Boys Undergoing Hypospadias Repair Research Articles

Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair.

Hypospadias is a syndrome of penile maldevelopment. The primary goal of hypospadias surgery is to create a penis with normal appearance and function. Historically, the outcome of hypospadias repair has been assessed based on the need for reoperation due to urethroplasty complications (UC), including fistula formation, dehiscence, meatal stenosis, or development of a urethral stricture. The Glans-Urethral Meatus-Shaft (GMS) score is a standardized tool to predict UC. Analysis of the cosmetic outcomes of hypospadias repair based on the appearance of the reconstructed penis has been validated, and standardized scores have been published. The Hypospadias Objective Penile Evaluation (HOPE) score is a validated questionnaire used to assess postoperative cosmetic outcomes. Although predictors of surgical outcomes and UC have been well documented, predictors of optimal cosmetic outcomes are lacking in the literature. Furthermore, reoperation due to cosmetic considerations has been poorly reported. To identify predictors of cosmetic outcomes after hypospadias repair and to assess the reoperation rate according to cosmetic considerations. This prospective cohort study included 126 boys who underwent primary hypospadias repair. The severity of hypospadias, degree of penile curvature, glans width, preoperative HOPE, and GMS scores were documented. The standard technique for single-stage repairs, the tubularized incised plate urethroplasty, was performed. The primary endpoint was cosmetic outcomes evaluated by the HOPE score questionnaire six months postoperatively. Optimal cosmetic results were defined by HOPE scores ≥ 57. The study population consisted of the following cases: 87 (69%) subcoronal, 32 (25%) shaft, and 7 (6%) proximal hypospadias. Among the study participants, 102 boys (81%) had optimal cosmetic results (HOPE ≥ 57), and 24 boys (19%) had surgeries with suboptimal cosmetic outcomes (HOPE < 57). Ancillary procedures were performed in 21 boys (16%), of which 14 (11%) were solely for cosmetic considerations, and 7 were secondary to UC. Using the Receiver Operating Characteristic analysis of potential predictors of optimal cosmetic outcomes, the preoperative HOPE score had the highest area under the curve (AUC = 0.79; 95% CI 0.69-0.89, p < 0.001). After multivariable analysis, the degree of penile chordee (p = 0.013), glans width (p = 0.003), GMS score (p = 0.007), and preoperative HOPE score (p = 0.002) were significant predictors of cosmetic outcomes. Although meatal location predicted suboptimal cosmetic results in univariate analysis, it was not a factor in multivariable analysis. Over 80% of boys undergoing hypospadias repair achieved optimal cosmetic outcomes. More than 10% of cases underwent ancillary procedures, secondary solely to cosmetic considerations. Predictors of optimal cosmetic outcomes after hypospadias surgery included degree of chordee, glans width, and preoperative HOPE and GMS scores, which were the best predictors of satisfactory cosmetic results. Although meatal location is the main predictor of UC, it was not a predictor for cosmetic outcomes. Factors affecting cosmetic outcomes should be clearly explained to parents during the preoperative consultation.

Effects of Sex Hormones on Vascular Reactivity in Boys With Hypospadias.

Arteries from boys with hypospadias demonstrate hypercontractility and impaired vasorelaxation. The role of sex hormones in these responses in unclear. We compared effects of sex steroids on vascular reactivity in healthy boys and boys with hypospadias. Excess foreskin tissue was obtained from 11 boys undergoing hypospadias repair (cases) and 12 undergoing routine circumcision (controls) (median age [range], 1.5 [1.2-2.7] years) and small resistance arteries were isolated. Vessels were mounted on wire myographs and vascular reactivity was assessed in the absence/presence of 17β-estradiol, dihydrotestosterone (DHT), and testosterone. In controls, testosterone and 17β-estradiol increased contraction (percent of maximum contraction [Emax]: 83.74 basal vs 125.4 after testosterone, P < .0002; and 83.74 vs 110.2 after estradiol, P = .02). 17β-estradiol reduced vasorelaxation in arteries from controls (Emax: 10.6 vs 15.6 to acetylcholine, P < .0001; and Emax: 14.6 vs 20.5 to sodium nitroprusside, P < .0001). In hypospadias, testosterone (Emax: 137.9 vs 107.2, P = .01) and 17β-estradiol (Emax: 156.9 vs 23.6, P < .0001) reduced contraction. Androgens, but not 17β-estradiol, increased endothelium-dependent and endothelium-independent vasorelaxation in cases (Emax: 77.3 vs 51.7 with testosterone, P = .02; and vs 48.2 with DHT to acetylcholine, P = .0001; Emax: 43.0 vs 39.5 with testosterone, P = .02; and 39.6 vs 37.5 with DHT to sodium nitroprusside, P = .04). In healthy boys, testosterone and 17β-estradiol promote a vasoconstrictor phenotype, whereas in boys with hypospadias, these sex hormones reduce vasoconstriction, with androgens promoting vasorelaxation. Differences in baseline artery function may therefore be sex hormone-independent and the impact of early-life variations in androgen exposure on vascular function needs further study.

