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PubMed2025

The wider erection angle in hypospadias: A neglected feature affecting surgical outcomes.

INTRODUCTION: Penile curvature often accompanies hypospadias, and numerous techniques have been described for its correction; however, in some cases, an abnormal erection angle may also be present, further exacerbating the perception of curvature. OBJECTIVE: This study investigates the significance of the erection angle in hypospadias cases and its correlation with the severity of the anomaly. STUDY DESIGN: A retrospective analysis of intraoperative photographs of hypospadias cases operated between 2019 and 2023 was performed. Erection angle was measured with a digital goniometer during a full artificial erection. Erection angles in proximal and distal hypospadias cases were analyzed and compared to data from Kinsey's subgroups representing healthy male erection angles. RESULTS: This study involved images of 68 patients, with 31 having proximal and 37 distal hypospadias. The median age of the whole group was 11 months (6-156, IQR 9). Median erection angle was 91 (63-119, IQR 11) for distal cases, whereas it was 96 (75-138, IQR 21) for proximal cases. The difference was statistically significant (p = 0.009). The erection angle distribution in our cohort, including both proximal and distal hypospadias cases, skewed toward wider angles, highlighting a distinct pattern compared to data constituted by Kinsey and Sparling. DISCUSSION: Our findings indicate that the erection angle in hypospadias is significantly wider in proximal cases, suggesting a correlation between erection angle and severity of the hypospadias. While we acknowledge the limitation of comparing our prepubertal cohort with Kinsey's adult data, the absence of evidence suggesting significant post-pubertal changes in erection angle justifies this approach. Additionally, the use of digital images for angle assessment is not a standardized technique in hypospadias evaluation; these images were initially captured for curvature assessment. Despite these limitations, our study provides novel insights into seldom mentioned association with hypospadias - a wide erection angle, emphasizing the need for further research on its implications for surgical planning and long-term outcomes. CONCLUSION: This study introduces a wider erection angle as an additional characteristic of hypospadias particularly pronounced in proximal cases. To our knowledge, this is the first focused investigation on addressing this aspect of the condition. It emphasizes the need for further research on adults with wide post-repair erection angles to explore its long-term impact on sexual function and aesthetics.

Humans↗

PubMed2026

How do we counsel patients on short- and long-term complications after hypospadias repair? - A survey study.

INTRODUCTION: Hypospadias correction remains one of the most performed pediatric urologic procedures, affecting up to 1/150 males born in the United States. Current studies suggest that surgical counseling has a significant impact on shared decision making, decisional regret, and long-term follow-up. However, no set paradigm currently exists for long-term follow-up or counseling. We sought to obtain consensus from established pediatric urologists the optimal content and potential short, intermediate, and long-term complications to be considered when counseling patients and parents of patients with hypospadias. METHODS: We conducted an IRB-approved survey study, which sampled the responses of Pediatric Urologists from National and International listservs. A google scholar search was performed using key words including "hypospadias" and "long-term complications." Descriptions of pertinent short, intermediate and long-term complications were identified and compiled from existing patient handouts. Survey items were then developed asking respondents to rate proposed descriptions, provide potential edits, and describe their overall approach to counseling. RESULTS: A total of 290 surgeons were contacted with 120 (41 %) responding. In total, 89 respondents (74 %) identified as male and 105 (88 %) had undergone a pediatric urology fellowship. Most surgeons described a reliance on verbal counseling (95 %) with the assistance of hand-drawn diagrams (75 %) to explain long-term care, rather than electronic or audiovisual materials (3-12 %). Of note, fewer surgeons endorsed routine discussion of long-term complications (Range 29.2 %-50.8 %) than shorter-term complications (56.7 %-89.2 %). On a Likert scale, physicians reported that they were mostly satisfied (72 %) with their current approaches to counseling. DISCUSSION: Perioperative counseling has an important yet often overlooked role in surgical care. The aim of this study was to better understand current counseling practices in pediatric hypospadias to identify gaps in urologic care and areas for improvement as one of the most common conditions treated by pediatric urologists. Our results suggest that surgeons who perform hypospadias repairs have potential to include more comprehensive discussion during post-operative follow-up. We proposed a preliminary counselling guide for these concerns which incorporates language from the most commonly selected complication description by survey respondents. Future studies will involve expert consensus and patient input to confirm the adequacy of the content, the method of delivery, content appearance, and accommodations for health literacy. Limitations of the study include small sample size and response bias. The results are reflective of the summed responses of participants and are not reflective of individual providers or practices. Importantly, this study omits the input of other advanced practice providers (nurse practitioners, physician assistants, etc.), nurses, and ancillary staff who are also crucial to hypospadias care. The proposed counseling guide represents a first attempt at creating standardization of hypospadias counseling. CONCLUSION: Surgeons who perform hypospadias repair do not routinely discuss long-term complications after repair, though are overall satisfied with their counseling practices. Better tools, such as improved multimodal counseling guides, could be used to deliver this counseling efficiently and accurately to ensure patients receive optimal long-term care. Future studies will focus on developing educational materials for short, intermediate, and long-term counseling on complications after hypospadias repair with input from patients and clinicians.

