EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15

available at www.sciencedirect.com
journal homepage: www.europeanurology.com

An Update of Current Practice in Hypospadias Surgery

Alexander Springer a, Serdar Tekgul b, Ramnath Subramaniam c,*

a
Department of Paediatric Surgery, Medical University of Vienna, Vienna, Austria; b Department of Paediatric Urology, Hacettepe University, Ankara, Turkey;
c
Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK

Article info Abstract

Keywords: Today, a multiple number of surgical techniques, modifications, and combinations

Hypospadias of techniques are used to improve cosmetic and functional outcomes and to
Update minimise the procedure burden for the patient. Nevertheless, controversy exists
Techniques regarding the ideal management of hypospadias. This update is based on current
Outcomes literature following a systematic review using MEDLINE.
# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please visit www.eu-acme.org/

europeanurology to read and
answer questions on-line. * Corresponding author. Leeds Teaching Hospitals NHS Trust, Level F, Martin Wing, Leeds General
The EU-ACME credits will then Infirmary, Leeds LS1 3EX, UK. Tel. +447818452603.
be attributed automatically. E-mail address: R.Subramaniam@leeds.ac.uk (R. Subramaniam).

1. Introduction
Modern hypospadiology has considerably evolved since the
1980s but significant challenges remain like standardising
the management with evidence-based protocols and the
assessment of longer-term outcomes. The salient points
from this update have been classified in terms of level of
evidence and grade of recommendation as proposed by the
Centre for Evidence Based Medicine [1] and shown in
Table 1. Application of a structured analysis of the literature
was not possible in many conditions due to a lack of well-
designed studies. The limited availability of large random-
ised controlled trials—influenced also by the fact that a
considerable number of treatment options relate to surgical
interventions on a large spectrum of a congenital patholo-
gy—means this document is largely a consensus document.
2. Why should hypospadias be corrected?
Hypospadias may implicate functional and cosmetic
impairment. Indication for hypospadias surgery therefore
includes the need for the correction of penile deviation and
rotation, glans cleft and tilt, ectopic and stenotic urethral
meatus, hooded prepuce, penoscrotal transposition, and
penile size.
The ideal result of surgery is construction of a good calibre
urethra with a slit-like urethral meatus at the tip of the glans
and a straight penis. Voiding and sexual activity should not
be impaired by hypospadias or its corrective procedure.
Surgery should allow boys with hypospadias to grow up
as self-confident young men with a normal body image.
Long-term outcome and health-related quality of life is
associated with the severity of hypospadias and the
sequelae of surgery. Hypospadias is usually classified based
on the anatomical location of the proximally displaced
urethral orifice. This is clinically not relevant, does not
relate well with the outcome, and pathology may signifi-
cantly change after degloving of the skin.
It is more common that hypospadias is classified as distal
and proximal, where proximal cases are more severe.
Patients with severe hypospadias and those with non-
favourable surgical outcomes are more likely to suffer a
negative psychological impact than those with minor
hypospadias and good surgical results. Therefore there is

http://dx.doi.org/10.1016/j.eursup.2016.09.006
1569-9056/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15 9

Table 1 – Summary of the Société Internationale d’Urologie Current Best Practice Options in the management of hypospadias

Topic Comments LE GR

Indication Substantial lack of long-term studies showing the effects of hypospadias surgery on cosmetic, functional, and 3–5 B–D
psychological outcome. Recommendation on indication for hypospadias surgery is based on common sense.
Classification Meatal location is only one of many meaningful parameters including quality of tissues, curvature, size of glans, 3–5 C–D
spongiosal division, and others. Classification of hypospadias is an evolving picture and at the moment there is
not one objective classification that is universally accepted.
Documentation Documentation of objective findings will help to establish prospective data bases and make future studies 3–5 B–D
comparable. There is no consensus on objective penile assessment and documentation of preoperative findings.
Further evaluation Routine evaluation of the upper urinary tract in an asymptomatic child with hypospadias is not recommended. In 3–5 B–D
suspicion of DSD, further investigations according to current guidelines.
Timing It is recommended that hypospadias repair be performed in infancy or early childhood ideally when there is a 3–5 B–D
trained paediatric anaesthetist available. Evidence concerning the ideal age of hypospadias repair is weak and
confusing.
Androgens Androgens are effective. There is neither consensus on the best type of androgen nor on the correct way of 2a–5 B–D
application and the potential side effects of androgens have not been studied thoroughly.
Mild hypospadias repair TIP repair is the most commonly used technique for the repair of distal hypospadias with good evidence in 2a–5 B
literature. However, high quality randomised trials (follow up rate > 80% and long term follow-up) are missing.
Therefore, personal experience, skill and surgical background will still play a major role in the choice of
procedure (GR D).
Severe hypospadias Two-stage repair is the most popular technique used in severe hypospadias. However, there is no consensus on 3a–5 C
repair the ideal technique and there is no evidence in the literature that there is a definitely superior technique in the
correction of severe hypospadias. Comparison between series is complicated by the lack of reliability in reporting
outcome, limited follow-up and failing to report long term outcome.
Foreskin reconstruction Foreskin reconstruction can be offered in mild hypospadias repair. 2a B

Urinary drainage No clear evidence can highlight advantages of one or another form of drainage although it seems logical to drain 2b–5 B–D
any reconstruction.
Wound dressing No clear evidence can highlight advantages of one or another form of wound dressing. 2b–5 B–D
Antibiotics Until further evidence is available, prophylactic broad spectrum antibiotics will be the standard in hypospadias 1b B
surgery. However, it is important to point out that prophylactic antibiotic versus no antibiotic in hypospadias
repair should be subject for future controlled studies.

