Journal of Pediatric Urology (2021) 17, 61.e1e61.
e5
a
Department of Urology, The
Children’s Hospital, Zhejiang
University School of Medicine,
National Clinical Research
Center for Child Health,
Hangzhou, China
b
Department of Pediatric
Surgery, The Children’s
Hospital, Zhejiang University
School of Medicine, National
Clinical Research Center for
Child Health, Hangzhou, China
* Correspondence to: Qiang
Shu, No. 3333, Bingshen Road,
Hangzhou, China, Tel.: þ86 571
87061007; fax: þ86 571
87033296
shuqiang@zju.edu.cn (Q.
Shu)
Keywords
Hypospadias; Reoperation; Se-
vere recurrent ventral curva-
ture; Urethral stricture;
Dehiscence; Primary staged
hypospadias repair
Abbreviations
RVC, Recurrent ventral curva-
ture; OR, Odds ratio
Received 17 September 2020
Revised 2 November 2020
Accepted 5 November 2020
Available online 12 November
2020
https://doi.org/10.1016/j.jpurol.2020.11.010
1477-5131/ª 2020 The Author(s). Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Identification of risk factors associated
with numerous reoperations following
primary hypospadias repair
Wei Ru a, Daxing Tang a, Dehua Wu a, Chang Tao a, Guangjie Chen a,
Jia Wei a, Hongjuan Tian a, Qiang Shu b,*
Summary
Introduction
Complications remain the top evaluation priority
subsequent to hypospadias repair. Complications
vary in further management, and usually require one
or more reoperations. Patients and/or their parents
concern not only with the success rate of reopera-
tion, but also with the risk of numerous
reoperations.
Objective
To identify the risk factors associated with numerous
reoperations following primary hypospadias repair.
Study design
Data were collected retrospectively from patients
who underwent reoperations for complications
following primary hypospadias repair at a single
institution from August 2008 to October 2017.
Results
A total of 507 patients required reoperations
following 2754 primary hypospadias repairs. Even-
tually, 486 patients were eligibly included with a
median age of 2.2 years. The median follow-up
period was 6.5 years. Preserved urethral plate ure-
throplasty for primary repair (including Snodgrass,
Onlay and Mathieu techniques) was performed in 307
(63.2%) patients, Duckett technique was performed
in 121 (24.9%) patients, and staged urethroplasty
(including staged Duckett, Byars and Bracka tech-
niques) was performed in 58 (11.9%) patients. The
Summary table Risk factors associated with numerous reoperations.
Odds ratio
Severe RVC 75.991
Urethral stricture 36.967
Dehiscence 11.765
Staged urethroplasty 3.074
Urethra diverticulum 0.443
RVC, Recurrent ventral curvature.
a
Compared with “Preserved urethral plate urethroplasty”.
complications included 302 fistulas, 108 dehiscence,
50 urethral strictures, 18 meatal stenosis, 38 diver-
ticula, 24 mild recurrent ventral curvature and 23
severe recurrent ventral curvature. A total of 363
(74.7%) patients needed 1 reoperation, 87 (17.9%)
needed 2 reoperations, 19 (3.9%) needed 3 reoper-
ations, and 17 (3.5%) needed >3 reoperations.
Ordinal logistic regression demonstrated that severe
recurrent ventral curvature, urethral stricture,
dehiscence and primary staged hypospadias repair
increased the risk of numerous reoperations, with
odds ratios of 75.991-fold, 36.967-fold, 11.765-fold
and 3.074-fold, respectively. In contrast, divertic-
ulum decreased the risk, with an odds ratio of 0.443-
fold.
Discussion
Our data demonstrated significant heterogeneity in
the risk of numerous reoperations for each compli-
cation. Severe recurrent ventral curvature
conferred the highest risk of numerous reoperations,
followed by urethral stricture, dehiscence. In addi-
tional, our data showed an increased risk of
numerous reoperations following primary staged
repairs. Identification the risk factors confers ad-
vantages in the assessment of postoperative out-
comes and anticipation of future reoperations.
