Hypospadias surgery: when, what and by whom?

Abstract

Summary Hypospadias is repaired by paediatric surgeons, paediatric urologists, adult reconstructive urologists and plastic surgeons. This review is unique in representing all four specialities, to provide a unified policy on the management of hypospadias. The surgeon of whichever speciality should have a dedicated interest in this challenging work, ideally having an annual volume of at least 40–50 cases. The ideal time for primary repair is at 6–12 months old, although when this is not practicable there is another opportunity at 3–4 years old. A surgical protocol is presented which emphasises both functional and cosmetic refinement. Using a logical progression of a very few related procedures allows the reliable correction of almost any hypospadias deformity. A one‐stage repair is used when the urethral plate does not require transection and its axial integrity can be maintained. Occasionally, when the plate is of adequate width and depth, it can be tubularized directly using the second stage of the two‐stage repair. When (usually) the urethral plate is not adequately developed and requires augmentation before it can be tubularized, then that second‐stage procedure is modified by adding a dorsal releasing incision ± a graft (alias Snodgrass and ‘Snodgraft’ procedures). The two‐stage repair offers the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. From available evidence this protocol combines excellent function and cosmesis with optimum reliability. Nevertheless, it would be complacent to assume that these gratifying results will be maintained into adult life. We therefore recommend that there is still a need for active follow‐up through to genital maturity.

Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes

“…Therefore, all hypospadias surgery should preferably be performed by a competent hypospadiologist, who ideally has an annual hypospadias surgical volume of 40-50 cases. 9 …”

“…9 The American Academy of Pediatrics suggests this time interval to limit psychological stress and subsequent behavioural problems seen in toddlers undergoing genital surgery. 21 There are conflicting reports regarding whether increasing age at surgery leads to a higher complication rate.…”

“…The key surgical principles to achieve optimal surgical outcomes include the use of magnification, fine instruments and sutures, minimal and atraumatic tissue-handling, careful hemostasis, and good surgical assistance. 9,11 Most surgeons perform stented repairs, although distal hypospadias repairs can be done without the use of stents. 24 There is no uniform consensus regarding dressings 25 and use of prophylactic antibiotics.…”

“…9 Postoperative assessments may include observed voiding and post-void residue assessments or formal uroflowmetry.…”

Hypospadias: an algorithm for repair with the aid of the microscope in 102 patients

“…Common meatal positions are distal penile 70%, mid-penile 10%, and proximal types 20%. [2] We follow an algorithm, which helps in choice of repair irrespective of the meatal site. The surgical procedure in itself requires magnification and a bloodless field to execute a successful repair.…”