Anatomical and intraoperative predictors of surgical complications after distal hypospadias repair with foreskin reconstruction: a prospective study

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PURPOSE: This study aimed to evaluate anatomical and intraoperative risk factors predicting complications following distal hypospadias repair with foreskin reconstruction in pediatric patients. METHODS: A prospective analysis was conducted on all patients with distal hypospadias undergoing tubularized incised plate urethroplasty (TIPU) with foreskin reconstruction over a 2-year period. Intraoperative measurements-stretched penile length, glans width, glans groove width, meatal position, ischemic time and preputial symmetry-were recorded. Postoperative complications and reoperations were analyzed through multivariate logistic regression to determine independent predictors. RESULTS: The patient cohort included 71 operated boys. Median patient age was 2.4 years (range 1-9.1), and median follow-up was 12.8 months. The most frequent complications were foreskin dehiscence (12.7%), non-retractile foreskin (12.7%), meatal/urethral stenosis (11.3%), and urethrocutaneous fistula (7.0%). Prolonged ischemic time (> 60 min) independently predicted foreskin dehiscence (p = 0.03) and reoperation (p = 0.003). Shorter PL (≤ 3 cm) was associated with higher stenosis rates, while more proximal distal meatal position (subcoronal/midpenile) increased the risk of foreskin dehiscence (p = 0.0006), fistula (p = 0.007), and reoperation (p = 0.02). Age > 2 years significantly predicted meatal/urethral stenosis (p = 0.01) and reoperation (p = 0.001). Preputial asymmetry correlated with foreskin dehiscence (p = 0.006), whereas glans width and groove width showed no significant associations (p > 0.05). CONCLUSION: Prolonged ischemic time, shorter penile length, more proximal distal meatal position, asymmetric prepuce and older age at surgery are independent predictors of postoperative complications and reoperations after distal hypospadias repair with foreskin reconstruction. Careful preoperative assessment, minimizing intraoperative ischemic duration, and considering earlier surgery before 2 years of age may improve both functional and cosmetic outcomes.

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