Is there an ideal age for hypospadias repair?: A reasonable quest

Dear Editor, In hypospadias repair, surgery is performed to reconstruct the anatomy so that the penis looks normal aesthetically, allows normal micturition and unimpaired sexual function, and to ensure good quality of life and normal psychological adjustment. Hypospadias surgery itself is highly stressful and, in conjunction with a quite long hospital stay, prolonged catheterization, and postoperative pain, can impact a child’s short- and long-term adjustments. These factors may become more important in the case of multiple surgeries or multistaged repairs1,2. It is well known that, at certain ages, children are more vulnerable to psychological trauma and anxiety related to surgery2. The American Academy of Pediatrics considers the age between 6 and 12 months to be the best time for surgery for hypospadias. This was based on the consideration that surgery at a very early age shortens the period during which the condition remains apparent to the family, thereby resulting in better psychosocial adjustment and family integration. Emotional and cognitive development, acquisition of body image, and sexual identity begin in early childhood. Considering these factors, especially genital awareness and a period of special emotional risks occurring around the age of 18 months, it was, therefore, suggested to complete surgery before this age2,3. Discussion on the best timing of hypospadias repair is also based on the assumption that the outcome can be affected by the age at which hypospadias repair is performed. This means that the age at which an optimal surgical outcome can be achieved may not necessarily be identical to the age at which the psychological adjustment is affected least. Therefore, what is the best age for hypospadias repair when we can expect the optimum outcome?” Factors that can influence the timing of hypospadias repair include the combination of environment in which the patient is to be managed, risk of anesthesia, severity of hypospadias, and the psychological effect of genital surgery. After the age of 6 months, the risk of anesthesia is lesser compared with much earlier, provided the anesthesia is administered in a dedicated pediatric facility. Penile size is not a limiting factor as moderate penile growth occurs in the first few years of development, and there is no technical advantage in delaying surgery. At 1 year of age, penile length is on average, only 0.7 to 0.8 cm less than at preschool age4. In the current era, even in patients with a very small penis, use of hormonal therapy is widely accepted because initial concerns about subsequent downregulation of androgen receptors appear to be unfounded. Testosterone enanthate (25 mg) administered intramuscularly or topical dihydrotestosterone cream, applied locally, are both viable options. Some studies suggest that initial hypospadias repair at a later stage in life may be associated with a higher rate of post-operative complications. Post-operative factors, like the urethral secretions, bladder contractions, and erections, may influence on the occurrence of complications. These controversial findings, including possible anesthetic risks, psychological impact, and post-operative complications, have led to discussion as to whether or not surgery should be delayed5. Current recommendations suggest that the optimum age for genital surgery is before 18 months, as delaying surgery beyond this age may negatively impact a child’s psychological development. Adequate penile growth is generally achieved by this time; however, the optimal age for surgical intervention remains debated and is influenced by factors such as anesthetic risks, tissue dimensions at different ages, postoperative complications, and psychosocial impact.