The ideal time for surgery is between 3 and 18 months. The infants are
amnesic of the procedure and 70 - 80 % of anomalies can be managed on an
Fine plastic, micro vascular or ophthalmic instruments including sharp
serrated scissors are necessary. Optic magnification is helpful, although low
magnification will suffice (X 1-2); some use an operating microscope routinely.
Sutures like 6/0 or 7/0 Vicryl (polyglactin 910), Monocryl (poliglecaprone 25)
or PDS (polydiaxanone) are used for urethroplasty.
To obtain a bloodless field, a tourniquet (released
every 30 - 45 min) or Epinephrine (1:100 000) in 1 % lidocaine is used.
Haemostasis should be ensured using bipolar diathermy. Urethroplasty should be
performed around a 10 Fr catheter to avoid subsequent stenosis. A compressing
dressing is applied post-operatively for 6 hours for hemostasis. The author
prefers to remove the dressing after 6 hours but many surgeons prefer to use
silastic foam or Tegaderm dressing for 2 - 5 days. The author does not leave a
catheter inside the urethra routinely because it causes irritation and
interferes with healing. However many surgeons leave a 6 Fr silastic catheter
for 7 - 10 days.
Choice of operative technique
More than three hundred operations have been described for the treatment of
hypospadias. Surgeons have proceeded through Browne repairs and scrotal flaps,
to Duplay tubes, to free skin grafts, to island flaps and onlays, to bladder
and buccal mucosal repairs, to a host of single-stage innovations, to different
concepts of chordee correction and with all manner of bladder drainage systems.
However, hypospadias repairs can be grouped into five or six major principles,
depending on the tissues used.
For glanular hypospadias with mobile meatus, the
author prefers to use the Inverted Y technique. For distal hypospadias,
he prefers to use the Y-V glanuloplasty modified Mathieu approach. The author
has adopted the lateral-based flap for proximal hypospadias. Two-stage repair
may be preferred in patients with perineal hypospadias to avoid the use of
hair-bearing areas of skin. Fig. 7
summarises the author's recommendations for primary hypospadias repair.
Recommendations for primary hypospadias repair
Grade I or
Glanular Hypospadias: "The Double Y
is suitable for a limited number of hypospadias patients. It is ideal for
patients with glanular hypospadias characterised with mobile meatus. If the
meatus is not mobile or can not be brought to the tip of the penis, the
technique is contra-indicated.
An inverted Y
incision is outlined on the glans.
The two diverging limbs are incised along
the upper edge of the meatus.
The longitudinal limb extends in the midline to
the tip of the glans.
A space is created for the new urethra.
The inverted Y is
sutured as an inverted V preserving the dog ears.
The glans is freely mobilised
to wrap around the urethra.
Urinary diversion and dressing is applied for 24
Fig. 8: The DoubleY Glanuloplasty (DYG) Technique
Grade II or Distal
Hypospadias: "The Slit-like
adjusted Mathieu (SLAM) Technique"
The meatal-based flap technique of Mathieu is the most popular technique
for distal hypospadias repair and has withstood the test of time. However, the
major drawback of the original Mathieu technique is the final appearance of the
meatus (a smiling meatus that is not very terminal). The Slit-like adjusted
Mathieu (SLAM) helps to employ the Mathieu operation in all forms of distal
hypospadias and gives a terminal, slit like meatus. This will include about 70
to 80 % of patients with hypospadias. The only contraindication is the presence
of severe chordee distal to the hypospadiac meatus (very rare in distal
boundaries of the urethral plate are outlined. A U-shaped incision is outlined. The two
parallel incisions at the glans region start along the true mucosal urethral
plate to have large, wide glanular wings. At the distal end, the two incision
converge as shown to have a slit-like meatus and to avoid having sutures at the
meatus. The two lateral incisions diverge near the meatus to produce a wide
Fig 1b.: Flap mobilisation: Using a sharp scissors, the incision is
deepened starting near the coronal sulcus, the lateral skin edge (not the
flap) is held with fine toothed forceps
and fascia and corpus spongiosum are included with the flap as much as possible.
Fig 1c.: Angle epithelium excision: The epithelium at the proximal two
angles of the flap is excised maintaining the fascia.
The edges of the flap are fixed to the converging edges of the urethral
plate 2-3 mm from the distal end of the incision. Urethroplasty is carried out
using 6/0 vicryl on a sharp needle in a continuous subcuticular fashion
starting 3 mm proximal to the angle of the flap. A sealing second suture
line in a continuous fashion is carried out.