Humans↗

PubMed2025

Mortality and Causes of Death in Boys and Men Born With Hypospadias: A Swedish Population-Based Cohort Study.

INTRODUCTION: Although hypospadias is not a life-threatening condition, studies have found perinatal factors and comorbidities which could increase mortality. We aimed to investigate mortality and causes of death in boys and men born with hypospadias. METHODS: We created a cohort of almost 3 million individuals including 16,890 with hypospadias using Swedish registers. We used Cox regression analysis to measure associations between hypospadias and all-cause mortality in different age groups (maximum age 65 years) as well as cause-specific mortality in adolescents and adults. RESULTS: We found associations between hypospadias and mortality in infancy (HR 2.07, 95% CI: 1.74-2.45), childhood (HR 1.77, CI: 1.34-2.33), and adolescence and adulthood (HR 1.31, CI: 1.11-1.56), with stronger associations for proximal hypospadias. Controlling for birth weight and congenital comorbidity significantly reduced the association in infancy. The association was lower in younger adults (HR 1.22, CI: 1.00-1.50) but increased again after age 35 years (HR 1.57, CI: 1.17-2.11). We found a significant association with death due to cardiovascular disease or diabetes (HR 3.20, CI: 1.93-5.32) and kidney or urological disease (HR 5.16, CI: 2.13-12.5), but not cancer overall, suicide, or accidents. CONCLUSIONS: While mortality overall was low, hypospadias is associated with relatively increased mortality from infancy to middle age. In early childhood, this is related to prenatal and perinatal factors. In adolescence and adulthood, the risk of death due to cardiovascular and urological disease was increased, providing further insight into long-term health in this patient group.

Humans↗

PubMed2026

Stretched penile length in boys with hypospadias: Population-based analysis using validated nomogram.

BACKGROUND: Hypospadias affects 1 in 200-300 male births. Parents are often concerned about penile adequacy beyond the urethral defect itself, yet few studies have systematically compared stretched penile length (SPL) in hypospadias against population-based reference standards. OBJECTIVE: To evaluate SPL distribution patterns in boys with Types I and II hypospadias and compare them with established normative data. METHODS: The authors studied 876 consecutive boys aged 1-14 years with unoperated Types I (distal) and II (mid-shaft) hypospadias. Two observers independently measured SPL using the validated SPLINT technique. The SPL measurements were compared against age-matched normative data from 1276 Indian children. Exact binomial probability tests were used for percentile distributions, chi-square tests for subtype comparisons and t-tests for mean deviations. RESULTS: The cohort included 479 Type I and 397 Type II cases. SPL distribution showed a marked leftward shift: 71% fell below the 50th percentile (expected 50%, p < 0.001) and 41.5% below the 25th percentile. Lower percentiles were overrepresented, 20.7% were below the 10th percentile and 20.8% in the 10th-25th range. Upper percentiles were depleted: only 7.4% in the 75th-90th range and 1.7% above the 90th percentile (all p < 0.001). Mean SPL was reduced by 6.8% (95% CI: -8.18 to -5.42%) in Type I and 7.5% (95% CI: -9.05 to -5.92%) in Type II. The two subtypes showed no significant distributional difference (χ2 = 6.22, p = 0.18), suggesting that meatal position does not predict SPL reduction. CONCLUSIONS: Boys with distal and mid-shaft hypospadias show clinically meaningful SPL reduction that follows a continuous distribution rather than an all-or-none pattern. SPL reduction appears independent of meatal position. These findings support routine SPL assessment using population-specific references and can guide preoperative counselling.

