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Introduction: Re-operative penile reconstruction is challenging and requires tension-free skin closure. The repair popularized by Cecil and Culp in the 1940s, using the scrotum to provide a temporary vascularized bed for complex hypospadias repairs, fell out of favor due to temporal trends towards single-stage repairs and concern for utilizing hair-bearing skin on the penile shaft., Objective: It was hypothesized that a modified Cecil-Culp (CC) concept of penile scrotalization, leaving the penis attached to the scrotum for 1 year rather than 6 weeks as originally described, improves outcomes with this reconstruction for ventral skin deficiency or poor vascular support., Methods: Institutional Review Board-approved registries were reviewed to identify patients who underwent a CC repair during 1987-2016 at two institutions. Cecil-Culp technique was utilized in multi-stage hypospadias complication repairs or for insufficient ventral penile shaft skin coverage. Anatomic abnormality, number and type of prior surgeries, and complications before and after CC were recorded., Results: Thirty-nine patients underwent CC: 23 failed hypospadias repairs, three hypospadias after bladder exstrophy, 10 penile curvature following circumcision, and three with skin loss from trauma. Mean age at CC was 61.8 months (hypospadias), and 59.8 months (non-hypospadias). Hypospadias patients underwent a mean of 3.6 surgeries (range 1-9) prior to CC. Four of the 39 patients (10.3%) had perioperative complications after CC, including scrotal abscess, skin infections, and difficulty removing the urethral stent. Eight of 37 (21.6%) patients had longer-term complications related to their hypospadias repair, including fistulae, diverticula, dehiscence, and stricture. Mean time from CC placement to release was 345 and 473 days for hypospadias and non-hypospadias cases, respectively. There was no apparent scrotal skin transferred to the penile shaft at the final take-down. Mean follow-up was 22.3 months., Discussion: Embedding the penis into the scrotum for added vascularity and ventral skin coverage has been used effectively in cases of the most tenacious fistulas and for significant skin loss and trauma. Limitations of this study were its retrospective approach at two institutions over an extended period of time by multiple surgeons, so patient selection and procedure may have varied., Conclusions: Modification of CC repair by delaying 9-12 months before CC take-down enhanced the benefits of a robust vascular bed for wound healing, and helped to avoid transfer of hair-bearing scrotal skin to the penile shaft. The CC technique is an important tool for penile reconstructive surgery of complex hypospadias repairs with inadequate skin, and for traumatic injuries., (Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: Boys with complex penile anomalies often undergo multiple operations, leaving a paucity of unscarred skin for further reconstructive procedures. Our objective was to evaluate the ability of tissue expansion to provide local skin for successful phallic reconstruction., Materials and Methods: Eighty boys (mean age of 11.9 years) with hypospadias (n = 42) or epispadias (n = 38) formed the study cohort. All patients had undergone at least one failed reconstructive operation. Indications for tissue expansion included scarcity of penile skin with urethral stenosis, urethrocutaneous fistula, chordee, and/or residual defect. One or two expanders were placed under the skin of the penile shaft and removed at the time of reconstruction., Results: Average time between expander placement and reconstruction was 10.9 weeks. Mean follow-up time was 25.3 months. Complications during expansion occurred in 33 patients (41.3%). Twenty-two patients (27.5%) had at least one expander removed prematurely and 46.9% were replaced. Expansion yielded adequate tissue for reconstruction in 76 patients (95.0%). Successful outcomes were achieved in 39 patients after initial reconstruction and 25 patients after further intervention, yielding an overall success rate of 80.0%., Conclusion: Tissue expansion is a useful tool with an acceptable rate of complications for phallic reconstruction in patients who have failed prior surgical reconstruction., (Copyright © 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: The early evolution of surgical reconstructive techniques has been well documented in the literature. However, a review of the Johns Hopkins hospital surgical files revealed an interesting participant in early hypospadias repair: Harvey Cushing (1869-1939)., Methods: Following IRB approval, we reviewed the surgical records from 1896 to 1912 and selected from among his non-neurosurgical patients, one case of first-stage hypospadias repair., Results: Cushing operated upon the 21-year-old patient, performing a first-stage repair of hypospadias, in conjunction with a repair of a right inguinal hernia. The patient was discharged following a second stage operation. At that time, the patient was in good condition and was voiding appropriately. There was no further follow-up., Conclusion: The repair of hypospadias evolved through the work of European surgeons, from the mid-eighth century through the early nineteenth century. The case we report here illustrates Cushing's early work in the fields of urologic and plastic surgery.

Purpose: The purpose of this study was to determine if there is an increased incidence of hypospadias in male offspring conceived by in vitro fertilization (IVF)., Materials and Methods: A retrospective institutional chart review from 1988 to 1992 and data from the Maryland Birth Defects Registry were statistically analyzed to assess the risk of hypospadias with IVF., Results: The data for the 5-year period indicated a 5-fold increased risk of hypospadias after IVF, with an incidence of approximately 1.5% in the IVF group and 0.3% in the control group. The only recognized difference between the groups was maternal progesterone administration in the IVF group but the cause of the increased risk of hypospadias was unknown. The distribution of hypospadias severity was similar in both groups., Conclusions: Male newborns conceived by IVF have a 5-fold increased risk of hypospadias, which may be related to maternal progesterone administration, or other maternal or fetal endocrine abnormalities that may or may not be related to infertility. Health care providers should be aware of this risk so that they can properly counsel infertile couples seeking assisted reproduction by IVF technology.

