Today, a multiple number of surgical techniques, modifications, and combinations of techniques are used to improve cosmetic and functional outcomes and to minimise the procedure burden for the patient. Nevertheless, controversy exists regarding the ideal management of hypospadias. This update is based on current literature following a systematic review using MEDLINE.
Keywords: Hypospadias, Update, Techniques, Outcomes.
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  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 randomised 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 pathology—means this document is largely a consensus document.
Summary of the Société Internationale d’Urologie Current Best Practice Options in the management of hypospadias
|Indication||Substantial lack of long-term studies showing the effects of hypospadias surgery on cosmetic, functional, and psychological outcome. Recommendation on indication for hypospadias surgery is based on common sense.||3–5||B–D|
|Classification||Meatal location is only one of many meaningful parameters including quality of tissues, curvature, size of glans, 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.||3–5||C–D|
|Documentation||Documentation of objective findings will help to establish prospective data bases and make future studies comparable. There is no consensus on objective penile assessment and documentation of preoperative findings.||3–5||B–D|
|Further evaluation||Routine evaluation of the upper urinary tract in an asymptomatic child with hypospadias is not recommended. In suspicion of DSD, further investigations according to current guidelines.||3–5||B–D|
|Timing||It is recommended that hypospadias repair be performed in infancy or early childhood ideally when there is a trained paediatric anaesthetist available. Evidence concerning the ideal age of hypospadias repair is weak and confusing.||3–5||B–D|
|Androgens||Androgens are effective. There is neither consensus on the best type of androgen nor on the correct way of application and the potential side effects of androgens have not been studied thoroughly.||2a–5||B–D|
|Mild hypospadias repair||TIP repair is the most commonly used technique for the repair of distal hypospadias with good evidence in 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).||2a–5||B|
|Severe hypospadias repair||Two-stage repair is the most popular technique used in severe hypospadias. However, there is no consensus on 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.||3a–5||C|
|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 any reconstruction.||2b–5||B–D|
|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 surgery. However, it is important to point out that prophylactic antibiotic versus no antibiotic in hypospadias repair should be subject for future controlled studies.||1b||B|
DSD = detrusor sphincter dyssynergia; GR = grade; LE = levels of evidence.
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 significantly 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 nonfavourable surgical outcomes are more likely to suffer a negative psychological impact than those with minor hypospadias and good surgical results. Therefore there is an argument for a new classification of hypospadias based on the cost-benefit ratio for the patient .
The position of the meatus allows standardised nomenclature and is thought to be a major prognostic factor for outcome . Other more complex items (level of division of the corpus spongiosum, penile curvature, ventral hypoplasia, 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  and .
3. When should hypospadias be corrected?
Based on expert opinion, it is better to perform surgery of the male genitalia between 6 mo and 18 mo of age  and . This recommendation is based on surgical and anaesthetic considerations and the psychology of the infant male (cognitive development, genital awareness, emotional development, and psychosexual development). However, there is spare evidence regarding this and there are contradictory findings . It is generally believed that early repair is associated with a lower complication rate, but again, there is inconsistency in literature. Last but not least, there are rising concerns by patient groups that esthetical genital surgeries in minor hypospadias without functional impairment should be postponed to an age where informed consent can be given by the patient himself .
4. Preoperative androgens?
Androgen stimulation has been used for a long time to enhance the size of the penis and to improve quality of tissues . There are two randomised controlled trials showing that preoperative androgen stimulation improves outcome (cosmesis and complication rate)  and . 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  and . It is a fact that androgens stimulate penile growth ; however, the real benefit in hypospadias surgery and long-term side effects of male sexual hormone application still needs to be defined.
5. Perioperative antibiotics, urinary drainage, and wound dressing
For now, there is no consensus on the type of urinary drainage, stenting of the urethra, wound dressing, or the use of antibiotics. Each surgeon has his or her own preference. Urine can be drained using a transurethral catheter, transurethral dripping stent, or a suprapubic tube of various sizes. Most surgeons would agree that postoperative urinary diversion seems to reduce complications. However, in cases of distal hypospadias, some surgeons prefer no drainage at all , , , , , , , and . With regards to urinary diversion, there is no clear evidence that wound dressing is of any benefit for surgical outcome. The rational for wound dressing seems clear: dry, safe, and clean immobilisation of the penis for a limited period of time to allow wound healing and minimise postoperative discomfort and there are many different products available: foam dressing (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  and . Most surgeons use prophylactic antibiotics in hypospadias repair but there is no consensus regarding when to administer what type of antibiotics for what period of time  and . 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 , , , and .
