Introduction

Introduction
Hypospadias is a congenital abnormality of the external genitalia defined as an arrest in the
embryological development of the urethra, foreskin, and ventral aspect of the penis
(Baskin& Ebbers, 2006).

Hypospadias is one of the most common congenital anomalies affecting one in every 125
live male births, and the incidence is rising (Goel et al, 2019).

Hypospadias is characterized by abnormal foreskin with a dorsal hood and an abnormally

located urethral meatus, which can be located anywhere from the ventral aspect of the glans
penis to the perineum, Hypospadias can be classified broadly into distal, mid-shaft, or
proximal types, with the proximal type being the most severe form. In general, more severe
forms of hypospadias are associated with a higher incidence and severity of penile ventral
curvature (Wong et al, 2018).
Surgical intervention for hypospadias can be performed at any age; however, most authors
recommend operative intervention at 6‒18 months (Keays et al.2017).

The basic principles of hypospadias surgery are to reconstruct the urethra to the tip of the
glans, to straighten the curvature of penis, to achieve acceptable cosmetic penile appearance,
and allow normal urinary and sexual function. These principles are well established in many
surgical procedures (Thiry et al, 2015).

The techniques can be classified in repair procedures based on advancement techniques,

tubularization techniques, or substitutional Uretheroplasty using grafts and flaps (Ramnath
et al, 2011)

Patients with proximal hypospadias, especially when accompanied by severe ventral

curvature, are a challenging group of hypospadias. Reconstruction of a proximal hypospadias
is associated with high complication and re-intervention rates. Although various techniques
have been proposed as the ‘ideal repair’ in proximal hypospadias, none has proven superior
(Rynja et al, 2018).

For these patients, the choice of a suitable technique partly depends on the quality of the
urethral plate and on the presence of a ventral curvature. Although preservation of the
urethral plate potentially lowers complication rates, this is not always possible when the
urethral plate is atretic causing severe ventral chordee (Rynja et al, 2018).

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Introduction

Two-stage repair involve correction of curvature, excision of the urethral plate, and
harvesting a graft or flap to create a neourethral plate in the first stage but the meatus remains
in its proximal location. The second stage involves tubularization of the graft or flap that was
placed during the first stage to move the urethral meatus to normal location in the glans
(Dason etal, 2014).

The inner prepuce is an ideal urethral substitute, as it is very thin, moist and flexible, takes
reliably, has no potential for hair growth and the donor site is both convenient and
expendable (Badawy& Fahmy, 2013).

Preputial grafts create a large, smooth neo-plate well affixed to the corpora. Prepuce is also
preferable to oral mucosa for grafts. There is virtually no donor site morbidity after preputial
harvest and the grafts heal subjectively more thin than do those from oral mucosa.
Additionally, the wide graft provides additional penile skin to re-cover the shaft (Snodgrass
and Nicol, 2017).

Another option for 2-stage repair is the use of Byars flaps but usually complicated by
neourethral diverticuli resulting from stretch of the distensible preputial skin, poor fixation of
the Byars flaps to the corpora cavernosa due to interposed dartos pedicle
(Dason et al, 2014).

Two-stage repairs permit compartmentalization of the repair, providing the opportunity to

reevaluate the situation along the way for complex hypospadias cases. The time interval
between the first and second stage allows for growth of the penile structures and reveals
complications that relate to recurrent chordee or graft contracture. Dealing with these
complications earlier can be simpler than after urethral tubularization, leading to a more
successful final outcome (Dason etal, 2014).