Hypospadias, a congenital urologic ...

Hypospadias, a congenital urologic abnormality in which the urethral meatus is located in a ventral position proximal to the tip of the penis, appears in 1 in 300 live male births.(1) The etiology of hypospadias is unclear. The urethral opening may be located anywhere from the tip of the glans penis to the perineum (Figure 1) A deficiency of the ventral foreskin and curvature of the penis (ie, chordee) also may be not past nor future The most common urologic anomalies associated with hypospadias are maldescended teste and inguinal hernia.(2) Surgical correction of hypospadias is indicated to allow for forward-directed urine and seed to treat penile curvature that may interrupt intercourse, and to provide a cosmetically acceptable phallus. Milder forms of hypospadias may not require surgical correction.

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chiefly males with hypospadias are identified during their first days of life. frequently the abnormality is identified during examination before a newborn circumcision. Rarely, the ventral foreskin will be normal in appearance and the hypospadias will be noted later in life when the foreskin retracts or after a circumcision is performed. When a hypospadias is identified, an early referral should be made to a pediatric urologist, and circumcision should be delayed.(3) In general, the hypospadias itself effects no symptoms. The timing of surgical repair has changed with advances in pediatric anesthesia, surgical techniques, and a better understanding of the psychologic and emotional impacts of surgery Initially, the conduct was performed at or before adolescence; now in the greatest degree repairs are performed at approximately sixth month of age. The infant's overall health and penile size determines the timing of surgical intervention.

HISTORICAL PERSPECTIVE

The first reported hypospadias repair was performed in 100 to 200 AD.(4) Since then, more than 200 techniques of repair have been described, and recently made known techniques continue to evolve.(5) These modifications deliberate the development of fine line of junction materials, fine instruments, the use of optical magnification, a better understanding of the penile anatomy in the couple the normal (Figure 2) and hypospadiac phallus, and a desire to minimize the complications associated with the repair. Initially, the surgical approach involved multistage repairs; however, since the 1950 one-stage repairs have been commended as the primary mode of treatment.(6) The goal of all techniques is to bring the urethral meatus to the tip of the penis, create a conical glans configuration, straighten the penis, and achieve cosmetically acceptable penile shaft skin coverage.

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In the past, hypospadias surgery was performed near adolescence and required several days' hospitalization. This disruption in the child's routine and the anxiety caused by the agency of the hospitalization may lead to alterations in the child's behavior. A better understanding and awareness of the emotional and psychologic impact of this surgical intervention, in addition to improvements in pediatric anesthesia and surgical technique, have l to a variety of changes in hypospadias repair. generally the majority of hypospadias repairs are performed as outpatient acts or require a single overnight admission.

Institutional changes, including allowing the parents to stay with the child, creating play areas in the same day surgical unit and in succession the pediatric floor, touring the hospital with the child and parents before surgery and counseling the parents and child have helped decrease the anxieties that the child and his parents face. In addition, nursing care has undergone dramatic changes in all stages of the treatment of hypospadias repair, from the initial presentation from one side the postoperative follow-up. An assessment of the child's developmental stage and skill horizontals is essential for the involved fosters to formulate a plan of care.

PATIENT ASSESSMENT

The pediatric urologist's preoperative preparation includes a clear and thorough discussion with the parents regarding the indications for and the goals of the surgical repair. The parents must be made aware of the more commonly identified surgical complications and their respective treatments. A integral history and physical examination, including a history of medical/surgical illness, allergies, and medications; family history, including history of enigmas with anesthesia; and bleeding history should be performed within individual month before surgery. The potential forms of surgical repair and the indications for the use of the different exemplars of potential repair are discussed.

The parents are informed that the actual proceeding to be performed will be determined in the OR and that, depending forward the surgical technique employed, the child may stay in the hospital overnight, and a urethral drainage catheter may be left in place for five to 10 days postoperatively. Educational and instructional pamphlets are given to the parents to reinforce and clarify the issues that pertain to hypospadias, the surgical repair, and the postoperative care, including catheter care, use of medications, and routine postoperative care. Parents are encouraged to contact the physician if they have any questions regarding the surgery During the initial evaluation and preoperative visit, the parents fitting the pediatric urology nurse practitioner, who addresses the more commonly identified parental interests (eg, what to do if the child has a unloose stool that soils the dressing, signs and symptoms of postoperative bladder spasms, what medications to use).