Çocuklarda Hipospadis Cerrahisinde Kanama Kontrolü: Turnike ve Adrenalin

Abstract

Amaç: Hipospadias yenidoğan penisinde görülen en sık konjenital malformasyonudur. Üretranın hem fizyolojik hem de estetik olarak yeniden şekillendirilmesi, titiz bir ameliyat gerçekleştirmek için iyi bir cerrahi alan görünümü gerektirir. Bu standartları elde etmek için geçmişte turnike uygulaması ve adrenalin enjeksiyonu yapılmıştır ancak en iyi sonucun alınıp alınmadığı konusunda hala tartışmalar devam etmektedir. Gereç ve Yöntem: Çocuk cerrahisi kliniğimizde Kasım 2017-Nisan 2022 tarihleri ​​arasında hipospadias onarımı nedeniyle ameliyat edilen 78 hastanın dosyaları geriye dönük olarak incelendi. Ameliyatlar tek cerrah tarafından tubularize insize plate üretroplasti (TIPU) tekniği kullanılarak gerçekleştirildi. Hipospadias olguları mea yerleşimlerine göre glanüler, distal ve proksimal hipospadias olarak gruplandırıldı. Bu hastalar daha sonra Turnike uygulaması (TA) ve Adrenalin enjeksiyonu (AI) ile komplikasyonları açısından 2 grupta karşılaştırıldı. Bulgular: Çalışma grubumuzda mea yerleşimine bağlı 12 (%15,4) hastada glanüler hipospadias, 58 (%74,4) hastada distal hipospadias ve 8 (%10,2) hastada proksimal hipospadias vardı. Toplamda 12 komplikasyonla karşılaşıldı. Genel komplikasyon oranı %15,3 idi. Mea yerleşiminden bağımsız olarak turnike uygulaması ile adrenalin enjeksiyonu arasındaki komplikasyonlarda istatistiksel olarak anlamlı bulundu. Glanüler, distal ve proksimal hipospadias olguları arasında fark bulunamadı. Sonuç: Geçmişte adrenalin enjeksiyonu tatmin edici sonuçlar vermesine rağmen, çalışmamız hipospadias cerrahisinde turnike uygulamasının hemostazı sağlayan güvenli ve güvenilir bir yöntem olduğunu göstermiştir. Bununla birlikte, en iyi seçeneği belirlemek için daha büyük gruplarla randomize çalışmalara ihtiyaç vardır.

Keywords

• Hipospadias
• hemostaz
• Turnike
• Adrenalin
• Çocuk

Bleeding Control in Pediatric Hypospadias Surgery: Tourniquet and Adrenaline

Abstract

Background: Hypospadias is the most encountered congenital malformation of the newborn penis. Refashioning of the urethra, both physiologically and aesthetically, requires a good surgical exposure to perform a scrupulous surgery. To obtain such standards tourniquet application and adrenaline injection have been performed in the past but there is still controversy for the best results. Materials and Methods: The files of 78 patients, who were operated on for hypospadias repair surgery in our pediatric surgery clinic between November 2017 and April 2022, were reviewed retrospectively. Operations were carried out by a single surgeon using tubularized incised plate urethroplasty (TIPU) technique. The hypospadias cases were grouped according to their meatal locations as to glanular, distal and proximal hypospadias. These patients were then compared in 2 groups by Tourniquet application (TA) and Adrenaline injection (AI) regarding their complications. Results: In our study group 12 (15,4%) patients had glanular hypospadias, 58 (74,4%) patients had distal hypospadias and 8 (10,2%) patients had proximal hypospadias relating to meatal locations. 12 complications were encountered in total. The overall complication rate was 15,3%. There was statistical significance in complications between tourniquet application and adrenaline injection irrespective of meatal locations. We found no difference in-between glanular, distal or proximal hypospadias cases. Conclusions: While adrenaline injection has been found with satisfying results in the past, our study showed that tourniquet application is a safe and reliable method obtaining hemostasis in hypospadias surgery. Nevertheless, further randomized studies with larger groups are required to determine the best option.