Fig. 1e:. V-Excision: A
triangle is removed from the tip of the flap to help having a slit like meatus.
Fig 1f, g: Glans and skin closure: The glanular wings are approximated
around the new urethra and the penile skin is closed. Notice that the new
meatus has one stitch only at 6 O’clock.
Complications: Fistula occurs in 2 - 5 % of patients.
Fig. 9: The SLAM technique for distal hypospadias
Grade IIIa - Proximal
hypospadias: "Lateral Based Onlay (LABO)
The lateral Based Onlay (LABO)
flap may be used in proximal hypospadias without deep chordee that requires
division of the urethral plate to straighten the penis. It is of particular
value in patients with small glans. The principle is to use the lateral penile
skin as well as part of the prepuce to reconstruct the new urethra. It has the
advantages over the classic lateral based flap of less complications, only one
catheter through the penis for one week and less hospital stay (8 days after
A U-shaped incision is outlined. The two parallel incisions go very deep
into the glans and converge as shown to
have a slit-like meatus. The left incision stops at the coronal sulcus and
continues distally in the prepuce at the muco-cutaneous junction and
constitutes the medial border of the LABO flap. The flap is designed to have a
wide base as shown in the figure.
2b.: Flap mobilisation: The right incision is deepened starting near the
Apex suture: The tip of the medial border of the LABO
flap (A) is sutured to the urethral plate 2 mm proximal to the edge (A´).
Fig.2c.: Urethroplasty: The medial border of the LABO flap is sutured to the left
edge of the urethral plate.
Fig.2d: The LABO flap is turned over the
Fig.2e: The second apex stitch is fixed 2 mm from the tip of
the urethral plate incision.
Fig.2f: Urethroplasty is completed on the
right side. A triangle is removed from the tip of the flap to help
having a slit like meatus.
Fig 2g: A second intermediate layer is used
from the scrotal dartos/tuncia vagnialis.
Fig 2h: Glans and skin closure: The
glanular wings are approximated around the new urethra and the penile skin is
closed. Notice that the new meatus has one stitch only at 6 O’clock.
Complications: 5-7 % in the form
of fistula, glans dehiscence or skin prolapsed from the meatus.
Fig 10: The lateral based Onlay (LABO) technique for proximal
Grade IIIb - Proximal hypospadias with deep chordee: "Lateral Based Flap"
The lateral based flap may be used in all types of proximal hypospadias
This flap with double blood supply, combines the advantages of meatal-based
flap, and preputial pedicle flap techniques into one procedure without the need
for an intervening anastomosis. It also allows for extensive excision of
ventral chordee and the urethral plate (if necessary) without damaging the
A deep Y-shaped incision is made on the glans. The centre of the Y is where
the tip of the neo-meatus will be located. The upper two short limbs of the Y
are 0.5 cm long. The long vertical limb Y extends down the whole length of the
glans penis to the coronary sulcus (Fig. 9 a). The resultant three flaps are
elevated and a core of soft tissue is excised to create a space for the
neo-urethra (Fig. 9 b).
Meticulous excision of any chordee or fibrous bands is carried out. This
fibrous tissue is particularly heavy in the midline but may extend well
laterally. The meatus is assessed and a cut back is made to widen the meatus
(Fig. 9 c).
A rectangular skin strip is outlined extending proximally from the urethral
meatus staying in the midline in the scrotum to avoid potentially hair bearing
skin. The skin strip is extended distally and laterally by curving towards the
prepuce. This allows for formation of a very long tube that can reach the tip
of the glans wherever the original position of hypospadias meatus is (Fig. 9
The skin incision is carried completely around the meatus leaving a small
cuff of skin. The meatus is freed proximally. The adjacent penile skin is
elevated (rather than the flap). The flap with its pedicle is mobilised through
the dorsum of the penis and down to the root of the penis to avoid penile
The skin strip and proximal cuff are tubularised around a Nelaton catheter
size 10 Fr inside the urethra. The author prefers to use Vicryl 6/0 on a
cutting needle. Suturing is carried out from distal to proximal in a
subcuticular continuous manner. Several reinforcing interrupted stitches are
usually taken to form water tight tube (Fig. 9 e).
