Hypospadias: Management and outcome

INTRODUCTION — Hypospadias is a congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening. The location of the displaced urethral meatus may range anywhere within the glans penis, shaft of penis, scrotum, or perineum (picture 1).

The management and outcome of hypospadias will be reviewed here. The pathogenesis, diagnosis, and evaluation of hypospadias are discussed separately. (See "Hypospadias: Pathogenesis, diagnosis, and evaluation".)

CLASSIFICATION — Hypospadias is classified into the following categories based on the appearance of the foreskin, urethral location, and presence and degree of penile curvature. The indication and choice of surgical procedure are based on the characteristics of the different classes of hypospadias. (See "Hypospadias: Pathogenesis, diagnosis, and evaluation", section on 'Classification' and 'Indications' below and 'Choice of surgical procedure' below.)

●Forme fruste of hypospadias (10 percent of cases) – Incomplete or partial presence of hypospadias (picture 2) typically do not need surgical correction.

●Standard hypospadias (65 percent of cases) – Ectopic urethral meatus that is accompanied by a classic dorsal hooded foreskin without fusion of the foreskin to the scrotum with a normal penile length, normal glans size (≥14 mm at maximal diameter [in the first year of life]), and variable penile curvature (picture 3 and picture 1).

●Severe hypospadias (20 percent of cases) – Ectopic urethral meatus located in the scrotum or perineum and/or an abnormally small glans size (<14 mm at maximal diameter [in the first year of life]) and severe curvature (picture 4).

●Less common variants (5 percent of cases), including chordee without hypospadias and megameatus with a normal-appearing foreskin (picture 5 and picture 6).

UROLOGIC REFERRAL — Surgical correction for hypospadias is an elective procedure. The clinician's role is to provide information regarding the balance of potential benefits and complications to the family/caregivers. The need for urologic referral is based on the severity of the hypospadias and family/caregiver preference (table 1).

Urologic referral is not needed for patients with mild defects unless the family/caregivers request surgical reconstruction [1]. This includes patients with forme fruste of hypospadias (incomplete or partial presence of hypospadias) and patients with standard distal hypospadias (eg, urethral opening at the proximal glans, coronal margin, or just below the coronal margin) and without penile curvature (table 1). This conservative approach was supported by a report of 56 adult men with uncorrected hypospadias including 44 with a mild form who were satisfied with the appearance of their penis, voided in a standing position, and were not infertile [1]. However, correction may be entertained for cosmetic reasons based on family/caregiver preference as some families/caregivers may want to correct any asymmetric foreskin defect for religious (circumcision), cultural, or social reasons.

Urologic referral and correction are reserved for those patients in whom there is a potential functional or developmental issue including:

●Significant deflection of the urinary stream

●Inability to urinate from a standing position

●Erectile dysfunction due to penile curvature, leading to intercourse difficulties

●Fertility issues due to sperm deposition difficulties

●Concern for developmental issues based on the appearance of the hypospadias

CONSIDERATIONS RELATED TO CIRCUMCISION — Hypospadias is a contraindication for routine neonatal circumcision as the foreskin is asymmetric with abnormal development on the ventral aspect of the penis. This anatomical configuration is not conducive to a safe neonatal circumcision using a Plastibell or Gomco device, due to the inability to properly place either device over the glans and have sufficient foreskin to complete the circumcision. In addition, for standard and severe forms of hypospadias, the foreskin needs to be preserved and reserved for use during the hypospadias reconstruction to help prevent fistula formation and, in severe cases, to reconstruct the new urethra. As a result, circumcision, should it be desired by the family/caregiver, is delayed until a freehand circumcision at the time of the hypospadias repair can be safely performed in the operating room.

However, if unanticipated hypospadias (megameatus intact prepuce) is found at the time of neonatal circumcision due to an intact normal foreskin, it appears that the circumcision does not affect future successful reconstruction and can be completed [2]. (See "Hypospadias: Pathogenesis, diagnosis, and evaluation", section on 'Other uncommon variants'.)

SURGICAL CORRECTION

Indications — Surgical correction is indicated for patients with hypospadias who are at risk for voiding or sexual dysfunction or developmental issues based on the appearance of the penis (table 1). (See 'Urologic referral' above.)