We report on 24 patients with hypospadias and severe chordee that could not be straightened with conventional techniques. We used small dermal grafts to augment the ventral tunica albuginea, which resulted in a completely straight, normal appearing erection in all patients. Subsequent urethroplasty was not complicated by the presence of the dermal graft. This procedure is technically straightforward and consistently results in a completely straight penis. Although required only rarely in hypospadias surgery, we recommend the dermal graft technique of tunica albuginea augmentation for cases of refractory chordee.

The goal of our study was to determine the frequency of endocrine abnormalities in sexually mature men with mild hypospadias. For this purpose we evaluated 16 men 22 to 52 years old with mild hypospadias. All patients had a urethral meatus distal to the penoscrotal junction. Serum concentrations of luteinizing hormone, follicle-stimulating hormone and testosterone were measured in all subjects. Dihydrotestosterone and testosterone precursors also were determined in men who had abnormally elevated levels of luteinizing hormone. The level of serum luteinizing hormone in patients was significantly higher than that of normal men, whereas the levels of serum follicle-stimulating hormone and testosterone were similar to those of normal subjects. Of the 16 men with mild hypospadias 3 had abnormally elevated levels of gonadotropins: 2 had primary gonadal dysfunction (elevated luteinizing hormone and follicle-stimulating hormone with low or normal testosterone) and 1 had hormonal evidence of partial androgen insensitivity (elevated luteinizing hormone, normal follicle-stimulating hormone with high normal testosterone and dihydrotestosterone). These patients are rather unique, since they did not have other compromising factors to account for the gonadal failure. In summary, our data demonstrated the presence of endocrine dysfunction in men with mild hypospadias.

Sixty-four cases of hypospadias repair by the Denis-Browne technique are reviewed. A urethrocutaneous fistula was the most common postoperative complication. Other less frequent complications were urethral stricture, residual chordee and improper location of the urethral meatus. These complications were corrected adequately and the results were satisfactory in all patients. This technique is simple, sound and trustworthy.

To determine which form of urinary diversion is most effective for each type of hypospadias, we polled all full-time practicing pediatric urologists in the United States and Canada. Each was asked to complete a questionnaire, specifying the method of urinary diversion used, based on the severity of the hypospadias. Ninety-eight per cent (84 of 86) of the urologists contacted replied to the survey. Our findings suggest that: Urinary diversion is usually not necessary for very mild types of hypospadias. Intraurethral drainage is the preferred form of diversion for moderate types of hypospadias. Suprapubic drainage with an intraurethral stent is the favored means of diversion for severe types of hypospadias. Perineal urethrostomy is rarely used today in hypospadias surgery.

Of 142 patients with hypospadias seen at this institute over the past 2 years, 8 developed meatal regression following repair of their anterior hypospadias with the meatal advancement and glanuloplasty technique (MAGPI); 5 had meatal regression which was attributed to a technical failure and 3 had severe regression of the meatus with significant subcoronal positioning, suggesting poor patient selection. None of these patients had chordee on intraoperative artificial erection. Five were treated successfully with a repeat MAGPI procedure and the remaining 3 required a Mathieu procedure. Although best indicated for mild degrees of anterior hypospadias, the success of the MAGPI procedure still requires meticulous technique and proper patient selection.

The cause of hypospadias in the majority of patients is unknown. We examined the hypothesis that hypospadias might be explained by androgen receptor abnormalities in the atretic spongiosal tissue commonly known as chordee. We studied 10 patients with relatively severe hypospadias but with a predominantly male phenotype and no readily ascertained explanation for the defect, including no evidence of an abnormality in testosterone biosynthesis. Eight subjects had midshaft hypospadias and 2 had a penoscrotal meatus. All 10 patients had severe chordee. Serum concentrations of testosterone, and luteinizing and follicle-stimulating hormones were measured before human chorionic gonadotropin stimulation and a serum testosterone level was determined 24 hours after the last dose of a 5-day human chorionic gonadotropin stimulation (3,000 units per M.2 per day). Androgen receptor content and binding affinity were assayed in fibroblasts cultured from preputial skin and chordee tissue of patients and foreskin from normal male neonates. With the endogenous ligand dihydrotestosterone the mean number (maximum binding capacity) of androgen receptors was 1,013 fmol. per mg. deoxyribonucleic acid in preputial skin and 833 fmol. per mg. deoxyribonucleic acid in chordee tissue of patients, and 627 fmol. per mg. deoxyribonucleic acid in the foreskin of controls. With the nonmetabolizable, synthetic androgen methyltrienolone (R1881) the mean maximum binding capacity was 1,004, 722 and 758 fmol. per mg. deoxyribonucleic acid, respectively. Dihydrotestosterone receptor affinity (dissociation constant) was similar in preputial skin (0.20 nM.) and chordee tissue (0.21 nM.) from patients, and foreskin (0.29 nM.) from controls. Androgen receptor binding affinity of R1881 also was similar (0.30, 0.24 and 0.21 nM., respectively). Furthermore, the 5 alpha-reductase activity of preputial skin and chordee tissue of patients with hypospadias was similar to that of foreskin from normal neonates. In conclusion, isolated hypospadias in these subjects was not associated with androgen insensitivity of the spongiosal tissues on the basis of either decreased androgen receptor binding affinity, receptor number or conversion of testosterone to dihydrotestosterone.