Curr Urol Rep (2015) 16:69
DOI 10.1007/s11934-015-0543-5
PEDIATRIC UROLOGY (M CASTELLAN AND R GOSALBEZ, SECTION EDITORS)
Surgery for Primary Proximal Hypospadias with Ventral
Curvature >30°
Warren Snodgrass 1 & Nicol Bush 1
# Springer Science+Business Media New York 2015
Abstract This review discusses means for straightening ven-
tral curvature >30°, and then subsequent urethroplasty using
either one-stage flaps or two-stage flaps or grafts. The wide
variation in reported results from these various techniques
makes determination of best management difficult; however,
it is clear that complications for repairs done in major centers
can range to ≥50 %. Given the rarity of proximal hypospadias
with ventral curvature >30°, which occurs in approximately
400 newborns annually in the USA, centers should refer these
cases to subspecialists within the group who can then develop
and maintain expertise.
Keywords Proximal hypospadias . Corporotomy . Prepucial
flaps . Prepucial grafts . Urethroplasty complications
Introduction
The best management of primary proximal hypospadias in
which the urethral plate is transected during straightening re-
mains uncertain. These comprise approximately 5 % of pri-
mary hypospadias repairs, which using CDC birth data (CDC,
2014) for the USA calculates to approximately 400 per year,
or 0.5 cases per pediatric urologist. With such low volumes, it
is difficult for specialists to achieve and maintain expertise,
and so, not surprisingly, complication rates are high. It is also
difficult to accumulate sufficient data to make comparisons
between the various surgical techniques used. This article will
This article is part of the Topical Collection on Pediatric Urology
* Warren Snodgrass
snodgrass@parcurology.com
1
PARC Urology, Dallas, TX, USA
review recent publications and suggest means to improve out-
comes for these most severe hypospadias cases.
Straightening Ventral Curvature
50 % of patients with proximal shaft to perineal hypospadias
have ventral curvature >30° after the penis is degloved, and
ventral dartos and scrotal attachments to the penile shaft are
released [1]. The next step to straighten the penis is transection
of the urethral plate. This usually corrects curvature in Asian
boys [2], although patients of European and African descent
most often remained bent—indicating an apparent difference
in etiology of ventral curvature by race (data not published).
The observation that urethral plate transection does not
straighten the penis in most patients operated in the USA led
John Duckett to explore correction while preserving the plate,
which he did by dorsal plications [3]. Although a single pli-
cation does not shorten the penis, the multiple plications need-
ed to straighten bending that can exceed 90° can, which is a
concern in boys with proximal hypospadias since their aver-
age penile size is smaller than that of normal boys [4•]. Fur-
thermore, one report found recurrent curvature more likely
when dorsal plication, versus ventral corporal lengthening,
was done for bending >30° [5].
Ventral lengthening can be done by either single
corporotomy with corporal grafting or three transverse
corporotomies without grafting the defects. With single
corporotomy, incision is made from 3 to 9 o’clock through
the point of maximum bending. The resulting defect is wid-
ened to create a diamond, and then grafted with dermis, SIS,
or similar material. When three incisions are made, the first is
also done through the maximum bending but from 4 to 8
o’clock, with the second and third then made approximately
4 mm above and below the first. The incision goes all the way
69 Page 2 of 5
through the tunica albuginea down to, but not into, the corpo-
ra. These defects are left linear rather than widened into dia-
monds, and are not grafted. We find that this is most easily
accomplished with a tourniquet at the base of the penis, and
we apply 1:1000 epinephrine topically if there is bothersome
bleeding when it is released.
Straightening is reliably achieved by either method [1]. We
recently reviewed our results, finding three corporotomies
successfully corrected curvature >30° with only one recur-
rence in 50 consecutive patients. Over half of these boys had
curvature >90°, with a maximum of 120° after urethral plate
transection (unpublished data).
