The importance of follow-up

Pediatric urologists commonly reconstruct congenital anomalies in infants and children. These surgical constructs are required to function well in the long term and ideally satisfy the patient throughout the lifespan. This being said, there is a dearth of long-term information regarding functional outcome and patient satisfaction for the reconstructive procedures we perform. The number of people in our country who currently practise both adult and pediatric urology is limited, and most of our patients leave our practices at 16–18 years of age. Even if we were to refer them on to local adult urology colleagues for follow-up, the mobility of the population is such that these young men would in large part relocate and become lost to follow-up. In my view, this is the Achilles' heel of our specialty.

The authors¹ are to be commended for obtaining such data on a population of patients who had hypospadias surgery at least 15 years earlier. One must not underestimate the tremendous amount of sweat equity invested in bringing these data to light. Admittedly, this study has some methodological weaknesses. There were 2 different questionnaires used, neither of which had been extensively validated. The response rate was a meager 28%, and therefore, the results may be biased. Perhaps patients who were the most dissatisfied with their outcome did not respond to the survey. The hypospadias repair techniques performed are not commonly used currently, and one could postulate that newer techniques would produce better outcomes. There were no control groups of normal subjects or unreconstructed hypospadias patients for comparison. It is reassuring that these patients are overall quite satisfied despite their initial challenges with planned or unplanned multiple operations. Despite persistent fistulae in 11%, and persistent chordee in 29%, these patients are voiding reasonably well and able to have penetrative sexual intercourse. Fully 86% are satisfied with the result of their hypospadias repair, and some even expressed gratitude for the care they had received.

Some interesting questions arise from this study. Would more current methods of hypospadias repair result in better outcomes, particularly regarding fistulae and persistent chordee? Why is there such a high rate of persistent chordee? Are the techniques of chordee correction inadequate in the long term, or do the corporeal bodies grow at differential rates dorsally versus ventrally? How important is chordee correction to normal sexual function if deviation of up to 45° allows for normal sexual activity?

The important take-home message from this study is that patients who have undergone hypospadias surgery require long-term follow-up. The patients want it (52%), and we need it to assess whether we are doing the right thing by them. In my practice, I follow these young men until feasible (age 18 yr) and make sure that by the time they leave they have had any cosmetic or functional issues addressed and know what to look for in the way of trouble and to whom they may direct any future concerns.