Association Between Penile Ischemia Duration and Complications After Hypospadias Repair in Children

Malin Dönig^1,2,3Volker Sander^1,2Ralf-Bodo Tröbs⁴Jochen Hubertus^1,2Matthias Nissen^1,2*

• ¹Ruhr-Universitat Bochum, Bochum, Germany
• ²Klinik für Kinderchirurgie Marien Hospital Witten, Witten, Germany
• ³Gemeinschaftskrankenhaus Herdecke gGmbH, Herdecke, Germany
• ⁴Sankt Vincenz-Krankenhaus GmbH, Paderborn, Germany

Introduction: Clinical evidence regarding the impact of intraoperative penile ischemia during pediatric hypospadias repair remains inconclusive. Although experimental studies suggest that ischemia–reperfusion injury may impair wound healing, clinical data on the relationship between ischemia duration and postoperative outcomes in children are limited. This study aimed to determine whether the duration of intraoperative penile ischemia is associated with postoperative complications—specifically urethral fistula formation and meatal stenosis—in patients undergoing primary hypospadias repair. This study aimed to evaluate whether intraoperative penile ischemia duration is associated with postoperative complications, specifically urethral fistula and meatal stenosis, in patients undergoing primary hypospadias repair. Methods: We conducted a retrospective, single-center cohort study of pediatric patients who underwent primary hypospadias repair with intraoperative penile tourniquet application over a 12-year period. The primary outcome was the occurrence of postoperative complications, specifically meatal stenosis or urethral fistula, requiring revision surgery. Secondary analyses assessed tourniquet duration, patient demographics, and key perioperative variables to identify potential risk factors for adverse outcomes. Results: Ninety-four patients were included. Postoperative complications requiring redo surgery occurred in 17 patients (18%), comprising urethral fistula (n=12), meatal stenosis (n=3), or both (n=2). Median ischemia duration did not differ significantly between patients with and without complications (39 [34–45] vs. 35 [30–42] min; p = 0.15). No significant differences were observed in operative time, biometric variables, hypospadias severity, suture material, stenting duration, or postoperative hospital stay. Mean follow-up was 76 months. A structured literature review revealed that ischemia duration is inconsistently reported across studies, limiting comparability. Conclusions: Intraoperative penile ischemia duration within the mid-range commonly applied in clinical practice was not associated with an increased risk of postoperative fistula or meatal stenosis following primary hypospadias repair. These findings support the safety of standard penile tourniquet use during routine surgical procedures. Nevertheless, prospective studies with standardized ischemia documentation are required to define evidence-based safety thresholds and to further elucidate potential ischemia–reperfusion effects. These findings support the safety of standard penile tourniquet use during routine surgical procedures. However, prospective studies with standardized documentation of ischemia duration are needed to establish evidence-based safety thresholds and to further clarify potential ischemia– reperfusion effects.