DSD = detrusor sphincter dyssynergia; GR = grade; LE = levels of evidence.

an argument for a new classification of hypospadias based
on the cost-benefit ratio for the patient [2].
The position of the meatus allows standardised nomen-
clature and is thought to be a major prognostic factor for
outcome [3]. Other more complex items (level of division of
the corpus spongiosum, penile curvature, ventral hypopla-
sia, quality of urethral plate, etc.) should also be taken into
account in the classification but they are much more
difficult to assess reliably and objectively with validity [4,5].
3. When should hypospadias be corrected?
tissues [10]. There are two randomised controlled trials
showing that preoperative androgen stimulation improves
outcome (cosmesis and complication rate) [11,12]. There is
no consensus on the best type of androgen, the application
route, and correct way of application. Two recent systematic
reviews and meta-analysis critically assess the effect of
androgen stimulation on surgical outcomes but remained
inconclusive [13,14]. It is a fact that androgens stimulate
penile growth [15]; however, the real benefit in hypospa-
dias surgery and long-term side effects of male sexual
hormone application still needs to be defined.

Based on expert opinion, it is better to perform surgery of

5. Perioperative antibiotics, urinary drainage, and
the male genitalia between 6 mo and 18 mo of age [6,7]. This
wound dressing
recommendation is based on surgical and anaesthetic
considerations and the psychology of the infant male
For now, there is no consensus on the type of urinary
(cognitive development, genital awareness, emotional
drainage, stenting of the urethra, wound dressing, or the use
development, and psychosexual development). However,
of antibiotics. Each surgeon has his or her own preference.
there is spare evidence regarding this and there are
Urine can be drained using a transurethral catheter,
contradictory findings [8]. It is generally believed that
transurethral dripping stent, or a suprapubic tube of various
early repair is associated with a lower complication rate, but
sizes. Most surgeons would agree that postoperative
again, there is inconsistency in literature. Last but not least,
urinary diversion seems to reduce complications. However,
there are rising concerns by patient groups that esthetical
in cases of distal hypospadias, some surgeons prefer no
genital surgeries in minor hypospadias without functional
drainage at all [16–23]. With regards to urinary diversion,
impairment should be postponed to an age where informed
there is no clear evidence that wound dressing is of any
consent can be given by the patient himself [9].
benefit for surgical outcome. The rational for wound
4. Preoperative androgens? dressing seems clear: dry, safe, and clean immobilisation
of the penis for a limited period of time to allow wound
Androgen stimulation has been used for a long time to healing and minimise postoperative discomfort and there
enhance the size of the penis and to improve quality of are many different products available: foam dressing
10 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15

(Cavicare), transparent film dressing (Tegaderm), simple
circular wound dressing, and indigenous home-made
devices. However, two prospective randomised trials show
no difference between postoperative dressing versus no
postoperative dressing [24,25]. Most surgeons use prophy-
lactic antibiotics in hypospadias repair but there is no
consensus regarding when to administer what type of
antibiotics for what period of time [26,27]. Evidence for
prophylactic antibiotics in hypospadias management is
very limited and there is still ongoing discussion if there is a
real benefit in administering antibiotics [28–31].
6. Preferred technique for hyposopadias repair
Literally hundreds of techniques have been reported over
the years. The choice of the technique mainly depends on
the experience of the surgeon with the technique and his
experience on different types of hypospadias. The surgeon
should be able to define the anatomic components well, and
choose and modify the technique according to the anatomy.
Although common sense demands standardisation of
procedures, many times there will be a need to make
minor modifications in the technique which can only
be done by dedicated surgeons at high-volume centres. The
use of magnification and microsurgical instruments, tissue
handling with minimal trauma and fine suture material are
essential. For now, the search for the ideal procedure for all
hypospadias continues. An algorthim to the management of
hypospadias is shown in Figure 1.
7. Mild hypospadias repair
In the recent past, tubularised incided plate urethroplasty
(TIP) repair has become the most popular technique for
distal hypospadias repair worldwide [32–34]. Meta-
analysis and systematic reviews of large retrospective
cohort studies show that there is enough evidence to
recommend the TIP repair as versatile, highly standardised,
and a simple technique that provides favourable cosmetic
and functional short- and long-term results with a
reasonably low complication rate [35–38]. Since its
introduction in 1994, TIP repair has evolved and consecu-
tive modifications have significantly lowered the complica-
tion rates and it has come down to a fistula rate of 5.7%
in primary mild hypospadias and a reoperation rate of
4.5%, respectively [39]. In particular, the fistula rate can

Hypospadias
preoperative androgen
application

Mild hypospadias Severe hypospadias

TIP Degloving
No correction
and others erection test

Good urethral plate Scarred tissue

no ventral hypoplasia ventral hypoplasia
Mild chordee severe chordee

TIP Staged repair

plication and other straightening plication
techniques Ventral corporotomy

Fig. 1 – Algorthim of surgical management of hypospadias.

