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Not all infants with hypospadias require surgery, especially if the meatus is well within the glans and the urinary stream is full and well directed. Also if there is no evidence of penile curvature in these same boys, surgery can be avoided.
The goals of surgery are to bring the meatus to the tip of the glans which will enable normal controlled voiding, to straighten the penis if curvature is present, to create a cosmetically “normal” appearance of the penis similar to that of a normal circumcised male and to allow for normal sexual function.
7.1.3 Indications and Timing of Referral
All boys with hypospadias or questionable hypospadias and/ or penile curvature should be referred to pediatric urologist at the time of diagnosis shortly after birth or while in the hospital. This will allow the specialist to counsel the family as to future plans and expectations for their child. Typically the patient will be seen between 3 and 4 months post natally for a second visit to assess him for penile growth and then to determine the need for hormonal supplement preoperatively. Typically if they are to receive depotestosterone, it will be administered 5 weeks before the procedure and repeated 2 weeks preoperatively such that the surgery will be performed as close to the 6-month mark as possible.
From a psychological standpoint it is recommended that genital reconstructive surgery be performed between 6 and 18 months of life with the ideal being under 1 year. There is no question that successful hypospadias surgery can be done beyond that recommended age, but the patients generally fare better emotionally and psychologically if done within the recommended time frame.
7.1.4 Complications of Surgery
Unfortunately, surgery has the risk of complications. Among the most common complications from hypospadias surgery is a urethrocutaneous fistula (Fig. 7.4), which presents as a leak
Chapter 7. |
Disorders of Male External Genitalia |
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FIGURE 7.4. (a, b) Urethrocutaneous fistula noted after hypospadias repair.
somewhere below the newly reconstructed new urethral opening. This may be difficult to notice especially when the infant is still in diapers and is the fistula is very small.Typically the parents will notice a small drip or fine spray from an abnormal location and bring it to the doctor’s attention. Depending on when the surgery had taken place will usually determine how long one needs to wait to perform outpatient excision and closure of this fistula.As long as the baby is comfortable, voids without straining and has no evidence of infection, a wait and see attitude is appropriate. Some fistulas close spontaneously but, the ones that do not can be readily corrected after the surrounding tissue softens up to allow success closure usually around 6 months after the initial surgery.
Meatal and/or urethral stenosis is another common complication heralded by the parents noting a fine thin or dribbling urinary stream or noting the baby straining to void. This requires prompt referral to prevent other significant problems
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such as infection. Depending on the scenario this may require simple office dilatation or minor meatotomy. However a more proximal stricture will require definitive surgery that may in fact include reopening the repair to where the urethral is normal and then reconstruct the urethra at a later date.
Recurrent or persistent penile curvature will be brought to the pediatric urologists’ attention by the parents after seeing an erection or referred by the primary care giver. Repeat correction is usually delayed at least 6 months from initial surgery.
Urethral diverticulum (Fig. 7.5) will present as a distinct bulge below the glans again usually seen by the parents while watching their child void. The mild diverticulum can be observed as long as the voiding pattern is good and there is no infection. However the large diverticulum require surgical reconstruction. These are far more common in proximal hypospadias repairs.6
Glans/urethral dehiscence (Fig. 7.6) is another complication that fortunately is uncommon but requires referral when seen and may or may not require reconstruction at a later date depending on the degree and associated symptoms.
FIGURE 7.5. Urethral diverticulum after proximal hypospadias repair. Note ventral bulging.