Reconstructive surgery for hypospadias: A systematic review of long-term patient satisfaction with cosmetic outcomes.

INTRODUCTION: Research on long-term results of hypospadias has focused on surgical techniques and functional outcomes, and it is only recently that patient satisfaction with appearance and psychosocial outcomes have been considered. The aim of this study was to provide an evidence-based systematic review of adolescent and adult patient perceptions of cosmetic outcomes following childhood surgery for hypospadias. METHODS: A systematic review was performed in accordance with the PRISMA and PICO guidelines, and studies assessed using the Oxford Centre for Evidence-Based Medicine system. MEDLINE, PsycInfo, EMBASE, and CINAHL databases were searched from 1974 to 2014 for clinical studies containing patient perceptions of appearance, deformity, and social embarrassment following hypospadias surgery. RESULTS: A total of 495 publications were retrieved, of which 28 met the inclusion criteria. Due to study design/outcome measure, heterogeneity data were synthesized narratively. Results indicate (i) patient perceptions of penile size do not differ greatly from the norm; (ii) perceptions of appearance findings are inconsistent, partially due to improving surgical techniques; (iii) patients who are approaching, or have reached, sexual maturity hold more negative perceptions and are more critical about the cosmetic outcomes of surgery than their prepubertal counterparts; (iv) patients report high levels of perceptions of deformity and social embarrassment; and (v) there is a lack of data using validated measurement tools assessing long-term patient perceptions of cosmetic outcomes, particularly with patients who have reached genital maturity. CONCLUSIONS: Protocols for clinical postpuberty follow-up and methodologically sound studies, using validated assessment tools, are required for the accurate assessment of cosmetic and psychological outcomes of hypospadias surgery.

The role of two-stage repair in modern hypospadiology.

Hypospadias surgery continues to evolve. The enthusiasm for flap-based urethroplasty is waning and instead there is an increasing preference for urethroplasty that uses either the urethral plate alone or in combination with grafts. From the vast armamentarium of hypospadias repairs that are still in use, the author suggests a simple protocol of just three closely related procedures with which we can now repair almost all hypospadias. The tubularised incised plate (TIP) repair and the 'Snodgraft' modification of the TIP principle are simple and effective one-stage solutions when partial circumference urethroplasty is required. Conversely, the Bracka two-stage graft repair remains an ideal and versatile solution when a full circumference urethroplasty is required. It is particularly appropriate for severe primary hypospadias associated with a poor plate and marked chordee and also to replace a scarred, hairy or balanitis xerotica obliterans diseased urethra in re-operative salvage hypospadias.

Hypospadias surgery: when, what and by whom?

Hypospadias is repaired by paediatric surgeons, paediatric urologists, adult reconstructive urologists and plastic surgeons. This review is unique in representing all four specialities, to provide a unified policy on the management of hypospadias. The surgeon of whichever speciality should have a dedicated interest in this challenging work, ideally having an annual volume of at least 40-50 cases. The ideal time for primary repair is at 6-12 months old, although when this is not practicable there is another opportunity at 3-4 years old. A surgical protocol is presented which emphasises both functional and cosmetic refinement. Using a logical progression of a very few related procedures allows the reliable correction of almost any hypospadias deformity. A one-stage repair is used when the urethral plate does not require transection and its axial integrity can be maintained. Occasionally, when the plate is of adequate width and depth, it can be tubularized directly using the second stage of the two-stage repair. When (usually) the urethral plate is not adequately developed and requires augmentation before it can be tubularized, then that second-stage procedure is modified by adding a dorsal releasing incision +/- a graft (alias Snodgrass and 'Snodgraft' procedures). The two-stage repair offers the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. From available evidence this protocol combines excellent function and cosmesis with optimum reliability. Nevertheless, it would be complacent to assume that these gratifying results will be maintained into adult life. We therefore recommend that there is still a need for active follow-up through to genital maturity.

Penile urethral reconstruction: concepts and concerns.

Reconstruction of the penile urethra is a challenging exercise, and for many surgeons an ungratifying experience. The past three decades have seen us move from predominantly 2-staged surgery, through foreskin grafts, and then single stage flap reconstructions, and now in the 3rd millennium, for some situations 2-stage repair has again become the favoured option. Satisfying short-term solutions have sometimes resulted in poor long-term outcomes when reviewed 10 years later. Clearly there are still problems to be resolved, hence the need for continuing evolution in our surgical management. Lessons have been learned from the treatment of Lichen Sclerosus, from strictures following hypospadias repair, and strictures associated with severe spongiofibrosis. Management of these problems has traditionally been associated with not only a high incidence of restricture and fistula formation, but also with poor cosmetic results, something that men today find increasingly difficult to accept. Several considerations are fundamental to achieving the best functional and aesthetic results. These include the presence or absence of Lichen Sclerosus, the extent of urethral disease and its grade (i.e. mucosal disease or with accompanying spongiofibrosis); furthermore the use of non-genital grafts for urethral reconstruction when the local penile tissues are deficient or unhealthy. In arriving at our present strategy, a collaborative approach that integrates established urological practice with the different perspectives of a plastic surgeon (A.B.) has proved constructive and beneficial.