TIP = tubularised incided plate urethroplasty.
 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15
be decreased by covering the urethroplasty with a
waterproofing layer of dartos tissue [40–42]. There are many
other techniques described with personal modifications. For
example, Mathieu urethroplasty and its modifications are
still popular procedures with excellent results [43]. System-
atic reviews comparing the TIP repair and Mathieu repair
show that no technique appears to be significantly superior
over the other with similar fistula rates (3.4–3.6%), but there
is a higher incidence of meatal stenosis in TIP (3.0% vs 0.6% in
Mathieu) after 6–12 mo follow-up [44,45].
8. Severe hypospadias
Management of severe hypospadias is challenging and
should only be offered in specialised centres with an
adequate number of patients. Outcome is influenced by the
presence of chordee (penile curvature), quality of the
urethral plate, quality of ventral tissues, scrotal transposi-
tion, and last but not least the size of the penis. Over the
years, large numbers of techniques have been described. In
single centre studies, most of those techniques could
provide favourable cosmetic and functional outcomes. In
a recent 20-yr systematic review for surgical correction of
severe hypospadias no approach appeared to be superior
over the other [46]. Another systematic review comparing
the transverse island flap technique and TIP show no major
differences in clinical outcome [47]. However, both reviews
indicated general problems of reporting data in hypospa-
diology: no clear definition of severe hypospadias, limited
number of patients, limited follow-up, and no clear defined
outcome measures. The authors therefore come to the
conclusion that ‘‘these data have to be confirmed by more
well-designed randomised controlled trials with high
quality in the future’’ [47]. Today’ s surgical armamentari-
um in the management of hypospadias is huge and diverse,
as shown in Table 2, with a clear international majority
favouring a staged repair in complex hypospadias [32].
The two-stage repair, either using grafts or flaps, is a
versatile technique when there is severe chordee, a small
glans, and ventral scarring [48,49]. In two-stage repair, the
operation starts with (ventral) degloving. The decision to
sacrifice the urethral plate is key and is left until after
artificial erection test. Chordee correction could take place
Table 2 – Most commonly performed techniques in the repair of severe hypospadias
Name Reference Yr N Generic name
Patel [77] 2004 73
Amukele [78] 2004 265
Obaidullah [79] 2005 1415
Djordjevic, Macedo [80,81] 2008, 2011 NA
Snodgrass [82] 2011 26
Vepakomma [83] 2013 24
Hadidi [84] 2014 63
f/u = follow-up; TIP = tubularised incided plate urethroplasty.
11
in many ways after fibrous tissue is excised as much as
possible. Multiple transverse corporotomy incisions can be
applied to lengthen the ventral aspect of the corpora
cavernosa [50]. If necessary, dorsal plication with or
without mobilisation of the neurovascular bundle can help
to straighten the penis [51,52]. The dorsal midline incision
minimises the risk of injury to the neurovascular bundle.
More aggressive techniques like ventral corporal grafting
are rarely needed and their long-term outcomes are
doubtful [53]. The glans wings are mobilised extensively.
Inner or outer preputial skin or buccal mucosa are the
preferred graft materials. The graft is quilted onto the
corpora. It is recommended to place tunica dartos flaps onto
the corpora laterally as a bed providing an extensive amount
of healthy tissue for the second-stage urethroplasty [54].
Appropriate urinary drainage and pressure wound dressing is
crucial for a good outcome. Second-stage urethroplasty is
performed by tubularisation of the graft with two further
layers of tunica dartos to cover the urethroplasty.
9. Follow-up and outcome
Long-term follow-up is of substantial importance. A recent
systematic review showed that there is a significant lack in
long-term data. Although there is a growing number of
articles reporting reliable and valid data like inclusion and
exclusion criteria, study design, primary and secondary
outcome parameters, follow-up, a detailed description of
the surgical procedure, and so on [55], quality of data is
influenced by low follow-up periods and rates, heteroge-
neous patients and data, and a lack of validated ques-
tionnaires and control groups [56]. It has been criticised that
follow-up periods—particularly in Northern America—are
short [39], although some believe that most complications
occur early after surgery [57]. However, there is evidence
that the real number of complications is only to be assessed
in long-term follow-up after puberty or even adulthood
[58,59]. Although some current long-term studies have
follow-up rates between 12.7%, 22.4%, and 56.2%, most
outcome studies do not provide a follow-up rate or those
lost to follow-up [60–62]. Table 3 shows long-term outcome
studies from 2010 to 2015. Although the majority of
patients do well after hypospadias repair there are reports
Comments
Duckett Preputial flap as transverse island tube or island onlay flap with long-
term f/u of 14.2 yr. Very versatile technique with many modifications in
literature, widely used.
Thiersch-Duplay Long-term proven reliable technique, difficult with extensive chordee
and low quality urethral plate.
Two stage repair Two-stage repair very safe and applicable to all cases.
Combinations, Flaps, grafts, buccal mucosa, technically very challenging, techniques
variations never gained popularity, short term follow-up.
TIP Suitable when no minor curvature and good quality of urethral plate.
Koyanagi Based on a parameatal foreskin flap, many modifications since its
introduction in 1983, technically challenging.
BILAB Bilateral based preputial and penile skin flaps, generous blood supply.
12 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15