The major difference that arises from these two methods is
the resulting options for urethroplasty. Corporal grafting re-
quires flap repair, as urethroplasty grafts likely will not heal
satisfactorily if placed onto corporal grafts. Ventral lengthen-
ing by three corporotomies without corporal grafting preserve
the option for graft urethroplasty.
Proximal Flap Urethroplasty
Flap repairs can be done in either one or two stages. A sys-
tematic literature review found urethroplasty complications
reported in 38 % of tubularized prepucial flap and 32 % of
Koyanagi repairs, which are one-stage options. Two-stage
Byars flap operations had a reported 22 % complication rate
[6]. However, the authors warned the studies reviewed were
generally of low scientific quality, providing little evidence
basis for management.
There have not been many recent studies published on one-
stage tubularized prepucial flap repairs. Our review found one
report with 25 primary cases, unusual in that the mean age at
repair was 12±11 years. The authors followed the original
description of the technique, suturing the prepuce into a tube
over a catheter which they rotated ventrally and secured to the
native urethra proximally and glans wings distally.
Urethroplasty complications occurred in 24 % [7].
Others reported improved results when the prepucial flap
was not simply tubularized, but instead transposed ventrally
with a portion sewn to the corpora between the native urethra
and the glans to create a neourethral plate, to which the remain-
ing portion was then secured. The intention was to make the
neourethra more smooth and uniform, to resemble an onlay
flap procedure. Two series comprising 12 and 22 patients re-
ported complications in 17 and 14 %, respectively [8, 9].
None of these studies described the authors’ prior results
using one-stage tubularized prepucial flaps. Were the cases
reported by Zheng et al. their first experience with this tech-
nique, and if not, were these results better than their earlier
outcomes? Assuming initial patients had more complications,
readers might have benefited from a description of technical
modifications the authors made to various steps. Similarly, a
Curr Urol Rep (2015) 16:69
time-randomized trial comparing the traditional tubularized
flap to the modified flap mimicking a urethral plate might
have highlighted the benefits, and remaining challenges, of
repair by the newer method.
The difficulties in deriving evidence-based management
and learning to reduce complications from reported hypospa-
dias series are further highlighted by two reports in the past
year concerning two-stage Byars prepucial flaps. Various ear-
lier publications regarding this technique reported complica-
tions occurring in from 5 to 70 % of patients [8, 10]. The
lowest rate came from a series which only stated there was
no meatal stenosis and that fistulas developed in 5 % of 58
cases with proximal shaft to perineal hypospadias. A subse-
quent review from the same institution with 134 patients de-
scribed fistulas in 29 % and meatal stenosis in 13 %, with up to
80 % complications overall [11•], although some patients may
have had more than one. Another retrospective review pub-
lished this year similarly found 66 % of cases developed com-
plications after Byars flap repair [12•]. Conversely, a third
recent report of 128 patients stated only 12 % developed com-
plications [13•].
Widely divergent outcomes reported by surgeons using the
same operation suggest selection bias for who is undergoing
the procedure, and/or technical differences in performing key
steps in the operation. These three recent articles all used
Byars flaps for proximal shaft to perineal hypospadias repair,
although the decision in whom to transect the urethral plate
potentially varied among the multiple surgeons involved. The
various steps in creating and securing the Byars flaps ventral-
ly, tubularizing the neourethra, waterproofing it with a barrier
flap, and performing glansplasty were only generally de-
scribed by Stanasel et al. and McNamara et al., likely because
there was variation between the surgeons involved and by
each surgeon over time. Yang et al. provided more technical
detail and reported the fewest complications, but did not con-
trast their outcomes to an earlier experience, when they might
have had more problems, to explain for others how to similar-
ly improve results.
One observation we have made is that flap repairs may not
create normal fusion of the glans wings between the
neomeatus and the corona. This distance normally averages
4.7 (±1.2)mm [14], and is needed to create a reliably compact,
straight urinary stream without spraying. Because the end of
the flap is sewn to the glans wings, there is less glans to
approximate below the neomeatus. A postoperative photo-
graph in the Yang et al. report shows the glans fused together
only at the corona below a large meatus. One report mention-
ing functional outcomes of Byars flaps stated that 37 % had
abnormal voiding and urinary spraying [15], which might in-
dicate inadequate glansplasty.