Vascular dysfunction and increased cardiovascular risk in hypospadias.

AimsHypogonadism is associated with cardiovascular disease. However, the cardiovascular impact of hypogonadism during development is unknown. Using hypospadias as a surrogate of hypogonadism, we investigated whether hypospadias is associated with vascular dysfunction and is a risk factor for cardiovascular disease.Methods and resultsOur human study spanned molecular mechanistic to epidemiological investigations. Clinical vascular phenotyping was performed in adolescents with hypospadias and controls. Small subcutaneous arteries from penile skin from boys undergoing hypospadias repair and controls were isolated and functional studies were assessed by myography. Vascular smooth muscle cells were used to assess: Rho kinase, reactive oxygen species (ROS), nitric oxide synthase/nitric oxide, and DNA damage. Systemic oxidative stress was assessed in plasma and urine. Hospital episode data compared men with a history of hypospadias vs. controls. In adolescents with hypospadias, systolic blood pressure (P = 0.005), pulse pressure (P = 0.03), and carotid intima-media thickness standard deviation scores (P = 0.01) were increased. Arteries from boys with hypospadias demonstrated increased U46619-induced vasoconstriction (P = 0.009) and reduced acetylcholine-induced endothelium-dependent (P < 0.0001) and sodium nitroprusside-induced endothelium-independent vasorelaxation (P < 0.0001). Men born with hypospadias were at increased risk of arrhythmia [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.4–5.6, P = 0.003]; hypertension (OR 4.2, 95% CI 1.5–11.9, P = 0.04); and heart failure (OR 1.9, 95% CI 1.7–114.3, P = 0.02).ConclusionHypospadias is associated with vascular dysfunction and predisposes to hypertension and cardiovascular disease in adulthood. Underlying mechanisms involve perturbed Rho kinase- and Nox5/ROS-dependent signalling. Our novel findings delineate molecular mechanisms of vascular injury in hypogonadism, and identify hypospadias as a cardiovascular risk factor in males.

A survey of parental perceptions and attitudes related to disclosure in hypospadias repair

Boys with hypospadias often undergo reconstructive surgery to improve cosmetic appearance and functional outcomes. While the ethics of physician-patient disclosure of illness are clear, parent-child disclosure is more ambiguous. There is a paucity of research regarding the parental disclosure of past urological procedures, specifically hypospadias repair. Our objective was to determine the rate of parental disclosure in boys undergoing hypospadias repair, and to evaluate the parental perspectives regarding concerns and amount of support in relation. A web-based questionnaire was distributed to parents of 240 hypospadias patients at our pediatric urology outpatient clinic over 12 months. The questionnaire assessed intent to disclose, decisional regret, and cosmetic perception. Data was analyzed using descriptive statistics and chi-square analyses. Two hundred and twenty-three survey responses were collected. The majority of respondents were urban dwellers (72.2%), and the mothers of the child (80.9%). Distal hypospadias was the most common variant of condition (62.7%). When asked if they plan to disclose the repair to their child, 93% said "yes", and of those, the optimal mean age of disclosure was 7.49±4.30 years. Ninety percent reported that they were not offered guidance on how/when to disclose, and 43% thought they would benefit from support on this. There was a significant difference in nervousness to disclose if the condition was distal versus proximal (χ2=15.19, p=<0.01), with proximal being more nervous. A significant difference was also observed regarding disclosure support with proximal being more likely to want formal support (χ2=4.55, p=0.03). As hypothesized, the majority of parents intended to disclose their son's surgery to them, but no statistically significant difference was seen between those with a distal vs. proximal repair. Additionally, demographic characteristics which were hypothesized to influence this decision (e.g., parents' level of education and relationship to the child) did not discriminate parental intent to disclose. To our knowledge, this is the first study to evaluate perceptions and attitudes around disclosure in patients with hypospadias and their families. The majority of respondents were planning to disclose the operation to their child, and were not offered any guidance or support as to the optimal way to disclose. Half of those parents thought they could benefit from resources to help them with this process. Further research is required to understand the impact of disclosure and to create tools to help caregivers with this responsibility.

