Chapter 2: Hypospadias and Surgery (part 1)
This second chapter is dedicated to exploring medical treatment. We shall look at the physical issues which are taken into account in the decision to operate and I shall describe briefly the necessary objectives and principles of surgery.
After a review of the history of surgery for hypospadias, I shall move on to the question of the appropriate age for surgery, where I will try to show that changes have taken place in this field in recent years. I will present a few surgical techniques in use today, and cite some complications inherent in this type of surgery. Finally, I will touch briefly on several elements concerning pre-admission and post-operative care.
Consequences of hypospadias
2.1. Functional problems
Medical practitioners believe that hypospadias runs the risk of a number of adverse physical consequences if it is not treated surgically (Bukowski & Zeman, 2001 ; De Sy & Hoebeke, 1996). Surgical intervention is generally recommended for posterior and median forms of hypospadias as well as distal forms presenting an associated pathology (e.g., chordee).
The existence of functional problems related to urination, sexuality and reproduction, has often been reported in the literature (Arap & Mitre ; Baskin, 2000 ; Zaontz & Packer, 1997). For example, misplacement of the urethral meatus can alter the direction of the stream of urine: depending on the anatomical condition, the stream of urine tends to deviate backwards, making it more difficult to urinate standing up. In posterior forms, deviation may be such that the individual has to sit down to urinate.
On attaining adolescence or adulthood , the presence of chordee may hinder sexual activity (e.g., through pain during intercourse). In adulthood, fathering a child may potentially be made more difficult if, due to the location of his urethral meatus, a man’s ejaculation takes place lower down the vagina, reducing the chances of semen reaching far enough into the vagina for insemination.
2.2. Aesthetic repercussions
To the three difficulties mentioned above (urination, sexual activity, fatherhood) must be added a fourth, which refers to problems of an aesthetic nature. The appearance of a hypospadic penis may be rather different to that of a ‘normal’ penis (Baskin, 2000; Sheldon & Duckett, 1987).
The external aspect of a penis with hypospadias must be taken into account during the clinical examination, even if there are no physical difficulties with the stream of urine or chordee  (Zaontz & Packer, 1997).
Objectives and principles of hypospadias surgery
3.1. Objectives of surgery
Surgical treatment aims to re-establish the functions (urination, erection) and anatomy of the genito-urinary organ, rendering it as similar as possible to a ‘normal’ penis (Wese et al., 1994). The objectives are to obtain, at the end of the operation, various functional and aesthetic characteristics (Zaontz & Packer, 1997):
– a straight penis (in erection)
– a urethral meatus situated, if possible, at the end of the glans
– urination with a straight, well-aimed stream
– a penis of aesthetically normal appearance
The straightening of the penis is carried out to permit the individual to have satisfactory sexual relationships later on. The creation of a urethral meatus as close as possible to the glans, or even at the tip, using new procedures, is designed to make it possible to urinate standing up, without misdirection of the stream of urine. The position of the newly created urinary meatus also permits insemination for reproduction. Finally, the objective is also to render the penis as close as possible to ‘normal’ in appearance.
3.2. Principles of surgery
According to Paparel et al. (2001), the current approach to hypospadias is governed by three fundamental principles which should, if possible, be dealt with at the same stage (Paparel et al., 2001); they are:
– correction of chordee
– reconstruction of the missing piece of urethra (urethroplasty)
– reconstruction of the ventral side of the penis
Before going into any further detail on the techniques currently utilized by pediatric urologists specializing in the surgical approach to hypospadias – known as ‘hypospadiology’ (Sheldon & Duckett, 1987) – I will briefly review the history of surgery for hypospadias as well as providing an overview of the main changes which have taken place regarding opinions about the best age for the operation.
Surgery for hypospadias: an historical view
Surgical treatment for hypospadias has long represented ‘a great challenge’ (Perovic, Scepanovic, Vukadinovic et al., 2000; Macedo & Srougi, 1998), for generation of surgeons and pediatric urologists, and it is very likely to remain so in the future.
While different types of surgical treatment have been mentioned over the centuries , the ‘modern principles’ of surgery for hypospadias were only described for the first time during the 19th century and beginning of the 20th century, in Europe, by German and French surgeons (e.g., Dieffenbach, 1936 et Tiersh, 1869 ; Duplay, 1874 ; Novè Josserand, 1897 ; Ombrédanne, 1923 ; Mathieu, 1932) (Smith, 1997). Moreover, the techniques in use today mainly stem from modifications based on discoveries made by the pioneers of this surgery (Santanelli, 2002).
The surgical procedures in existence during the 20th century have been divided into two main types: multi–stage reconstructive techniques and single stage reconstructive techniques.
