Introduction

Hypospadias is a congenital anomaly characterized by abnormal ventral penile development, ranging from isolated distal glandular ectopy to severe forms with proximal meatal ectopy, significant ventral curvature, and scrotal and various skin anomalies [1, 2]. The condition results from incomplete fusion of the urethral folds during weeks 8 to 14 of gestation via androgen-dependent signaling pathways [3].

Hypospadias occurs in approximately 1/200–300 live births, with severe variants accounting for approximately 20% of cases [1, 2]. Etiology is multifactorial, involving genetic susceptibility, maternal comorbidities, placental insufficiency, prematurity, intrauterine growth restriction, and endocrine-disrupting compounds. While severe hypospadias may occur in isolation, it can be associated with WAGR, Denys-Drash, and disorders of sex development (DSD) [4, 5]. In a study of 60 males with severe hypospadias, 28% had genetic anomalies and 15% had a diagnosis traditionally classified as a DSD (e.g., mixed gonadal dysgenesis) [5]. The DSD designation is often applied to patients with proximal hypospadias and concomitant cryptorchidism; however, consensus guidelines for evaluation and management remain limited, and diagnostic workup, multidisciplinary referral, and surgical decision-making vary across institutions [6, 7].

Defining Severe Hypospadias

Standardized nomenclature for hypospadias severity is lacking, complicating interpretation of existing literature. Traditional classification relies on meatal location, yet meatal position alone does not reflect anatomic complexity. Degree of ventral curvature, urethral plate quality, and extent of ventral tissue deficiency critically influence operative planning. For this review, “severe” hypospadias will describe proximal meatal location (penoscrotal, scrotal, or perineal) with significant ventral curvature.

Pre-Operative Planning

Medical Evaluation

For patients with severe hypospadias, there is often a role for additional testing in the form of endocrine and genetic evaluation. There are currently no standardized guidelines to assist clinicians in pre-operative medical evaluation, however, evaluation algorithms have been proposed [5]. Clinicians should remain aware that in patients with severe forms of hypospadias, there is the possibility of endocrine dysregulation and genetic anomalies that extend beyond DSD. For this review, we will focus on the surgical management alone.

Counseling and Timing of Intervention

Preoperative planning for patients with hypospadias requires deliberate consideration of age, anatomy, and patient/family goals. The primary objectives of surgical intervention are to achieve a straight penis with a urethral meatus at or near the glans, to optimize urinary and sexual function, and to achieve aesthetically acceptable genitalia.

Although surgical intervention is elective in all cases of hypospadias, nonoperative management of severe hypospadias has been associated with significant functional and psychosocial morbidity [8,9,10]. In a contemporary series of 51 adult men with uncorrected hypospadias, 50–80% report urine spraying, 33% describe penile curvature impairing sexual function, and approximately 60% report dissatisfaction with penile appearance [9].

Thus, when elective repair is chosen, it is commonly performed between 6 and 18 months of age to balance anesthetic safety and psychosocial impact. While data on psychosocial impact of delayed repair is limited, Snodgrass and Bush describe a constellation of psychosocial consequences for older patients presenting for delayed repair including: preoperative anxiety severe enough to manifest as hypertension, subjective embarrassment regarding explanation of surgery to peers, heightened post-operative pain and frustration with healing timelines. Notably, the authors report that no teen or adult, in their experience, has expressed gratitude for their surgery being deferred until an older age and in fact, many endorse anger learning they condition could have been addressed in childhood. While this data is subjective and drawn from clinical observation, it does highlight the psychosocial morbidity of delayed repairs [11]. Historic reports also suggest that delayed repair may be associated with increased complication rates; although early repair remains more common practice, contemporary cohort studies have not demonstrated age at time of repair to be an independent predictor of postoperative complications [12,13,14].

Surgery is not without risk; overall complication rates for proximal hypospadias repair range from approximately 12% to 56% across different surgical techniques and institutions with re-operation rates reported as high as 49% in one study of 134 patients [15, 16]. Families must be counseled on common complications, including: urethrocutaneous fistula, meatal stenosis, glans dehiscence, urethral stricture, and urethral diverticulum. Of note, these complications can arise early or late thus warranting longitudinal follow-up.