WS initially preserved the glandular portion of the urethral
plate when it was transected during penile straightening, and
used interposed Byars flaps with distal TIP. Therefore, the
Curr Urol Rep (2015) 16:69
glans closure was the same as in primary TIP repairs, which
we are now systematically measuring and observing to be 3–
5 mm between the meatus and corona. There were 100 %
complications in nine patients, five of which were diverticu-
lum despite the absence of distal stenosis. Thinking the strip
for urethroplasty was possibly cut too widely at the second
stage, he made it narrower in the next patient, resulting in a
stricture.
We subsequently changed from Byars flaps to two-stage
prepucial graft repairs, and despite using the same tissue for
urethroplasty and similar glansplasty technique, no diverticu-
lum have occurred in the latter patients. The dartos underlying
Byars flaps hinders fixation to the corpora, resulting in a more
tortuous neourethra with turbulent flow. Yang et al. sutured the
midline approximation of the two halves of the Byars flaps to
the corpora, which may have facilitated creation of a more
uniform, straight neourethra.
Two-Stage Graft Urethroplasty
The same prepucial tissues used for tubularized and Byars
flaps can also be harvested for either one- or two-stage graft
urethroplasty. As mentioned above, the choice between these
options depends in part on methods used to straighten ventral
penile curvature. Before artificial erection was introduced in
the 1970s, the general belief was that meticulous excision of
Bchordee^ tissues between the meatus and the glans was suf-
ficient to correct bending. Plication might also be done if
persistent curvature was suspected, but ventral corporotomies
were thought to be rarely indicated after their description by
Devine and Horton [16]. That surgical team experimented
with both multiple corporotomies without corporal grafting
and single corporotomy with dermal corporal grafts. Of these
two methods, single corporal incision with grafting became
most popular, and favored prepucial urethroplasty flaps to
avoid placing urethral grafts onto corporal grafts.
Although a number of studies regarding one-stage
tubularized grafts report similar urethroplasty complication
rates as with flaps, the patients discussed in this article with
transection of the urethral plate and ventral corporotomy like-
ly were not the subject of most these reviews.
Dissatisfaction with results of Byars flaps led WS to con-
sider two-stage primary graft repairs at a time when he was
learning that technique for salvage repairs. To do so, he had to
straighten ventral curvature without incision and corporal
grafting, which led him to revive the Devine and Horton Bfairy
cuts^. The name is misleading, however, as these incisions
extend just as deep as do single corporal incisions, which is
through the tunica albuginea avoiding injury to the enclosed
erectile tissues. As discussed above, our data indicate these
three incisions without corporal grafting are as effective in
straightening the penis as are single incisions with corporal
grafts.
Page 3 of 5 69
We have been reluctant to then place a tubularized graft
onto these three incisions, which we have made in nearly
75 % of cases after transecting the urethral plate for persistent
ventral curvature. Instead, we perform a two-stage repair,
allowing the smooth rectangular graft to heal for 6 months
before tubularization. After harvesting the prepucial graft,
we spread it over the incised corpora from the meatus to the
tip of the glans, quilt it into place, and then apply a tie-over
compression bandage to facilitate graft take. Overall graft take
was 95 %, with no difference in those placed onto smooth
versus incised corporal surfaces [17].
Beginning in 2008 and continuing through 2014, we per-
formed 65 first-stage and completed 50 second-stage
prepucial or labial (when foreskin reconstruction was re-
quested) primary proximal repairs for ventral curvature
>30° persisting after transecting the urethral plate. The ini-
tial degloving incision was made approximately 4 mm be-
low the corona to preserve most the inner prepuce for the
graft. Straightening was done, and the penoscrotal junction
was incised on each side from 6 to 2 or 3 and 9 to 10 o’clock,
respectively. This frees the dorsal shaft skin and the hooded
prepuce. Stay sutures were placed into the distal corners of
the unfurled prepuce and the underlying dartos was excised.
