1. 3rd Surgical Workshop Of CUGRS (Complex Uro-Genital Reconstructive Surgery)
Surgical challenge in patients who underwent failed hypospadias repair: is it time to change?
Salvatore Sansalone MD
Senior Lecturer in Urology University of Tor Vergata Rome, Italy

2. UNKNOWN FAILED HYPOSPADIAS POPULATION Incidence Characteristics
European Center for Failed Hypospadias Repair

3. European Center for Failed Hypospadias Repair
For many years, failed hypospadias repair was considered a complex chapter in reconstructive urethral surgery, and any book on the urethra includes “hypospadias cripple” or re-operative hypospadias surgery as a special topic
Stecker JF, Horton CE, Devine CJ, McCraw JB: Hypospadias cripples.
Urol Clin N Amer 1981;8:
European Center for Failed Hypospadias Repair

4. observational, descriptive survey 1998 – 2007
J Urol 2010
observational, descriptive survey
1998 – 2007
1176 failed hypospadias repair
urethral strictures & penile defects
European Center for Failed Hypospadias Repair

5. Center for Reconstructive Urethral Surgery
Age range in 1176 patients
age (years)
N. patients
1 – 16
250 (21.2%)
16 – 20
451 (38.4%)
20 – 40
358 (30.5%)
40 – 60
112 (9.5%)
> 60
5 (0.4%)
< 16 years 250 (21.3%)
> 16 years 926 (78.7%)
Center for Reconstructive Urethral Surgery

6. Primary site of meatus European Center for Failed Hypospadias Repair
position n %
glandular
193
16.4
penile
702
59.7
penoscrotal
281
23.9
European Center for Failed Hypospadias Repair

7. Number of operations to repair primary hypospadias in 1176 patients
N. operations
N. patients 1
130 (11.1%) 2
347 (29.5%) 3
320 (27.2%) 4
159 (13.5%) 5
108 (9.2%)
> 5
112 (9.5%)
minimum: 1 maximum: 23 mean: 3.3
Center for Reconstructive Urethral Surgery

8. Number of operations to repair complications following primary hypospadias repair in 1176 patients
N. operations
N. patients 1
760 (64.6%) 2
280 (23.8%) 3
82 (6.9%) 4
31 (2.7%) 5
9 (0.8%)
> 5
14 (1.2%)
minimum: 1 maximum: 8 mean: 2.3
Center for Reconstructive Urethral Surgery

9. Total number of operations to repair primary
hypospadias repair and complications in 1176 patients
N. operations
N. patients 2
102 (8.7%) 3
289 (24.6%) 4
369 (31.4%)
5 – 10
311 (26.4%)
11 – 20
91 (7.7%)
> 20
14 (1.2%)
minimum: 2 maximum: 23 mean: 5.8
Center for Reconstructive Urethral Surgery

10. Center for Reconstructive Urethral Surgery
In patients underwent a mean of 5.8 surgical operations to repair primary and failed
hypospadias
No other congenital abnormality of the body requires a mean of 5.8 surgical operations to be cured !
Center for Reconstructive Urethral Surgery

11. QUERIES proximal > distal? older techniques > new techniques ?
single staged procedures ? NO NO NO
European Center for Failed Hypospadias Repair

12. Failed hypospadias repair may consist in defects of single compartments of the male genitalia (urethra, corpora cavernosa, glans, penile and scrotal skin), or in a combination of them
It is a reasonable hypothesis that the outcome of repairing failed hypospadias depends on the number of compartments involved
This widespread survey allowed to us to focus on some concepts and concerns, developing a new view of this old problem.

13. smaller penile size and curvature.
The main reason for dissatisfaction was
smaller penile size and curvature.
European Center for Failed Hypospadias Repair

14. THE JOURNAL OF UROLOGY Vol. 182, 1736-1743, October 2009
THE JOURNAL OF UROLOGY Vol. 180, , September 2008
……..we assume that satisfaction with genital self-perception by our patients will decrease with advancing age.
European Center for Failed Hypospadias Repair

15. European Center for Failed Hypospadias Repair

17. 59-year-old patient with 7 previous surgeries - one stage repair

18. Artificial erection shows severe ventral curvature
Elipsoid excision of longitudinal layer of albuginea at several points

19. Complete penile straightening Running suturing of wounded surfaces
(PDS 3-0)

20. Neourethral reconstruction and “spongioplasty”

21. Creation of abundant dartos flap for suture line covering
Glans wings
Dartos flap
Dartos flap

22. Aspect at the end of surgery
Outcome after one year
Aspect at the end of surgery

23. 34-year-old patient with 6 previous surgeries - one stage repair

24. Diverticular skin urethra
Double - “S” curvature
ventral
dorsal

25. Longitudinal tunica excision
Ellipsoid excision of longitudinal tunical layer and plication at two points (arrows)
Longitudinal tunica excision

26. Urethral tailoring by external plication

27. Reconstruction of penile skin using remaining penile skin and scrotal flaps
Peno-pubic and peno-scrotal angles are formed by tacking penile base skin to the albuginea (arrows)

28. Fixation of loose compressive dressing at the base and at subcoronal level
European Center for Failed Hypospadias Repair

29. 39-year-old patient with 33 previous surgeries Two stage repair
Fixed and elevated testicle

30. Testicular mobilization
Extensive degloving and partial urethral augmentation with buccal mucosa
Buccal
mucosa
inlay
Urethral
stricture
Testicular mobilization

31. Penile skin reconstruction using scrotal flap
Buccal mucosa inlay
Scrotal flap
Bilateral
orchiopexy

32. Second stage urethroplasty after 6 months - buccal mucosa tubularisation, glans, penis and scrotum plasty

33. CRIPPLED PENIS: Severe curvature and short, strictured, fistulous neourethra with small, deformed glans
Severe curvature and short, strictured, fistulous neourethra and small deformed glans

34. I-stage: Penile lenghtening by ventral grafting
(InteXen® 3x7cm)
Graft
Meatus

35. III-stage: Tubularizing urethroplasty
Completely straightened and lenghtened penis

36. Glanular and urethral reposition; skin reconstruction

37. Outcome after 14 months
Before
After

38. Take home message www.failedhypospadias.com
Urethral complications in patients with failed hypospadias repair are less frequent than complications involving the corpora cavernosa, and the esthetic appearance of the genitalia.
To repair these defects, collaboration between the urethral surgeon and the surgeon who has developed vast experience in plastic and reconstructive surgery of the male genitalia is indeed mandatory

39. MULTI SPECIALIZED SKILLS URETHRAL P E D P I L A A T S R T I C C
ANDROLOGICAL