Preoperative Hormonal Therapy

Preoperative hormonal therapy is more frequently used in severe cases with small glans width, proximal meatal ectopy, significant chordee, or microphallus, with the goal of increasing vascularity and anatomic dimensions [17,18,19]. Common formulations include intramuscular (IM) testosterone enanthate, topical 5% testosterone cream, or 2.5% dihydrotestosterone (DHT) gel, with only minimal, transient side effects [20].

In one study of 44 males, intramuscular testosterone given 5 and 2 weeks preoperatively produced a mean penile length increase of 2.7 cm and circumference increase of 2.3 cm, with increased vascularity in all patients [20]. Another study of 25 males given testosterone enanthate 25 mg IM monthly for three doses demonstrated significant penile length and glans circumference growth without side effects [21].

Preoperative hormonal therapy may also reduce postoperative complications. In distal hypospadias with urethroplasty, testosterone was significantly associated with reduced complication odds [22]. A randomized trial of DHT gel showed significantly lower glandular dehiscence (0% vs. 8%, p < 0.05) and reoperation rates (3% vs. 24%, p < 0.05) [23]. In two-stage proximal repair, preoperative testosterone decreased the risk of requiring reoperation for complications by 27%; of the 134 patients in this study, 50 (37.3%) were given testosterone prior to first surgical stage and 36 (26.8%) prior to the second stage [15].

No consensus exists on the ideal route of administration, formulation, or timing thus practice remains individualized. Prospective, standardized trials are needed to define optimal patient selection, timing of administration and regimens.

Surgical Planning

Figure 1 presents a general framework intended to guide clinical decision-making in the management of severe hypospadias. As emphasized throughout this review, the management of this condition is inherently complex and multifactorial; accordingly, this framework should not be interpreted as a definitive algorithm, but rather as a conceptual scaffold to assist clinicians in identifying approaches appropriate to individual patient presentations.

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Hypospadias Repair Framework

Single Versus Multi-Stage

The decision to pursue single versus multi-stage reconstruction in severe hypospadias has traditionally been a subject of debate. Single-stage repair is reserved for carefully selected patients with mild residual ventral curvature (< 30° after degloving) and a wide/healthy urethral plate. Urethral plate–preserving techniques include tubularized incised plate (TIP/Snodgrass) for vascularized/wide plates and onlay preputial island flap for vascularized/narrowed plates. When the urethral plate requires transection, reconstruction can proceed with a tubularized preputial island flap (TPIF/Duckett) which retains a vascularized dartos pedicle and can be performed in one or two stages, or with a Bracka technique using a free graft (often preputial skin or buccal mucosa) quilted onto ventral surface then subsequently tubularized in a second stage [24, 25].

Fang et al. established an algorithm for hypospadias management using objective measurements to guide whether the urethral plate should be preserved or transected; their nomogram suggests patients with longer glans length, narrower glans width, and more severe degree of curvature have higher likelihood of benefiting from urethral plate transection. Furthermore, they identified a urethral plate width of 4.25 mm could be used as an objective measurement to guide who benefits from TIP (> 4.25 mm) versus onlay (< 4.25 mm) [26]. In a contemporary systematic review and meta-analysis, single-stage repairs were associated with 67% increased odds of urethrocutaneous fistula compared with multi-stage reconstruction (OR 1.67) [27]. In a retrospective cohort comparing TPIF (Duckett) to staged Bracka repair in severe hypospadias, multi-stage reconstruction demonstrated a significantly lower overall complication rate (13% vs. 35.4%), with the greatest benefit observed in perineal variants [28].

Given high rates of complications with single-stage repair, multi-stage reconstruction is favored in patients with significant curvature (> 30°) requiring urethral plate transection, poor urethral plate quality, long urethral defects, or ventral skin deficiency. In a global survey of 377 surgeons across 68 countries, Springer et al. found that two-stage repair was the overwhelmingly preferred technique for proximal hypospadias, selected by 43.3–76.6% of respondents depending on meatal location, while TIP repair was used by only 0.9–16.7% and onlay flaps/tubes by 11.3–29.5% [29]. The remainder of this review will focus on modern staged repairs of severe hypospadias.

Surgical Techniques and Considerations

Physical Examination and Assessment of Curvature

Preoperative assessment should characterize penile size/length, meatal location and caliber, degree of curvature, glans configuration, urethral plate quality, dorsal preputial tissue quality, and scrotal anomalies. Initial degloving releases tethering ventral tissue, may resolve a proportion of curvature, and often reveals meatal location mismatch; residual curvature must be reassessed after this step.