Table 3 – Long-term outcome studies from 2010 to 2015

Name Reference Yr N Age at Age at FU Fistula Curvature Stenosis Comments

surgery FU (yr) period (%) (%) (%)
(yr) (mo)

Örtqvist [85] 2015 167 4 34 29 16.4 23 5 Impaired cosmesis,

shorter penis, more
LUTS.
Andersson [86] 2015 40 3.6 15.2 11.6 5 15 22.5 Uroflow improves
over time.
Hueber [87] 2015 153 2.9 >10 21/16/5 0/4/2 16/16/10 Favourable outcomes
(TIP/Mathieu/MAGPI).
Fraumann [61] 2014 13 1.2 21 20 7.5 38.5 7.5 Satisfactory outcome,
lower orgasmic
function.
Ekmark [88] 2013 114 4.5–5 16 12 11 5.4 3.6 Curvature can develop
over time.
Aulagne [62] 2010 27 3.3 25 33 18 26 Generally good
outcomes.
Perera [60] 2012 60 1.8 11.3 Uroflow lower than
controls, associated
with previous chordee.
Ciancio [89] 2015 20 5 33 28 Good cosmesis, no
erectile dysfunction,
low IPSS, penis shorter.
Ruppen-Greff [90] 2013 45 26.2 HRQoL were not
impaired among men.
Chertin, Prat [73,91] 2012, 119 2.7 Adults Good cosmetic results,
2013 mild erectile
dysfunction, numerous
techniques, high
complication rates (0–
100%).
Robinson [92] 2012 18 2.5 12.5 10.5 Good flow and cosmesis.
Kiss [59] 2011 104 24–42 20–30 Less satisfaction with
genital appearance,
however healthy
psychosexual
development possible.
Jiao [64] 2011 43 21.6 Main complaint penile
size and curvature,
sexual function
impaired.

FU = follow-up; HRQoL = health-related quality of life; IPSS = International Prostate Symptom Score; LUTS = lower urinary tract sysmptoms; MAGPI = meatal
advancement and glanduloplasty; TIP = tubularised incided plate urethroplasty.

of adult reconstructive urologists trying to attract attention
to the fact that some patients need redo surgery in
adulthood. Table 4 shows the current series of hypospadias
redo surgeries in adults.
In literature, short-term and mid-term outcomes of
hypospadias surgery seem favourable. However, the major-
ity of these publications present single-centre and single-
surgeon retrospective case series with a limited follow-up
period and a limited number of patients undergoing
follow-up [63]. Assessment of outcome includes: cosmesis,
functional outcome (micturition and sexuality), and quality
of psychosexual life.
9.1. Cosmesis
Patients who had surgery for hypospadias may have a
significant concern about penile appearance and penile size.
Generally, a better cosmetic outcome is related to better

Table 4 – Series of hypospadias redo surgery in adults

Name Reference Age at FU period (mo) n Comments

surgery (yr)

Stein [70] 2014 39.7 15 (3–28) 163 54% erectile dysfunction.

Myers [93] 2012 38 7.4 50 Difficult surgery, additional procedures common.
Ching [94] 2011 37 55 Voiding problems 82%, UTI 36%, curvature 24%,
BXO 13%, fistula 14%.
Barbagli [95] 2010 31 60.4 1176 (926 older 12% failure rate.
than 16 yr)

BXO = balanitis xerotica obliterans; FU = follow-up; UTI = urinary tract infection.

