Failed Hypospadias Repair

  • Introduction
  • Lectures
  • Articles
  • F.A.Q.
  • Results
Hypospadias is a condition manifested by 3 anatomical problems, including an abnormal site of the urethral meatus, penile curvature and abnormal foreskin development or dorsal hooded foreskin. It is the most common congenital penile anomaly, occurring in 1/300 live births with a multifactorial aetiology of genetic susceptibility plus endocrine disruptors. Recent studies show that the incidence of hypospadias is increasing in Western countries, and even higher incidence is expected in developing countries and in the Third World.
The American Academy of Paediatrics recommends performing hypospadias repair at ages 6 to 12 months. The current standard of care is to repair hypospadias with a 1-stage procedure on an outpatient basis to improve the appearance of the penis, allow voiding while standing, and improve the chances of fertility.
The repair of primary hypospadias may result in postoperative complications requiring secondary surgery, such as fistula, diverticulum, retrusive urethral meatus, residual chordee, and stricture. These operative failures during primary repair are caused by errors in design, technique and postoperative care, such as infection, wound dehiscence, urine extravasation, haematoma, ischemia and necrosis of transplanted tissues. Hypospadias repair may also fail many years after achieving successful functional and cosmetic results by primary repair and urethral strictures may develop decades after the initial hypospadias surgery. Treatment for complications in children and adults with a history of paediatric hypospadias repair remains complex because the penis is densely scarred, immobile, hypovascular or significantly shortened. Epidemiological data on the incidence of failed hypospadias repair and the number of adults seeking further surgical treatment remains unknown. This may by due to the fact that the pediatric followup stops early in the patient lifetime and the urologist takes over late in the lifetime.
Management of complications in patients in whom multiple attempts of hypospadias repair have failed is still a complex problem for the health care system, involving health care providers, general practitioners, pediatricians, surgeons, patients and parents because this difficult population of patients has been left with deformities that are significantly worse than the primary congenital anomaly.
In our Center, 14.7% of 1,510 patients treated for urethral stricture disease, and 51% of patients treated for penile urethral strictures showed failed hypospadias repair. Half of the patients with penile strictures had a history of failed hypospadias. The data probably underestimate the true incidence of this problem in the adult population.
Our experience shows 2 adult populations with failed hypospadias repair. Some patients had multiple penile deformities significantly worse than the primary congenital anomaly, such as fistula, residual hypospadias, penile curvature and cosmetically unacceptable glans or penile skin appearance. On the other hand, some patients had a satisfactory result of primary hypospadias repair with a cosmetically acceptable meatus and no evident penile deformities, but they had obstructive symptoms due to urethral stricture. These patients had increasing urinary problems and difficulties many years after surgery when pediatric followup had already stopped and they were fully involved in sexual activity. In these patients the congenital lack of spongiosum tissue may promote urethral deterioration with time. Probably, the new skin urethra cannot tolerate the repeated stretch and trauma during erection and sexual activity, which is tolerate by the normal normal spongiosum urethra. As an analogy, during sexual activity the corpus spongiosum is to the urethra what the airbag is to the body during a motor vehicle accident.
Lecture n° 1:

Failed hypospadias presenting in adults
2006 ESGURS Third Congress
September 29 – 30, 2006
Milan – Italy
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Lecture n° 2:
Failed hypospadias repair presenting in adults
International Congress on Hypospadias Surgery
September 2-5, 2007
Prishtina – Kosova
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Lecture n° 3:
Hypospadias: problems in the adult patients
24th Annual EAU Congress
March 17-21, 2009
Stockholm – Sweden

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Lecture n° 4:
Failed Hypospadias Repair
2nd Surgical Workshop of Complex Uro-Genital Reconstructive Surgery in Adulthood
September 11-12, 2009
Belgrade – Serbia

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Lecture n° 5:
Problems of urethral stricture in adult male after penile and urethral reconstructive surgery in childood
41st Scientific Congress
September 8 – 10, 2011
Gdańsk – Poland

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Lecture n° 6:
Surgical options in adult patients with failed hypospadias repair
9th Conference of the Arab Association of Urology
7th International Conference of Jordanian Association of Urological Surgeons
November 22 – 24, 2011
Amman – Jordan

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Article n° 1
Failed hypospadias repair presenting in adults
Eur Urol. 2006 May;49(5):887-94  

Objectives: To evaluate the results of one-stage and multistage urethroplasty in adults with complications following multiple failed hypospadias repairs.
Methods: Sixty adults underwent reconstructive surgery of the following complications after hypospadias repair: stricture (34), residual hypospadias (26), fistula (18), meatal stenosis (11), penile curvature (9), hair (4), diverticula (2), and stone (1). A total of 36% of the patients had one complication and 64% had two or more complications. Twenty-nine patients underwent one-stage repair with buccal or skin grafts or direct repair, and 31 underwent multistage repairs with buccal or skin grafts.
Results: Mean follow-up was 33.8 mo. Of the 60 cases, 45 (75%) had a final successful outcome and 15 (25%) failed. One-stage repair provided 24 (82.7%) successes and 5 (17.3%) failures. Multistage repair provided 21 (67.7%) successes and 10 (32.3%) failures. Buccal mucosa grafts provided 81% of success in one-stage procedures and 82.3% in multistage procedures. Penile skin grafts provided 80% of success in one-stage procedures and 50% in multistage procedures.
Conclusions: Adults with complications following childhood hypospadias repair are still a difficult population to treat with a high failure rate for reoperative surgery.