Goal — The goal of surgical correction is to create a penis with normal function and appearance with a urethral opening as close as possible to the ventral tip of the penis. Surgical correction should result in a properly directed urinary stream and a straightened penis upon erection [3]. In most cases, the corrected penis will be similar in appearance to a circumcised normal penis; however, the foreskin may be preserved in cases of standard hypospadias with a glanular or penile shaft opening and without penile curvature [4].

Timing — General consensus within the pediatric urology community, including our own practice, is to perform surgery between six months and one year of age in full-term, healthy infants. For preterm infants, repair is delayed until age-adjusted catchup growth has occurred and other health issues that could affect safety of anesthesia have resolved. This timing, which is consistent with recommendations from the American Academy of Pediatrics, allows ample time for completion of a two-stage procedure in patients with severe hypospadias [5]. In general, six months is the minimum time needed between staged procedures for severe hypospadias to ensure complete wound healing following the initial surgery.

Surgical procedures — Numerous techniques to repair hypospadias are available and used based on the severity of the defect. All of the interventions are performed under general anesthesia and, in most cases, as a same-day (ambulatory) procedure without an overnight admission to the hospital. The time of surgery varies from one to three hours and depends on the severity of the hypospadias deformity.

The operations used to correct hypospadias include:

●Primary tubularization – Tubularized urethroplasty, with or without incision of the urethral plate (tubularized incised plate), is commonly used for glandular and penile shaft hypospadias repair [6]. This procedure consists of making a new urethra by rolling a ventral strip of penile shaft skin (the urethral plate) that would have formed the urethra if development had not been arrested (figure 1).

●Onlay island flap – For more severe hypospadias, an onlay island flap is used in which the urethra is created by transferring a vascular strip of inner foreskin onto the ventral skin (urethral plate) (figure 2) [7,8]. The skin is sewn to the urethral plate in an onlay fashion, hence the name of the procedure.

●Two-stage hypospadias repair – For the most extreme or severe forms of hypospadias, including cases with significant penile curvature, a two-stage approach is used to straighten the penis and create a new urethral opening [9-11]. In the first operation, which is typically performed at six months of age, the curvature, if mild to moderate, can be corrected by the insertion of dorsal midline plication sutures in the nerve-free zone at the 12 o'clock position, which straightens the penis (figure 3A-B). For moderate to severe curvature, ventral dermal grafting is indicated. Both techniques allow preservation of sexual function as they do not affect penile innervation. After correction of the curvature, excess dorsal foreskin is transferred to the ventral side of the penis as this tissue is required for the second stage. (See "Hypospadias: Pathogenesis, diagnosis, and evaluation", section on 'Anatomy'.)

The second operation is performed at least six months later, after healing is complete from the first procedure. In this stage, the urethra is reconstructed using the transferred dorsal skin that is now on the ventral aspect of the penis in a manner similar to the primary tubularization.

●Penile curvature (chordee) – Correction of penile curvature is a critical step in successful hypospadias surgery. As noted, based on anatomical studies of the human fetal penis, a simpler approach is advocated for mild and moderate curvature that entails placement of dorsal midline plication sutures in the nerve-free zone at 12 o'clock (figure 4) [12,13]. This allows for preservation of sexual function without manipulation of the penile innervation.

In any of the procedures, the addition of a complete covering layer of subcutaneous tissue over the newly constructed urethra is recommended as this reduces the risk of developing a urethral fistula [14-17]. (See 'Complications' below.)

Choice of surgical procedure — The choice of surgical procedure depends on the type of hypospadias based on the appearance of the foreskin, urethral location, and presence and degree of penile curvature (table 1). (See "Hypospadias: Pathogenesis, diagnosis, and evaluation", section on 'Classification'.)

●Standard hypospadias – For standard hypospadias (ectopic urethral meatus located on the glans, coronal margin, or penile shaft (picture 1 and picture 3)), the procedure of choice is primary tubularization and, when necessary, incision of the urethral plate. (See "Hypospadias: Pathogenesis, diagnosis, and evaluation", section on 'Standard hypospadias'.)

