

General considerations in hypospadias surgery

Amilal Bhat
Department of Urology, SP Medical College, Bikaner, Rajasthan, India

ABSTRACT
Nonsystemic review of the literature was done for timing of surgery, preoperative evaluation and plan, anesthesia, suture materials,
magniÞcation, tissue handling, stent and diversion problems, intra and postoperative care, dressing, and follow-up protocol.
The best time for hypospadias repair is between 6 and 18 months. Preoperative evaluation in proximal hypospadias includes
hormonal and radiological examination for intersex disorders, as well as for upper tract anomalies along with routine evaluation.
General anesthesia is a rule but local blocks help in reducing the postoperative pain. MagniÞcation, gentle tissue handling, use of
microsurgical instruments, and appropriate-sized stent for adequate period help in improving the results. Hormonal stimulation
is useful to improve growth and vascularity of urethral plate and decrease the severity of chordee in poorly developed urethral
plate with severe curvature. Urethral plate preservation urethroplasty with spongioplasty is the procedure of choice in both
proximal and distal hypospadias. Algorithms are proposed for management of hypospadias both with curvature and without
curvature. Two-stage urethroplasty has its own indications. A good surgical outcome may be achieved following basic surgical
principles of microsurgery, Þne suture materials, choosing one or two-stage repair as appropriate, proper age of surgery, and with
good postoperative care. Future of hypospadiology is bright with up coming newer modalities like laser shouldering, robotics,
and tissue engineering.

Key words: Algorithm, diversion, general considerations, hormonal stimulation, hypospadias, postoperative care, preoperative
evaluation, repair, stent, suture material, urethroplasty

Hypospadiology is still recognized as an expanding many, do many, and then teach many.” Who should operate
and evolving speciality. The results of hypospadias the hypospadias? General surgeons, general urologists,
repair have improved in the last three decades. Davis pediatric surgeons, pediatirc urologists, or hypospadialogists?
long back said that “I believe the time has arrived As hypospadias surgery is technically demanding, any one
to state that the surgical repair of hypospadias is no of them can, provided the surgeon has a temperament for
longer dubious, unreliable, or extremely difÞcult. If hypospadias surgery, has mastered six common techniques in
tried and proven methods are scrupulously followed, hypospadias and has at least 40-50 cases to operate per year.
a good result should be obtained in every case. Experience in hypospadias surgery has a deÞnite co-relation
Anything less than this suggests that the surgeon is with a successful outcome. There is a signiÞcant difference in
not temperamentally Þtted for this kind of surgery.”[1] outcome of hypospadias surgery done by pediatric urologists
One of John Ducket’s many enduring legacies has been vs. other surgical specialists.[2,3]
the emergence of the ‘hypospadiologist’, i.e., a surgeon
committed to excellence in hypospadias surgery with John Duckett had said “There are many successful methods,
a case load sufÞcient to develop and maintain a high no single procedure works for all hypospadias cases, choose
level of specialist expertise. As a result the era of the a suitable technique for individual case.”
‘occasional’ hypospadias surgeon is fast disappearing.
While science undoubtedly merits a higher proÞle TIMING OF SURGERY
within ‘hypospadiology,’ for the child with this
condition what matters most remains the commitment Most males with hypospadias are often diagnosed just after
and skill of the surgeon. The traditional saying that birth or identiÞed during examination before a newborn
“see one, assist one and do one” does not hold true for circumcision. Rarely, the ventral foreskin will be normal
the hypospadias surgeon; it should be “see many, assist in appearance and the hypospadias will be noted later in
life when the foreskin is retracted or after a circumcision is
For correspondence: Dr. Amilal Bhat, Department of Urology, performed. Treatment starts with birth of the child, the Þrst
S.P. Medical College, C-15 Sadul Ganj, Bikaner - 334 003, and foremost step being to inform and console the parents
Rajasthan, India. about the congenital anomaly, timing and outcome of
E-mail: [email protected] surgical procedures, and establishing a bond of conÞdence

