eMedicine Specialties > Pediatrics: Surgery > Urology

Hypospadias: Follow-up

Author: John M Gatti, MD, Associate Professor and Director of Minimally Invasive Urology, Department of Pediatric Surgery and Urology, Children's Mercy Hospital; Assistant Professor, Department of Pediatric Surgery and Urology, University of Missouri School of Medicine at Kansas City, Missouri; Assistant Clinical Professor, Division of Pediatric Urology, University of Kansas School of Medicine at Kansas City, Kansas
Coauthor(s): Andrew J Kirsch, MD, FAAP, FACS, Clinical Professor of Urology, Emory University School of Medicine, Children's Healthcare of Atlanta; President, Georgia Urology, PA; Howard M Snyder III, MD, Professor, Department of Surgery, Division of Pediatric Urology, University of Pennsylvania School of Medicine
Contributor Information and Disclosures

Updated: Sep 25, 2009

Follow-up

Complications

  • Immediate postoperative concerns
    • Local edema and blood spotting can be expected early after repair and generally do not cause a significant problem.
    • Postoperative bleeding rarely occurs and is usually controlled with a compressive dressing. Infrequently, this requires reexploration to evacuate a hematoma and to identify and treat the source of bleeding.
    • Infection is a rare complication of hypospadias repair in the modern era. Skin preparation and perioperative antibiotics are generally used, and patients are often maintained on an antibiotic course until any stents are removed.
  • Long-term issues
    • Fistula: Urethrocutaneous fistulization is a major concern in hypospadias repair. The rate of fistula formation is generally less than 10% for most single-stage repairs but rises with the severity of hypospadias, approaching 40% with complex reoperative efforts. Fistulas rarely close spontaneously and are repaired using a multilayered closure with local skin flaps 6 months after the initial repair. After repair, fistulas recur in approximately 10% of patients.

      A urethrocutaneous fistula has appeared after hyp...

      A urethrocutaneous fistula has appeared after hypospadias repair. Note one stream from true urethral meatus, and second stream through more proximal fistula.

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      A urethrocutaneous fistula has appeared after hyp...

      A urethrocutaneous fistula has appeared after hypospadias repair. Note one stream from true urethral meatus, and second stream through more proximal fistula.

    • Meatal stenosis: Meatal stenosis, or narrowing of the urethral meatus, can occur. A urethral stent prevents any problems initially, but a fine-spraying urinary stream that is associated with straining to void likely requires operative meatal revision.
    • Stricture: Urethral strictures may develop as a long-term complication of hypospadias repair. These are generally repaired operatively and may require incision, excision with reanastomosis, or patching with a graft or pedicled skin flap.
    • Diverticula: Urethral diverticula may also form and are evidenced by ballooning of the urethra while voiding. A distal stricture may cause outflow obstruction and may result in a urethral diverticulum. Diverticula can form in the absence of distal obstruction and are generally associated with graft- or flap-type hypospadias repairs, which lack the subcutaneous and muscular support of native urethral tissue. The redundant urethral tissue is generally excised, and the urethra is tapered to an appropriate caliber.
    • Hair in the urethra: Hair-bearing skin is avoided in hypospadias reconstruction but was used in the past. When incorporated into the urethra, it may be problematic and can result in urinary tract infection or stone formation at the time of puberty. This generally requires cystoscopic depilation using a laser or cautery device or, if severe, excision of hair-bearing skin and repeat hypospadias repair.

Prognosis

  • Present prognosis: With modern anesthetics, instruments, sutures, dressing materials, and antibiotics, hypospadias repair has become quite successful. Long-term studies on the outcomes of hypospadias using current practices are limited. Although some earlier studies have been discouraging, these reflect an era with poorer technical outcomes, increased number of operations, and a lack of appreciation for the psychological morbidity associated with intervention at an older age.
  • Future prognosis: Although the techniques of hypospadias repair continue to evolve, the broader future of hypospadias is truly promising. Nontraditional tissue adherence techniques are being developed, including tissue glues and laser-activated soldering techniques that have been shown to improve wound healing and to reduce fistula formation. Urethral substitutes, which may obviate the difficulties associated with severe hypospadias and poor tissue availability, are currently under investigation. These substitutes are generally acellular synthetic or natural matrices that can incorporate the patient's normal urethral cellular components. The embryology of hypospadias is being elucidated, and the understanding of its causes is improving; with new information, an exciting new paradigm shift to hypospadias prevention or antenatal intervention may occur.

Patient Education

Because most patients with hypospadias are surgically treated at a very young age, parental teaching and reassurance is very important to ensure a satisfactory experience for the families of patients with hypospadias.

 


More on Hypospadias

Overview: Hypospadias
Differential Diagnoses & Workup: Hypospadias
Treatment & Medication: Hypospadias
Follow-up: Hypospadias
Multimedia: Hypospadias
References
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Further Reading

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Keywords

hypospadias, chordee, penile deformity, anterior urethral anomaly, penile development anomaly, subcoronal hypospadias, ventral curvature of the penis, circumcision, human chorionic gonadotropin, undescended testes, inguinal hernias, disorder of sexual development, DSD, penis development

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Contributor Information and Disclosures

Author

John M Gatti, MD, Associate Professor and Director of Minimally Invasive Urology, Department of Pediatric Surgery and Urology, Children's Mercy Hospital; Assistant Professor, Department of Pediatric Surgery and Urology, University of Missouri School of Medicine at Kansas City, Missouri; Assistant Clinical Professor, Division of Pediatric Urology, University of Kansas School of Medicine at Kansas City, Kansas
John M Gatti, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Urological Association, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Kirsch, MD, FAAP, FACS, Clinical Professor of Urology, Emory University School of Medicine, Children's Healthcare of Atlanta; President, Georgia Urology, PA
Andrew J Kirsch, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, and Society for Fetal Urology
Disclosure: QMED Grant/research funds Investigation, Consulting; COOK Urological Royalty Consulting

Howard M Snyder III, MD, Professor, Department of Surgery, Division of Pediatric Urology, University of Pennsylvania School of Medicine
Howard M Snyder III, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, and National Kidney Foundation
Disclosure: Nothing to disclose.

Medical Editor

Martin David Bomalaski, MD, FAAP, Pediatric Urologist, Alpine Urology
Martin David Bomalaski, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Harry P Koo, MD, Chairman of Urology Division and Director of Pediatric Urology, Virginia Commonwealth University; Professor of Surgery, VCU School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond
Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Marc Cendron, MD, Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston
Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Johns Hopkins Medical and Surgical Association, New Hampshire Medical Society, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

 
 
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