Artificial erection is the gold standard for quantifying residual curvature. Saline is injected via a 21–25 gauge needle through the lateral corpus cavernosum at the midshaft or via the glans; a tourniquet is generally not recommended during artificial erection in the pediatric population, as it can distort anatomy and obscure proximal curvature [30].

Multiple methods exist for curvature assessment: unaided visual inspection (UVI), handheld goniometry, and smartphone app-based measurement. UVI is prone to significant error; one study found pediatric urologists over- or under- estimated curvature by an average of 10° resulting in selection of the wrong operation 34% of the time at the < 30° single-stage threshold [30, 31]. Handheld goniometry provides more objective data but demonstrates comparable mean error (3.5–13.6°) and similar rates of incorrect operative choice near this threshold [32]. App-based technology offers improved accuracy, with mean error of 1.9–7.1° (versus 4.4–15.9° for goniometry and 6.5–15° for UVI), and significantly lower rates of potential unintended surgeries (17% vs. 37%, p = 0.0133) [30, 33].

Importantly, artificial erection and curvature measurements should be repeated after each curvature corrective step discussed throughout the remainder of this review; serial assessments allow for the most accurate means of addressing persistent curvature.

Chordee Correction

Chordee correction requires a stepwise approach. In most cases of severe hypospadias, the urethral plate is narrow, dysplastic, and leads to ventral tethering. Reports have shown that transection of the plate alone can correct curvature in roughly 10–28% of patients by releasing ventral tension [34]. In cases where persistent curvature remains after urethral plate transection, additional maneuvers in curvature correction can be pursued. Existing literature suggests low rates of recurrent penile curvature with all approaches; practically speaking, dorsal plication has been commonly used for mild to moderate curvature (< 30°) while ventral lengthening is reserved for more severe cases (> 30°) and in patients with more proximal meatal ectopy [35, 36].

Dorsal Plication

Dorsal plication corrects curvature through shortening the longer dorsal aspect of the corpora to match the shorter ventral side and several plication techniques exist to achieve straightening. Non-incisional (suture-only) plication techniques, including the 8-dot and 16-dot techniques, involve placing multiple plication sutures without any incision. Incisional plication techniques (Baskin-Duckett, Nesbit, Modified Nesbit) involve incising, and sometimes excising, the tunica albuginea prior to plication suture placement [37]. In Cayan’s adult population study, both non-incisional and incisional techniques achieved compelling straightening success (87.6% for 16-dot vs. 89.7% for Nesbit); the 16-dot technique had lower rates of penile sensory loss (p = 0.001) and erectile dysfunction (ED) (p = 0.016) [38]. The 16-dot technique may not be possible in a younger child with a relatively small penis. Importantly, meta-analysis demonstrates that dorsal plication alone carries a 25.4% recurrent chordee rate compared to 5.3% with ventral lengthening procedures (p = 0.0001). This suggests that dorsal plication does not address the underlying corporal disproportion inherent to severe hypospadias and should be used only in select cases of mild curvature [39]. The robustness of dorsal plication in maintaining a straight penis through puberty is also not well understood secondary to poor long-term follow-up data. Additionally, suture selection at the time of plication is an important consideration. Most favor the use of a permanent suture such as Prolene Polypropylene suture or Ethibond Polyester suture for repair longevity.

Corporal Body Incisions

In patients with significant corporal disproportion (curvature > 30°), ventral lengthening procedures are often indicated. Ventral lengthening techniques range from partial thickness corporal body incisions to full thickness incisions with corporal body grafting. Snodgrass described multiple superficial, transverse corporotomies at and around the point of greatest curvature, without exposing erectile tissue, ameliorating the need for corporal body grafting (referred to by some as “fairy cuts”) [24]. In the Snodgrass cohort (n = 11), at a mean follow up of 19 months, no patients had recurrent ventral curvature. Babu’s meta-analysis confirms a low (5.3%) recurrence rate, significantly lower than dorsal plication alone (25.4%) with this superficial incision technique [39].

