| Abstract|| |
Introduction: Understanding of anatomical vascular patterns and anatomy of prepuce is critical for a good outcome in hypospadias surgery. A well-vascularized neourethral and preputial flaps used for repair are exceptionally important for a successful outcome, especially in cases of proximal hypospadias undergoing one-stage procedures. Objective: To evaluate the vascular anatomy of prepuce in cases of proximal hypospadias and to evaluate microvessel density (MVD) by immunohistochemistry and its correlation with postoperative complications. Material and Methods: This was a prospective observational study done between November 2013 and March 2015; 33 cases of proximal hypospadias undergoing surgery were evaluated for vascular pattern by intraoperative cold light method and postoperatively by MVD. Results: Twenty-six cases with a predominant vessel pattern were identified (18 of type 1, 7 of type 2, and 1 of type 3), while seven cases had a reticular pattern (type 4) on cold light transillumination. The mean MVD in cases with predominant vascular pattern (Type 1–3) was 64.83. In cases of Type 4 pattern, mean MVD was found to be low 55.57 (P = 0.37). Patients who underwent single-stage surgery and developed postoperative complications had a low MVD score (mean 45.88, P = 0.040). Conclusion: Cold light transillumination is an effective perioperative test, reliable in the assessment of preputial vascularity. There is no statistically significant difference between the MVD of predominant vascular pattern and reticular pattern signifying that MVD may or may not be good in a given vascular pattern. MVD can be a helpful marker in assessing prognosis of repair in proximal hypospadias.
Keywords: Hypospadias, immunohistochemistry, microvessel density, proximal, transillumination
|How to cite this article:|
Narang V, Sen A, Bhardwaj M. Emerging role of preputial vascular pattern and postoperative microvessel density in cases of proximal hypospadias: A pilot study. Indian J Pathol Microbiol 2017;60:521-3
|How to cite this URL:|
Narang V, Sen A, Bhardwaj M. Emerging role of preputial vascular pattern and postoperative microvessel density in cases of proximal hypospadias: A pilot study. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Sep 20];60:521-3. Available from: http://www.ijpmonline.org/text.asp?2017/60/4/521/222993
| Introduction|| |
Hypospadia is one of the most common problems in pediatric surgery, and the quest for the perfect repair still continues. It has been difficult to obtain a consensus based on outcomes specifically for cases of proximal hypospadias with interests dwindling between single-stage and two-staged repairs. Corrective surgical techniques depend upon a multitude of factors ranging from morphological, anatomical parameters to surgeons technical skills, and a recently developed interest in the vascularity of tissues being used for reconstruction., Proximal hypospadias cases present a challenge as they are more prone to postoperative complications. Microvessel density (MVD) evaluation is a novel method being used in oncology, but there have been limited studies on MVD of prepuce in hypospadias.,
| Methods|| |
This study was a prospective observational study carried out from November 2013 to March 2015 after taking approval from the institutional review board and ethical committee. Consecutive cases of proximal hypospadias were included (n = 33).
Intraoperatively, transillumination test was carried out on prepuce using front-and-back lighting technique using a cold light source and type of vessel pattern recorded, and the distal most part of the prepuce was harvested for immunohistochemical (IHC) evaluation, and the patient underwent surgical procedure. Preputial vascular pattern was divided into vessel predominant (Type 1–3) or reticular pattern (Type 4)[Figure 1], [Figure 2], [Figure 3]. Patients who were found to have a predominant pattern underwent single-stage surgery provided that other morphological parameters, for example, size of glans and phallus, were satisfactory. Patients with reticular pattern underwent only chordee correction in the first stage followed by definitive correction 6 months later.
|Figure 2: Complications in relation to predominant vascular pattern on cold light|
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|Figure 3: Intraoperative photograph showing Type 4 and Type 1 vascular pattern in the first and second images, respectively|
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IHC examination was carried out using CD31 antibodies on paraffin-embedded samples of harvested prepuce. Areas of high vascularity were identified in low power fields (×100). Microvessel consists of capillaries, venules, and arterioles having single endothelial layer. MVD was defined as neovascularity counted in five random high power fields (×200) within these hotspots. The mean results were recorded for analysis (mean MVD).
| Results|| |
The mean age in our study was 3.85 years. The final position of meatus was recorded after chordee correction was proximal penile in 17 cases, penoscrotal in eight cases, and scrotal in five cases. 19 (58%) patients had superficial chordee which was corrected on skin degloving alone.
The mean MVD was 62.86 for all cases (16–110). Vascular pattern observed on cold light transillumination had a predominant pattern in 26 patients (Type 1; 18, Type 2; 7, Type 3; 1), while seven patients (21%) had a Type 4 or reticular pattern.
