Age-dependent early complications of hypospadias repair: a single institutional experience

Abstract

Purpose

To correlate age at hypospadias repair with early post-operative complications and highlight need for adaptation to post-operative care in older children.

Methods

Anecdotal evidence suggests boys with delayed surgery for hypospadias suffer increased rates of early post-operative complication. Hence, a retrospective analysis was conducted of all patients undergoing hypospadias repair between March 2019 and 2022.

Results

Ninety eight patients were divided into Group A (< 2years of age at first surgery) or Group B (> 2years). While patients in Group A encountered no early post-operative complications, seven in Group B (11%) suffered a range of complications including dislodged stents (3/7), significant spasmodic pain requiring prolonged hospital stay (2/7) and urinary retention (2/7). More than half of these children required emergency supra-pubic catheter insertion.

Conclusion

Significantly more children undergoing hypospadias surgery after the age of 2 years suffered complications within the early post-operative period. This resulted in prolonged hospital stays and a number returning to theatre for insertion of a supra-pubic catheter. We recommend a tailored approach to the post-operative care of older children undergoing hypospadias repair, including strict parental education regarding dressing/stent care and medication compliance, as well as efforts to enhance robustness of dressings and stent anchorage in children likely to pull at stents.

Introduction

Hypospadias is a congenital abnormality in which incomplete closure of the ventral penile architecture during embryogenesis results in proximal displacement of the urethral meatus. Approximately 70% of patients with hypospadias have what Duckett classified as the milder phenotype [1], i.e. with the urethral meatus being sited distally on the penis and without other urogenital deformity. However, roughly one-third will suffer a more proximal and complex variant [1] and 9% will have a concurrent defect or syndrome [2].

The sequaelae of hypospadias includes spraying of urine on micturition, difficulties engaging in sexual intercourse due to penile curvature, psychological turmoil associated with atypical genital appearance and reduced fertility due to hindered sperm delivery. As such, surgery aims to both normalise the function of the penis and attain a more satisfactory cosmesis.

Hypospadias is second only to cryptorchidism in terms of incidence in the newborn male [3], affecting 1 in every 200 boys [4]. Hence, hypospadias repair is consequently one of the more common operations performed by paediatric urologists.

There are thought to be over 100 different operative techniques that have been developed to tackle hypospadias repair, with the choice of procedure depending predominantly on the severity of the defect and the surgeon’s own experience and training. Regardless of the adopted operative approach, there is general consensus that corrective surgery should be undertaken between 6 and 18 months of age [5]. This consensus was arrived at in trying to reach a balance between factors such as age-dependent genitalia dimensions and anaesthetic risks (including the purported anaesthesia-induced neurodegeneration of the central nervous system [6]), as well as the effects on toilet-training and the potential psychological outcome of delaying surgery to an age at which the child is genital-aware and will remember the procedure [7].

Unfortunately, it is not always possible to perform the operation during the optimum age window. Milder defects are often diagnosed late and access to specialist paediatric urologists is not universal. Furthermore, hypospadias repair is categorised in the UK as a surgery of the least priority [8].

Moreover, the effects of COVID-19 on healthcare has been gargantuan and wide-spread, with one example of such an effect being the global halting of elective surgical and outpatient activity. Indeed, Juul et al. [9] reported an 11% increase in the number of patients on paediatric urology waiting lists by the end of April 2021, with the effect on hypospadias being an upsurge as high as 36%. As a result, many patients with hypospadias experience delays in receiving care and are, inevitably, operated on at an older, less preferable age. This, of course, places them at risk of suffering the consequences outlined above. Indeed, anecdotal evidence from our institution has suggested that boys with delayed surgery for hypospadias suffer increased rates of early post-operative complication.

Purpose

To examine potential correlation between early complications of hypospadias surgery and the age at which that surgery is carried out.

To undertake root cause analysis on any complications encountered, in an effort to better understand what adaptations to the post-operative care of older children may be necessary to avoid such complications in future.

