Hypospadias: a critical analysis of cosmetic outcomes using photography.

OBJECTIVE: To analyse the cosmetic outcome of hypospadias surgery using photography, rather than the classical assessment by reoperation rate secondary to fistula, diverticulum, stenosis and residual penile curvature. PATIENTS AND METHODS: The study included 181 consecutive patients with hypospadias who underwent surgery between 1997 and 1999. Distal hypospadias (47) was repaired using either the 'meatal advancement and glanuloplasty' or the glans approximation procedure. Proximal hypospadias (68) was repaired using the onlay island-flap technique with preservation of the urethral plate. Penile curvature when present was corrected by dorsal plication ( approximately 20%). Two patients with perineal hypospadias required a two-stage repair. Complex repeat repairs (36) were defined as those patients who had undergone previous surgery 1-7 times and required a new urethroplasty by a secondary onlay island-flap technique. The follow-up ranged from 6 months to 3 years. Photographs of the penis were taken before, immediately and 3-12 months after surgery; these were assessed to document objectively the cosmetic outcome. The final photographs were evaluated for overall appearance, a mucosal collar, the location and configuration of the meatus. The standard was to create a penis that would pass cosmetically as a normal circumcised penis.
RESULTS: The patients who had chordee without hypospadias (15) and fistula repair (13) did not undergo glanuloplasty and therefore were not included in the final photographic analysis; this left 153 patients with follow-up photographs. There were five cases of urethral fistula (7%) and one of meatal stenosis (1%) in the proximal group, and three of fistula (8%) and two meatal stenosis (6%) in the complex group. The distal group had one complication (haematoma) and the two-stage group had no complications. Analysis of the photographs showed that most patients had the appearance of a normal circumcised penis. Not unexpectedly, the patients who had undergone previous surgery had the least satisfactory results (60% appearing normal) compared with the proximal and distal groups (76% and 82% appearing normal, respectively).
CONCLUSIONS: Hypospadias can be repaired safely with few complications in a single stage in most patients. Classical complications such as fistula and stenosis occur in < 10% of patients, including those undergoing complex revisions. Cosmetic outcomes are generally good and photography is an objective means to document the appearance.