Journal of Pediatric Urology (2005) 1, 81e83

Management of urethral diverticulum

complicating hypospadias repair
Charles L. Snyder*, Apostolos Evangelidis, Ryan P. Snyder,
Daniel J. Ostlie, John M. Gatti, J. Patrick Murphy
Department of Surgery, Childrens Mercy Hospitals and Clinics,
24th and Gillham Road, Kansas City, MO 64108, USA
Received 17 October 2004; accepted 26 October 2004

KEYWORDS
Hypospadias;
Diverticula;
Complication;
Stricture

Abstract Background Urethral diverticula can occur after hypospadias repair,

and may lead to stone formation, incomplete voiding, infection, postvoid dribbling,
haematuria and other problems. We previously reviewed our experience with
hypospadias complications. We separately analyzed those patients who developed
urethral diverticula to attempt to identify predisposing factors and appropriate
management strategies.
Patients and methods We reviewed the available medical records and charts of
123 patients undergoing re-operation for hypospadias complications at The
Childrens Mercy Hospital from 1 May 1984 until 1 January 2003. Hypospadias
cripples, traumatic fistulae, complications after circumcision and true intersex
patients were excluded.
Results Diverticula accounted for 11% of all complications (13 patients). The
patients with diverticula were more likely to have perineal/proximal hypospadias.
The initial repair was island tube urethroplasty in five, island onlay urethroplasty in
seven and bladder mucosal graft in one child. The repair of the diverticulum in one
stage was successful in 10 of the 13 patients. There was one recurrent diverticulum
and two fistulas. A stricture was present in only one of the 13 patients but was
detected overall in 14 of the 123 patients (11%).
Conclusion Diverticula are uncommon after hypospadias repair, accounting for
11% of all complications in the present series. The stricture was not causative in 12
of 13 children. Repair of the diverticulum was successful after one attempt in 10 of
13 patients. The management of this complication is discussed.
2004 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights
reserved.

* Corresponding author. Tel.: C1 8162343576; fax: C1 9134910911.

E-mail address: csnyder@cmh.edu (C.L. Snyder).
1477-5131/$30 2004 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpurol.2004.10.001

82

Introduction
Urethral diverticula can be congenital or acquired;
the most common cause of an acquired diverticulum in children is previous hypospadias repair. The
reported incidence of diverticula formation after
hypospadias repair is 0e21% [1]. Factors increasing
the risk of diverticula include a proximal defect,
use of poorly supported tissue for interposition
grafting (e.g. bladder mucosa or tubularized pedicle grafts), and the presence of a distal stricture
resulting in relative obstruction/higher outlet
pressures [2].
We reviewed our experience with hypospadias
complications over the past 18 years, identifying
patients with diverticula, analysing factors associated with this complication, and examining the
management and outcome.

Patients and methods

We reviewed the available medical records and
charts of 123 patients undergoing surgery for hypospadias complications at our institution from 1 May
1984 until 1 June 2002. Hypospadias cripples (more
than five hypospadias revisions), traumatic fistulas,
complications after circumcision, and intersex patients were excluded. A proportional analysis was
used, with a chi-squared analysis, and Students ttest used to compare sample means, in both tests
P ! 0.05 was used to indicate statistical significance. Institutional Review Board approval was
obtained before the review was initiated.

Results
There were 123 patients with complications after
initial hypospadias repair; the most common complication was urethrocutaneous fistula and the
distribution of complications is shown in Table 1.
The mean age of the 13 patients with diverticula
was 3.0 years at the primary repair, and for the
diverticula repair was 5.7 years. The mean interval
from initial operation to repair of the diverticulum
was 1.4 years (for patients whose initial operation
was at our institution). The opening was proximal/
perineal in 11 of 13 children with diverticula, in
contrast to fistula, strictures and other complications, which were more evenly divided between
proximal, middle and distal. Diverticula were
strongly associated with more severe hypospadias
variants. Fistula, the most common complication,
was relatively independent of the severity of the
defect.

C.L. Snyder et al.

Table 1 The distribution of complications among
123 patients; urethrocutaneous fistula was the most
common and some patients had more than one
Complication
Diverticulum
Yes, n
No. (% of 110)
Fistula
Stricture
Breakdown

Hypospadias, n (%)
Proximal

Middle

Distal

11
29 (26)
23
5
4

1
46 (42)
30
4
5

1
35 (32)
20
3
4

Anatomically, diverticula were more frequently associated

with a proximal/perineal urethral opening than other
complications. Some patients with no diverticulum underwent initial repair elsewhere, and the anatomy at
presentation was unknown. The type of complication is also
shown with the severity of hypospadias; there was a strong
correlation with proximal anatomy (a more severe defect).