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.
Algorthim of surgical management of hypospadias.
TIP = tubularised incided plate urethroplasty.
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 , , and . 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 , , , and . Since its introduction in 1994, TIP repair has evolved and consecutive modifications have significantly lowered the complication 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 . In particular, the fistula rate can be decreased by covering the urethroplasty with a waterproofing layer of dartos tissue , , and . There are many other techniques described with personal modifications. For example, Mathieu urethroplasty and its modifications are still popular procedures with excellent results . Systematic 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  and .
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 transposition, 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 . Another systematic review comparing the transverse island flap technique and TIP show no major differences in clinical outcome . However, both reviews indicated general problems of reporting data in hypospadiology: 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” . Today’ s surgical armamentarium 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 .
Most commonly performed techniques in the repair of severe hypospadias
|Patel||||2004||73||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.|
|Amukele||||2004||265||Thiersch-Duplay||Long-term proven reliable technique, difficult with extensive chordee and low quality urethral plate.|
|Obaidullah||||2005||1415||Two stage repair||Two-stage repair very safe and applicable to all cases.|
|Djordjevic, Macedo|| and ||2008, 2011||NA||Combinations, variations||Flaps, grafts, buccal mucosa, technically very challenging, techniques never gained popularity, short term follow-up.|
|Snodgrass||||2011||26||TIP||Suitable when no minor curvature and good quality of urethral plate.|
|Vepakomma||||2013||24||Koyanagi||Based on a parameatal foreskin flap, many modifications since its introduction in 1983, technically challenging.|
|Hadidi||||2014||63||BILAB||Bilateral based preputial and penile skin flaps, generous blood supply.|
f/u = follow-up; TIP = tubularised incided plate urethroplasty.
The two-stage repair, either using grafts or flaps, is a versatile technique when there is severe chordee, a small glans, and ventral scarring  and . 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 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 . If necessary, dorsal plication with or without mobilisation of the neurovascular bundle can help to straighten the penis  and . 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 . 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 . 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 , quality of data is influenced by low follow-up periods and rates, heterogeneous patients and data, and a lack of validated questionnaires and control groups . It has been criticised that follow-up periods—particularly in Northern America—are short , although some believe that most complications occur early after surgery . 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  and . 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 , , and . Table 3 shows long-term outcome studies from 2010 to 2015. Although the majority of patients do well after hypospadias repair there are reports 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.
Long-term outcome studies from 2010 to 2015
|Name||Reference||Yr||N||Age at surgery (yr)||Age at FU (yr)||FU period (mo)||Fistula (%)||Curvature (%)||Stenosis (%)||Comments|
|Örtqvist||||2015||167||4||34||29||16.4||23||5||Impaired cosmesis, shorter penis, more LUTS.|
|Andersson||||2015||40||3.6||15.2||11.6||5||15||22.5||Uroflow improves over time.|
|Hueber||||2015||153||2.9||>10||21/16/5||0/4/2||16/16/10||Favourable outcomes (TIP/Mathieu/MAGPI).|
|Fraumann||||2014||13||1.2||21||20||7.5||38.5||7.5||Satisfactory outcome, lower orgasmic function.|
|Ekmark||||2013||114||4.5–5||16||12||11||5.4||3.6||Curvature can develop over time.|
|Aulagne||||2010||27||3.3||25||33||18||26||Generally good outcomes.|
|Perera||||2012||60||1.8||11.3||Uroflow lower than controls, associated with previous chordee.|
|Ciancio||||2015||20||5||33||28||Good cosmesis, no erectile dysfunction, low IPSS, penis shorter.|
|Ruppen-Greff||||2013||45||26.2||HRQoL were not impaired among men.|
|Chertin, Prat|| and ||2012, 2013||119||2.7||Adults||Good cosmetic results, mild erectile dysfunction, numerous techniques, high complication rates (0–100%).|
|Robinson||||2012||18||2.5||12.5||10.5||Good flow and cosmesis.|
|Kiss||||2011||104||24–42||20–30||Less satisfaction with genital appearance, however healthy psychosexual development possible.|
|Jiao||||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.
