Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 120e125

Assessment of long term function following

hypospadias reconstruction: Do flow rates, flow
quality and cosmesis improve with time? Results
from the modified Bretteville technique*
A.J. Robinson a,*, L.E. Harry b, J.H. Stevenson b

a
Department of Plastic Surgery, Ward 11, Ulster Hospital, Dundonald, Belfast BT16 1RH, Northern Ireland, UK
b
Department of Plastic Surgery, Ninewells Hospital and Medical School, Dundee, Scotland, UK

Received 27 September 2011; accepted 17 July 2012

KEYWORDS Summary Background: Very few studies on long term evaluation of functional outcome
Hypospadias; following hypospadias reconstruction are available. Results from the modified Bretteville
Modified Bretteville method have shown excellent cosmesis with a low risk of fistula and stenosis. This study
technique; addresses the question; do flow rates, quality of urinary stream and cosmesis change over
Long term follow up; time?
Uroflowmetry; Methods: A sample of 18 patients who had undergone the 2 stage modified Bretteville
Spray analysis technique between 1998 and 2004 were reviewed. Following a mean interval of 10 years
and 5 months from initial functional assessment, repeat evaluation was performed using the
“HOSE” questionnaire, flowmetry, and spray analysis.
Results: Improvement in mean flow rate (15.3 vs 10.1 ml/s; p value Z 0.0036), reduced
spraying (3.2 g vs 4.4 g; p value Z 0.2927), with a mean increase in the “HOSE” score (from
13.8 (maximum score 16) to 15.4 (maximum score 16); p value Z 0.0440) was observed over
the follow up time.
Conclusion: Improvement in flow rates, flow quality, and cosmesis over a mean interval of 10
years 5 months has been demonstrated in a random cohort of patients undergoing the modified
Bretteville method of hypospadias reconstruction.
ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

*
This work was presented at the Scottish BAPRAS Plastic Surgery Meeting, 27e28th October 2011, Dunkeld, Scotland and it was also
presented at the Winter BAPRAS Meeting, Royal College of Surgeons of England, 30th November to 2nd December 2011, London, UK.
* Corresponding author.
E-mail address: arobinson13@doctors.org.uk (A.J. Robinson).

