Predictors of Postoperative Complications after Primary Distal and Midpenile Hypospadias Repair: A Retrospective Cohort Study

A BSTRACT Aim: The aim of the study was to identify preoperative predictors of postoperative complications after primary tubularized incised-plate urethroplasty (TIPU) for distal and midpenile hypospadias and to determine whether obstructive and structural complications have different risk profiles. Materials and Methods: This retrospective cohort study included 166 consecutive boys who underwent primary TIPU between February 2023 and January 2025. Patients with residual ventral curvature >30° after degloving were excluded, resulting in a homogeneous plate-preserving cohort. Multivariable logistic regression was performed using glans diameter, meatal position, and age as prespecified covariates. Urethral-plate quality and spongiosal development were analyzed using Firth penalized logistic regression because of near-complete separation. Results: Postoperative complications occurred in 35 patients (21.1%), including meatal stenosis or urethral stricture in 13.3% and urethrocutaneous fistula in 6.6%. Midpenile meatal location (odds ratio [OR] 5.61), smaller glans diameter (OR 0.53 per mm), and older age (OR 1.73 per year) were independently associated with complications (all P < 0.001), with the strongest associations observed for obstructive complications. Poor urethral-plate quality showed the strongest association with postoperative complications (OR 68.5) in Firth regression and was associated with smaller glans diameter and a more proximal meatal position. Conclusion: Postoperative complications after primary TIPU are heterogeneous, and obstructive and structural complications demonstrate different patterns of association. Glans diameter and meatal position are simple anatomical variables that independently predict postoperative complications and may improve preoperative risk stratification in boys undergoing plate-preserving TIPU.