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SKRIPSI

DECEMBER 2017

THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR. WAHIDIN

SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 – JUNE 2017

PREVALENSI PASIEN HYPOSPADIA DI RSUP DR WAHIDIN SUDIROHUSODO,

MAKASSAR PERIODE JUNI 2016 – JUNI 2017

PREPARED BY:

AMALINA IZATI NUR BINTI IBRAHIM

NIM: C111 14 868

SUPERVISED BY:

DR. SACHRASWATY R. LAIDDING, SP. B, SpBP-RE(K)

MEDICAL EDUCATION COURSE

MEDICAL FACULTY

UNIVERSITAS HASANUDDIN

2017

HALAMAN PENGESAHAN

Telah disetujui untuk dilaksanakan

Judul Proposal Penelitian



Oleh :

AMALINA IZATI NUR BINTI IBRAHIM

C111 14 868

Makassar, 22 November 2017

Dosen Pembimbing,

dr. Sachraswaty R. Laidding, SpB, SpBP-RE (K)

NIP: 197601122006042001

DEPARTEMEN PENDIDIKAN KEDOKTERAN

FAKULTAS KEDOKTERAN

UNIVERSITAS HASANUDDIN

2017

TELAH DISETUJUI UNTUK DICETAK DAN DIPERBANYAK

Skripsi dengan judul:

“THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR. WAHIDIN

SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 – JUNE 2017”

Makassar, 22 November 2017

Dosen Pembimbing


NIP: 197601122006042001

PANITIA SIDANG UJIAN SKRIPSI

FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN

Skripsi dengan judul “THE PREVALENCES OF HYPOSPADIA PATIENT IN RSUP DR.

WAHIDIN SUDIROHUSODO, MAKASSAR FOR THE PERIODE OF JUNE 2016 –

JUNE 2017”

telah disetujui, diperiksa dan dipertahankan di hadapan Tim Penguji Skripsi Departemen

Pendidikan Kedokteran

Fakultas Kedokteran Universitas Hasanuddin pada :

Hari / Tanggal : Rabu, 22 November 2017

Pukul : 2030 WITA

Tempat : Rumah Sakit Hikmah, Makassar

Pembimbing


NIP: 197601122006042001

Dr. A. J. Rieuwpassa, SpB, SpBP

NIP: 130222269

FOREWORD

Sincere praise and prayer are given to Allah SWT for His grace and mercy upon the

completion of this thesis as a requirement for completing the Thesis subject of the Medical

Faculty of Hasanuddin University, entitled “The Prevalences of Hypospadia Patient in RSUP

Dr. Wahidin Sudirohusodo, Makassar for the Periode of June 2016 – June 2017”.

The purpose of this research is done to show the prevalence and characteristic of

hypospadia patients that seek treatment at the referred hospital of Wahidin Sudirohusodo in

Makassar, South Sulawesi. With this research being done, it is hope that hypospadia is not taken

lightly and better procedures are being taken into account for a better management on

hypospadia patients.

The success in the completion of this thesis is not possible without the help from various

parties that gave guidance, moral assistance and cooperation towards any obstacles faced during

the whole procedure of the research. On this occasion, a sincere appreciation is given to:

1. Beloved parents, siblings and family member who have always been providing

encouragements, assistance and also guidance during the whole preparation of this thesis.

2. dr. Sachraswaty R. Laidding, Sp. B, SPBP-RE(K), as the supervisor who took time to

give guidance with sincerity and patience, from the moment of picking a topic for the

research to the proposal examination until the end of the final research examination.

3. Dr. A. J. Rieuwpassa, SpB, SpBP for taking time off from the busy schedule to be an

examiner during the proposal and final thesis examination, and dr. M. Asykar A.

Palinrungi, Sp. U for also taking the time to be an examiner during the proposal

examination and also giving advice and input in the process of writing and completing

the thesis.

4. The Dean, Vice Dean, Head of the Medical Education Unit (MEU), lecturers and staff

faculty of Medical faculty of Hasanuddin University that has helped and guided in

making this research.

5. Lecturers and all staffs of the plastic surgery department of medical faculty of

Hasanuddin University that has help giving guidance in writing this thesis.

6. Head of Medical Record Installation and all staff of RSUP Dr. Wahidin Sudirohusodo

Makassar that has helped in obtaining the medical record needed in this research.

7. My companion under the same supervisor Nur Nadhirah Iman, friends, fellow batchmates

that are undergoing the same process of completing the research thesis and multiple

individuals those names cannot be written for they are too many.

The realization that this thesis conducted is far from perfection so any form of criticism and

advice from any parties in order to improve this thesis is well appreciated. Hoping this thesis will

be any sort of help to any parties in the future.

Makassar, 22 December, 2017

Amalina Izati Nur Ibrahim

TABLE OF CONTENT

Title Page……………………………………………………………………………………….….I

Approval Page…………………………………………………………………………………….II

Foreword………………………………………………………………………………….………V

Table of Content………………………………………………………………………………..VII

List of Figures……………………………………………………………………………………IX

List of Tables……………………………………………………………………….…………….X

Abstract…………………………………………………………………………...…………….XI

Chapter 1. Introduction

1.1 Research Background…………………………………………………………………1

1.2 Summary of Study…………………………………………………………………….2

1.3 Objectives……………………………………………………………………………..3

Chapter 2. Literature Review

2.1 Literature Review…………………..…………………………………………………4

2.2 Theoretical Framework………………………………………………………………10

Chapter 3. Conceptual Framework

3.1 General Concept for the Manipulated Variable…………...…………………………11

3.2 The relationship pattern of the manipulated variable………………………..……....12

3.3 Operational definition and objective criteria…………………………...………....…13

Chapter 4. Research Method

4.1 Mode of Research……………………………………………………………………15

4.2 Location of Research………………………………………………………………...15

4.3 Population and Sample of Research…………………………………………………15

4.4 Sampling Method…………………………………………………………………….16

4.5 Presentation of Data………………………………………………………………….16

4.6 Work Method………………………………………………………………………...16

Chapter 5. Presentation of Data and Analysis of Data

Table 5.1 Age Distribution for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo

Makassar for the Period of June 2016 – June 2017…..………………………………….17

Table 5.2 Hypospadia Classification Parameter for Hypospadia Patient in RSUP DR.

