dias repairs, with postoperative complications less than 10 % of cases. TIP repair can also be used to repair more proximal hypospadias when the penis is straight or has mild downward curvature.

•Various sutures have been used to repair of hypospadias.

•The buccal mucosa has been used for urethral grafting mainly for repeat repairs after unsuccessful surgery for hypospadias. This is specially so for patients who already had circumscion.

•There are several methods used to decrease the risk of fistula. One method is to increase the layers of tissue between the urethra and overlying skin using dartos flaps either single or double flaps.

21.9Urinary Diversion

•The use of postoperative urinary diversion is still controversial.

•The importance of urinary diversion for preventing postoperative complications is not clear.

•There those who do not use routine urinary diversion while others prefer routine urinary diversion for all cases of hypospadias.

•Postoperative urinary diversion is performed to prevent urination against the newly created urethra.

•This is supposed to support wound healing.

•The use of urinary diversion restrict the activity of the child and may necessitates prolonged hospitalization especially those with a suprapubic urinary diversion.

•There are three different types of urinary diversion (Figs. 21.66 and 21.67):

–Suprapubic urinary diversion (cistofix)

–Transurethral urinary diversion with a balloon catheter (Foley’s catheter)

–Transurethral urinary diversion with a “dripping stent”, which drains the bladder on a diaper.

•The duration of catheter drainage is variable ranging from 5 to 10 days depending on the extent of repair.

•Catheter drainage is also valuable in eliminating the possibility of acute urinary retention as this makes postoperative catheterization difficult and potentially harmful.

21.10 Postoperative Complications

•Repair of hypospadias is known to be associated with complications.

•Repair of the more proximal hypospadias are known to be associated with a greater incidence of complications.

•Immediate postoperative complications:

–Local edema

–Bruising

–Postoperative bleeding and hematoma formation

–Glans dehiscence

–Wound dehiscence

–Flap or graft necrosis

–Urinary tract infections

–Urinary tract obstruction

–Catheter blockage

–Infection is a rare complication of hypospadias repair

•Long-term complications:

–Urethrocutaneous fistula (Figs. 21.68, 21.69, 21.70, and 21.71):

•A fistula is an unwanted opening through the skin along the course of the urethra, and can result in urinary leakage or an abnormal stream.

•This is one of the common complications of hypospadias repair and a major concern.

•The incidence of fistula is variable and depends on the type of hypospadias and the repair used.

•Generally, the rate of fistula formation is less than 10 % for most single-stage repairs (5–10 %).

•This however rises with the severity of hypospadias, approaching 40 % with complex more proximal hypospadias.

•There are reports of spontaneous closure of fistula but this extremely rare.

•Fistulas are repaired by using a multilayered closure with local skin flaps 6 months after the initial repair.

•After repair, fistulas recur in approximately 10 % of patients.

Fig. 21.72 A micurating cystourethrogram showing urethral stricture following repair of hypospadias

–Meatal stenosis (7–15 %):

•Another common complication of hypospadias is narrowing of the urethral meatus.

•This may be cured with urethral dilatation or meatoplasty.

–Urethral strictures (Fig. 21.72):

•These are long-term complication of hypospadias repair.

•A stricture is a narrowing of the urethra severe enough to obstruct flow.

•Dilatation is not effective in treating these strictures.

•These are generally repaired operatively and may require incision, excision with reanastomosis, or patching with a graft or pedicle skin flap.

–Urethral diverticula (Figs. 21.73, 21.74, and 21.75):

•A urethral diverticulum is an “outpocketing” of the lining of the urethra which interferes with urinary flow and may result in posturination leakage.

•This lead to ballooning of the urethra while voiding.

•Urethral diverticulum is also a cause of post void drippling of urine.

•It also causes recurrent urinary tract infection.

•There is usually an associated distal stricture which causes outflow obstruction.

•Diverticula can also form in the absence of distal obstruction and are generally associated with graftor flap-type hypospadias repairs, which lack the subcutaneous and muscular support of native urethral tissue.

•The treatment is surgical excision of the diverticulum, the redundant urethral tissue and tapering of the urethra over a Foley’s catheter.

–Hairy urethra:

•Hair-bearing skin should be avoided in hypospadias repair.

•The use of hairbearing skin will lead to hairy urethra which is known to be problematic and can result in repeated urinary tract infection or stone formation.

•The treatment is cystoscopic depilation using a laser or cautery device.

•In severe cases, the hair-bearing skin can be excised and a repeat hypospadias is done.

–Rarely, hypospadias is associated with mild degrees of erectile dysfunction. This is more seen in those with more proximal hypospadias repairs.

–Scarring is usually seen in patients following hypospadias repair. This is seen more in patient who underwent repeated attempts of hypospadias repair.

–Penile curvature is sometimes seen following hypospadias repair.

–Deviated penis (Fig. 21.76):

Fig. 21.76 A clinical photograph showing penile deviation following repair of hypospadias