Long-term Outcomes of Pediatric Urethroplasty: A Systematic Review and Meta-analysis

Abstract Background Short-term outcomes of pediatric urethroplasty for hypospadias have been extensively reported, but the long-term morbidity — including complications emerging years after the index procedure — has been synthesised less systematically. Objective To systematically review and quantitatively synthesise the long-term (mean or median ≥ 2 years) outcomes of pediatric urethroplasty, restricted to hypospadias for the quantitative synthesis, and to explore the extent to which the pooled estimates are limited by clinical, methodological, and study-quality heterogeneity. Methods PubMed, MEDLINE, Embase, Scopus, and CENTRAL were searched from inception to 31 December 2024, following PRISMA 2020 (PROSPERO CRD420261470670). Random-effects meta-analysis with the DerSimonian–Laird estimator was used to pool proportions; heterogeneity was assessed with I²; sensitivity analyses were performed restricted to high-quality studies (Newcastle–Ottawa Scale ≥ 7) and to prospective cohorts. Certainty of evidence was rated using GRADE (post-hoc protocol amendment). Results Twenty-two studies (3,842 patients; mean follow-up 8.6 years, range 2–22) met inclusion criteria; 18 hypospadias cohorts (n = 3,842) contributed to the quantitative synthesis. The pooled long-term complication rate was 22.9% (95% CI 20.8–25.2; I² = 68.4%). Urethrocutaneous fistula (11.4%) was the commonest anatomical complication; the pooled reoperation rate was 22.1%. In a sensitivity analysis restricted to the 14 high-quality studies (NOS ≥ 7), the pooled complication rate was 21.8% (95% CI 19.4–24.5). Cumulative complications increased throughout follow-up but with a decelerating rate over time. Certainty of evidence was Moderate for objective anatomical outcomes and Low to Very Low for patient-reported outcomes. Conclusions In this synthesis of pediatric hypospadias urethroplasty cohorts, approximately one in five patients experienced at least one long-term complication and a similar proportion underwent reoperation. Estimates should be interpreted in the context of substantial between-study heterogeneity, inconsistent outcome definitions, and a shortage of cohorts with genuinely adolescent or adult follow-up. Long, structured follow-up and standardised outcome reporting are required before firm conclusions about the trajectory of late complications — including any pubertal effect — can be drawn. Registration Registered in PROSPERO on 05 August 2026 (CRD420261470670). The timing of registration relative to data extraction is disclosed and discussed under limitations.