Surgical Repair of Hypospadias in Pediatrics

What Is Hypospadias in Children?

Hypospadias is a congenital condition that affects newborn boys, characterized by the abnormal placement of the urethral opening on the penis. Instead of being located at the tip of the penis, the opening can be found anywhere along the underside of the penis, ranging from the tip to the rectum. This condition is often accompanied by a downward curvature of the penis, known as chordee. Hypospadias can be classified into different types based on the location of the urethral opening: distal, midshaft, and proximal.

What Are the Goals of the Surgical Treatment of Hypospadias in Children?

The surgical treatment of hypospadias strives to accomplish the following goals:

• Attain a straight penis with a properly positioned and appropriately sized meatus at the tip of the glans.

• Reconstruct a conical-shaped glans.

• Provide a circumcised appearance or, if parents desire, a fully encircling and easily retractable foreskin through preputial reconstruction.

• Achieve a satisfactory cosmetic outcome that can be objectively evaluated.

Various surgical options are available, but no procedure guarantees universal success. The first operation offers the best chance of success. Even distal hypospadias can be challenging due to small glans size, poor urethral plate quality, spongiosal hypoplasia, and ventral curvature.

What Are the Factors to Be Considered Before the Surgical Treatment of Hypospadias?

Before the surgery, certain factors need to be taken into account:

• A physical examination of the child with hypospadias is crucial for determining the appropriate surgical approach.

• The examination helps assess the location of the meatus and the extent of proximal spongiosal hypoplasia.

• The presence and severity of ventral curvature (VC) are evaluated.

• The quality of the urethral plate, including its width and depth, is assessed.

• The size of the glans and the depth of the navicular fossa are examined.

• The degree of ventral skin deficiency is noted.

• Scrotal abnormalities such as penoscrotal transposition and bifid scrotum are taken into consideration.

• The availability of the foreskin and the penile length are also evaluated.

What Is the Role of Preoperative Androgen Therapy in Children With Hypospadias?

Preoperative androgen therapy, involving the use of hormones like systemic testosterone, topical testosterone, dihydrotestosterone (DHT), and human chorionic gonadotropin (hCG), has been explored to enhance glans size before hypospadias surgery. The goal is to improve the tubularization of the urethral plate and minimize the risk of glans dehiscence. However, there are no guidelines or specific recommendations for using androgens in this context. Concerns arise due to potential adverse effects on wound healing and increased bleeding during surgery. Furthermore, the effectiveness of preoperative androgen therapy in reducing glans dehiscence has not been conclusively proven. Studies evaluating such treatment have shown considerable variation in the choice of drugs, dosages, and assessment of hypospadias outcomes. Despite limited evidence supporting the benefits of testosterone supplementation, it remains a widely practiced approach, with approximately 78 % of urologists employing it. It is crucial to discontinue therapy one to two months before surgery to prevent any adverse effects during or after the procedure.

How Is the Surgical Repair of Hypospadias in Children Done?

Timing of Surgery:

The timing of hypospadias surgery is a topic of discussion, and while it can be performed at any age, many experts recommend intervention between six and 18 months. The American Academy of Pediatrics suggests this timeframe to minimize the psychological stress and potential behavioral issues that may arise in toddlers undergoing genital surgery. However, there are differing opinions regarding whether delaying surgery to an older age increases the risk of complications.

Surgical Procedure:

During hypospadias surgery, several operative steps are involved to achieve successful outcomes. These steps include penile degloving, correction of ventral curvature (orthoplasty), urethral reconstruction (urethroplasty), providing vascularized coverage for the urethra, glans reconstruction (glansplasty), and creating a cosmetic skin covering for a circumcised appearance. To ensure optimal results, surgeons adhere to key surgical principles such as using magnification, fine instruments, and sutures, minimizing tissue trauma, ensuring careful hemostasis, and having skilled surgical assistance.

While most surgeons prefer stents for repairs, sometimes they repair distal hypospadias without them. The choice of dressings and prophylactic antibiotics differ among surgeons and depends on their preferences. Typically, hypospadias surgery is performed outpatient, and caudal or dorsal penile nerve blocks are used for postoperative pain relief.

