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Hypospadias is the most frequent genital variation in male newborns with an incidence of 1:200-300. The variation within this anomaly is very high, from isolated distal hypospadias to very complex penoscrotal cases with accompanying genital or nongenital anomalies, genetic anomalies or even disorders of sexual differentiation. In the literature one can find up to 250 different surgical techniques for hypospadias repair. The goal of the new S2k guideline on hypospadias (AWMF registry no. 006-026), developed by the German Association of Urology (DGU) and the German Association of Pediatric Surgery (DGKCH), was a certain standardisation of the preoperative diagnostic workup, the surgical management and the postoperative care of patients with distal, middle or proximal hypospadias. In this article, the most important facts of the guideline are presented using a fictional case of an infant with distal hypospadias. For further reading, we refer to the S2k guideline, which can be easily accessed by scanning the pictured QR code., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra., Objectives: To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction., Materials and Methods: The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity., Results: The general rules of reconstruction that should be applied in each particular situation are described., Conclusions: Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

The severity of secondary hypospadias can range from a mild cosmetic problem to severe functional impairment. Accordingly, surgical management of the defect can be either simple or extremely demanding. During the operation the penis should always be regarded as a functional unit so that the treatment goal of a good cosmetic and functional result can be achieved. In addition, the surgeon should have an extensive repertoire of operative techniques at his disposal and should be well versed in skin grafting methods so that he is able to adapt the procedure optimally to the intraoperative findings as necessary. If certain do's and don'ts of hypospadias correction are additionally observed good results can usually be obtained even in complicated hypospadias patients with multiple previous operations. Unreflected treatment, on the other hand, usually leads to further worsening of the problem resulting in the so-called hypospadias cripple.

Purpose: Reconstruction of urethral plate with hairless skin. Reconstruction of ventral penile skin in patients with hypospadia., Material and Methods: Utilization of foreskin or a circular penile island flap to form the urethral plate. Second stage urethral reconstruction with buccal mucosa. Resurfacing of the ventral surface of the penis with a foreskin island flap using the buttonhole technique. An innovation in contrast to previously described procedures is the resection of a transversal strip of dorsal penile skin to avoid bulky wedges of skin on the sides of the penis., Material and Results: The urethral plate was reconstructed in 2 hypospadia-scripples and in one patient with penoscrotal hypospadia. Urethra reconstruction with buccal mucosa was accomplished without complications in 2 patients in a second stage. Partial necrosis of the most distal port of penile skin was observed as a complication after the first operation in one patient. Functional and cosmetic results were good after treatment with split skin thickness grafts. The penis was straightened in 2 patients with hypospadis sine hypospadis and the urethra reconstructed according to Mathieu in 3 patients with distal urethral defects. The ventral skin defect was covered with an outer leaflet of foreskin island flap using the buttonhole technique. Complications were not observed postoperatively or in later follow-ups. Functional and cosmetic results were good in all patients., Conclusion: The foreskin island flap is excellent for reconstruction of missing skin on the ventral shaft of the penis.

Objectives and Methods: 252 hypospadias operations were performed at our department from 1985 to 1990. We conducted 173 primary repairs and 79 reoperations. In distal hypospadias (n = 98), we used the meatoplasty and granuloplasty procedure as well as the Mathieu technique. In penile hypospadias (n = 40), a tubularized dorsal preputial flap (Duckett procedure) was performed. Proximal and scrotal hypospadias (n = 23) were operated using a combination of Duckett's tube and the Thiersch-Duplay procedure., Results: We saw a 15% complication rate in distal hypospadias, 36% in penile hypospadias, and 27% in proximal hypospadias., Conclusion: The Mathieu technique gave a complication rate of 35.5% in our hands, and so it was replaced by the island onlay flap technique as described by Duckett.

Between January 1985 and December 1990, a total of 40 patients aged 2-40 years underwent surgical reconstruction for complicated failure of hypospadias repair. These included 19 patients with multiple previous operations, severely scarred skin, penile deviation, long urethral defects and scarred or cleft glans, who were classified as hypospadias cripples (group I). The remaining 21 patients had distal urethral defects and a scarred or cleft glans but better skin condition; this group was classified as having defects of the distal urethra and glans (group II). Island flaps were used in 17 patients, and transversal or axial random penile skin flaps in 18. In 4 patients the urethra was reconstructed with mesh graft and in 1 case, with a bladder mucosa graft. With the designed single-session procedure primary treatment was successful and free of complications in 52% of the patients in group I and 67% in group II. In each of 3 patients three further operations were required. In 15 patients revision surgery was confined to simple fistula closure, stricture incision or correction of scarred skin. Follow-up examination at 7-72 months showed that treatment had been successful in all patients.

The treatment of hypospadias has developed over the years from a disabling intervention to a surgical procedure devised with due consideration for the needs of paediatric patient. The operation is timed to fit in with the child's psychological development, being performed early in life before it becomes too traumatic for the child. Resection of the chordee and creation of the neourethra in a single session is increasingly superseding the two-stage procedure usual earlier, especially for distal and medial hypospadias. However, when the surgeon is sufficiently experienced even proximal hypospadias can be corrected in a single session, for example by a combination of a Thiersch and a free island flap or by free bladder mucosal flaps or grafts. The use of suitably fine instruments and suture material should be a matter of course, as should the use of magnifying lenses. Urinary diversion is still obligatory in most centres, and, like the sort of dressing used, it depends on the individual experience and judgement of the surgeon. The incidence of postoperative complications should be below 10% regardless of the degree of hypospadias.

We report 28 boys who underwent repair of a distal hypospadias with a combination of a modified meatal advancement and glanduloplasty and reconstruction of the foreskin. An excellent result was achieved in 24 patients. In 4 boys, preputial reconstruction failed. Only one group of parents demanded further surgery. Improved cosmetic results with avoidance of serious complications make this operation ideal for treating distal hypospadias in countries where the circumcised penis is an exception.