1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2012.07.011

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Assessment of long term function following hypospadias reconstruction
Introduction
The objective of reconstructive surgery in hypospadias is to
produce a penis that is aesthetically and functionally
normal. This requires a penis that is straight on erection
with a vertically orientated meatus at the tip of the glans,
thus promoting a single coherent urinary stream. There are
many techniques described for reconstruction in hypospa-
dias. These fall into three broad categories: longitudinal
incision of the urethral plate, flaps or onlay grafts. Irre-
spective of which method is employed, the ideal result
should have a low complication rate, with low rates of
fistula formation and stenosis, and no residual chordee.
Long term follow up data are lacking for many of the
procedures described.
Gorm Bretteville described a new technique for hypo-
spadias repair in 1986 which consisted of an initial glans
split and preputial flap, followed by tubing of the neo-
urethra six months later. The modified Bretteville tech-
nique was described by Moir and Stevenson in 1996,1 in
which tubing of the flap and closure of the glans over the
neourethra was completed at the first stage. Division of the
base of the preputial flap and insetting, to create the new
urethral meatus, was carried out as a day case at the
second stage 6 months later (including preputioplasty as an
option following discussion with the patient/parents). The
modified Bretteville technique has been shown to have
a low complication rate with good aesthetic outcome. The
mid-term results from Jeans et al., show an overall fistula
rate of 5.4% and stenosis rate of 6.8% over a mean follow up
of 5 years.2
The Hypospadias Objective Scoring Evaluation (HOSE)
questionnaire is a validated objective outcome question-
naire with good inter-observer correlation that is used to
assess cosmesis of hypospadias repairs.3 However, the
main drawback is that it does not comment accurately or
adequately on the overall cosmesis. The original authors
of the HOSE questionnaire state that a score of 14 or
more infers an acceptable outcome with the proviso that
the meatus is at least proximal meatus with a single
urinary stream and only moderate angulation of the
penile shaft.
A recent long term retrospective follow up study of
a series of patients who underwent a variety of hypospadias
repairs confirmed that 53.5% of patients where dissatisfied
with the overall cosmesis of the penis.4 The factors of
dissatisfaction were the small size and residual curvature of
the penis. Patients with proximal hypospadias were more
likely to be dissatisfied than patients with distal defects.
Better cosmetic outcome is related to better sexual
outcome.4 Although some patients have erection, ejacula-
tion and intercourse problems in adulthood, the majority
have a rather normal sexual function. In a separate study,
patients who had underwent hypospadias repairs, reported
to be more satisfied in their sex lives compared to healthy
volunteers despite being dissatisfied with the overall
cosmesis.5 The meatus was on average 1.5 cm from the tip
of the penis.
We present the long term follow up results of uro-
flowmetry and spray analysis from the modified Bretteville
technique to answer the questions; do flow rate, flow
quality and cosmesis improve with time?
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121
Methods
The previous paper by Reid et al. from our unit on the
“Objective outcome assessment of the modified Bretteville
technique” identified patients from hypospadias clinics in
2005/2006, who had previously undergone the two stage
modified Bretteville technique between 1998 and 2006. The
mid term results were published in 2009.6
We have followed a sample of eighteen patients from
this cohort (as some were lost to follow up) of patients over
the next 5 years and preformed the same objective
measures of outcome in 2011. This gave an average follow
up period of 10 years 5 months (5.5 yearse17 years 3
months). These papers represent a continuum of results
and we now present the long term results.
Each patient attended an annual follow up clinic. On
arrival at the clinic, patients were supplied with water and
orange juice. They were asked to complete a symptom
based questionnaire. Patients were then asked to urinate
into a spinning-disc-type uroflowmeter in privacy when
they had sensation of a full bladder. The uroflowmeter was
equipped with an absorbant pad placed around the toilet
bowl to catch the sprayed flow, as previously described by
Reid et al.6 (Figure 1).
After the questionnaire, uroflowmetry and spray anal-
ysis, patients underwent an outpatient consultation. The
questionnaire was reviewed and any issues with regard to
function and aesthetics were elaborated upon. Clinical
assessment and the HOSE questionnaire were completed
independently by the senior author and a senior trainee.
The mass of urine sprayed was calculated by measuring
the spray pad before and after flowmetry using calibrated
digital scales, measured to the nearest 0.1 g. The spray
stream was assessed by marking the sprayed areas with
a permanent marker (Figure 2).
Calculation of the area of spray was performed by digital
photograph capture followed by analysis using Image J
analysis software. Image J is a java-based image processing
program developed at the National Institute of Health.
Image J can analyse and calculate area and pixel value
statistics of user-defined selections from digital images.
Statistical analysis was undertaken using the paired sample
Figure 1 Uroflowmeter with an absorbent pad to measure spray.
122 A.J. Robinson et al.

Ninety four percent of patients had a normal flow study

Figure 2 An example of an absorbant pad with the spray
marked.
Wilcoxon Signed rank test and statistical significance was
achieved if the p value was less than 0.05.
Results
The mean age at which both stages of the modified Brette-
ville technique where completed at was 2 years and 5
months with of a range of 1 year 7 months to 4 years 4
months. Patients were followed up for an average of 10 years
5 months. The distribution of hypospadias was: 72% coronal,
11% glandular, 11% distal shaft and 6% proximal shaft.
with 83% of patients having a “Bell Urogram”. Peak flow and
volume of urine passed at flowmetry increased over the
period of follow up. The average peak flow increased from
11.1 ml/s to 16.4 ml/s over the interval of 5 years
(p Z 0.0036) (Table 1). Eighty nine percent of patient’s
urograms were above the 5th percentile at the most recent
examination with 44% above the 50th percentile. This
compared with 72% of patients above the 5th percentile 5
years previously and only 14% of patients were above the
50th percentile compared with age matched controls on the
Gaum nomograms7 (Figure 3).
The volume of urine sprayed decreased from a mean of
4.35 g (0e17 g) to 2.98 g (0e14.3 g). However, this differ-
ence was not significant (p Z 0.2927). The area of spray
and the percentage of urine sprayed significantly decreased
over the follow up. The mean area of spray reduced from
281.92 cm2 to 38.72 cm2 (p Z 0.0033). The percentage of
urine sprayed decreased from a mean of 10.4%e1.9%
(p Z 0.0033). HOSE questionnaire scores for cosmesis
increased from an average of 13.8e15.4 over the time
period (p Z 0.044) (Table 2).
For this cohort of patients who underwent the modified
Bretteville method of hypospadias reconstruction, over the
time interval studied, improvement in urinary maximum
flow rates, flow quality (spray analysis) and cosmesis was
observed.
Discussion
Hypospadias is a common condition accounting for 73% of
all congenital genital defects in Scotland.8 The condition is

Table 1 Hypospadias data of uroflowmetry.