Correcting ventral penile curvature (VC) is a crucial aspect of hypospadias surgery, aiming to achieve a straight penis without compromising penile length and erectile function. Before deciding on the method of VC correction, the assessment of VC is done before the surgery, and the surgical decision is made during the penile degloving process. The steps involved in VC correction include:

• Penile degloving involves releasing all penoscrotal tethering bands and reaching the penopubic and penoscrotal junctions.

• Releasing the glans wings and the hypoplastic spongiosum from the corporal bodies.

• Performing dorsal plication using the Baskin modification of the Nesbitt procedure helps correct the curvature.

• Proximal dissection of the spongiosum and distal division of the urethral plate.

• Making multiple fairy cuts to incise through the fibrotic spongiosal tissue without entering the corporal bodies.

• Performing corporotomy by incising through the tunica of the corpora cavernosum from the three to nine o'clock position. This elevates the tunica, creating an ellipsoid defect that lengthens the ventral penile length. Dermal grafts, small intestinal submucosa (SIS), or a vascularized tunica vaginalis flap from the testes are used for coverage.

• VC below 15 degrees usually does not require correction. Curvature between 15 to 30 degrees can be managed with dorsal plication, while curvatures exceeding 30 degrees may require more extensive techniques like urethral plate transection. There is a trend towards ventral reconstruction for higher degrees of curvature due to concerns that dorsal plication may lead to shorter penile length and increased rates of recurrent curvature compared to ventral correction in cases with curvature more significant than 30 degrees.

What to Expect After Hypospadias Surgery in Children?

After the surgery, the penis will be dressed with a wound dressing, which should not be removed until the scheduled follow-up appointment. To prevent sticking, a topical antibiotic ointment should be applied to the wound during diaper changes and after bathing. A catheter will be inserted into the external urethral opening to allow continuous urine drainage. Two diapers should be worn for comfort and protection, with the inner diaper used for bowel movements and the outer one absorbing urine from the catheter. The catheter will be removed within two to seven days, and some urine spraying is normal afterward.

After the child returns home, it is crucial to carefully observe their development and communicate with the doctor if any issues emerge. Such concerns may involve a high body temperature, excessive bleeding, decreased appetite, or uncontrollable discomfort. The recovery duration may differ, and the penis might exhibit swelling, redness, and potential bruising. These indications are expected to diminish over a few months. The healthcare provider will provide a prescription for pain medication, and it is imperative to adhere to the prescribed dosage instructions.

Additionally, the doctor might sometimes recommend bladder spasm medication and antibiotics. During recovery, bathing should be limited until the catheter is removed. Physical activity should be restricted initially, with no swimming, straddling toys, or sports for a specified period.

What Are the Postoperative Complications That May Occur Following Hypospadias Surgery?

Postoperative complications following hypospadias surgery can often be identified within the first few months. Still, it is crucial to have long-term follow-up due to the possibility of delayed presentation of issues like urethral fistula and recurrent penile curvature during puberty. Assessments may involve observing voiding, checking for post-void residue, or conducting formal uroflowmetry.

Common complications of hypospadias repair include the following:

• Urethrocutaneous fistula.

• Meatal stenosis.

• Urethral stenosis.

• Glans dehiscence.

• Urethral diverticulum or urethrocele, which can cause infections and post-void dribbling.

• Cosmetic concerns include excess residual skin, skin tags, inclusion cysts, skin bridges, and suture tracts.

• Presence of hair in the urethra.

• Recurrent or persistent penile curvature.

• Spraying or misdirected urinary stream and irritative symptoms.

• Erectile dysfunction.

• Balanitis xerotica obliterans of the urethra leading to strictures.

• Regular and thorough postoperative monitoring is necessary to promptly detect and address these complications.

Conclusion:

Surgical intervention is the primary approach for treating hypospadias in children. The specific surgical techniques employed depend on the type and severity of the condition. The objectives of hypospadias repair include repositioning the urethral opening, correcting penile curvature, and enhancing the aesthetic appearance of the penis. By utilizing advanced surgical techniques, careful preoperative planning, and diligent postoperative care, pediatric urologists can achieve positive outcomes and enhance the quality of life for children with hypospadias. It is vital to maintain regular follow-up appointments and continuous monitoring to ensure the long-term success of the surgical repair and address any potential complications that may arise.