Overall, genitourinary anomalies were present

in 9.7% (12 of 123 patients; some had more than
one abnormality), with genitourinary abnormalities in seven, undescended testes in seven, VUR in
three, pelvic/horseshoe kidney in two, PUV in one
and penile torsion in one. Of the patients with
diverticulum, 3 of 13 (25%) had this association,
present in only 8 of 110 (7%) of the non-diverticula
patients (P Z 0.057).
The type of initial hypospadias repair was island
onlay urethroplasty in seven and tubularized island
onlay in five; one patient had a bladder mucosal
graft. Nine patients had their primary repair at our
institution and the remaining four were referred
after initial repair elsewhere. Two of the four
referred patients had had at least one previous
attempt at repair of hypospadias complications
elsewhere. Overall, 40% of the 123 children had
their initial hypospadias repair at our facility.
All patients had urethral calibration; a stricture
was present in only one of those with diverticula.
In the remaining 110 patients there were 13
additional strictures, for an overall incidence of
14/123 (11.4%). This difference was not statistically significant (P Z 0.658).
Fistula was the most common reason for reoperation, occurring in 72% (88/123) patients with
hypospadias complications. Four of 13 patients
with a diverticulum also had a urethrocutaneous
fistulae, and the fistula was closed with the
diverticulum repair.
Seven diverticula were treated with resection
of redundant tissue and multilayer closure.
The patient with a concomitant diverticulum and
stricture had internal urethrotomy with later
staged diverticulum resection. Another patient

Management of urethral diverticulum

had revision of the diverticulum with a ThierschDuplay repair. The diverticulum repair was successful in 10 of the 13 patients. Re-repair of the
diverticulum was necessary in one child and repair
of a subsequent fistula in two. One of the patients
in whom the initial diverticulum repair failed had
previously had several attempted revisions elsewhere before referral.
The mean follow-up was 23.8 months for all
patients, and did not differ significantly for
patients with or with no diverticulum.

Discussion
Diverticula account for 11% of all complications
after hypospadias repair in the present series,
similar to the values in previous reports [1]. This
complication appears to correlate with the severity of the underlying defect; most patients with
a diverticulum had a perineal/proximal anatomic
defect.
There may be a causal association between
stricture and diverticula [3e5] but this was not
the case in the present series. Only one of 13
children with a diverticulum had a stricture, and
no diverticulum was present in 13 with a postoperative stricture. Possibly, the early detection
of stricture by routine calibration resulted in
recognition and treatment of the stricture before
the deleterious effects of long-term increased
voiding pressure and subsequent diverticulum formation.
Although not statistically significant, there was
a trend to a greater incidence of genitourinary
anomalies in patients who developed diverticula
(P Z 0.057). This correlation is probably explained
by a hidden covariant, in that diverticula were
more common in proximal hypospadias, and more
proximal defects are more likely to be associated
with other genitourinary anomalies.
Symptoms of diverticula include dribbling, infection and bulging of the anterior urethra with
voiding [5]. Although turbulent flow and stasis may
predispose to stone formation, this complication

83
was not seen in the present series. Lateral/oblique
views during a retrograde urethrogram will usually
show the abnormality [6]; cystoscopy is confirmatory.
It is important to exclude other abnormalities
such as distal stricture or fistula, as it was not
unusual to see more than one complication in the
same patient. We deferred repair of the diverticulum until R 6 months had elapsed from the time
of the primary repair. As diverticula tend to be
present late (a mean of 1.4 years in the present
series) this is not usually an issue.
In the absence of other complications, simple
partial excision with multilayer closure is sufficient. Other techniques have been reported,
depending on the presence or absence of other
complications such as stricture or fistula [3,7]. If
the anatomy permits, a pants over vest closure
may be used. Stents were used after repair of all
diverticula. Because such a large proportion of the
present patients were referred after a variety
of attempted repairs elsewhere, it is difficult to
determine the influence of stenting on the
development of diverticula. The overall results
were good, with 10 of 13 successful at a mean of 2
years follow-up.

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