Hypospadias – A Journey of Learning Over 25 Years

by Apr 28, 2026Hypospadias0 comments

This sentiment remains deeply relevant today. Over the years, several key principles have emerged in the hypospadias literature, and staying abreast of these outcomes is essential. Our understanding of hypospadias has evolved from rigid dogma to nuanced decision-making. This shift is perhaps most evident in our approach to pre-operative optimization. What was once applied routinely is now guided by careful patient selection and a deeper understanding of tissue biology.

Hormonal Preparation: When and Why, It Matters

Due to potential ill effects on wound healing, routine testosterone use is no longer recommended for all cases. However, for patients with a small glans (diameter <14 mm) or a small phallus, pre-operative testosterone (2 mg/kg IM) is increasingly adopted to improve tissue vascularity and glans width, which in turn reduces the risk of glans dehiscence. In proximal cases or among testosterone non-responders, dihydrotestosterone (DHT) gel has proven extremely useful. Beyond preparation, the operative strategy itself must be guided by a careful assessment of anatomy.

Let the Anatomy Guide the Repair

The intraoperative measurement of glans and urethral plate width has become routine. In patients with a deep glans groove and a urethral plate width >10 mm at the glans hillocks, a simple Duplay repair yields excellent results. For those with a borderline urethral plate width (8–10 mm, the Tubularized Incised Plate (TIP) repair remains a reliable choice. Foreskin reconstruction is now feasible in 30–50% of cases; it is often preferable, as the preserved tissue can be utilized if complications arise. However, not all cases present with ideal anatomy, and the surgeon must be prepared to

When the Plate is Not Ideal: The Value of Flaps

Mastery of flap repairs—such as the Mathieu, On-lay, and LABO for re-operative cases—is an essential skill set that can “bail out” a surgeon when the glans or urethral plate is narrow (<7mm). In parallel with urethral reconstruction, attention to penile curvature remains equally important.

Addressing Curvature: A Critical Step

Ventral curvature requires careful assessment and correction during the primary repair. Ventral lengthening procedures (such as urethral plate division, “fairy cuts,” or corporotomy) are necessary when curvature exceeds 30°. For severe proximal hypospadias with significant chordee, the Bracka two-stage approach (using a free foreskin graft) is widely favored in the literature over the staged Byars flap repair or single-stage repairs. The journey does not end in the operating room; post-operative care plays a crucial role in outcomes.

Refinements in Post-operative Care

Post-operative management has also evolved. While distal repairs can occasionally be performed “stent-less,” most meta-analyses support stenting for 7 days in distal cases and up to 10 days for proximal repairs. While many centers have moved toward “sandwich” dressings or no dressing at all, occlusive dressings remain practical when there is a risk of the child displaced or pulling out the catheter. Despite the introduction of various specialized stents and silastic tubes, the appropriately sized infant feeding tube remains the most widely used and reliable option. Underpinning all successful repairs are the fundamental principles of surgical technique

Technique Matters: Respecting Tissue

Respecting tissue planes and maintaining vascularity of outer skin are crucial steps for any type of hypospadias repair. The adoption of fine suture materials, such as 7-0 PDS or Vicryl, alongside 2.5x magnification, has significantly improved hypospadias outcomes over the years. Yet, beyond techniques and protocols lies a more personal challenge for the surgeon

The “Fear Zone” and the Young Surgeon

A recent survey among young consultants revealed that many lack confidence when managing proximal and complex hypospadias. While some surgeons fail to cross the “fear zone” and abandon these repairs prematurely, others persist, attending focused workshops and courses to master the craft. In this field, “Success is never permanent, and failure is never final.” One must never stop striving for improvement after a setback. For the young surgeon, the journey is ongoing: it is essential to continue attending workshops and updating one’s technical repertoire to master this complex and rewarding field!
SPUIAPS

SPUIAPS

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