Then a horizontal line was marked on the prepuce where the
distal shaft skin would join the inner prepucial collar, leav-
ing a graft which was mostly inner prepuce with some outer
prepuce. The graft was set aside while circumcision,
scrotoplasty, and the proximal urethrostomy were
completed.
We have learned that this prepucial graft will cover defects
extending from deep within the scrotum to the tip of the glans.
It is important that the glans be opened widely, to 3 and 9
o’clock, to place sufficient graft that meatal stenosis will not
occur during second-stage tubularization. The grafts were first
sutured to the edges of the glans wings at the coronal on either
side, and then gently stretched distally and sewn to the end of
the glans. We used 7–0 polyglactin, placed through the epi-
thelium all along the perimeter, except across the end of the
glans where subepithelial sutures were used to avoid marks at
the future neomeatus. Proximally, the graft was incised in the
midline to extend to either side of the proximal urethrostomy
to 4 and 8 o’clock.
After the graft perimeter was secured, additional Bquilting^
stitches of 6–0 polyglactin on a RB1 needle were sewn in the
midline and on either side at 5-mm intervals to secure the graft
to the surface of the corpora. This reduces likelihood for blood
or serum to accumulate under the graft during revasculariza-
tion postoperatively.
5–0 polypropylene sutures at the urethrostomy, midpenis
and corona were tied over a rolled Vaseline gauze to further
immobilize the graft and promote revascularization during the
first postoperative week. We discharged infants and children
the same day as surgery.
69 Page 4 of 5
Second-stage tubularization was done 6 months later in two
subepithelial layers: the first with interrupted 7–0 polyglactin
and the second with a continuous 7–0 polydioxanone for
prepucial grafts and interrupted 6–0 polyglactin, and then con-
tinuous 6–0 polydioxanone for labial grafts. We always cov-
ered the neourethra with tunica vaginalis, not dartos. Most of
these patients had a small glans diameter, less than the 14 mm
average of healthy newborns [4•]. Consequently, we dissected
the glans from the corpora; first, laterally to 3 and 9 o’clock,
and then distally another 4 mm on each side before closing the
wings over the neourethra. As with TIP repair, the underlying
end of the tubularized neourethra was not sewn to the glans
wings. This reliably created a vertical slit meatus with 3–4 mm
of glans wings fusion, closely resembling the normal glans
and meatus.
Our first 22 patients were repaired before we began the
Bextended^ glans wings dissection discussed above. That
group had 45 % complications, all glans dehiscences, in one
case combined with a fistula. After changing the glansplasty,
and operating as a surgical team, complications significantly
decreased in the second group of 28 boys to 14 %, three glans
dehiscences, one with a fistula, and one recurrent curvature
>30° [17].
Progress in Proximal Hypospadias Repair
3Ps
We previously reported technical modifications in proximal
TIP repair which significantly reduced urethroplasty compli-
cations from an initial 54 to 13 % [18]. Our journey with two-
stage proximal hypospadias repair for ventral curvature >30°
and urethral plate transection began with a 100 % complica-
tion rate using Byars flaps, decreased to 45 % in our initial
experience with two-stage grafts, and subsequently signifi-
cantly decreased further to 14 %. This indicates that
urethroplasty complications should be considered potential
warning signs that technical changes are needed.
Assessment of outcomes before and after technical modi-
fications is greatly facilitated by prospective data collection.
This is especially true for uncommon operations such as prox-
imal hypospadias, in which a surgeon’s impression of personal
outcomes frequently is found to be wrong because of recall
bias, since these complications occur sporadically and are eas-
ily forgotten within the overall surgical practice.
For quality assurance, a simple spreadsheet listing the pa-
tient name, date of surgery, meatal location, primary versus
reoperative repair, surgical technique, date of last follow-up,
and complications suffices to inform a surgeon regarding ac-
tual results. Entering this data on the day of service requires
minimal time, and a review to determine the number of pro-
cedures and complications can be done rapidly.
