3.3 Treatment

Surgical intervention is recommended for intermediate and more severe forms of hypospadias, and for distal forms with associated pathology (penile curvature, meatal stenosis and phimosis). In simple distal hypospadias, cosmetic correction should be performed only after a thorough discussion of the psychological aspects and clarification of the lack of a functional indication.

The therapeutic objective is to correct the penile curvature, to form a neo-urethra and to bring the neo-meatus to the tip of the glans penis, if possible. The use of magnifying spectacles and special suture materials, knowledge of a variety of plastic surgical techniques (use of rotational skin flaps, as well as free tissue transfer), the handling of dermatomes, wound care and post-operative treatment are essential for a satisfactory outcome.

Pre-operative treatment with the local application of testosterone propionate over a period of 4 weeks can be helpful. For distal forms of hypospadias a range of techniques are available (e.g. Mathieu, MAGPI, King, Duplay, Snodgrass, Onlay). Along with the 'skin' chorda, the connective tissue of the genuine chorda and the distal corpus spongiosum, running longitudinally under the glans on both sides of the urethral channel, are usually responsible for the curvature. If there is a residual curvature after chordectomy, and if the remaining skin channel of the open urethra is thin and of poor circulation, incision or excision of the urethral plate may be required. In corporeal dysproportion, orthoplasty (modification of Nesbit dorsal corporeal plication) must be added. Orthoplasty (Nesbit, modified Nesbit, Schroder-Essed) and closure may be considered in a two-stage procedure.

The Onlay technique with preservation of the urethral plate and avoidance of circumferential anastomosis is the method of choice, with low complication rates for moderate and severe hypospadias. Prerequisite is an intact and well-vascularized urethral plate, or a satisfactory result after the first session with a straight penis and a well-covered shaft. If the urethral plate is not completely preserved (after excision or division), a tube-onlay flap or an inlay-onlay flap are used. The two-stage procedure may be an option in severe hypospadias. If preputial or penile skin is not available, buccal mucosa, bladder mucosa and free skin grafts can be used.

Only fine absorbable suture materials should be used (6/0-7/0). For blood coagulation, bipolar instruments are required along with swabs soaked in 1:10,000 epinephrine solution. Glans preparation may be facilitated by infiltration with a 1:100,000 epinephrine solution. Tourniquets should not be used for longer than 20 minutes.

After preparation of the dorsal neurovascular bundle, modified Nesbit sutures (monofilic non-resorbable suture material 4/0-5/0, e.g. Goretex, Prolene) are placed with the knots folded in. Urine is drained via a transurethral or suprapubic catheter. In case of a suprapubic catheter, the neo-urethra should be stented. For urethral stenting and drainage, an 810 F catheter with multiple side holes is used ending in the bulbar urethra (not into the bladder). Circular dressings with slight compression, as well as an antibiotic administration have become established procedures.