The Adolescent Glans Penis: functional and aesthetic issues following childhood hypospadias repair
Chrystal Chang, MD1, Ashraf G. Fahmy, MD, MRCS2, Jennifer E. Reifsynder, MD3, Moneer K. Hanna, MD FRCS4.
1Rutgers New Jersey Medical School, Newark, NJ, USA, 2Department of Urology, Masr Elgedida Military Family Hospital, Cairo, Egypt, 3Division of Pediatric Urology, Cohen Children's Medical Center, Northwell Health, Queens, NY, USA, 4New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY, USA.
BACKGROUND:As children with childhood hypospadias repairs transition into adolescence, the function and appearance of the genitalia acquire greater importance. For some, the direction and shape of the urinary stream can be embarrassing if abnormal, and the appearance of the glans penis and meatus are a concern. As time goes by, some minor imperfections from previous repairs that could have been overlooked or underestimated may manifest with urine spraying or other significant findings as children age. We examine the long-term outcome of what appeared to be a good repair at initial repair. Herein, we address the surgical correction and outcomes of urine spraying with or without fistulae, and cosmesis over 12 years.
METHODS:We retrospectively reviewed hypospadias revisions by a single surgeon over 12 years. We included adolescents and young adults who complained of abnormal urinary stream and/or aesthetic complaints. Patients then evaluated the post op result as very good, good, acceptable, or unsatisfactory and were asked to document the angle and/or degree of the urinary stream by photography or video using smartphones. We excluded patients who originally had proximal hypospadias as the complications tend to be more major in addition to urinary spraying and aesthetics (e.g. chordee, diverticulum, or stricture). Revision was performed with specific attention to meatal contouring and glans sculpting to achieve the function and appearance of an anatomically normal glans penis.
RESULTS:Of 542 patients who underwent revisionary procedures, 90 (16.6%) presented with complaints of urinary spraying, and appearance of the glans penis and/or meatus (see figure 1). Of these, 19 (21.1%) presented with aesthetic complaints alone, 37 (41.1%) presented with aesthetic complaints and spraying, and 34 (37.7%) presented with aesthetic concerns, spraying, and were noted to have urethral fistula either during preoperative examination or during surgery (see table).
| Original Repair Technique | ||||||
| Presenting Complaint | N | Mean Age (years) and range | Thiersch Duplay | Tubularized Incised Plate | Prepuce Skin Onlay | Unknown |
| Group 1: spraying, cosmesis | 37 (41.1%) | 13 (11-16) | 12 (32.4%) | 8 (16.2%) | 8 (21.6%) | 9 (24.3%) |
| Group 2: spraying, cosmesis, fistula | 34 (37.7%) | 14 (12-16) | 9 (26.5%) | 10 (29.4%) | 3 (8.8%) | 12 (35.3%) |
| Group 3: Cosmesis only | 19 (21.1%) | 20 (16-24) | 1 (5.3%) | 1 (5.3%) | 8 (4.2%) | 9 (4.7%) |
| Total | 90 | 22 (22.4%) | 19 (21.1%) | 19 (21.1%) | 30 (33.3%) |
3/90 patients (3.3%) developed wound infection and dehiscence and subsequently underwent successful repeat surgical repair, and received hyperbaric oxygen therapy. See figure 2 for an example of our repair following meatal contouring and glans sculpting.
CONCLUSIONS: Adolescents and young adults who underwent hypospadias repair during childhood can return with concerns regarding functional and aesthetic abnormalities of the glans penis. Glans sculpting and meatal contouring may be utilized to normalize the urinary stream and achieve a normal aesthetic appearance of the glans penis. Surgeons should follow these patients through adolescence and into adulthood, because complications from hypospadias repairs acquire greater significance later and young adults seek to normalize their phalluses. Our series supports the importance of long-term follow-up for these patients.
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