 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15
sexual outcome [64]. There are several objective and
validated scores to evaluate the outcome of hypospadias
surgery (Hypospadias Objective Scoring Evaluation, Paedi-
atric Penile Perception Score, Hypospadias Objective Penile
Evaluation Score) [65–67]. For example, the Hypospadias
Objective Penile Evaluation Score evaluates the position and
shape, the shape of the glans, the penile skin, and curvature
and torsion of the penis [65]. An independent person should
ideally rate the outcome. Scoring is easy to apply, can be
kept in the patients notes, and allow prospective evaluation.
The International Disorders of Sex Development registry
[68] and The Dutch (International) Hypospadias Study [65]
are international databases for the allocation of prospective
hypospadias patients. Every hypospadias surgeon is
encouraged and invited to join such a database for personal
audit and research purposes.
9.2. Functional outcome
Functional outcomes are just beginning to be reported in
literature. A recent systematic review recommends a
uroflow study after toilet training. Children with obstructed
flow parameters or borderline flows should be followed
until adulthood. However, the significance of this advice
remains uncertain [69]. In an Australian study of long-term
follow-up, urinary flow rates were significantly lower
compared with age-matched controls but still fell within
the normal range without significant association with lower
urinary tract symptoms and poor urinary flow. However,
severe chordee preoperatively seems to be a significant risk
factor for poor urinary flow [60]. Therefore, in adults
following hypospadias surgery it may be necessary to have a
repeated close look at urinary flow, postvoid residuals,
symptoms of lower urinary tract symptoms, or other
urinary signs.
In most of the cases sexual function, strength and duration
of erection, problems with ejaculation (spraying, dribbling,
retrograde ejaculation, and premature ejaculation), and
masturbation are not impaired. However, depending on
the severity of chordee, ventral hypoplasia, type and length
of urethroplasty, burden of surgery, and other factors, there
may be concerns for the patient and there are standardised
assessment scores available to objectively rate those
concerns (International Prostate Symptom Score, Interna-
tional index of erectile function, and Sexual Summary Score)
[63]. A certain prevalence of erectile dysfunction hypospadi-
as patients has been reported [70].
9.3. Psychosexual outcome
Psychosexual well-being is far more difficult to evaluate.
There are only a few studies assessing long-term
psychosexual adjustment and sexual function, health-
related quality of life, and quality of sexual life without or
matched with control groups. These data are very limited
and controversial [62,64,71–76]. Generally speaking, hypo-
spadias patients should do well in adulthood in all regards
(cosmesis, function, and psychology), but there can be
significant issues, like impaired capacity for social and
13
emotional relations, self-esteem, relationships, sex life, etc.
The more severe the hypospadias, the less satisfactory the
long-term outcome and as alluded to earlier, better cosmetic
outcome is related to better sexual outcome [64]. In patients
at risk, it seems important to provide meticulous transitional
care where the paediatric patient is transferred into an adult
urology service.
Conflicts of interest
The authors have nothing to disclose.
References
[1] Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-based
Medicine—levels of evidence. 2009. http://www.cebm.net/
oxford-centre-evidence-based-medicine-levels-evidence-march-
2009/.
[2] Springer A, Spinoit AF, Nappo S, et al. Current best practice options
in the management of hypospadias. In: DeVries CR, Nijman JM,
editors. Congenital anomalies in children—A joint SIU-ICUD Inter-
national Consultation. Montreal: Société Internationale d’Urologie;
2014. p. 52–78.
[3] Spinoit AF, Poelaert F, Van Praet C, Groen LA, Van Laecke E, Hoebeke
P. Grade of hypospadias is the only factor predicting for re-
intervention after primary hypospadias repair: A multivariate anal-
ysis from a cohort of 474 patients. J Pediatr Urol 2015;11:, 70.e1-6.
[4] Hadidi AT. Classification of hypospadias. In: Hadidi AT, Azmy AF,
editors. Hypospadias surgery. Heidelberg: Springer; 2004. p. 79–83.
[5] Mouriquand PD, Mure PY. Current concepts in hypospadiology.
BJU Int 2004;93(Suppl 3):26–34.
[6] Timing of elective surgery on the genitalia of male children with
particular reference to the risks, benefits, and psychological effects
of surgery and anesthesia. American Academy of Pediatrics. Pedi-
atrics 1996;97:590-4.
[7] Tekgül S, Riedmiller H, Gerharz E, et al. Guidelines on Paediatric
Urology of the EAU. 2013. https://uroweb.org/wp-content/uploads/
24_Paediatric_Urology.pdf.
[8] Weber DM, Schonbucher VB, Gobet R, Gerber A, Landolt MA. Is there
an ideal age for hypospadias repair? A pilot study. J Pediatr Urol