The mean MVD scores in the predominant vascular pattern patients (Type 1–3) was higher as compared to the patients having reticular pattern (Type 4) though this association was statistically insignificant (P = 0.376) [Table 1]. The vascular pattern when compared with MVD, hospital stay was found to be statistically insignificant [Table 2].
|Table 1: Mean microvessel density scores of good and bad vascular pattern|
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|Table 2: Correlation between vascular pattern, microvessel density, and age|
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Nineteen patients out of 26 patients having predominant vascular pattern underwent single-stage surgery. Seven patients with predominant vascular pattern could not undergo single-stage definitive procedure because of a multitude of factors such as small size of phallus, length of urethral defect after chordee correction signifying that vascular pattern alone cannot be a determining factor for single stage surgery, especially in proximal hypospadias cases (single-stage surgery done was: Duckett's n = 4, Snodgraft n = 3, Snodgrass n = 12). In both Snodgraft and Snodgrass preputial dartos, flap was used as a barrier layer. Five patients developed postoperative complications (P > 0.05) [Table 3]. There was no significant correlation between MVD and meatus, before and after chordee correction. Comparison of peroperative vascular pattern assessment with MVD also did not yield a significant correlation. Patients with predominant vascular pattern who underwent single-stage surgery and developed postoperative complications had a statistically significant low MVD score (P = 0.040) [Table 4] [Figure 2].
|Table 3: Correlation of vascular pattern with postoperative complications|
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|Table 4: Correlation of microvessel density with postoperative complications in patients undergoing single-stage surgery|
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| Discussion|| |
Our results show that there is no statistically significant difference between the MVD of predominant vascular pattern and reticular pattern signifying that MVD score may or may not be good in a given vascular pattern. When MVD was corelated to postoperative complications in patients undergoing single-stage surgery P value was significant, patients developing complications had mean MVD (45.88) significantly less as compared to 69.43 in cases with a favorable outcome, implying that MVD is a good marker for prognosis, while similar correlation between peroperative vascular pattern and postoperative complications yielded an insignificant correlation.
Researchers across the globe have been trying to elucidate criteria, parameters which effect outcome in hypospadias repair. Aboutaleb analyzed the urethral plate features in the success of TIP repair and found fistula more common in patients with a flat navicular fossa and urethral plate width <8 mm. A well-vascularized neourethral and preputial flaps are essential for a successful outcome, with limited data available on the outcomes of hypospadias repair in relation to blood supply of prepuce.
Perovic and Radojicic classified preputial vascular pattern into four types on the basis of transillumination and compared it with the India ink method and found the transillumination method to be reliable., Yucel et al. compared the vascular anatomy of normal and hypospadiac prepuce by multiple methods and found the transillumination method to be accurate. Caǧrı Savaş et al. found the hypospadiac prepuces to have a lower MVD (P< 0.05); they also stated that as the severity of disease increases MVD also decreased though in this study surgical outcomes in relation to prepuce were not studied.,
Ceyhan et al. in 2013 investigated preputial blood flow by laser Doppler and MVD and found MVD to be reduced in hypospadias group while there was no effect on blood flow. Recently, Elbakry et al. made an observation that EGFR was reduced in both outer and inner preputial layer, while MVD is reduced in outer layer; however, outer layer vessels had more caliber thus compensating for the low MVD.
Ours is a new study that has compared transillumination method in influencing the surgical planning of proximal hypospadias and role of MVD with postoperative complications. It clearly highlights that patients with higher MVD have less complication rate.
| Conclusion|| |
Cold light transillumination is an effective perioperative test, reliable in assessment of preputial vascularity There is no significant difference between the MVD of predominant vascular pattern and reticular pattern although it can be a helpful marker in assessing prognosis of repair in proximal hypospadias.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Baskin LS, Erol A, Li YW, Cunha GR. Anatomical studies of hypospadias. J Urol 1998;160:1108-15.
Bhat A. General considerations in hypospadias surgery. Indian J Urol 2008;24:188-94.
] [Full text]
Bracka A. The role of two-stage repair in modern hypospadiology. Indian J Urol 2008;24:210-8.
] [Full text]
Caǧrı Savaş M, Kapucuoǧlu N, Gürsoy K, Başpınar S. The microvessel density of the hypospadiac prepuce in children. J Pediatr Urol 2011;7:162-5.
Ceyhan L, Cagri Savas M, Baspinar S, Duman L, Büyükyavuz BI. The correlation between preputial blood flow and microvessel density in distal hypospadias: A prospective clinical study. J Pediatr Urol 2014;10:103-6.
Dabbs DJ. Diagnostic Immunohistochemistry. Philadelphia, PA: Elsevier Health Sciences; 2013. p. 1157.
Aboutaleb H. Role of the urethral plate characters in the success of tubularized incised plate urethroplasty. Indian J Plast Surg 2014;47:227-31.
] [Full text]
Radojicic ZI, Perovic SV. Classification of prepuce in hypospadias according to morphological abnormalities and their impact on hypospadias repair. J Urol 2004;172:301-4.
Perovic SV, Radojicic ZI. Vascularization of the hypospadiac prepuce and its impact on hypospadias repair. J Urol 2003;169:1098-100.
Yucel S, Guntekin E, Kukul E, Karaguzel G, Ciftcioglu A, Melikoglu M, et al.
Comparison of hypospadiac and normal preputial vascular anatomy. J Urol 2004;172:1973-6.
Elbakry A, Matar A, Zalata K, Zakaria A, Al Atrash G. Microvasculature and healing potential of the inner versus outer preputial skin: Preliminary immunohistochemical observations. Int Urol Nephrol 2015;47:217-22.
Dr. Vishrut Narang
Department of Pediatric Surgery, MMIMSR, Mullana, Ambala - 133 207, Punjab
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]