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 Bhat: General consideration in hypospadias

between parents and the surgeon. This helps in removing Other congenital anomalies associated with severe hypospadias
the worry, guilt, and fear of the unknown to parents and in are pelvi ureteric junction obstruction, vesicoureteric
better planning of surgical treatment of the child. Meatal reßux, renal agenesis, persistent Mullerian structures and
dilatation should be done at the time of Þrst examination intersex disorders, undescended testis and inguinal hernia
if hypospadiac opening is associated with meatal stenosis. with or without hydrocele.[9] Associated anomalies with
The timing of surgery is chosen after considering milestones hypospadias increase with severity of the disease. Patients with
of development, size of penis, child response to surgery, severe hypospadias require complete evaluation including
anesthesia risk, and toilet training. The infant develops good ultrasonography for upper tract anomalies and internal sex
tolerance to surgery and anesthesia by the age of 6 months. organs, karyotyping, micturating cystourethrogram and
The penile length at 1 year is on an average 0.8 cm less pandoscopy.[4,10] Urethrogram or endoscopy is needed for
than at preschool age. The child is well aware about his proper assessment of prostatic utricle which may create
genitalia and toilet training by the age of 18 months. So the problems in catheterization during surgery. Patients with
most suitable age for operation of hypospadias is between hypospadias of any degree with impalpable one or both gonads
6 and 18 months. Another opportunity is at 3-4 years if the should be evaluated for intersex disorders. Such patients should
previous optimal age is missed.[4] The American Academy have karyotyping and ultrasonography of the urinary tract
of Pediatrics review suggest that the ideal age for genital and internal genital organs.[10] Accurate assessment of type of
surgery is between 6 and 12 months.[5] Others prefer hypospadias, severity of curvature, and the urethral quality
to operate even earlier on an adequate-sized phallus at is often possible under anesthesia and, therefore decision of
4 months of age as healing is quicker with minimal scars surgical plan may have to be changed on the table.[4]
and the infant overcomes the stress of surgery easily.[6] Age
of presentation (mean age 5 years) to the hospital in the HORMONAL STIMULATION
developing countries is higher than in the western part of
world because of ignorance, illiteracy, and unaffordability, There is no general agreement on the use of hormonal
so patients may be operated whenever the child is brought stimulation in hypospadias surgery. Use of βHCG or
to the hospital after the age of 4 years.[7] testosterone or dihydrotestosterone is sometimes indicated
in patients with a small penis or for repeat surgery; it is
PREOPERATIVE EVALUATION unclear how safe these treatments are in the longterm.[11]
HCG is best suited in cases of patients with undescended
The preoperative assessment includes not only the medical testis. But if one suspects a hypogonadotrophic etiological
checkup of the child including history of problems, but factor of hypospadias then HCG should be used cautiously as
also counseling of the parents. Parents should be told experimental micropenis model supports delaying hormonal
about the goals of the surgery, plan of surgical repair, likely therapy until puberty.[12]
modiÞcations during surgery, common complications and
their treatments, period of hospitalization, postoperative Local testosterone cream 5% twice a day for 5 weeks is
protocol including catheter care, dressings and medications. preferred by most of the pediatric urologists and others
The perineum is inspected for diaper rash or infection and favour systemic testosterone, as per Koff’s regimen (two
if present then surgery is to be postponed till such infection injections a week for 5 weeks). Hormonal stimulation
is cleared off. increases length of penis signiÞcantly, increases vascularity
and thickness of corpus spongiosum and decreases the
Preoperative examination includes measurement of the severity of hypospadias.[13]
size of the penis, shape of the glans, location and size of
the meatus, urethral plate for it’s development, width MAGNIFICATION
and length, severity of hypospadias, length of hypoplastic
urethra, chordee and it’s severity, size of dorsal hood, shape Key of success in hypospadias surgery is proper dissection
of the scrotum, and associated anomalies like undescended and meticulous approximation of tissues. So magniÞcation
testis, inguinal hernia or penile torsion. Sometimes multiple becomes an important tool in hypospadias surgery in small
pinpoint dimples may be present on the surface of the children.[11] Various magniÞcation tools are high-powered
urethral plate in addition to a hypospadiac meatus and in simple glasses, loupes and operating microscope. The choice
such cases location of the meatus should be conÞrmed by depends upon the availability and acclimatization of the
a probe.[6] Occasionally probing may conÞrm the partial surgeon to use the magniÞcation.
duplication of urethra that should be laid open to convert
it to one urethra. According to the location of meatus ANESTHESIA
the hypospadias is divided in to anterior (glanular and
subcoronal 50%), middle (Distal penile, mid-shaft, and General anesthesia is the rule, often associated with caudal
proximal penile 30%) and posterior (Penoscrotal, scrotal or penile anesthesia. The evidence examined shows an
and perineal 20%).[8] increased duration of analgesia with caudal bupivacaine,

