categories on the PPPS, the lowest average was associated with the appearance of the penis at 1.77 ± 0.49 in Group 2, while the highest average at 2.60 ± 0.55 in Group 1. Parent satisfaction for the position and shape of the urethral opening, shape of the glans, penile skin, and length exhibited no statistically relevant difference between the group [Table 3]. Parent satisfaction with the appearance of the genitals in Group 1 was relatively high 2.60 ± 0.55, as compared to Group 2 1.77 ± 0.49 which is statistically significant (P < 0.00028).
Table 1: Study group 1 questionnaire results: Number of responses for each category and satisfaction score

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Table 2: Study group 2 questionnaire results: Number of responses for each category and satisfaction score

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Table 3: Comparison of study groups for parent perception regarding the appearance of genitals

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Postoperative evaluation by caregivers:

  1. Position and shape of the urethral opening produced 91.4% (32/35) very satisfied and satisfying responses in both groups. The average meatus evaluation was 2.02 ± 0.56 in Group 1 and 2.03 ± 0.45 in Group 2
  2. The shape of the glans yielded 97.14% (34/35) very satisfied and satisfying responses in both groups. The average of glans assessment was 2.34 ± 0.53 in Group 1 and 2.40 ± 0.55 in Group 2
  3. Penile shaft skin: All patients (35/35) had very satisfied and satisfying responses in Group 1 and 85.71% (30/35) in Group 2. The average shaft skin estimation was 2.48 ± 0.5 in Group 1 and 2.28 ± 0.71 in Group 2
  4. Penile length: Very satisfied responses were seen in 8.57% (3/35) and 74.3% (26/35) were satisfied in Group 1. In Group 2, it was 11.42% (4/35) and 68.6% (24/35), respectively. The average penile length was 1.88 ± 0.58 in Group 1 and 1.82 ± 0.74 in Group 2
  5. The general appearance of the penis: Thirty-four patients, 97.14% (34/35) gave very satisfied and satisfying responses in Group 1. In Group 2, 74.3% (26/35) had very satisfied and satisfying responses. The average general appearance was 2.6 ± 0.55 in Group 1 and 1.77 ± 0.49 in Group 2. This study showed a significant difference (P < 0.00028).



   Discussion Top


Cosmetic outcomes and patient satisfaction with postoperative appearance are now considered just as critical as functional outcomes by most surgeons. It was not until recently that surgeons began to pay more attention to how patients perceive the cosmetic results and the psychological effects of hypospadias repair.[3],[5],[6]

Parents often request for their child to be uncircumcised. The decision to have a PR does not raise the risk of urethroplasty-related complications,[4] but it has an inherent risk of preputial dehiscence and secondary phimosis.[7]

In cultures where circumcision is not a usual practice, the absence of prepuce is a major factor in making hypospadias patients conscious of their malformation, and parents and patients worry more about the gross absence of prepuce.[8],[9] While it is important to obtain both the parents' and the patients' assessments when assessing the cosmetic results of hypospadias, most patients are not old enough to determine their genitalia due to early reconstructive procedural age.[10] We believe that a child of that age is incapable of comprehending the various measurements or judging the appearance of the penis. Nonetheless, satisfaction with penile appearance during childhood is significant because it is one of the factors that can affect psychosexual development and can interfere with health-related quality of life even after they have grown up.[3],[11]

The decision-making process for surgery and the cosmetic outcome strongly psychologically affects the caregivers. Parents can compare their son's penises to others, and they know where he started and what he expected the result to look like. Since the parental attitude toward a malformation can be another factor that correlates with the psychosexual development of the child,[12] this negative evaluation of the outcome may be important for the patients.

The satisfaction with penile length was not found to be related to the actual length of the penis in this study, and parents' satisfaction was moderate. Even though surgery does not affect this parameter, some studies indicate that patient satisfaction is influenced by penile length.[13] The impact of preoperative and postoperative meatal position on satisfaction is debatable. Some studies[6],[13] found a connection between postoperative meatal position and patient satisfaction, but we did not find this link in this study.

This study showed a significant difference (P < 0.00028) between the two groups regarding the general appearance of the penis with the preserved prepuce. In Group 1, 97.14% (34/35) gave very satisfied and satisfied responses, while in Group 2, 74.3% (26/35) had very satisfied and satisfied responses.

Aulagne et al. documented 30% dissatisfaction due to the absence of a foreskin.[14] The subject of a circumcised appearance after hypospadias surgery[15] and the impact of the cultural system[16] have been addressed in several studies. Perceiving one's penis as different from the norm within a given society, however, is not the same as being discontent with its appearance. Despite a 78% perception of abnormality, only 25% expressed dissatisfaction with appearance, according to Mureau et al.,[17] Jones et al.,[18] who found that 31.4% of their sample thought their penis was odd in comparison to their peers, also found that 81% were pleased with their genital appearance and 90% with their overall body image.

A lack of counseling about the condition may lead to social morbidity,[19] emphasizing the importance of reassuring patients postoperatively about the normality of their penis, particularly in terms of size and absence of the foreskin. If a circumcised status is expected to cause significant social embarrassment, due to a specific cultural context, foreskin reconstruction, which has a low complication rate,[20] may be considered an option. Some, but not all, of these outcomes can be explained by the patient's circumcision status. The frequent findings of social humiliation when undressing in public could be explained by these notions of abnormality or “strange.”