The neomeatus is then constructed by suturing the terminal end of the
neourethra to the central V of the glans. A final slit like meatus is obtained
by excising a small V from the tip of the neo-urethra. Then, the glanular wings
are wrapped around the neourethra and approximated in the midline. When
completed a near normal wide meatus is created at the tip of a conical shaped glans.
The long anastomotic contact between the neo-meatus and glans created by the Y
glanuloplasty is important to create a wide meatus and avoid post operative
meatal stenosis. The vascular areolar subcutaneous tissue layer is then used to
provide a complete covering for the neourethra (Fig. 9 f). The skin is closed
in the midline using 6/0 Vicryl in a continuous transverse mattress. This helps
to simulate the normal ventral median skin raphae (Fig. 9 g). A percutaneous
suprapubic cystocath is inserted into the bladder for 10 - 14 days. A
compression dressing is applied for 6 hours for haemostasis.
Complications: Fistula occurs in 6 - 12 % of patients. Penile
rotation may occur if the pedicle is not mobilized down to the root of the
Fig. a - h: Steps of
lateral-based (LB) flap technique for single stage repair of proximal
hypospadias. (a, b) Y-shaped deep incision of the glans; (c) chordectomy; (d)
outline skin incision and flap mobilisation; (e) formation of the neourethra;
(f) glanulomeatoplasty; (g) protective intermediate layer; (h) skin closure
Tubularized Incised Plate
The Tubularized Incised Plate repair (Snodgrass 1994) is based on the
assumption that midline incision into the urethral plate may widen it
sufficiently for urethroplasty without stricture. Many centres report excellent
results with this technique. There are two important criteria to achieve good
results: the urethral plate should not be less than 1 cm wide and there should
be no distal deep chordee. The technique has gained popularity because it is
easily performed, with few complications and results in a slit like meatus. The
importance of regular dilatation is still controversial.
A traction suture is placed in the glans just beyond the anticipated dorsal
lip of the neomeatus. A circumscribing skin incision is made 1 to 2 mm proximal
to the meatus and the shaft skin is degloved to the penoscrotal junction. If a
portion of the native urethra is excessively thin, however, a "U" shaped
incision is made extending to more healthy tissues.
The urethral plate is separated from the glans wings by parallel incisions
along their junction. A tourniquet placed at the base of the penis provides
better visualization of the operative field. The glans wings are mobilized
avoiding damage to the margins of the urethral plate.
A relaxing incision is made using scissors in the midline from within the
meatus to the end of the plate. The incision should not reach the tip of glans.
The depth of the relaxing incision depends on the plate width and depth. A 6 Fr
stent is secured into the bladder. A 7-0 polyglactin is preferred to tubularize
the urethra, with the first stitch placed at approximately the midglans.
Tubularization is completed with a 2 layer running subepithelial closure.
Any adjacent dartos tissues are used to cover the neourethra and then a
dartos pedicle is developed from the dorsal shaft skin, button-holed, and
transposed to the ventrum to additionally cover the repair.
The coronal margins of the glans are approximated with subepithelial 6 - 0
polyglactin. The skin edges of the glans are sutured, and the meatus with 7 - 0
ophthalmic chromic catgut.
Byars' flaps are created from the preputial skin to mimic the median raphe.
Subepithelial stitches are used throughout to avoid suture tracks. A tegaderm
dressing is applied. The stent is removed approximately 1 week later.
Complications: Complications occurs in 5-35 % in distal hypospadias and upto 65 % in
proximal hypospadias. Complications include meatal stenosis, persistent
fistula, functional urethral obstruction and persistent chordee (vental
curvature of the penis).
Transverse Preputial Island Flap
A deep Y-shaped incision is made on the glans
as in the Lateral based (LB) flap technique. Meticulous excision of any
chordee or fibrous bands is carried out. This fibrous tissue is particularly
heavy in the midline but may extend well laterally. The meatus is assessed
and a cut back is made to widen the meatus. A sub coronal incision is made
around the glans. The incision continues laterally until it reaches the gap
where the fibrous chordee was excised.
The penile and preputial skin is dissected
free off the shaft from distal to proximal close to the Buck's fascia
preserving the arteries that constitute the pedicle to the preputial flap.
A 1.5 cm wide rectangular flap is prepared.
The length must suffice the gap between the meatus and the tip of the glans.
Extra length can be obtained by going down into the penile skin in a
horseshoe fashion on either side. The flap is tubularised around a 10 Fr
catheter and sutured into the meatus beginning with the suture line
underneath the pedicle utilizing interrupted 7-0 polyglactin suture.
