Hypospadias Repair Impact of Perioperative and Operative Variables on Early Postop Complications

Dear All,

I am rather confused with this article from ‘Urology’. I always believed that technically demanding procedures like Hypospadias be better performed in the morning hours than afternoon. The article seems to be having an opposed view. A significant increase in the rate of any complication was noted with morning vs afternoon cases for the group overall with morning cases having a hazard 2.3 times higher than afternoon cases.

I always believed that technically complex procedures are better performed in the morning hours when the surgeon is fresh. I would appreciate the views of others on this matter.

With warm Regards,


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  • Amilal Bhat
    Amilal Bhat
    10 Jan 2023 08:59:19 PM

    Dear all

    Sorry for the delay in posting the comments

    I compliment the authors for their well conducted study. There are many studies on the variables on hypospadias repair. I have also dedicated a full chapter to the variables in hypospadias repair in my book titled Hypospadiology : Principles and Practices.  

    1. I agree with the authors age being an independent variable. We also conducted a prospective study published in Journal of pediatric Urology and the same is cited in European guideline for hypospadias. The article is attached for ready reference.

    2.     With due regards to Authors, I have my reservation about their view on the type of hypospadias, application of tourniquet and timing of surgery.  

    3.     As far as the severity of hypospadias is concerned our study results were: “There was a statistically significant (p-value = 0.001) correlation of hypospadias severity with complications rate; 30% was seen in proximal (proximal penile 11, penoscrotal 6, and perineal 3) compared to 5.7% in distal hypospadias and 11.1% in mid penile hypospadias.”

    4.  In our experience application of the Tourniquet/ local adrenaline does not have impact on the outcome of the surgery.

    5. Similarly, the duration of surgery depends on the type of hypospadias as well as the type of the repair. Severe hypospadias and flap tube repair takes longer time which was not considered by the Authors while comparing the time and the type of surgery.  In our experience severe hypospadias and flap tube repair take longer time and exhibit poorer results as compared to Thiersch Duplay (complication rate: 20% vs 5-7%).

    6. The new variable authors  have  evaluated are the morning and afternoon surgery.  I have my reservation about it. Authors have not mentioned in their afternoon set up what type of surgery was done in the morning session and how much tiring was this one?

    Similarly in the morning session the number of surgical procedures for the day following the hypospadias surgery and  whether the surgeon has to rush through to complete the surgery may be contributory factors. Another important point is tiredness of the assistants and nursing staff.

    Multiple previous surgeries, movements of many people are likely to compromise sterilization of the OT environment, which may be dangerous in hypospadias surgery.  

    Hypospadias surgery has to be done by the surgeon with a relaxing and cheerful mood, fresh mind with least / no tension. Most of the surgeons, assistants and nursing staff in our set up are fresh the morning hours. My own preference is to take hypospadias as first case in my OT list.  One should not change his practice by one observational study, Surgeon should follow is way, he is comfortable. The authors have also advised the same “As noted, not all potential factors associated with risk of hypospadias complications carry the same risk across all surgeons, so the reader is cautioned not to over-extrapolate our findings to their own practice.”

    7.  In hypospadias surgery Severity of hypospadias, Degree of chordee, Development of urethral plate and spongiosum, type of repair ,age of the patient  and size of glans and penis are independent risk factor , but the suture material type and size , use of tourniquet/ local infiltration, caudal anaesthesia and type of dressing   does not have significant impact on the outcome of hypospadias surgery. The gist of a successful repair is proper approximation of urethral / skin tissue, maintaining proper plane of dissection to keep blood supply intact, proper selection of technique and your own satisfaction at the completion of the surgery.   

    8. An important point which is rarely studied and discussed is to review whether your decision about the surgical choice was right or the other technique might have been better after completion of the surgery. As far warm up, in my opinion performance on the OT table and athletes are different. On the contrary the strenuous muscle exercises may compromise the fine and delicate moments of the fingers required for hypospadias and similar other delicate surgeries       



    Amilal Bhat      

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