小儿尿道下裂Hypospadias术后护理及康复指导

尿道下裂是男性下尿路及外生殖器常见的先天性畸形,约125～250个出生男婴中有1例[1].患儿因阴茎下弯及尿道口异常,不能站立排尿及伴有勃起疾病或成年后不能生育,故1岁后至学龄前须行尿道下裂手术,以减少疾病对小儿心理影响及家长的焦虑.因此,加强小儿尿道下裂术后护理及康复指导,对提高手术成功率及改善患儿愈后生活质量尤为重要.现将具体情况介绍如下:

Hypospadias： an update

Hypospadias is the most common congenital anomaly of the penis. The problem usually develops sporadically and without an obvious underlying cause. The ectopically positioned urethral meatus lies proximal to the normal site and on the ventral aspect of the penis, and in severe cases opens onto the scrotum or perineum. The foreskin on the ventral surface is deficient, while that on the dorsal surface is abundant, giving the appearance of a dorsal hood. Chordee is more common in severe cases. Cryptorchidism and inguinal hernia are the most common associated anomalies. The frequency of associated anomalies increases with the severity of hypospadias. For isolated anterior or middle hypospadias, laboratory studies are not usually necessary. Screening for urinary tract anomalies should be considered in patients with posterior hypospadias and in those with an anomaly of at least one additional organ system. The ideal age for surgical repair in a healthy child is between 6 and 12 months of age. Most cases can be repaired in a single operation and on an outpatient basis. Even patients with a less than perfect surgical result are usually able to enjoy a satisfactory sexual life.

Trends in the incidence of cryptorchidism and hypospadias of registry-based data in Korea： a comparison between industrialized areas of petrochemical estates and a non-industrialized area

This study aimed to represent the recent trends in the nationwide incidence of cryptorchidism and hypospadias in Korea, and to determine whether there is evidence of spatial heterogeneity in the incidence. The incidence was calculated as the number of newly diagnosed patients （males） during the first 4 years after a live birth in a population, nationally and regionally （a non-industrialized area （Chuncheon） and petrochemical estates （Yeocheon and Ulsan））, between 2000 and 2005. The data （numerator） for new patients were acquired from the National Health Insurance Review Agency, and the data （denominator） for the resident registration population were from the National Statistical Office. Between 2000 and 2005, the national incidence of cryptorchidism and hypospadias had an increased tendency from 5.01 to 17.43 per 10 000 persons and from 1.40 to 3.28 per 10 000 persons, respectively. The incidence of cryptorchidism was significantly higher in Yeocheon （throughout the study period） and in Ulsan （2001, 2002, 2004 and 2005） than the national incidence, whereas the incidence in Chuncheon was significantly lower in 2001 and 2002. It was difficult to compare the rates of hypospadias yearly and regionally because of the small number of cases. In conclusion, the incidence of cryptorchidism has recently increased in Korea. The petrochemical estates, Yeocheon and Ulsan, had a significantly higher incidence of cyptorchidism than the national incidence, which suggests that further study is needed to obtain a more precise estimation of the trends in the incidence of the anomalies and to confirm the association between petrochemicals and the anomalies.

Long-term sexual activity status and influencing factors in men after surgery for hypospadias

The aim of this study was to compare the long-term postoperative status of hypospadiac patients by analysing their sexual psychology, sexual behaviour, sexual function and influencing factors. A total of 130 hypospadiac patients hospitalized between January 1988 and December 2007 were followed up with questionnaires using Zung＇s Self-rating Depression Scale （SDS）, Self-rating Anxiety Scale （SAS）, a self-designed sexual function questionnaire and a 5-item version of the International Index of Erectile Function （IIEF-5）. The surveys served to evaluate the effects of hypospadias type, number of operations and surgical procedures on sexual psychology, sexual behaviour and sexual function. The control group consisted of 50 healthy adults. The postoperative SDS / SAS scores and occurrences of depression/anxiety in hypospadiac patients were significantly higher than those of normal controls （P 〈 0.001）. Patients with proximal hypospadias and multiple procedures differed from those with distal hypospadias and a single procedure in all parameters of sexual psychology （P 〈 0.05）. The average penile lengths and circumferences ofhypospadiac patients under either erect or flaccid conditions were significantly shorter than those of normal controls （P 〈 0.001）. A similar difference existed between patients with distal and proximal hypospadias （P 〈 0.01）. There was no significant difference in any parameter of sexual function between patients with different numbers of operations and surgical procedures. Hypospadiac patients were clearly impaired in sexual psychology and penile development. The severity of hypospadias and number of operations were key factors that influenced the sexual psychology of patients. This finding indicated the importance of long-term follow-up and psychological counselling for hypospadiac patients postoperatively.

