Long-Term Cosmetic and Sexual Outcome of Hypospadias Surgery: Norm Related Study in Adolescence

Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults

OBJECTIVES

We report our experience with urethral reconstruction for hypospadias surgery-related urethral stricture in terms of surgical and patient-reported outcomes.

METHODS

Twenty-nine adult males who underwent urethral reconstruction for hypospadias surgery-related urethral stricture between August 2008 and January 2022 were retrospectively reviewed. Uroflowmetry and patient-reported outcomes were evaluated at 3, 6, and 12 months, and annually thereafter. Surgical success was defined as the absence of additional procedures. Patients were asked to rate their satisfaction with urethral reconstruction as "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied".

RESULTS

The median patient age at referral was 43 years. The median number of previously performed hypospadias surgeries was three, and 18 patients (62.8%) had been treated with repeated transurethral procedures. The median stricture length was 54 mm (interquartile range 36-81). Performed urethral reconstruction included staged urethroplasty in 22 (75.9%), one-stage onlay augmentation in 3 (10.2%), and perineal urethrostomy in 4 (13.8%) cases. Urethral reconstruction was successful in 26 patients (89.7%) over a median postoperative period of 31 months. Patient-reported outcomes were assessed in 25 (86.2%) patients. The mean maximum flow rate, international prostate symptom score total score, international prostate symptom score quality of life score, and EuroQol-5 dimensions index significantly improved postoperatively. Twenty-three patients (92%) were "very satisfied" or "satisfied" with the outcome of their urethral reconstruction.

CONCLUSIONS

Urethral reconstruction is a highly successful and patient-satisfying treatment for hypospadias surgery-related urethral stricture in adult patients. Perineal urethrostomy is a reasonable alternative for elderly patients and for patients with complicated hypospadias surgery-related urethral strictures.

An Objective Assessment and Comparison of the Cosmetic Outcome: Parental Perspective after Tubularized Incised Plate Urethroplasty with Foreskin Reconstruction and Circumcision

Aim

We aimed to evaluate the parents' view of the cosmetic outcome after hypospadias surgery.

Materials and Methods

Between January 2017 and December 2020, 70 patients aged between 2 and 7 years underwent surgical correction of hypospadias. Group 1 had 35 patients (coronal: 6, distal: 19, and mid-penile: 10) assigned for tubularized incised plate urethroplasty (TIPU) with modified foreskin reconstruction. Group 2 had 35 patients (coronal: 4, distal: 22, and mid-penile: 9) assigned for TIPU and circumcision. Parents were assessed with the Pediatric Penile Perception Score (PPPS).

Results

Parent satisfaction for the position and shape of the urethral opening, shape of the glans, penile skin, and length exhibited no statistically relevant difference between the group. Parent satisfaction with the appearance of the genitals in Group 1 was relatively high 2.60 ± 0.55, as compared to Group 2 1.77 ± 0.49 which is statistically significant (P < 0.00028).

Conclusion

Our experience shows good early cosmetic results of foreskin reconstruction and high parental satisfaction. Foreskin reconstruction should constitute a key element of the final result to restore a penis with an appearance as normal as possible.

Sexual dysfunction in patients with late complications of hypospadias surgery

Most hypospadias cases are successfully treated in childhood. Still, patients with sequelae of failed hypospadias repair and sexual dysfunction may be encountered. We evaluated 112 patients with a history of failed hypospadias repair, defined as the presence of voiding symptoms or cosmetic problems remaining despite previous surgery or caused by it. Patients' median age was 29.5 years (range: 18-62). There were no intersex cases. Only 9.8% (11/112) underwent single attempt at surgical reconstruction, the median number of attempts was 3.5 (range: 1-9). Patients with IIEF-EF score ≤25 were considered to have erectile dysfunction; those with IIEF-EF ≤16 underwent penile doppler ultrasound, penile electromyography and endocrine assessment. About 64.2% of patients (72/112) were dissatisfied with penile appearance, 40.2% (45/112) had ED, 71.4% (80/112) had ejaculation disorders. Psychogenic ED was diagnosed in 21 patients with preserved non-coital erections and no evidence of organic ED. Median IIEF-EF in ED patients was 20 (range: 8-25). Asthenic ejaculation, delayed ejaculation and anejaculation were present in 63.4% (71/112), 7.1% (8/112) and 3.5% (4/112) patients respectively. Premature ejaculation was present in 28.6% (32/112) patients, but its association with hypospadias or previous surgery is unlikely.

High satisfaction on genital self-perception and sexual function in healthy Norwegian male adolescents

BACKGROUND

Genital self-perception and self-reported outcome on sexual function represent important information in studies focusing on male adolescents born with a genital malformation. Normal data from an age-matched control group are essential for comparison and more knowledge is needed concerning age after puberty and before entering adulthood.

OBJECTIVE

To investigate the self-reported outcome on genital perception and sexual outcome of healthy male adolescents aged 16 and 17 years.

STUDY DESIGN

Sixty-one individuals were included in this cross-sectional study. The assessment tools included the adolescents' self-report on genital perception and sexual function measured by the Pediatric Penile Perception Score (PPPS) and their responses to a semi-structured interview. In addition, we added information on mental health and psychosocial functioning measured by the Strengths and Difficulties Questionnaire, and health-related quality of life (HRQoL) measured by the Pediatric Quality of Life Inventory. Body satisfaction and self-esteem were also measured by the Global Self-Worth and Physical Appearance subscales of the revised version of the Self-Perception Profile for Adolescents (SPPA).

RESULTS

Of the 73 individuals invited, a total of 61 participated. The adolescents reported high satisfaction on genital self-perception and sexual function with a score close to 10 on the overall PPPS score (maximum overall score is 12). Participants who were dissatisfied with their genitals reported penile length, alongside foreskin, as their main concern. More than 90% reported satisfaction on sexual function, concerning erection, masturbation, ejaculation, and orgasm. Results showed a higher score on body satisfaction, self-esteem, mental health and psychosocial functioning and a lower score on HRQoL compared to the normative Norwegian data. The small numbers of individuals that scored more negatively on genital self-perception and sexual function also scored more negatively in all items studied.

DISCUSSION

A key finding in our study was their high satisfaction on the overall PPPS score and reported sexual function. The results are comparable to other studies related to healthy male adolescents and the sample studied deviate little from a representative Norwegian sample. A comparison group of age-matched adolescents from the normative population is important to determine long-term outcomes on genital appearance and sexual function of patients born with a genital malformation and operated on in early childhood. Limitations of this study are the small sample-size and the lack of information on non-participants.

