What Is Hypospadias Repair Surgery?

Overview

Hypospadias is a congenital anomaly affecting male newborns, characterised by the displacement of the urethral opening to the underside of the penis rather than the tip. This condition varies in severity, and when conservative measures prove insufficient, hypospadias repair surgery becomes a crucial intervention. This comprehensive guide aims to elucidate the intricacies of hypospadias, emphasising the diagnostic process, treatment options, surgical procedures, postoperative care, potential risks, and the overall outlook for patients.

What is hypospadias?

At the heart of understanding hypospadias is recognising it as a congenital birth defect resulting from incomplete closure of the urethral tube during foetal development. This leads to the misplacement of the urethral opening, creating a spectrum of abnormalities in the penis. The curvature or irregular shape of the penis in affected boys is a visible manifestation of this condition.^1,2

Hypospadias is a common birth defect in boys, affecting around 1 in 250 newborns, with a possible increasing trend. It involves an underdeveloped tube in the penis, causing the urine opening to be in an unusual place.¹ Hypospadias is usually diagnosed right after birth during a physical exam.

Classification of hypospadias

The severity of the hypospadias is categorised into three types based on the opening's location:

• Near the tip (distal)
• Along the shaft (mid-penile)
• Close to the scrotum (proximal)

In the Western world, distal hypospadias is most common, while Asia sees more severe forms.^1,3

The classification of hypospadias is debated, with some suggesting it be determined after surgery. Repair methods vary widely among surgeons, making it difficult to establish guidelines due to a lack of well-designed studies. Repair techniques include advancement, tubularization, and the use of grafts and flaps.¹

What is hypospadias repair surgery?

Hypospadias repair surgery varies based on the severity of the deformity. The first step is straightening the penis, often done by removing the skin around it. If further correction is needed, two methods are employed: tucks on the penis's topside for mild curvature and inserting a graft underneath for more severe cases. Preserving the urethral plate simplifies the repair but may require division if too short. Severe cases may undergo staged repairs involving multiple surgeries. Preserving the urethral plate allows for a more natural result, and outpatient procedures are common. In complex or preoperative cases, a free graft from the penis, inner arm, or mouth lining may be necessary, potentially requiring hospitalisation for proper healing.

Stages of hypospadias

Hypospadias repair has one or two stages depending on its severity.

• Stage 1: Mild cases usually need a one-stage procedure, which involves a single surgery.
• Stage 2: In more severe cases, like penoscrotal hypospadias, a two-stage repair is required, involving two surgeries spaced six months apart. In the two-stage procedure, the urologist may use skin from the child's mouth to create a new urethra.

Diagnosis and assessment

• The journey of addressing hypospadias begins with early detection during routine newborn examinations. Healthcare providers adeptly identify the abnormal positioning of the urethral opening, prompting further diagnostic measures. To diagnose distal hypospadias, the megameatus intact prepuce variant is often found when the foreskin can be pulled back or during newborn circumcision. The wide urine opening goes up to the corona. Even though circumcision is usually delayed for hypospadias, the results of surgery seem similar in circumcised penises with distal hypospadias using the tubularized incised plate (TIP) repair.
• Advanced imaging studies and urological examinations are employed to gauge the extent and severity of the condition, providing a foundation for informed decision-making regarding treatment.

Treatment and management of hypospadias

Hypospadias surgery aims to achieve a straight penis with a properly positioned opening at the tip, a reshaped glans, and a satisfactory cosmetic appearance. The options for surgery vary, and success is not guaranteed for all surgeons. The first operation provides the best chance for a good outcome, even for seemingly minor cases. It's essential to recognise that the difficulty in reconstruction is not solely determined by the opening's position. Even seemingly less severe cases may pose challenges due to factors like small glans size, poor urethral plate quality, spongiosal hypoplasia, and possible curvature. Therefore, hypospadias repair surgery must be performed by a skilled specialist with a substantial annual surgical volume.³

While some instances of hypospadias may be managed conservatively, hypospadias repair surgery emerges as a primary treatment for moderate to severe cases. Conservative management may involve observation and the application of topical medications. However, surgical intervention is often recommended to achieve a more permanent and comprehensive resolution.