Wahidin Sudirohusodo Makassar for the Period June 2016 – June 2017……………….19

Table 5.3 Other Congenital Anomalies Parameter Associated with Hypospadia Patient in

RSUP Dr. Wahidin Sudirohusodo Makassar for the Period June 2016 – June 2017.…...21

Table 5.4 Treatment Parameter for Hypospadia Patient in RSUP Dr. Wahidin

Sudirohusodo Makassar for the Period June 2016 – June 2017………….………….…..23

Table 5.5 Post-Operative Complication for Hypospadia Patient in RSUP DR. Wahidin

Sudirohusodo Makassar for the Period June 2016 – June 2017.............................…….25

Chapter 6. Discussion

6.1 Age…………………………………………………………………………………...27

6.2 Classification…………………………………………………………………………28

6.3 Other Congenital Anomalies Associated……………………………………………29

6.4 Treatment…………………………………………………………………………….30

6.5 Post-Operative Complication………………………………………………………...30

Chapter 7. Conclusion and Suggestion

7.1 Conclusion…………………………………………………………………………...32

7.2 Suggestion……………………………………………………………………………33

References………………………………………………………………………………………..34

Appendices

LIST OF FIGURES

Diagram 1 : Classification of Hypospadia………………………………………………….…6

Graph 5.1 : Age Distribution for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo

Makassar for the Period of June 2016 – June

2017…..…………………………………………………….…………………….18

Graph 5.2 : Hypospadia Classification Parameter for Hypospadia Patient in RSUP DR.

Wahidin Sudirohusodo Makassar for the Period June 2016 – June

2017……………………………………………………………………...……….20

Graph 5.3 : Other Congenital Anomalies Parameter Associated with Hypospadia Patient in

RSUP Dr. Wahidin Sudirohusodo Makassar for the Period June 2016 – June

2017.……………………………………………………………………………...22

Graph 5.4 : Treatment Parameter for Hypospadia Patient in RSUP Dr. Wahidin

Sudirohusodo Makassar for the Period June 2016 – June

2017……………………………………………………………….………….…..24

Graph 5.5 : Post-Operative Complication for Hypospadia Patient in RSUP DR. Wahidin

Sudirohusodo Makassar for the Period June 2016 – June

2017...............................................................................................................…….26

LIST OF TABLES

Table 5.1 Age Distribution for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo

Makassar for the Period of June 2016 – June 2017…..………………………………………….17

Table 5.2 Hypospadia Classification Parameter for Hypospadia Patient in RSUP DR. Wahidin

Sudirohusodo Makassar for the Period June 2016 – June 2017………………………...……….19

Table 5.3 Other Congenital Anomalies Parameter Associated with Hypospadia Patient in RSUP

Dr. Wahidin Sudirohusodo Makassar for the Period June 2016 – June 2017…………………...21

Table 5.4 Treatment Parameter for Hypospadia Patient in RSUP Dr. Wahidin Sudirohusodo

Makassar for the Period June 2016 – June 2017………….………………………………….…..23

Table 5.5 Post-Operative Complication for Hypospadia Patient in RSUP DR. Wahidin

Sudirohusodo Makassar for the Period June 2016 – June 2017...........................................…….25

SKRIPSI

MEDICAL FACULTY

HASANUDDIN UNIVERSITY

December 2017

Amalina Izati Nur Ibrahim (C111 14 868)




ABSTRACT

Background: Hypospadia is known to be one of the most common congenital urogenital defects

that occur in males. The incidence rate reported for hypospadia is approximately 1 in every 250-

300 births of male baby. Objective: The aim of this research is to gain information regarding the

prevalence of hypospadia patient that was treated at RSUP. DR. Wahidin Sudirohusodo,

Makassar within the period of June 2016 until June 2017. Method: The method used for this

research study is descriptive non-analytic study method where the entire research study will be

conducted in the manner of describing the prevalence and characteristic of hypospadia patient

from June 2016 until June 2017 based on the secondary data obtained from medical records. The

data collected will be utilized and presented in the form of statistic or table with further

elaboration on each respective data with respect to the objective of the research study using

Microsoft Excel. Sample: The sampling method used in this research is by total sampling.

Results: There were 34 cases of hypospadia presented and most patient present with hypospadia

is at age 0-10 years old (52.9%), with highest classification of posterior hypospadia (52.9%) and

highest other anomalies associated with hypospadia is undescended testis, and hernia ingualis

(5.9%). The highest treatment procedure received was the two-step repair procedure (73.5%) and

had the highest post-operative complication of urethrocutaneous fistula (20.6%). Conclusion:

Majority of the patients were of age 0-10 years old, with posterior hypospadia, highest number of

anomalies associated is undescended testis and hernia ingualis, received the two-step repair

procedure and faced urethrocutaneous as the post-operative complication.

Key Words: Hypospadia, prevalence, Makassar.