2009;5:345–50.
[9] Springer A, Baskin L. Timing of hypospadias repair in patients with
disorders of sex development. In: Hiort O, Ahmed SF, editors.
Understanding differences and disorders of sex development.
Basel: Karger; 2014. p. 197–202.
[10] Malik RD, Liu DB. Survey of pediatric urologists on the preoperative
use of testosterone in the surgical correction of hypospadias.
J Pediatr Urol 2014;10:840–3.
[11] Asgari SA, Safarinejad MR, Poorreza F, Safaei Asl A, Mansour
Ghanaie M, Shahab E. The effect of parenteral testosterone ad-
ministration prior to hypospadias surgery: a prospective, random-
ised, and controlled study. J Pediatr Urol 2015;11:143.e1-6.
[12] Kaya C, Bektic J, Radmayr C, Schwentner C, Bartsch G, Oswald J. The
efficacy of dihydrotestosterone transdermal gel before primary
hypospadias surgery: a prospective, controlled, randomized study.
J Urol 2008;179:684–8.
[13] Wright I, Cole E, Farrokhyar F, Pemberton J, Lorenzo AJ, Braga LH.
Effect of preoperative hormonal stimulation on postoperative com-
plication rates after proximal hypospadias repair: a systematic
review. J Urol 2013;190:652–9.
[14] Netto JM, Ferrarez CE, Schindler Leal AA, Tucci Jr S, Gomes CA,
Barroso Jr U. Hormone therapy in hypospadias surgery: a sys-
tematic review. J Pediatr Urol 2013;9:971–9.
14 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15
[15] Nerli RB, Koura A, Prabha V, Reddy M. Comparison of topical versus
parenteral testosterone in children with microphallic hypospadias.
Pediatr Surg Int 2009;25:57–9.
[16] Radwan M, Soliman MG, Tawfik A, Abo-Elenen M, El-Benday M.
Does the type of urinary diversion affect the result of distal hypo-
spadias repair? A prospective randomised trial. Ther Adv Urol
2012;4:161–5.
[17] Xu N, Xue XY, Wei Y, et al. Outcome analysis of tubularized incised
plate repair in hypospadias: is a catheter necessary? Urol Int
2013;90:354–7.
[18] Ritch CR, Murphy AM, Woldu SL, Reiley EA, Hensle TW.
Overnight urethral stenting after tubularised incised plate urethro-
plasty for distal hypospadias. Pediatr Surg Int 2010;26:639–42.
[19] Hardwicke J, Jones E, Wilson-Jones N. Optimisation of silicone
urinary catheters for hypospadias repair. J Pediatr Urol 2010;6:
385–8.
[20] Lorenz C, Schmedding A, Leutner A, Kolb H. Prolonged stenting does
not prevent obstruction after TIP repair when the glans was deeply
incised. Eur J Pediatr Surg 2004;14:322–7.
[21] Leclair MD, Camby C, Battisti S, Renaud G, Plattner V, Heloury Y.
Unstented tubularized incised plate urethroplasty combined with
foreskin reconstruction for distal hypospadias. Eur Urol 2004;46:
526–30.
[22] Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypospadias
dilemmas: a round table. J Pediatr Urol 2011;7:145–57.
[23] Castagnetti M, El-Ghoneimi A. The influence of perioperative fac-
tors on primary severe hypospadias repair. Nat Rev Urol
2011;8:198–206.
[24] McLorie G, Joyner B, Herz D, et al. A prospective randomized clinical
trial to evaluate methods of postoperative care of hypospadias. J
Urol 2001;165:1669–72.
[25] Van Savage JG, Palanca LG, Slaughenhoupt BL. A prospective ran-
domised trial of dressings versus no dressings for hypospadias
repair. J Urol 2000;164:981–3.
[26] Hsieh MH, Wildenfels P, Gonzales Jr ET. Surgical antibiotic practices
among pediatric urologists in the United States. J Pediatr Urol
2011;7:192–7.
[27] Springer A. The use of antibiotics in hypospadias surgery. Results
from an international survey. Unpublished data. 2013.
[28] Lee YC, Huang CH, Chou YH, Lin CY, Wu WJ. Outcome of hypospa-
dias reoperation based on preoperative antimicrobial prophylaxis.
Kaohsiung J Med Sci 2005;21:351–7.
[29] Meir DB, Livne PM. Is prophylactic antimicrobial treatment neces-
sary after hypospadias repair? J Urol 2004;171:2621–2.
[30] Baillargeon E, Duan K, Brzezinski A, Jednak R, El-Sherbiny M. The
role of preoperative prophylactic antibiotics in hypospadias repair.
Can Urol Assoc J 2014;8:236–40.
[31] Kanaroglou N, Wehbi E, Alotay A, et al. Is there a role for prophy-
lactic antibiotics after stented hypospadias repair? J Urol 2013;190:
1535–9.
[32] Springer A, Krois W, Horcher E. Trends in hypospadias surgery:
results of a worldwide survey. Eur Urol 2011;60:1184–9.
[33] Cook A, Khoury AE, Neville C, Bagli DJ, Farhat WA, Pippi Salle JL. A
multicentre evaluation of technical preferences for primary hypo-
spadias repair. J Urol 2005;174:2354–7, discussion 7.
[34] Steven L, Cherian A, Yankovic F, Mathur A, Kulkarni M, Cuckow P.
Current practice in paediatric hypospadias surgery; a specialist
survey. J Pediatr Urol 2013;9:1126–30.
[35] Braga LH, Lorenzo AJ, Salle JL. Tubularised incised plate urethro-
plasty for distal hypospadias: a literature review. Indian J Urol
2008;24:219–25.
[36] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich
R. Tubularised incised plate hypospadias repair: results of a multi-
center experience. J Urol 1996;156:839–41.
[37] Sarhan OM, El-Hefnawy AS, Hafez AT, Elsherbiny MT, Dawaba ME,
Ghali AM. Factors affecting outcome of tubularized incised plate