Humans↗

PubMed2026

Preoperative intramuscular testosterone and urethrocutaneous fistula formation after primary hypospadias repair.

INTRODUCTION: Preoperative androgen stimulation is widely used before hypospadias repair to increase penile dimensions and optimise surgical conditions. However, its impact on postoperative complications, particularly urethrocutaneous fistula formation, remains controversial. OBJECTIVE: To evaluate the association between preoperative intramuscular testosterone therapy and urethrocutaneous fistula formation in children undergoing primary hypospadias repair. STUDY DESIGN: This was a retrospective comparative analysis of prospectively collected clinical data from 111 boys undergoing primary hypospadias repair at a single tertiary pediatric urology center. Patients were divided into two groups: those who did not receive hormonal therapy (Group 1, n = 55) and those who received intramuscular testosterone enanthate (2 mg/kg administered 5 and 2 weeks before surgery; Group 2, n = 56). Preoperative penile measurements, operative characteristics, and postoperative complications were compared. The primary outcome was urethrocutaneous fistula formation. The mean follow-up duration was 11.9 months (median 7 months). RESULTS: Preoperative testosterone therapy was associated with significant increases in glans diameter and stretched penile length at the time of surgery. The hormone-treated group had a significantly higher proportion of proximal hypospadias (p = 0.001), underwent more complex urethroplasty procedures, and had longer operative times (p = 0.007). Postoperative edema and local inflammatory changes were more frequently observed in the hormone-treated group. Despite these differences, urethrocutaneous fistula occurred in four patients in each group (7.3% vs 7.1%, p = 0.357), with no statistically significant difference between groups. DISCUSSION: Despite greater baseline anatomical severity and operative complexity in the hormone-treated group, preoperative testosterone administration was not associated with an increased risk of urethrocutaneous fistula. These findings suggest that improved tissue bulk and vascularity may offset the potential adverse effects of transient inflammatory changes. CONCLUSION: Selective preoperative intramuscular testosterone therapy was not associated with increased urethrocutaneous fistula risk and may be considered a reasonable adjunct in appropriately selected patients undergoing primary hypospadias repair. CLINICAL/TRANSLATIONAL APPLICABILITY: These findings provide clinical reassurance that preoperative testosterone can be used selectively in patients with smaller penile dimensions or anticipated technical difficulty without increasing fistula risk, thereby supporting shared decision-making in clinical practice.

Humans↗

PubMed2026

Clinical and endocrine correlates of genetic etiologies in severe hypospadias: Study from 34 patients.

OBJECTIVE: Hypospadias is a prevalent congenital anomaly (0.3%-1.0%); however, severe hypospadias (defined as proximal cases with the meatus at the penoscrotal junction, scrotum, or perineum) is a rare and clinically challenging entity with a multifactorial etiology. This study aimed to characterize the interrelationships among the clinical, endocrine, and genetic profiles in children with severe hypospadias. MATERIALS AND METHODS: We conducted a comprehensive analysis of 34 male patients with severe hypospadias. Preoperative hormone levels were measured using two methods: chemiluminescent immunoassay for luteinizing hormone and follicle-stimulating hormone, and liquid chromatography-tandem mass spectrometry for testosterone (T), dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA), 17α-hydroxyprogesterone (17α-OHP), and other steroids. Genetic analysis was conducted via whole exome sequencing. RESULTS: The diagnostic yield of clinically relevant genetic variants (including pathogenic and likely pathogenic, and variants of uncertain significance) in our cohort was 41.2% (14/34) of patients. Patients carrying these variants exhibited a more complex phenotypic profile compared to non-carriers, including a significantly higher rate of patients with ≥3 associated malformations and a greater prevalence of cryptorchidism. Furthermore, the group with clinically relevant variants showed selective elevations in adrenal-derived precursors, specifically 17α-OHP and DHEA. Correlation analysis revealed significant positive associations of both 17α-OHP levels and the T/DHT ratio with the number of associated malformations. CONCLUSION: This study reveals significant genetic heterogeneity in patients with severe hypospadias. Those carrying genetic variants was associated with more severe clinical phenotypes, while certain endocrine variations, including the elevation of adrenal-derived hormones, were also observed in this cohort.