Single stage dorsal inlay buccal mucosal graft with tubularized incised urethral plate technique for hypospadias reoperations

Aim： To report the experience with single stage dorsal inlay buccal mucosal grafts using the Snodgrass technique for complex redo cases. Methods： From May 2004 to December 2005, a total of 53 patients aged from 3 to 34 years old （average 11.62 ± 7.18 years） with failed previous hypospadias surgery were included in the present study. Indications included urethral strictures and repair breakdown. The unhealthy urethra was unroofed from the meatus in the ventral midline, a buccal mucosal graft was inlayed between the incised urethral plate and fixed to the corpora cavernosa. The neourethra was tubularized, and covered with subcutaneous （dartos） tissue and penile skin. Glanuloplasty was also performed in all cases. Outcome analysis included clinical follow-up, and endoscopy in 2 selected cases. Results： The buccal mucosal graft was 3.0-7.5 cm in length and 0.7-2.0 cm in width. All patients required glanuloplasty, with buccal mucosal grafts extended to the tip of the glans. After a follow-up of 14-30 months （mean 22.6 months）, the total complication rate was 15.1%, with five cases of fistula and three cases of stricture. Conclusion： Inlaying dorsal buccal mucosal grafts applying the Snodgrass technique is a reliable method for creating a substitute urethral plate for tubularization. The recurrent rate of urethral stricture and fistula is at an acceptable level for redo cases. This approach represents an effective, simple and safe option for reoperations.

Risk factors for hypospadias in China

This case-controlled study was designed to evaluate the association between various baseline parental factors and the risk of hypospadias in China. Patients were selected from tertiary referral hospitals in Anhui, a province in mid-eastern China. A questionnaire was given to the parents of each patient. The final database included 193 cases and 835 controls. The incidence of additional coexistent anomalies was 13.0%, primarily cryptorchidism （9.8%）. Ten patients （5.1%） were from families with genital anomaly, including five families （2.6%） with hypospadias. The risks of hypospadias was higher for children of mothers 〉 35 （odds ratio [OR] =1.47） and 〈 18 （OR = 2.95） years of age, and in mothers who had consumed alcohol （OR = 2.67）, used drugs （OR = 1.53） and had an infection （OR = 1.87） during pregnancy. The risk of hypospadias was also higher when mothers （OR = 1.68） and fathers （OR = 1.74） were engaged in agriculture. Other factors assessed were not associated with the risk of hypospadias.

Management of 220 adolescents and adults with complications of hypospadias repair during childhood

Objective:The goal of hypospadias repair is to achieve normal voiding and good penile cosmesis with minimal complications.Some urethroplasties deteriorate from childhood to adolescence and late stage failures have been reported.We report our experience with adult patients who have had a previous repair during childhood and present with a late complication.Methods:We reviewed the records of 220 patients aged 15e39 years old with a history of hypospadias repair who presented to our clinic.Forty-five patients with chordee,39 with urethral strictures,11 urethral fistulae,five with hairy urethras,three with urethral diverticula,and 117 patients with an abnormal glans or subterminal meatus were repaired.Results:Median follow-up was 14 months.Two patients had persistent chordee.Island skin flap urethroplasty afforded one patient with a urethral fistula and another with a recurrent urethral stricture,while the buccal mucosa group had one fistula which healed spontaneously and two recurrent strictures.For the patients undergoing glanular repairs,seven had dehiscence or breakdown of the repair.All other operations were successful.Conclusion:Complications of childhood hypospadias repair may present later in life as some urethroplasties deteriorate with time.We now recommend to parents of children with repaired proximal hypospadias to come for follow-up as their child transitions to adolescence.