The limitations of this study were small sample groups and absence of the long-term results. Postpubertal follow-up from the patients themselves could not be assessed. Penile straightness upon erection and erectile function were not included in the study for practical reasons due to the young age group. The present study is further limited by being a single-center evaluation.


   Conclusion Top


This study revealed good early cosmetic results of foreskin reconstruction which is a valid surgical alternative to circumcision in properly selected patients. Long-term follow-up of these hypospadias repairs is critical for appreciating the cosmetic outcomes after puberty. If the goal of distal hypospadias surgery is to reestablish a penis with a look as normal as possible, prepuce reconstruction should constitute an important part of the final result.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
AG. In: Pediatric Surgery. 5th ed. Philadelphia: Mosby Year Book Inc.; 1998. p. 1761-81.  Back to cited text no. 1
    
2.
Gilpin D, Clements WD, Boston VE. GRAP repair: Single-stage reconstruction of hypospadias as an out-patient procedure. Br J Urol 1993;71:226-9.  Back to cited text no. 2
    
3.
Weber DM, Schönbucher VB, Landolt MA, Gobet R. The pediatric penile perception score: An instrument for patient self-assessment and surgeon evaluation after hypospadias repair. J Urol 2008;180:1080-4.  Back to cited text no. 3
    
4.
Pan P. A prospective study comparing modified foreskin reconstruction versus circumcision with tubularized incised plate urethroplasty for distal and mid penile hypospadias. J Pediatr Urol 2020;16:674.e1- 674.e7.  Back to cited text no. 4
    
5.
Thiry S, Saussez T, Dormeus S, Tombal B, Wese FX, Feyaerts A. Long-term functional, cosmetic and sexual outcomes of hypospadias correction performed in childhood. Urol Int 2015;95:137-41.  Back to cited text no. 5
    
6.
Mureau MA, Slijper FM, Slob AK, Verhulst FC, Nijman RJ. Satisfaction with penile appearance after hypospadias surgery: The patient and surgeon view. J Urol 1996;155:703-6.  Back to cited text no. 6
    
7.
Castagnetti M, Scarpa MG, Musi L, Rigamonti W. Evaluation of cosmetic results in uncomplicated distal hypospadias repairs. J Androl Sci 2009;16:121-24.  Back to cited text no. 7
    
8.
Cimador M, Castagnetti M, De Grazia E. Risks and relevance of preputial reconstruction in hypospadia repair. Pediatr Med Chir 2003;25:269-72.  Back to cited text no. 8
    
9.
Mureau MA, Slijper FM, Nijman RJ, van der Meulen JC, Verhulst FC, Slob AK. Psychosexual adjustment of children and adolescents after different types of hypospadias surgery: A norm-related study. J Urol 1995;154:1902-7.  Back to cited text no. 9
    
10.
Mittal AG, Labbie A, Kozakowski K, Gosalbez R, Castellan M. Cosmetic results using penile perception scores in proximal hypospadias with ventral corporal grafting. EC Paediatr 2016;3:334-38.  Back to cited text no. 10
    
11.
Schönbucher VB, Landolt MA, Gobet R, Weber DM. Health-related quality of life and psychological adjustment of children and adolescents with hypospadias. J Pediatr 2008;152:865-72.  Back to cited text no. 11
    
12.
Schultz JR, Klykylo WM, Wacksman J. Timing of elective hypospadias repair in children. Pediatrics 1983;71:342-51.  Back to cited text no. 12
    
13.
Moriya K, Kakizaki H, Tanaka H, Furuno T, Higashiyama H, Sano H, et al. Long-term cosmetic and sexual outcome of hypospadias surgery: Norm related study in adolescence. J Urol 2006;176:1889-92.  Back to cited text no. 13
    
14.
Aulagne MB, Harper L, de Napoli-Cocci S, Bondonny JM, Dobremez E. Long-term outcome of severe hypospadias. J Pediatr Urol 2010;6:469-72.  Back to cited text no. 14
    
15.
Bracka A. Sexuality after hypospadias repair. BJU Int 1999;83 Suppl 3:29-33.  Back to cited text no. 15
    
16.
Adams J, Bracka A. Reconstructive surgery for hypospadias: A systematic review of long-term patient satisfaction with cosmetic outcomes. Indian J Urol 2016;32:93-102.  Back to cited text no. 16
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17.
Mureau MA, Slijper FM, Slob AK, Verhulst FC. Genital perceptions of children, adolescents, and adults operated on for hypospadias: A comparative study. J Sex Res 1995;32:289-98.  Back to cited text no. 17
    
18.
Jones BC, O'Brien M, Chase J, Southwell BR, Hutson JM. Early hypospadias surgery may lead to a better long-term psychosexual outcome. J Urol 2009;182 Suppl 4:1744-9.  Back to cited text no. 18
    
19.
Bracka A. A long-term view of hypospadias. Br J Plast Surg 1989;42:251-5.  Back to cited text no. 19
    
20.
Snodgrass WT, Koyle MA, Baskin LS, Caldamone AA. Foreskin preservation in penile surgery. J Urol 2006;176:711-4.  Back to cited text no. 20
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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