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    Pediatric hypospadias repair in 2015

    A practical guide to preoperative counseling, nuances of surgical technique, and current controversies

    Mark Faasse, MD, MPHMark Faasse, MD, MPH Earl Y. Cheng, MDEarl Y. Cheng, MD

    Mark A. Faasse, MD MPH, is a pediatric urology fellow and Dr. Cheng is head of pediatric urology at Ann & Robert H. Lurie Children’s Hospital of Chicago. Dr. Cheng is also professor of urology at Northwestern University Feinberg School of Medicine, Chicago. The authors thank Elizabeth B. Yerkes, MD, for figures 1B, 2A, and 2D, and Kristin M. Faasse for photo-editing.

     

    Hypospadias affects between 1 in 125 and 1 in 300 males, resulting from premature arrest of urethral fold tubularization. Some evidence suggests that the number of hypospadias cases is rising, with potential reasons including in utero exposure to endocrine-disrupting chemicals, higher maternal age, and improved survival of infants with associated syndromes (J Urol 2012; 188:2362-6). However, this trend remains controversial and may simply reflect greater awareness and reporting of milder forms (European Urology Supplements 2012; 11:33-45).

    Read: Managing bone health in men with metastatic prostate cancer

    This article provides a contemporary perspective on several aspects of hypospadias surgery, including preoperative counseling, use of androgen stimulation, and technical nuances for repair of routine midshaft-to-distal hypospadias, as well as more complex cases. A brief discussion of surgical outcomes and directions for future research is also included.

    Parental counseling and timing of surgical repair

    Patients with hypospadias usually present for evaluation as asymptomatic infants, and parents must decide whether to pursue surgery. Considerations include a desire to optimize future urinary function (i.e., being able to stand to void with a straight, directable stream) while preventing sexual dysfunction related to penile curvature, infertility related to inability to deposit semen in the vaginal fornix, cosmetic dissatisfaction, and psychosocial/sexual embarassment.

    The natural history of untreated hypospadias is poorly defined. However, the severity of impact on urinary and sexual function is likely to correlate with the location of the urethral meatus and the degree of ventral curvature. Limited survey data suggest that adults with coronal or glanular hypospadias are generally satisfied with penile appearance and have little or no clinically significant differences in urinary or sexual function compared to normal controls (Urology 2008; 71:682-5; J Pediatr Urol 2014; 10:672-9). In these cases, foregoing surgery or opting for meatoplasty, correction of ventral curvature, and/or circumcision versus foreskin reconstruction alone may be suitable, with lower risk of complications than complete hypospadias repair.

    We generally perform primary hypospadias repair between 6 and 12 months of age. We defer repair at younger ages because of potentially higher risks related to anesthetic exposure and our desire to allow the penis to grow larger during the “mini-puberty” that occurs within the first 6 months of life.

    NEXT: Preoperative androgen stimulation

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