189 Indian Journal of Urology | April-June 2008 |

Bhat: General consideration in hypospadias

clonidine, ketamine and midazolam. However, routine difference was noted in Þstula rate in stented vs. nonstented
use of these adjuvants in the setting of elective outpatient repair and none of the patients, even in caudal anesthesia
surgery shows an improved patient outcome. It is unclear group, had urinary retention postoperatively.[17] Others had
if the potential for neurotoxicity is outweighed by clinical successful stent free repair with Snodgrass modiÞcation.[18]
beneÞts. Further testing, including large clinical trials, is According to some authors, there was signiÞcant difference
required before recommending routine use of nonopioid in outcome of stented vs. unstented patients[4] while others
additives for caudal blockade in children. [14] Routine claim no difference in outcome.[19] In author’s opinion using
local penile block at the beginning and ending of surgery silastic catheter of adequate size according to the age of child,
signiÞcantly improves relief from postoperative pain.[15] just inside the bladder for about a week is safer and improves
the results. The stent can be left in the diapers and patient
SUTURE MATERIAL can be sent home the same day in day care centers.

The composition of suture material and the technique DRESSING

of suture placement may contribute signiÞcantly in the
outcome of hypospadiac surgery. SigniÞcantly low Þstula Hypospadias surgeons have different views about
rate (4.95% vs. 16.6%) were noted by Ulman and co-workers postoperative dressings; some concluded that no dressing
in subcuticular repair compared to full thickness through is required in plate preservation procedures,[19] while others
and through technique,[16] while others are of the opinion have used various innovative methods. The techniques
that sutures used either subcuticular or through and through described and found suitable include polyurethrane bio
does not affect the results provided polyglactin suture is occlusive foil, Cavi care, SANAV, glove-Þnger, Fibrin seal
used.[17] Late absorbable sutures may be the cause for small (Tisseal), Melolin, Peha-Haft, and adhesive membrane
Þstulae. Usually polyglactin absorbable sutures are useful dressings. Silicon foam dressing was found effective in
for the inner most layer closure with epithelial inversion, restricting edema, hematoma formation and stabilization
while polyglyconate sutures are used for other layers.[2] The with easy removal.[20] Pressure during the dressing following
author is of the opinion that when the technique involves hypospadias repair is a controversial issue. Excessive pressure
passing the sutures through the epithelium of urethral plate may compromise the blood supply of ßap and skin which
or skin, then early absorbable suture like Vicryl rapid should may lead to tissue necrosis while no pressure may lead to
be used and in subcuticular suturing, any of the absorbable hematoma, edema and infection increasing the incidences
or late absorbable suture material can be used. of complications. The author believes that dressing is
essential to control postoperative edema, prevent hematoma
TISSUE HANDLING formation that predisposes to infection and it works as a
barrier from surroundings specially in third world countries
General principles in hypospadias surgery include minimal where the ward cleanliness and hygiene may not be ideal.
tissue trauma, minimal and pin point use of cautery, tension
free repair in all layers, use of well-vascularized tissue SURGICAL TREATMENT
closure in as many layers as possible, and single-stage repair
with epithelial inversion.[4] The goals in management of hypospadias repair are creating
a straight penis, reconstructing slit-like meatus at the tip of