In multi-stage procedures, a first operation was necessary to correct the chordee. Urethroplasty only took place afterwards, necessitating one or more operations (Horton & Devine, 1972). These procedures, used during the major part of the last century, and which used multiple skin grafts  as substitute material for the urethroplasty thus lengthening the time taken for the operation, are not in use today .
In the field of surgery for hypospadias, as stressed by Babut (1996, p. 64), ‘the ideas are evolving and certain principles have been abandoned’. If some surgeons still make use of multi-stage techniques, these are no longer likely except in very severe cases (Ferro, Zaccara, Spagnoli & al., 2002 ; Gershbaum, Stock & Hanna, 2002).
The single stage procedures are surgical procedures which permit correction of chordee and urethroplasty in one and the same operation. These procedures, mostly using penile skin (skin from the penis or prepuce), were introduced during the 1960s, then popularized around the 1980s (Lottman, 1998). They have never ceased to be remodeled and subtly improved (Belman, 1997). In the last few years, hypospadias repair has seen unprecedented evolution. Reconstruction work, originally purely functional, has today combined with aesthetic repair work of increasing finesse (see for example, Hoebeke, De Kuyper et Van Laeke, 2002).
- The preferred age for surgery
5.1. Changes in the timing
Initially, surgical reconstructions for hypospadias were practiced during later childhood, or even postponed to early adolescence (Ellsworth et al., 1999). It was only around the second half of the 19th century that certain north American surgeons proposed that the operations be carried out before children entered primary school, to permit them to urinate standing up in the boys’ toilets (Culp, 1951, cited in Mills, McGovern, Coleman et al., 1981).
The idea of operating on boys born with hypospadias before they started school spread throughout the USA where it became accepted practice at the end of the 1970s (Hodgson, 1981). At that time, according to the American Academy of Pediatrics (AAP), technical considerations remained of prime importance (American Academy of Pediatrics 1975) .
At the beginning of the 1980s, two publications appeared concerning the technical possibilities of starting to operate on very young children (Belman & Kass, 1982 ; Manley & Epstein, 1981). As technical changes reduced the possible age of surgery, an awareness began to develop about the psychological implications of surgery at such a young age. For example, in the mid-1970s, Robertson and Walker (1975) were able to observe that the child candidates for hypospadias surgery, and their parents, could be anxious regarding the surgical procedures used or regarding the condition of hypospadias itself (Robertson & Walker, 1975).
And at the end of the decade, Lepore and Kesler (1979) described a specific pattern of negative behavior in a group of children who had just been operated upon. The authors alerted the medical community to the danger to the children’s psychological health caused by genital surgery around the age of three years.
Around the same time, the publication of an article by Schultz, Klykylo and Wacksman (1983) contributed further to revision of the timing of the operation. These authors primarily emphasized the fact that the psychological impact of hypospadias, or a repair operation, varied according to age. According to a review of the literature at that time, Shultz et al. (1983) suggested – with regard to emotional and cognitive development and the emergence of self-image and sexual identity – that surgical interventions should be practiced during the first year of the child’s life.
They also stated that it should be arranged so that parent-child separation during hospitalization was minimized and that parental accompaniment should be encouraged, with the aim of reassuring parents and allowing them to express their anxieties, worries or feelings of guilt, emotions which are often present.
The issues of a psychological order tackled thirty years ago by Shultz et al. (1983), as well as those concerning technological advances in the domain of ‘hypospadiology’, were reprised in a more recent article from the American Academy of Pediatrics (AAP) (American Academy of Pediatrics, 1996).
According to the AAP (1996), it has become technically possible (e.g., using optical magnifiers, micro-instruments, delicate materials and sutures, and with progress in anesthesia) to operate on almost all forms of hypospadias in very young children while minimizing not only the time spent in hospital and the amount of separation from parents , but also the number of operations required (e.g., by using single stage procedures).
According to the AAP (1996), because emotional and cognitive development and body image can be profoundly affected both by the genital condition and the experience of surgery, the ‘best’ time to operate is between 6 and 12 months of age.
5.2. Current practice
Current practice, in north America, is to carry out this type of surgical intervention between the ages of 6 and 18 months (AAP, 2000). However, there is still no true consensus on this question internationally. In France, for example, some surgeons prefer to wait until the child is one or two years old (Paparel et al., 2001). Overall, however, the tendency is to operate increasingly early, with as few operations as possible and in as limited a time period as possible, with the aim of diminishing the psychological impact of both the hypospadias and the experience of surgery (Arap & Mitre, 2000; Baskin, 2000; Paparel et al., 2001).