Suprapubic versus transurethral diversion after hypospadias repair: A systematic review and meta-analysis

Hypospadias repair is a common pediatric urological procedure often requiring urinary diversion to minimize postoperative complications. The optimal diversion technique-transurethral versus suprapubic diversion -remains debated. The aim of this study is to systematically review and compare outcomes of transurethral versus suprapubic diversion following hypospadias repair in pediatric patients.

A systematic review and meta-analysis were performed in accordance with PRISMA guidelines. PubMed, Scopus, Web of Science, and Cochrane Library were searched through December 2024. Eligible studies included randomized controlled trials and comparative observational studies reporting outcomes of transurethral versus suprapubic diversion. Main outcomes included urethrocutaneous fistula, meatal stenosis, and bladder spasms.

Five studies including 680 patients were analyzed. Initial pooled analysis showed no significant difference between transurethral and suprapubic diversion in fistula incidence (RR 1.21, 95% CI 0.75-1.96; p = 0.42). Sensitivity analysis excluding one study suggested a potential reduction in fistula risk with suprapubic diversion (RR 0.35, 95% CI 0.16-0.78; p = 0.01). Meatal stenosis rates were comparable between groups (RR 1.25, 95% CI 0.60-2.59; p = 0.55). For bladder spasms, pooled analysis showed no difference (RR 0.81, 95% CI 0.55-1.20; p = 0.29), but sensitivity analysis favored suprapubic diversion (RR 0.08, 95% CI 0.02-0.32; p = 0.0003).

Both methods yield comparable outcomes with some potential advantages of suprapubic diversion in some outcomes only after sensitivity analysis. While SPT may offer a viable alternative to traditional urinary catheterization in select cases of hypospadias repair, the current evidence base does not support definitive conclusions about its superiority or inferiority. Given the variability in study quality, small sample sizes, and heterogeneity in reported outcomes, no definitive recommendation can yet be made. Future RCTs are essential to guide practice.