Discussion
hypospadias, bladder spasm, swelling, edema, penile block, Postoperative penile edema, Edema, hypoinnervated, postoperative edema, pain, skin infection, fistula, necrosis, hematoma, trismus, penile swelling, voiding dysfunction
RECURRENCE, SCAR, ENGORGEMENT, PENIS, NECROSIS, EVENTS, URETHRA, HYPERTROPHIC, POSTOPERATIVE COMPLICATIONS, EDEMA, SCROTUM, EDEMA, COMPLICATION, HEMATOMA, TRISMUS, EXTRAVASATION, COMPLICATIONS, INFILTRATION, EDEMATOUS, SKIN INFECTION, MACULAR OEDEMA, MACULAR EDEMA
The main goal for hypospadias repair is to achieve cosmetic and functional normality, so the same principles of plastic and reconstructive surgery are needed [Postoperative penile edema is one of the most common complications that may affect the cosmetic and functional results. The edema may be excessive and may involve the penis and the whole scrotum. Edematous meatus may cause splaying of the urinary stream but is rarely of long-term significance [Kundra et al. found that caudal block was associated with higher incidence of postoperative urethral fistula compared to those who received penile block. This was explained by 27% increase in penile volume due to penile engorgement with caudal block which increases the tension on the surgical sutures thus increasing complications [The penile swelling may be aggravated by hematoma or urine extravasation because of bladder spasm. Edema can be prevented by carful tissue handling without lymphatic disconnection, use of suction drain, compressing dressing (The compression has to adequate as excessive pressure may compromise the blood supply of flap and skin which may lead to tissue necrosis), scrotal support and use of anti-inflammatory [Sensory innervation of the skin affects wound healing through the release of neuropeptides from the nerve endings. Nazir et al. found that the hypospadiac prepuce was found to be hypoinnervated for protein gene product (PGP) 9.5 and calcitonin gene-related peptide (CGRP) positive nerves when compared with the normal prepuce (We found that more complications and less functional and cosmetic satisfaction were in complex and proximal hypospadias. The incidence of recurrence was higher in proximal hypospadias of group B. Some studies showed the same results as Rynja SP et al. who evaluated functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood, they also reported that the worst results were in proximal and complex hypospadias cases where more than 50% were dissatisfied with their penile appearance. And that almost 39% reported voiding dysfunction, mainly hesitancy and spraying after proximal hypospadias repair [Long et al. also found higher overall complication rate (56%) in proximal hypospadias cases in their study. They found that patients who underwent two stages repair had lower complication rate (49%) compared to those of one stage repair (62%) [Local steroids were used as anti-inflammatory and anti-edematous drugs in many fields in medicine. Steroids act in cell nucleus by binding with chromatin, then by specific gene sequence produces enzymes and proteins which act on target cells to stabilize cell membrane and inhibit fibroplasias and cell mediators thus the inflammatory process is reduced [Steroids have been extensively used in ophthalmology since their discovery in 1948, recently alternate ways of steroid delivery are being tried like intravitreal injection in macular oedema which can control macular edema efficiently for months and years after a single administration in the meantime reducing the possibility of adverse systemic events of oral or intravenous steroids [For the first time in 1965, Maguire used local steroid injections for the treatment of hypertrophic scar and keloid tissue [In a study on dexamethasone injection after third molar surgery, Majid OW found a significant improvement in postoperative parameters (swelling, pain, and trismus) in both dexamethasone groups (group A injected locally, and group B injected intramuscular) compared to group C (No dexamethasone injected). Moreover the results of both groups A and B were comparable denoting that local dexamethasone injection gives similar results to intramuscular injection with the benefit of avoiding systemic side effects of IM injection [Another study published in the British journal of plastic surgery reported that local steroid infiltration after pediatric cranio-maxillofacial surgeries significantly decreased postoperative facial swelling and avoided the eye closure 2 days after surgery which allowed more effective monitoring of any neurological or ophthalmological complications, consequently achieved a significant clinical benefit [We locally injected long acting corticosteroid (betamethasone) into dartos fascia after surgical repair of hypospadias to limit the postoperative edema thus preserving the suture line without tension for proper healing. We spared the area around the neo urethra from injection to avoid any possible effect of steroids on healing of the suture line.In our study, we found significant higher incidence of postoperative complications in group B (No betamethasone injected). There was a higher incidence of superficial skin infection (As an initial study we had a relatively small number of patients and we lack longer follow-up, so depending on our preliminary results, we recommend future larger trials with longer follow-up.