Similarly, Salle et al. have described deep transverse incisions of tunica albuginea (DTITA) [40]. This technique has been recommended for patients with a narrow, inelastic urethral plate with curvature > 50°. DTITA is a partial-thickness technique; multiple parallel incisions are made from the 4 to 8 o’clock position along the arc of maximum curvature, carried through the outer layer of the tunica albuginea until the underlying cavernosal tissue is visualized but not exposed [40]. Repeat artificial erection test can be performed after incision to ensure superficial and incomplete incision of the tunica is made without leak. The authors suggest that even if mild entry into the erectile tissue is seen, hematoma is rare, and bleeding stops after coverage with a preputial graft. In their 10-year, single-institution series (n = 60), 75% of patients underwent DTITA with or without concurrent dorsal plication for curvature correction. Despite being reserved for the most severe cases, the staged repair group achieved the lowest recurrence of ventral curvature at 4.1% (compared to 14% for TIP and 17.3% for dorsal inlay graft repairs). These results suggest that DTITA with staged repair provides durable curvature correction [40]. As noted, combined DTITA and dorsal plication is an option when minor residual curvature remains. Care in maintaining adequate glandular blood supply must be considered if this approach is taken.

Corporal Body Grafting

If residual ventral curvature persists, or surgeons are not comfortable with partial thickness incision techniques, a full thickness incision of the corporal bodies at the point of maximal curvature remain a mainstay in curvature correction. With full thickness incisions of the corporal bodies, autologous or allograft materials are traditionally used for coverage of the tunica albuginea defect. Options include tunica vaginalis, dermis, single layer small intestine submucosa (SIS), acellular porcine bladder matrix, and more. Tunica vaginalis, which can be harvested as a free graft or pedicle flap to retain native blood supply, has well-established efficacy. Braga et al. reported a recurrent curvature rate of only 4.3% with tunica vaginalis flap versus 44.4% with lyophilized dura (n = 38, p = 0.02) [41]. In another study, 44 patients who underwent corporoplasty with a tunica vaginalis flap demonstrated a recurrent curvature rate of only 7% at a median follow-up of 5 years [42]. Dermis is another established autologous option; in an institutional series of 191 proximal hypospadias repairs, recurrent curvature rates were comparable between tunica vaginalis and dermal grafts at 2% each [43]. Among acellular, off-the-shelf options, single-layer SIS has demonstrated promising results. Castellan et al. achieved a straight phallus with good cosmesis in 57/58 patients undergoing single-layer SIS corporal body grafting at a mean follow-up of 4.8 years [44]. Longer-term data assessing post-pubertal outcomes with SIS grafting have similarly been encouraging, with erectile function and genital self-perception scores comparable to age-matched healthy controls [45]. Leslie et al. reported successful outcomes across SIS, tunica vaginalis, and dermal grafts in a single-institution series of 71 patients, with no statistically significant differences in residual or recurrent curvature rates between techniques [46].

General considerations for success with placement of grafts include extending the incision laterally on the ventral corporal body to the borders of the neurovascular bundle, oversizing the graft material to allow for contraction with healing, testing for watertight closure, and placing ventral quilting sutures to the underlying erectile tissue.

Though corporal body grafting provides significant curvature correction, the technique carries important long-term concerns. Potential complications of the procedure include recurrent curvature, corporal fibrosis, and ED [45]. In a series of patients (n = 100) who had undergone repeated (3 or more) failed hypospadias repairs, 37% reported moderate to severe ED; on multivariate analysis, use of corporal grafting was significantly associated with ED (24% vs. 1.5% in those without a graft, p = 0.0003) [47]. While corporal grafting can preserve penile length, there remains a paucity of long-term data to fully elucidate post-repair erectile function rates across graft types, and further studies are needed to determine whether these interventions reliably prevent curvature recurrence over time.

Alternate Techniques

Adjunctive measures targeting scar remodeling and tissue quality have gained interest as a means of optimizing post-operative outcomes. There is emerging, albeit limited, literature supporting the utility of silicone scar tape to improve the tissue quality, reduce fibrosis, and potentially eliminate the need for corporal grafting [34]. The concept draws on the principle of mechanotransduction, whereby sustained strain from taping promotes collagen remodeling and extracellular matrix expansion, analogous to its established role in Peyronie’s disease. Ting et al. conducted the first prospective study incorporating taping as a form of penile traction therapy following urethral plate transection, demonstrating that complete intraoperative straightening may not be necessary at the time of stage 1 repair. In their cohort (n = 46) with a median initial curvature of 70° after degloving, urethral plate transection alone reduced curvature to a median of 60°. With the addition of continuous (24 h/day excluding baths) postoperative taping to the patient’s pubis starting from 3 weeks post-op until the second stage repair (median 7.9 months), full correction was achieved in 91% of patients by stage 2. Notably, a preoperative curvature angle greater than 73° after degloving was identified as the optimal cutoff predictive of residual curvature at stage 2, offering a potential risk-stratification tool [34]. These findings challenge the prevailing consensus that corporal disproportion must be corrected surgically at the time of urethral plate transection, though long-term follow-up is necessary before this approach can be widely adopted.