Methods

A retrospective analysis was conducted of all paediatric patients (age 0–16 years) undergoing hypospadias repair between March 2019 and March 2022, at our institution. Patients were identified through clinical coding and theatre databases.

Data were gathered from electronic records, case notes and operation notes and included: age at surgery, type of hypospadias (anterior, midshaft or posterior), nature of operation (single-stage vs two-stage repair), whether a dripping stent was left in situ following the procedure and, if so, what size of stent was employed, number and nature of early complications (within 72 h of surgery). All documented complications (Clavien–Dindo I–V) were included in the analysis.

Patients were allocated to either group A (less than 2 years of age at time of surgery) or group B (2 years of age or above at time of surgery) for comparison. Statistical analysis comparing the two groups was undertaken, with a p-value of < 0.05 being considered significant.

Results

Of 108 patients identified as having undergone hypospadias repair within the investigated time period, it was necessary to exclude 10 from our analysis owing to lack of, or incomplete documentation.

One third (37%, n = 36) of patients were aged < 2 years and these were designated as group A, with the remaining patients (63%, n = 62) constituting group B. Mean age at surgery was 2.5 years overall (range of 1.2–4.6 years), with mean age in Group A being 1.7 years (range 1.2–1.96 years) and mean age in group B 3.0 years (range 2.0–14.5 years). 53% of patients were suffering with an anterior hypospadias (n = 52), 38% (n = 37) had a midshaft hypospadias and 9% (n = 9) had a posterior hypospadias.

83% (n = 81) had single-stage hypospadias repair and in 60% (n = 59) it was considered necessary to leave a dripping stent or catheter in situ post-operatively, of which 3% (n = 2) were size 5 Fr, 69% (n = 41) were size 6 Fr, 19% (n = 11) were size 8 Fr, 3% (n = 2) were size 10 Fr and 5% (n = 3) unfortunately had insufficient documentation to determine stent size.

Both groups were comparable in co-morbidities, severity of defect, type of operation performed and urethral stent size. On reviewing patient records, it was apparent that application of dressings, prescription of post-operative medications and timing of stent and dressing removal adhered to locally agreed protocols and, as such, were also equivalent between both groups.

There were no early post-operative complications in group A (0/36). However, 11% of patients in group B experienced early post-operative complications (7/62, p-value 0.048). The most common post-operative complication was a malfunction of the urethral stent (3/7). 2 of these were a result of the dressings not adequately anchoring the stent in place, resulting in them becoming dislodged and falling out. The other malfunction was a consequence of the stent becoming twisted and kinked at its exit from the urethral meatus, again likely a result of sub-optimal application of dressings. The other early post-operative complications were urinary retention upon removal of urethral stents (2/7) and significant post-operative pain requiring re-admission to hospital (2/7). Review of patient notes revealed that at least one of these patients had not complied with taking their prescribed oxybutynin post-operatively. 4 out of these seven patients required insertion of a supra-pubic catheter (both patients who had gone into urinary retention and both patients with dislodged stents) and one had recurrent urinary retention requiring a second supra-pubic catheter.

	Group A (< 2years at first surgery)	Group B (> 2years at first surgery)	p value
Early post-operative complications n (%)	0/36 (0%)	7/62 (11%)	0.048
Emergency SPC insertion	0/36 (0%)	4/62 (6%)	0.131

After triangulating the feedback from surgeons, nursing staff on the post-operative ward and parents, we have made the following recommendations:

1. 8 Fr stents are recommended for patients older than 2 years.

2. Application of dressings must be meticulous and checked for security, taking care to direct the penis downwards in an attempt to avoid direct trauma or manual dislodgement in active children.

3. Oxybutynin is to stop 36 h before the removal of the dressing and the stent, to try to reduce the risk of urinary retention upon stent removal.

Discussion

Paediatric urologists generally aim to operate on children with hypospadias between 6 and 18 months of age due to the perceived benefits in terms of psychological impact, development (weighing toilet-training vs. potential for anaesthesia-induced neurodegeneration) and operative facility as a consequence of genitalia dimensions.