Humans↗

PubMed1978

Metabolism of androstenedione in skin and serum levels of gonadotrophins and androgens in prepubertal boys with hypospadias.

The metabolism of 4-[1,2-3H]androstene-3,17-dione in the prepuce, axillary skin and skin from the arm was investigated in 27 boys operated for phimosis (controls) and 13 unselected boys with hypospadias (a congenital defect of the male urethra). In all types of skin investigated, androstenedione was metabolized to 5alpha-androstane-3,17-dione, 3alpha-hydroxy-5alpha-androstan-17-one, 3beta-hydroxy-5alpha-androstan-17-one and testosterone. Conversion to testosterone was found in the prepuce of two out of 11 boys with hypospadias. Mild forms of hypospadias in the age group 1--4 years had a higher level of 5alpha-reductase activity in the prepuce than controls in the same age group (P less than 0.05); no such differences were found in the few severe cases of hypospadias in this group. No other differences in 5alpha-reductase activity were found between hypospadic boys and controls. The ratio of 5alpha-reductase activity in the prepuce: 5alpha-reductase activity in skin from the arm was significantly higher (P less than 0.05) in hypospadic boys than in controls in the age group 1--4 years. Serum levels of LH and FSH were the same in normal and hypospadic boys but the concentration of prolactin in the serum was lower in boys with hypospadias compared with control subjects in the age group 1--4 years (P less than 0.005). No differences were found in serum concentrations of androstenedione, testosterone, oestradiol and testosterone-binding globulin.

3-Oxo-5-alpha-Steroid 4-Dehydrogenase↗

PubMed2026

A randomized study of antibiotic prophylaxis after hypospadias repair in children.

BACKGROUND AND OBJECTIVE: Antibiotic resistance is a challenge in contemporary world. Urethroplasty for hypospadias is one of the most common urological surgeries performed around the world, yet, there is still no consensus on the use of antibiotics pre- and post-operatively. Our objective was to analyze the effectiveness of antibiotic prophylaxis and therapy before, during, and after hypospadias repair in children. METHODS: A prospective randomized trial was carried out including patients with coronal hypospadias who underwent urethroplasty performed by one surgeon. Urethral catheters were used in all cases for 10 days. Study participants were randomly assigned in a 1:1:1 ratio to receive a single intraoperative administration of antibiotics (Group I); an intraoperative antibiotic prophylaxis and antibiotic therapy for 10 days until the removal of urethral catheter (Group II); no antibiotic administration (Group III). Randomization was performed using computer-generated permuted blocks with randomly varying block sizes, prepared by an independent statistician. The results were analyzed using the analysis of variance (ANOVA). The following criteria were compared: postoperative functional complications, such as: urethral fistula, stenosis, diverticulum; wound infection symptoms: hyperemia of surgical site, pain during palpation, and symptomatic urinary tract infection. RESULTS: A total of 300 patients were included in the study. Two patients (2%) in Group I, two patients (2%) in Group II, and four patients (4%) in Group III had urethral fistulas, requiring surgery 6 months after primary repair, yet without statistical difference between groups. We found no significant difference in frequency of symptomatic UTIs between three groups (p = 0.182). CONCLUSION: There is no effect of antibiotic prophylaxis and therapy on the frequency of postoperative surgical and infectious complications after urethroplasty for coronal hypospadias repair in children.

Humans↗

PubMed1979

Cecil urethroplasty with concurrent scrotoplasty for repair of hypospadias.