CONCLUSIONS

Our results show generally positive genital self-perception and sexual function in a healthy group of Norwegian male adolescents, aged 16 and 17.

Self-reported outcomes after the onset of puberty in patients undergoing primary distal hypospadias repair by the tubularized incised plate technique combined with preputial reconstruction vs. circumcision: A norm related study

PURPOSE

We assessed self-reported outcomes after the onset of puberty in patients undergoing tubularized incised plate (TIP) repair in combination with preputial reconstruction (PR) or circumcision for primary distal hypospadias, in comparison to normal controls.

MATERIAL AND METHODS

Out of 498 patients undergoing primary distal hypospadias repairs between 2001 and 2012, 83 underwent TIP repair associated with PR or circumcision before age 10-year, and had a Tanner stage ≥2 at study. Outcomes were assessed by online self-administration of validated questionnaires and additional non-validated questions. Results were compared between patients undergoing TIP repair vs. normal age-matched controls (healthy volunteers), and, between patients undergoing PR vs. circumcision.

RESULTS

Forty-one of the 83 eligible patients completed the study (response rate 49.3%). Of these, 26 had undergone PR. Median post-operative follow-up was 11.8 (range 6.5-16.2) years. The control group included 45 healthy boys. Comparing groups, there were no statistically significant differences in the cosmetic aspect of the penis, patient perception of penile appearance, and quality of life. Irrespective of preputial management, patients reported fear of being teased for the appearance of their genitalia much more commonly than controls (p = 0.02), but this did not affect their relationship patterns and quality of life.

CONCLUSION

Self-reported outcomes after the onset of puberty were not significantly different between patients undergoing primary TIP repair of distal hypospadias in childhood and normal controls. Patients were significantly more commonly feared of being teased for their genital appearance, but this did not interfere with their social skills. Preputial management, namely PR vs. circumcision, did not affect the outcome.

Sexual functions and fertility outcomes after hypospadias repair

Hypospadias is a common abnormality of the urogenital tract with a wide range of variety in its presentation and severity. The primary aim to correct hypospadias is to restore normal penile function and appearance. Although it can be corrected at any age, early correction between the 6 and 18 months of life is recommended. The functional and cosmetic outcomes have been very-well presented in the literature, although the aspects of sexuality and fertility of hypospadias repair in the long term are vague. In this narrative review, we aimed to gather the data around the sexuality and fertility outcomes of hypospadias repair and acknowledge urologists and parents of boys with hypospadias who will have a correction surgery about future sexual and fertility concerns.

Urological results and patient satisfaction in adolescents after surgery for proximal hypospadias in childhood

BACKGROUND

Proximal hypospadias repair is associated with a considerable complication risk. Long-term follow-up is required to present realistic expectations in pre-operative counseling.

OBJECTIVE

To investigate adolescents after childhood surgery for proximal hypospadias in a prospective cohort study describing the urological outcome, complication rates and patient satisfaction with penile appearance.

STUDY DESIGN

39 adolescents ≥14 years with penoscrotal to perineal hypospadias and primary urethroplasty (tubularized incised plate (TIP), preputial flap as Onlay or tubularized (Duckett)) from 1996 to 2005 at a single center were evaluated. The clinical assessment, at Md 16.5 years (14-25), included voiding history, genital examination including the Hypospadias Objective Scoring Evaluation (HOSE), uroflowmetry plus chart data from previous urinary flows and evaluation of patient satisfaction using the Penile Perception Score (PPS).

RESULTS

Twenty-nine patients with penoscrotal and 10 with scrotal/perineal hypospadias underwent surgery with TIP (N = 14), Onlay (N = 14) and Duckett (N = 11). Uroflows improved significantly compared with prepubertal maximal flows. Impaired flow rate (<10 mL/s) was found in 14% (5/36). Fifty-one percent (20/39) required reoperations, 29% (4/14) of TIP, 50% (7/14) of Onlay and 82% (9/11) of Duckett (p = 0.0062). Median penile length in adolescence was 8.7 cm (4.0-11.0). Forty-four percent (12/27) of patients were dissatisfied with penile length. Patients were 'satisfied' or 'very satisfied' with meatal position and shape despite HOSE for meatal position being 11% (4/38) distal, 76% (29/38) proximal glanular and 13% (5/38) coronal. TIP patients had more curvature at puberty than Duckett (p = 0.0062). Patients that had a decurvature procedure had shorter penile length (p = 0.019).

DISCUSSION

A high complication rate is previously described, predominantly within the first years. Our study shows 50% of reoperations were performed after >3 years, illustrating the need for long-term follow-up. Patient satisfaction with a deviant meatal position is rarely reported [1,2]. Our results support a conservative approach to an asymptomatic retracted meatus. Limitations of this descriptive study are the non-comparable groups and the retrospective data for correlation, impeding evaluation of prognostic outcome-factors. The shorter penile length found in patients after plication, and increased curvature after TIP, is therefore merely descriptive. However, the findings are in line with earlier publications suggesting limited use of TIP, and plication (recommending ventral lengthening instead) to avoid penile shortening and curvature in these cases [3-5].

CONCLUSIONS

The urological long-term outcome after proximal hypospadias repair is good, although late reoperations are common. In adolescence, patients were dissatisfied with the short penile length but satisfied with meatal position, indicating that in proximal hypospadias, preserving penile length and correcting curvature are prioritized over a distal meatus.

Double-face preputial island flap revisited: is it a reliable one-stage repair for severe hypospadias?

PURPOSE

We have studied outcome of double-face preputial island flap (DFPIF) technique in severe types of hypospadias: penoscrotal, scrotal and perineal.

METHODS

We have used DFPIF in 75 boys at a median age of 1.1 years (1.0-1.5). The meatus was penoscrotal, scrotal or perineal after de-gloving the penis. The inner face of the foreskin was used for urethroplasty and the outer face for ventral skin covering. Modifications were added: proximal anastomosis was protected by a spongioplasty; in case of urethral plate transection, we anastomosed on onlay proximal and distal segments of the flap (onlay-tube-onlay) and the tubularized part was sutured to corpus cavernosa. FU was scheduled at one month then every 3 months for a year then annually. At each consultation, the surgeon filled out a detailed cosmetic and functional sheet including flowmeter.

