What happens if hypospadias surgery fail

There is no single answer to this question. The solution of this difficult problem will be changed according to each surgeon’s knowledge and experience

Careful patient analysis is fundamental in choosing the technique, thereby attaining a successful salvage repair outcome

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Careful and structured evaluation at the outpatient clinic is the key to the proper choice of surgical technique. Assessment of meatal site and size, stricture length, presence of surrounding tissue integrity and quality that might help in closure, size of the penis and glans, presence of fistulae, and degree of curvature are all important in deciding which repair technique should be used. Careful counseling of patients before surgery, taking into account their aspirations and giving them a realistic expectation of functional and sexual functional outcome, is essential. Even in seemingly simple cases, other issues are frequently seen, such as fistulae, scarring, recurrent chordee, and an abnormal meatus, often related to a small glans, and nearly always with a deficiency of the dartos layer, often with underlying associated psychosexual problems. Options for re-operative urethroplasty after failed hypospadias surgery include the use of either a flap or a graft to create a new urethra; this might be done in a single stage or usually over multiple stages depending on the extent of the repair needed. In particular, in addition to any underlying tissue deficiency, the presence of chordee, which has to be released, will often lead to proximal migration of the urethral meatus. Thus, treatment of strictures of the urethra and/or a meatal stenosis as a result of previous hypospadias surgery usually needs to be individualized.

There are several reported surgical techniques for the repair of complications after failed hypospadias repair in adults. The main principles of repair include excision of fibrosis to release any chordee and excision of scar tissue, which may include part, or even the whole length, of the previous urethroplasty, with any surrounding fibrous tissue. An adequate glans cleft is then created with the inlay of a graft or flap. The graft is secured to the corpora cavernosa from the proximal meatus out to the tip of the glans. If it is feasible, distal, and uncomplicated with good surrounding tissues and the urethroplasty segment is short, the creation of a neourethra and reconstruction of the glans can be done in one stage. If it is proximal and lengthy and needs a more extensive reconstruction and there is a deficiency of skin and subcutaneous tissues and dartos, it is best performed as a staged procedure with the inlay of a graft or flap and a subsequent closure procedure. Adequate time between staged procedures is needed for proper tissue healing and neovascularization to occur. This usually takes an average of 4–6 months. Patients are then evaluated in the outpatient clinic after the first stage to ensure that adequate healing has occurred with any significant fibrous contracture of the first stage and/or stenosis of the proximal urethral meatus. In some cases, a revision of the first stage might be necessary to deal with tissue contracture and/or inadequate take of the graft. Subsequently, to ensure optimal results, the final stage (closure) should include a watertight neourethral closure with good vascularized overlying tissue cover. In particular, care is taken not to overlap the suture lines in order to mitigate against fistula formation. The neourethra is reconstructed over a catheter or stent to divert the urine for 10–14 days with appropriate prophylactic antibacterial cover. In some cases, in our experience after the first stage procedure, a patient may decide to remain with the first stage rather than risk complications such as a meatal stenosis or chordee.

In adults with complications after failed hypospadias repair, no single procedure is considered standard of care. It is rare to see a patient who just needs a simple straightforward repair. Usually, taking down the previous urethroplasty and creating a new urethra, requiring more than one stage, is necessary. Owing to the variability of the deformities seen and the consequent functional abnormality, each patient should be evaluated as a separate entity and the treatment should be individualized. It is a challenging surgery, which needs comprehensive experience in the field of reconstruction. It must be borne in mind that any complex reconstructive procedure of this type has to be considered to comprise two phases—one has to take apart before putting back together—therefore, the surgeon’s experience is an important factor associated with a successful outcome . Nevertheless, all methods of urethral repair in this group of patients have the potential to fail; therefore, it is important to extend the follow-up after any such surgery, particularly in the more complex cases.