Series of hypospadias redo surgery in adults
|Name||Reference||Age at surgery (yr)||FU period (mo)||n||Comments|
|Stein||||2014||39.7||15 (3–28)||163||54% erectile dysfunction.|
|Myers||||2012||38||7.4||50||Difficult surgery, additional procedures common.|
|Ching||||2011||37||55||Voiding problems 82%, UTI 36%, curvature 24%, BXO 13%, fistula 14%.|
|Barbagli||||2010||31||60.4||1176 (926 older than 16 yr)||12% failure rate.|
BXO = balanitis xerotica obliterans; FU = follow-up; UTI = urinary tract infection.
In literature, short-term and mid-term outcomes of hypospadias surgery seem favourable. However, the majority 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 . Assessment of outcome includes: cosmesis, functional outcome (micturition and sexuality), and quality of psychosexual life.
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 sexual outcome . There are several objective and validated scores to evaluate the outcome of hypospadias surgery (Hypospadias Objective Scoring Evaluation, Paediatric Penile Perception Score, Hypospadias Objective Penile Evaluation Score) , , and . 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 . 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  and The Dutch (International) Hypospadias Study  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 . 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 . 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, International index of erectile function, and Sexual Summary Score) . A certain prevalence of erectile dysfunction hypospadias patients has been reported .
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 , , , , , , , and . Generally speaking, hypospadias 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 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 . 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.
-  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/.
-  A. Springer, A.F. Spinoit, S. Nappo, et al. Current best practice options in the management of hypospadias. C.R. DeVries, J.M. Nijman (Eds.) Congenital anomalies in children—A joint SIU-ICUD International Consultation (Société Internationale d’Urologie, Montreal, 2014) 52-78
-  A.F. Spinoit, F. Poelaert, C. Van Praet, L.A. Groen, E. Van Laecke, P. Hoebeke. Grade of hypospadias is the only factor predicting for re-intervention after primary hypospadias repair: A multivariate analysis from a cohort of 474 patients. J Pediatr Urol. 2015;11 70.e1-6
-  A.T. Hadidi. Classification of hypospadias. A.T. Hadidi, A.F. Azmy (Eds.) Hypospadias surgery (Springer, Heidelberg, 2004) 79-83
-  P.D. Mouriquand, P.Y. Mure. Current concepts in hypospadiology. BJU Int. 2004;93(Suppl 3):26-34 Crossref
-  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. Pediatrics 1996;97:590-4.
-  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.
-  D.M. Weber, V.B. Schonbucher, R. Gobet, A. Gerber, M.A. Landolt. Is there an ideal age for hypospadias repair? A pilot study. J Pediatr Urol. 2009;5:345-350 Crossref
-  A. Springer, L. Baskin. Timing of hypospadias repair in patients with disorders of sex development. O. Hiort, S.F. Ahmed (Eds.) Understanding differences and disorders of sex development (Karger, Basel, 2014) 197-202 Crossref
-  R.D. Malik, D.B. Liu. Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias. J Pediatr Urol. 2014;10:840-843 Crossref
-  S.A. Asgari, M.R. Safarinejad, F. Poorreza, A. Safaei Asl, M. Mansour Ghanaie, E. Shahab. The effect of parenteral testosterone administration prior to hypospadias surgery: a prospective, randomised, and controlled study. J Pediatr Urol. 2015;11 143.e1-6
