What is the treatment for hypospadias?

Treatment for Hypospadias

Surgical repair is the definitive treatment for hypospadias, ideally performed between 6-18 months of age, with the specific technique determined by the severity and location of the defect. 1, 2

Timing of Surgical Repair

• The optimal age for primary hypospadias repair is 6-12 months, with an alternative window at 3-4 years if earlier repair is not feasible 1, 3
• Surgery can be performed at any age with comparable complication rates and functional outcomes, though patients older than 12 months show higher complication rates (18.7% vs. 3.4% in younger patients) 2, 4
• Delaying repair beyond 18 months increases emotional impact on the child, though functional results remain acceptable 3, 4

Preoperative Evaluation

For proximal hypospadias, especially with undescended testes, endocrinological evaluation is mandatory to exclude disorders of sexual development 5, 2

• Renal and bladder ultrasound should be performed to screen for urinary tract anomalies, particularly in posterior (proximal) hypospadias 5
• Voiding cystourethrogram (VCUG) may be indicated if moderate to severe hydronephrosis is present on ultrasound to evaluate for vesicoureteral reflux 5
• Hormonal stimulation may be useful preoperatively to improve growth and vascularity of the urethral plate and decrease severity of chordee in poorly developed cases 3

Surgical Approach Algorithm

For Distal Hypospadias (70% of cases):

One-stage repair is preferred when the urethral plate does not require transection and axial integrity can be maintained 1, 2

• If the urethral plate is of adequate width and depth, it can be tubularized directly using urethral plate preservation urethroplasty with spongioplasty 1, 3
• When the plate requires augmentation, use a dorsal releasing incision with or without graft (Snodgrass or "Snodgraft" procedures) 1

For Proximal Hypospadias (30% of cases):

Two-stage repair offers the most reliable solution when the urethral plate requires transection and full circumferential substitution urethroplasty 1

• First stage involves urethral plate preparation and grafting if needed 1
• Second stage completes the tubularization after adequate healing 1
• Preputial graft may be used, though this carries higher risk of megalourethra complications 4

Surgical Principles

The surgeon should have dedicated expertise with an annual volume of at least 40-50 cases 1

• Use magnification, gentle tissue handling, and microsurgical instruments 3
• Fine suture materials (absorbable) are essential for optimal outcomes 3
• Appropriate-sized urethral stent should be maintained for adequate period 3
• General anesthesia is standard, but regional blocks (penile block, caudal block, or pudendal nerve block) significantly reduce postoperative pain 6

Perioperative Pain Management

A multimodal analgesic approach combining regional anesthesia with systemic medications is recommended 6

Basic Level:

• Rectal NSAID (ibuprofen 10 mg/kg every 8 hours or diclofenac 0.5-1 mg/kg every 8 hours) 6
• Rectal paracetamol 6
• Landmark-based penile block or bilateral pudendal nerve block 6

Intermediate/Advanced Level:

• Ultrasound-guided caudal block with long-acting local anesthetics plus adjunct (clonidine) 6
• Intravenous paracetamol loading dose 6
• Consider methylprednisolone or dexamethasone to reduce postoperative swelling 6
• Intraoperative ketamine as co-analgesic 6

Postoperative Ward Management:

• Continue oral or intravenous NSAIDs and paracetamol throughout postoperative period 6
• Tramadol or nalbuphine available as rescue analgesia 6

Postoperative Care and Follow-Up

• Day surgery is appropriate whenever possible, with no difference in complication rates compared to traditional hospitalization 4
• Overall complication rate ranges from 6-7%, with urethral fistula being most common (62% of complications) 4
• Other complications include penile deformity requiring revision (17%), megalourethra (11%), meatal stenosis (4%), and urethral stenosis (4%) 4

Follow-up must continue at least until the end of puberty and ideally through sexual debut 1, 4

• Long-term complications include lower urinary tract symptoms (occurring twice as often as general population), sexual function concerns, and cosmetic issues 2, 7
• Men who undergo hypospadias repair may be more inhibited in seeking sexual contact despite good functional outcomes 2, 7

Critical Pitfalls to Avoid

• Avoid operating on patients with proximal hypospadias and undescended testes without first excluding disorders of sexual differentiation 5, 2
• Do not use potent topical steroids in pediatric patients if lichen sclerosus is suspected, as this can cause cutaneous atrophy and other complications 6
• Avoid repeated endoscopic procedures for recurrent strictures in patients with previous hypospadias repair, as these are unlikely to succeed and may compromise future reconstructive options 6
• Do not delay surgery significantly beyond 18 months without clear medical contraindication, as this increases psychological impact 3, 4