(TIP) urethroplasty: single-center experience with 500 cases. J
Pediatr Urol 2009;5:378–82.
[38] Snodgrass WT, Bush N, Cost N. Tubularised incised plate hypospa-
dias repair for distal hypospadias. J Pediatr Urol 2010;6:408–13.
[39] Pfistermuller KL, McArdle AJ, Cuckow PM. Meta-analysis of com-
plication rates of the tubularized incised plate (TIP) repair. J Pediatr
Urol 2015;11:54–9.
[40] Yigiter M, Yildiz A, Oral A, Salman AB. A comparative study to
evaluate the effect of double dartos flaps in primary hypospadias
repair: no fistula anymore. Int Urol Nephrol 2010;42:985–90.
[41] Djordjevic ML, Perovic SV, Vukadinovic VM. Dorsal dartos flap for
preventing fistula in the Snodgrass hypospadias repair. BJU Int
2005;95:1303–9.
[42] Cimador M, Pensabene M, Sergio M, Catalano P, de Grazia E.
Coverage of urethroplasty in pediatric hypospadias: randomised
comparison between different flaps. Int J Urol 2013;20:1000–5.
[43] Hadidi AT. The slit-like adjusted Mathieu technique for distal
hypospadias. J Pediatr Surg 2012;47:617–23.
[44] Wilkinson DJ, Farrelly P, Kenny SE. Outcomes in distal hypospadias:
a systematic review of the Mathieu and tubularised incised plate
repairs. J Pediatr Urol 2012;8:307–12.
[45] Wang F, Xu Y, Zhong H. Systematic review and meta-analysis of
studies comparing the perimeatal-based flap and tubularized in-
cised-plate techniques for primary hypospadias repair. Pediatr Surg
Int 2013;29:811–21.
[46] Castagnetti M, El-Ghoneimi A. Surgical management of primary
severe hypospadias in children: systematic 20-year review. J Urol
2010;184:1469–74.
[47] Xiao D, Nie X, Wang W, et al. Comparison of transverse island flap
onlay and tubularized incised-plate urethroplasties for primary
proximal hypospadias: a systematic review and meta-analysis.
PLoS One 2014;9:e106917.
[48] McNamara ER, Schaeffer AJ, Logvinenko T, et al. Management of
proximal hypospadias with 2-stage repair: 20 year experience. J
Urol 2015;194:1080–5.
[49] Bracka A. The role of two-stage repair in modern hypospadiology.
Indian J Urol 2008;24:210–8.
[50] Snodgrass W, Prieto J. Straightening ventral curvature while pre-
serving the urethral plate in proximal hypospadias repair. J Urol
2009;182:1720–5.
[51] Nesbit RM. Operation for correction of distal penile ventral curvature
with or without hypospadias. Trans Am Assoc Genitourin Surg
1966;58:12–4.
[52] Baskin LS, Duckett JW. Dorsal tunica albuginea plication for hypo-
spadias curvature. J Urol 1994;151:1668–71.
[53] Braga LH, Pippi Salle JL, Dave S, Bagli DJ, Lorenzo AJ, Khoury AE.
Outcome analysis of severe chordee correction using tunica vagi-
nalis as a flap in boys with proximal hypospadias. J Urol
2007;178:1693–7, discussion 7.
[54] Springer A, Subramaniam R. Split dorsal dartos flap transposed
ventrally as a bed for preputial skin graft in primary staged hypo-
spadias repair. Urology 2012;79:939–42.
[55] Snodgrass W. Hypospadias reporting—how good is the literature? J
Urol 2010;184:1255–6.
[56] Rynja SP, de Jong TP, Bosch JL, de Kort LM. Functional, cosmetic and
psychosexual results in adult men who underwent hypospadias
correction in childhood. J Pediatr Urol 2011;7:504–15.
[57] Snodgrass W, Villanueva C, Bush NC. Duration of follow-up to
diagnose hypospadias urethroplasty complications. J Pediatr Urol
2014;10:208–11.
[58] Spinoit AF, Poelaert F, Groen LA, Van Laecke E, Hoebeke P. Hypo-
spadias repair at a tertiary care center: long-term followup is
 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 8–15
mandatory to determine the real complication rate. J Urol
2013;189:2276–81.
[59] Kiss A, Sulya B, Szasz AM, et al. Long-term psychological and sexual
outcomes of severe penile hypospadias repair. J Sex Med 2011;
8:1529–39.
[60] Perera M, Jones B, O’Brien M, Hutson JM. Long-term urethral func-
tion measured by uroflowmetry after hypospadias surgery: com-
parison with an age matched control. J Urol 2012;188:1457–62.
[61] Fraumann SA, Stephany HA, Clayton DB, et al. Long-term follow-up
of children who underwent severe hypospadias repair using an
online survey with validated questionnaires. J Pediatr Urol 2014;
10:446–50.
[62] Aulagne MB, Harper L, de Napoli-Cocci S, Bondonny JM, Dobremez
E. Long-term outcome of severe hypospadias. J Pediatr Urol
2010;6:469–72.
[63] Springer A. Assessment of outcome in hypospadias surgery—a
review. Front Pediatr 2014;2:2.
[64] Jiao C, Wu R, Xu X, Yu Q. Long-term outcome of penile appearance
and sexual function after hypospadias repairs: situation and rela-
tion. Int Urol Nephrol 2011;43:47–54.
[65] van der Toorn F, de Jong TP, de Gier RP, et al. Introducing the HOPE
(Hypospadias Objective Penile Evaluation)-score: a validation
study of an objective scoring system for evaluating cosmetic
appearance in hypospadias patients. J Pediatr Urol 2013;9:
1006–16.
[66] Holland AJ, Smith GH, Ross FI, Cass DT. HOSE: an objective scoring
system for evaluating the results of hypospadias surgery. BJU Int
2001;88:255–8.
[67] Weber DM, Schonbucher VB, Landolt MA, Gobet R. The Pediatric