RESULTS

Thirty-four patients had onlay preputial flap repair with urethral plate preservation. Forty-one had the onlay-tube-onlay technique. All children had a curvature, 19 had a significant residual curvature after dissection, corrected by dorsal plication (n = 9) and ventral lengthening (n = 10). Median FU was 4.2 years (2.7-6.5). 36 children (48%) had complications and needed redo surgery: 12 fistulas, 11 diverticula, 7 meatal stenosis, 3 strictures and 2 residual curvatures. All children but three voided within the normal limits for their age.

CONCLUSION

DFPIF remains a good option for a one-stage repair of severe hypospadias. After a median of 1.8 procedures, the final success rate was 96%. The healthy well-vascularized ventral skin allows safe redo surgery when needed.

Analysis of the association between paternity and reoperation for urethral obstruction in adult hypospadias patients who underwent two-stage repair in childhood

Background

The association between surgical outcome of hypospadias repair and long-term male reproductive function has not been documented. The purpose of this study was to clarify association between paternity in adult hypospadias patients and reoperation for urethral obstruction after two-stage repair during childhood.

Methods

Ninety hypospadias patients who underwent the same kind of two-stage repair in our institute by a single surgeon, were initially treated at < 18 years old, and who were ≥ 18 years old during the survey were included in the study. Present physical, social, and life status were evaluated by a mailed self-entry questionnaire, and clinical background and surgical outcome data were evaluated by medical records. National survey data of the general population were used as external control. The paternity rate of the patient groups was evaluated by Kaplan-Meier curve analysis and log-rank tests.

Results

Twenty-six patients (28.9%) underwent 43 reoperations after completion of the initial repair. Twelve patients were reoperated for obstructive complication (Study group) and were compared with 14 patients who were reoperated only for non-obstructive causes and 64 patients who were not reoperated as Study control group (N = 78). The Study group patients showed sexual intercourse rate and marriage rate not statistically different in comparison with the Study control, although marriage rate at 32.5 years old were lower than the general population (p = 0.048, z-test). None of the Study group achieved paternity, which showed a significant difference to the Study control (p = 0.032, log-rank test). The difference was also statistically significant in the analysis among the 31 married patients (p = 0.012, log-rank test). Patients reoperated for obstructive complication documented worsened Quality of Life score in the International Prostate Symptom Score (2.3 ± 2.0 vs. 1.4 ± 1.2, p = 0.031, t-test) and ejaculation problems (66.7% vs. 17.4%, p = 0.003, chi-square test).

Conclusions

History of reoperation for obstructive complication was associated with lower paternity rate in patients with hypospadias, presumably for multifactorial causes associated with marriage age and ejaculation problems. The present results may implicate importance of uncomplicated urethroplasty during childhood for achieving paternity, although it should be further tested in the future for larger groups of hypospadias patients.

Electronic supplementary material

The online version of this article (10.1186/s12894-019-0512-2) contains supplementary material, which is available to authorized users.

Does grafted tubularized incided plate improve the outcome after repair of primary distal hypospadias: A prospective randomized study?

OBJECTIVE

To detect whether grafting the incised plate during Snodgrass repair would improve outcome.

MATERIALS AND METHODS

Sixty patients with primary distal hypospadias were included. Patients were equally randomized using closed envelop method to either Snodgrass or grafted tubularized incised plate repair (GTIP). All operations were performed by a single surgeon. All intaroperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meatus at the tip of the glans with no stenosis, fistula or diverticulum.

RESULTS

All 60 patients were evaluated at 1 year of follow-up. Mean age at surgery was 40±15months. Both groups were comparable as regard to patients' age, meatus location, length and width and depth of urethral plate and glans width. Success was documented in 29/30 patients (96.7%) in the Snodgrass group. The only complication was meatal stenosis in one patient, whereas success was documented in 28/30 patients (93.3%) in the GTIP group. The two failures were secondary to partial glans dehiscence. Success rate was not statistically different. Flow rate data at 1 year showed insignificant difference between both groups as regards Q-max and voiding time. The only statistically significant difference between both groups was a longer operative time 106±12min in the GTIP group compared to only 77±9 for the Snodgrass group (p = 0.005).

CONCLUSIONS

Snodgrass and GTIP techniques for primary distal hypospadias repair have similar outcome. With a significantly shorter operative time, Snodgrass repair remains the first choice for primary distal hypospadias repair.

TYPE OF THE STUDY

Prospective randomized study.

LEVEL OF EVIDENCE

Level I.

Voiding patterns of adult patients who underwent hypospadias repair in childhood

OBJECTIVE

This study aimed at evaluating the voiding patterns of adult patients who underwent hypospadias repair in childhood.

METHOD

Following IRB approval 103 (22.7%) of 449 adult patients who underwent hypospadias repair between 1978 and 1993 responded to the following questionnaires: International Prostate Symptom Score (I-PSS) and Short Form 12 questionnaire (SF-12). Uroflowmetry (UF) was performed for all patients. The patients were divided into three groups according to the primary meatus localization. Group I had 63 patients (61.5%) treated for glanular hypospadias, group II had 19 patients (18.4%) treated for distal hypospadias, and group III comprised the remaining 21 patients (20.4%) treated for proximal hypospadias.

RESULTS

The mean ± SD I-PSS score for all patients who responded to the questionnaire was 2.3 ± 2.4, and UF was 21.1 ± 4.3 mL/s. The patients from groups I and III had fewer urinary symptoms compared with those of the group II: 1.3 ± 1.5, 5.5 ± 2.4, and 1.6 ± 1.4, respectively (p < 0.0001). With regards to UF, the patients from the groups I and III did better compared with those from the group II: 22.1 ± 4.1 mL/s, 18.91 ± 4.2 mL/s, and 20.11 ± 3.42 mL/s, respectively (p = 0.021) (Figure). The UF was better in patients with normal vs. abnormal IPSS (p = 0.0064). The physical component summary was 49.8 ± 10.3, 51.1 ± 3.6, and 46.4 ± 0.3 in groups I, II, and III, respectively. The mental summary component was 42.64 ± 4.1, 42.2 ± 2.4, and 39.89 ± 2.9 in groups I, II, and III, respectively.

CONCLUSIONS

Most of the adult patients who underwent hypospadias repair in childhood had normal or mild voiding disturbance, with no effects on their physical or mental status.

The SIGHT questionnaire: A novel assessment tool for Satisfaction In Genital Hypospadias Treatment

PURPOSE

Psychosexual development is currently underrepresented in hypospadias outcome research. The aim of this study was to develop and validate a questionnaire addressing psychosexual long-term satisfaction, specifically of adolescent patients, after hypospadias repair.

