Hypospadias can be corrected using surgery to achieve normal appearance and functioning of the penis. The outcomes of the surgery can be assessed depending upon the rate of complication, psychological factors such as psychosexual life and cosmetic look of the penis, and functional outcomes such as sexuality and micturition.
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There are short-term outcomes such as persistent chordee, meatal regression, and disasters-cripple hypospadias. An uncommon complication, Balanitis xerotica obliterans (BXO), associated with chronic inflammation and fibrosis of the glans and meatus is possible. Upon failure of topical steroids, redo urethroplasty with the help of buccal mucosa or meatoplasty is needed. About 30% of patients with posterior hypospadias have long-term issues that are complex.
In the instance of bladder mucosal graft urethroplasties, mucosal ectropion is common along with frequent pseudopolyps. Secondary meatal stenosis and recurrence is also common, which may lead to discarding of bladder mucosal grafts.
There could be difference in the tissue compliance among the reconstructed and native urethra—urethrocele. Koyanagi methods are often related with urethrocele complication.
While modern procedures do not allow a hairy urethra, following a Koyanagi procedure may have this complication. In the urethra (hairy region), urethral stones may be developed. A redo urethroplasty is done to excise the hairy segment.
The points of view of the patient and the surgeon may differ, which may lead to unsatisfactory outcomes such as irregular suture lines, redundant skin that forms a jabot, and skin blobs. The outcomes are disappointing when mucosal collar just about the glans are absent or the ventral aspect (of the glan) is very short.
The assessment/score sheet proposed by Hadidi is inclusive of functional and cosmetic outcomes and the complications include glans size, location, size and appearance of the meatus, appearance of foreskin, curvature, and functional outcomes such as erection and urinary stream.
Each patient is assessed independently by the nurse, parents of the child, and the surgeon in hypospadias objective scoring evaluation (HOSE) system.
Pediatric penile perception score (PPPS) is found to be a reliable method for assessing penile self-perception among children after the repair surgery and also for appraising the results of the surgery by parents and those who are not involved in the surgery. The score involves penis size, appearance of the glans and meatus, curvature, and penile skin, which are rated by the surgeon, parents, and patients.
The Hypospadias Objective Penile Evaluation Score (HOPE) makes use of reference images for the appearance and position of the meatus, general cosmesis, and foreskin.
However, most of the scores do not consider the severity of the condition and preoperative findings while evaluating the final outcome.
Glans-Meatus-Shaft Score (GMS) provides a method to describe the severity of hypospadias. The score evaluates the urethral plate quality, glans size, degree of chordee, and the position of the meature and correlates with the outcomes of the surgery.
Small and large fistulas
Fistulas are also common complications that may result in drops or a stream of urine to ooze out of the urethra that is reconstructed. However, the occurrence of fistulas differs by the treatment techniques employed.
Compared with pediculized grafts, fistula is more common among free graft. Around 10–15% of incidences are reported in the majority of the one-stage hypospadias repairs. While the Onlay procedure accounts for a 15% fistula rate, cripple hypospadias report 20% fistula rates.
Small fistulae heal spontaneously. However, if they remain after 6 months of the initial procedure, they have to be covered and sutured with many layers of tissues. Though larger fistulas are uncommon, if found, a urethroplasty can be performed.
In terms of location, fistulas are common in the lateral position, proximal to glans corona. They are not easy to cover and may tend to reoccur if the coverage method is just a simple excision. A complete urethroplasty is suggested to be done again; Mathieu urethroplasty would help.
It is important to identify and provide treatment for urethral strictures as ongoing urethral urine flow could lead to abnormal behavior of the bladder and can damage the upper urinary tract. Even when the reconstruction is found to be satisfactory, in many instances, urine flow studies do not seem to be reliable for assessing the urethral caliber as they prove to be abnormal.
There are some common complications that may require treatment post the initial treatment for the tissues to recover completely. However, upon analyzing the results of the surgery using objective and subjective criteria, there are long-term outcomes as well.
While objective criteria involve functional assessment of micturition, subjective criteria are difficult to be defined and evaluated, and involve the appearance, sexual function, body function, and psychosocial adjustment.
The urinary flow rates are normal in most patients who have undergone tubularized incised plate urethroplasty (TIP); some patients have post-voiding residue. The uroflow rates are found normal in patients who have undergone Duckett or Onlay procedures.
Among patients who had undergone two-stage repair, complaints were recorded for urinary spraying and urethral milking after voiding. The same was the case with patients who had gone through buccal mucosa graft surgeries. Unless hypospadias are connected with undescended testes, fertility was not found to be affected.
Reviewed by Susha Cheriyedath, MSc