SKRIPSI

FAKULTAS KEDOKTERAN

UNIVEERSITAS HASANUDDIN

Desember 2017

Amalina Izati Nur Ibrahim (C111 14 868)


PREVALENSI PASIEN HYPOSPADIA DI RSUP DR. WAHIDIN SUDIROHUSODO,

MAKASSAR UNTUK PERIODE JUNI 2016 - JUNI 2017

ABSTRAK

Latar Belakang: Hypospadia merupakan satu kelainan kongenital urogenial yang paling umum

terjadi pada pria. Tingkat kejadian yang dilaporkan untuk hipospadia adalah sekitar 1 dari setiap

250-300 kelahiran bayi laki-laki. Tujuan: Tujuan dari penelitian ini adalah untuk mendapatkan

informasi tentang prevalensi hipospadia yang dirawat di RSUP. DR. Wahidin Sudirohusodo,

Makassar dalam kurun waktu dari Juni 2016 sampai Juni 2017. Metode: Metode yang digunakan

dalam penelitian ini adalah metode prevalensi dan karakteristik hipospadia dari bulan Juni 2016

sampai Juni 2017 berdasarkan data sekunder yang diperoleh dari rekam medis. Data yang

terkumpul akan digunakan dalam bentuk statistik atau tabel dengan penjelasan yang lebih lanjut

dari Microsoft Excel. Sampel: Metode pengambilan sampel yang digunakan dalam penelitian ini

adalah dengan total sampling. Hasil: Terdapat 34 kasus hipospadia dan kebanyakan pasien

dengan hipospadia berada pada usia 0-10 tahun (52,9%), dengan klasifikasi tertinggi adalah

hipospadia posterior (52,9%) dan anomali tertinggi lainnya yang terkait dengan hypospadia

adalah testis yang tidak turun, dan ingualis hernia (5,9%). Prosedur perawatan tertinggi adalah

prosedur perbaikan dua tahap (73,5%) dan memiliki komplikasi pascaoperasi tertinggi yaitu

fistula urethrocutaneous (20,6%). Kesimpulan: Mayoritas pasien hipospadia berusia 0-10 tahun,

dengan hipospadia posterior, jumlah anomali tertinggi yang terkait dengan testis yang tidak turun

dan hernia ingualis, menerima prosedur perbaikan dua tahap dan menghadapi urethrocutaneous

sebagai komplikasi pasca operasi.

Kata Kunci: Hipospadia, prevalensi, Makassar.

CHAPTER 1

INTRODUCTION

1.1 RESEARCH BACKGROUND

Hypospadia is known to be one of the most common congenital urogenital defects that

occur in males (Al-Salem A.H, 2014). Hypospadia occurs due to abnormal development of the

urethral spongiosum, ventral preputium, and penile chordee (Nugroho T. D, Duarsa G. W, 2016).

This condition is described where the urethral meatus is abnormally located from its normal site,

which is located at the top end of the glans penis but along the urethral groove that includes the

glanular, scrotal and even the perineal (Maritska Z, 2015). The incidence rate reported for

hypospadia is approximately 1 in every 250-300 births of male baby (Risa, A. et al, 2017). A

research was conducted in the urology sub division in the hospital of M Djamil located in

Padang, Indonesia stating that there was increase rate of urethroplasty action in cases of

hypospadia from 15 cases in the year of 2009-2011 to 65 cases in the year of 2011-2014 (Praja

H, et al, 2017).

Studies shows that the reasons used for treating hypospadia patients are due to improper

urinary flow or other inconvenient urinary symptoms, possible infertility due to difficulty in

deposition of sperm, complication during intercourse as a result of ventral curvature of the penis,

and unsatisfied penile appearance that leads to delayed sexual development. Those are the

probability that those reasons may become a concern in untreated hypospadia patients (Schlomer

B. et al 2014). According to the Urology Committee of the American Academy of Pediatrics, the

optimal psychological age for someone to undergo genitalia surgery is below six month of age or

at the age of four years old (Duarsa G. W, Nugroho T. D, 2016)

Based on the Urology Committee of the American Academy of Pediatrics, within the

sixth month of age or by the age of four years old is the optimal psychological age for the

surgery of the genitalia. Based on the size of the penis, in the age of three months it is considered

sufficient enough for a surgery to be done with the help of a magnifier. With the intention of

doing early intervention, doctors are trying to do hypospadia repair on children at the age of four

to eight months old which is better for psychological and emotional state. The main purpose for

the hypospadia repair is to obtain a nearly normal cosmetic and functional results and the

decision for the technique used is based on the type of hypospadia, the penile curvature, and the

quality of the surrounding tissues (Duarsa G. W, Nugroho T. D, 2016).

1.2 SUMMARY OF STUDY

Based on the background of the research study mentioned above, a study will be

conducted regarding the prevalence of hypospadia patient that was treated at RSUP. DR.

Wahidin Sudirohusodo, Makassar within the time frame of June 2016 until June 2017.

1.3 OBJECTIVES

1.3.1 General Objective

To gain information regarding the prevalence of hypospadia patient that was treated at

RSUP. DR. Wahidin Sudirohusodo, Makassar within the period of June 2016 until June

2017.

1.3.2 Specific Objective

1. To study the prevalence of hypospadia patient according to age

2. To study the prevalence of hypospadia patient according to classification

3. To study the prevalence of hypospadia patient with other congenital anomalies

4. To study the prevalence of hypospadia patient according to treatment

5. To study the prevalence of hypospadia patient according to postoperative complication

CHAPTER 2

LITERATURE REVIEW

Hypospadia is one of the most common congenital anomalies and also one of the most

frequent male genital malformations. The word hypospadia is originally taken from two Greek

words hypo and spadon which means below and hole, crack or gutter respectively. According to

definition taken from the Greek word, it means that the meatus of the urethra is below the

intended hole of the urethra, which was suppose to be at the tip of the glans penis. The urethral

meatus located in this case can be anywhere along the urethral groove, whether glanular, scrotal,

or perinal (Maritska Z, 2015). The severity of the hypospadia varies on the location of the

meatus, the farther the meatus is to the tip of the penis the severe the case of hypospadia it is

(Schlomer. B, 2014).