Urethral Plate Preparation and Reconstruction: Flaps versus Grafts

Following adequate penile straightening, attention turns to urethral reconstruction. Before selecting ideal tissue for urethral plate substitution, a critical principle must guide the decision: free grafts are typically contraindicated when ventral lengthening with full-thickness corporotomies and corporal body grafting has been performed, as the graft generally lacks a sufficient vascular bed for proper imbibition and inosculation, with worse graft survival. In these cases, vascularized flaps or three stage procedures are recommended [48].

If there is well vascularized, redundant dorsal preputial skin, it can be split longitudinally in the midline creating bilateral preputial flaps, commonly referred to as Byars flaps. Advantages of Byars flaps include a reliable blood supply. The use of Byars flaps has been criticized due to poor backing of neourethra, hypermobility of the flap, and bulkiness of tissue in the glans. Alternate flap options to Byars flaps include vascularized transverse preputial island flaps (TPIF) or onlay island flaps. In these cases, inner preputial tissue is used as a urethra plate substitute and has a reliable blood supply. The tissue is thin and can be quilted to the corporal bodies to provide a sturdy backing to the future neourethra, with less hypermobility and in some cases less bulk when placed in the glans [49]. Comparatively, free grafts like preputial skin or oral mucosa offer versatility when flaps are not feasible. It is important to note variable outcomes when comparing grafts and flaps; one study found grafts had higher complication rates overall (71% grafts versus 31% flaps) while another study found no significant difference between grafts and flaps overall [48, 50]. Though the later study subset analysis did reveal tubularized free grafts had higher stricture rate than onlay grafts [50].

When a surgeon is confronted with which graft material to select, tissue bulk must be evaluated and weighed relative to glans size. Generally, thinner grafts from inner preputial or oral mucosa are preferred for glans reconstruction to avoid excessive bulk. Oral mucosa has been commonly utilized in cases where there is a paucity of preputial skin (prior circumcision, re-operative field) [51]. Manasherova et al. compared complications and cosmetic outcomes of preputial versus buccal grafts in severe hypospadias and found a lower complication rate in their buccal group (20%) compared to preputial (31%) [52].

Graft and flap healing after placement is important to assess prior to consideration of urethroplasty. Several adjunct methods to improve graft healing have been discussed including graft massage with bland ointments, the use of Vitamin E ointments, low potency topical steroids, silicone scar tape, nitroglycerin, and hyperbaric oxygen therapy (HBOT) [53, 54]. The role of HBOT in improving graft success in complex or redo hypospadias repair has shown recent promise, though further investigation into the role of HBOT in the management of hypospadias is important to better understand success, ideal patient selection, and treatment protocols.

Urethroplasty

Urethroplasty practices vary considerably across institutions and surgeons, reflecting the absence of a single standardized technique and the degree to which surgical decision-making is guided by individual experience and patient-specific factors. Regardless of approach, the overarching goal of urethroplasty is a tension-free, multilayer closure over a catheter. Prior to proceeding with urethroplasty, careful assessment of the urethral plate is essential; it must be of adequate quality, free of scar tissue, and amenable to a tension-free repair. If any of these criteria are not met, delay or repair with methods to improve tissue health or revision of the first-stage repair should be undertaken before urethroplasty is attempted.

Urethral reconstruction is performed with meticulous attention to suture technique, tissue handling, and a vascularized coverage layering to minimize complications. For staged procedures, the interval between first and second stages typically ranges from 6 to 12 months to allow for adequate graft/flap maturation and tissue healing. A median interval of 8 months has been reported in large series, with successful graft take rates exceeding 90% when adequate time is allowed between stages [15].