Keywords

• Hypospadias
• hemostasis
• Tourniquet
• Adrenaline
• Children

References

1. Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia. American Academy of Pediatrics. Pediatrics. 1996 Apr;97(4):590-4.
2. Belman AB. Hypospadias update. Urology 1997;49:166-72.
3. Snodgrass WT, Shukla AR, Canning DA. Hypospadias. In: Docimo SG, editor. The Kelalis-King-Belman Textbook of Clinical Pediatric Urology. London: Informa Healthcare; 2007:1205–9.
4. Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151(2):464–5.
5. Snodgrass W, Bush N. Recent advances in understanding/management of hypo-spadias. F1000 Prime Rep 2014;6:101.
6. Akbiyik F, Tiryaki T, Senel E, Mambet E, Livanelioglu Z, Atayurt H. Clinical experi-ence in hypospadias: results of tubularized incised plate in 496 patients. Urology 2009;73(6):1255–7.
7. Hansson E, Becker M, Aberg M, Svensson H. Analysis of complications after repair of hypospadias. Scand J Plast Reconstr Surg Hand Surg. 2007;41(3):120-4.
8. Wilkin P, Metcalfe JO, Lakey WH. Hypospadias: a review. Can J Surg. 1979 Nov;22(6):532-7.Klenerman L. The tourniquet in surgery. J Bone Joint Surg 1962:44: 937-43

9. Redman JF. Tourniquet as hemostatic aid in repair of hypospadias. Urology. 1986 Sep;28(3): 241.Devine CJ Jr and Horton CE: Hypospadias repair. J Urol 1977; 118: 188.
10. Duckett JW, Keating MA. Technical challenge of the megameatus intact prepuce hypospadias variant: the pyramid procedure. J Urol. 1989 Jun;141(6):1407-9.
11. Hadidi, A.T. (2004). Classification of Hypospadias. In: Hadidi, A.T., Azmy, A.F. (eds) Hypospadias Surgery. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-07841-9_7
12. Crawford DS, Blackburn AV, Ragoowansi R. The Penrose drain tourniquet for hypospadias repair. Plast Reconstr Surg. 2004 Apr 15;113(5):1525-6.
13. Lahoti BK, Aggarwal G, Diwaker A, Sharma SS, Laddha A. Hemostasis during hypospadias surgery via topical application of feracrylum citrate: A randomized prospective study. J Indian Assoc Pediatr Surg. 2010 Jul;15(3):87-9.
14. Laddha AK, Mulla M, Sharma SS, Lahoti BK, Mathur R. A prospective comparison of topical feracrylum citrate versus adrenaline as haemostatic agent in hypospadias surgery in children. Afr J Paediatr Surg. 2014 Jul-Sep;11(3):215-8.
15. Borges LF, Taboga SR, Gutierrez PS. Simultaneous observation of collagen and elastin in normal and pathological tissues: analysis of Sirius-red-stained sections by fluorescence microscopy. Cell Tissue Res. 2005 Jun;320(3):551-2.
16. Belman AB. The de-epithelialized flap and its influence on hypospadias repair. J Urol. 1994 Dec;152(6 Pt 2):2332-4.
17. Cakmak M, Caglayan F, Kisa U, Bozdogan O, Saray A, Caglayan O. Tourniquet application and epinephrine injection to penile skin: is it safe? Urol Res. 2002 Sep;30(4):268-72.
18. Bozkurt NB, Moralioglu S, Vural IM, Sarioglu Y, Pekiner C. Does tourniquet application alter the nitrergic responses of rabbit corpus cavernosum penis? A functional study. World J Urol. 2008 Apr;26(2):191-6.
19. Rabinovitch HH. Experience with a modification of the Cloutier technique for hypospadias repair. J Urol. 1988 May;139(5):1017-9.
20. Wilhelmi BJ, Blackwell SJ, Miller JH, Mancoll JS, Dardano T, Tran A, Phillips LG. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg. 2001 Feb;107(2):393-7.
21. Kajbafzadeh AM, Payabvash S, Tavangar SM, Salmasi AH, Sadeghi Z, Elmi A, Tirgari F, Razavi AE. Comparison of different techniques for hemostasis in a rabbit model of hypospadias repair. J Urol. 2007 Dec;178(6):2555-60.
22. Schnabl SM, Herrmann N, Wilder D, Breuninger H, Häfner HM. Clinical results for use of local anesthesia with epinephrine in penile nerve block. J Dtsch Dermatol Ges. 2014 Apr;12(4):332-9.
23. Alizadeh F, Fakoor A, Haghdani S. A comparison between tourniquet application and epinephrine injection for hemostasis during hypospadias surgery: The effect on bleeding and postoperative outcome. J Pediatr Urol. 2016 Jun;12(3):160.e1-5.
24. Cakmak M, Caglayan F, Kisa U, Bozdogan O, Saray A, Caglayan O. Tourniquet application and epinephrine injection to penile skin: is it safe? Urol Res. 2002 Sep;30(4):268-72.