●Severe hypospadias – For severe hypospadias (ectopic urethral meatus located in the scrotum or perineum), there is no consensus on the best surgical approach (see "Hypospadias: Pathogenesis, diagnosis, and evaluation", section on 'Severe hypospadias'). The choice is primarily based on the clinician's personal experience and preference. Major impediments in establishing best surgical clinical practice include the lack of a clearcut definition of severe hypospadias and penile curvature, defined outcome measures, and effect of potential concomitant conditions (eg, disorders [differences] of sex development) on outcome. In addition, rates of secondary surgery remain high regardless of the surgical technique used, especially for patients with more severe hypospadias [18]. Further studies are needed to establish consistency within the pediatric urology community for accurate diagnosis and definition of severe hypospadias, identification of potential confounding factors, measurable and clinically significant outcome measures, and appropriate timing of follow-up.

PREOPERATIVE CONSIDERATIONS

Preoperative hormonal therapy — For patients with microphallus, defined as penile length 2 standard deviations below the mean length for age (figure 5), testosterone therapy may stimulate penile growth and is administered prior to hypospadias correction in collaboration with our pediatric endocrinology team. The recommended starting dose is 25 to 50 mg of testosterone propionate given intramuscularly once a month for three consecutive months, with surgery performed one month after the last injection [19,20]. (See "Management of the infant with atypical genital appearance (difference of sex development)".)

However, for males with standard hypospadias (table 1) and normal size penis, we typically do not provide preoperative testosterone therapy, as it has not been shown to improve surgical outcome [21]. Although published data are limited and of poor quality, preoperative testosterone therapy may increase complications. This was illustrated by a systematic review of retrospective observational studies, which reported that for patients with severe penoscrotal defects, there was a trend of increased complications with preoperative intramuscular testosterone compared with no hormonal therapy (odds ratio 1.67, 95% CI 0.96-2.91) [21].

Planning for postoperative care — These procedures are usually performed in an ambulatory setting, and patients are discharged on the same day of surgery. In our practice, we suggest that families/caregivers who have traveled a long distance spend the night nearby, so that if questions or problems arise during the night after the surgery, they can be addressed in an expeditious manner, thereby minimizing parental/caregiver's anxiety.

It is important to review initial postoperative care with the parents/caregivers. This includes instructions on dressing care, pain control, double diapering if needed, bladder catheter care, diet, activity, prophylactic antibiotics, and findings that require clinical evaluation by care providers (eg, fever, excessive bleeding, urination difficulties, and intractable pain). (See 'Initial postoperative care' below and 'Indications for reevaluation during perioperative period' below.)

POSTOPERATIVE MANAGEMENT

Initial postoperative care — Initial postoperative care performed by the family/caregivers involves the following:

●Dressings – Patients usually go home with the original dressing consisting of a clear plastic cover over gauze pads that are taped over the penis (picture 7). The dressing is typically removed two to three days after surgery, which can be done by soaking the child in the bath. The dressing may become soiled from old blood from the procedure, urine, and, rarely, a bowel movement. If this occurs in the first few days after surgery, the dressing is typically left in place and caregivers should clean around the dressing with soapy warm water (wiping away from the child's penis toward the rectum).

Once the dressing is removed, the penis may appear swollen, discolored, and/or bruised. There may also be a bloody discharge from the penis, which may result in blood spots on the dressing, diaper, or underpants. These findings are normal and will resolve with time. Bathing the area twice daily will help resolve the swelling and facilitate dissolving of the absorbable sutures.

●Diapers – In infants that require a catheter after the repair, we use the double diaper technique (ie, use of two diapers) (picture 8). The parents/caregivers should be instructed on how to arrange the double diapers, with the inner diaper used to capture stool and the outer diaper for urine drainage from the catheter. The inner diaper has a small hole cut in it where the catheter can exit, and, then, urine drains into the outer diaper.

Powder or any other ointment should not be applied to the genital area. Once the dressing soaks off, lubricant (eg, KY jelly, Vaseline, or Aquaphor) can be applied to the outer diaper where the penis will touch the diaper to prevent the child's penis from sticking to the diaper.