The main idea that causes the occurrence of hypospadia is due to the arrest or incorrect

normal development of the urethra during various stage of the embryonic development, which is

within the 9 till 13 weeks of gestation (Al-Salem, 2017). The etiology for hypospadia is known

to be multifactorial, which includes genetic, endocrine disruptors, environmental influences and

other miscellaneous risk factors such as multiple birth, small gestation age, maternal age and

smoking parents (Maritska Z, 2015). There have been maternal-placental factors that have been

identified that enhance the probability of hypospadia, such as maternal hypertension,

prematurity, preeclampsia, preexisting maternal diabetes and many more. The influence of the

maternal dietary nutrients and medication has also been proven to contribute to the prevalence of

hypospadia, such as low consumption of organic food during pregnancy and also hormone

containing contraceptives during embryonal life. Though the pathophysiology of how this

condition occurs, there are studies that show that congenital penile malformation is somehow

connected to the microscopic organization of the smooth muscle fibre of the dartos tissue

(Fahmy, 2016).

Hypospadia is defined by three major anatomical defects that include ectopic urethral

meatus, abnormal foreskin that shows irregular penile raphe and dorsal hood, and chordee that

during erection shows congenital bend in the penis (Baskin, L. 2004). The main anomaly seen in

cases of hypospadia is the failure of the midline perineal mesenchyme to grow ventrally to cover

the urethral plate that causes the ectopic urethral meatus. Incomplete morphogenesis is the most

common embryological defect that causes the arrest of the urethra opening at or near the coronal

groove of the glans. When the opening is located more proximal on the penile shaft, it suggests a

more severe defect in the androgenic action. Some hypospadia patient may show abnormal

foreskin that shows irregular penile raphe may be explained by the failure of androgen-

dependent growth of the ventral penile mesenchyme, this leaves a wedge-shaped defect in the

ventral prepuce with absent of frenulum. While chordee, it is present in most patients but its

related to the severity of the hypospadia. It is usually present in patients with perineal or scrotal

anomalies, this maybe because it showed feminine development of the phallus with possible

testicular dysplasia and/or abnormal function of androgens (Hutson, J. M., Penington, E. C.,

2004)

Hypospadia is classified by the ectopic location of the urethral meatus, which can be

divided as anterior or distal hypospadia, middle or mid-penile hypospadia, and posterior or

proximal hypospadia. Anterior hypospadia is described when the urethral meatus is located at the

glandular, the meatus on the ventral surface of the glans penis;corona, the meatus in the

balonopenile furrow; or at the distal, which is in the distal third of the penile shaft. The second

category, middle or mid-penile hypospadia is when the urethral meatus is located aligning the

middle third of the penile shaft. The posterior hypospadia extends through the one third proximal

end of the penile shaft to the perineum, at the base of the shaft; scrotal, on the scrotum; and

perineal, behind the scrotum. The severity of the hypospadia is usually present with the

downward curvature of the chordee or penile curvature (Baskin, L. 2004).

Diagram 1 Classification of hypospadia

The symptoms shown on hypospadia patients are usually that they urinate downwards

instead of outwards and away from the body and causing wetness of the clothes and shoes, other

than that it may also lead to difficulty in depositing sperm and causing possible infertility, and if

it isn’t properly corrected, during adulthood, it may be a complication during intercourse due to

its ventral curvature of the penis and delayed sexual development because of its unsatisfied

penile appearance. In a certain case of severe hypospadia, which is usually the proximal type, it

is more likely to have an additional congenital anomaly. The most common urogenital anomaly

linked with hypospadia are cryptorchidism (undescended testis) and inguinal hernias. Patients

that has both hypospadia and undescended testis has a chance of having and underlying disorder

of sexual development (DSD). DSD has a higher risk of happening to those with proximal

hypospadia. DSD is shown with approximately 30% of patients with unilateral or bilateral

undescended testis with hypospadia, but increases 50% with patients with non-palpable testis. A

number of cases of hypospadia has also shown an anomaly with low-grade vesicoureteral reflux.

Any anomalies related with upper urinary tract anomalies are rarely present (Duarsa G. W,

Nugroho T. D, 2016).

Based on the Urology Committee of the American Academy of Pediatrics, within the

sixth month of age or by the age of four years old is the optimal psychological age for the

surgery of the genitalia. Based on the size of the penis, in the age of three months it is considered

sufficient enough for a surgery to be done with the help of a magnifier. With the intention of

doing early intervention, doctors are trying to do hypospadia repair on children at the age of four

to eight months old which is better for psychological and emotional state. There are no ideal

techniques that can be applied to repair all types of hypospadia. The main purpose for the

hypospadia repair is to obtain a nearly normal cosmetic and functional results and the decision

for the technique used is based on the type of hypospadia, the penile curvature, and the quality of

the surrounding tissues (Duarsa G. W, Nugroho T. D, 2016). Where else the main point for the

operation for correcting the hypospadia is making a new opening on the tip of the penis. After

the tempo of healing, most boys will have normal functions and appearance of the penis. The

type of surgery needed to fix hypospadia depends on several points which include the position of

the meatus and also the amount of foreskin (Mohamed, S. A, 2015).

The technique used to repair hypospadia should consider the type of hypospadia, the

penile curvature and the surrounding tissues. The operative steps includes degloving of the penis,

straightening the penile (chordectomy), reconstruction of the urethra, providing a good

vascularization coverage for the urethroplasty, reconstruction of the glans (glansplasty) and

create a circumcised penile appearance by doing a cosmetic skin coverage. At the end of the

surgery to repair hypospadia is to check the intravesical position of the bladder catheter and to

apply the proper wound dressing (Snodgrass, W. T, 2006)

There are several techniques to repair hypospadia, and the one used in this research is the

one-step and two-step operation. In relevancy, the one-step operation is usually used because it

spares the urethral plate and it is the ideal approach for the hypospadia repair. However, a two-

step approach is more ideal in most proximal cases of hypospadia when the urethra is located at

the scrotal or the perineal area, or cases with severe chordee and small penis (Duarsa G. W,

Nugroho T. D, 2016). In the one-step procedure in repairing hypospadia, the chordee is repaired

by chordectomy along urethroplasty, a method that tabularized perpucial flaps. Buccal grafts are

frequently used in the one-step procedure as a ventral patches or tube, though risk factor for

complication increases in approximately 50% of the cases due to irregular revascularization. For

the two-step procedure, the chordee is repaired during the first stage and followed by the

urethroplasty, and glansplasty are repaired after the first step has completely healed. The second

stage is usually performed prior 6-12 months after the first stage procedure (Al-Salem, 2017).

