HOW SEVERE IS MY CHILD’S CASE?

The actual position of the meatus (pee hole) underneath the penile shaft is the tip of the iceberg. There are other factors to be evaluated and considered in the evaluation and management of your child in order to arrive at a proper outcome.

When a urologist trained in the surgical repair of hypospadias evaluates this penile abnormality, there are several factors that must be considered before recommending and performing surgical repair. The goal of all hypospadias surgery is a penis that is cosmetically normal in appearance and straight for normal sexual function. As a parent of a young boy with this condition or an adult who may now be seeking repair, you should be aware of adverse or complicating factors that increase the technical complexity of the repair and by extension the risks for a complication for the surgical procedure. In general, in the best of hands worldwide, distal hypospadias (pee hole is close to the tip of the penis at birth) has a greater than 90% success rate in achieving a cosmetically normal penis. Internationally renowned hypospadiologists- Drs. Snodgrass and Bush- have a 5% complication rate with native distal hypospadias cases, however, with re-do cases that complication rate goes up to 15%. The repair of the more proximal hypospadias (pee hole is at mid-shaft or further away from tip at birth) is much more complex and carries a higher complication rate. Again, recognized experts such as Snodgrass & Bush of the Hypospadias Specialty Center in Dallas, Texas have published complication rates of 16% in dealing with proximal hypospadias. Thus, as a parent it is important that you realize all hypospadias surgeons have complications – even the very best surgeons worldwide. The presence of one or more of the following physical findings can increase the technical challenges in the performance of the surgical repair resulting in possible increases in complication rates.

  • The position of the meatus at birth underneath the penile shaft – technical challenges increase the further away the meatus is from the tip of the penis.

  • Size of the glans – (the head of the penis) – less than 14 mm in a child is associated with a higher complication rate

  • Degree of Penile curvature if present – greater than 30 degrees curvature after degloving the penile skin requires advanced surgical techniques

  • The location of the point of maximal bend if curvature is present – the closer the point of maximal bend is to the tip of the penis, the more likely more than one operation will be required for a satisfactory outcome

  • The amount of skin present on the undersurface of the penis

  • Presence of penile torsion – associated with ventral skin deficiency

  • Presence of penoscrotal transposition – associated with ventral skin deficiency

  • A positive surgical history for previous attempts at surgical repair with subsequent scarring of tissues. Multiple failed surgeries historically definitely add to the complexity of a repair as previous failures can potentially compromise the outcome functionally and aesthetically.

  • A history of prior circumcision in the presence of ( an undetected hypospadias associated with penile curvature) at the time the circumcision was originally being performed

  • Presence of other congenital anomalies

It’s not just a simple matter of looking at the position of the meatus. In addition to the position of the meatus, other factors such as the degree of penile curvature present and the amount of skin underneath the penile shaft can weigh heavily in designing a surgical plan for a successful outcome. Thus, even though most cases can be repaired successfully with one surgical procedure, the repair can sometimes require two or more surgical procedures. The anatomy of the presenting condition dictates the surgical plan for a successful repair. Attempting to repair complex presentations with a single operation can often lead to serious surgical complications and an unfortunate experience for both parents and child alike. Unsuccessful attempts at surgical repair adds to the complexity of the task for the surgeon to follow. Knowledge, detailed assessment and surgical experience in the application of proper techniques suited for the unique anatomical presentation of the condition are key ingredients for a successful outcome.