●Bladder catheter care

•For patients with mild forms of hypospadias, a catheter may not be used or a catheter may be left in for 24 to 48 hours and fall out when the dressing is removed at home. The double diaper technique may also be used for these patients.

•In patients with more complicated hypospadias repairs, a catheter (stent or urinary diversion tube) will be left in the bladder to drain urine for 5 to 10 days (figure 6).

-Not toilet-trained children – In most patients who are not yet toilet trained, the double diaper technique is used, with the catheter extending through the inner diaper and draining directly into the outer diaper (picture 8).

-Toilet-trained children – In older toilet-trained children, the catheter is connected to a leg bag. The catheter is removed during a follow-up appointment 5 to 10 days after surgery. For patients who live far away, the catheter can be removed by a urologist or pediatrician in the community and, in some cases, a family member/caregiver can be taught how to remove the catheter.

●Bladder spasms – Bladder spasms can occur in patients with a catheter. During an episode of spasm, the child typically will arch their back and bring their knees up to their chest and squirts of urine may be noted through or around the tube. Although spasms are not harmful, they are uncomfortable. In these patients, anticholinergic medications can be used to relieve bladder spasms until the night before the tube is removed. Typically, we use oxybutynin at a dose of 0.2 mg/kg given three times per day. Side effects of anticholinergics include a dry mouth and flushing of the face.

●Prophylactic antibiotic – A prophylactic antibiotic is generally given until a few days after catheter removal. Amoxicillin, ampicillin, and cephalosporins are not generally recommended, because of the likelihood of resistant organisms [19]. Since individuals are typically six months or older, single daily prophylactic doses of commonly used antimicrobial agents include:

•Trimethoprim-sulfamethoxazole (TMP-SMX) or TMP alone – Dosing is based on TMP at 2 mg/kg

•Nitrofurantoin – 1 to 2 mg/kg

●Pain control – Children will begin to experience discomfort and/or pain approximately six to eight hours after the procedure, when the analgesic effect of the caudal or penile nerve block disappears. Surgical pain typically lasts 48 to 72 hours. Children may also have pain on voiding for 24 to 48 hours.

To prevent pain and discomfort, a combination of acetaminophen alternating with ibuprofen is administered approximately three to four hours after surgery, even if the child appears comfortable.

•Acetaminophen is administered 10 to 15 mg/kg per dose given every six hours as needed

•Ibuprofen is administered as an oral suspension (100 mg/5 mL [teaspoon]) every six to eight hours as needed in the following doses based on age:

-Infants <6 months of age – 4 to 10 mg/kg per dose

-Infants 6 to <12 months – 50 mg per dose

-Children 12 to <24 months – 75 mg per dose

-Children two to three years – 100 mg per dose

-Children four to five years – 150 mg per dose

-Older children (six years and older) – 200 mg per dose

-Children >12 years of age and adolescents – Start at 200 mg per dose; if pain is unresponsive, may increase dose to 400 mg per dose (maximum intake 1200 mg/day)

•Opioid therapy is not used in our center for pain control following hypospadias repair

●Diet – A normal diet can be resumed, and fluid intake should be encouraged. Some children may experience nausea or vomiting from general anesthesia, which resolves within one or two days.

●Activity – In toddlers and older children, strenuous physical activity and straddling toys (eg, bicycle riding) should be avoided for four weeks.

Indications for reevaluation during perioperative period — The following findings require medical evaluation in the perioperative period through three weeks following surgery:

●Oral temperature greater than 101°F (38.3°C)

●Excessive bleeding (more than spotting or blood stains on the dressing)

●Extreme irritability/inconsolability or pain

●Increasing redness of the penis

●Continuous vomiting

●Change in urination pattern or urinary stream (eg, two urinary streams or thin stream)

●Difficulty in urination

●Excessive scrotal or penile shaft swelling after catheter removal suggestive of subcutaneous urinary extravasation

Routine follow-up care — Follow-up appointments are scheduled six weeks after surgery, one year from surgery, after toilet training, and as an adolescent. At each visit, patients are assessed for signs and symptoms for urinary tract infection, fistula, diverticulum, urethral stricture, and cosmetic outcome.