SUN-551 Impaired Vascular Relaxation and Altered eNOS Regulation in Boys with Hypospadias

Background: Sex hormones influence vascular function. Whether boys with hypospadias who have insufficient androgen exposure during the masculinisation programming window have altered vascular function is unknown. Objective: To investigate whether vascular function is impaired in boys with hypospadias and to explore the putative role of eNOS. Methods: Peripheral arteries from excess foreskin tissue obtained from boys undergoing hypospadias repair (cases) or circumcision (controls) were used. Vascular function was assessed by myography. mRNA expression was measured by qPCR in vascular smooth muscle cells (VSMCs). Nitric oxide (NO) was measured by DAF fluorescence assay and peroxynitrite levels measured via ELISA. Results: 23 boys with hypospadias and 34 age-matched controls were studied. There were 18 (52%) cases of distal, 7 (22%) of midshaft and 9 (26%) of proximal hypospadias and none of them had biochemical evidence of hypogonadism or a variant in AR. Clinical cardiometabolic parameters were similar between groups. Endothelium-dependent relaxation to acetylcholine (ACh) and endothelium-independent relaxation to sodium nitroprusside (SNP) were reduced in arteries from cases vs controls (Emax %U46619: 72.4 vs 1.2, p<0.0001 and Emax %U46619: (42.7 vs 11.8, p<0.01 respectively). Incubation with the NO synthase inhibitor, L-NAME (1x10-5 M) worsened endothelial-dependent relaxation in controls (Emax % U46619: 76.8 vs 1.2, p<0.0001) but had no effect in cases (Emax % U46619:60.6 vs 72.4, p=0.3). Testosterone (1x10-7 M) ameliorated vascular relaxation (p<0.05), whereas17[[Unsupported Character - Symbol Font 𝝱]];-estradiol stimulation (1x10-9 M) did not. In cultured VSMCs, mRNA expression of eNOS and iNOS was reduced whereas that of nNOS was increased in cases versus controls. Nitric oxide production was reduced in cases (5 fold, p<0.01), as was peroxynitrite production (0.5 fold, p<0.05). Testosterone increased expression of eNOS in VSMCs. There was no difference in mRNA expression of the AR and GPRC6A but cases had increased expression of ESR1 (2.71 fold), ESR2 (2.63 fold) and GPR30 (2.86 fold) (p<0.05). Conclusion: Arteries in eugonadal boys with hypospadias show vascular dysfunction which involves impaired NOS/NO regulation effects that are ameliorated with testosterone but not oestrogen. These processes may predispose to long-term cardiovascular disease.

Re: The Association between Caudal Anesthesia and Increased Risk of Postoperative Surgical Complications in Boys Undergoing Hypospadias Repair

Re: The Association between Caudal Anesthesia and Increased Risk of Postoperative Surgical Complications in Boys Undergoing Hypospadias Repair

Abstract 040: Vascular Dysfunction and Androgen Deficiency - Insights From Children With Hypospadias