Comparison of post-urethroplasty complication rates in pediatric cases with hypospadias using Vicryl or polydioxanone sutures

Objective:Hypospadias is a common congenital problem among male newborns.Both rapid absorbable sutures(polyglactin,Vicryl)and delayed absorbable sutures(polydioxanone,PDO)are used in hypospadias repair based on the surgeon's preference.This study was conducted to compare post-urethroplasty complication rates in pediatric patients with hypospadias using Vicryl or PDO sutures.Methods:This is a retrospective study which was designed and performed on 583 children aged 1-7 years old who had undergone hypospadias repair from January 2012 to December 2018.Required data were obtained from the patients'medical records.Results:Overall,post-surgical complications were observed in 60(10.3%)patients comprising urethro-cutaneous fistula(n=39,6.7%),meatal stenosis(n=10,1.7%),urethral stricture(n=7,1.2%),and glans dehiscence(n=4,0.7%).The mean age of the children with complications was 3.0±1.3 years.According to Kaplan-Meier estimate,the interval between surgery and development of complications was significantly shorter in the Vicryl group(p=0.037).Overall,complications were more prevalent in Vicryl suture than PDO suture(15.1%vs.5.3%,p<0.001).Regression model revealed that in comparison to the distal type,proximal hypospadias(odds ratio[OR]:103.9,95%confidence interval[CI]:32.2-334.9,p<0.001)and mid-shaft hypospadias(OR:82.9,95%CI:25.9-264.6,p<0.001)while using Vicryl suture instead of PDO suture(OR:62.4,95%CI:21.2-183.8,p<0.001)increased the odds of developing post-urethroplasty complications.Conclusion:We suggest PDO suture in the repair of hypospadias due to its lower complication rate,especially in cases of proximal and mid-shaft hypospadias which can get more complicated than the distal type.

The role of tunica vaginalis flap in staged repair of hypospadias

Objective:The surgical repair of hypospadias is done in two stages in a select group of patients with severe anomaly.The first stage(Ⅰ)procedure consists of correction of penile shaft curvature and second stage(Ⅱ)repair involves the creation of a neourethra.This neourethra needs a cover of an intermediate layer in order to have good functional and cosmetic results.Among the various local flaps,tunica vaginalis flap is a good option for the use as an intermediate layer.Methods:We have managed 22 patients of chordee with hypospadias by staged repair.In Stage I,chordee correction was done by dividing the urethral plate and covering the penile shaft with dorsal prepucial flaps.In Stage Ⅱ,a neourethra was created and covered with tunica vaginalis flap either through the same incision(14/22)or via a subcutaneous tunnel(8/22).An indwelling catheter was kept for 10 to 12 days.Results:Eighteen(81.8%)patients had successful functional and cosmetic repair.Two patients(9.1%)had urethrocutaneous fistula of which one healed on subsequent dilatation while the other one(4.5%)needed repair.Overall fistula formation rate was 4.5%.In two patients,the external urinary meatus could be made upto subglanular or coronal level.Conclusion:Staged repair of chordee with hypospadias is valuable in selected group of patients and tunica vaginalis flap is an excellent intermediate layer to cover the neourethra.However preoperative counseling is particularly essential in patients where the external urinary meatus can be created at coronal or subglanular level.

A modified method for the treatment of urethral fistula after hypospadias repair

Urethrocutaneous fistula （UCF） is a common complication of hypospadias surgery for severe hypospadias. We report our experience in the management of UCF following hypospadias surgery with a prepuce-degloving method （PDM）. Our study included 87 patients who developed UCF after hypospadias repair from May 2001 to December 2011. Either simple closure or PDM was performed to repair the fistula. In total, 61 patients underwent a simple closure or Y-V plasty of the fistula, and 26 underwent a PDM repair. The success rate was 78.7% for simple closure or Y-V plasty and 96.2% for PDM repair （P〈0.05）. PDM repair represents a good choice for UCF repair after hypospadias, and our high 96.2% success rate demonstrates its applicability.

