This paper is evidence of an increasing trend (especially in the USA) to lower the age at which hypospadias repair is undertaken. The current generalised best accepted age to repair hypospadias is between 6-18 months, which was reduced in the mid 1990s from over three years of age. The main determining factors to consider are penile size, genital awareness and anaesthetic risk. Penile size does not appreciably change after the mini-puberty of the first three to four months of age. Anaesthetic risk is said to be lower after the age of one year. Apparent reduced patient co-operation is said to occur between ages two and a half to four years so surgery is avoided at this age if possible. A number of reports have suggested that complications increase if surgery is carried out after six months or certainly 12 months of age, although the reason for this is unclear. These authors reviewed their database of 967 hypospadias repairs, of which 843 were tubularised incised plates (TIP) procedures, 687 had > one-month follow-up and 669 were pre-pubertal procedures (mean age 17.1 months / SD 22.5 – of whom 230 were under six months of age at time of operation; and mean follow-up at nine months / SD 11.9). Complications occurred in 77. None of the patients under six months experienced an anaesthetic complication (unanticipated overnight hospital stay / cardiac arrest) apart from five aged three to five months who had intraoperative bronchospasm documented in the anaesthetic record but that did not prevent discharge the same day. Multiple logistic regression analysis showed that re-operative TIP and meatal location were the only independent risk factors for complications with age, learning curve and suture used all non-contributory. The authors do not make any specific recommendations but only question the rationale for operating at over six months. The major flaw in this cohort study is the short follow-up, which at nine months postoperative means that many patients would still have been in nappies without a full assessment of stream direction, observation or otherwise of functional outcome. It is well known that late fistulae and other complications can occur as much as two to four years post surgery for hypospadias.

Age does not impact risk for urethroplasty complications after tubularised incised plate repair of hypospadias in prepubertal boys.
Bush NC, Holzer M, Zhang S, Snodgrass W.
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Henrik Steinbrecher

Southampton University Hospital NHS Trust

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