Korean J Urol.  2008 Dec;49(12):1059-1066.

Hypospadias Repair: Recent Concept and Development in Surgical Techniques

• Kim MK
• Kim YG

Abstract

Hypospadias is one of the most common congenital anomalies defined by abortive development of the urethral spongiosum and the ventral prepuce. The current standard of care for hypospadias includes not only a functional penis adequate for sexual intercourse and urethral reconstruction offering the ability to stand to urinate, but also a satisfactory cosmetic result. The techniques of hypospadias surgery continue to evolve. The major technical advances in hypospadias surgery that have improved surgical outcomes are 1) Preservation of the urethral plate, 2) Incision of the urethral plate, 3) Dorsal midline plication, 4) Deepithelized urethroplasty dartos flap coverage, and 5) Two stage alternative techniques. Tubularized incised plate repair has been the mainstay for distal hypospadias. In cases of proximal hypospadias, one-stage repairs such as the Duckett repair or the Koyanagi repair have been well established, while two-stage repairs remain important alternatives. Whether dorsal plication or ventral lengthening should be used to correct penile curvature is still controversial, and long-term results are required. This article reviews the new concept and development in surgical techniques.

Keyword

Hypospadias; Surgery; Urethra

MeSH Terms

Coitus
Cosmetics
Female
Hypospadias
Male
Penis
Standard of Care
Urethra
Cosmetics

Reference

References

1. Baskin LS, Himes K, Colborn T. Hypospadias and endocrine disruption: Is there a connection? Environ Health Perspect. 2001; 109:1175–83.

2. Belman AB. Hypospadias update. Urology. 1997; 49:166–72.

3. Duckett JW Jr. Transverse preputial island flap technique for repair of severe hypospadias. Urol Clin North Am. 1980; 7:423–30.

4. Elder JS, Duckett JW, Snyder HM. Onlay island flap in the repair of mid and distal penile hypospadias without chordee. J Urol. 1987; 138:376–9.

5. Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol. 1994; 151:464–5.

6. Snodgrass W, Koyle M, Manzoni G, Hurwits R, Caldamone A, Erlich R. Tubularized incised plate hypospadias repair for proximal hypospadias. J Urol. 1998; 159:2129–31.

7. Cook A, Khoury AE, Neville C, Bagli DJ, Farhat WA, Pippi Salle JL. A multicenter evaluation of technical preferences for primary hypospadias repair. J Urol. 2005; 174:2354–7.

8. Betts EK. Anesthesia in the neonate and young infant. Dial Pediatr Urol. 1981; 4:3–5.

9. Manley CB, Epstein ES. Early hypospadias repair. J Urol. 1981; 125:698–700.

10. Belman AB, Kass EJ. Hypospadias repair in children less than 1 year old. J Urol. 1982; 128:1273–4.

11. American Academy of Pediatrics. Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia. Pediatrics. 1996; 97:590–4.

12. Moreno-Garcia M, Miranda EB. Chromosomal anomalies in cryptorchidism and hypospadias. J Urol. 2002; 168:2170–2.

13. Kaefer M, Diamond D, Hendren WH, Vemulapalli S, Bauer SB, Peters CA, et al. The incidence of intersexuality in children with cryptorchidism and hypospadias: stratification based on gonadal palpability and metal position. J Urol. 1999; 162:1003–6.

14. Kojima Y, Hayashi Y, Maruyana T, Sasaki S, Kohri K. Comparison between ultrasonography and retrograde urethrography for detection of prostatic utricle associated with hypospadias. Urology. 2001; 57:1151–5.

15. Ikoma F, Shima H, Yabumoto H. Classification of enlarged prostatic utricle in patients with hypospadias. Br J Urol. 1985; 57:334–7.

16. Milla SS, Chow JS, Lebowitz RL. Imaging of hypospadias: pre- and postoperative appearances. Pediatr Radiol. 2008; 38:202–8.

17. Nonomura K, Kakizaki H. Recent trends of genitourinary endoscopy in children. Int J Urol. 2005; 12:607–14.

18. Duckett JW. MAGPI (meatoplasty and glanuloplasty): a procedure for subcoronal hypospadias. Urol Clin North Am. 1981; 8:513–9.

19. Park JM, Faerber GJ, Bloom DA. Long-term outcome evaluation of patients undergoing the meatal advancement and glanuloplasty procedure. J Urol. 1995; 153:1655–6.

20. Zaontz MR. The GAP (glans approximation procedure) for glanular/coronal hypospadias. J Urol. 1989; 141:359–61.

21. Stock JA, Hanna MK. Distal urethroplasty and glanuloplasty procedure: results of 512 repairs. Urology. 1997; 49:449–51.

22. Snodgrass WT, Lorenzo A. Tubularized incised-plate urethroplasty for hypospadias reoperation. BJU Int. 2002; 89:98–100.