Scrotal septal flap and two-stage operation for complex hypospadias:A retrospective study

BACKGROUND Complex hypospadias is a surgical challenge.AIM To present the long-term outcomes of two-stage repair of complex hypospadias using a scrotal septal flap.METHODS This was a retrospective study of patients with complex hypospadias who were operated on between January 1st,2001,and January 1st,2019,at a single hospital using a scrotal septal flap(two-stage surgery)or prepuce flap(one-stage surgery;control group).In the scrotal group,the urethra was first repaired using oral mucosa;in the second stage,a scrotal septal flap was used as a second impermeable layer.Maximal/average urinary flow rates after surgery were compared.All patients were followed for≥6 mo(range:6-96 mo).RESULTS Ninety-seven patients were included(46 in the scrotal group and 51 in the prepuce group).The maximal urinary flow rate was 15.4±2.1 mL/s in the scrotal group and 14.3±3.0 mL/s in the control group(P=0.035).The average urinary flow rate was 8.4±2.3 mL/s in the scrotal group and 7.5±1.5 mL/s in the control group(P=0.019).The proportion of patients achieving good therapeutic effects was higher in the scrotal group than in the control group[24(52.2%)vs 16(31.4%),P=0.042;34(73.9%)vs 25(49.0%),P=0.014].The scrotal flap two-stage surgery was independently associated with a higher maximal urinary flow rate(OR=2.416,95%CI:1.026-5.689,P=0.044)and with a higher average flow rate(OR=2.484,95%CI:1.054-5.854,P=0.038).CONCLUSION In complex hypospadias,a scrotal septal flap could be a versatile and reliable option for resurfacing the penis.

Comparison of Results of TIPU Repair for Hypospadias with “Spongioplasty Alone” and “Spongioplasty with Dorsal Dartos Flap”

Objective: The aim of our study was to compare the results of tubularized plate urethroplasty with interposing healthy tissue spongioplasty alone and spongioplasty with dorsal dartos flap to assess the role of dartos flap in prevention of fistulae. Patients and Methods: A retrospective study was performed on 80 patients, aged 4 months to 27 years who underwent hypospadias repair using the Snodgrass technique. The patients were assigned to two groups. In group I (40 patients) the neourethra was covered with spongioplasty only, and in group II (40 patients) the neourethra was covered with spongioplasty plus dartos flap. Integrity of the urethral plate was maintained in all the cases. The ventral curvature & torsion was corrected by penile de-gloving, mobilization of the urethral plate and spongiosum and mobilization of the proximal urethra if needed. The results were analysed in view of complication rates. The average period of hospital stay was 7 days & follow-up varied from 8 months to 28 months with a mean of 14 months. Results: In group I, hypospadias were distal penile in 31 (77.5%), mid-penile in 4 (10%) and proximal/peno-scrotal in 5 (12.5%) patients. In group II, hypospadias were distal penile in 17 (42.5%), mid penile in 9 (22.5%) and proximal/peno-scrotal in 14 (35%) patients. Sixty five percent in group I and 80% in group II had ventral curvature but the difference was not statistically significant. Good functional results were achieved in 97.5% patients in group I and in 95% patients in group II?which were statistically similar (p value—0.585). Urethral fistula was encountered in 2.5% in group I & in 2 cases (5%) in group II. Meatal stenosis was noted in 7.5% each in both groups, which responded to urethral dilatation. One patient in group II had complete disruption.?There was no statistically significant difference in early and late complications in both groups (p value—0.812). Conclusions:?Spongioplasty with healthy spongiosal tissue is strong enough and is?effective waterproofing?as an interposition layer. However, more prospective studies in different hands are needed to omit the step of dorsal dartos interposition.

A Two-Stage Buccal Mucosal Graft (BMG) for Managing Recurrent Proximal Penile Hypospadias in Pediatric &Adolescent Populations

Introduction: The presence of a recurrent proximal penile hypospadius represents a surgical challenge to the urologist due to the presence of excessive scarring and fibrosis of the tissues. This problem is more pronounced in circumcised patients, in whom there is no enough skin for one stage procedures. Buccal mucosal grafts represent a good surgical option. The aim of this study was to evaluate the results of two stages buccal mucosal urethroplasty in pediatric & adolescent patients, presenting with recurrent proximal penile hypospadias who are circumcised. Methods: Thirty seven pediatric & adolescent patients underwent two stages buccal mucosal urethroplasty for recurrent proximal penile hypospadius. In all cases the buccal graft was placed dorsally followed by the second stage closure after 6 months. Results: The mean age was 17.7 (14-20) years. With a mean follow-up of 28.3 months, 33 patients (89.2%) had a final successful outcome. Of the 4 cases that were considered as failure, 3 patients (8.1%) developed urethra-cutaneous fistula that required closure after 3 months. The remaining patient developed meatal stenosis. Conclusion: Although buccal mucosal urethroplasty is a two staged procedure, it is feasible option for pediatric & adolescent patients presenting with recurrent proximal penile hypospadius, who had no skin available for penile flaps, with a success rate approaching 89.2%.