Background: Hypospadias in boys may be associated with a lack of androgen exposure during the masculinisation programming window. As testosterone has effects on the vasculature, we assessed whether boys with hypospadias show any evidence of vascular dysfunction. Methods: Excess foreskin tissue was obtained from boys undergoing hypospadias repair (cases) or circumcision (controls) and small arteries dissected from this tissue. Vascular contractility was assessed by wire myography in response to U46619 (thromboxane A2 analogue). Vascular smooth muscle cells (VSMCs) were cultured and generation of reactive oxygen species (ROS) was measured by amplex red and chemiluminescence. NADPH oxidase (Nox) mRNA expression was measured by qPCR. Results: 19 cases and 22 age-matched controls were enrolled in this study (median age 1.9 (range 1.3,12.2) years). There were no differences in clinical cardiometabolic or biochemical parameters between the cases and controls. Arteries from cases demonstrated increased constriction to U46619 compared to controls (Emax 175.6 vs 66.3 p&lt;0.001), an effect inhibited by the ROS scavenger N-acetylcysteine (NAC). VSMC superoxide anion (5.3 fold) production and H 2 0 2 (3.3 fold) levels were increased in cases compared to controls (p&lt;0.05). Expression of Nox5, a major ROS-generating oxidase in vascular cells, was increased in cases (2.6 fold,p&lt;0.05). Exposure of vessels to testosterone increased vasoconstriction to U46619 (Emax 66.3 to 124.6 p&lt;0.001) in controls, but not in cases. Incubation with NAC abolished the testosterone-induced vascular effects. Vascular hypercontractility in boys with hypospadias was associated with reduced endothelium-dependent and -independent vasorelaxation, compared with controls. Conclusions: These novel data, from a unique cohort of patients, demonstrate that small arteries from boys with hypospadias exhibit increased vascular contractility and decreased vasorelaxation with associated increased Nox-derived ROS generation. The functional significance of vascular dysfunction in these boys is unclear but may play a role in immediate surgical outcome as well as altered long-term cardiovascular risk.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair: Comment on data sparsity

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair: Comment on data sparsity

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair.

Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence. All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed. We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications. In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair.

Shorter anogenital and anoscrotal distances correlate with the severity of hypospadias: A prospective study

Anogenital distance (AGD) is a recognised marker of in utero androgen action. This study aimed to evaluate the relationship between severity of hypospadias and AGD. Boys undergoing hypospadias repair in a single tertiary centre between May 2012 and February 16 were included in the study. Anogenital distance was measured from the centre of the anus to the base of the penis, and anoscrotal distance (ASD) from the centre of the anus to the junction between the smooth perineal skin and scrotal skin. Trained paediatric urologists made all measurements using digital callipers. Fifty-nine boys with hypospadias and 31 age-matched controls undergoing circumcision (median age 1.37 years, range 1.01-1.96) had AGD and ASD measured under anaesthetic. The patients were divided into two groups, according to hypospadias severity: group 1-distal penile/subcoronal/glandular (n=40); and group 2-perineal/penoscrotal/midshaft (n=19). The median AGD for controls was 74.0mm (range 53.2-87.8) and for hypospadias it was 72.3mm (range 50.7-90.0) (P=0.816). The median ASD for controls was 42.3mm (range 31.0-56.1) and for hypospadias it was 39.4mm (range 20.7-77.0) (P=0.224). Considering severity of hypospadias, the median AGD for group 1 and group 2 was 73.7mm (range 50.7-90.0) and 63.3mm (range 53.6-77.0), respectively (P<0.001). The median ASD was also higher in group 1, at 41.3mm (range 20.7-65.0), compared to 35.2mm (range 23.5-77.0) in group 2 (P=0.119) (Summary Fig.). This study showed that more severe forms of hypospadias are associated with shorter AGD and ASD. These findings agree with two previous studies that identified reduced AGD in boys with hypospadias. However, these studies did not investigate an association with severity of hypospadias. As hypospadias is multifactorial, only a small proportion of cases are thought to be associated with impaired in utero androgen exposure. The shorter AGD in boys with severe hypospadias compared with mild hypospadias would indicate that AGD is a marker of the severity of androgen production. This may also suggest that less severe forms of hypospadias have a different aetiology involving a later stage of development, and that they are not the result of reduced androgen exposure in the male programming window between the 8-14 weeks gestation. This study identified that boys with more severe hypospadias are more likely to have a shorter AGD and ASD than boys with mild hypospadias. This may indicate that there is a more profound impairment of in utero androgen action in severe hypospadias.