Following surgical reconstruction, the urinary stream should be observed. Initially, there may be some spraying of urine, which is normal. This should resolve over a few months as the swelling from the operation resolves. However, two urinary streams are suggestive of a urinary fistula and a thin urinary stream is suggestive of a urethral stricture. If this occurs, the pediatric urology team should be notified. (See 'Surgical complications' below.)

COMPLICATIONS

Risk of complications — The risk of complications varies based on the degree of hypospadias, with the lowest reported complication rate for standard hypospadias (approximately 10 percent) and a range of one-third to one-half of patients with severe repairs (picture 1 and table 1) [22-24]. In a study from an academic practice plan consortium database (Clinical Practice Solutions Center) of 5718 boys, the rates of second operations within 10 years following initial primary repairs for perineal, proximal, and distal hypospadias were 47, 38, and 13 percent, respectively [25].

Because of the risk of long-term complications, we recommend long-term follow-up at five years of age, prior to onset at puberty and 18 years of age [24]. In a case series of 1280 patients, there was an overall complication rate of 11 percent, but only one-half of the complications presented within the first year postoperatively and the mean time to complication was 69.2 months [24].

Surgical complications — The following complications may occur after hypospadias repair [22,24,26]:

●Urethral fistula – The most common complication following hypospadias surgery is urethrocutaneous fistula (picture 9), which is characterized as two urinary streams because of the extra urethral opening. This complication is reported in approximately 4 to 20 percent of patients, depending on the severity of their hypospadias [9,22,24,27]. Fistula correction requires a second operation that is performed six months after the initial procedure.

●Urethral stricture – Urethral stricture can occur within the glans, which is referred to as meatal stenosis, or, less commonly, within the reconstructed urethra in the penile shaft. These children will have symptoms of straining or pushing on urination and a thin or fine urinary stream. Correction of a urethral stricture requires a second operation at least six months following the prior surgery.

●Urethral diverticulum – Urethral diverticulum is due to outpouching of the reconstructed urethra. These children can have ballooning of the ventral aspect of the penis on urination and dribbling from retained urine after they void. Correction of a urethral diverticulum requires a second operation, ideally at least six months following the prior surgery, unless recurrent infection requires more immediate intervention.

●Urinary extravasation – Urinary extravasation of the reconstructed urethra typically presents with excess penile or scrotal swelling a day or two after removing the urethral stent in patients with more severe hypospadias. This is a rare postoperative hypospadias complication due to urinary leak in the newly constructed urethra. Because a subcutaneous flap is used as secondary coverage of the urethroplasty, urine tracks subcutaneously into the penile shaft and scrotum, presenting as swelling and decreased wet diapers rather than flowing to the skin resulting in a fistula. The urinary leak is resolved by replacing the catheter or diverting the urine with a suprapubic tube, allowing the urethra to heal.

Anesthesia risks — Parents/caregivers should also understand the potential of anesthetic risks. Questions about possible neurotoxic effects of anesthesia are discussed separately. (See "Neurotoxic effects of anesthetics on the developing brain".)

OUTCOME — With the variety of available techniques, surgical repair of hypospadias has resulted in improved cosmetic and functional outcome [28,29]. The best long-term outcomes are for patients with standard hypospadias based on a survey of adult patients who had similar quality of life to controls [30]. Reports based on patient surveys data suggest that individuals ≥14 years of age with severe hypospadias have similar interest in sex and sexual experiences compared with normal controls and those with distal hypospadias but are more likely to be dissatisfied with penile length and have concerns about physical contact [31].

The rate of reintervention varies:

●Based on a survey of 176 individuals with a history of hypospadias, one center reported that 40 percent required reintervention at a mean age of 18 and 19 years [32]. The risk of reintervention was associated with proximal hypospadias and suboptimal urinary and sexual outcome. However, there is concern for potential bias as only one-half of the invited patients participated in the study.

●Another center reported that subsequent surgery is seldom necessary for infants who underwent hypospadias repair as the reconstructed urethra grows appropriately and urinary flow is typically near normal flow rates [33].