The two-stage technique allows more anatomic reconstruction compared to one stage complete

replacement technique that uses tubes from foreskins or penile skin flaps. The skin flaps can be

used from the local penile tissues from the healthy dorsal side of the penis. Though, higher rates

of complication are observed in this technique due to internal problems such as vascularization

problem, possible retraction, flap necrosis and many more. With that, many surgeons avoid the

complication by using free tissue grafts compared to flaps (Fahmy, M 2016).

Complications after postoperative can be observed on the first few days to months after

the surgery has successfully performed, but nevertheless long-term follow up is necessary. Acute

complications occur 7-10 days after the operation that needs proper assessment and management.

Any mismanagement of the complication may lead to failure in the procedure and also higher

risk of complication afterwards. Acute complication includes bleeding, bruising, wound

dehiscence, flap or graft necrosis, urinary tract infection and urinary tract obstruction

(.Mohamed, S. A, 201). They have been also reported delayed complications that occur months

after the surgery that shows urethral fistula and recurrent curvature of the penis after puberty

happened. Postoperative assessments may include observed voiding and post-void residue

assessments or formal uroflowmetry. Common complication that happens postoperative

hypospadia repair may include urethrocutaneous fistula, meatal stenosis, urethral stenosis,

recurrent penile curvature, erectile dysfunction and many more. Any complication faced

postoperative of hypospadia surgery can be performed after 4 – 6 months after healing (Keays,

M. A, Dave, S 2017)

Theoretical Framework

Hypospadia

Etiology

Arrest or incorrect normal development

of the urethra in embryonic

development

Genetic

Endocrine disruptors

Environment influences

Multiple birth

Small gestation age

Maternal age

Smoking parents

Maternal-placental factors

o Maternal hypertensioion

o Preeclampsia

o Preexisting maternal

diabetes

Maternal dietary nutrients and

medication

o Low consumption of

organic food

o Hormones containing

contraceptives

Classification

Anterior or distal hypospadia

Middle or mid-penile hypospadia

Posterior or proximal hypospadia

Symptoms

Urinate downwards

Difficulty in depositing sperm

causing infertility

During adulthood, during

intercourse

Surgical technique used for hypospadia

treatment

One-step procedure

Two-step procedure

Complications postoperative

Urethral fistula

Recurrent curvature of penis after

puberty

Meatal stenosis

Urethral stenosis

Congenital Anomalies Associated

Cryptorchidism (undescended

testis)

Inguinal hernias

Middle or mid-penile hypospadia

CHAPTER 3

CONCEPTUAL FRAMEWORK

3.1 General concept for the manipulated variable

The research study conducted will be divided into two variables which is the dependent

variables; the prevalence of hypospadia patients and the independent variables; age,

classification and treatment.

List of the manipulated variables:

- Age

- Classification

- Congenital Anomalies Associated

- Treatment

- Postoperative complication

3.2 The relationship pattern of the manipulated variable.

The relationship between the manipulated variable and the prevalence of Hypospadia

patients

Remarks:

= Independent variable

= In-between variable

= Dependent variable

Host factor

- Age

Hypospadia

Clinical symptoms

Classification

Postoperative complications

Surgical treatment

Anomalies Associated

3.3 Operational definition and objective criteria

3.3.1 Age

Age is the time of life a person had lives from the moment they were born until

they seek medical attention and been diagnose with the disease as stated in the

medical records.

Objective criteria based on WHO (World Health Ogranization)

1. Childhood 0 – 10 years

2. Adolescent 11 – 19 years

3. Young adult 20 – 40 years

4. Adult 41 – 65 years

5. Elderly > 65 years

3.3.2 Classification

Classification is groups of categories divided according to the position of the

ectopic meatus of the urethra

1. Anterior or distal hypospadia

2. Middle or mid-penile hypospadia

3. Posterior or proximal hypospadia

3.3.3 Congenital Anomalies Associated

Congenital anomalies are defined as structural or functional anomalies found

together with hypospadia that occur during intrauterine life.

1. Cryptorchidism (undescended testis)

2. Inguinal hernias

3.3.3 Treatment

Treatment is the act of seeking cure once the medical problem has started

1. One-step procedure

2. Two-step procedure

3.3.4 Postoperative complication

Complication is the problem faced by the patient after the repair operation.

1. Urethrocutaneous fistula

2. Meatal stenosis

3. Urethral stenosis

4. Recurrent penile curvature

CHAPTER 4

RESEARCH METHOD

4.1 MODE OF RESEARCH

The method used for this research study is descriptive non-analytic study method where

the entire research study will be conducted in the manner of describing the prevalence

and characteristic of hypospadia patient based on the secondary data obtained from

medical records

4.2 LOCATION OF RESEARCH

The location of research will be taken place in the surgical department of at RSUP. DR.

Wahidin Sudirohusodo, Makassar.

4.3 POPULATION AND SAMPLE OF RESEARCH

The target population and samples used for this research study will be patient that has

received treatment in RSUP. DR. Wahidin Sudirohusodo, Makassar within the period of

June 2016 until June 2017, either as in inpatient or outpatient.

4.4 SAMPLING METHOD

The sampling method used in this research is by total sampling, where the sample taken

is same as the population. The secondary data obtained from the written information of

the patient found in the medical record in RSUP. DR. Wahidin sudirohusodo, Makassar

during the month of June 2016 till June 2017. The medical records used must meet the

specific criteria and incomplete and damaged medical records will not be included in the

research.

4.5 PRESENTATION OF DATA

The data collected for this research study will be utilized and presented in the form of

statistic or table with further elaboration on each respective data with respect to the

objective of the research study using Microsoft Excel.

4.6 WORK METHOD

Obtain ethical approval from the Hasanuddin University Medical Faculty Ethics Committee.

