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Purpose: The purpose of this paper is to elucidate the presentation and treatment of patients with recalcitrant urethral strictures following hypospadias repair, referred to a transitional urology practice.
Materials and Methods: A prospective data base (1991 to date) is maintained for patients presenting to us between 18-30 yrs of age referred for management of a urethral stricture that developed following hypospadias repair. The symptoms at time of presentation, the interventional treatments required to manage the complications and outcome are reviewed.
Results: A total of 64 pts met our study criteria, median age at presentation was 25 yrs (range 18-30). 37% (23/63) presented with a chief complaint of a diminished urinary stream and concurrent erectile dysfunction, 35% (22/63) with a diminished urinary stream , 14%(9/23) were on CIC with a request to be reconstructed, 1 of whom had developed a recent false passage and was unable to continue (range of CIC, 3-12 yrs), 14% (9/23)presented with a watering pot perineum and 1 (2%) with a indwelling suprapubic tube for 17 yr. The median number of open procedures performed for urethral reconstruction prior to presentation was 5, range 2-18, median number for endoscopic interventions was 0, range 0-8. Ballanitis xerotica obliterans (BXO) was present in 19% (12/64). The median length of the stricture at presentation was 8 cm, range 3 to 18 cm. 19% (12 /64) had failed a prior staged buccal graft repair, 67% (8/12) had also failed a staged urethral repair using a skin graft.
After discussing options , only 42% (27/64) elected to proceed with additional urethral reconstructive surgery , 36%(23/63) underwent a staged (18) or inlay buccal graft (5). Complications developed in 21%(5/23), 3 fistulas requiring closure, 2 strictures, 1 requiring repeat buccal graft, 1 with recurrent BXO required revision with first stage urethroplasty. 6% (4/63) underwent a vascularized flap reconstruction without complications. Median follow up of 4 yrs (range 2-12).
58% ( 37/64) chose to undergo proximal urinary diversion or be managed by daily CIC. 27%(17/63) underwent partial urethrectomy and perineal urethrostomy. Complications developed in 12% (2/17), with BXO recurring in the perineal stoma requiring revision, Median follow up of 5 yrs, range 2-9. 21% (13/63) are managed with daily CIC, no complications have developed during a median follow up of 4 yrs, range 2-21. 6%(4/63) were managed by a continent stoma, and 5% (3/63) with a first stage urethroplasty with no plans for further reconstruction, no complications in these later patients with a median follow up of 7 yrs, range 2-11.
Conclusion: Of concern, transitional urologic care of recalcitrant urethral stricture disease secondary to hypospadias surgery reveals the development of early erectile dysfunction in a third of our referred patients. Over half of our patients have extensive surgical fatigue and will choose management by a proximal meatus or CIC over additional urethral reconstruction.