Penile Perception Score: an instrument for patient self-assessment
and surgeon evaluation after hypospadias repair. J Urol 2008;
180:1080–4, discussion 4.
[68] Network I-D. I-DSD Network. 2014. http://gtr.rcuk.ac.uk/projects?
ref=G1100236.
[69] Gonzalez R, Ludwikowski BM. Importance of urinary flow studies
after hypospadias repair: a systematic review. Int J Urol 2011;18:
757–61.
[70] Stein DM, Gonzalez CM, Barbagli G, Cimino S, Madonia M, Sansa-
lone S. Erectile function in men with failed hypospadias repair. Arch
Esp Urol 2014;67:152–6.
[71] Bubanj TB, Perovic SV, Milicevic RM, Jovcic SB, Marjanovic ZO,
Djordjevic MM. Sexual behavior and sexual function of adults after
hypospadias surgery: a comparative study. J Urol 2004;171:1876–9.
[72] Rynja SP, Wouters GA, Van Schaijk M, Kok ET, De Jong TP, De Kort
LM. Long-term followup of hypospadias: functional and cosmetic
results. J Urol 2009;182:1736–43.
[73] Chertin B, Natsheh A, Ben-Zion I, et al. Objective and subjective
sexual outcomes in adult patients after hypospadias repair per-
formed in childhood. J Urol 2013;190:1556–60.
[74] Svensson J, Berg R, Berg G. Operated hypospadiacs: late follow-up.
Social, sexual, and psychological adaptation. J Pediatr Surg
1981;16:134–5.
[75] Mieusset R, Soulie M. Hypospadias: psychosocial, sexual, and re-
productive consequences in adult life. J Androl 2005;26:163–8.
[76] Singh JC, Jayanthi VR, Gopalakrishnan G. Effect of hypospadias on
sexual function and reproduction. Indian J Urol 2008;24:249–52.
[77] Patel RP, Shukla AR, Snyder 3rd HM. The island tube and island
onlay hypospadias repairs offer excellent long-term outcomes: a
14-year followup. J Urol 2004;172:1717–9, discussion 9.
15
[78] Amukele SA, Weiser AC, Stock JA, Hanna MK. Results of 265 conse-
cutive proximal hypospadias repairs using the Thiersch-Duplay
principle. J Urol 2004;172:2382–3.
[79] Obaidullah, Aslam M. Ten-year review of hypospadias surgery from
a single centre. Br J Plast Surg 2005;58:780–9.
[80] Djordjevic ML, Majstorovic M, Stanojevic D, et al. One-stage repair
of severe hypospadias using combined buccal mucosa graft and
longitudinal dorsal skin flap. Eur J Pediatr Surg 2008;18:427–30.
[81] Macedo Jr A, Liguori R, Ottoni SL, et al. Long-term results with a one-
stage complex primary hypospadias repair strategy (the three-in-
one technique). J Pediatr Urol 2011;7:299–304.
[82] Snodgrass W, Bush N. Tubularised incised plate proximal hypospa-
dias repair: continued evolution and extended applications. J
Pediatr Urol 2011;7:2–9.
[83] Vepakomma D, Alladi A, Ramareddy RS, Akhtar T. Modified koya-
nagi repair for severe hypospadias. J Indian Assoc Pediatr Surg
2013;18:96–9.
[84] Hadidi AT. Perineal hypospadias: the Bilateral Based (BILAB) skin
flap technique. J Pediatr Surg 2014;49:218–23.
[85] Ortqvist L, Fossum M, Andersson M, et al. Long-term follow-up of
men born with hypospadias: urological and cosmetic results. J Urol
2015;193:975–81.
[86] Andersson M, Doroszkiewicz M, Arfwidsson C, Abrahamsson K,
Sillen U, Holmdahl G. Normalised urinary flow at puberty after
Tubularised Incised Plate (TIP) urethroplasty of hypospadias in
childhood. J Urol 2015;194:1407–13.
[87] Hueber PA, Antczak C, Abdo A, Franc-Guimond J, Barrieras D, Houle
AM. Long-term functional outcomes of distal hypospadias repair: a
single center retrospective comparative study of TIPs, Mathieu, and
MAGPI. J Pediatr Urol 2015;11:68.e1-7.
[88] Ekmark AN, Svensson H, Arnbjornsson E, Hansson E. Postpubertal
examination after hypospadias repair is necessary to evaluate the
success of the primary reconstruction. Eur J Pediatr Surg
2013;23:304–11.
[89] Ciancio F, Lo Russo G, Innocenti A, Portincasa A, Parisi D, Mondaini
N. Penile length is a very important factor for cosmesis, function
and psychosexual development in patients affected by hypospadi-
as: results from a long-term longitudinal cohort study. Int J Immu-
nopathol Pharmacol 2015;28:421–5.
[90] Ruppen-Greeff NK, Weber DM, Gobet R, Landolt MA. Health-related
quality of life in men with corrected hypospadias: an explorative
study. J Pediatr Urol 2013;9:551–8.
[91] Prat D, Natasha A, Polak A, et al. Surgical outcome of different types
of primary hypospadias repair during three decades in a single
center. Urology 2012;79:1350–3.
[92] Robinson AJ, Harry LE, Stevenson JH. Assessment of long term
function following hypospadias reconstruction: do flow rates, flow
quality and cosmesis improve with time? Results from the modified
Bretteville technique. J Plast Reconstr Aesthet Surg 2013;66:120–5.
[93] Myers JB, McAninch JW, Erickson BA, Breyer BN. Treatment of
adults with complications from previous hypospadias surgery. J
Urol 2012;188:459–63.
[94] Ching CB, Wood HM, Ross JH, Gao T, Angermeier KW. The Cleveland
Clinic experience with adult hypospadias patients undergoing
repair: their presentation and a new classification system. BJU
Int 2011;107:1142–6.
[95] Barbagli G, Perovic S, Djinovic R, Sansalone S, Lazzeri M. Retrospec-
tive descriptive analysis of 1176 patients with failed hypospadias
repair. J Urol 2010;183:207–11.