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Purpose: During the last 10 years there has been controversy in the approach to severe hypospadias. Many pediatric urologists have elected to perform a 2-staged procedure to minimize complication rates and improve cosmesis. We continued to perform a single staged repair using the Hodgson XX or Koyanagi technique for even the most severe hypospadias. We review our results during the last 5 years in severe cases of penoscrotal hypospadias with bifid scrotum or penoscrotal transposition., Materials and Methods: The medical records of 20 consecutive children presenting to a single surgeon from 1996 to 2000 with severe penoscrotal hypospadias were reviewed. Patients underwent a 1-stage repair using an operative microscope. Cases not requiring further surgery were grouped as successful while cases requiring subsequent procedures were considered as complications., Results: After an average followup of 23 months 16 patients have not required subsequent procedures. Two patients had urethrocutaneous fistulas and 2 had a urethral diverticulum for an overall complication rate of 20%. All 4 patients were successfully treated with 1 additional procedure and have not required further intervention. Another patient with a small urethral diverticulum is being treated conservatively. All patients had satisfactory cosmetic results., Conclusions: We believe that a single staged repair can be safely and effectively performed even in patients with the most severe penoscrotal hypospadias. The Hodgson XX and Koyanagi repairs are excellent techniques with relatively low complication rates. Pediatric urologists should continue to use these techniques in their armamentarium and strive to perfect a 1-stage approach to severe hypospadias.

Purpose: The complication rate after Mathieu hypospadias repair was recently reported to be 3.6% in unstented cases. We reviewed our experience and results of the Mathieu repair performed at our institution during the last 5 years., Materials and Methods: We performed 197 primary and 5 secondary repairs in 202 patients. Reconstruction of the neourethra was done with a 2-layer anastomosis using optical magnification. Urethral stents were placed for postoperative drainage in all but 1 patient. Followup was up to 54 months., Results: There were no incidences of stent migration or symptomatic urinary tract infection while the stent was in place and all patients voided spontaneously after stent removal. Excellent cosmetic results were obtained in 201 cases. In 1 patient meatal retraction required subsequent meatoplasty with meatal advancement. In 2 patients pinpoint urethrocutaneous fistulas were successfully repaired. The total rate of reoperation was 1.5% in our series. There was no report of urethral stricture during followup., Conclusions: The well established Mathieu repair provides excellent cosmetic and functional results. The overall complication rate is minimal and compares favorably with stentless repair. A 2-layer neourethral anastomosis performed under sufficient optical magnification produces a watertight closure with minimal risk of fistula formation. Postoperative urethral stenting decreases this risk even further, while adding only minimal morbidity. We believe that in the era of newly reported techniques the well established Mathieu procedure should be the standard by which distal repair is judged.

We present our experience with the pyramid hypospadias repair in 37 patients with distal or subcoronal hypospadias. We also describe a significant modification (in the 7 most recent patients) of Duckett's original procedure that minimizes the risk of ventral fistula formation. This modification involves the creation of a vascularized second-layer tissue flap. We incorporated the modified pyramid hypospadias repair into the general surgical approach to subcoronal hypospadias. Our operative approach permits the delayed selection of either a perimeatal-based flap, preputial flap or a modified pyramid type repair after release of the shaft skin. In 35 patients the repair achieved excellent results, while only 2 had urethrocutaneous fistulas. No patient who underwent the modified repair suffered fistula formation. Our surgical technique is applicable to a number of variants of subcoronal hypospadias and maximizes repair options.

Hypospadias and cryptorchidism constitute common problems in urology for which the use of routine screening urography has been challenged recently. To assess better current thinking 233 urologists who devote a significant part of their practice to children were surveyed as to the number of procedures performed as well as to the instances when excretory urography was obtained. Of 163 physicians who responded 70 per cent do not favor routine screening urography in cryptorchid patients, while approximately 50 per cent believe that it is worthwhile in hypospadias. In the cryptorchid responses there was a definite decrease in the percentage of physicians obtaining x-rays as the yearly volume of cases increased (50 per cent with less than 10 cases per year and 18 per cent with greater than 20 cases per year), while this relationship was not maintained for hypospadias. A review of the literature correlates well with this survey in that excretory urography is not necessary in cases of cryptorchidism but its value is still debated in cases of hypospadias.

Psychological concerns for the timing of medical procedures on children result from the longstanding realization that events and behavioral patterns of childhood have wide-ranging effects on the later behavior of the adult. A review of the literature regarding the effects of surgery on psychological development is presented. Particular reference is made to the impact of genitourinary surgery with specific emphasis on the repair of hypospadias, a congenital anomaly affecting 1:250 to 1:400 live male births. Studies of adults who underwent hypospadias repair as children suggest that they are psychologically different from their peers who did not have this surgery. Specifically, as adults they frequently have sexual difficulty despite erectile competence and they generally occupy less responsible, less competitive, and less independent professions than similarly intelligent cohorts. These findings imply that the experience of hypospadias or its surgical repair may in some way affect psychological development. By examining these experiences in light of emotional and cognitive development and the emergence of body image and sexual identity, predictions for psychologically optimal timing of surgery are made. Importance of the role of the family in the psychological outcome and a discussion of surgical considerations are also provided.

The use of optical magnification (loupes) to repair hypospadiac anomalies in children is well known. A mouth-controlled operating room microscope (Zeiss OPMI 6CH Contraves Stand) became available that has been utilized in 34 cases of hypospadias repair which included 13 flip-flap, 4 MAGPI, 14 Hodgson XX (modified Asopa), and 3 other procedures. Other results show that in 2 patients fistula developed and in 1 meatal stenosis. Based on our experience, we believe this new microscope compares favorably with previous results and allows the surgeon to use small sutures with great accuracy.

Between 1977 and 1981, 106 children were operated on for hypospadias anomalies. Of these patients 51 have undergone the modified flip-flap urethroplasty or meatal advancement and glanuloplasty, 30 were repaired using a 1-stage Hodgson or Duckett tube urethroplasty, 10 have completed a 2-stage Belt-Fuqua procedure and 15 were treated for multiple complications. A urethrocutaneous fistula developed in 4 patients (4 per cent), meatal stenosis in 3 (3 per cent) and a transient urethral stricture in 1 (1 per cent). All procedures were performed using optical magnification, 2.5 times during the first 1 1/2 years followed by 4.5 times during the subsequent years. In addition, 58 children completed repair before age 2 years, with a mean age of 16 months, with no difference in complication rate. These results indicate that through the use of optical magnification hypospadias surgery can be accomplished safely using a 1-stage reconstruction repair before the child is 2 years old.

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.

The management of patients with hypospadiac anomalies requires sound surgical judgment to obtain optimal results. From January 1983 to June 1985, 150 patients were operated on for hypospadias. Of these patients 37 underwent the Hodgson XX (modified Asopa) repair. Two patients suffered urethral fistulas, 1 had meatal stenosis and 1 had mild torsion. No strictures were noted. Based on our findings it appears that the Hodgson XX (modified Asopa) procedure provides excellent results for patients with hypospadias and chordee.