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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:

Hypospadias repair can cause urethral strictures (narrowing of the reconstructed urethra)

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.

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.

Other causes are that the skin tube used to create the neourethra may not expend

Some of the recent techniques create a ‘narrow’ neourethra which causes problems with urination which develops gradually over a period of time

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.

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.

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My talk at the Hypospadias International Society (HIS)meeting

I had the great privilege to take part in the HIS meeting held in Brazil a few months ago. I couldn’t go there physically due to some family commitments. So, I attended the virtual meeting for 3 days. In the meeting, I delivered a talk on 2-stage repair for complex failed hypospadias cases with the use of oral mucosal graft. I was among the very few doctors from India to attend this meeting and deliver a talk at this prestigious meeting.

Hypospadias is one of the most common congenital anomalies. Unfortunately, there is not much awareness in the general public or even among many doctors about this problem. There are several reasons for this:

Hypospadias is an external anomaly and is not usually life-threatening. So, most people think that it is a minor problem.

Many doctors also don’t realise that hypospadias surgery is a technically demanding operation and has to be only done by the best surgeon.

Most people have little awareness about the far-reaching complications of hypospadias, which not only affects urination but can potentially disrupt the normal adult life of the person and the family.

The social and psychological stigma associated with hypospadias. Being a genital problem, most parents are not ready to share the information with family and friends and take their help to search for the best doctor for hypospadias surgery.

Once the child grows older, he becomes shy and doesn’t discuss the problem with the parents anymore.

Most parents and many doctors think that hypospadias is a minor problem and seek a solution from the local doctors; if the surgery is successful, it is ok. But more often than not, the operation may result in failure, and only then do the parents start looking for an expert. This results in the child undergoing multiple operations, including more complex reoperations, which could have been avoided if an expert surgeon had been involved from the beginning.

Thus, hypospadias remains a common and neglected problem. In addition, many surgeons of many specialities perform hypospadias surgery, and there are hundreds of techniques for hypospadias repair. This makes things more complicated for parents to choose the best surgeon and for family physicians to refer these cases to the best surgeon for hypospadias!

The purpose of the Hypospadias International Society (HIS) was to disseminate proper knowledge about hypospadias correction techniques among its members. Many enthusiastic surgeons from across the globe participate in its annual meetings. The latest meeting in Brazil was attended by over 100 hypospadialogists. Various techniques of hypospadias repair, including primary and complex failed hypospadias repairs, were discussed by experts. The pros and cons of various techniques were debated by experts in a scientific atmosphere. The long-term follow-up and results of hypospadias repairs were also discussed. 

My talk in the HIS meeting was about the most complex cases of hypospadias, which come after multiple failed operations elsewhere. These cases are very complex and require the expertise of the best hypospadias surgeon. Typically, a 2-stage (sometimes 3-stage) repair is performed utilising the skin taken from inside the oral cavity (mouth) as a graft to prepare the deficient urinary tube (urethra). We have done more than 100 such cases over the past 8 years in Hyderabad, with over 90% success of such complex operations. Our patients come from all over India, including Andhra Pradesh, Maharashtra, Karnataka, Tamil Nadu, Kerala, Orissa, West Bengal, Bihar and UP. We also performed complex redo hypospadias repairs on international patients who underwent their initial failed hypospadias operations in other countries.

My talk about the technique and results of complex hypospadias reconstructions at the HIS meeting was highly appreciated. I received positive messages from many surgeons across the world congratulating us for our work and the good results. However, an ideal situation is where no child requires such complex reconstructions for failed hypospadias. This is possible if the initial hypospadias surgery is performed by experts only. When choosing the best hypospadias surgeon for their child, parents should spend some time identifying the best surgeon with the best results in hypospadias repair. Remember, even the best surgeon can have complications (like the best driver can have an accident), but the complications will be a small percentage, usually minor and easily treatable. I discussed a few tips for parents in my earlier blog about how to choose the best hypospadias surgeon for their child. That blog may be referred to by those interested in knowing more about this.

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Is Hypospadias a Genetic Problem?

I saw a charming young couple in my clinic today. They brought their 1-year-old son to me for hypospadias surgery. After examining the child, I discussed the plan of treatment with them. They were obviously concerned that their child has this defect of his penis and would require surgery at such a young age! Further, they had apparently read somewhere that hypospadias is a genetic problem. Just before they left my clinic, they asked a common question asked by parents of a child with hypospadias “Doctor, if we have another child (boy) in future, is he also going to get hypospadias?”

To know more click here :  Best pediatric surgeon in hyderabad