Conclusion
Severe recurrent ventral curvature, urethral stric-
ture, dehiscence and primary staged hypospadias
repair were associated with numerous reoperations
following primary hypospadias repair.
95% CI P
29.834e193.560 <0.01
16.629e82.181 <0.01
5.876e23.556 <0.01
1.529e6.184 <0.01a
0.219e0.899 <0.05
61.e2
Introduction
Complications remain the top evaluation priority subse-
quent to hypospadias repair. The overall incidence was
approximately 5e10% for distal repair and 32e68% for
proximal repair [1,2]. Complications vary in further man-
agement, and usually require one or more reoperations.
Patients and/or their parents concern not only with the
success rate of reoperation, but also with the risk of
numerous reoperations. In this study, we described the
surgical outcomes of complications following primary
hypospadias repair, and analyzed the risk factors associated
with numerous reoperations.
Material and methods
Data were collected retrospectively from patients who
underwent reoperations for complications following pri-
mary hypospadias repair at a single institution from August
2008 to October 2017. Collected information included
initial meatal location, primary repair techniques, subse-
quent complications, age at reoperation, reoperative
techniques and the total number of reoperations. Compli-
cations included fistulas, dehiscence, urethral strictures,
meatal stenosis, diverticulum, mild recurrent ventral cur-
vature (RVC) and severe RVC. Approval of the ethical
committee was previously obtained.
Inclusion criteria
The inclusion criteria were as follows: ①Follow-up
completed more than 6 months after the last reoperation
and no specific complications were identified; or ②Any one
or more of above complications could still be identified
after 3 or more reoperations. Patients were excluded from
the cohort if any one of the first three reoperations were
performed in other institutions.
Additional remarks on complications
Fistula was considered an unwanted opening through the
skin along the course of the urethra and can result in uri-
nary leakage or an abnormal urinary stream.
Dehiscence was defined as the complete separation of
the urethra and/or glans wings. Coronal or subcoronal fis-
tulas beneath a thin bridge of skin holding dehisced glans
wings were also classified as dehiscence [3].
Meatal stenosis or urethral stricture was diagnosed by
both obstructive voiding symptoms and further calibration
<8-Fr in infants, <10-Fr in prepubescent individuals, or
<12-Fr in postpubescent individuals. Meatal stenosis was
considered obstruction at the meatus, and urethral stric-
ture was obstruction at any other part of the neourethra.
Diverticulum was defined as visible neourethra
ballooning during voiding.
Recurrent ventral curvature was defined as either a
curvature degree greater than 30 before reoperation or
greater than 15 after degloving. According to the critical
value of 30 after degloving, RVC was further divided into
two subtypes: mild RVC and severe RVC.
W. Ru et al.
Reoperation algorithm
Decision-making of reoperation for each complication was
standardized between six surgeons who had at least 10
years’ experience in pediatric urology. Commonly, reoper-
ations were performed by the surgeon who operated on
primary hypospadias, but some were not limited to the
same surgeons.
Surgical correction of remaining RVC after degloving was
considered based on the following circumstances: ① if the
curvature degree was less than 15 , the RVC usually did not
require any more correction; ② if the curvature degree was
between 15 and 30 , the RVC was corrected by dorsal
plication; and ③ if the curvature degree was greater than
30 , the RVC was corrected by urethral tissue transection
with or without constrictive urethral tissue excision, and
the residual RVC (15e30 ) was corrected by three ventral
corporotomies with or without dorsal plication.
After RVC correction, urethroplasty was performed with
a variety of surgical techniques. Coronal or subcoronal fis-
tulas beneath a thin bridge of skin holding dehisced glans
wings were usually corrected by urethra reconstruction
after reopening the bridge; a simple fistula closure was not
generally performed. Once urethral stricture occurred
(usually 1e3 months after last operation) and resulted in
acute urinary retention, a temporary urethrostomy was
performed, followed by permanent urethroplasty 6e12
months later. The decision to perform a urethroplasty
particularly focused on the health of the urethral plate and
local skin tissue. ①For healthy urethral tissue, urethra
reconstruction was corrected by Snodgrass, Duplay or
Mathieu techniques. ②For unhealthy urethral tissue with
high-quality local skin, urethroplasty was carried out with a
one-stage tubularized oral mucosal graft technique. ③For
unhealthy urethral tissue with poor-quality local skin, a
urethroplasty was carried out with a two-staged oral
mucosal graft Bracka technique. Lip mucosa was preferen-
tially used, followed by buccal mucosa and lingual mucosa.