-  C. Kaya, J. Bektic, C. Radmayr, C. Schwentner, G. Bartsch, J. Oswald. The efficacy of dihydrotestosterone transdermal gel before primary hypospadias surgery: a prospective, controlled, randomized study. J Urol. 2008;179:684-688 Crossref
-  I. Wright, E. Cole, F. Farrokhyar, J. Pemberton, A.J. Lorenzo, L.H. Braga. Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review. J Urol. 2013;190:652-659
-  J.M. Netto, C.E. Ferrarez, A.A. Schindler Leal, S. Tucci Jr., C.A. Gomes, U. Barroso Jr. Hormone therapy in hypospadias surgery: a systematic review. J Pediatr Urol. 2013;9:971-979 Crossref
-  R.B. Nerli, A. Koura, V. Prabha, M. Reddy. Comparison of topical versus parenteral testosterone in children with microphallic hypospadias. Pediatr Surg Int. 2009;25:57-59 Crossref
-  M. Radwan, M.G. Soliman, A. Tawfik, M. Abo-Elenen, M. El-Benday. Does the type of urinary diversion affect the result of distal hypospadias repair? A prospective randomised trial. Ther Adv Urol. 2012;4:161-165 Crossref
-  N. Xu, X.Y. Xue, Y. Wei, et al. Outcome analysis of tubularized incised plate repair in hypospadias: is a catheter necessary?. Urol Int. 2013;90:354-357 Crossref
-  C.R. Ritch, A.M. Murphy, S.L. Woldu, E.A. Reiley, T.W. Hensle. Overnight urethral stenting after tubularised incised plate urethroplasty for distal hypospadias. Pediatr Surg Int. 2010;26:639-642 Crossref
-  J. Hardwicke, E. Jones, N. Wilson-Jones. Optimisation of silicone urinary catheters for hypospadias repair. J Pediatr Urol. 2010;6:385-388 Crossref
-  C. Lorenz, A. Schmedding, A. Leutner, H. Kolb. Prolonged stenting does not prevent obstruction after TIP repair when the glans was deeply incised. Eur J Pediatr Surg. 2004;14:322-327 Crossref
-  M.D. Leclair, C. Camby, S. Battisti, G. Renaud, V. Plattner, Y. Heloury. Unstented tubularized incised plate urethroplasty combined with foreskin reconstruction for distal hypospadias. Eur Urol. 2004;46:526-530 Crossref
-  W. Snodgrass, A. Macedo, P. Hoebeke, P.D. Mouriquand. Hypospadias dilemmas: a round table. J Pediatr Urol. 2011;7:145-157 Crossref
-  M. Castagnetti, A. El-Ghoneimi. The influence of perioperative factors on primary severe hypospadias repair. Nat Rev Urol. 2011;8:198-206 Crossref
-  G. McLorie, B. Joyner, D. Herz, et al. A prospective randomized clinical trial to evaluate methods of postoperative care of hypospadias. J Urol. 2001;165:1669-1672
-  J.G. Van Savage, L.G. Palanca, B.L. Slaughenhoupt. A prospective randomised trial of dressings versus no dressings for hypospadias repair. J Urol. 2000;164:981-983
-  M.H. Hsieh, P. Wildenfels, E.T. Gonzales Jr. Surgical antibiotic practices among pediatric urologists in the United States. J Pediatr Urol. 2011;7:192-197 Crossref
-  Springer A. The use of antibiotics in hypospadias surgery. Results from an international survey. Unpublished data. 2013.
-  Y.C. Lee, C.H. Huang, Y.H. Chou, C.Y. Lin, W.J. Wu. Outcome of hypospadias reoperation based on preoperative antimicrobial prophylaxis. Kaohsiung J Med Sci. 2005;21:351-357 Crossref
-  D.B. Meir, P.M. Livne. Is prophylactic antimicrobial treatment necessary after hypospadias repair?. J Urol. 2004;171:2621-2622 Crossref
-  E. Baillargeon, K. Duan, A. Brzezinski, R. Jednak, M. El-Sherbiny. The role of preoperative prophylactic antibiotics in hypospadias repair. Can Urol Assoc J. 2014;8:236-240
-  N. Kanaroglou, E. Wehbi, A. Alotay, et al. Is there a role for prophylactic antibiotics after stented hypospadias repair?. J Urol. 2013;190:1535-1539 Crossref
-  A. Springer, W. Krois, E. Horcher. Trends in hypospadias surgery: results of a worldwide survey. Eur Urol. 2011;60:1184-1189 Crossref
