Reconstructive urology leaders have remarked on the difficulty of writing a satisfactory journal article on failed hypospadias repair.7,8
Given the heterogeneity and range of abnormalities of patients with failed hypospadias repair and the imperfect treatments provided, reporting outcomes is a challenge.
The complexity of these cases is highlighted by the largest report to date on failed hypospadias by Barbagli et al.8
In the 1,176 treated patients a median of 3 operations was required to repair primary hypospadias while almost 10% of patients required 5 or more operations.
Most groups who report these outcomes do so in conjunction with pediatric patients or adults without prior surgery who undergo initial repair.4,9–11
These reports often lack detail on preoperative problems and commonly describe only a single technique and its outcomes,11–14
not the myriad of surgeries needed in this patient population.
In addition to reporting our overall success rates, we grouped procedures to determine the success rate of any particular approach. Group 1 (stage 1 urethroplasty) had the greatest success rate of any group at 81%. We previously reported a similar stage 1 urethroplasty success rate of 84% in patients with heterogeneous causes of urethral sticture.15
However, the patients in this study with complications did not require surgical revision other than dilatation of stenosis at the urethrostomy site. This finding was dissimilar to our patients with previous hypospadias repair, who required surgical revision secondary to penile or graft related complications. In fact, 22% of the men treated with stage 1 urethroplasty using buccal mucosa experienced graft contracture. Contracture of buccal mucosa grafts was reported by others9,16
with a rate as high as 12% in hypospadias salvage surgery.14
The high rate of graft contracture in our series and others in the literature likely results from inadequate blood supply and scarring along the ventral corporeal bodies associated with previous failed surgeries.
Group 2 (1-stage urethroplasty) included patients treated with various surgeries. These surgeries were grouped together since the intent of the surgeries was a 1-stage operative solution. The success and ultimate success rates in this group were 52% and 72%, respectively. This is far lower than we would expect when comparing success rates in men without a history of hypospadias repair. For instance, buccal mucosa onlay has an 84% to 94% success rate when placed in a dorsal or ventral manner.17–20
Likewise penile skin flaps also have greater than 80% durable success at 10-year followup21
while excision and primary anastomosis of urethral stricture also has greater than 90% durable success.22,23
Poor vascularity due to previous repair was likely the underlying reason for the lower than expected success in this group, particularly in patients with a penile skin flap. These patients fared the worst with a 75% complication rate. We attributed this to the scarred nature of the penile skin and to the unpredictable anatomical blood supply after failed hypospadias repair. With time due to our poor outcomes using penile skin flaps we have evolved to mostly a 2-stage approach with buccal mucosa grafting for penile urethral stricture.
Group 3 (stage 2 urethroplasty) had the lowest initial success rate of 36% and urethrocutaneous fistula was the most common complication. Despite this high complication rate our overall 73% success rate is comparable to that of Barbagli et al, who noted 67% success in patients who underwent stage 2 repair with skin or buccal mucosa.24
Others reported outcomes that were much more favorable for hypospadias salvage using 2-stage repair.11,25
Meeks et al recently reported an 86% success rate.25
The contrast between success rates in our series and those of others must represent patient selection and differences in technique.
In group 4 (urethrocutaneous fistula closure) 50% of the small postoperative fistulas healed spontaneously with additional time for catheter drainage. Many reports do not mention small postoperative fistulas that heal spontaneously and the fistula rate in these studies only includes fistulas that persist and require surgery.7,24
We found that the success rate of urethrocutaneous fistula closure was poor at 37%, similar to our results of stage 2 urethroplasty. This may be explained by poor urethral vascularity in the 2 groups since staged surgical approaches were only used in the worst cases and postoperative fistulas may also arise from an ischemic area after urethroplasty. We used local tunica dartos flaps for tissue interposition to prevent fistula. In children a tunica vaginalis flap has been used to prevent fistula with primary hypospadias repair.26
Adding this flap might improve the fistula rate.
Our study is limited by several factors. This is a case series and procedures were done at a single institution by a single surgeon. For this reason there was a strong bias in our approach to hypospadias salvage that may have strongly influenced our outcomes.
Selection of the surgical approach for any given patient generally depended on the presenting problem as well as the site and extent of urethral stricture disease, if present. The shows our treatment algorithm, which summarizes our general strategy for approaching patients with hypospadias failure. It cannot encompass all of the complexities and ancillary surgical maneuvers that may be needed in these heterogeneous cases. Generally in patients with strictures well away from the previous surgical site, such as the mid or proximal bulbar urethra, or short strictures with an otherwise healthy urethra, 1-stage operations can be done, including excision and primary anastomosis or buccal mucosa graft onlay urethroplasty. In patients with longer strictures or persistent hypospadias who have normal supple preputial skin we used a local or dorsolateral penile skin flap. In patients with extensive urethral stricture and penile scarring involving the preputial skin we offered stage 1 urethroplasty with excision of the urethral plate and buccal mucosa graft if necessary, or perineal urethrostomy. Older men and those with multiple failed operations in the past were the usual patients who elected this final option. Those with urethrocutaneous fistula or chordee but without stricture disease underwent site specific repair of the problem.
Algorithm of general strategy for surgical management of common presenting problems in men with previous hypospadias treatment. PU, perineal urethrostomy. BMG, buccal mucosa graft. PSF, penile skin flap.