The two-staged procedure was counted as two reoperations.
Meatal stenosis was repaired by meatotomy or meato-
plasty. In the case of meatal stenosis combined with severe
scarring, a meatoplasty with a dorsal skin graft inlay can be
performed [4].
A simple fistula closure can be carried out for fistula with
a healthy local urethra. Specifically, a distal glans fistula,
with a band of skin bridging the gap between the wings, was
corrected by reopening the bridge.
Neourethral coverage was routinely performed after
urethroplasty and fistula closure. Based on the principle of
proximity, coverage was harvested from the dartos fascia,
scrotal fascia or a combination of the two if the donor had
good vascularity and redundancy. Otherwise, coverage was
harvested from the tunica vaginalis.
Local skin tissue with poor blood supply or obvious
scarring was excised. In cases of ventral foreskin deficiency
after urethroplasty, a pedicled scrotal flap was harvested
for foreskin coverage.
Penile scrotal transposition was corrected in conjunction
with complication management. If there was no complica-
tion, penile scrotal transposition was corrected, but the
procedure was not counted in the number of reoperations.
Numerous reoperations following primary hypospadias repair 61.e3

Postoperative follow-up and evaluation

Table 1 Patients demographics and outcomes of
reoperations.
Routine follow-up for all patients included assessment in
the clinic at 6 weeks and 6 months postoperatively and No. pts 486
continuing annual telephone interviews. Further assess- Median age (range) 2.2 (0.9e17.3)
ment in the clinic was carried out if a suspicion of Median follow-up period (range) 6.5 (2.3e11.8)
complication arose from a telephone interview. Initial meatal location (%)
Distal and midshaft 141 (29%)
Proximal shaft and scrotal 309 (63.6%)
Statistical analyses Perineal 36 (7.4%)
Primary repair techniques (%)
The aim of the study was to compare the potential risk Preserved urethral plate urethroplasty 307 (63.2%)
factors for number of reoperations by 1, 2, 3 and > 3. Po- Duckett procedure 121 (24.9%)
tential risk factors included age at first reoperation, initial Staged urethroplasty 58 (11.9%)
meatal location, primary repair techniques and subsequent Complications
complications (each complication was identified as a Fistula 302
separate variable). Ordinal logistic regression was per- Dehiscence 108
formed to analyze the association between number of Urethral stricture 50
reoperations and the potential risk factors included in the Meatal stenosis 18
model. The odds ratios (ORs) of potential risk factors for Urethra diverticulum 38
numerous reoperations were confirmed. The level of sta- Mild RVC 24
tistical significance was prospectively identified to be Severe RVC 23
P < 0.05. All analyses were carried out using SPSS software, Number of reoperations
version 20 (SPSS, Chicago, IL, USA). 1 363 (74.7%)
2 87 (17.9%)
3 19 (3.9%)
Results >3 17 (3.5%)

A total of 507 patients required reoperations for compli-

cations following 2754 primary hypospadias repairs. The
overall incidence of complications was 18.4%. Eventually,
486 patients with a median age of 2.2 years for first reop-
eration (range 0.9e17.3 years) were eligible for inclusion.
In the remaining 21 patients, 10 were excluded because of
loss to follow-up, 6 were excluded because further reop-
eration was needed after one or two reoperations, and 5
were excluded because any one of the first three reoper-
ations were performed in other institutions. The median
follow-up period was 6.5 years (range 2.3e11.8 years).
Patients demographics and number of reoperations are
shown in Table 1. The initial meatal location was distal or
midshaft in 141 (29%) patients, proximal shaft and scrotal in
309 (63.6%) patients and perineal in 36 (7.4%) patients.
