In this section, we would like to present information of importance to anyone who is considering a surgery for hypospadias repair for their child, or themselves.
First off, HEA does not have an official position on surgery, whatsoever. We feel that the need for surgery is a personal determination and one of our organizational missions is to insure that all the information is available to the patient, and his decision is based on sound and solid advice and fact. No one can truly make an informed decision without all the possible outcomes of the procedure described and discussed–this is known as informed consent. In just about every legal system, informed consent is a patient right and the responsibilities to the patient on the part of the health care provider is codified in civil law.
All surgical procedures carry a degree of risk, it does not matter if the procedure is circumcision or open heart surgery. Most of the risks that a patient takes in surgery are the common ones, like bleeding, infection, adverse reaction to anesthesia, failure to heal, scarring and the like. Hypospadias surgeries will range from the very simple “touch up” of a glanular hypospadias without chordee, to the most severe case of penoscrotal hypospadias with severe chordee, requiring creation of a complete urethra in multiple staged surgeries. No one would argue that the child with the most severe case of hypospadias will require surgery, often to allow basic sexual and normal urinary function where none existed previously. For this child the risk of surgery is clearly a sensible undertaking compared to the benefit of undergoing procedures.
As the hypospadias becomes more distal, or less severe, the functional impact on daily life and sexual activity is not as great, and in the vast majority of mild coronal cases, no surgery is often chosen. Surgery in the mildest cases is cosmetic in benefit and will not confer much functional improvement to the patient, if at all. In this case, the risk is relatively higher, since the benefit of the process is not as great as it was for the first patient with severe impairment of function. The basic risks are still the same. In this case, the patient has more choices and options, since he can choose to do nothing.
Choosing No Treatment
About 60 to 65% of all cases of hypospadias are of the coronal or glanular type, which means the defect is confined to the glans or head of the penis or just at the junction of glans and shaft. For the most part, these children can urinate standing, and the erection is straight enough for intercourse in adulthood. A great majority of men and boys in this classification of hypospadias do not have corrective surgery, so this is a completely valid option that many parents have chosen.
Complications Normally Associated with Hypospadias Repair
Note that there is no guarantee of success, nor does the possibility of having a complication mean that any particular patient will have complications…the following is presented as a description of the complications of surgery we have experienced as a collective group of patients.
Wound Breakdown and Fistulae
The most frequent complication of hypospadias surgery is wound breakdown during the healing process, or surgeries that “fall apart” or grafts and flaps that fail to “take.” A re-do session is often the only recourse in these cases. Fistulae are passages from the urethra to the surface of the penis that leak or spray urine. These are usually always caused by failure of the healing process along a suture line, and most modern repair techniques avoid allowing suture holes in the various tissue layers to line up, creating paths for leaks. Separate closure of layers and good technique are the best defense against a fistula. It is possible for a fistula to open months or years after a surgery, when it is thought that the penis had completely healed.
All incisions in tissue will incur some degree of scarring during healing, including internal structures like the lining of the urethra. A stricture is a local scar formation in the urethra which restricts or stops the flow of urine. Stricturing is the main cause for revision of childhood surgeries in adult patients. It seems that there is a definitely lifespan to hypospadias surgeries performed using earlier techniques, and we advise men in this situation to find a specialist in adult hypospadias revision surgery. Adult and pediatric hypospadias is not the same thing, and adult hypospadias repair is a growing specialty in urologic surgery. Newer techniques like buccal mucosa grafts that use the lining of the mouth to fashion new urethra have far less risk of stricture formation, since buccal mucosa is very scar resistant. The downside is that two surgical sites are created to recuperate from. Buccal Mucosa surgeries are still fairly new, so long term longevity of these repairs is not known.
Hair Growth in Urethra
Older surgeries often grafted hair bearing skin for urethroplasties, and when the child became an adolescent, hair would grow in the urethra causing discomfort and urinary dysfunction. The use of hair bearing skin is avoided in current practice. Laser ablatement of the hair can bring some relief, but often a repeat urethroplasty is necessary.
Scarring of the skin of the penis and glans can result in loss of sensation, or change in existing sensation that may be positive or negative. It is very uncommon for sensation to be completely impaired, but extensive scarring from multiple procedures in the past may make it necessary to remove all scarred tissue and begin with fresh grafts. Scarring can be very upsetting to the patient anxious about the appearance of his penis.
Expectations for the outcome of surgery is something you must discuss with your surgeon. In the past, ability to urinate standing and a straight erection for intercourse was the yardstick by which hypospadias surgery was judged. To be charitable, some of the aesthetics of surgeries following this doctrine were less than optimal. It was almost a universal given that the penis would be circumcised in the process. Now, the appearance of the penis has become very important, and foreskin reconstruction is practiced for those who wish to remain intact. As a patient and consumer of your surgeons’ services, it is up to you to discuss your expectations of the outcome of the surgery and make sure you understand the goals your surgeon is working to achieve in the procedure. Although the technique now is very good and aesthetics are much better than in the past, the surgeon must still work with what the patient brings to the operating table; the basic proportions and size of the penis cannot be changed.
The discussion so far has centered on physical and functional concerns of hypospadias. Psychologically, living with hypospadias can be very complicated, and while one man with a mild case has no concerns or problems whatsoever, the next may find his mild hypospadias a huge burden in life, and surgery becomes an obsession. Simply having surgery is not going to change a life pattern and correct all the issues one faces in life overnight. This is why an honest discussion of the mental aspects of surgery is very important, with the assistance of a mental health professional or other trusted persons as a support mechanism for the patient moving forward.