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Updated: Aug 16, 2026
Vessel-sparing Excision and Primary Anastomosis
Published on: January 7, 2019
Management and outcome of complex hypospadias repairs
Samuel A Amukele1, Jeffrey A Stock, Moneer K Hanna
1Department of Urology, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, New York, NY 11021, USA.
Insights
This study evaluated outcomes for complex hypospadias repairs in 126 patients. Buccal mucosa for urethral substitution yielded better results than skin grafts or bladder mucosa, reducing complications in hypospadias cripples.
Area of Science:
- Urology
- Pediatric Surgery
- Reconstructive Surgery
Background:
- Hypospadias repair can be challenging, especially after multiple failed attempts.
- Complex hypospadias cases, termed 'hypospadias cripples,' often present with scarred, hypovascular, and shortened penises.
Purpose of the Study:
- To report clinical outcomes of surgical repair for complex hypospadias.
- To evaluate different techniques and materials for urethral substitution in challenging cases.
Main Methods:
- Retrospective review of 126 patients (ages 14 months to 35 years) with complex hypospadias after 2-23 prior repairs.
- Patients were divided into single-stage (98) and multi-stage (28) repair groups.
- Urethral substitution materials included skin grafts, bladder mucosa, and buccal mucosa.
Main Results:
- Major complications occurred in 17% of single-stage repairs and 7% of multi-stage repairs.
- Urethral substitution with skin grafts/bladder mucosa had high complication rates (32-37%), while buccal mucosa had a 15% rate.
- Minor complications were observed in 9% (single-stage) and 14% (multi-stage) of cases.
Conclusions:
- Buccal mucosa is preferred for urethral substitution over skin grafts or bladder mucosa due to lower complication rates.
- Multi-stage repairs and specific tissue coverage techniques (dartos/tunica vaginalis flaps, scrotal skin flaps) are valuable for complex cases.
- Preoperative psychological support is beneficial for patients undergoing complex hypospadias repair.
Purpose:
Repeated attempts at surgical repair of hypospadias may leave the penis scarred, hypovascular and shortened. We report on the clinical outcomes of our repaired complex hypospadias cases, often referred to as hypospadias cripples.
Materials And Methods:
We evaluated the records of 137 children and young adults from January 1980 through December 2002 who were referred to us after multiple unsuccessful hypospadias repairs. The records of 11 patients were inadequate. The ages of the remaining 126 patients ranged from 14 months to 35 years. The number of prior surgical procedures ranged from 2 to 23. Of the 126 cases 98 (78%) were repaired in a single stage (group 1) and 28 (22%) underwent multistage repairs (group 2).
Results:
Major complications occurred in 17 cases (17%) in group 1 and in 2 (7%) in group 2. Major complications included repair breakdown, stricture, diverticulum and multiple fistulas. Minor complications occurred in 9 (9%) cases in group 1 and in 4 (14%) in group 2. Minor complications included a single small urethrocutaneous fistula, skin tethering, inclusion cysts and glandular irregularity. Urethral substitution using skin grafts and/or bladder mucosa resulted in a high complication rate of 32% and 37%, respectively, whereas use of buccal mucosa resulted in a 15% complication rate.
Conclusions:
Preoperative psychological counseling and discussion with other parents or patients were helpful. We no longer use free skin grafts and/or bladder mucosa for urethral substitution. Waterproofing the urethral tube was performed using either a dartos or tunica vaginalis flap. When the quality of the tissues was poor or severely scarred a 2-stage repair was performed. When resurfacing the penis local skin flaps may be insufficient or unreliable, and rotation of scrotal skin flaps or burial of the penis in the scrotum (Cecil-Culp) offers dependable skin coverage.