SAFETY AND EFFICACY OF TOPICAL EPINEPHRINE SOLUTION 1/100,000 IN HYPOSPADIAS SURGERY

Objectives: To evaluate the safety and the efficacy of topical epinephrine solution 1/100,000 in hypospadias surgery.

Methods: Prospective study of 143 patients with variant types of hypospadias aged between 1-14 years who underwent different procedures for correction of hypospadias over 12 months period (August 2004 –August 2005) was included in the study. Topical epinephrine solution 1/100,000 was used in 103 patients (group 1), 40 patients were operated without topical epinephrine solution 1/100,000 (group 2). Heart rate, blood loss, skin ischemia, formation of haematoma, operative time and wound infection were evaluated.

Results: Tourniquet was used in group 1 only for erection test in 4 patients with proximal penile hypospadias and 2 with penoscrotal hypospadsias, minimal use of bipolar diathermy in 4 patients with complicated hypospadias where extensive dissection was needed, minimal blood loss (average 5ml), negligible increase in heart rate and no skin ischemia. The average operative time was 100 minutes (range from 50 -150). Tourniquet and bipolar diathermy were used in 36 in group 2 with average blood loss of (25ml).The average operative time was 135 minutes (range from 60-185). In group 1, one patient developed hematoma after accidental trauma 5-days post-operatively at home, 23 patients discharged in the same day with or without urethral stent, 70 patients discharged within 1 to 3 days post-operatively with urethral stent, 10 patients had 7-10 days hospital stay for major hypospadias repair with Foley catheter and suprapubic catheter for urinary diversion. One patient had wound infection. The majority of patients in group 2 were admitted for 7-10 days with Foley catheter. Few patients had suprapubic catheter as well for urinary diversion. Two patients had wound infection and 4patients had post operative bleeding.

Conclusion: Topical epinephrine solution 1/100000 is safe, decreases bleeding and wound hematoma in hypospadias surgery. It eliminates the need of tourniquet, minimizes the use of bipolar diathermy, and decreases the operative time, early hospital discharge and minimal complications.

Key words:  Hypospadias surgery, Topical epinephrine solution

JRMS April 2009; 16(1): 30-33


Introduction

Hypospadias is a congenital defect associated with proximal placement of urethral meatus. The meatus can be located from the glans to the perineum but the majority of boys have distally positioned meatus.(1) A chordee; a ventral curvature, may a accompany this anomaly.(2)

The cause of hypospadias is still unknown but it is most likely polygenic because of high familial incidence which is about 8%. The incidence of hypospadias has been calculated to be 3.2 in 1000 live male births or approximately 1 in every 300 male children, but this number vary from one country to another.(3)

Bleeding is the most common complication of hypospadias repair; there are many methods to manage this type of complication: Tourniquet use, epinephrine and Cauterization, epinephrine in lidocaine-injection into the site of incision.(4-6) 

Control of bleeding during surgery will give better exposure to the surgeon for better repair. Also bleeding and oozing from the site of surgery in the early postoperative period may require sometimes immediate exploration to identify and treat the source.

If a haematoma is formed in the postoperative period and increased in size, if not evacuated in addition to cosmetic matter it can cause breakdown of repair.(7, 8)      


Methods

Prospective study of 143 patients with variant types of hypospadias; proximal, middle and distal penile hypospadias aged between 1-14 were included in our study over 12 months period (August 2004 –August 2005).

They underwent different procedures for correction of hypospadias such as local tube urethroplasty (Ducket, Snodgrass), Mathieu flip flap, single stage long tube urethroplasty and MAGPI for the glanular type. Topical epinephrine solution 1/100,000 was used by our surgical team in 103 patients (group 1), 40 patients were operated by another surgical team using tourniquet and bipolar diathermy without topical epinephrine solution 1/100,000 (group 2). The epinephrine solution 1/100,000 was prepared by adding 1ml (1:1000) of epinephrine to 100ml of normal saline and the average volume used was 10ml as topical irrigation during dissection.

Heart rate and estimated blood loss were evaluated during the surgical procedure. Operative time, skin ischemia, formation of haematoma and wound infection were also evaluated in the early postoperative period and in the 3rd post operative upon removal of dressing. The hospital stay was estimated.  Urethrocutaneous fistula formation was evaluated through the follow up period (2 weeks -6 months).


Results

Tourniquet was used in group 1 only for erection test in 4 patients with proximal penile hypospadias and 2 with penoscrotal hypospadias, minimal use of bipolar diathermy in 4 patients with complicated hypospadias where extensive dissection was needed to complete the surgery.

In group 1, there was minimal blood loss (average 5ml), no significant increase in heart rate (average 8 beats/min), Minimal edema and no skin ischemia.Haematoma formation was not encountered in any patient.