MATERIALS AND METHODS

In a multistep participative design we identified key interests of adolescent patients with hypospadias. Next, a questionnaire addressing specifically the psychosexual satisfaction of adolescents after hypospadias repair was established. A population of 109 former patients with hypospadias was then assessed using this questionnaire. Furthermore, functional and cosmetic aspects, behavioural anomalies, and sexual activity were investigated. Age-matched patients undergoing circumcision served as control patients. Possible influence factors on patient satisfaction were investigated. Clinical trial registry site: German Registry of Clinical Trials DRKS, Freiburg, Germany (Reference: DRKS00003432).

RESULTS

Key interests of adolescent patients were "normal appearance of the penis", "normal function of the penis regarding voiding and sexual activity", "no limitations regarding cosmetic appearance to others", "no limitations to sexual activity", and an "unimpaired masculine identity". The "Satisfaction In Genital Hypospadias Treatment" (SIGHT) questionnaire was developed using these items and using previously published evaluation systems. Nine questions address psychosexual aspects and two additional questions address current sexual activity. Internal consistency was high and retest reliability acceptable. The patient population showed a normal strength and difficulties score (SDQ). Overall satisfaction was high and similar to that of the control group. In a Spearman correlation a high SDQ value, erectile problems, and complications correlated negatively with satisfaction.

CONCLUSION

To date, few studies have examined patients' satisfaction and psychosexuality. To our knowledge, the SIGHT questionnaire is the first to be developed participatively and in a stepwise fashion in collaboration with a paediatric psychologist and an open approach to determine items specifically important for adolescents. The SIGHT questionnaire can thus offer a relevant assessment of patients' psychosexual satisfaction. It is most suitable to supplement current strategies that so far mostly neglect the impact on psychosexual wellbeing.

Hypospadias

Hypospadias is a hypoplasia of the tissues forming the ventral side of the penis responsible of an ectopic meatus of the urethra. This congenital anomaly results in a fusion defect of the two epithelial surfaces of the urethral groove between the 11th and the 18th weeks of development. The earlier this process arrests, the more the form is proximal and severe. This is the second genital malformation in boys with 1 case per 250 male births. Its origin is often multifactorial (genetic, endocrine, placental and environmental). Three anatomical forms exist: proximal, middle and distal (the most common). Additional exams (endocrine, genetic and morphological) are realized early, before surgery, in case of severe hypospadias, familial, associated with cryptorchidism, bifid scrotum, micropenis and/or skeletal, kidney, and/or heart abnormalities. It clarifies pubertal prognosis. The surgical management is made between 6months and 12months: it limits the functional and aesthetic impact of this malformation. Many surgical techniques are described. They all have in common the three operating time: penile straightening, urethroplasty, reconstruction of the ventral side of penis. They are based on direct sutures, local flaps pedicled, and grafts (skin or mucosa). The rate of postoperative complications is between 6 and 30 %. The two main complications are fistulae and stenoses. The psychological follow-up of these children is necessary to adulthood. Surgery of hypospadias remains a delicate surgery and must be performed by experienced surgeons.

Patient-reported long-term outcome after primary hypospadias repair

PURPOSE

Long-term evaluation of the surgical outcome after puberty, particularly patient reported outcome is rare in the literature. The aims of this study were to investigation the patients' satisfaction with the long-term results and their views and memories of their childhood surgery and follow-up.

METHODS

A modified version of previously used questionnaire was sent to 134 patients ages 18 years or older previously primarily repaired due to hypospadias by one of the authors (HS) between 1989 -2009.

RESULTS

Thirty-nine patients responded. Eighty-two per cent were satisfied with the appearance of their penis, 87% were satisfied with their ability to urinate and their sexual function and 92% were satisfied with the overall surgical results. Ninety per cent of patients were positive to the current duration of our post-pubertal follow-up program or would have preferred an even longer follow-up.

CONCLUSIONS

The majority of patients were satisfied with the long-term surgical results and the duration of follow-up. Despite having problems patients does not always contact the health care system spontaneously, which warrants long-term follow-up.

Fertility Potential in Adult Hypospadias

INTRODUCTION

Hypospadias is a congenital anomaly of the urogenital tract characterized by abnormal location of the external urethral meatus over ventral aspect of penis. The ideal time to correct primary hypospadias is when aged 6-12 months. However, in some developing countries, such as ours, this anomaly may be left untreated until adulthood. There are multiple risk factors responsible for development of this anomaly, out of which paternal sub fertility is one of them. As the child grows into adulthood, fertility status becomes an important issue, frequently raised by patients.

AIM

To evaluate the fertility potential of adult hypospadiac patients and to rule out the effect of age of surgical correction over fertility potential.

MATERIALS AND METHODS

Seventy three adult patients of hypospadias were prospectively evaluated, out of which 43 were operated during adulthood. All patients underwent measurement of penile length and circumference in both flaccid and erect positions along with testicular volume, serum LH, FSH and testosterone and semen analysis. A set of questionnaire was given to all the patients which included assessment of erectile function (IIEF-5), ejaculatory function, strength of libido and level of satisfaction after sexual intercourse. Results were compared with an age matched control group of 70 healthy person.

RESULTS

Out of 73 patients with a mean age of 23.73 years, 14(19.17%) had proximal and rest 59(80.82%) had distal type of hypospadias. Mean penile length in both type of hypospadiac patients under both flaccid and erect conditions (7.92±1.33 and 9.62±1.31cm) were significantly shorter than those of control (10.78±0.94 and 13.15±1.15 cm) (p<0.001). In spite of short penile length, the level of satisfaction of all patients and their partner after penetrating intercourse were comparable to control (p>0.05). The strength of libido (p>0.05) was comparable with control in both type of hypospadiac patients; however IIEF-5 scores was poor in the proximal type of hypospadias. Semen volume (ml), sperm concentration (mill/ml), active sperm motility (%), and normal sperm morphology were comparable between distal hypospadiac group and control (p>0.05), however these parameters were poor in proximal type. The serum FSH and LH levels were significantly higher and serum testosterone level was significantly lower in hypospadiac patients than control (p <0.001). However, no difference in testicular size was found. The patients who were operated during childhood had shorter penile length compared to patients operated during adulthood.

CONCLUSION

Fertility potential parameters in distal type of hypospadias were comparable with control. However the proximal type had poor erectile function and semen quality. Patients operated in either childhood or in adulthood, there was no significant difference in fertility potential.

