Two-Stage Hypospadias Repair

Last week we operated on 2 children with severe hypospadias. One of them underwent stage 1 operation. The other child, who had undergone stage 1 operation last year, now underwent stage 2 operation.

Child has Severe Hypospadias

When I tell the parents that their child has severe hypospadias, many parents ask me the following questions:

Hi Doctor, we are really concerned about this;

  1. Why are you saying that my child has severe hypospadias? What are the criteria to say that my child has severe hypospadias?
  2. What are the other problems associated with severe hypospadias?
  3. Can you repair my child’s severe hypospadias with a single operation?
  4. What is a 2-stage operation for severe hypospadias?
  5. What are the advantages and disadvantages of 2-stage operation for severe hypospadias?

I will try to answer these questions and address the concerns of parents in a simple way:

As discussed in my previous blog, many hypospadias are of the mild to moderate variety, hence they can be successfully repaired in a single operation. However, there are some hypospadias which are considered as severe cases. How is the severity of hypospadias defect assessed? There are 2 criteria to assess this, one based on the position of the urinary opening (the more distance between tip of the penis and urinary opening, the more severe is the hypospadias); the other, more accurate assessment of severity is based on the degree of downward penile curvature (chordee). In general, any chordee >300 is considered to be severe by most experts.

Many Hypospadias

Many cases of severe hypospadias may be associated with other problems of the genitourinary system; one or both testis may be abnormal (undescended/absent), the penis may be small in size (so-called micropenis when it is very small), or in extreme cases, there may be some female structures in the child, with or without genetic abnormalities. It is not necessary that every severe hypospadias should have these additional problems, but we need to rule out these associated problems. Thus, these children might require karyotyping, endoscopy and sometimes laparoscopy to see the internal genital structures.

The repair of severe hypospadias is a surgical challenge, and needs to be done only by expert surgeons. Some of these children with a small penis may be given 2-3 injections of testosterone to increase the size of the penis before surgery. An adequate size of the penis is important for a successful hypospadias repair. Some of the cases of severe hypospadias can be corrected in a single operation. However, the parents should allow the expert surgeon to decide whether the severe hypospadias should be repaired in one operation or 2 operations. The ultimate aim is to give a good cosmetic and functional result, which in some cases is better achieved with a planned, 2-stage operation. Trying to correct severe hypospadias with a single operation might result in severe complications, which is best avoided whenever possible.

Two-stage repair of severe Hypospadias

In the first stage (first operation), the chordee is corrected and the penis is made straight. Chordee correction is the most important first step in any hypospadias repair, and involves a step-wise approach. In mild to moderate chordee, it is possible to correct the chordee while preserving the urethral plate, so that reconstruction of the neourethra (urinary tube) can be done in the same sitting. However, in the presence of severe chordee, it may be necessary to divide and resect the urethral plate to excise all the chordee tissue and achieve a straight penis. This leaves a large raw area on the undersurface of the penis, which is then covered by a skin graft obtained from the foreskin (which is typically present on the upper surface of the penis). This completes the first stage of the operation. Thus, after the first stage, the child will continue to pass urine from the previous urinary opening only. The second stage is performed 6-12 months later, after confirming that the grafted skin has healed well. In the second stage, the neourethra (urine tube) is reconstructed using the grafted skin, and the reconstruction of the penis is completed to give the shape of a normal, circumcised penis. Both stages are followed by application of penile dressing and placement of a temporary urinary catheter for 1-2 weeks.

In general, in expert hands, 2-stage repair of severe hypospadias has a very good (about 90%) success. Some complications like fistula (urine leak thru one or more stitches), narrowing of the neourethra or neourethral diverticulum (excess baggy urethra) may occur in a few children. However, in expert hands, most of the complications are minor and can be easily managed, with a final acceptable result. However, all children with severe hypospadias should be followed up (once every 1-2 years) till they become adults. Some problems may arise once these children grow up and become sexually active, so a long-term follow-up is necessary.

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