Collect the data of hypospadia patients from the medical records of the surgery department of RSUP. DR. Wahidin sudirohusodo,

Makassar.

The medical records must meet certain criteria

The data is then gathered, interpreted, and presented in the research

CHAPTER 5

PRESENTATION OF DATA AND ANALYSIS OF DATA

This research has been conducted by obtaining secondary data from the written

information of hypospadia patients found in the medical record in RSUP DR. Wahidin

Sudirohusodo medical record during the period of June 2016 till June 2017. The number of

sample used was based on the total sample the hospital had within the period of June 2016 – June

2017, which was 34 samples. From the medical record, the information on age, classification,

other congenital anomalies, treatment and post-operative complication was jotted down. The data

obtain was then processed using Microsoft Excel. The processed data are presented in the form

of tables and graphs followed by explanation on them.

5.1 Age Distribution for Hypospadia Patient

Table 5.1 Age distribution for hypospadia patient in RSUP Dr. Wahidin Sudirohusodo

Makassar for the Period of June 2016 – June 2017

Age Total (n) Percentage (%)

0 - 10 years 18 52.9

11 - 19 years 13 38.2

20 -40 years 3 8.8

41 - 65 years 0 0.0

> 65 years 0 0.0

Total 34 100

Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar.

Graph 5.1 Age distribution for hypospadia patient in RSUP Dr. Wahidin Sudirohusodo

Makassar for the Period of June 2016 – June 2017


Table 5.1 shows the age distribution from the patient population, it is divided into 6

different age groups of 0 – 10 (childhood), 11 – 19 (adolescent), 20 – 40 (young adult), 41 – 65

(adult), and above 65 (elderly). The most dominant age group among the patient was in the age

group of 0 – 10 with summation of 18 patients and the percentage of 52.9%. Next would be the

age group of 11 – 1 9 that has 13 patients and holds 38.2%. And lastly, the least amount of

patients is in the age group of 20 – 40 with the amount of 3 patients with a distribution of 8.8%.

For the age group of 41-65 and above 65, there were no noted patients present.

0

10

20

30

40

50

60

0 - 10 years 11 - 19 years 20 -40 years

Age Distribution

Age Distribution

5.2 Classification Parameter for Hypospadia Patient

Table 5.2 Hypospadia classification parameter for hypospadia patient in RSUP DR.

Wahidin Sudirohusodo Makassar for the period June 2016 – June 2017.

Classification Total Percentage (%)

Anterior 8 23.5

Middle 8 23.5

Posterior 18 52.9

Total 34 100


Table 5.2 shows the classifications for the patients with hypospadia that are distributed into

groups of anterior, middle and posterior hypospadia. The number of people with posterior

hypsopadia holds the highest number with 18 patients and a percentage of 52.9%. This is then

followed by the middle and anterior hypospadia that have similar number of patient with a

distribution of 8 people and a percentage of 23.5%.

Graph 5.2 Classification distributions for hypospadia patient in RSUP Dr. Wahidin

Sudirohusodo Makassar for the Period of June 2016 – June 2017

Source: Medical record of RSUP Dr. Wahidin Sudirohusodo Makassar

5.3 Other Congenital Anomalies Parameter Associated with Hypospadia Patient

0

10

20

30

40

50

60

Anterior Middle Posterior

Classification Distribution

Percentage (%)

Table 5.3 Other congenital anomalies parameter associated with hypospadia patient in

RSUP Dr. Wahidin Sudirohusodo Makassar for the period June 2016 – June 2017.

Anomalies Associated Total Percentage (%)

Hypospadia 29 85.3

Hypospadia + Undescended testis 2 5.9

Hypospadia + Undescended testis +

Hernia Ingualis Lateralis 2 5.9

Hypospadia + Micropenis 1 2.9

Total 34 100.0


Table 5.3 shows the distribution of patient of hypospadia with other congenital anomalies.

Patients with only hypospadia and without any other congenital anomalies are more than half the

data which is 29 people with a percentage of 85.3 %. Patients with hypospadia and congenital

anomalies of undescended testis are noted with only 2 patients with a percentage of 5.9%. The

amount of patients with hypospadia and undescended testis with additional of hernia ingualis

lateral has the similar number with patients with hypospadia and undescended testis with a total

of 2 patients, which is 5.9%. The least number of patients with any congenital anomalies

associated with hypospadia is hypospadia with micropenis with a total of only 1 patient with the

percentage of 2.9%.

Graph 5.3 Distribution of other anomalies associated with hypospadia patient in RSUP Dr.

Wahidin Sudirohusodo Makassar for the Period of June 2016 – June 2017

0

10

20

30

40

50

60

70

80

90

Hypospadia Hypospadia +Undescended testis

Hypospadia +Undescended testis +

Hernia IngualisLateralis

Hypospadia +Micropenis

Anomalies Associated

Percentage (%)

5.4 Treatment Parameter for Hypospadia Patient

Table 5.4 Treatment parameter for Hypospadia patient in RSUP Dr. Wahidin

Sudirohusodo Makassar for the period June 2016 – June 2017.

Treatment Total Percentage (%)

One-step Procedure 9 26.5

Two-step Procedure 25 73.5

Total 34 100.0


Table 5.4 shows the data for the treatment received by the hypospadia patients. Based on the

table, more than 50% of the patient received the two-step procedure compared to the one-step

procedure. 25 patients with the percentage of 73.5% received the two-step procedure compared

to the patients with the one-step procedure was only 9 patients contributing 26.5%.