Tissue trauma can be minimized by proper handling of penis, creating a urethra of adequate length and uniform
the tissues by using stay sutures, skin hooks, microsurgical caliber, symmetry in appearance of glans and penile shaft,
instruments and dissecting the tissues in proper plane, projectile stream and normalization of erections, and
maintaining the proper vascularity of the ßap for neo- thereby imposing conÞdence in the child. These goals can
urethra, and skin is very important in prevention of ischemic be achieved by meatoplasty and glanuloplasty, orthoplasty,
complications. During penile degloving plane of dissection urethroplasty, scrotoplasty and skin cover.
is kept at the level of Buck’s fascia [Figure 1] and while
dissecting the inner prepucial ßap it is between two layers Meatoplasty and glanuloplasty
of Dartos fascia [Figure 2]. For mobilizing the urethral plate This helps in creating the conical glans, Þsh mouth wide
and urethra, a plane of dissection is created, beginning at the meatus at the tip, giving projectile stream and prevents
level of Buck’s fascia in normal urethra and then proceeding meatal stenosis and Þstula. V ßap or W shape ßap meatoplasty
distally in the same plane. Incision for glanular wings should are commonly done with ßap urethroplasty. Circumcoronal
be in continuity with corpus spongiosum [Figure 3]. incision is planned 5-7 mm away from corona to raise para-
glanular ßaps, suturing of which will reduce the incidence
URINARY DIVERSION of subcoronal Þstula [Figure 4]. An important point in
meatoplasty and glanuloplasty is raising adequate length
Use of stents and diversion is still a debatable issue. In a of glanular wing to prevent pressure on the neo-urethra
multicentric retroscopic review of Mathieu’s repair, no [Figure 5] that will reduce ischemic complications.

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 Bhat: General consideration in hypospadias

Figure 4: Showing glanular and para-glanular flaps for glanuloplasty

Figure 1: Showing deep plane of dissection at Buck’s fascia

Figure 5: Showing glanuloplasty with adequate space between neourethra and

glanular flaps

proceeding for the urethroplasty. Various method of chordee

Figure 2: Showing superficial plane of dissection at two layers of dartos fascia correction are penile de-gloving, plication procedures,
split and roll technique, extended urethral mobilization,
penile disassembly and tunica grafting procedures. Rational
approach in correction of chordee is described step-by-step
by Bhat 2007[7] and Bhat et al. 2007.[21] Pharmacological
erection by intracorporeal injection of Prostaglandin E1 has
been found useful both intraoperative as well as in follow-up
visits to check for correction of curvature.[22]

Urethroplasty
Various factors in deciding the type of urethroplasty are
size of penis, chordee, location of the meatus, size and
configuration of the glans, development and width of
urethral plate, development of corpus spongiosum, length
of hypoplastic urethra, ventral penile skin proximal to the
meatus and skin available on the dorsal hood and penile
shaft.
Figure 3: Showing mobilization of corpus spongiosum and urethral plate in to
glans Urethral plate preservation procedures are preferred as
there is no substitute for urethra. Final decision about the
Orthoplasty type of urethroplasty is to be taken only after correction of
Mclaughlin and Gitte’s test (1974) is the most important chordee. In distal and middle hypospadias with minimal
mile stone in deciding the single-stage repair. Straight penis chordee or without chordee, the Þrst choice of procedure
is the Þrst requirement for a successful repair and complete is TIP urethroplasty with inlay graft if required and second
chordee correction, should be tested on table before is onlay flap urethroplasty. An algorithm [Figure 6] is