23. Hakim S, Merguerian PA, Rabinowitz R, Shortliffe LD, McKenna PH. Outcome analysis of the modified Mathieu hypospadias repair: comparison of stented and unstented repairs. J Urol. 1996; 156:836–8.

24. Baskin LS, Duckett JW, Ueoka K, Seibold J, Snyder HM 3rd. Changing concepts of hypospadias curvature lead to more onlay island flap procedures. J Urol. 1994; 151:191–6.

25. Rushton HG, Belman AB. The split prepuce in situ onlay hypospadias repair. J Urol. 1998; 160:1134–6.

26. Gonzalez R, Smith C, Denes ED. Double onlay preputial flap for proximal hypospadias repair. J Urol. 1996; 156:832–4.

27. Hyun JH, Shin JS, Park KH. Comparison of the surgical outcome between onlay island flap and tubularized incised plate urethroplasty in hypospadias repair. Korean J Urol. 2004; 45:573–7.

28. Duckett JW. The current hype in hypospadiology. Br J Urol. 1995; 76:1–7.

29. Perovic S, Vukadinovic V. Onlay island flap urethroplasty for severe hypospadias: a variant of the technique. J Urol. 1994; 151:711–4.

30. Barroso U Jr, Jednak R, Spencer Barthold J, Gonzalez R. Further experience with the double onlay preputial flap for hypospadias repair. J Urol. 2000; 164:998–1001.

31. Hollowell JG, Keating MA, Snyder HM 3rd, Duckett JW. Preservation of the urethral plate in hypospadias repair: extended applications and further experience with the onlay island flap urethroplasty. J Urol. 1990; 143:98–100.

32. Braga LH, Pippi Salle JL, Lorenzo AJ, Skeldon S, Dave S, Farhat WA, et al. Comparative analysis of tubularized incised plate versus onlay island flap urethroplasty for penoscrotal hypospadias. J Urol. 2007; 178:1451–7.

33. Greenfield SP, Sadler BT, Wan J. Two-stage repair for severe hypospadias. J Urol. 1994; 152:498–501.

34. Retik AB, Bauer SB, Mandell J, Peters CA, Colodny A, Atala A. Management of severe hypospadias with a 2-stage repair. J Urol. 1994; 152:749–51.

35. Glassberg KI, Hansbrough F, Horowitz M. The Koyanagi-Nonomura 1-stage bucket repair of severe hypospadias with and without penoscrotal transposition. J Urol. 1998; 160:1104–7.

36. Koyanagi T, Nonomura K, Kakizaki H, Takeuchi H, Yamashita T. Experience with one-stage repair of severe proximal hypospadias: operative technique and results. Eur Urol. 1993; 24:106–10.

37. Hayashi Y, Kojima Y, Mizuno K, Nakane A, Kohri K. The modified Koyanagi repair for severe proximal hypospadias. BJU Int. 2001; 87:235–8.

38. Emir H, Jayanthi VR, Nitahara K, Danismend N, Koff SA. Koyanagi technique for the single-stage repair of proximal hypospadias. J Pediatr Urol. 2007; 3:239–42.

39. Koff SA, Eakins M. The treatment of penile chordee using corporeal rotation. J Urol. 1984; 131:931–2.

40. Cendron J, Melin Y. Congenital curvature of the penis without hypospadias. Urol Clin North Am. 1981; 8:389–95.

41. Snodgrass W. A farewell to chordee. J Urol. 2007; 178:753–4.

42. Bologna RA, Noah TA, Nasrallah PF, McMahon DR. Chordee: varied opinions and treatments as documented in a survey of the American Academy of Pediatrics, Section of Urology. Urology. 1999; 53:608–12.

43. Nesbit RM. Congenital curvature of the phallus: report of three cases with description of corrective operation. J Urol. 1965; 93:230–2.

44. Montague DK. Correction of chordee. The Nesbit procedure. Urol Clin North Am. 1986; 13:167–74.

45. Baskin LS, Duckett JW. Dorsal tunica albuginea plication for hypospadias curvature. J Urol. 1994; 151:1668–71.

46. Baskin LS, Erol A, Li YW, Liu WH. Anatomy of the neurovascular bundle: is safe mobilization possible? J Urol. 2000; 164:977–80.

47. Hayashi Y, Kojima Y, Mizuno K, Tozawa K, Sasaki S, Kohri K. Modified technique of dorsal plication for penile curvature with or without hypospadias. Urology. 2000; 59:584–7.

48. Devine CJ. Controversies in hypospadias surgery: the urethral plate. Dial Pediatr Urol. 1996; 19:1–8.

49. Devine CJ Jr, Horton CE. Use of dermal graft to correct chordee. J Urol. 1975; 113:56–8.

50. Horton CE Jr, Gearhart JP, Jeffs RD. Dermal grafts for correction of severe chordee associated with hypospadias. J Urol. 1993; 150:452–5.