Then, the pedicle is separated from the outer
preputial skin in a plane just below the intrinsic blood supply of the outer
prepuce down to the root of the penis.
The upper small median flap resulting from the
Y incision is sutured to the upper dorsal end of the tube. A V is excised
from the tip to obtain a slit like meatus. The mobilized glans wings are
rotated medially around the neo-urethra. Three transverse mattress sutures
maintain firm approximation of the glanular wings in the midline. The
mobilized glans wings are rotated medially and three transverse mattress
sutures maintain firm approximation of the glanular wings in the midline.
De-epithelialisation of skin to protect the neourethra.
Complications: Fistula, wound disruption, diverticulum and
rotation occur in 10 - 30 % of patients.
MAGPI (Meatal Advancement and Glanuloplasty
This technique may be used in glanular
hypospadias with mobile urethral meatus that can be pushed to the tip of the
glans. If the meatus is not mobile enough, the results are less satisfactory.
Meatal advancement: The dorsal lip distal to
the meatus is cut longitudinally to avoid urine deflecting downwards. In the
classic MAGPI, the incision is closed transversely (Heineke Mickulicz
technique). Thus the dorsal meatal edge is advanced distally. Recently, some
surgeons leave it without closure as a modification from Snodgrass technique.
The glanuloplasty is accomplished by elevating
the ventral edge of the meatus forwards and rotating the flattened glanular
wings upwards and ventrally in a conical manner. It is important to
reapproximate glans tissue in a two layers fashion with a deep closure of
glans mesenchyme and a superficial layer of glans epithelium.
There have been
several modifications of this technique (Duckett and Baskin, 1996).
Complications: Meatal regression may occur if the technique
is used in patients with immobile urethral meatus. Precision is required to achieve a
Onlay Island Flap
The Onlay Island Flap is ideal for patients with proximal hypospadias
without deep Chordee. According to the author experience, most patients with
proximal hypospadias have deep chordee that necessitates excision. However,
recently, many surgeons prefer to perform dorsal placation if the chordee is
less than 30o after skin degloving and preserve the urethral plate.
The tip of the neo-meatus is identified. This point is where the flat
ventral surface of the glans begins to curve around the meatus. A midline
vertical incision is made in the glans until the width of the glanular groove
is adequate for the meatus. The vertical incision is left open without closure
for secondary epithelialisation.
A subcoronal incision is made around the glans. The incision continues on
either side of the urethral plate at the junction with the normal ventral skin,
then up on either side of the glanular groove to the apex of the glansplasty.
The skin is degloved from distal to proximal close to the Buck's fascia
preserving the arteries that constitute the pedicle to the preputial flap. The
pedicle is then separated from the outer preputial skin in a plane just below
the intrinsic blood supply of the outer prepuce. The elevation of the glans
wings will permit them to be rotated around the urethroplasty.
A 1-cm wide onlay flap is prepared from the inner prepuce. The onlay flap
is sutured into place beginning with the suture line underneath the pedicle
utilizing running 7-0 polyglactin suture. The glans should be drawn together
setting up the first stitch of the glansplasty ventrally at its apex.
The mobilized glans wings are rotated medially around the neo-urethra.
Three transverse mattress sutures maintain firm approximation of the glanular
wings in the midline.
Complications: Fistula, wound disruption, rotation, recurrent
curvature occurs in 10 - 20 % of patients.
Two Stage repair
A small group of patients with severe proximal hypospadias, chordee, and a
small phallus as well as patients with recurrent hypospadias and fibrous
unhealthy skin may benefit from a two-stage procedure (Fig. 10).
In the first stage, a circumferential incision is
made proximal to the coronal sulcus, the chordee is excised, and the penile
shaft is de-golved. Penile straightening and removal of all chordee tissue must
be confirmed by the use of the artificial erection test.
of two stage repair: identification of chordee, excision of ventral chordee and
plication if needed. Coverage of raw surface with skin graft. Tubularisation in
the second operation.
The glans is divided deeply in the midline to the tip. The dorsal foreskin is
unfolded carefully and divided in the midline. A midline closure is performed,
and the midline sutures catch a small portion of Buck's fascia. The bladder is
drained with an 8 French Silastic Foley catheter for approximately 5 to 7 days.