The neourethra is typically reconstructed using absorbable suture in a multi-layer closure, with suture selection and closure technique subject to considerable surgeon variability; while 5 − 0 or 6 − 0 polydioxanone (PDS) or Vicryl suture is commonly employed, other absorbable sutures are utilized based on individual preference, and closure may be performed in either a running or interrupted fashion. Similarly, catheter selection is also variable both in terms of size and duration; surgeon preference, urethroplasty length, and case complexity of the repair help guide these individualized decisions [55].

A vascularized covering layer over the neourethra is important to decrease the rate of fistula formation. A dartos flap is a commonly used barrier due to its accessibility and reliable vascularity. When available, dartos tissue can be mobilized from the penile or scrotal skin, taking care to not devascularize the penile shaft skin. Tunica vaginalis flaps also offer well-vascularized tissue for coverage. In a large systematic review, Fahmy et al. reported that single-layer dartos fascia coverage was associated with the highest fistula rate among proximal hypospadias repairs at 8.8%, and recommended tunica vaginalis flap (TVF) as the first-choice coverage for proximal, repeat, and fistula repair cases based on an evidence-based algorithm [56]. Similarly, a recent systematic review comparing dartos flap to TVF, including 4 randomized controlled trials with patients of all hypospadias severities, showed a lower risk of fistula in the TVF group [57]. When performing a TVF, care must be taken to create an adequately long pedicle flap to prevent penile torsion, curvature, or tension on the testicle with erections. Additionally, testicular injury and secondary testicular ascent are potential consequences with TVF. Ultimately, the urethroplasty covering layer is one of the many factors associated with urethroplasty success. Available tissue, surgeon preference, and surgeon comfort with each technique remain important factors.

The final meatal configuration goal is to achieve a vertically oriented, slit-like meatus positioned at the tip of the glans that approximates normal anatomy and allows for forward-directed urinary stream [58]. Success rates for achieving a normally positioned neomeatus range from 77 to 98% in staged repairs of severe hypospadias, with most requiring one or two minor revisions for complications [58]. Several surgeons favor intentional positioning of the meatus at the corona or subcoronal location. In some cases where the glans is very small, achieving a perfectly orthotopic meatus may not be possible, and may come with high risk of glans dehiscence, meatal stenosis and fistula formation. As such, families should be adequately counseled prior to repair on the possible meatal location and configuration at the end of the repair. Limited data exist regarding patient perspectives and satisfaction with penile appearance based on meatal location. In a survey of 38 adolescents who underwent prior proximal hypospadias repair, all patients subjectively reported being “satisfied” or “very satisfied” with meatal position and shape; objectively, their meatal positions were measured as distal (11%), proximal glandular (76%), and coronal (13%) per the Hypospadias Objective Scoring Evaluation (HOSE) system [59]. This suggests that a proximal glans or coronal meatus may be cosmetically acceptable to many in adolescence and adulthood.

Alternate Staged Reconstruction Approaches: STAG and STAC

Several alternative staged repair strategies have been described. The STAG (staged tubularized autograft) is a two-stage technique described by Snodgrass and Bush and consists of: (1) penile straightening via urethral plate transection, ventral corporotomies, and preputial graft or flap placement with dartos coverage over the corporal defect, followed by (2) tubularization. Snodgrass and Bush reported outcomes in 43 males (mean curvature 70°), with a 77% primary success rate [58]. At a mean follow-up of 22 months, 23% of patients experienced complications, most commonly glans dehiscence and fistula, with revision surgery yielding subsequent success rates of 92% [58]. This repair differs from those discussed previously, in that multiple full thickness incisions into the corporal bodies are made as opposed to a single incision and closure of the corporal defect with a graft is not performed. Relatively high complication rates and poor graft healing led to the advent of the STAC (staged tubularized autograft with corporoplasty), a three-stage approach: (1) ventral corporotomies with dartos coverage, (2) preputial or oral mucosa graft preparation, and (3) tubularization. This three-stage approach allows for the corporal defect to heal before graft placement and subsequently allows additional healing time prior to tubularization. In their comparative study, Snodgrass and Bush found that compared to STAG, STAC had a lower rate of graft complications (5% vs. 23%, p = 0.0001), re-grafting was required less often, and urethroplasty complications were less common (13% vs. 22.5%, p = 0.02) [60]. Other authors have also assessed outcomes with these techniques with Demirtas et al. reporting recurrent curvature in 25% of STAG versus 13.3% of STAC patients [61].

