Recent advances in understanding/management of hypospadias

Abstract

Hypospadias is the second most common birth anomaly, affecting 1 of every 300 males. The abnormal position of the urinary opening, and associated downward curvature of the penis in some cases, potentially impact both urinary and sexual function. Modern surgical correction most often involves tubularization of the urethral plate, those tissues which normally should have completed urethral development. This article discusses recent progress in hypospadias repair. Prospective data collection in consecutive patients promotes better understanding of both patient and technical factors that influence surgical complications. Patients with a proximal urinary opening near or within the scrotum, those failing prior to repairs, and/or those with a small glans diameter have increased likelihood for urethroplasty complications. Quality review of reliable data led to two layer urethroplasty covered with tunica vaginalis in proximal repairs, significantly reducing postoperative fistulas. Neither preoperative androgens used to grow a small diameter glans, nor a change in sutures used to approximate the glans wings reduced wound dehiscence, but a recent technical modification of the glansplasty with more extensive dissection before suturing has. The observation that reoperation increases risk for further complications three-fold suggests the less common proximal repairs and reoperations should be subspecialized so that designated surgeons can gain greater expertise. In addition, surgeons performing hypospadias repair must better define the complications that occur so that scientific reporting of outcomes becomes more standardized. Standardized objective means to assess results are also needed so that surgeons performing different repairs can compare outcomes.

Figure 1.. The phenotype of hypospadias

(a) Distal. (b) Scrotal. (c) Perineal.

Figure 2.. Proximal hypospadias with ventral curvature of more than 30° after release of the penile shaft skin

Figure 3.. Measuring maximum glans width

Figure 4.. Subcoronal fistulas

(a) Fistula with a well-healed glans allowing simple fistula closure. (b) Fistula resulting from glans dehiscence beneath a thin band of skin between the glans.

Figure 5.. Glans dehiscence

(a) Complete separation of the glans wings with a subcoronal meatus. (b) Pseudoglandular meatus created by skin bridge across separated glans wings, resulting in urinary spraying.

Figure 6.. Appearance after hypospadias repair

(a) Following tubularized incised plate urethroplasty, with a vertical slit meatus resembling normal. (b) Following Mathieu, with an abnormal, rounded meatus.