The present study supports this recommendation for carefully considered timing of hypospadias repair surgery by expanding on these factors, adding the conclusion that children over the age of 2 years are at significantly greater risk of experiencing early post-operative complications.

On thorough review of patient records, we were able to deduce that the reason for this increased risk is multi-factorial and identified several examples of factors at play. Poor compliance with prescribed medication (in particular laxatives and oxybutynin), as well as the increased activity and genital/stent awareness in the older child subsequently resulting in forceful interference with stents and dressings, compounded further by sub-optimal stent-anchorage or application of dressings, provides a basis for inevitable complication, occasionally significant enough to warrant further invasive procedures (such as supra-pubic catheter insertion).

On review of the literature, we were unable to identify any papers comparing outcomes with different-sized urethral stents. At least five of our seven patients suffering early post-operative complications had had a 6 Fr dripping stent placed at the time of surgery. One had had an 8 Fr stent placed (this patient’s complication was stent dislodgement, requiring supra-pubic catheter insertion) and the other patient’s operation note indicated that a stent had been used, but unfortunately did not state what size this was (complication was development of urinary retention post-repair, also requiring supra-pubic catheter insertion). It is for this reason that we recommend the use of a larger, more robust stent in the older child undergoing hypospadias repair, i.e. size 8 Fr instead of 6 Fr. We are unable to comment on whether the type of stent employed has any bearing on risk of complication. Indeed, Lee et al. [10] found no significant differences in stent-related complications between Silastic and Koyle stents.

We have identified age as a risk factor for post-operative complications of hypospadias repair. While there are some studies that refute this finding [11–13], others [14–16] corroborate it. Garnier et al. [17], a large study in which outcomes for boys of various ages undergoing urethroplasty were reviewed, concluded that age greater than 2 years was a significant predictor of complications including fistula, stenosis, and relapse of curvature. However, where our study differs is in the finding of an association with early complications. The vast majority of complications reported in the studies by each of Yildiz et al. Lu et al. Lee et al. and Garnier et al. [14–17] were delayed complications, with fistula formation being a recurring theme throughout. Moreover, Garnier et al. [17] included patients in their study that were significantly older than our eldest patient and were, therefore, able to comment on the effect of age on outcomes for those experiencing puberty. Furthermore, they were able to postulate that age-related physiological factors, such as cytokine modulation and dermal papilla apoptosis, may account for the poorer healing observed in pubertal boys.

The comparatively smaller overall age range of patients included in our study is, thus, a limitation. Nonetheless, it allows us to make a different conclusion in that behaviour, rather than physiology, is seemingly responsible for the majority of early complications encountered in boys with hypospadias. All of our patients who had dislodged stents and subsequently required supra-pubic catheter insertion were of an age when they were aware of (and able to pull at) their dripping stents, yet not old enough to understand why this should be avoided. It would thus be interesting to extend our study to an older cohort to investigate whether there is any drop-off in early complications when the patients are old enough to better understand and comply with post-operative management. Nevertheless, the cohort of patients examined here is a true representative of our centre’s patient population and addition of adolescents would require a broader inclusion of patients from other centres.

Beyond this, we recognise that our study is limited by a relatively small cohort, investigated retrospectively. Reassessment of the changes we have implemented, in a second cycle of data collection, has not yet been conducted. However, given that the waiting-list backlog and the resultant global increase in age of patients undergoing hypospadias repair is a problem that is unlikely to abate any time soon, we believe it crucial to robustly share our experience at the earliest. We recommend changes for the post-operative care of older children undergoing hypospadias repair. In our institution, we have introduced strict parental education regarding dressing/stent care and medication compliance, as well as efforts to enhance robustness of dressings and stent-anchorage in children more likely to pull at them.

Author contributions

Data was collected by J Dale and B Woodward. The manuscript was written by all authors.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of interest

The authors have no conflicts of interest. No funds, grants, or other support was received for conducting this study.