Preserved urethral plate urethroplasty for primary repair
(including Snodgrass, Onlay and Mathieu techniques) was
performed in 307 (63.2%) patients, Duckett technique was
performed in 121 (24.9%) patients, and staged ure-
throplasty (including staged Duckett, Byars and Bracka
techniques) was performed in 58 (11.9%) patients. Com-
plications included 302 fistulas, 108 dehiscence, 50 urethral
strictures, 18 meatal stenosis, 38 diverticula, 24 mild RVC
and 23 severe RVC. A total of 67 (13.8%) patients presented
two or more complications. Specially, severe RVC was cor-
rected at the median age of 9.1 years (range 1.5e17.2),
which was statistically older than the overall median age of
2.2 years (P < 0.01). Reoperations were performed ranging
in number from 1 to 6, which are detailed as follows: 363
(74.7%) patients needed 1 reoperation, 87 (17.9%) patients
needed 2 reoperations, 19 (3.9%) patients needed 3 reop-
erations, and 17 (3.5%) patients needed >3 reoperations
(including patients who had undergone 3 reoperations but
still needed more).
The association between potential risk factors and
numerous reoperations was shown in Table 2. Severe RVC,
urethral stricture and dehiscence increased risk of
numerous reoperations, with ORs of 75.991-fold (95% CI
29.834e193.560, P < 0.01), 36.967-fold (95% CI
16.629e82.181, P < 0.01) and 11.765-fold (95% CI
5.876e23.556, P < 0.01), respectively. In contrast, diver-
ticulum decreased the risk of numerous reoperations, with
an OR of 0.443-fold (95% CI 0.219e0.899, P < 0.05).
Compared with preserved urethral plate urethroplasty for
primary repair, staged urethroplasty increased risk of
numerous reoperations, with an OR of 3.074-fold (95% CI:
1.529e6.184, P < 0.01), while Duckett technique did not.
Fistula, meatal stenosis, mild RVC, age and initial meatal
location were not associated with numerous reoperations.
Discussion
This reoperations-based study identified the risk factors
associated with numerous reoperations following primary
hypospadias repair. Most patients needed only one reop-
eration for complications, but 25.3% of patients still needed
more. The data demonstrated significant heterogeneity in
the risk of numerous reoperations for each complication.
Severe RVC conferred the highest risk of numerous reop-
erations, with an extremely high OR of 75.991. Urethral
stricture was the second highest, at 36.967, and dehiscence
was the third highest, at 11.765. In additional, our data
showed an increased risk of numerous reoperations
following primary staged repairs. Identification the risk
factors confers advantages in the assessment of
61.e4 W. Ru et al.

urethroplasty when combined with urethral stricture or

Table 2 Ordinal logistic regression analysis of potential
other complications. Sam [9] utilized the expanded tissues
risk factors associated with numerous reoperations.
of both the diverticulum and the overlying skin to create an
Odds ratio 95% CI P island of diverticular roof with its blood supply from over-
Age (1 year 1.035 0.977e1.095 0.242 lying skin as a composite flap that could be advanced
increments) adequately without loss of vascularity.
Initial meatal location In recent decades, lower complication incidence has
Perineal 2.213 0.816e6.004 0.119a been associated with a staged approach for primary hypo-
Proximal shaft 1.492 0.670e3.320 0.327a spadias [10e12]. However, a staged approach increases the
and scrotal number of primary repairs, and may not reduce the total
Distal and number of operations [13]. Therefore, debate continues as
midshaft to whether a single stage or staged technique is superior.
Primary repair techniques Snodgrass’s study supported the theory that the vascularity
Staged 3.074 1.529e6.184 <0.01b of penile tissues decreases with successive operations,
urethroplasty which obviously affects wound healing [6]. Due to the
Duckett 1.266 0.684e2.344 0.453b increased risk of numerous reoperations, it is necessary to
procedure reconsider the increasing prevalence of staged repairs for
Preserved primary proximal hypospadias, particularly for those that
urethral plate are eligible for one-stage repair.
urethroplasty There is still no consensus on the optimal algorithms for
Fistula 1.557 0.845e2.871 0.156 reoperation. Nozohoor [7] proposed an algorithm for failed
Dehiscence 11.765 5.876e23.556 <0.01 hypospadias utilizing the remaining local skin tissue but did
Urethral stricture 36.967 16.629e82.181 <0.01 not propose a solution if local skin tissue was insufficient.