Graph 5.4 Distribution of treatment for hypospadia patient in RSUP Dr. Wahidin

Sudirohusodo Makassar for the Period of June 2016 – June 2017


0

10

20

30

40

50

60

70

80

One-step Procedure Two-step Procedure

Treatment

Percentage (%)

Table 5.5 Post-operative complication for hypospadia patient in RSUP DR. Wahidin

Sudirohusodo Makassar for the period June 2016 – June 2017

Post-operative complication Total Percentage (%)

Bleeding 2 5.9

Urethracutaneous Fistula 7 20.6

Urethracutaneous Fistula + infection 2 5.9

Infection + Necrosis + Urine retention 1 2.9

Urine retention + Urethra stricture 1 2.9

No Complication 21 61.8

Total 34 100


Table 5.5 show the distribution on the post-operative complication faced the the hypospadia

patients. Based on the table, most of the patient did not face any complication. 21 out of 34

patients in this research did not face any complication, contributing to 61.8% of the data. This is

then followed by 7 patients with a percentage of 20.6% that faced the complication of

urethrocutaneous fistula. Patients that faced the complication of urethrocutaneous fistula with

additional complication of infection were totaled of 2 patients that contribute 5.9%. Bleeding

complication has the same number of patient as the urethrocutaneous fistula with infection,

which were 2 patients with the percentage of 5.9%. The least number of post-operative

complications was both patient that had a sign of infection, necrosis that was associated with

urethra retention and urine retention due to urethra stricture. Both of those post-operative

complications had one patient with the percentage 2.9% each.

Graph 5.5 Distribution of post-operative complication for hypospadia patient in RSUP Dr.

Wahidin Sudirohusodo Makassar for the Period of June 2016 – June 2017


0 10 20 30 40 50 60 70

Bleeding

Urethracutaneous Fistula

Urethracutaneous Fistula + infection

Infection + Necrosis + Urine retention

Urine retention + Urethra stricture

No Complication

Post-operative Complication

Percentage (%)

CHAPTER 6

DISCUSSION

This research was conducted for almost two months in order to investigate the prevalence

of hypospadia patients that was treated in RSUP Dr. Wahidin Sudirohusodo Makassar from the

period of June 2016 until June 2017. After prior screening of the data and taking the total sample

that fulfills the criteria and variable, a total of 34 data was selected. In this research, the

prevalence of hypospadia patients are based on the variables of age, classification, congenital

anomalies associated with the hypospadia, treatment and post-operative complication. All the

data collected was tabulated and briefly explained.

5.1 AGE

Research done by the Urology Committee of the American Academy of

Pediatrics, within the sixth month of age or by the age of four years old is the optimal

psychological age for the surgery of the genitalia. Where else based on the size of the

penis, in the age of three months it is considered sufficient enough for a surgery to be

done with the help of a magnifier. Based on this research that was conducted on the

patients with hypospadia at RSUP Dr. Wahidin Sudirohusodo Makassar within the

month period of June 2016 until June 2017 and can be seen on table 5.1, the age group

of 0 – 10 years old has the most number of patients in the research. The number of

patients in the age group of 0 – 10 years old is 18 people (52.9%). The result of this

study has similar outcome with the research conducted by Yu-Fen Chen (2013) at

Kang-Ning Junior College of Medical care and management in Taiwan where 60.6% of

their subject has hypospadia repair after the optimal age of 18 month but decreases to

12.4 % after the age of 60 months (Chen, 2013). A similar case is also seen in Khan

(2014) research in Hayatabad Medical Complex, where a total of 428 patients with age

ranging from one to 40 years with mean age of 8.12 are presented for hypospadia repair

(Khan, 2014). Early correction for hypospadia has shown to have advantages such as

easier to handle post-operative care due to good restraint for hygienic purposes,

decrease possibility of catheter dislodgement, less pain control needed, lesser amount of

emotional disturbance faced post-operative, and might improve bonding between parent

and infant (Chen, 2013).

5.2 CLASSIFICATION

Hypospadia is classified by the ectopic location of the urethral meatus, which can be

divided as anterior or distal hypospadia, middle or mid-penile hypospadia, and posterior

or proximal hypospadia (Baskin, L. 2004). In this research that was conducted, it has

been found that the most classification group among the three classifications is the

posterior type of hypospadia that shows 18 out of 34 subject of the research with

posterior hypospadia with a percentage of 52.9%. The outcome of this research saying

that the posterior hypospadia among the other classification has the highest number of

patients resembles the research conducted by Wang-Hseng Wu (2002) at Chang Gung

Children’s Hospital, China where from 356 patients, 234 (65.7) were classified as

posterior hypospadia, showing majority of the patients were facing posterior hypospadia

(Wu, 2002). The possibility why the posterior hypospadia has a higher prevalence than

other classification is because the hospital done for the research is known to be a referred

hospital where severed cases are referred and handled. For the less severe cases of

hypospadia, any hospital without specialization can also handle this case causing the

prevalence for the anterior and middle hypospadia to be less.

5.3 OTHER CONGENITAL ANOMALIES ASSOCIATED

In a certain case of severe hypospadia, it is more likely to have an additional congenital

anomaly. The most common urogenital anomaly linked with hypospadia are

cryptorchidism (undescended testis) and inguinal hernias (Duarsa G. W, Nugroho T. D,

2016). This may be due to the abnormal occurrence during the 8 week of gestation where

the external genitalia development under the influence of testosterone. Testosterones are

converted to dihydrotesterone that acts locally to change the external genetalia into a

masculine (Al-Salem, A. H., 2017). According to the data acquired from the sample in this

research, only 5 out of 34 patients had other congenital anomalies associated with

hypospadia. Two of the patients had hypospadia with undescended testis, and another two

had hypospadia with undescended testis with additional hernia ingualis lateralis, with both

categories giving a percentage of 5.9%. The end result of this research is synchronized with

the research performed by Yu-Fen Chen (2013) at Kang-Ning Junior College of Medical

care and management in Taiwan where the common anomalies associated with hypospadia

were inguinal hernia with 11 patients (12.4%) and undescended testis with 8 patients (9%).