Glans size is an independent risk factor for urethroplasty complications after hypospadias repair

We hypothesized small glans size could increase urethroplasty complications (UC) following hypospadias repair. To test this, we measured glans width at its widest point in consecutive patients with hypospadias, and following a protocol for surgical decision-making, we then assessed post-operative UC using pre-determined definitions. We now report analysis of glans size as a potential additional independent risk factor for UC after hypospadias repair. Consecutive prepubertal patients undergoing hypospadias repair (2009-2013) had maximum glans width measured using calipers (Fig. 1). There were no differences in surgical technique for urethroplasty or glansplasty in this series based on the measured size of the glans. Multivariate logistic regression analyzed UC (fistula, glans dehiscence, diverticulum, stricture and/or meatal stenosis) based on glans size while adjusting for patient age, meatus (distal or midshaft/proximal), type of repair (TIP, inlay, 2-stage), surgeon, and primary or reoperative repair. Glans size was analyzed as both a continuous and dichotomous variable, with small glans defined as <14mm. Mean glans size was 15mm (10-27mm) in 490 boys (mean 1.5 years) undergoing 432 primary repairs (380d/19mid/33prox), and 58 reoperations (28d/7mid/23prox). Increasing age between 3 months and 10 years did not correlate with increasing glans size (R=0.01, p=0.18). 17% had small glans <14mm. UC occurred in 61 (13%) primary TIP, 2-stage, and reoperative repairs, including 20/81 (25%) patients with small glans <14mm, versus 41/409 (10%) in patients with glans width ≥14mm (p=0.0003). On multivariate analysis, small glans size (OR 3.5, 95% CI 1.8-6.8), reoperations (OR 3.0, 95% CI 1.4-6.5) and mid/proximal meatus (OR 3.1, 95% CI 1.6-6.2) were independent risk factors for UC. Surgeon, repair type, and patient age did not impact risk for UC. Analysis with glans size as a continuous variable demonstrated each 1mm increase in size decreased odds of UC (OR 0.8, 95% CI 0.7-0.9). Our analysis of prospectively-collected data from a standardized management protocol in 490 consecutive boys undergoing hypospadias repair adds small glans size, defined as width <14mm, to proximal meatal location and reoperation as an independent risk factor for UC. Best means to modify this factor remain to be determined. Our data suggest that others analyzing potential risks for hypospadias UC should similarly measure and report glans width.

A Prospective Audit of Hypospadias Correction in a Regional Paediatric Surgery Centre

To prospectively review the management and treatment of hypospadias in a single regional centre, and in particular, to assess the spectrum of cases treated, techniques used and to determine the nature of the complications. One hundred and fifty-three consecutive boys undergoing hypospadias repair during a 36-month period were included in the study. Information was collected prospectively and included the site of the urethral meatus, presence of chordee, surgical technique employed, use of urinary diversion, and the prescription of postoperative antibiotics and analgesics. Patients were assessed in the clinic following surgery at which time information on outcome and complications was obtained. One hundred and fifty-seven procedures for hypospadias were performed. Single-stage reconstruction was performed in 145 boys. GRAP (glanular reconstruction and preputioplasty) repair was the most common operation employed (n=112). The overall fistula rate was 11.7 % with the majority of patients having a satisfactory functional and cosmetic outcome following surgery. A variety of techniques can be employed to provide satisfactory correction of hypospadias with an increasing emphasis on single-stage day case procedures. GRAP repair is the favoured option for distal hypospadias and incorporates preservation of the prepuce.

Hypospadias repair: parental involvement in quality.

Informed decision-making and informed consent are major issues for the family of a child requiring surgery. Providing and sharing information and answering the child’s and parents’ questions are fundamental to the process of informed consent. Listening to and learning from children and parents is essential. According to the Department of Health (DoH), the voices of patients, their carers and the public should be heard through every level of the service, acting as a powerful lever for change and improvement (DoH 1998, 2001). This article reports on the development of an audit which aimed to identify strengths, weakness and opportunities with respect to information sharing and facilitating understanding between parents and medical/ nursing staff for boys undergoing hypospadias repair. Focus groups with parents helped to develop the audit tools, improve communication and change practice.

