Management of Proximal Hypospadias with 2-Stage Repair: 20-Year Experience

Abstract

Purpose To describe our experience with 2-stage proximal hypospadias repair and report outcomes. To look at patient and procedure characteristics associated with surgical complications. Materials and Methods This was a retrospective study of patients with proximal hypospadias who underwent staged repair from January 1993–December 2012. Demographics, preoperative management, and operative technique were reviewed. Complications included glans dehiscence, fistula, meatal stenosis, non-meatal stricture, urethrocele/diverticula, and residual chordee. Cox proportional hazards model was used to evaluate the associations between the time to surgery for complications and patient- and procedure level factors. Results There were 134 patients. The median age at time of first stage surgery was 8.8 months. The median age at time of second stage surgery was 17.1 months and median time between surgeries was 8 months. The median follow-up was 3.8 years. Complications were seen in 71/134 (53%), the most common being fistula in 39/134 (29.1%). Reoperation was performed in 66/134 (49%) patients. Median time from urethroplasty to surgery for complication was 14.9 months. Use of preoperative testosterone decreased risk of having surgery for complication by 27% (hazard ratio (HR)=0.73 95%CI:0.55–0.98, p=0.04). In addition, patients that identified as Hispanic had an increased risk of having surgery for complications (HR=2.40 95%CI:1.28–4.53, p=0.01). Conclusions This study reviews the largest cohort of patients undergoing 2-stage hypospadias repair at a single institution. Complications and reoperation are close to 50% in the setting of complex genital reconstruction.

Intermediate-Term Followup of Proximal Hypospadias Repair Reveals High Complication Rate

“…11 McNamara et al from Boston Children’s Hospital performed staged repair in 134 boys in a 20-year period. 12 At a median followup of 46 months the surgical complication rate was 49%. Pippi Salle et al from Toronto compared their results of 3 techniques in 140 boys during a mean followup of 30 to 48 months.…”

Primary hypospadias repair techniques: A review of the evidence

“…One was a 20 years review with 134 patients, of which complications developed in from 46% (reoperation rate) to 80% (total number of complications). [29] A second reported 56 patients operated over a 12-year period, with 66% complications that included fistulas, meatal stenosis/urethral stricture, diverticulum and glans dehiscence. [30]…”

Current challenges with proximal hypospadias: We have a long way to go

“…Although a single institution study, in total 14 surgeons were involved. Surgical complications were seen in 53% of patients with a 49% re-operation rate following the secondstage repair [25]. Urethrocutaneous fistula was the most common complication (29.1%), with glans dehiscence (14.2%) and meatal stenosis (12.7%) following.…”

“…The nature of the skin that makes up the Byar's flaps means that the resultant neourethra after the second stage tends to be longer than normal, at times hypermobile, and with irregularities within the lumen that can make catheterization difficult. The neourethra in cases of Byar's flaps is also prone to diverticulum or "megalourethra" formation as seen from the McNamara and Stanasel papers [25,26].…”