Skin Management

Once urethroplasty is complete, surgeons must complete skin closure. As stated, a paucity of ventral shaft skin is often present, leading to challenges with shaft coverage. Several surgical techniques exist for resurfacing including rearrangement of existing penile skin with dorsal to ventral skin flaps (Byars), Z-plasty techniques, or pedicle rotational skin flaps. At times, there is insufficient local skin, requiring skin transfer from the scrotum or from a full thickness skin graft. Such techniques have highly variable cosmetic results with the potential for extensive scarring or the presence of hair bearing skin along the penile shaft with undesirable long-term outcomes. Tissue expansion and modified versions of the Cecil-Culp procedure have also been reported with success in cases with severe skin paucity [62, 63]. Several small studies have administered the penile perception score after proximal hypospadias repair, demonstrating variable satisfaction with the appearance of the penile skin [64, 65].

In addition to skin coverage, surgeons must be attentive to anatomic variability including but not limited to concealed penis, penoscrotal transposition, and bifid scrotum. Specific techniques in surgical correction of such anomalies go beyond this review but must be considered in achievement of optimal aesthetic outcomes.

Wound healing also remains a crucial component of hypospadias care. Numerous surgical dressings, post-op wound care regimens (emollients, steroids, etc.) have been reported, with no consensus on optimal management. Ultimately, this remains surgeon specific and detailed descriptions of dressing, and post-op care pathways are not discussed in this review.

Patient Follow Up and Directions for Future Work

Comprehensive outcome assessment following hypospadias repair requires a longitudinal approach extending beyond the immediate post-operative period. While several studies suggest most complications present within the first postoperative year, one series found the median time to complication detection was 69.2 months, with 29.4 months for proximal repairs specifically [66]. Given re-operation rates as high as 40–50% in some series, structured surveillance is essential [15].

Post-operative physical exam is pivotal to ensure proper wound healing and identification of common complications including urethrocutaneous fistula, meatal stenosis, and wound breakdown [66, 67]. Residual or recurrent curvature should be evaluated at each follow-up, as this impacts both function and cosmesis. While success is often defined as < 30° of curvature, patient-reported satisfaction with penile straightness does not always correlate with objective measurements, highlighting the need for research on acceptable curvature thresholds [68, 69].

Objective urinary flow can be assessed with uroflowmetry to detect strictures and incomplete emptying early. The Penile Perception Score (PPS) and Hypospadias Objective Score Evaluation (HOSE) assess satisfaction with meatal location, glans shape, penile skin, overall appearance, and penile length. Patients with proximal hypospadias express greater dissatisfaction with penile length compared to controls (39% vs. 12%), despite overall satisfaction rates of 80–89% [70]. Pooled analyses have found 12% of patients who underwent childhood repair experience erectile dysfunction and 16% report sexual dissatisfaction [71].

While a significant amount of surgical technique innovation and research has been performed to progress and improve the care of children with severe forms of hypospadias, additional research is needed. Assessing post-operative outcomes, both short and long-term, remains a challenge for several reasons: one being the overall poor post-operative follow-up rates and limited long-term follow-up into adolescence and adulthood among cohorts. This has been highlighted in recent studies showing low rates of follow-up for all patients after toilet training, though higher rates of adherence among those with more severe forms of hypospadias [72]. Limited long-term follow-up data make understanding true rates of complications and surgical success difficult. Identifying effective and reliable ways of improving follow-up adherence into adulthood are still needed. Standardized follow-up protocols have been initiated at our institution, though variable follow-up has still been seen. The follow-up protocol at Lurie Children’s hospital involves follow-up visits after urethroplasty as follows: catheter/stent removal, 6 months post-op, 1- and 2-years post-op, ages 3, 4, 5, 7, 10, 12, and 15, with uroflow studies at ages 5, 10, and 15. Recent efforts to introduce routine objective patient outcome measures have also been undertaken, but remain limited by difficulties with follow-up into adolescence.

As stated previously in this review, there are also challenges with phenotypic nomenclature to describe hypospadias severity, with great variability in classification of hypospadias features across studies. This makes comparing outcomes challenging and limits our true understanding of outcomes with pooled data (e.g., systematic reviews/meta-analyses). Whether phenotypically similar patients are being compared is unclear. This leads to increasing difficulty in adequately counseling families on long-term outcomes based on visualized phenotypic features. Greater standardization in phenotypic descriptions, minimum reporting criteria for publishing, or risk categorization of hypospadias based on phenotypic characteristics could improve this shortcoming in the literature.

