The primary goal of pediatric urology in managing hypospadias is achieving functional and aesthetic anatomical normalization. Hypospadias occurs when the developmental fusion of the urethral folds is incomplete during embryonic growth, resulting in a urethral orifice located on the ventral aspect of the penis, scrotum, or perineum. Reconstructive surgery, termed hypospadias repair or urethroplasty, involves straightening the penile shaft, building a functional urethral canal, and reconfiguring the surrounding glans and skin tissue.

Hypospadias repair begins with general anaesthesia induction and placement of a caudal regional block. A traction suture is placed in the glans penis for stability. The surgeon measures defect severity and assesses penile curvature via an artificial erection test using saline injection into the corpus cavernosum. If present, chordee is corrected through degloving of penile skin or dorsal plication. The neourethra is constructed using local skin flaps or an incised urethral plate (Snodgrass technique), tubularized over a soft silicone catheter (size 6 or 8 Fr). A protective intermediate layer of tunica vaginalis or dartos fascia is placed over the suture line to prevent fistula formation. Glans folds are approximated around the neourethra (glansplasty), and preputial or penile shaft skin is reconstructed. A compressive dressing is applied, and the patient is moved to the post-anaesthesia care unit.

Evidence-based clinical benefits of timely pediatric urological intervention include:

• Restoration of a forward-directed, single urinary stream while standing
• Correction of ventral curvature to enable normal adult erectile function
• Preservation of long-term fertility and sexual health
• Prevention of psychological distress related to genital divergence during childhood
• High primary repair success rates exceeding 85% to 90% in distal cases (EAU/ESPU Guidelines 2023)

Initial wound healing occurs over 10 to 14 days, during which a soft stent drains urine into a double diaper. Pain is managed with regional nerve blocks and oral analgesics. Complete tissue stabilization requires 6 to 8 weeks. Physical activities involving straddle toys, bicycles, and rough play are restricted for 4 to 6 weeks postoperatively. Long-term follow-up visits assess urinary flow and cosmetic outcomes at key developmental milestones.

Pediatric urology addresses a wide range of congenital anomalies and functional conditions, including:

• Hypospadias (distal, middle, and proximal variations)
• Chordee (ventral penile curvature)
• Cryptorchidism (undescended testes)
• Vesicoureteral Reflux (VUR) (retrograde urine flow from bladder to kidneys)
• Ureteropelvic Junction Obstruction (UPJO) (blockage at the kidney-ureter junction)
• Hydrocele and Inguinal Hernia
• Neurogenic Bladder and pediatric voiding dysfunction

Preoperative assessment includes a physical examination by a pediatric urologist to determine meatal location, tissue elasticity, and presence of undescended testes or hernia. Preoperative hormonal priming with topical or parenteral testosterone/hCG may be prescribed 4 to 8 weeks prior in cases of microphallus or severe tissue deficiency to enlarge the glans penis and increase vascularity. Routine blood work is generally not required in healthy infants. Strict fasting guidelines for clear fluids (2 hours) and breast milk/formula (4 to 6 hours) must be followed prior to anaesthesia. Neonatal circumcision must be avoided to preserve foreskin tissue for reconstruction.

Complications are classified by severity. Early minor risks include wound edema, mild bleeding, local skin breakdown, and catheter blockage. Moderate structural complications include urethrocutaneous fistula (formation of an abnormal opening along the penile shaft, reported in 5% to 15% of cases), urethral stricture (narrowing causing urinary obstruction), and meatal stenosis. Rare severe complications include complete glans breakdown, urethral diverticulum (ballooning of the new urethra), graft failure in complex staged repairs, and chronic urinary retention requiring surgical revision.

The clinical pathway begins with early diagnostic evaluation during infancy by a pediatric urologist. If surgical intervention is indicated, preoperative planning occurs between 6 and 18 months of age. Surgery is performed under general anaesthesia combined with regional analgesia. Following repair, a temporary urinary stent or catheter remains in place for 7 to 14 days to support urethral healing. Long-term follow-up extends through toilet training and puberty to monitor urinary stream, wound stability, and psychosexual development.