FREE GRAFT TWO-STAGE URETHROPLASTY FOR HYPOSPADIAS REPAIR

Objective To evaluate the effectiveness of free graft transplantation two-stage urethroplasty for hypospadias repair. Methods Fifty-eight cases with different types of hypospadias including 10 subcoronal, 36 penile shaft, 9 scrotal, and 3 perineal were treated with free full-thickness skin graft or (and) buccal mucosal graft transplantation two-stage urethroplasty. Of 58 cases, 45 were new cases, 13 had history of previous failed surgeries. Operative procedure included two stages: the first stage is to correct penile curvature (chordee), prepare transplanting bed, harvest and prepare full-thickness skin graft, buccal mucosal graft, and perform graft transplantation. The second stage is to complete urethroplasty and glanuloplasty. Results After the first stage operation, 56 of 58 cases (96.6%) were successful with grafts healing well, another 2 foreskin grafts got gangrened. After the second stage operation on 56 cases, 5 cases failed with newly formed urethras opened due to infection, 8 cases had fistulas, 43 (76.8%) cases healed well. Conclusions Free graft transplantation two-stage urethroplasty for hypospadias repair is a kind of effective treatment with broad indication, comparatively high success rate, less complications and good cosmatic results, indicative of various types of hypospadias repair.

Animal Experimental Study on Surgical Repair of Hypospadias by Free Peritoneal Graft

Surgical repair of hypospadias was successfully performed by using free peritoneal graft in the model of rabbit hypospadias. The results showed that free peritoneal graft used as a substitute for urathra had a high survival rate, and the canal was formed well. Our study demonstrated that peritoneum could be used for the surgical repair of hypospadias and other urethral disorders such as urethral stricture.

Appendicular Mucosal Tube Implant with Dartos Wrap Operation for Hypospadias

Aims and Objective: To develop a better operation for hypospadias patients with poor and bad quality urethral plate and damaged urethral plate as in hypospadias cripples. Materials and Methods: I operated 21 cases of hypospadias with Appendicular mucosal tube implant with Dartos wrap operation from 17/04/2017 to 03/03/2019, in Jawale Institute of pediatric Surgery, and that group was labeled as group A. 27 cases of hypospadias were operated in same time span with conventional techniques such as extended Snodgrass operation and Byar’s two-stage operation (group B), kept as control. 7 patients (33.33%) were cases of hypospadias cripples with multiple surgeries done in the past. 4 patients (9.52%) patients had congenital short urethra. Remaining 10 patients (50%) were fresh cases with no operation done in past but with bad and fibrotic urethral plate. The longest follow up was 3 years and the shortest of 1 year. Technique of Operation: Appendicectomy performed by open technique and the serosa of Appendix cut longitudinally and stripped off the mucosal tube. The proximal hypospadias opening sutured with the appendicular mucosal tube with 6 sutures of 5-0 Vicryl. Dartos fascia is raised from the scrotum wrapped over the tube and 8 - 10 interrupted stitches taken with 5-0 Vicryl. Glanuloplasty performed over it. Suprapubic diversion did and kept for 3 weeks postoperatively. Results: In group A, 3 patients developed fistula and only 1 (4.76%) required repair at the end of 6 weeks. 2 (9.52%) patients developed grade 3 infection and settled with conservative treatment. UFR was normal at the end of 12 weeks (12.85 Ml/sec. In group B, 11 patients developed fistula and 9 (33.33%) required repaired. 9 (33.33%) patients developed strictures and all of them required multiple urethral dilatation under GA. 7 (25.92%) patients developed meatal stenosis.UFR was badly reduced with average of 5.78 ML/Sec. Conclusion: The operation proves to be a much better option compared to the conventional for group A patients. We need a series with longer follow up and larger number of patients.