During 13 years about 8 per cent of 234 patients operated upon for hypospadias presented surgical problems of reconstruction of the urethra from the urethral meatus proximal to the penoscrotal junction. These cases commonly are referred to as perineal or penoscrotal hypospadias. The problem occurs when the urethral groove fails to develop adequately and the scrotal folds have failed to rotate caudally. This hypospadias is in contrast to penoscrotal or distal hypospadias, when the urethral groove is developed but fusion is incomplete. In these patients the Cecil procedure has been used but modified to extend the urethra from behind the penoscrotal junction to the glans at the second stage of the urethroplasty. The modification consists of rotating the scrotum caudally from its high location. The tension and acute angulation that contributed to frequent complications previously associated with such attempts have been avoided and results are satisfactory.

Humans↗

PubMed1979

Male hypospadias, 625 cases, associated malformations and possible etiological factors.

Records from 625 patients with hypospadias have been reviewed, with reference to associated malformations. Cryptorchidism was found to be the most common associated malformation and was present in 6% of cases with hypospadias. The highest incidence of cryptorchidism was found in the more severe forms of hypospadias. Other concomitant genital malformations, such as bifid scrotum, hypoplasia of penis and remnants of the Müllerian system showed the same pattern. The recorded incidence of bifid scrotum and hypoplasia of the penis was 4% and 8% respectively. A high incidence of abnormalities in the lower urinary tract was found; 50% of 84 patients investigated. The hypothesis of hypospadias being a result of testicular hormone insufficiency is discussed.

Abnormalities, Multiple↗

PubMed1975

[Hypospadias in infancy I) pathophysiologic considerations II) hormonal balance studies (author's transl)].

Animal studies (Goldman, Jost) and test results in patients with hypospadias (Bongiovanni, Zachmann, Knorr) put up the question, whether all forms of hypospadias could be caused by a disturbance or peculiarity of the adrenal or gonadal androgen metabolism. Healthy volunteers and boys with glandal, penile and scrotal hypospadias were examined for their basal hormon status and response to stimulation. The following test-results are uniform, however due to the small number of cases, we would like to use these data more as a suggestion for peculiarities of the androgen metabolism, these are: 1. signs of quantitatively decreased testosteron production. 2. signs of qualitatively deranged testosteron-biosynthesis in patients with hypospadias due to a) decrease in certain enzymes in the testosteron-biosyntheticpathway (3-beta-hydroxysteroid-dehydrogenase, 17,20-desmolase, 17-beta-hydroxysteroid oxidoreductase) b) increased peripheral conversion of androgen metabolites 3. signs of a suggested "saving" of androgens in the catabolism of those compounds and, last not least 4. signs of gonadal transformation of the adrenals, seen by increased adrenal androgen production and an adrenal transformation of the gonads, which can ultimately be considered as faulty differentiation of these 2 organ systems.

Androgens↗

PubMed2026

A stent-plus-irrigation protocol after adolescent hypospadias repair: a multicentre randomised controlled trial.

OBJECTIVES: To evaluate whether a stent-plus-irrigation protocol reduces complication rates following hypospadias repair in adolescents compared with catheter drainage alone. PATIENTS AND METHODS: In this multicentre randomised controlled trial, adolescents (Tanner Stage II-V) undergoing hypospadias repair were randomly assigned to either a stent-plus-irrigation group or a catheter-drainage group. The catheter-drainage group received standard urethral catheter drainage alone, whereas the stent-plus-irrigation group received an additional small-calibre urethral stent positioned within the reconstructed urethra and twice-daily saline irrigation. The primary outcome was the overall postoperative complication rate; secondary outcomes included urinary function and cosmetic outcomes. RESULTS: A total of 172 adolescents were assessed for eligibility, with 150 participants (75 in the stent-plus-irrigation group and 75 in the catheter-drainage group) included in the final analysis. Compared with the catheter-drainage group, the stent-plus-irrigation group demonstrated a significantly lower overall complication rate (risk ratio [RR] 0.33, 95% confidence interval [CI] 0.20-0.56; P < 0.001), urethral fistula rate (RR 0.27, 95% CI 0.14-0.51; P < 0.001), and surgical site infection (SSI) rate (RR 0.43, 95% CI 0.21-0.87; P = 0.020). CONCLUSIONS: A postoperative stent-plus-irrigation protocol was associated with lower rates of postoperative complications, particularly urethral fistula and SSI, compared with catheter drainage alone after adolescent hypospadias repair. Because the intervention included both an additional urethral stent and saline irrigation, the independent contribution of irrigation cannot be determined in this two-arm trial.