Pt no. Date of birth Age of surgery Severity of Follow up in months Maximum urinary Maximum urinary
completion hypospadias flow 2006 (ml/s) flow 2011 (ml/s)
1 26/07/2002 27 Coronal 70 14.20 17.6
2 20/05/2000 34 Glandular 92 17.00 18.1
3 08/01/2000 31 Coronal 89 6.80 8
4 09/08/1999 28 Coronal 101 9.40 17.9
5 12/05/2001 40 Distal shaft 62 7.90 6.3
6 04/06/1999 31 Coronal 66 6.00 4.6
7 18/06/1999 35 Distal shaft 106 14.10 23.3
8 05/06/1999 29 Proximal shaft 106 17.40 14.7
9 16/03/1998 25 Coronal 144 6.50 30.3
10 10/07/1998 19 Coronal 142 14.10 10.9
11 19/04/1998 29 Glandular 140 9.50 19.2
12 27/02/1998 20 Coronal 146 7.2 9.7
13 11/07/1999 31 Coronal 137 6.70 12.8
14 31/12/1996 24 Coronal 160 8.10 21.8
15 05/01/1996 39 Coronal 151 11.10 15.6
16 19/08/1996 27 Coronal 158 5.70 14.7
17 17/04/1995 26 Coronal 177 8.70 12.1
18 05/09/1992 23 Coronal 207 29.50 38
Mean 2 years 5 months 10 years 4 months 11.11 16.42
Standard 5.94 8.32
deviation
Range (1 year 7 monthse4 (5 years 2 monthse17 (5.7e29.5) (4.6e38)
years 4 months) years 3 months)

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Assessment of long term function following hypospadias reconstruction 123

Urogram Centiles

6
Number of Patients

2006
5

4 2011

0
Below 5th Below 10th Above 10th Above 50th
Centiles

With time more patients are above the 50th centile for age matched Uroflowmetry.

Figure 3 Urogram centiles comparing 2006 with 2011.

associated with both functional and psychological sequelae
that can extend well into adulthood if not treated. Even
after surgical repair complications present both early and
later into adulthood. There have been many methods
described to reconstruct hypospadias defects. However,
there are very few published reports describing long term
objective results beyond 5 years of follow up. The interim
results of the modified Bretteville technique over a mean
time interval of 5 years have been published.2 These results
compare favourably with the other commonly performed
techniques, such as the Bracka repair and the Snodgrass
(tubularized incised plate urethroplasty) repair.9e12 Long
term published results of the Duckett repair, Matthieu and
onlay flap repair with a follow up of over 10 years have
demonstrated fistula rates of 30, 19, 44% respectively and
stenosis rates of 34, 9.5, 11% respectively.13

Table 2 Hypospadias spray and HOSE data.

Pt no. Spray weight Spray weight Spray area% Spray area% HOSE HOSE
2006 (g) 2011 (g) 2006 2011 2006 2011
1 3.2 1.77 15 15
2 2 1 2.98 0.61 13 15
3 0 0.5 0 0.29 15 16
4 8 1.3 20.96 0.80 16 16
5 3 1.8 4.23 1.47 16 16
6 3 14.3 8 11.87 16 16
7 2 0.6 4.6 1.06 14 16
8 5 0 9.24 0 12 15
9 13 12.5 32 6.13 15 13
10 0 4.8 0.73 2.45 14 16
11 4 2.5 10.73 0.90 16 14
12 1 0.4 0.87 0.31 16 16
13 5 0.5 12.5 0.06 15 15
14 1 2.1 2.01 0.85 15 15
15 17 3 42 2.42 15 16
16 2 2.2 3.44 1.75 15 16
17 6 1.8 16.9 0.69 13 16
18 2 1.4 5.31 0.49 13 16
Mean 4.11 g 2.99 g 10.38 1.89 13.78 15.44
Standard deviation 4.595 4.102 11.71 2.95 1.24 0.86
Range (0e17) (0e14.3) (0e20.96) (0e11.87) (12e16) (13e16)