Given the shortcomings in comparing existing studies, there is an opportunity for multi-center collaboration to obtain larger data sets. Such data sets will also have the benefits of comparing outcomes based on surgeon specific technique preference. This may help to better answer existing questions such as what type of urethral reconstruction leads to the best long-term flow rate, or what type of curvature correction has the lowest rate of long-term erection dysfunction.

Another challenge with post-operative outcomes lies in means of assessing such outcomes. Traditional markers of success in hypospadias are largely surgeon driven, such as rates of complication, urinary flow rates, or perceived aesthetic outcomes. Recently, greater recognition has been placed on the importance of patient reported outcomes in hypospadias, with a specific focus on associations with quality of life. Improved understanding of patient reported functional and outcomes, especially those that drive long-term quality of life, are important to understand the impact of the underlying condition and interventions on individuals. Improved capture of patient reported perceptions can help to shape future areas of research, technique refinement, and family/patient counseling on potential outcomes after surgery. While the literature remains sparse, with few hypospadias specific measures available, several authors have sought to design and validate new outcome measures [73,74,75]. The development and implementation of such measures will help to capture the breadth of concerns faced by patients with hypospadias.

Conclusion

Proximal hypospadias is a complex reconstructive challenge for pediatric urologists and the breadth of described operative techniques reflect the complexity and variability inherent to surgical repair. While numerous surgical approaches exist, staged repair has emerged as the preferred strategy for severe hypospadias, guided by core principles that underpin successful outcomes: precise measurement and complete correction of penile curvature, substitution of a deficient or inadequate urethral plate, and a tension-free urethroplasty reinforced with an interposing barrier layer. Adherence to these fundamentals remains critical regardless of the specific technique employed. Despite decades of surgical refinement, outcomes remain variable and complication rates continue to be substantial, underscoring the need for ongoing appraisal, innovation, and refinement in surgical technique. Progress is hindered by poor long-term follow-up, inconsistent outcome assessment, and limited patient-reported outcome data. With growing collaborative efforts, evolving surgical innovation, and an increasing emphasis on patient-centered outcomes, there is reason for optimism that the standard of care for proximal hypospadias will continue to improve and advance the field in a meaningful way.

Key References

  • Ting CS, Ting SW, Kuo G, Chang PY. Taping alone for persistent ventral curvature after urethral plate transection in hypospadias. J Pediatr Urol. 2024 Jun;20(3):409.e1-409.e8. doi: 10.1016/j.jpurol.2023.10.035. Epub 2023 Oct 31. PMID: 38631939.

    • ○ In this study, the authors challenge the current standard approach of ventral lengthening for chordee correction during staged hypospadias repair. Rather than performing ventral incisional techniques after urethral plate transection, the authors rely on the use of daily silicone taping of the penis to the abdomen for further penile straightening. While the results are short term, they are compelling to suggest that penile curvature can be corrected without ventral lengthening techniques beyond transection of the urethral plate. This may have implications for long-term penile function and decrease surgical morbidity. Several questions remain regarding the long-term success of this technique.

  • Batra NV, Heiman J, Koehlinger J, Dangle P, Meldrum KK, Whittam BM, Szymanski KM, Rink RC, Kaefer M, Cain MP, Misseri R, Roth JD. Adherence to follow-up ten years after hypospadias repair. J Pediatr Urol. 2025 Jun;21(3):614-620.

    • ○ This study highlights a key challenge in the hypospadias literature: loss to follow-up. The authors identified an overall poor follow-up rate for patients undergoing hypospadias repair at a single institution. This is a consistent challenge across centers and among published literature. Poor follow-up hinders the ability to understand the true long-term outcomes of the techniques described in this review.

  • Keays MA, Tsangaris E, Gulati S, et al. Protocol for the development of a patient-reported outcome measure for patients with hypospadias. BMJ Open 2025;15.

    • ○ In this study, the authors highlight the need to better understand patient reported outcomes after hypospadias repair and present the first phase of development of a new hypospadias-specific patient reported outcome measure (PROM). This study sets the groundwork for future measure development, which will be fundamental to understanding patient challenges, perspectives and outcomes after repair