Reconstructive surgery for hypospadias: A systematic review of long-term patient satisfaction with cosmetic outcomes

INTRODUCTION

Research on long-term results of hypospadias has focused on surgical techniques and functional outcomes, and it is only recently that patient satisfaction with appearance and psychosocial outcomes have been considered. The aim of this study was to provide an evidence-based systematic review of adolescent and adult patient perceptions of cosmetic outcomes following childhood surgery for hypospadias.

METHODS

A systematic review was performed in accordance with the PRISMA and PICO guidelines, and studies assessed using the Oxford Centre for Evidence-Based Medicine system. MEDLINE, PsycInfo, EMBASE, and CINAHL databases were searched from 1974 to 2014 for clinical studies containing patient perceptions of appearance, deformity, and social embarrassment following hypospadias surgery.

RESULTS

A total of 495 publications were retrieved, of which 28 met the inclusion criteria. Due to study design/outcome measure, heterogeneity data were synthesized narratively. Results indicate (i) patient perceptions of penile size do not differ greatly from the norm; (ii) perceptions of appearance findings are inconsistent, partially due to improving surgical techniques; (iii) patients who are approaching, or have reached, sexual maturity hold more negative perceptions and are more critical about the cosmetic outcomes of surgery than their prepubertal counterparts; (iv) patients report high levels of perceptions of deformity and social embarrassment; and (v) there is a lack of data using validated measurement tools assessing long-term patient perceptions of cosmetic outcomes, particularly with patients who have reached genital maturity.

CONCLUSIONS

Protocols for clinical postpuberty follow-up and methodologically sound studies, using validated assessment tools, are required for the accurate assessment of cosmetic and psychological outcomes of hypospadias surgery.

Modified Penile Augmentation by Dermal-Fat Graft in Post-Hypospadias Adults

BACKGROUND

Although a considerable part of patients desire further improvement in penile size after hypospadias repairs, penile augmentation is only considered in patients with congenital penile hypoplasia or acquired penile retraction. Modified penile augmentation by free dermal-fat graft is introduced to satisfy these patients and improve surgical safety.

METHODS

From April 2012 to December 2014, a total of 15 male adults after hypospadias repairs, aged 18-24 years, underwent modified penile augmentation which involved girth enhancement by a free dermal-fat graft and penile elongation (suprapubic skin advancement-ligamentolysis). A specially designed tunneling instrument was introduced to facilitate pericavernous thickening without degloving. Outcome evaluation was mainly based on objective penile measurements and results of the Male Genital Image Scale.

RESULTS

With 6 months' follow-up, all patients had achieved excellent cosmetic results, with a significant average dimensional increase of 1.53 ± 0.23 cm in flaccid girth and 1.67 ± 0.24 cm in flaccid length. No erection deficiencies or urinary fistula occurred. Patients' perception of male genitalia improved postoperatively, with the average MGIS score rising from 31.73 ± 4.86 to 40.20 ± 4.54.

CONCLUSIONS

This modified technique is safe and effective in enlarging penile size. The use of the specially designed tunneling instrument simplifies penile girth enhancement, avoiding unnecessary trauma to the neo-urethra and neurovascular bundle. It is confirmed that physical dimensional enhancement does contribute to improving their underestimation of penile size.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Factors affecting post-pubertal penile size in patients with hypospadias

Objectives

To evaluate actual post-pubertal penile size and factors affecting it in hypospadias patients, we retrospectively reviewed medical charts.

Patients and methods

Hypospadias patients whose external genitalia were categorized into Tanner stage 5, and whose stretched penile length was evaluated at 15 years old or older from April 2008 to April 2015, were enrolled in the present study. Stretched penile length was measured by a single examiner. Actual post-pubertal stretched penile length and factors affecting the post-pubertal stretched penile length were estimated. Statistical analysis was performed using Mann–Whitney U test and univariate and multivariate linear regression models for the determination of independent factors.

Results

Thirty patients met the inclusion criteria. Median age at evaluation was 17.2 years. Thirteen and 17 had mild and severe hypospadias, respectively. Endocrinological abnormality was identified in 5. Multivariate analysis showed that the severity of hypospadias and endocrinological abnormality were significant factors affecting stretched penile length. Stretched penile length in 25 patients without endocrinological abnormality was significantly longer than that in those with endocrinological abnormality (p = 0.036). Among patients without endocrinological abnormality, stretched penile length in 13 with severe hypospadias was significantly shorter than that in 12 with mild hypospadias (p = 0.004).

Conclusions

While the severity of hypospadias and endocrinological abnormality at post-pubertal evaluation were factors affecting post-pubertal penile size, stretched penile length in patients with severe hypospadias was shorter even in cases without endocrinological abnormality. These results suggest that severe hypospadias is not only a disorder of urethral development, but also a disorder of penile development.

Role of penile biometric characteristics on surgical outcome of hypospadias repair

PURPOSE

To assess influence of penile biometric characteristics on surgical outcome of tubularized incised plate (TIP) repair for hypospadias.

METHODS

We prospectively studied 42 boys with distal hypospadias that underwent TIP urethroplasty. Biometric assessment prior to surgery consisted of classifying glans shape, urethral plate (UP) length and width, prepuce vascularization and penile size, using a caliper rule, according to previous definitions. Surgical outcome was assessed according to the occurrence of dehiscence, fistula or urethral stricture.

RESULTS

There was no statistical difference among groups concerning postoperative complications. Glans shape: grooved (24/57 %), shallow (9/21 %) and conical (9/21 %). UP width: <10 mm (26/62 %) and ≥10 mm (16/38 %). UP length was evaluated in 29 patients: <10 mm in (12/41 %) and ≥10 mm (17/59 %). Prepuce vascularization: one predominant blood vessel (17/41 %), two predominant blood vessels (8/19 %), H-like form with communication between two well-developed blood vessels (6/14 %) and net-like form with no predominant blood vessels (11/26 %). Penile size was measured in 28 patients under 50th percentile (25/89 %).

CONCLUSION

Glans shape, UP width, UP length, prepuce vascularization and penile size do not significantly affect the complication rate of TIP repair in distal hypospadias. Most of the patients with distal hypospadias presented with penile size under mean length for age suggesting some form of mild hypogonadism.

Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood

PURPOSE

We evaluated sexual function and psychosexual adjustment in adults who underwent hypospadias repair in childhood.