191 Indian Journal of Urology | April-June 2008 |

Bhat: General consideration in hypospadias

proposed for choice of procedures in hypospadias without Preputioplasty is feasible in patients where prepuce is not
curvature. The controversy still continues in management utilized in urethroplasty and satisfies the patients and
of proximal hypospadias. On one end of the spectrum are parents to have an uncircumcised penis. This adds about
one-stage procedures with utilization of urethral plate[7,23,24] 20 extra minutes to the operating time. Klijn et al. had
and on the other are two-stage procedures.[2,25,26] Lam et higher complications of urethroplasty with preputioplasty
al. reported spraying of stream in 40%, milking of urethra and they discouraged preputioplasty when circumcision
after voiding in 40%, milking of the ejaculate 42.9%, and is done.[30] While others recommend preputioplasty since
painful ejaculation in 7.7% in spite of good cosmetic results they had no difference in results with preputioplasty.[29,31,32]
in two-stage procedures.[27] So hypospadias surgery should Author is of the opinion that preputioplasty is to be added
aim to preserve and utilize the urethral plate and supplement to urethroplasty in distal hypospadias where prepuce is not
with spongioplasty to improve the results. To avoid the utilized and parents demand preservation of prepuce.
confusion, a rational approach is proposed [Algorithm 2,
Figure 7] taking into consideration all the factors inßuencing SKIN COVER
the repair with stress on preserving the urethral plate and
one-stage urethroplasty.[7,21,28] Dorsal hood is brought to ventrum by Byar’s technique or
by Nesbit’s technique. Disadvantage of Nesbit is the suture
Healthy tissue cover line on lateral side, but it helps in reducing the Þstula
Healthy-vascularized tissue cover over neourethra or rate. Author recommends the midline suture simulating
corporal graft deÞnitely helps in overall surgical success. median raphae with trimming of skin margins to avoid
Poorer the tissue more is the need to provide healthy ischemic complications. In two-stage procedures or in redo
vascularized tissue to optimize the chances of success. cases, there may be tension on suture line requiring dorsal
Various healthy and well-vascularized tissues used are
dorsal/ventral dartos flap, [Figure 8] tunica vaginalis,
[Figure 9] denuded inner prepucial skin, and spread out Algorithm 2
corpus spongiosum [Figure 10]. Dorsal dartos vascular
Hypospadias with Severe Curvature
pedicle is mobilized up to root of penis to avoid torsion
and tunica vaginalis requires adequate mobilization on its
TIP with
vascular pedicle to prevent inherent sequelae of torque. Skin Spongioplasty Penile De-gloving
is to be denuded completely to prevent the complication of Urethral Curvature persisted
buried skin inclusion dermoid. Spongioplasty is the most Plate
Wide Mobilization Urethral plate with Curvature corrected
suitable healthy tissue cover for neourethra and reconstructs diverting corpus spongiosum
a near normal urethra. Curvature corrected
Curvature persisted Urethral
Plate
PREPUTIOPLASTY Proximal urethral mobilization Narrow

Curvature persisted
In distal hypospadias, surgery is done more for cosmetic Mobilization of urethral plate with
Corpus spongiosum in to glans Dorsal Inlay and TIP
appearance. Many parents and patients demand prepucial With spongioplasty
reconstruction. Circumcision is less acceptable to both the Curvature persisted
general population and medical profession; the prepuce can Single stitch dorsal plication
be preserved and refashioned to give good cosmetic results.[29]
Curvature persisted
Hypospadias Without Curvature
Corporal disproportion Tethering of urethral plate

