Management of adults with prior failed hypospadias surgery

Abstract

Hypospadias is one of the most prevalent anomalies of the male genitalia. Contemporary hypospadias repair is very successful, but patients that have the surgery fail often require multiple surgeries throughout their life. Complications from failed hypospadias repairs have a significant impact on patients both psychologically and physically. Failed hypospadias repair encompasses a spectrum of problems that include hypospadias recurrence with an ectopic meatus, urethral fistula, urethral stricture, and ventral penile curvature. Repairs of hypospadias complications can be challenging due to the poor quality of surrounding tissue from disruption of normal vasculature in the re-operative field associated with the underlying disorder. One of the most challenging issues is dealing with urethral strictures. There have been multiple methods described at repairs of these in both a single stage and multiple staged procedures. Particular attention has been directed towards applications of grafts due to worse outcomes with flaps. Buccal mucosa has emerged as the leading graft material in staged repairs. When counseling patients with failed hypospadias it is important to discuss the expected outcome as repairs directed towards a terminally positioned meatus with a straight phallus may require multiple surgeries due to post-operative complications as well as the necessity of proceeding in a staged approach.

Keywords: Hypospadias; complication; management; stricture.

Figure 1

An algorithm for the treatment of adults with complications of failed hypospadias complications (2). PU, perinealurethrostomy; BMG, buccal mucosal graft; PSF, penile skin flap.

Figure 2

Coronal margin meatus (A) with stricture requiring excision of the scarred urethra followed by buccal graft onlay and quilting (B). Example of bolster dressing (C).

Figure 3

(Courtesy of Snow, B): example of harvested tunica vaginalis flap. The testicle is separated from the tunic vaginalis and there is a generous amount of tissue available for coverage of the phallus.