MATERIALS AND METHODS

After receiving institutional review board approval, 119 of 449 adult patients (26.6%) who underwent hypospadias repair between 1978 and 1993 responded to questionnaires on penile appearance and sexual life. Patients were divided into 3 groups according to primary meatal location in childhood, including group 1-45 (37.8%) with glanular hypospadias, group 2-56 (48.2%) with distal hypospadias and group 3-18 (14%) with proximal hypospadias.

RESULTS

All group 1 and 2 patients, and 11% in group 3 were satisfied with the penile appearance. Of group 1 patients 8.9% reported mild erectile dysfunction, as did 50% and 72.2% in groups 2 and 3, respectively. A total of 99 patients (83.2%) complained of premature ejaculation. All group 1 and 2 patients reported excellent self-esteem and relationship on the Self-Esteem and Relationship questionnaire. Most group 3 patients were satisfied with their relationship and only 1 (5.6%) was not satisfied. Two-thirds of the patients in groups 1 and 2 reported that sexual quality of life was excellent and the others described it as good. In group 3 sexual quality of life was somewhat decreased in all patients and 1 (5.6%) had poor sexual quality of life. Physical and mental component summaries were satisfactory in all patients reviewed.

CONCLUSIONS

Our data show that the high incidence of mild erectile dysfunction and premature ejaculation should not be disregarded and requires appropriate counseling before surgery.

Penile length is comparable in boys with and without hypospadias

INTRODUCTION

It has been suggested that penile length is negatively correlated to the degree of hypospadias; however, there are no studies in the literature actually comparing penile length in normal patients and patients with hypospadias.

MATERIAL AND METHOD

Between January and May 2011, we measured penile length in two groups of children aged up to 5 years. The first group comprised all boys admitted for hypospadias (40 patients; 25 distal and 15 proximal hypospadias). The control group comprised 100 boys seen for other surgical procedures excluding those with endocrine disorders. We measured the length of the dorsal aspect of the penis in the flaccid state, without stretching. We then established, using our control group, a range of 'normal' values for penile length in our population and determined whether children with hypospadias were within this 'normal' range.

RESULTS

Mean penile length in the control group was 4.07 ± 0.92 cm, mean penile length in the hypospadias group was 4.36 ± 0.9 cm (4.48 ± 0.89 cm for distal hypospadias and 4.21 ± 0.79 cm for proximal hypospadias). There was no difference in penile length between the hypospadias group and the control group regardless of degree of hypospadias.

CONCLUSION

This study indicates that penile length in children with hypospadias whether proximal or distal is within the normal range.

The psychosexual aspects of hypospadias repair: A review

OBJECTIVE

To review the psychosexual effects on men after hypospadias repair.

METHODS

We reviewed all English-language publications in the MEDLINE database from the US National Library of Medicine with the search terms 'hypospadias adult', 'psychosexual hypospadias', 'psychosocial hypospadias', and 'social hypospadias'. Each term returned 1036, 35, 19 and 68 results, respectively, which were reviewed.

RESULTS

While improvements in surgical techniques have improved function, the abnormality and repair still causes a disruption in perceived quality of life for many men. After repair, many men suffer from a negative view of their genitals and some degree of sexual inhibition. However, they still maintain a satisfactory sex life.

CONCLUSIONS

Psychosexual effects of hypospadias repair they endure in adulthood, although affected men maintain satisfaction with their sexual life.

Effect of hypospadias on sexual function and reproduction

Hypospadias is a highly prevalent congenital anomaly. The impact of the defect and operative interventions on sexual and reproductive function has been addressed by few publications. It is essential to know the possible outcomes of intervention for appropriate counseling, operative planning, and follow-up. English articles indexed in Pubmed dealing with the long-term sexual and reproductive outcome following hypospadias repair from 1965 to 2007 were reviewed. To our knowledge, there was no prospective trial comparing the impact of various techniques on sexual outcome. There is considerable discordance in literature regarding the effects on sexual function. A few publications report patient and partner dissatisfaction with the appearance of genitalia. Sexual dissatisfaction is often attributed to penile size. Ejaculatory disturbances range between 6 and 37% of operated individuals. There is no convincing evidence for impaired fertility. The long-term follow-up is essential to identify problems and to address them appropriately. Literature documenting the outcome of specific operative procedures and analysis based on severity of hypospadias will be informative. The long-term follow-up of the newer techniques which are more commonly used are awaited.

Psychosexual adjustment and age factors in 130 men undergone hypospadias surgery in a Chinese hospital

The study investigated the psychosexual status and sexual function in adults who had hypospadias surgery at different ages. A detailed questionnaire was mailed to 130 patients who underwent hypospadias surgery between January 1988 and December 2007, and 50 healthy males who served as the control group. The patients were divided into three groups based on their age at which surgery was completed: group A (n=32; <10 years); group B (n=45; 10-18 years); and group C (n=53; >18 years). The Zung Self-Rating Anxiety Scale and The Zung Self-Rating Depression Scale were used to assess psychosexual status; a designed questionnaire and the International Index of Erectile Function-5 were used to assess sexual function. The incidence of anxiety and depression was significantly higher in patients than that in controls (P < 0.001), and was correlated with the age at which surgery was completed. The length and circumference of penises in patients were shorter than those of control groups with statistically significant differences (P < 0.01). There were no significant differences between patients and controls regarding libido strength, overall sexual satisfaction and erectile function (P > 0.05). In conclusion, difference existed in certain aspects of psychosexual and penile development between patients and controls. Hypospadias surgery should be performed early.

Long-term outcome of penile appearance and sexual function after hypospadias repairs: situation and relation

OBJECTIVE

The aim of this study was to assess the long-term cosmetic and sexual outcomes of hypospadias surgery performed in childhood and to analyze the relation between them.

METHODS

A long-term follow-up was made to 174 patients who were operated for hypospadias in this institute between 1984 and 1992. Their records were analyzed retrospectively, and a detailed questionnaire was mailed to them. Responses from returned questionnaires were pooled and analyzed.