Sking De-gloving

Corporoplasty by flap / graft Transection of urethral plate

Sub-coronal / Distal penile Mid-penile /

Glanular / Coronal
Proximal penile
Curvature corrected Flap inadequate

Meatus normal Meatus narrow Urethral plate Urethral plate Urethral plate
Urethral plate Urethral plate Wide & Healthy Narrow Wide & Healthy Inner prepucial flap urethroplasty
Wide & Healthy Narrow
Inner prepucial flap – Short
TIP* TIP* TIP* Dorsal Inlay and TIP* TIP*
MAGPI** UAP***** Barcat Mathieu Barcat
MIV*** Barcat UAP***** On lay flap Mathieu One tube from urethral plate + Inner prepucial flap tube
Barcat GAP**** Mustardae Onlay Flap
Still short
*Tubularized incised plate urethroplasty. **Meatal advancement and glanuloplasty. ***Minverted V glanuloplasty.
****Glans approximation procedure. *****Urethral advancement procedures Two stage urethroplasty

Figure 6: Algorithm 1 for hypospadias without curvature Figure 7: Algorithm 2 for hypospadias with curvature

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 Bhat: General consideration in hypospadias

(0.2 mg/kg/dose every 6 h). Prophylactic antibiotics are

advised till patient is on catheter drainage. The parents are
instructed to apply an antibiotic ointment to the tip of the
glans penis and urethra meatus every time the diapers are
changed or after passing urine.

FOLLOW-UP PTOTOCOL

Usual period of follow-up is for two years after surgery as it

Figure 8: (a) and (b) Showing dartos flap as healthy tissue cover is expected that by this time most of the complications will
appear and follow-up beyond the period may not be cost
effective. Any patient with complications beyond this period
will automatically present to the surgeon. Early discharge is
being justiÞed on the grounds that it is best to let the patient
forget his genital abnormality and surgery. Repeated visits
to the hospital will remind the child of his abnormality
and may have psychological implications. Only a section
of surgeons like adult urologists have an access to these
patients up to teenage and may contribute a lot in long-term
follow-up, actual outcome of surgery and real incidence of
chronic complications. An ideal follow-up will be at 1, 3,
6 months and then yearly up to 2 years and review follow-up
at puberty and mid-teens by which time genital maturity
is at or near completion and patient can express his social
and sexual problems following genital surgery. A previous
asymptomatic Þstula too may start leaking, chordee may
Figure 9: Showing tunica flap as healthy tissue cover appear due to failure of growth of scarred urethra, shape
and size of the penis may be of concern to the patient. These
late complications may need to be treated.

FUTURE

Though many new concepts and innovations have been

added, but the importance of current techniques are not
going to be obsolete suddenly. Future of hypospadiology is
directed toward the new innovative techniques and use of
developments in biotechnology like LASER shouldering,
robotics, and tissue engineering. Laser shouldering has
been tried, but it still has to prove its results better than
conventional suturing. Urethral regeneration has been
identiÞed as one of many potential applications of tissue
engineering. Tubular acellular collagen matrices seeded
with urothelial cells have been used experimentally with
Figure 10: Showing spongioplasty as healthy tissue cover
success to repair a created urethral defects in a rabbit
model. Similarly others have grown and used the corpus
releasing incision or some times nongenital skin graft is cavernosum.[33,34] But the complexity of urethral structure
needed. (urethral mucosa surrounded by spongiosum) makes it
difÞcult to do urethral replacement by tissue engineering. So
POSTOPERATIVE CARE it is unlikely that there will be routine use of the technology
in hypospadias surgery, though it could Þnd a limited role
The important points which require attention in postoperative in complex salvage cases. Robotics can play a major role by
period are dressing, catheter care, analgesics and antibiotics. removing the effects of tremors for meticulous suturing.
Postoperatively the child may experience incisional pain
and pain related to bladder spasms. We treat incisional ACKNOWLEDGMENT
pain with acetaminophen or acetaminophen with codeine.
Bladder spasms are best treated acutely with Oxybutynin The author would like to thank Dr. R.P.S. Tomar for the help.

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Bhat: General consideration in hypospadias

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Source of Support: Nil, Conflict of Interest: None declared.
in successful repair successful repair of urethrocutaneous fistula after

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