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124
Uroflowmetry is non-invasive, and provides objective
data for measuring lower urinary tract function. Gaum
et al.7 described age related flow rate nomograms in
a normal paediatric population based on 511 consecutive
subjects. When compared to these urograms, 89% of
patient’s in our study were above the 5th percentile at the
most recent uroflowmetry with 44% above the 50th
percentile. This compared with 72% of patients above the
5th percentile 5 years previously and only 14% of patients
above the 50th percentile.
Malyon et al.,14 found that the majority of patients with
hypospadias who have undergone surgery, tend to be below
the 5th percentile for age matched uroflowmetry.14 These
patients had undergone either Bracka repairs, meatal
advancement surgery or preputial onlay flaps. We have
shown that, in patients who have undergone the modified
Bretteville method for hypospadias reconstruction, over
the time interval observed, maximum urinary flow rates
increase, and uroflowmetry studies show progression to
normal values. Regular uroflowmetry is a useful investiga-
tion in detecting asymptomatic stenosis following hypo-
spadias repair. A maximum urinary flow rate below the 5th
centile for an age related urogram is highly suggestive of
meatal stenosis. Theoretically, the scarring resulting from
reconstruction could result in reduction of neourethral
circumference and hence reduced flow. The findings in this
study with this particular technique, would suggest that
this is not occurring, but until evaluation of flow rates/flow
quality is carried out for other methods of reconstruction,
comparative statements on different methods of hypospa-
dias repair cannot be made.
In this study, using this technique of hypospadias repair,
objective analysis of urinary stream shows improvement
over the timescale measured, with reduced spraying.
This improvement may be due to maturation of the scar
tissue in the neourethra, improved support with growth of
the surrounding corpora as the penis develops, or a combi-
nation of these and there may be other factors currently
unknown. There is an ongoing discussion within hypospadi-
ology regarding the merits of reconstruction using “flaps” or
“grafts” for creating the neourethra. The method being
investigated in this paper uses a preputial flap. The method
for assessing spray is applicable to any method of repair,
and could potentially be used to help answer this question.
Our study shows using this technique based on a preputial
flap, that spraying may improve with increasing age. Though
clearly, we are not making any statement regarding the
situation in adulthood, which remains to be investigated.
The HOSE questionnaire represents a validated objective
outcome questionnaire with good inter-observer correla-
tion.3 It is a useful adjunct to analysis of outcome of
hypospadias reconstruction, and can be used for compar-
ison of outcome between different techniques. Recent
studies have emphasized the importance of the penis
cosmesis following hypospadias surgery and the impact it
has on long term sexual activity. A better cosmetic result
leads to a better sexual outcome. The majority of adults in
the long term have a rather normal sexual function but
some have problems with erection, ejaculation and inter-
course problems.
The modified Bretteville technique gives a good
cosmetic result which is maintained over the period of
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A.J. Robinson et al.
study. Historically, for some single stage procedures the
meatus can migrate proximally from the terminal position
on the glans penis over a period of months to years. Our
results show that with the modified Bretteville technique,
using the scoring systems as outlined in the paper, that this
is not occurring. However, the HOSE questionnaire in
particular suggests that with increasing age, the shape of
the meatus improves and as scarring associated with the
neourethra matures, any minor residual curvature of the
penis is corrected; this is what is observed.
Conclusion
 We conclude that the modified Bretteville technique
provides a reliable repair that has a low complication
rate and provides an aesthetically pleasing and func-
tionally sound penis.
 Objective analysis of urinary flow shows improved flow
rates and quality of stream, with reduced spraying over
the time period observed.
 Uroflowmetry and spray analysis together with the
HOSE questionnaire, are useful objective tests that can
be used to compare outcomes between different
methods of hypospadias reconstruction, and could be
used to set standards between different surgeons for
the purposes of appraisal and accreditation
 The modified Bretteville technique for hypospadias
reconstruction, in our experience, is a reliable tech-
nique for hypospadias reconstruction, with good
cosmetic and functional outcomes.
Conflict of interest statement
The authors have no conflict of interest to disclose.
Acknowledgements
We would like to thank Mr A Curnier, Consultant Plastic
Surgeon, Aberdeen Royal Infirmary, for his advice and help
with the preparation of this manuscript. We also acknowl-
edge support from the Specialist Nurses in the Departments
of Urology and Paediatrics, Ninewells Hospital and Medical
School, for their with the hypospadias clinics.
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