5.4 TREATMENT

There are many reported ways on treatments for hypospadia repair, but the main concept is

using the one-step or two-step procedure. One-step procedure is mainly used because it

spared the urethral plate and reduces cost, hospital stay and anesthetic risk. Where else the

two-step procedure is the most ideal for the proximal case of hypospadia, severe case of

chordee or micropenis and gives an anatomic satisfactory outcome (Duarsa G. W, Nugroho

T. D, 2016) (Dason, 2014). The outcome of this research shows that more than half the

number of patients had the two-step procedure for hypospadia repair, which was a total of

25 patients (73.5%), and the one-step procedure only had 9 patients (26.5%). Due to the

majority classification of hypospadia is the posterior type, its leads to the majority

prevalence for the two-step procedure to occur. This result is supported by Khan (2014)

where his subject of total 428 cases, a total of 326 patients (76.2%) were treated with the

two-step procedure, while 20.8% with total of 89 patients were treated with the one-step

procedure (Khan, 2014).

5.5 POST-OPERATIVE COMPLICATION

Literatures that have been studied shows that any acute post-operative

complication that occurs in hyospadia patients are very thin. Though there are articles

saying that complication that occurs are only one or two but never all together at once.

Common complication includes bleeding, fistula, skin necrosis and wound infection

(Bhat, 2008). The study sample on this research shows that after the hypospadia repair,

a total of 21 patients (61.8%) did not face any complication of any kind. But among the

patients that faced any sort of complication, the highest would be the urethrocutaneous

fistula. This research shows that 7 patients (20.6%) had urethrocutaneous fistula.

Another 2 patients with a percentage of 5.9% showed a complication of

urethrocutaneous fistula with additional complication of infection around the surgery

location. The outcome of this research are similar as the on conducted by Idiodi-

Thomas (2016), where 64% of his patients had acute complication of urethrocutaneous

fistula, and based on Srivastava (2011) where urethrocutaneous fistula formation is

among the common complication with incidence reported of 4 – 25% after the

hypospadia repair. Though there are no evident that shows the causes of

urethrocutaneous fistula, but there are probably an error that occurs in the technique

with inadequate inversion of the mucosa, inadequate layers of closure, ischaemic tissue

or overlapping of suture line that leads to a suture line leak (Srivastava, 2011).

CHAPTER 7

CONCLUSION AND SUGGESTION

7.1 CONCLUSION

After performing data analysis and also discussing the distribution of the data collected on the

prevalence of hypospadia patients in RSUP Dr. Wahidin Sudirohusodo, Makassar for a year

period from June 2016 until June 2017, a conclusion can be made that:

1. The distribution for most patients presented with hypospadia at the hospital is within the

age group of 0 until 10 years old.

2. Most of the patient presented with hypospadia is mostly presented with posterior or

proximal hypospadia.

3. Undescended testis and hernia ingualis lateralis are the most common congenital

anomalies associated with hyspospadia.

4. The treatment procedure most surgeons take to repair hypospadia is the two-step

procedure.

5. The common post-operative complication featured in hypospadia patient is

urethrocutaneous fistula.

7.2 SUGGESTION

After the research has been conducted on the prevalence of hypospadia patient that was

treated at RSUP Dr. Wahidin Sudirohusodo during a year period of June 2016 until June

2017, suggestion that made on form of:

1. For primary prevention, it is important to do health promotion to the people on the

risk factor that may cause hypospadia such as smoking parents, preeclampsia,

preexisting maternal diabetes and many more.

2. It is suggested to the parents of a newborn son and the health care provider to check

the condition of the penis of the baby, and to detect any anomalies to the penis. Once

any anomalies are detected, the health care provider is obligated to educate the

parents on the anomalies and when to come for further testing and treatment.

3. It is expected for the public, especially male, that feels like there are any anomalies

that can be seen at their private part to get it looked at by the doctor and to get it

treated.

4. It is hoped from the health institution by filling the medical record data with more

complete and better system of rules and hopes that the result of this research can be

used as one of the information sources for a deeper research on the characteristic of

hypospadia with more variables and for a longer period of time

5. This suggestion is addressed to the educational institution in hoping that this research

can be used as a reference to the next researcher.

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APPENDIX

APPEND1X 1 – MASTER DATAOF HYPOSPADIA PATIENTS

no. Age Classification Treatment Procedure

Anomalies

Associated

Post-operative

Complication

1 2 Posterior Chordectomy two-step Bleeding

2 2 Middle

Chordectomy

Urethroplasty

Orchidopexy sinistra one-step

Hypospadia

Undescended testis Bleeding

3 5 Posterior Chordectomy two-step

Hypospadia

Micropenis

4 9 Posterior Urethroplasty two-step

Urethrocutaneous

fistula


Urethrocutaneous

fistula

6 11 Anterior

Chordectomy

Glansplasty two-step

7 1 Middle

Chordectomy

Urethroplasty two-step

8 18 Middle Urethroplasty two-step

9 14 Anterior

Chordectomy

Urethroplasty one-step

10 5 Posterior

Chordectomy






15 19 Posterior

Chordectomy


16 5 Anterior

Chordectomy


Urethrocutaneous

fistula


Urethrocutaneous

fistula


Urine retention

Urethra stricture

19 6 Anterior Urethroplasty one-step


Hypospadia

Undescended testis

Hernia ingualis

lateralis


Infection

Necrosis

Urine retention

22 34 Posterior

Chordectomy


23 6 Anterior

Chordectomy


24 4 Middle

Chordectomy


25 2 Posterior

Chordectomy



Urethrocutaneous

fistula

27 11 Middle

Chordectomy


Urethrocutaneous

fistula


Urethrocutaneous

fistula

Infection

29 22 Anterior Chordectomy two-step

30 5 Anterior Urethroplasty two-step

Hypospadia

Undescended testis

Hernia ingualis

lateralis

31 13 Posterior

Chordectomy

Urethroplasty

Granuloplasty

Meatoplasty two-step

Hypospadia

Undescended testis


33 12 Anterior Urethroplasty two-step

Urethrocutaneous

fistula


Urethrocutaneous

fistula

infection

skripsi december 2017 the prevalences of...

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