Hypospadias is the most common genital malformation in boys, yet a unified approach has proven elusive to urologists for many reasons. Studies suggest that late failures in the form of fistulae and recurrent strictures do happen. Moreover, there is poor association between surgeon perception of cosmesis and function and the patient perception.¹ Some have reported decisional regret by both parents and patients later in life.² Patients with multiple failed repairs may be relegated to several operations before and after puberty and have both psychological and physical distress as each subsequent repair proves more likely to fail.

In an adult reconstruction population the majority of patients presenting with problems (approximately 60%) demonstrate severe scarring and lack of skin for coverage from multiple prior repairs. A minority (13%) of adults present never having had any corrective operations, usually from lichen sclerosus-associated strictures.³ The remaining typically had a single repair in childhood followed by failure in adult life. This suggests that all patients born with hypospadias, whether they have been repaired previously or not, may be at risk for urethral problems in adulthood. In addition to urethral strictures and fistulae, patients can present with recurrent urinary tract infections from sacculation or stone formation, chordee, penoscrotal transposition or concerns about length or quality of erections. The complications seen in adults in 2021 represent repairs done prior to the proliferation of modern pediatric hypospadias repair techniques, so there is hope that the severity of late complications will decline in future generations. All patients with prior hypospadias repair in childhood should be examined by a urologist after puberty and screened for stricture, fistula, recurrent chordee and satisfaction with cosmesis.

Figure. (A) Although most hypospadias patients requiring urological surgery in adult life present with recurrent stricture or fistula associated with neourethra, some may be more complex. (B) A retrograde urethrogram demonstrates a stricture in the neourethra as well as a midpenile fistula (arrows).

The most important factor in successfully treating hypospadiac adults is a clear understanding of patient goals and realistic explanation of what is achievable surgically. As with pediatric repairs, a diminutive glans with a shallow cleft may not permit successful construction of a terminal meatus. Chordee correction is almost always achievable but typically at the expense of dorsal length loss. Therefore, the practical impact of the chordee on function and the cost of correction must be clearly explained. The most severely affected patients, those born with penoscrotal hypospadias and ambiguous genital appearance, often demonstrate associated impaired androgenization, subfertility and penile length challenges. Addressing these covariables directly can be difficult but is critical to aligning expectations and reality.

Looking to the future, there are increasing calls to delay genitalia altering surgeries until after the age of assent. International bodies, like Human Rights Watch, Amnesty International and the European Union are already moving to legislate prevention of pediatric genital altering surgery. Concurrently, many cultures have shifted away from a binomial definition of sexuality and by association from a binomial acceptance of genital ideal. It still remains to be determined how changing political forces and societal norms will impact the ability of urologists to perform hypospadias repairs and the willingness of parents and patients to submit to them. However, it will be incumbent on urologists to better characterize long-term effects and understand differences in outcomes of repairs done before and after puberty so that parents and patients can make informed decisions.