Curr Urol Rep (2015) 16:69
The first step towards improving outcomes is for surgeons
to learn their current results. We have consistently found they
are less favorable than we presumed, leading to practice
changes. Such quality assessment and improvement can be
summarized as the 3Ps: prospective data collection, periodic
outcomes review, and practice change.
Reducing the Surgical Algorithm
Given the low number of proximal hypospadias cases, to gain
expertise and to train others subspecialists must rely on a
limited number of surgical techniques so that the key steps
can be learned and refined. We have found that all proximal
hypospadias can be corrected using either TIP or two-stage
grafts, depending on the extent of ventral curvature. Others
subspecializing in proximal repairs should also choose few
methods that are widely applicable.
Although we believe that two-stage prepucial graft repair is
superior to Byars flap repair, surgeons such as Yang et al. who
can achieve similar low complication rates using flaps have no
reason to change their practice once they have determined
cosmetic and functional results are also optimal. To make
the assessment of glansplasty results more objective, we are
measuring the distance from the lower lip of the neomeatus to
the corona, and encourage others to systematically do the
same and record, and then report their results. Urinary func-
tion is more likely to be normal when glans anatomy is
normal.
Subspecialization
It is not reasonable to expect that a surgeon who performs an
average of two repairs annually for the most severe forms of
hypospadias can either achieve or maintain expertise. While
the minimum case volume needed for these goals has not been
established in hypospadias surgery, numerous studies demon-
strate that better results are obtained by surgeons performing
higher volumes. For a condition with <500 new cases per year,
referral to designated colleagues who subspecialize in com-
plex hypospadias surgery is clearly needed. The reports from
Houston and Boston on Byars flaps referenced above both
included multiple surgeons vying for an average of 5–7 repairs
per year, implying most did very few cases each year. In con-
trast, the experience reported by Yang et al. involved an aver-
age of 43 cases a year divided among three surgeons. To
accumulate data, determine current complication rates, and
then make changes to improve results, cases need to be con-
centrated into fewer surgeons’ hands in each major institution.
Surgical Teams
All hypospadias surgery needs an assistant, which is most
often a trainee or a nurse. As we subspecialized within our
Curr Urol Rep (2015) 16:69
university group, we also realized that a team approach using a
senior and junior faculty surgeon might improve intraopera-
tive decision-making, following the example of many centers
closing bladder exstrophy. Furthermore, a junior surgeon has
to gain experience to eventually assume the role of a senior
hypospadias surgeon. The reduction in complications we
achieved in two-stage graft repairs occurred in part due to a
technical change in glansplasty, but also in part due to working
as a surgical team.
Compliance with Ethics Guidelines
Conflict of Interest Warren Snodgrass and Nicol Bush each declare no
potential conflicts of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
1. Snodgrass W, Prieto J. Straightening ventral curvature while pre-
serving the urethral plate in proximal hypospadias repair. J Urol.
2009;182:1720.
2. Yoshino K. Personal communication
3. Hollowell JG, Keating MA, Snyder III HM, Duckett JW.
Preservation of the urethral plate in hypospadias repair: extended
applications and further experience with the onlay island flap
urethroplasty. J Urol. 1990;143:98.
4.• Bush NC, DaJusta D, Snodgrass W. Glans penis width in patients
with hypospadias compared to healthy controls. J Pediatr Urol.
2013;9:1188. This study measured maximum glans width in
infants with distal and proximal hypospadias at median age 9
months and compared them to controls undergoing elective
circumcision at median age 1 month. Mean glans widths were
14.8, 12.9 and 14.3 mm.
Page 5 of 5 69
5. Braga LHP, Lorenzo AJ, Bagli DJ, Dave S, Eeg K, Forhat WA,
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Complications occurred in 68 % of patients after Byars flaps
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procedure for hypospadias after urethral plate transection. J
Pediatr Urol. 2014;10:1133. This large series reported only
12% complications after Byars flap repair.
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Pediatr Urol. 2011;7:2.