Adult hypospadias repair
Primary and redo reconstruction in adults, including men whose childhood repair has broken down decades later.
What the surgery aims to achieve
Adult hypospadias repair has three goals, and they are not always achievable in equal measure:
- Function — a straight, forward-directed stream from an opening at or near the tip, with no fistula, no stricture and the ability to stand to pass urine
- Straightness — correction of chordee so that intercourse is comfortable and effective
- Appearance — a result you are comfortable with
Where a compromise has to be made, it is made in consultation with you. A durable functional result in a heavily scarred penis sometimes matters more than a perfect cosmetic one, and you should be part of that decision.
Primary versus redo repair
Primary repair in an adult who has never had surgery is generally more straightforward, because the tissue is healthy, the blood supply is intact and the foreskin is often available for use.
Redo repair after previous childhood surgery is a different undertaking. The local skin is scarred, the blood supply has been disturbed, the foreskin has usually already been used or removed, and the anatomy has been altered. Techniques that work in children do not necessarily transfer, and importing tissue from elsewhere is typically necessary. This is among the more demanding areas of reconstructive urology and warrants a surgeon who does it regularly.
The operations
The plan is built around what is wrong and what tissue is available:
- Fistula repair — closing an abnormal opening leaking urine along the shaft, with healthy tissue interposed to prevent recurrence
- Meatoplasty — widening or repositioning the opening, using staged or Malone techniques where appropriate
- Chordee correction — releasing the tethering tissue, with plication or grafting to straighten the shaft
- Single-stage urethroplasty — rebuilding the urethra in one operation where enough healthy local tissue exists
- Two-stage reconstruction — the first operation opens the urethral plate, removes scar and lays down a buccal or preputial graft; the second, usually around six months later, forms that graft into a tube. This is the reliable route in scarred, multi-operated cases
- Stricture repair where a narrowing has developed at the site of a previous repair — see urethroplasty
- Hair removal by laser before reconstruction, where hair-bearing skin was used in a previous repair or will need to be used
Why two stages is often the right answer
Men understandably want it done in one operation. But in a heavily scarred penis, a graft needs time to take and develop its own blood supply before it can safely be formed into a tube. Attempting everything at once in poor tissue is the commonest reason redo repairs fail. Two well-planned stages produce a more durable result than one ambitious operation followed by a third and fourth attempt.
Assessment
Planning requires a detailed record of every previous operation — original operative notes are extremely helpful if your family or the treating hospital can provide them. Examination assesses the position of the meatus, the presence and degree of chordee, the quality and quantity of usable skin, and any evidence of lichen sclerosus, which rules out the use of affected genital skin as graft. Investigation includes flow rate measurement, flexible cystoscopy and urethrography. Where fertility or sexual function is affected, those are assessed alongside.
Recovery
Surgery is performed under general anaesthetic, usually with an overnight stay. You will go home with a catheter, generally for two to three weeks, and sometimes with a dressing that stays in place for several days. Where buccal graft has been taken, your mouth will be sore for one to two weeks.
Most men return to desk work within two to three weeks. Avoid heavy lifting, cycling and strenuous exercise for around six weeks, and sexual activity for six weeks or as advised. If you are having a two-stage repair, the interval between operations is typically six months, during which the graft matures.
Risks
Risks include fistula formation, stricture at the repair, graft contraction or partial loss, wound infection, bleeding, recurrent chordee, a cosmetic result that differs from expectation, and the need for further surgery. Redo cases carry higher rates of all of these than primary repairs, and I will be direct with you about the realistic prospects in your particular case rather than optimistic.
My practice
Primary and redo adult hypospadias repair is a core part of my reconstructive practice. I set up and lead the Southeast London Urethral Reconstruction Team at Guy's Hospital, established in 2012, and I use the full range of techniques including staged repair, buccal, lingual and preputial grafting, and staged and Malone meatoplasty. I teach these techniques nationally and internationally and accept tertiary referrals from other units.
Frequently asked
How many operations will I need?
It depends entirely on what is found. A simple fistula may need one small operation. A heavily scarred multi-operated penis usually needs a planned two-stage repair. I will give you a specific plan after assessment, and I would rather tell you at the outset that two operations are likely than promise one and deliver three.
Can I have surgery if I had my repair as a child in another country?
Yes. Missing operation notes make planning harder but not impossible — cystoscopy, urethrography and examination establish the current anatomy. Bring whatever records you have.
Will I be able to stand to pass urine afterwards?
That is one of the primary goals of the repair and is achieved in most men. Where the original opening is very proximal or the tissue is severely compromised, the realistic target may be a straight, controllable stream rather than an opening at the very tip. This is discussed before surgery.
Is there an age limit?
No. Adults of all ages undergo hypospadias reconstruction. General health and tissue quality matter far more than your date of birth.
Will surgery help my fertility?
If a proximal opening is preventing semen being deposited effectively, repair can improve the chance of natural conception. Hypospadias does not itself affect sperm production. If you are also concerned about fertility, it can be assessed at the same time — see male infertility.
Speak to my team
Appointments at The Shard and Canary Wharf are arranged by my PA, Jeanette Bush. Tell us briefly what the problem is and we will find the right clinic slot for you.