Hidden Complications of Hypospadias Surgery: Urethral Stricture

An 8-year-old boy with a history of 3 prior operations for hypospadias elsewhere was brought to be with recurrent urinary tract infections. His Ultrasound (USG) examination revealed that he had swelling in both kidneys (hydronephrosis) with a thick urinary bladder which did not empty when he passed urine (over 50% of urine remained in the bladder)!  The parents of the child said that the child’s urination was ok; however, when someone tried to place a urinary tube (catheter) for doing an MCUG test, the tube simply did not go through his neourethra (the urinary tube which was reconstructed at the time of previous hypospadias operations). He was then referred to me. We put him under sedation and on careful examination, realized that the neourethra was very narrow (called stricture or stenosis). This was responsible for all his symptoms, infections and problems. We discussed the situation with his parents and opened up his narrow urethral tube till we reached his natural, normal, original urinary tube at the base of his penis. We re-created his natural opening, and all his symptoms disappeared. His kidney swelling reduced, his bladder was emptying normally now and he had no further infections. After 6 months, he underwent a 2-stage reoperation using an Oral Mucosal graft (OMG/ mucosa from inside the oral cavity). He is doing well henceforth.

This case underscores several important points:

1. Hypospadias repair can cause urethral strictures (narrowing of the reconstructed urethra)
2. The child may not complain of typical symptoms like difficulty in urination or thin stream, especially if the stricture develops gradually over a period of time.
3. The most important cause of stricture after hypospadias repair is the poor surgical technique of not creating a good-sized neourethra at the time of the operation.
4. Other causes are that the skin tube used to create the neourethra may not expend
5. Some of the recent techniques create a ‘narrow’ neourethra which causes problems with urination which develops gradually over a period of time
6. It is important to follow the children after hypospadias repair for many years because some complications like stricture may develop gradually and may not cause many symptoms during the initial period.
7. Urethral Stricture after hypospadias repair can be a very serious and sometimes dangerous complication. I have personally seen some children coming to me with kidney damage after hypospadias repair elsewhere, because of urethral stricture.

Now the question arises: How can we avoid urethral stricture after hypospadias repair? The answer to this question is to create a good size (adequate caliber for the child’s age) neourethra (urinary tube) during the surgery. This requires that the surgeon should have expertise in many techniques of hypospadias repair, including some complex techniques that involve the creation of vascularized skin flaps from the penile skin to create a good caliber neourethra. Many surgeons may find these techniques difficult to perform and may resort to easy techniques of repair; such easy techniques, some of which are popular, may involve the creation of small size neourethra, thus resulting in urethral stricture. Apart from this, delicate handling of the tissues, use of magnification and fine sutures may also play a role in better healing of the surgery. Thus, the most important factor in avoiding urethral stricture after hypospadias repair is the skill and expertise of the surgeon. In some cases, other factors like poor wound healing or infection might play a role.

Some surgeons routinely advise regular urethral dilatations after hypospadias repair, with the hope of periodically enlarging the urethra and preventing stricture. However, as I have discussed in my previous blogs also, there is no role of routine urethral dilatations after surgery to prevent urethral strictures. In fact, forcible dilatation of the narrow urethra might cause injury and make the stricture more severe. Thus, although such dilatations may cause temporary relief in a few cases, they are usually ineffective in a child with established urethral stricture. Thus, a good hypospadias surgeon would create an adequate size neourethra during the surgery, rather than rely on urethral dilatations after surgery. The hallmark of a good hypospadias surgeon is high success and low incidence of complications like urethral stricture. Parents have to search well for the expert surgeon before they plan their child’s hypospadias repair.