RESULTS

Forty-three (24.7%) of 174 patients finished the questionnaire. The mean patient age of the 43 patients was 21.6 years. Twenty-three (53.5%) of 43 patients were dissatisfied with penile appearance. The main reason for dissatisfaction was smaller penile size and curvature. Thirty-six (83.7%) of 43 patients were satisfied with overall sexual function. Of these 43 patients, 76.7% reported good quality of erection, but 23.3% reported the existence of problems during erection. The main complaint was smaller penile size and curvature. There were 17 patients (39.5%) with ejaculation problems, mainly including impotent ejaculation. Sixteen (88.9%) of the 18 patients who had experienced sexual intercourse reported no problems during intercourse. Depending on the severity of hypospadias, these patients with proximal hypospadias were more dissatisfied with penile appearance than those with distal hypospadias (76.5 vs. 38.5%, P < 0.025). And they complained more problems during erection (41.2 vs. 11.5%, P < 0.05), ejaculation (100 vs. 0%), and sexual intercourse (50 vs. 0%, P < 0.05), and were less likely to experience sexual intercourse (23.5 vs. 53.8%, P < 0.05), compared to those with distal hypospadias. Depending on their self-evaluation on penile appearance, these patients who were satisfied with penile appearance had less problems in achieving erection (5.0 vs. 39.1%, P < 0.025) and ejaculation (20 vs. 56.5%, P < 0.025) and were more likely to experience sexual intercourse (60 vs. 26.1%, P < 0.05), compared to those who were dissatisfied. The self-rated satisfaction scale correlates positively with the penile appearance and sexual function (r = 0.469, P < 0.01).

CONCLUSIONS

Patients who had been operated for hypospadias have a significantly careful concern on penile appearance. Penile size can obviously impact satisfaction with penile appearance and sexual function. Some patients have erection, ejaculation, and intercourse problems in adulthood, but majority have a rather normal sexual function. The more severe the hypospadias, the more dissatisfactory the long-term outcome. Better cosmetic outcome is related to better sexual outcome. Although remaining challenging, it is necessary to follow up hypospadias patients after surgeries into adulthood.

Outcome of pediatric hypospadias repair in adulthood

PURPOSE

To review the evolution of the technique of hypospadias repair.

METHODS

A search of Pubmed, Medline and the Journal of Pediatric Urology was performed, and papers dealing with surgical techniques for hypospadias repair were critally reviewed. Special emphasis was given to papers on the effects in the long term of hypospadias repair on voiding and sexual dysfunction.

RESULTS

The techniques for hypospadias repair have evolved over the years. The most popular technique now is tubularized incised plate urethroplasty. Long-term results with the use of the new techniques of the hypospadias repair in terms of voiding and sexual problems should be addressed.

CONCLUSION

There is a need for valid studies on the outcomes of hypospadias repair in adults that were performed in childhood in terms of cosmetic appearance, voiding and sexual performance.

Body image and sexuality in adolescents after hypospadias surgery

OBJECTIVE

Patients operated on for hypospadias often display a range of emotional and functional postoperative problems at an early age. This study explores the social, psychosocial and sexual development of adolescent boys operated on for hypospadias at an early age.

PATIENTS AND METHOD

Ten boys between the ages of 11 and 18 years and an age-matched reference group of 10 boys completed three mailed questionnaires: the Child Behavior Checklist/4-18, the Youth Self Report, and the Self-Perception Profile for Adolescents. Data on body image and genital perception, and on social, psychosocial and sexual development were gathered by interview and standardized questionnaire.

RESULTS

Internalizing or externalizing problems were not reported to be increased. Boys operated on for hypospadias had a significantly lower score on the Self-Perception Profile for Adolescents, Social Acceptance subscale. Fewer boys in the clinical group considered their penis to be normal or judged their penis as similar to that of friends. No difficulties were found regarding psychosocial or sexual development; there was however a tendency towards a more negative genital appraisal.

CONCLUSION

Boys operated on for hypospadias appear to experience normal social, psychosocial and sexual development.

Long-term followup of hypospadias: functional and cosmetic results

PURPOSE

We assessed long-term results after hypospadias surgery with respect to urinary and sexual function, cosmetic appearance and intimate relationships.

MATERIALS AND METHODS

We contacted 116 patients who are now adults and who underwent surgery between 1987 and 1992. Participation included mailed questionnaires containing the International Prostate Symptom Score, International Index of Erectile Function and the Dutch Survey of Intimate Relations (Nederlandse Relatie Vragenlijst) as well as uroflowmetry and cosmesis assessment using the Pediatric Penile Perception Score. A control group of 151 male students completed the International Prostate Symptom Score and International Index of Erectile Function, and underwent uroflowmetry.

RESULTS

A total of 91 patients (78%) were traceable, 57% returned the questionnaires and 27% visited the clinic. Hypospadias was distal, mid shaft and proximal in 47, 8 and 11 patients, respectively. International Prostate Symptom Score was greater than 7 in 9 of 64 patients (14%) compared to 10 of 151 controls (7%). Patients with distal hypospadias complained more about micturition. Patients with proximal hypospadias had lower maximum urine flow than other patients and controls. For sexuality the total International Index of Erectile Function did not differ between patients and controls. Patients with proximal hypospadias reported less satisfaction with penile length and objectively penile length was less than the average of all patients (10.8 vs 12.1 cm). Cosmetic outcome was considered satisfactory. Outcomes in the 33 patients who returned the Dutch Survey of Intimate Relations correctly were above average, especially for sexuality and independence.

CONCLUSIONS

Patients with distal hypospadias have a higher International Prostate Symptom Score and patients with proximal hypospadias have lower maximum urine flow than controls. Sexual function and cosmesis are rated good. The quality of intimate relationships is above average.

Long-term sexual activity status and influencing factors in men after surgery for hypospadias

The aim of this study was to compare the long-term postoperative status of hypospadiac patients by analysing their sexual psychology, sexual behaviour, sexual function and influencing factors. A total of 130 hypospadiac patients hospitalized between January 1988 and December 2007 were followed up with questionnaires using Zung's Self-rating Depression Scale (SDS), Self-rating Anxiety Scale (SAS), a self-designed sexual function questionnaire and a 5-item version of the International Index of Erectile Function (IIEF-5). The surveys served to evaluate the effects of hypospadias type, number of operations and surgical procedures on sexual psychology, sexual behaviour and sexual function. The control group consisted of 50 healthy adults. The postoperative SDS / SAS scores and occurrences of depression/anxiety in hypospadiac patients were significantly higher than those of normal controls (P < 0.001). Patients with proximal hypospadias and multiple procedures differed from those with distal hypospadias and a single procedure in all parameters of sexual psychology (P < 0.05). The average penile lengths and circumferences of hypospadiac patients under either erect or flaccid conditions were significantly shorter than those of normal controls (P < 0.001). A similar difference existed between patients with distal and proximal hypospadias (P < 0.01). There was no significant difference in any parameter of sexual function between patients with different numbers of operations and surgical procedures. Hypospadiac patients were clearly impaired in sexual psychology and penile development. The severity of hypospadias and number of operations were key factors that influenced the sexual psychology of patients. This finding indicated the importance of long-term follow-up and psychological counselling for hypospadiac patients postoperatively.