As a result, parents/caregivers can be counseled that surgical correction generally results in an excellent outcome in boys with standard hypospadias with a good cosmetic and functional repair and satisfactory genital self-perception, sexual performance, and fertility in the majority of patients with hypospadias. Additional psychosocial support is needed for individuals with severe hypospadias who are more likely to have a specific genetic diagnosis, such as a disorder of sex development and/or higher complication rate [31].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Hypospadias (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Classification ‒ Hypospadias is a congenital anomaly in males that results in abnormal ventral placement of the urethral opening. It is divided into separate categories based on the foreskin appearance, urethral location, and presence and degree of penile curvature. These characteristics are used to determine the surgical management of hypospadias (picture 1 and table 1). (See "Hypospadias: Pathogenesis, diagnosis, and evaluation", section on 'Classification'.)

●Circumcision ‒ Routine newborn circumcision is contraindicated in patients with hypospadias as the devices (Plastibell or Gomco device) are associated with increased risk of complication. In addition, the foreskin needs to be preserved for possible reconstruction in cases of standard and severe hypospadias. Circumcision, should it be desired by the family/caregiver, is delayed until a freehand circumcision can be safely performed in the operating room later in life. (See 'Considerations related to circumcision' above and "Neonatal circumcision: Techniques", section on 'Contraindications'.)

●Urologic referral and indications ‒ Surgical correction is an elective procedure. Urologic referral and reconstruction are indicated for patients with hypospadias who are at risk for voiding and sexual dysfunction, which are manifested by the following (table 1) (see 'Urologic referral' above and 'Indications' above):

•Significant deflection of the urinary stream

•Inability to urinate from a standing position

•Erectile dysfunction due to penile curvature, leading to intercourse difficulties

•Fertility issues due to sperm deposition difficulties

•Concern for developmental issues based on the appearance of the hypospadias

●Surgical correction

•Goal ‒ The goal of surgical correction is to create a penis with normal function and appearance with a urethral opening as close as possible to the ventral tip of the penis. Surgical correction should result in a properly directed urinary stream and a straightened penis upon erection. (See 'Goal' above.)

•Timing ‒ Hypospadias correction is performed between six months and one year of age in full-term, healthy infants. This timing allows for completion of a two-stage hypospadias repair (if necessary) by 18 months of age before the beginning of sex identification. For preterm infants, repair is delayed until age-adjusted catchup growth has occurred and other health issues that could affect safety of anesthesia have resolved. (See 'Timing' above.)

•Choice of surgical procedure ‒ (See 'Surgical procedures' above and 'Choice of surgical procedure' above.)

-For forme fruste (incomplete or partial presence of hypospadias), we suggest not to perform surgical correction versus surgical correction (Grade 2C). This type hypospadias does not affect voiding or sexual function. Examples would be a distally located ectopic urethral opening and a penis without significant curvature (picture 2 and picture 3). However, surgery is an option for some families/caregivers who want to pursue reconstruction to improve cosmetic appearance for religious (circumcision) or social reasons.

-For standard hypospadias, primary tubularization and, when necessary, incision of the urethral plate are most commonly used.

-For severe hypospadias, there is no consensus or data on the best surgical approach and the procedural choice is primarily based on the clinician's personal experience and preference.

●Hormonal therapy ‒ We suggest not to administer preoperative hormonal therapy for patients with standard hypospadias and penis of normal length (Grade 2C). (See 'Preoperative hormonal therapy' above.)

●Postoperative care ‒ Because most of the cases are performed as ambulatory procedures, it is important to review postoperative care with the parents/caregivers. This includes instructions on dressing care, pain control, double diapering, diet, activity, prophylactic antibiotics, findings that require clinical evaluation (eg, fever, excessive bleeding, urination difficulties, and intractable pain), and bladder catheter care. (See 'Planning for postoperative care' above and 'Postoperative management' above.)

●Complications ‒ The risk of complications increases with increasing severity of the hypospadias, with the lowest risk associated with distal hypospadias and the highest with urethral openings in the scrotum or perineum. Late complications are common, and, as a result, long-term follow-up should include visits throughout childhood and adolescence. Surgical complications include urethral fistula, stricture, and diverticulum. (See 'Complications' above.)

●Outcome ‒ Surgical correction generally results in an acceptable cosmetic and functional repair of the penis and satisfactory genital self-perception, sexual performance, and fertility. (See 'Outcome' above.)