Humans↗

PubMed1979

Developmental anomalies associated with hypospadias.

We reviewed 272 patients with hypospadias who were treated surgically to survey the complicated anomalies in these patients. Urogenital anomalies were recognized in 40 per cent of the 272 cases and extra-urogenital anomalies were noted in 9.2 per cent. Undescended testis was the most frequently seen anomaly, having been noted in 13.2 per cent of the 272 cases. The incidence of male vagina or utriculus masculinus was 11.8 per cent, prepenile scrotum 7.7 per cent and hypoplasia of the testis 6.6 per cent. Each of these 4 anomalies associated with hypospadias increased in incidence in proportion to the severity of the penile deformity. The necessity of systemic urological and hormonal examinations was emphasized, especially in cases of severe hypospadias.

Abnormalities, Multiple↗

PubMed1979

Use of penile corporeal injection to assess coronal hypospadias.

Coronal hypospadias is a frequent abnormality of the genitalia. It is recommended that patients with coronal hypospadias be assessed with the technique of penile corporeal injection during anesthesia and any patient with coronal hypospadias should be circumcised with the utmost caution and surgical discretion.

Child↗

PubMed1979

Hypospadias: a familial study.

The families of 177 boys with varying degrees of hypospadias were evaluated prospectively to determine the occurrence of hypospadias and other congenital anomalies within this population. A significant number of male subjects in each family member category were affected, with first degree relatives (brothers and fathers) having a 14 and 9 per cent incidence, respectively. Siblings were at a greater risk for having this anomaly when the proband had a more severe degree of hypospadias and when the abnormality also was present in other relatives. A multifactorial mode of inheritance is suggested as the basis for transmission of this congenital defect.

Abnormalities, Multiple↗

PubMed1978

Etiologic considerations in penoscrotal hypospadias repair.

Superficial location of fivrous bands causing chordee in patients with penoscrotal hypospadias has been demonstrated by microscopic and gross photographs. Our technique to manage this problem is similar to that described by Allen and Spence and by King for distal hypospadias and has been used in 120 patients. The technique involves the repair of the embryologic penile defect by advancing the closure of the urethral groove and transposing the scrotum to its appropriate caudal position. The repair is applicable in patients with failure of fusion rather than failure of the development of the urethral groove as in perineal hypospadias.

Child↗

PubMed1975

Psychological factors in hypospadias repair.

Children undergoing hypospadias repair and their parents have anxieties related not only to the operation but to future expectations. These anxieties are expressed by children through their drawings and by parents through interviews. They are enhanced by the fact that the hypospadias defect is only noticeable to the parents and child and is kept as secret information. Other defects, such as cleft palate, are obvious and cannot be hidden. The anxieties associated with hypospadias appear to be different whem compared to those associated with more obvious deformities.

Adult↗

PubMed1976

Plasma androgen responce to hCG stimulation in prepubertal boys with hypospadias and cryptorchidism.

Serum levels of testosterone, androstenedione and dehydroepiandrosterone were measured before and after 5 days of treatment with hCG (2000 IU/d) in 36 prepubertal boys with cryptorchidism and 11 with hypospadias in order to determine whether a defect in androgen synthesis could be a common cause for these disorders. Baseline and stimulated levels of testosterone, androstenedione and dehydroepiandrosterone were similar in patients with unilateral cryptorchidism, monorchism and hypospadias; baseline and stimulated levels of testosterone were lower in boys with bilateral cryptorchidism. Testosterone levels did not correlate with either the anatomical location of the testis in patients with unilateral cryptorchidism or with the site of the urethra in boys with hypospadias. Seven of 36 patients with cryptorchidism had a positive family history of a similar disorder; testosterone levels were similar in patients with and without a family history. It is concluded: 1) in all patients studied, the gonadotropin dependent phase of testosterone production is present; 2) hCG stimulation cannot detect unilateral Leydig cell dysfunction; and 3) in familial cases of cryptorchidism, some factor other than an abnormality in androgen synthesis may be responsible for the hereditary tendency.

Adolescent↗