Hypospadias is a condition manifested by 3 anatomical problems:
- including an abnormal site of the urethral meatus,
- penile curvature
- abnormal foreskin development or dorsal hooded foreskin.
It is the most common congenital penile anomaly, occurring in 1/300 live births with a multifactorial aetiology of genetic susceptibility plus endocrine disruptors. Recent studies show that the incidence of hypospadias is increasing in Western countries, and even higher incidence is expected in developing countries and in the Third World.
The American Academy of Paediatrics recommends performing hypospadias repair at ages 6 to 12 months. The current standard of care is to repair hypospadias with a 1-stage procedure on an outpatient basis to improve the appearance of the penis, allow voiding while standing, and improve the chances of fertility.
The repair of primary hypospadias may result in postoperative complications requiring secondary surgery, such as fistula, diverticulum, retrusive urethral meatus, residual chordee, and stricture.
These operative failures during primary repair are caused by errors in design, technique and postoperative care, such as infection, wound dehiscence, urine extravasation, haematoma, ischemia and necrosis of transplanted tissues. Hypospadias repair may also fail many years after achieving successful functional and cosmetic results by primary repair and urethral strictures may develop decades after the initial hypospadias surgery. Treatment for complications in children and adults with a history of paediatric hypospadias repair remains complex because the penis is densely scarred, immobile, hypovascular or significantly shortened. Epidemiological data on the incidence of failed hypospadias repair and the number of adults seeking further surgical treatment remains unknown. This may by due to the fact that the pediatric followup stops early in the patient lifetime and the urologist takes over late in the lifetime.
Management of complications in patients in whom multiple attempts of hypospadias repair have failed is still a complex problem for the health care system, involving health care providers, general practitioners, pediatricians, surgeons, patients and parents because this difficult population of patients has been left with deformities that are significantly worse than the primary congenital anomaly.
In our Center, 14.7% of 1,510 patients treated for urethral stricture disease, and 51% of patients treated for penile urethral strictures showed failed hypospadias repair. Half of the patients with penile strictures had a history of failed hypospadias. The data probably underestimate the true incidence of this problem in the adult population.
Our experience shows 2 adult populations with failed hypospadias repair.
- Some patients had multiple penile deformities significantly worse than the primary congenital anomaly, such as fistula, residual hypospadias, penile curvature and cosmetically unacceptable glans or penile skin appearance.
- On the other hand, some patients had a satisfactory result of primary hypospadias repair with a cosmetically acceptable meatus and no evident penile deformities, but they had obstructive symptoms due to urethral stricture. These patients had increasing urinary problems and difficulties many years after surgery when pediatric followup had already stopped and they were fully involved in sexual activity. In these patients the congenital lack of spongiosum tissue may promote urethral deterioration with time. Probably, the new skin urethra cannot tolerate the repeated stretch and trauma during erection and sexual activity, which is tolerate by the normal normal spongiosum urethra. As an analogy, during sexual activity the corpus spongiosum is to the urethra what the airbag is to the body during a motor vehicle accident.