Hypospadias surgery has developed into a well defined art and science.
Surgeons dealing with this anomaly should have a detailed understanding of the
various basic surgical principles and experience with delicate, precise
optically assisted techniques and maintain a clinical workload that is
sufficient to obtain consistently good results.
One in 125 boys has hypospadias. In the United States a study reported that
hypospadias was the most common congenital anomaly among whites. The incidence
has been rising during the 1970s and 1980s.
Anatomic classification of hypospadias recognizes the level of the meatus
without taking into account curvature. A more recent classification was
described. This classification indicates the site of urethral meatus (before
and after chordee correction), the prepuce (incomplete or complete), the glans
(cleft, incomplete cleft or flat), the width of urethral plate, the degree of
penile rotation if present and the presence of scrotal transposition (Fig. 1,
2). Using the general classification (Fig. 4), surgeons are able to conduct
multi-centre studies to evaluate different techniques of repair.
of hypospadias, according to location of meatus into 4 grades
Fig. 2 a - c: Classification of glans configuration in hypospadias. (a) Cleft glans.
There is a deep groove in the middle of the glans with proper clefting; the
urethral plate is narrow and projects to the tip of the glans. (b) Incomplete
cleft glans. There is a variable degree of glans split, a shallow glanular
groove and a variable degree of urethral plate projection. (c) Flat glans. The
urethral plate ends short of the glans penis, no glanular groove. There may be
a variable degree of chordee, especially in proximal forms of hypospadias.
Evaluation of risk for hypospadias repair from birth to age 7 years. The
optimal window is from 3 to 18 months of age (modified from Schulz et al.
General classification: surgeons are able to conduct multi-centre studies to
evaluate different techniques of repair
Different tissues used for correction of
Although the penile repairs can be grouped
into 8 major principles, depending on the tissues used, each has been subject
to countless variations as one surgeon after another adds yet another
modification to an already thrice-modified variation of a procedure adapted
from a principle derived from the original.
To correct hypospadias and achieve a terminal
meatus, one may use one of the following basic principles or tissues: 1)
mobilisation of the urethra; 2) skin distal to the meatus; 3) skin proximal
to the meatus; 4) preputial skin; 5) combined prepuce and skin proximal the
meatus; 6) scrotal skin; 7) dorsal penile skin; 8) different grafts.
- Urethral mobilisation
- Double Y Glanuloplasty (DYG) by Hadidi 2010.
- Urethral mobilisation first described by Beck
and Hacker (1897).
- MAGPI described by Duckett (1981, midline
vertical incision closed transversely and mobilization).
- M configuration by Arap (1984), a modification
of MAGPI by placing two sutures on the ventral edge.
- UGPI modification of MAGPI by Harrison and
Grobelaar (1997) by having a V-shaped incision around the original
meatus, and having deep glanular wings before urethral advancement and
upward rotation of the glanular wings.
- Skin distal to the meatus
- Use of ventral skin distal to the meatus to
reconstruct a completely epithelialized neo-urethra
- Lateral Baed Onlay Flap (LABO) by Hadidi 2012
- U-shaped incision as first described by
Thiersch (1869). Notice the U incision is not central to avoid suture
lines on top of each other.
- Pyramid repair by Duckett and Keating (1989)
for Megameatus Intact prepuce (MIP).
- glanular hypospadias with cleft glans.
- DUG repair by Stock and Hanna (1997) combining
U-shaped incision with vertical midline incision closed transversely.
- Use of ventral skin distal to the meatus to
reconstruct a partially epithelialized neo-urethra (Fig. 6)
- Duplay incomplete
- Denis Browne technique (1949)
- Rich et al (1989) hinging of the urethral plate
- Snodgrass Tubularized Incised Plate (TIP)
- Skin proximal to the meatus
- Slit- like adjusted Mathieu (SLAM) by Hadidi (1996,
- Wood (1875) described meatal based flap with
button hole of prepuce
- Omberdanne (1911) repair, a large round flap,
and a purse string suture
- Mathieu repair (1932), a U-shaped incision and
two suture lines
- Mustarde repair (1965), a rectangular flap and
one suture line
- Barcat balanic groove technique (1969), and a
deep midline incision
- Preputial skin
- Button holing of the prepuce described by
- Midline incision of the prepuce described by
Edmunds (1913) and Byars (1955).
- Preputial skin as a skin graft to cover the
ventral defect of the penis described by Nove-Josserand (1897) and Bracka
- Preputial skin as a free skin graft to form the
neo-urethra described by Devine and Horton (1961).
- Preputial Island Flap as described by Hook
(1896), … and Duckett (1980).
- Onlay Island Flap as described by Elder (1987).
- Preputial vascular fascia as a second
protective layer described by Retik (1988)
a - d: Use
of ventral skin distal to the meatus to reconstruct a partially epithelialised
neourethra: (a) Duplay incomplete urethroplasty (1880); (b) Denis Browne
technique (1949); (c) hinging of the urethral plate (Rich et al. 1989); (d)
Snodgrass TIP urethroplasty (1994)
- Combined use of prepuce and the skin distal to
- Lateral based flap (LAB) by Hadidi (2003,
- Lateral oblique flap from the side of the penis
suggested by Hook (1896).
- One stage repair for proximal hypospadias by
- Parameatal foreskin flap described by Koyanagi
- Yoke repair described by Snow (1994).
- Scrotal skin (not
recommended for fear of hairy urethra)
- Bouisson (1861) was the first to use scrotal
skin for urethral reconstruction.
- Rosenberger (1891) used scrotal tissue for
urethroplasty and buried the penis in scrotum.
- Rochet (1899) used a large scrotal flap for
- Lowsley and Begg (1938) constructed a long
urethral tube from scrotum.
- Beck (1897) suggested Duplay type of
urethroplasty and used a rotation flap from scrotum for coverage.
- Cecil (1946) used a modification of Rosenberger
operation following reconstruction of the urethra from ventral penile
- Dorsal penile skin
Davis in 1940 tubed the dorsal
penile skin with the base proximal in the direction of the circulation. The
detached distal end of this tube was passed through a channel in the glans and
penis by angulating the penis acutely upward and backward. In the second stage,
the proximal pedicle was cut and the penis returned to its normal position. The
penile gymnastics required for the Davis procedure apparently seemed too
demanding for most surgeons.
- Different grafts
- Nove-Josserand (1897) used a split thickness
skin graft on a metal probe.
- Devine and Horton (1961) used preputial full
thickness skin graft in single stage repair.
- Bracka (1995) used full thickness skin graft in
two stage repair.
- Mommelaar (1947) used bladder mucosa for
- Humby (1941) first described the use of buccal
mucosa for urethral reconstruction.