How to prevent failures in Hypospadias Surgery (Urethroplasty)

Hypospadias is a complex and challenging clinical problem. Worldwide accepted failure rates for single stage hypospadias repair (urethroplasty) are 5-10% and these children who have encountered a failure require a second surgery. This situation is never pleasant for the surgeon or the parents or the child who is actually undergoing another surgery. The key thing to understand here is that everyone including the parents and the doctors are on the same side in this situation and everyone wants the child to get better.

Infact when the parents come and see me in the clinic and ask about my second surgery or failure rates – I often tell them “I want your kid to have only one surgery, you want your kid to have only one surgery and the whole reason why you came to meet me and came to know that there is someone called Dr Singal is that your son has hypospadias. Our goals are, thus, aligned towards pursuing a good result with only one surgery in mind but at the same time realizing that inspite of our best intentions and experience and all the money and the efforts, 5% of the kids may still require a second surgery. Another reassuring fact is that the second surgeries are often minor with faster recovery and overall at the end of it all the child would be absolutely normal in almost all the cases. The only difficulty is to assess with full surety which child will have a failed surgery. For the child whom the second surgery becomes a reality the individual failure rate is thus 100% and for the rest the result is 100%”

Fortunately, there are some fine pointers which tell us about the increased risk of second surgery. These are:

• Severe hypospadias
• Severe chordee (the penis is very bent)
• Associated issues like chromosomal problems or disorder of sex development.

The steps which one takes to avoid failure in hypospadias have to be titrated for each case thus giving each child undivided individual attention and care. Some of the mantras in avoiding pitfalls are:

• Spending enough time to understand the subtle nuances and variations in anatomy of every case.
• Proper selection of technique of surgery- single most important step in ensuring good outcome. There are over 100 techniques described for hypospadias repair. Most of the surgeons master 4-5 techniques and then for every case we have to diligently assess and assign a technique. This is best done at the time of surgery in the operation theatre. That is why a proper training, experience and dedication is very important in assuring good results. Pediatric urology training allows a surgeon to be flexible in the approach and decide at the last moment and even change the technique if something is not working out. It is akin to waiting for a ball to spin and then playing a shot called “late cut” in cricket. The whole hypospadias repair mirrors that philosophy.
• A thorough re-operative assessment of the child for nutritional and health status is very important. The hemoglobin should be atleast 10gm% and the overall child should be well nourished so that the tissues will heal faster and better after surgery.
• Fitness for anesthesia: Hypospadias surgeries require general anesthesia for the child. It is very important that blood tests and urine tests are normal for the child. Also, a very good clinical examination is done to make sure that the child does not have any other coexisting abnormality of infection such as chest infection, cough, cold, diarrhea or skin infection. Infection anywhere in the body makes the body weak as the body is consuming energy in fighting the infection and thus healing would be delayed. Also, there is a risk of a cross infection in the operated area. Since hypospadias is not an emergency, ideally we should wait till the child is fully well and in the “Pink of the health” (so to speak) before surgery.
• Planning the surgery in a dedicated, good, well equipped & sterile operation theatre to prevent infection
• Having microsurgical instruments which are dedicated only towards hypospadias repair and not used for any other surgery. Infact I personally have 3 such sets allowing me to sometimes perform 2-3 hypospadias repairs in one day
• Using a magnifying loupe during surgery to perform surgery with finesse. Magnification helps in proper and fine dissection of tissues. Also the stitches used are of very fine caliber so magnification helps in tying knots properly.
• Working with fine sutures- this goes hand in hand with using magnification since using magnification allows surgeon to use finer sutures.
• Trained staff for surgery and post-operative care.

In the end it is important to remember that for a child with hypospadias, first surgery is the best chance at a complete functional and cosmetic result. Pediatric Urologist and the medical team should make sure and do whatever in their power to give the child a 100% result in the first stage.
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