-  A. Cook, A.E. Khoury, C. Neville, D.J. Bagli, W.A. Farhat, J.L. Pippi Salle. A multicentre evaluation of technical preferences for primary hypospadias repair. J Urol. 2005;174:2354-2357 discussion 7 Crossref
-  L. Steven, A. Cherian, F. Yankovic, A. Mathur, M. Kulkarni, P. Cuckow. Current practice in paediatric hypospadias surgery; a specialist survey. J Pediatr Urol. 2013;9:1126-1130 Crossref
-  L.H. Braga, A.J. Lorenzo, J.L. Salle. Tubularised incised plate urethroplasty for distal hypospadias: a literature review. Indian J Urol. 2008;24:219-225
-  W. Snodgrass, M. Koyle, G. Manzoni, R. Hurwitz, A. Caldamone, R. Ehrlich. Tubularised incised plate hypospadias repair: results of a multicenter experience. J Urol. 1996;156:839-841
-  O.M. Sarhan, A.S. El-Hefnawy, A.T. Hafez, M.T. Elsherbiny, M.E. Dawaba, A.M. Ghali. Factors affecting outcome of tubularized incised plate (TIP) urethroplasty: single-center experience with 500 cases. J Pediatr Urol. 2009;5:378-382 Crossref
-  W.T. Snodgrass, N. Bush, N. Cost. Tubularised incised plate hypospadias repair for distal hypospadias. J Pediatr Urol. 2010;6:408-413 Crossref
-  K.L. Pfistermuller, A.J. McArdle, P.M. Cuckow. Meta-analysis of complication rates of the tubularized incised plate (TIP) repair. J Pediatr Urol. 2015;11:54-59
-  M. Yigiter, A. Yildiz, A. Oral, A.B. Salman. A comparative study to evaluate the effect of double dartos flaps in primary hypospadias repair: no fistula anymore. Int Urol Nephrol. 2010;42:985-990 Crossref
-  M.L. Djordjevic, S.V. Perovic, V.M. Vukadinovic. Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair. BJU Int. 2005;95:1303-1309 Crossref
-  M. Cimador, M. Pensabene, M. Sergio, P. Catalano, E. de Grazia. Coverage of urethroplasty in pediatric hypospadias: randomised comparison between different flaps. Int J Urol. 2013;20:1000-1005
-  A.T. Hadidi. The slit-like adjusted Mathieu technique for distal hypospadias. J Pediatr Surg. 2012;47:617-623 Crossref
-  D.J. Wilkinson, P. Farrelly, S.E. Kenny. Outcomes in distal hypospadias: a systematic review of the Mathieu and tubularised incised plate repairs. J Pediatr Urol. 2012;8:307-312
-  F. Wang, Y. Xu, H. Zhong. Systematic review and meta-analysis of studies comparing the perimeatal-based flap and tubularized incised-plate techniques for primary hypospadias repair. Pediatr Surg Int. 2013;29:811-821 Crossref
-  M. Castagnetti, A. El-Ghoneimi. Surgical management of primary severe hypospadias in children: systematic 20-year review. J Urol. 2010;184:1469-1474
-  D. Xiao, X. Nie, W. Wang, 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 Crossref
-  E.R. McNamara, A.J. Schaeffer, T. Logvinenko, et al. Management of proximal hypospadias with 2-stage repair: 20 year experience. J Urol. 2015;194:1080-1085
-  A. Bracka. The role of two-stage repair in modern hypospadiology. Indian J Urol. 2008;24:210-218 Crossref
-  W. Snodgrass, J. Prieto. Straightening ventral curvature while preserving the urethral plate in proximal hypospadias repair. J Urol. 2009;182:1720-1725 Crossref
-  R.M. Nesbit. Operation for correction of distal penile ventral curvature with or without hypospadias. Trans Am Assoc Genitourin Surg. 1966;58:12-14
-  L.S. Baskin, J.W. Duckett. Dorsal tunica albuginea plication for hypospadias curvature. J Urol. 1994;151:1668-1671
-  L.H. Braga, J.L. Pippi Salle, S. Dave, D.J. Bagli, A.J. Lorenzo, A.E. Khoury. Outcome analysis of severe chordee correction using tunica vaginalis as a flap in boys with proximal hypospadias. J Urol. 2007;178:1693-1697 discussion 7 Crossref
-  A. Springer, R. Subramaniam. Split dorsal dartos flap transposed ventrally as a bed for preputial skin graft in primary staged hypospadias repair. Urology. 2012;79:939-942 Crossref
