F1000 Commentary: Treatment of adults with complications from previous hypospadias surgery

Myers JB, McAninch W, Erickson BA, Breyer BN. J Urol. 2012 Aug;188(2):459-63

DOI: 10.1016/j.juro.2012.04.007

Abstract

Purpose:
Adults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.

Materials and Methods:
We reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.

Results:
A total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).

Conclusions:
Managing problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed

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SandbergBoyse

 

Summary

This interesting study demonstrates that the initial failure rate for hypospadias surgery and the likelihood of subsequent surgery are high.

Out of 1127 male patients who had received urethroplasty for urethral stricture by a single surgeon at a single institution from 1980 to 2009, a total of 50 were included in this study. The inclusion criteria were as follows: the patients had suffered complications of previous hypospadias surgery; they were over the age of 18; and follow-up was greater than six months. The authors then calculated the success rates for subsequent urethroplasties, which were categorized as stage 1 urethroplasty, 1-stage urethroplasty, stage 2 urethroplasty, and urethrocutaneous fistula closure. Treatment was initially successful for 50% of the participants, and after additional procedures, the overall success rate was 76%.

This study raises several questions. First, was this strictly a database/chart review, or was there some degree of patient interaction? Second, while evaluating cases of a single surgeon at a single institution offers the benefit of consistency across cases, how representative are this surgeons’ cases and treatment outcomes (e.g. is he highly skilled and has better outcomes than average?)? Third, what were the previous surgical histories of the subjects — at what age did they undergo hypospadias surgery, what techniques were used, how successful were the surgeries and how many surgeries did they require? Finally, how durable will the ‘successful’ surgeries prove to be? Because the study follows patients who underwent surgeries starting in 1980, some longer-term outcomes would be possible to report for early patients.

Importantly, this study underscores the high initial failure rate for hypospadias surgeries, and the likelihood that subsequent surgeries will be required. Further, the study highlights how transitioning from pediatric urology to adult urology care results in research challenges in tracking surgical outcomes longitudinally from childhood to adulthood. Myers and colleagues take a positive step in examining longer-term outcomes after complications following surgery. Next, studies linking childhood surgeries to adult outcomes are needed. Also, future research could analyze health-related quality of life for pediatric patients and families who receive psychosocial intervention as an alternative to or adjunct to surgery.

Recommendation Citation:

F1000Prime Recommendations, Dissents and Comments for [Myers JB et al., J Urol 2012, 188(2):459-63].

 

 

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