Gestational obesity and risk of hypospadias in male newborns. A population based case-control study

Aim: Hypospadias is a relatively common male genital anomaly that may be caused by anomalies in maternal hormone levels and/or blood glucose levels as well as nutritional deficiencies. Maternal obesity, which increases the risk of diabetes, may alter hormone levels, and may thereby be associated with risk of hypospadias. This study was designed to determine the impact of these risk factors on hypospadias in boys born at the largest tertiary hospital in Qatar. Methods: This population-based, case-control study used linked birth-hospital discharge data from Hamad General Hospital in Doha, Qatar, from January 2007 to December 2012. Boys with hypospadias were identified, and risk factors were determined. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for hypospadias were estimated by multivariable logistic regression models adjusted for maternal age, parity and body mass index (BMI). Results: Seventy-three newborn male infants with hypospadias and 100 without the condition, with birth weight above 2500 g, were compared. Maternal obesity (BMI ≥ 30 kg/m2) was not associated with risk of hypospadias (aOR 1.07;95% 0.95 - 1.21), and no trend in risk with increasing maternal BMI was observed. Conclusion: Although the causes of male genital malformation are multifactorial, the present data do not support the hypothesis that gestational maternal obesity is a cause of hypospadias in male infants.

Four Cousins with Hypospadias, Is It Familial or Environmental? (Case Report)

Hypospadias is one of the most common birth defects. However, its etiology remains largely unknown. Genetic and also intrauterine environmental factors have a principal role in causing familial hypospadias. Hypospadias repair is done through several techniques, one of which is Snodgrass technique which has many advantages. The 4 cousins underwent repair with no complications during 6 months follow up period. Methods: Urethroplasty using Snodgrass hypospadias repair of 4 cousins with positive parental consanguinity and absent family history of hypospadias. Results: 4 cousins underwent Snodgrass (Tubularized incised plate urethroplasty) with no complications after 6 months follow up. Conclusion: Although there is high heritability of hypospadias that also aggregates within second- and third-degree relatives, environmental factors may play a principal role in causing familial hypospadias. Hypospadias repair has a long learning curve. The continuous auditing should be done to improve the results.

Hypospadias Repair and Its Complications at the Plastic Surgery Department, Khoula Hospital

This study reviewed the complications associated with hypospadias repair surgery done at Khoula hospital, Oman during the period of January, 2010 to October, 2015. During this period, 178 cases were operated. Snodgrass and Bracka’s techniques were the most used techniques. Complications were noted in 16 out of 82 patients operated using Snodgrass technique and 2 out 10 patients operated via Bracka’s technique. This study helped in shifting the practice towards the technique associated with the lowest complications. As a result we adopted for our practice MAGPI for glandular hypospadias, Snodgrass for any type of hypospadias without chordee and Bracka’s two stages repair for hypospadias with chordee.

The Complication Rate after Hypospadias Repair and Correlated Preoperative Symptoms

Aim: To assess the rate of complications following hypospadias repair in a consecutive series of boys and the correlations of those complications with their preoperative symptoms, degree of hypospadias and method of operation. This study was conducted to address the question of whether all boys with all degrees of hypospadias should undergo reconstruction. Methods: This was a prospective cohort study. We included every boy who underwent an operation for the primary repair of hypospadias between January 2011 and April 2014. The median follow-up time was 24 months. The study ended in October 2014. The main outcome measurements were the frequency of postoperative complications and their correlations with the degree of hypospadias, the preoperative symptoms and the operative intervention performed. Results: Among the 76 boys who underwent operations, 23 had degree 1, 47 had degree 2, and 6 had degree 3 hypospadias. Preoperatively, 43 of the boys had symptoms that motivated the operation, including stenosis (38), a curvature (10) or both (5). Forty-three boys underwent operations with the MAVIS technique, 28 underwent TIP repair, 1 underwent a Duckett procedure, and 4 underwent Byar two-stage procedures. There were complications requiring reoperations including fistulas or ruptures in 26 (34%) boys. There were no significant differences in the rates of complications with surgery, fistulas (P = 0.4775), ruptures (P = 0.2417) or other complications (P = 0.5165) between the groups with or without preoperative symptoms, those with different degrees of hypospadias or those who underwent different operative methods for repair. Conclusions: The complication rate in this series was high. The study was prospective, and no boy was lost during follow-up. Because the complication rate did not correlate with the degree of hypospadias nor the preoperative symptoms, there may be a group of boys with hypospadias without symptoms for whose operations are questionable. The preoperative symptoms should be reported in future reports of the results of hypospadias surgery.