-  W. Snodgrass. Hypospadias reporting—how good is the literature?. J Urol. 2010;184:1255-1256 Crossref
-  S.P. Rynja, T.P. de Jong, J.L. Bosch, L.M. de Kort. Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood. J Pediatr Urol. 2011;7:504-515 Crossref
-  W. Snodgrass, C. Villanueva, N.C. Bush. Duration of follow-up to diagnose hypospadias urethroplasty complications. J Pediatr Urol. 2014;10:208-211 Crossref
-  A.F. Spinoit, F. Poelaert, L.A. Groen, E. Van Laecke, P. Hoebeke. Hypospadias repair at a tertiary care center: long-term followup is mandatory to determine the real complication rate. J Urol. 2013;189:2276-2281 Crossref
-  A. Kiss, B. Sulya, A.M. Szasz, et al. Long-term psychological and sexual outcomes of severe penile hypospadias repair. J Sex Med. 2011;8:1529-1539 Crossref
-  M. Perera, B. Jones, M. O’Brien, J.M. Hutson. Long-term urethral function measured by uroflowmetry after hypospadias surgery: comparison with an age matched control. J Urol. 2012;188:1457-1462 Crossref
-  S.A. Fraumann, H.A. Stephany, D.B. Clayton, et al. Long-term follow-up of children who underwent severe hypospadias repair using an online survey with validated questionnaires. J Pediatr Urol. 2014;10:446-450 Crossref
-  M.B. Aulagne, L. Harper, S. de Napoli-Cocci, J.M. Bondonny, E. Dobremez. Long-term outcome of severe hypospadias. J Pediatr Urol. 2010;6:469-472 Crossref
-  A. Springer. Assessment of outcome in hypospadias surgery—a review. Front Pediatr. 2014;2:2
-  C. Jiao, R. Wu, X. Xu, Q. Yu. Long-term outcome of penile appearance and sexual function after hypospadias repairs: situation and relation. Int Urol Nephrol. 2011;43:47-54 Crossref
-  F. van der Toorn, T.P. de Jong, R.P. de Gier, 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;9:1006-1016 Crossref
-  A.J. Holland, G.H. Smith, F.I. Ross, D.T. Cass. HOSE: an objective scoring system for evaluating the results of hypospadias surgery. BJU Int. 2001;88:255-258 Crossref
-  D.M. Weber, V.B. Schonbucher, M.A. Landolt, R. Gobet. The Pediatric Penile Perception Score: an instrument for patient self-assessment and surgeon evaluation after hypospadias repair. J Urol. 2008;180:1080-1084 discussion 4 Crossref
-  Network I-D. I-DSD Network. 2014. http://gtr.rcuk.ac.uk/projects?ref=G1100236.
-  R. Gonzalez, B.M. Ludwikowski. Importance of urinary flow studies after hypospadias repair: a systematic review. Int J Urol. 2011;18:757-761 Crossref
-  D.M. Stein, C.M. Gonzalez, G. Barbagli, S. Cimino, M. Madonia, S. Sansalone. Erectile function in men with failed hypospadias repair. Arch Esp Urol. 2014;67:152-156
-  T.B. Bubanj, S.V. Perovic, R.M. Milicevic, S.B. Jovcic, Z.O. Marjanovic, M.M. Djordjevic. Sexual behavior and sexual function of adults after hypospadias surgery: a comparative study. J Urol. 2004;171:1876-1879 Crossref
-  S.P. Rynja, G.A. Wouters, M. Van Schaijk, E.T. Kok, T.P. De Jong, L.M. De Kort. Long-term followup of hypospadias: functional and cosmetic results. J Urol. 2009;182:1736-1743 Crossref
-  B. Chertin, A. Natsheh, I. Ben-Zion, et al. Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood. J Urol. 2013;190:1556-1560 Crossref
-  J. Svensson, R. Berg, G. Berg. Operated hypospadiacs: late follow-up. Social, sexual, and psychological adaptation. J Pediatr Surg. 1981;16:134-135 Crossref
-  R. Mieusset, M. Soulie. Hypospadias: psychosocial, sexual, and reproductive consequences in adult life. J Androl. 2005;26:163-168
-  J.C. Singh, V.R. Jayanthi, G. Gopalakrishnan. Effect of hypospadias on sexual function and reproduction. Indian J Urol. 2008;24:249-252 Crossref