51. Amin M, Broghamer L Jr, Harty JI, Long R Jr. Autogenous tunica vaginalis graft for Peyronie's disease: an experimental study and its clinical application. J Urol. 1980; 124:815–7.

52. Ritchey ML, Ribbeck M. Successful use of tunica vaginalis grafts for treatment of severe penile chordee in children. J Urol. 2003; 170:1574–6.

53. Vandersteen DR, Husmann DA. Late onset recurrent penile chordee after successful correction at hypospadias repair. J Urol. 1998; 160:1131–3.

54. Hayashi Y, Kojima Y, Mizuno K, Nakane A, Kurokawa S, Kohri K. Novel technique for correcting penile curvature with severe hypospadias; ventral lengthening with tunica vaginalis flap patching. Int J Urol. 2005; 12:234–8.

55. Braga LH, Pippi Salle JL, Dave S, Bagli DJ, Lorenzo AJ, Khoury AE. Outcome analysis of severe chordee correction using tunica vaginalis as a flap in boys with proximal hypospadias. J Urol. 2007; 178:1693–7.

56. Retik AB, Keating M, Mandell J. Complications of hypso-padias repair. Urol Clin North Am. 1988; 15:223–36.

57. Elder JS, Duckett JW. Complications of hypospadias repair. Smith RB, Ehrich RM, editors. editors.Complications of urologic surgery. 2nd ed.Philadelphia: Saunders;1990. p. 549–68.

58. Retik AB, Mandell J, Bauer SB, Atala A. Meatal based hypospadias repair with the use of a dorsal subcutaneous flap to prevent urethrocutaneous fistula. J Urol. 1994; 152:1229–31.

59. Cheng EY, Vemulapalli SN, Kropp BP, Pope JC 4th, Furness PD 3d, Kaplan WE, et al. Snodgrass hypospadias reapir with vascularized dartos flap: the perfect repair for virgin cases of hypospadias? J Urol. 2002; 168:1723–6.

60. Snodgrass WT, Nguyen MT. Current technique of tubularized incised plate hypospadias repair. Urology. 2002; 60:157–62.

61. Djordjevic ML, Perovic SV, Slavkovic Z, Djakovic N. Longitudinal dorsal dartos flap for prevention after a Snodgrass hypospadias procedure. Eur Urol. 2006; 50:53–7.

62. Jang SW, Kim YG. Results of tubularized incised plate (TIP) urethroplasty with button hole flap in hypospadias repair. Korean J Urol. 2005; 46:281–7.

63. Snow BW, Cartwright PC, Unger K. Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: an 8-year experience. J Urol. 1995; 153:472–3.

64. Yamataka A, Ando K, Lane GJ, Miyano T. Pedicled external spermatic fascia flap for urethroplasty in hypospadias and closure of urethrocutaneous fistula. J Pediatr Surg. 1998; 33:1788–9.

65. Hayashi Y, Kojima Y, Kurokawa S, Mizuno K, Nakane A, Kohri K. Scrotal dartos flap for the prevention of the urethrocutaneous fistula on hypospadias urethroplasty. Int J Urol. 2005; 12:280–3.

66. Hayashi Y, Mogami M, Kojima Y, Mogami T, Sasaki S, Azemoto M, et al. Results of closure of urethrocutaneous fistulas after hypospadias repair. Int J Urol. 1998; 5:167–9.

67. Scherz HC, Kaplan GW, Packer MG, Brock WA. Post-hypospadias repair urethral strictures: a review of 30 cases. J Urol. 1988; 140:1253–5.

68. Hsiao KC, Baez-Trinidad L, Lendvay T, Smith EA, Broecker B, Scherz H, et al. Direct vision internal urethrotomy for the treatment of pediatric urethral strictures: analysis of 50 patients. J Urol. 2003; 170:952–5.

69. Lee HY, Han SW. Surgical correction of post-hypospadias repair urethral diverticulum and stricture using rotational flap. Korean J Urol. 2006; 47:1225–9.

70. Gittes RF, McLaughlin AP 3rd. Injection technique to induce penile erection. Urology. 1974; 4:473–4.

71. Garibay JT, Reid C, Gonzalez R. Functional evaluation of the results of hypospadias surgery with uroflowmetry. J Urol. 1995; 154:835–6.

72. Hammouda HM, El-Ghoneimi A, Bagli DJ, McLorie GA, Khoury AE. Tubularized incised plate repair: functional outcome after intermediate follow up. J Urol. 2003; 169:331–3.

73. Sandberg DE, Meyer-Bahlburg HF, Yager TJ, Hensle TW, Levitt SB, Kogan SJ, et al. Gender development in boys born with hypospadias. Psychoneuroendocrinology. 1995; 20:693–709.

74. Aho MO, Tammela OK, Tammela TL. Aspects of adult satisfaction with the result of surgery for hypospadias performed in childhood. Eur Urol. 1997; 32:218–22.