The average operative time was 100 minutes (range from 50 -150). Twenty three patients had Meatal Advancement Glanulo-Penile Incorporation  (MAGPI )or urethrocutaneous fistulae repair discharged in same day as outpatients with or without urethral stent,70 patients had local tube urethroplasty either Ducket, Snodgrass or Mathieu flip-flap discharged within 3days post-operatively with urethral stent,  one patient developed haematoma after accidental trauma 5-days post-operatively at home ,10 patients had 7-10 days hospital stay for major hypospadias repair with foley catheter and suprapubic catheter for urinary diversion. One patient had wound infection and urethrocutaneous fistula encountered in 4% of this group.

In group 2 tourniquet and bipolar diathermy were used in 36 patients with average blood loss of (25ml).The average operative time was 135 minutes (range from 60-185). The majority of patients in group 2 were admitted for 7-10 days with Foley catheter. Few patients had suprapubic catheter as well for urinary diversion. Two patients had wound infection and 4 patients had post operative bleeding. Through out the follow up period, urethrocutaneous fistula encountered in nearly 14% of this group.


Discussion

Bleeding during hypospadia repair remains common, there is a wide range of incidence; in a case of circumcision the bleeding incidence ranges from 0.1 to 35%, this wide range due to varying criteria had been used when recording bleeding complication and because of inadequacies in documentation;  also  bleeding  and  oozing from the site of surgery in the early postoperative period may require sometimes immediate exploration to identify and treat the source.
 
Table I: The use of epinephrine 1/100,000, tourniquet and bipolar diathermy in hypospadias surgery in group I patients

Type of hypospadias	Use of epinephrine n=patients	Use of tourniquet n=patients	Use of bipolar n=patients
Glanular	20	0	0
Subcoronal	32	0	0
Distal penile	17	0	0
Midpenile	21	0	0
Proximal penile	11	4	2
Penoscrotal	2	2	2
Total	103	6	4

Table II:  The type of hypospadias and the days spent in hospital post-surgery among  group I patients

Type of hypospadias	Number of patients	Days in hospital
		Outpatient	Inpatient
Glanular	20	19 patients	1 patient one day
Subcoronal	32	2 patients	30 patients  one day
Distal penile	19	1 patient	18 patients two days
Mid penile	22	1 patient	21 patients two days
Proximal penile	6	0	6 patients 7 days
Penoscrotal	4	0	4 patients 10 days
Total	103	23	80

Table III: Types of hypospadias, days spent in hospital, the use of tourniquet and bipolar diathermy in hypospadias surgery among group II patient

Type of hypospadias	Number of patients	Out patient	In patients (average 7days)	Bipolar diathermy	Tourniquet
Glanular	7	4	3	6	6
Subcoronal	8	4	4	6	6
Distal Penile	12	1	11	11	11
Midpenile	9	0	9	9	9
Proximal	2	0	2	2	2
Penoscrotal	2	0	2	2	2
Total	40	9	31	36	36

If haematoma is formed in the postoperative period and increased in size, if not evacuated in addition to cosmetic matter it can cause breakdown of repair.(9-12) When we compare this with the results had been achieved in our study we can see that bleeding during surgery is minimal when we use epinephrine solution 1/100,000. None of our patients needed to be explored in the early postoperative period for bleeding or hematoma formation.

In the UK the commonest aid to hemostasis is the electrosurgical diathermy for coagulating vessels; when used in monopolar form an electrical current flows from indifferent electrode (plate) to the active electrode (forceps) and the tissue surrounding the forceps is heated, resulting in coagulation. However this coagulation process can spread proximally in small vessels and the extent of vessel coagulation may be far greater than anticipated or intended and we don’t recommend its use at any time in penile and hypospadias surgery. Use of bipolar also can cause minor diathermy burns and sloughing of the affected penile skin.(13-15)

Use of tourniquet is time limited and should be relieved every 30 minutes, it can cause direct pressure injury or ischemia. In our center we started to use topical epinephrine 1/100,000 solution (group 1) during dissection while repairing hypospadias to achieve hemostasis. While revising our results none of our patients developed skin ischemia, bleeding was minimal and no hematoma developed in postoperative period. There was obvious reduction in the operative time in group 1. Most of our patients were treated as a day case except those with a complicated type of hypospadias with overall reduction of hospital stay and wound infection.

In group 2 we notice an increase of operative time, blood loss and post operative bleeding as well as prolonged hospitalization, use of catheters and increased rate of infection.

Urethrocutaneous fistula was encountered in 4% of patients in group 1, compared to nearly 14% in group 2.


Conclusion

Topical use of epinephrine solution 1/100,000 is safe and effective, decreases bleeding and wound hematoma in hypospadias surgery, eliminates the need of tourniquet use, minimizes the use of bipolar diathermy with reasonable reduction of operative time, early hospital discharge, minimal complications and decrease in urethrocutaneous fistula formation
 

References

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