Article n° 2
Retrospective Descriptive Analysis of 1,176 Patients With Failed Hypospadias Repair
J Urol 2010; 183: 207-211

Purpose: To our knowledge epidemiological data on the incidence of failed hypospadias repair and the number of patients seeking further surgical treatment remain unknown. We report an observational, descriptive survey of patients who were evaluated and treated for urethral stricture disease and/or penile defects after primary hypospadias repair.
Materials and Methods: We performed a retrospective observational chart analysis of patients evaluated and treated for urethral stricture disease and/or penile defects at 2 tertiary European centers from January 1998 to December 2007. In each case we investigated the primary abnormal meatal site, the number of operations needed to repair primary hypospadias and complications of this primary repair. Patients were offered surgical repair for previous failed hypospadias treatment. After surgery evaluation was scheduled at 3, 6 and 9 months. Success was defined as a functional urethra without fistula, stricture or residual chordee and a cosmetically acceptable glanular meatus after the completion of all secondary procedures.
Results: A total of 1,176 patients with a mean age of 31 years were evaluated and treated. To treat failed hypospadias repair 760 (64.6%) and 416 patients (35.4%) underwent 1-stage and staged repair, respectively. Mean followup was 60.4 months. Of 1,176 cases 1,036 (88.1%) were classified as successful and 140 (11.9%) were considered failures.
Conclusions: Failed hypospadias repair may be corrected by multiple and complex surgeries. Its effects are experienced during the lifetime of the patient and parents.

Article n° 3
Surgical challenge in patients who underwent failed hypospadias repair: it is time to change?
Urol Int 2010; 85: 427-435

Introduction: Our purpose was to evaluate patients who underwent failed hypospadias repair.
Patients and Methods: We evaluated 4 different groups of patients who underwent failed hypospadias repair. Group 1: patients who underwent only urethral surgery; group 2: patients who underwent only corpora cavernosa surgery; group 3: patients who underwent urethral and corpora cavernosa surgery; group 4: patients who underwent complex reconstructive surgery. Success was defined as a functional urethra without fistula, with glandular meatus and acceptable esthetic appearance of the genitalia.
Results: Out of 1,176 patients, group 1 included 301 patients (25.5%), group two 60 patients (5.2%), group three 166 patients (14.1%) and group four 649 patients (55.2%). The mean follow-up was 60.4 months. Out of 1,176 cases, 1,036 (88.1%) were considered successful and 140 (11.9%) failures.
Conclusions: In the majority of patients (55.2%) with failed hypospadias repair, urethral reconstruction is associated with complex surgical procedures to fully resurface glands, penile shaft and genitalia.

Article n° 4
Surgical Repair of Late Complications in Patients Having Undergone Primary Hypospadias Repair during Childhood: A New Perspective
Hindawi Publishing Corporation
Advances in Urology
Volume 2012, Article ID 705212, 5 pages

Background: The repair of complications in patients who had undergone hypospadias repair is still an open problem.
Patients and Methods: We conducted a retrospective study of patients treated for late complications after hypospadias repair. Study inclusion criteria were patients presenting urethral, corpora cavernosa deformity, and/or penile defects due to previous hypospadias repair. Exclusion criteria were precancerous ormalignant lesions and incomplete data on personalmedical charts. Preoperative evaluation included clinical history, physical examination, urine culture, residual urine measurement, uroflowmetry, urethrography, urethral sonography, and urethroscopy. The patients were classified into four different groups. Success was defined as a normal functional urethra, with apical meatus, no residual penile curvature or esthetic deformity of the genitalia.
Results: A total of 1,176 patients were entered in our survey. Out of the 1,176 patients, 301 patients (25.5%) underwent urethroplasty (group 1), 60 (5.2%) corporoplasty (group 2), 166 (14.1%) urethroplasty and corporoplasty (group 3), and 649 (55.2%) complex genitalia resurfacing (group 4).Mean followup was 60.4 months. Out of the 1,176 cases, 1,036 (88.1%) were considered successful and 140 (11.9%) failures.
Conclusion: The majority of patients (55.2%) with failed hypospadias repair require surgical reconstruction to fully resurfacing the glans and penile shaft.
1. Question: Is the surgical procedure fully covered by the National Health Care System?
Answer: Yes.

2. Question: What kind of anesthesia is used for this surgery?
Answer: General anesthesia with nasal or oro-tracheal intubation.

3. Question: How many hours does the surgery take?
Answer: About 2 hour.

4. Question: Are there any risks concerning erection?
Answer: No.

5. Question: How many days of hospital recovery are expected following the surgery?
Answer: In general, from 2 to 4 days.

6. Question: How long will I have to use a urethral catheter following surgery?
Answer: The urethral catheter must stay in place for one or two weeks following surgery.

7. Question: Are there any particular recommendations during convalescence?
Answer: During convalescence, antibiotic use is suggested until the catheter is removed. It is also suggested that sexual activity be avoided.

8. Question: When will I be able to resume sexual activity?
Answer: Sexual activity can be gradually resumed one month after surgery.

9. Question: Can I ride a bike or a motorcycle immediately after the surgery?
Answer: Yes.

10. Question: What kinds of foods and drinks should be avoided after the surgery?
Answer: None.