Hypospadias

Hypospadias is one of the most common congenital anomalies of the male genitalia, occurring in approximately 1 in 200 to 300 male births worldwide. It is characterized by: (1) an abnormally positioned urethral meatus (urinary opening) located anywhere along the undersurface of the penis — ranging from the glanular tip (mild, anterior — 50 to 65% of cases) to the penile shaft (moderate, mid) to the perineum (severe, posterior); (2) associated ventral curvature of the penile shaft (chordee) that becomes apparent on erection; and (3) an incomplete foreskin (dorsal hooding with a ventral skin deficit). Severity classification guides surgical technique and complexity.

The internationally accepted optimal age for primary hypospadias repair is 6 to 18 months of age, with most pediatric urologists and plastic surgeons operating between 6 and 12 months. Operating within this window takes advantage of: the small, well-anaesthetized infant who is unaware of genital surgery; naturally soft and pliable penile skin tissues; growth of the phallus under dihydrotestosterone (DHT) stimulation after neonatal testosterone surge, which enlarges tissue dimensions for easier surgery; and completion of repair before the child reaches toilet-training age and sexual identity awareness.

Technique selection depends on the position of the meatus, the severity of chordee, and the quality and quantity of available preputial and penile skin. For distal (mild) hypospadias, the Tubularized Incised Plate (TIP / Snodgrass repair) is the global gold standard — incising and rolling the urethral plate into a neo-urethra with a single-layer waterproof closure. For moderate to severe forms with inadequate urethral plate, staged repairs (Bracka two-stage procedure using buccal mucosal grafts) are preferred. Chordee is corrected by releasing tethering fibrous bands or by dorsal plication (Nesbit) of the tunica albuginea.

Urethrocutaneous fistula (an abnormal communication between the reconstructed urethra and the skin surface causing urinary leakage through a pinhole) is the most common complication, occurring in 2 to 15% of cases depending on severity and technique. Fistulae are not repaired immediately — they must mature for a minimum of 6 months to allow tissue vascularization and inflammation to resolve completely before secondary closure. A meatal stenosis (narrowing of the urinary opening) and urethral diverticulum (ballooning of the neo-urethra) are other recognizable complications, each managed by specific secondary procedures after adequate maturation.

A soft silicone urethral stent (infant feeding tube or Silastic catheter) is left in place for 7 to 14 days post-operatively to serve three critical functions: it splints and maintains the tubular shape of the neo-urethra while suture-line epithelialization occurs, it diverts urine completely away from the healing sutured neo-urethral tissue (preventing urine from disrupting the delicate repair), and it prevents the new urethral lumen from collapsing during the vulnerable early healing phase. Stent removal at day 7 to 10 is performed gently in the outpatient clinic with topical anaesthetic cream.

The goals of hypospadias repair are fully functional: a meatus at the tip of the glans allowing a straight forward urinary stream suitable for standing urination; complete release of chordee allowing straight, functional erections; and a cosmetically normal-appearing uncircumcised or circumcised penis. Studies of adult men who underwent childhood hypospadias repair in experienced centers report high rates of normal sexual function, satisfactory sexual intercourse, and normal fertility. Minor issues (such as reduced penile sensitivity in the reconstructed zone or mild chordee persistence) may require secondary revision in a small proportion of patients at adulthood.