A new algorithm for primary hypospadias repair based on tip urethroplasty

Background/Purpose: Decision making in hypospadias repair potentially can be simplified by tubularized incised plate (TIP) urethroplasty. The authors report management and outcomes in a consecutive series of primary hypospadias repairs in which the intent was to perform TIP. Methods: Records of 106 consecutive boys undergoing hypospadias repair by 1 surgeon were reviewed. Position of the meatus, degree and management of curvature, technical details of the urethroplasty, and postoperative complications were recorded. Results: Curvature was noted in 24 (23%) of patients, but could be corrected with preservation of the urethral plate in all but 3. In another boy, the incised plate was thought “unhealthy” for tubularization. The remaining 102 underwent TIP, of whom, 75 had distal and 27 had proximal hypospadias. Complications, primarily fistulas, occurred in 14 (13%) of these patients. The other 4 boys underwent staged repairs that utilized TIP for the glanular urethra at the second operation. Conclusions: The authors found decision making was no longer determined by meatal location as in the past, but by severity of curvature and appearance of the incised urethral plate. Because severe curvature requiring plate transection or an “unhealthy” incised plate are uncommonly encountered, TIP repair can be performed for most hypospadias operations.

A review of current practice for boys undergoing hypospadias repair: from pre-operative work up to removal of dressing post-surgery.

The aim of this article was to examine an area from dinical practice, in this instance, paediatric urology and to look at the information needs of families prior to their young sons' having surgery to correct a hypospadias. Involving families and promoting informed decision-making with families prior to hypospadias repair for their child is important. To be able to facilitate real involvement the information has to be shared and parents and families given adequate support and opportunity to seek answers to questions. Providing an environment to undertake this, to then learn from the families for the future and to support the development of a National Support group, www.hypospadias.co.uk have been outcomes from setting up a pre-admission clinic. Literature in respect of after-care is very sparse. It became evident from clinical practice that the rationale for applying a dressing postoperatively needed to be explored. Furthermore limited evidence about dressing removal, coupled with the anxiety and upset this caused parents, identified the need to consider two issues (i) a better method of removal of dressings and (ii) the effects on pain scores. A blinded randomized controlled feasibility study was developed and implemented, with completion due at the end of 2001.

Hypospadias repair by laser tissue soldering:Intraoperative results and follow-up in 30 children

Objectives. We examined the use of laser tissue soldering (LTS) as an adjunct to suturing of, as well as aprimary means of, tissue closure in urethral reconstruction. Methods. Since June 1994, 26 boys ranging in age from 3 months to 14 years (mean 3.0 years) underwenthypospadias repair using LTS techniques. The classification of hypospadias was subcoronal in 13, midpenile in 5, penoscrotal in 7, and scrotal in 1. Laser tissue soldering was used in an additional 4 patients: tunica vaginalis patch graft corporoplasty in 2 (scrotal hypospadias), epispadias fistulae in 1, and urethral diverticulum in 1. Of these cases, 3 hypospadias repairs were completely sutureless. An intraoperative comparision was made between suturing and LTS with respect to operative time and degree of difficulty in performing LTS. Postoperatively, patients were examined to determine complications, including stricture, fistula, or impaired wound healing. An unselected group of 25 consecutive boys undergoing hypospadias repair between 1991 and 1992 served as a historical control group. Results. No intraoperative complications resulted from laser activation. In 5 of the 30 procedures (16.6%),suture disruption was noted to occur, with a higher incidence seen with finer, dyed suture material. For hypospadias repair, the average time to suture was 6.7 min/cm (n=23), whereas it was, 3.1 min/cm for adjunctive LTS (n=23) and 1.4 min/cm for sutureless urethroplasty (n=3). Follow-up ranged from 3 to 22 months (average 9.6). Four fistulae were noted (1 onlay, 2 skin tube grafts, 1 Thiersch tube) each following penoscrotal or scrotal hypospadias repair; a fifth fistula developed following a traumatic catheterization in a sutureless repair. The overall complication rate in the LTS group was 19% (5 of 26) versus 24% (6 of 25) for controls, whereas that for the distal forms of hypospadias was 11% (2 of 18) and 13.6% (3 of 22), respectively. Conclusions. Tissue soldering with laser and chromophore-doped solder is feasible, safe, and easy to perform.Laser tissue soldering may be an alternative to standard microsuture technique for hypospadias repair.