Meatal stenosis 1.225 0.342e4.384 0.755 Craig [14] proposed an algorithm for failed hypospadias in
Urethra 0.443 0.219e0.899 <0.05 adults that detailed the treatment for urethral stricture but
diverticulum did not include urethral tissue transection for severe RVC
Mild RVC 1.795 0.694e4.641 0.227 correction. In our algorithm, RVC correction was at the top
Severe RVC 75.991 29.834e193.560 <0.01 of the list, and the selection of technique for further ure-
throplasty depended on the health of urethral plate and
The test of parallel lines showed that the location parameters
local skin tissue.
(slope coefficients) were the same across response categories
(P Z 0.073). RVC was underreported and often recurred after puberty
a
Compared with “Distal and mid shaft”. [15,16]. Our data showed that severe RVC tended to occur
b
Compared with “Preserved urethral plate urethroplasty”. in older children (median age of 9.1 years vs overall median
age of 2.2 years). Thus, some younger patients who suf-
fered mild RVC without any other complications were
postoperative outcomes and anticipation of future waiting until puberty for correction and were not included
reoperations. in this study. Long-term follow-up into adolescence was
Essentially, the complexity of reoperation was associated essential to identify the possibility of progressive RVC.
with the extent of the urethral defect and the quality and The influence of age on primary hypospadias repair or
quantity of available local materials for urethroplasty. Se- reoperation varied in different studies. Our previous study
vere RVC was corrected by urethral tissue transection or indicated that age was not associated with complications
constrictive urethral tissue excision at our institution, incidence following primary repair [17]. This study indi-
although this resulted in a large area of urethral tissue cated that age was also not associated with numerous
deficiency with or without foreskin deficiency. Urethral reoperations. Thus, there was no extra disadvantage in
stricture after hypospadias repair was usually caused by delayed RVC correction after puberty. Initial meatal loca-
severe scarring, and increased higher surgical complexity tion has been traditionally considered when dealing with
than either trauma, idiopathic or catheter-associated ure- complications. However, in contrast to prior belief, the
thral stricture [5]. Dehiscence was usually associated with location was not significantly associated with numerous
necrosis of the ventral foreskin and/or poor healing of glans reoperations for complications in our data. This implied
wings. Although urethral plate tissue was relatively avail- that, when dealing with complications, more attention
able, local skin tissue may have been insufficient and/or full should be paid to the primary surgical techniques rather
of scars. The above-mentioned three complications were than the initial meatal location.
called “failed hypospadias” in some studies [6e8]. One or Our study has several limitations. Complications, espe-
two-stage oral mucosal graft techniques were more com- cially RVC, may be underreported and can result in detec-
mon used to treat the patients with less available urethral tion bias. Due to the shortage of complete information,
and skin tissue after failed hypospadias repairs. Techniques some patients who underwent operations at other in-
with a relatively low incidence of the three complications stitutions were not included in the cohort, and thus, se-
are worth promoting for primary hypospadias repair. lection bias could have occurred. Furthermore, the results
As a complication, diverticulum required surgical man- we present were based on our reoperation algorithms and
agement. Interestingly, diverticulum decreased the risk of may not be generalizable to those who manage hypospadias
numerous reoperations in our analysis. Available additional and its surgical complications differently. Further study is
material from diverticulum may be beneficial in needed to verify selection of algorithms.
Numerous reoperations following primary hypospadias repair
In conclusion, this study identified the risk factors
associated with numerous reoperations following primary
hypospadias repair. Severe recurrent ventral curvature
conferred the highest risk of numerous reoperations, fol-
lowed by urethral stricture, dehiscence and primary staged
hypospadias repair.
Funding
This work was supported by the Zhejiang Provincial Program
for the Cultivation of High-level Innovative Health Talents
(grant numbers 2016e6).
Conflict of interest
None.
Acknowledgments
None.
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