Self-ratings of genital anatomy, sexual sensitivity and function in men using the 'Self-Assessment of Genital Anatomy and Sexual Function, Male' questionnaire

OBJECTIVE

To assess the perceptions of healthy men of their genital anatomy and sexual sensitivity, along with the re-test reliability of these ratings, in a new self-reported questionnaire, the Self-Assessment of Genital Anatomy and Sexual Function, Male (SAGASF-M).

SUBJECTS AND METHODS

Eighty-one healthy, sexually active, men aged 22-57 years (median 33), with no history of genital surgery, completed the SAGASF-M. This questionnaire comprises written text and images enabling men to rate details of their genital appearance, overall genital erotic and pain sensitivity, orgasm intensity, and effort required for achieving orgasm through stimulation of specified areas around the glans and shaft of the penis, scrotum and anus, along with the contribution of other sexually sensitive areas of the body. Anatomical locations were compared for the functional ratings by mixed-model analysis of variance (anova). A second sample of 38 healthy men (median age 26 years, range 22-64) from the same source completed the SAGASF-M twice with an interval of 2 weeks.

RESULTS

There was little variability in anatomy ratings. Ratings of overall penile sensitivity to sexual stimulation gave higher values of 'sexual pleasure' for penile stimulation by the partner than by self (P = 0.002) and marginally higher ratings of 'orgasm intensity' by partner stimulation (P = 0.077), but there were no corresponding differences on ratings of 'effort needed to reach orgasm' or of 'discomfort/pain'. Overall discrimination between genital areas was highly significant (mixed-model anova, P = 0.001) for ratings of 'sexual pleasure', 'orgasm intensity' and 'orgasm effort', but was not significant for 'discomfort/pain'. Ranked by degree of 'sexual pleasure', the area 'underside of the glans' was highest, followed by 'underside of the penile shaft', 'upper side of the glans', 'left and right sides of the glans', 'one or both sides of the penis', 'upper side of the penile shaft', 'foreskin' (11 subjects), 'skin between the scrotum and anus', 'back side of the scrotum', 'front side of the scrotum', and 'around anus', but not all pair differences were significant. The rank order was similar for 'orgasm intensity', but less similar and with fewer significant pair differences for 'orgasm effort'. Overall discrimination of other body parts that help orgasm when touched/stimulated was also highly significant (P = 0.001) and included (in order of degree) scrotum, ear, skin between scrotum and anus, neck, breast/nipples, buttocks, anus (exterior skin), anus (inside with penetration), wrist, and axilla, but many pair differences were not significant. In the reliability study, which was limited to the 45 function items with sufficient variability and sample size, the re-test reliability values (Pearson r) were distributed as follows: seven were >or=0.80, 16 >or=0.70, 15 >or=0.60, four >or=0.50, two >or=0.40, and one >or=0.30.

CONCLUSION

The SAGASF-M discriminates reasonably well between various genital and nongenital areas in terms of erotic sensitivity, when administered to genitally unoperated men varying widely in age and socio-economic level.

Long-Term Patient Reported Outcome of Urinary Symptoms After Hypospadias Surgery: Norm Related Study In Adolescents

PURPOSE

Although there are some reports of the functional outcome after hypospadias surgery, long-term patient reported data on urinary symptoms are sparse. We evaluated the long-term outcome of urinary control in patients with hypospadias who were operated in childhood.

MATERIALS AND METHODS

A detailed questionnaire was mailed to 33 patients with hypospadias who were between 18 and 26 years old and had undergone the first operation at age 6 years or younger, and to 50 age matched controls.

RESULTS

A total of 22 patients (66.7%) and 38 controls (76.0%) returned the questionnaire. Mean age was 20.6 years in the hypospadias group and 21.0 years in the control group. Of the 22 patients 8 had mild and 11 had severe hypospadias, while severity was unknown in 3. Straight direction of the urinary stream was noted at a similar rate in the hypospadias and control groups (77% and 71%, respectively). Regarding the urinary stream, no subjects in either group reported it as bad or very bad. Of the hypospadias group 95% of subjects and 89% of controls reported mild or no urinary frequency bother. The incidence of individuals who always or mainly voided while standing was similar in the hypospadias and control groups (91% and 84%, respectively). However, 32% of subjects in the hypospadias group reported moderate or severe terminal dribbling, in contrast to only 3% of controls. When subjects with mild and severe hypospadias were compared, 4 of 11 (36%) with severe hypospadias needed to squeeze the urethra after voiding to eliminate residual urine in the urethra, whereas none with mild hypospadias needed to squeeze the urethra.

CONCLUSIONS

Although patients with hypospadias mostly have good urinary control, terminal dribbling is not uncommon, especially in those with severe hypospadias.

Extended urethral mobilization in incised plate urethroplasty for severe hypospadias: a variation in technique to improve chordee correction

PURPOSE

The feasibility of tubularized incised plate urethroplasty in proximal hypospadias with severe chordee was studied after correction of chordee by extended urethral mobilization.

MATERIALS AND METHODS

Boys with severe hypospadias who underwent tubularized incised plate urethroplasty were included. A total of 34 patients (28 with proximal penile/penoscrotal hypospadias and 6 with scrotal hypospadias) 18 months to 13 years old (mean 5 years) with severe hypospadias underwent tubularized incised plate urethroplasty between January 1999 and March 2006. A Gittes test was performed to assess the chordee after penile degloving and preservation of the urethral plate. Subsequently, the urethral plate with divergent corpus spongiosum and proximal healthy urethra were mobilized up to the bulbar urethra. Glanular chordee was corrected by mobilizing the urethral plate into the glans. The urethral plate was tubularized with or without incision and spongioplasty to complete the urethroplasty.

RESULTS

Chordee correction was possible by mobilization of the urethral plate with corpus spongiosum from the meatus to the glans and the proximal urethra up to the bulbar region in 88% of the cases. Mean followup was 23 months (range 6 months to 3 years). Overall complication rate was 12% (fistula in 3 patients, meatal stenosis in 1). Two patients (6%) required dorsal plication, and in 2 (6%) the urethral plate had to be divided to correct the chordee. No patient had residual chordee during followup.

CONCLUSIONS

The technique of chordee correction by mobilization of the urethral plate and proximal urethra with preservation of the urethral plate is simple and effective, and enlarges the scope of tubularized incised plate urethroplasty in severe hypospadias.