-  R.P. Patel, A.R. Shukla, H.M. Snyder 3rd. The island tube and island onlay hypospadias repairs offer excellent long-term outcomes: a 14-year followup. J Urol. 2004;172:1717-1719 discussion 9 Crossref
-  S.A. Amukele, A.C. Weiser, J.A. Stock, M.K. Hanna. Results of 265 consecutive proximal hypospadias repairs using the Thiersch-Duplay principle. J Urol. 2004;172:2382-2383 Crossref
-  Obaidullah, M. Aslam. Ten-year review of hypospadias surgery from a single centre. Br J Plast Surg. 2005;58:780-789 Crossref
-  M.L. Djordjevic, M. Majstorovic, D. Stanojevic, et al. One-stage repair of severe hypospadias using combined buccal mucosa graft and longitudinal dorsal skin flap. Eur J Pediatr Surg. 2008;18:427-430 Crossref
-  A. Macedo Jr., R. Liguori, S.L. Ottoni, 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 Crossref
-  W. Snodgrass, N. Bush. Tubularised incised plate proximal hypospadias repair: continued evolution and extended applications. J Pediatr Urol. 2011;7:2-9 Crossref
-  D. Vepakomma, A. Alladi, R.S. Ramareddy, T. Akhtar. Modified koyanagi repair for severe hypospadias. J Indian Assoc Pediatr Surg. 2013;18:96-99
-  A.T. Hadidi. Perineal hypospadias: the Bilateral Based (BILAB) skin flap technique. J Pediatr Surg. 2014;49:218-223 Crossref
-  L. Ortqvist, M. Fossum, M. Andersson, et al. Long-term follow-up of men born with hypospadias: urological and cosmetic results. J Urol. 2015;193:975-981
-  M. Andersson, M. Doroszkiewicz, C. Arfwidsson, K. Abrahamsson, U. Sillen, G. Holmdahl. Normalised urinary flow at puberty after Tubularised Incised Plate (TIP) urethroplasty of hypospadias in childhood. J Urol. 2015;194:1407-1413
-  P.A. Hueber, C. Antczak, A. Abdo, J. Franc-Guimond, D. Barrieras, A.M. Houle. 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
-  A.N. Ekmark, H. Svensson, E. Arnbjornsson, E. Hansson. Postpubertal examination after hypospadias repair is necessary to evaluate the success of the primary reconstruction. Eur J Pediatr Surg. 2013;23:304-311
-  F. Ciancio, G. Lo Russo, A. Innocenti, A. Portincasa, D. Parisi, N. Mondaini. Penile length is a very important factor for cosmesis, function and psychosexual development in patients affected by hypospadias: results from a long-term longitudinal cohort study. Int J Immunopathol Pharmacol. 2015;28:421-425
-  N.K. Ruppen-Greeff, D.M. Weber, R. Gobet, M.A. Landolt. Health-related quality of life in men with corrected hypospadias: an explorative study. J Pediatr Urol. 2013;9:551-558 Crossref
-  D. Prat, A. Natasha, A. Polak, et al. Surgical outcome of different types of primary hypospadias repair during three decades in a single center. Urology. 2012;79:1350-1353
-  A.J. Robinson, L.E. Harry, J.H. Stevenson. 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;66:120-125 Crossref
-  J.B. Myers, J.W. McAninch, B.A. Erickson, B.N. Breyer. Treatment of adults with complications from previous hypospadias surgery. J Urol. 2012;188:459-463 Crossref
-  C.B. Ching, H.M. Wood, J.H. Ross, T. Gao, K.W. Angermeier. The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system. BJU Int. 2011;107:1142-1146 Crossref
-  G. Barbagli, S. Perovic, R. Djinovic, S. Sansalone, M. Lazzeri. Retrospective descriptive analysis of 1176 patients with failed hypospadias repair. J Urol. 2010;183:207-211 Crossref
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
Corresponding author. Leeds Teaching Hospitals NHS Trust, Level F, Martin Wing, Leeds General Infirmary, Leeds LS1 3EX, UK. Tel. +447818452603.
☆ Please visit www.eu-acme.org/europeanurology to read and answer questions on-line. The EU-ACME credits will then be attributed automatically.
© 2016 Published by Elsevier B.V.