While most surgeons use stents during repairs, some distal hypospadias repairs don't require them. There's no universal agreement on dressings and antibiotics, as surgeon preference often guides these choices. Hypospadias surgeries are mostly outpatient procedures, and pain relief is typically achieved through nerve blocks. There's an ongoing debate about whether certain pain relief methods increase the risk of urethral complications, but more research is needed for confirmation.³

Hypospadias repair procedure

Before delving into the intricacies of hypospadias repair surgery, thorough preoperative preparations are conducted. Patient assessments are meticulous, and parents are counselled to ensure a clear understanding of the procedure. The surgical process involves the mobilisation of tissue, reconstruction of the urethra, and glansplasty to restore a more normal appearance to the penis.

Preoperative preparation

Examining a child with hypospadias provides crucial information for planning surgery. This includes checking the location of the urine opening, the extent of spongiosal hypoplasia near the opening, the presence and severity of any curvature, the width and depth of the urethral plate, the size of the glans and depth of the navicular fossa, the amount of skin on the underside, any scrotal abnormalities, the presence of foreskin, and the length of the penis.³

Postoperative care

The journey does not conclude with the surgery itself; rather, it extends into a carefully managed postoperative care phase. After hypospadia repair, your child's stitches are covered with bandages, and a stent is secured. The anaesthesiologist stops administering anaesthesia to allow your child to wake up. In the recovery room, nurses monitor their health. Since most hypospadia repairs are outpatient procedures, your child can go home the same day.

Healthcare providers will give you recovery instructions, especially for the first week, and may prescribe pain medication. Once the providers confirm your child is healthy and no longer needs monitoring, you can take them home.

Risks and complications

While hypospadias repair surgery is generally deemed safe and effective, it is not without its share of risks and complications. Some risks include:  

• Potential issues with anaesthesia
• Healing problems
• Infections
• Blood clots
• Swelling
• Bruising
• Scarring

After the procedure, there's a risk of:

• Wounds breaking down
• The development of a hole in the skin leading to the urethra (urethrocutaneous fistula)
• Scarring causing a narrow urethra (urethral stricture)
• The formation of a fluid-filled pouch in the urethra (urethral diverticulum)
• Shortening of the penis
• Recurrent curvature
• Other complications like a weak urine stream
• Pain during urination
• Discomfort during sex
• Urinary tract infections.

It's essential to be aware of these potential complications and discuss them with your healthcare provider.

Patient outlook

The success of hypospadias repair surgery hinges on several factors, ranging from the severity of the condition to the presence of associated anomalies. After hypospadias repair, your child may feel tired and need extra sleep for several days, which is normal and aids in a quicker recovery. Every child's body is different, so recovery times can vary. Typically, swelling and bruising should improve within about two weeks, and most children fully recover in about six weeks.

FAQs

How common is hypospadias?

Hypospadias is a common birth defect in boys, affecting around 1 in 250 newborns, with a possible increasing trend.

Is hypospadias repair a major surgery?

Yes, hypospadias repair is a major surgery. In certain cases, especially more complex ones, your child might need additional procedures.

What happens next after hypospadias repair surgery?

Most procedures are outpatient, so your child can go home the same day. Providers will give you recovery instructions, and prescribe pain medication if needed, and once your child is deemed healthy, you can take them home.

What is the success rate of hypospadias repair surgery?

Hypospadias surgery in babies is usually very successful, with repairs often lasting a lifetime. After the surgery, your child's penis will function normally, allowing for regular urination and ejaculation.

What happens if hypospadias is not corrected?

Most boys with this issue undergo the procedure. If not corrected, it can lead to difficulties in controlling urine flow, a curved penis during erection, reduced fertility, and potential embarrassment about the penis's appearance later.

What are some of the benefits of hypospadias repair surgery?

Hypospadias repair will be of benefit as it corrects the position of the tube (urethra), straightens the penis, and makes it look better.

How long does hypospadias repair surgery take?

The surgery would usually take between 1 and 2 hours.

Summary

Hypospadias repair surgery is a procedure to correct a common birth defect in boys where the urethral opening is located on the underside of the penis. The surgery aims to create a straight penis with a normal urine opening, a reshaped glans, and a cosmetic appearance. The severity of hypospadias determines whether it's a one-stage or two-stage procedure. After the surgery, the child is monitored in a recovery room and can usually go home the same day. Successful outcomes are common, with benefits including improved urination, a straightened penis, and enhanced appearance. The recovery process involves following healthcare provider instructions and may include pain medication. Regular follow-ups ensure the child's health and well-being post-surgery.