If there is inadequate genital skin available, buccal mucosa or rarely
bladder mucosa may be used. The buccal mucosa is harvested from the inner
surface of the cheek or the inner surface of the upper or lower lip. The
parotid duct is identified opposite the upper molars, and cannulated with 3-0
nylon. The graft is outlined and the submucosa infiltrated with 1% lignocaine
containing 1:2000 epinephrine. The graft is incised and the mucosa is dissected
away by sharp dissection.
The second stage of the procedure is carried out 6 to 12 months later. The
previously transferred skin or mucosa is used to reconstruct the glans and
urethra. A 16-mm diameter strip is measured, extending to the tip of the glans.
The strip is tubularized with a running subcuticular stitch of 6-0 Vicryl® all
the way to the tip of the glans. Tension is reduced by generous mobilization
and undermining of adjacent tissues. A protective intermediate layer (either
tunica vaginalis or dartos) helps to reduce post-operative complications.
The lateral skin edges are mobilized, and the
remaining tissue is closed over the repair in at least two layers. A strip of
skin (3 - 5 mm wide) is de-epithelialised on one side to provide a raw surface
of deep dermis. This is achieved by cutting 2 or 3 fine longitudinal strips
with a pair of small curved-on-scissors. The medial edge of the shaved flap is
brought across the buried urethroplasty and sutured to fascial tissue beneath
the other flap (double breasting).
Artificial erection test and chordee (curvature)
Ventral curvature (chordee) may be evaluated by the artificial erection
test. There are two types of chordee associated with hypospadias:
associated with distal hypospadias (skin chordee). This superficial chordee is
subcutaneous, proximal to the meatus and can be corrected by mobilization of
the skin proximal to the meatus.
The other type of chordee is commonly
associated with proximal hypospadias. It is usually deep, fibrous and located
distal to the meatus. This curvature may be corrected either by Heineke
Mikulicz technique, dorsal placation, corporal rotation or the "Split
& Roll technique".
Use of protective intermediate layer
The use of an intermediate or interposition layer between the neourethra
and the skin layer has greatly improved the results following hypospadias
surgery and reduced complications. Types of protective intermediate layer include:
Durham Smith (1973)
Snow (1986) described the use of Tunica vaginalis
Retik (1988) was the first to use dorsal
subcutaneous flap from the prepuce.
Motiwala (1993) described the use of Dartos flap
from the scrotum.
Yamataka (1998) reported the use of external
spermatic fascia flap
Stenting: several studies showed that stenting of
the neourethra may be associated with more complications.
Dressing: several studies also showed that the
type of dressing has a major impact on the outcome of surgery, some
studies showed better results without any dressing at all.
In general: if a complication occurs, one should
not operate again before 6 months to allow time for complete healing of
the tissues and to give better chance for the success of surgery.
Fistula management: The most important two steps
in the management of fistula are to exclude distal obstruction and to
excise the cornu of the fistula to reduce the chances of recurrence.
Failed distal hypospadias repair: the technique
to be adopted depends on the degree of fibrosis and the amount of healthy
tissue available. Failed Mathieu repair does not necessarily mean that we
can not do another Mathieu repair.
Failed proximal hypospadias repair: the most important
step is to excise all the unhealthy tissues. Then, according to the
healthy tissues available, one may use lateral based flap, a graft … etc.
If scrotal transposition is present, it is
suggested to correct hypospadias first and then correct the scrotal
transposition at a later stage to ensure adequate blood supply to the flap
used in urethroplasty.
The role of tissue culture and tissue engineering
is a point of major research. So far the indications for tissue culture in the
field of hypospadias are still limited.
Hadidi AT: “Proximal
hypospadias with small flat glans; The lateral based onlay (LABO) flap technique", Journal of Pediatric Surgery 2012 (in press)
Hadidi AT: “The slit-like adjusted Mathieu for distal hypospadias", Journal of Pediatric Surgery 47 (3), 797–801, 2012
Hadidi AT: “Double Y
Glanuloplasty for glanular hypospadias", Journal of Pediatric Surgery 45 (3), 655–660, 2010
Hadidi AT: “Lateral
Based Flap: A single stage urethral reconstruction for proximal hypospadias”, Journal of
Pediatric Surgery 44 (4), 797–801, 2009
Hadidi A, Azmy A (eds.) "Hypospadias Surgery, An illustrated guide"
(2004), Springer Verlag, Heidelberg, Germany, (second edition will be published in 2013)
All illustrations and operative descriptions are copyright
for Prof. A Hadidi and Springer Verlag,