More than 300 operative techniques have been described for the correction of hypospadias. The surgeon should use the technique that brings in his own hand the best results.

The following algorithm summarizes Professor Hadidi´s protocol for different forms of hypospadias:

About one third of patients referred to the Hypospadias Centre had a failed TIP procedure. The concept of the TIP procedure results in leaving a large raw surface in the reconstructed urethra. This raw surface usually contracts during healing, resulting in a very narrow urethra and persistent fistula. Occasionally, the whole wound disrupts completely and urine comes out from the original opening.

The condition becomes more complicated when the surgeon during the TIP procedure has excised the foreskin. This makes the job of correction more difficult as there is no excess skin available to reconstruct the narrow urethra.

← Pin point meatus after TIP	← More urine from fistula
← Partial dehiscence	← Complete dehiscence

When the child has glanular hypospadias without chordee and the urethra is long enough to reach the tip of the glans, Professor Hadidi prefers to use the Double-Y-Glanuloplasty (DYG) technique. In this technique, the urethra is mobilized and brought to the tip of the penis. In other words, there is no new urethra reconstruction needed and therefore, the success rate is more than 98%.

When the urethral opening is in the outer half of the penis without deep chordee, Professor Hadidi prefers to use the Slit-Like Adjusted Mathieu (SLAM) technique. In this technique, a skin flap from the penile skin is turned upward to form the lower surface of the new urethra. The new urethra can be made as wide as the original urethra, and the success rate of this technique in experienced hands is more than 95%. Complications that include fistula, stenosis, and wound dehiscence are less than 5%.

The “Slit-Like Adjusted Mathieu (SLAM)” for distal Hypospadias:

When the urethral opening is in the inner half of the penis with deep chordee, Professor Hadidi prefers to use the Lateral Based (LAB) technique. In this technique, the hypoplastic tissues that prevent the penis from being straight are excised, and a skin flap from the penile skin as well as the prepuce is used to reconstruct the whole new urethra. The new urethra can be made as wide as the original urethra. The success rate of this technique in experienced hands is more than 85%. Complications that include fistula, stenosis, wound dehiscence, and diverticulum are less than 15%.

The Lateral Based (LAB) flap for proximal hypospadias with deep chordee:

When the urethral opening lies in the perineum and the scrotum is usually divided, sometimes one or both testes are not in the scrotum, Professor Hadidi prefers to perform a two-stage urethral reconstruction. In the first operation, the chordee is excised, the testes (when high) are brought down to the scrotum, and the glans is opened widely and covered with preputial skin as a preparation for urethroplasty. In the second operation, urethroplasty is performed to the tip of the glans. The success rate of this technique in experienced hands is more than 85%. Complications that include fistula, stenosis, wound dehiscence, and diverticulum are less than 15%.

The two-stage repair for perineal hypospadias with deep chordee:

Before operation	After the first operation	2 years after 2nd operation

Chordee means downward curvature of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well. Chordee is usually, but not always, associated with hypospadias.

80% of distal hypospadias have no curvature. The remaining 20% have curvature due to shortening of the skin, which is usually corrected during the operation for hypospadias.

According to Professor Hadidi’s experience, 50% of the patients with proximal hypospadias have no chordee or superficial chordee that can be corrected by skin mobilization. The other 50% of proximal hypospadias (Grade IIIb) have deep curvature that has to be corrected by excision of the short hypoplastic tissue that is usually present distal to the urethral opening.

Almost all patients with perineal hypospadias (Grade IV) have deep chordee that has to be corrected in the first-stage operation.

Essentially, there are two main types of chordee associated with hypospadias: Superficial and Deep chordee.

SUPERFICIAL type is usually present in 20% of distal hypospadias and in about 50% of proximal hypospadias. It is important to notice that in superficial chordee, the tethering bands and the penile curvature are present proximal to the hypospadias meatus (left photo).

The 2nd type of chordee is the DEEP chordee. It is usually present in about 50% of proximal hypospadias and about 10% of distal hypospadias. It is important to notice that in deep chordee, the hard, rigid tethering bands and the penile curvature are present distal to the hypospadias meatus (right photo).

Superficial chordee	Deep Chordee

The “Nesbit-Procedure” is a procedure that tries to correct ventral curvature of the penis by shortening the upper surface of the penis (dorsal plication). This usually results in further shortening of the penis.

Prof. Hadidi does not recommend this approach for the correction of the penile curvature, as it results in shortening an already short penis (correcting one deformity below by creating another deformity above).

In addition, many adults complain of short penis and painful erection following the Nesbit procedure or dorsal plication.

When a child has hypospadias associated with deep chordee (penile curvature), the first step is to correct the chordee. There are two approaches for this:

• Possibility A: Excision of all the hypoplastic tissues that prevent the penis from being straight. With this approach, the penis is straighter and longer than before surgery.
• Possibility B: Shortening the upper surface of the penis. With this approach, the penis is straight but shorter than before surgery. In addition, many adults complain of pain with erection, as the penile body needs space for expansion and is restricted above by the sutures and below by the hypoplastic tissue.

There are 3 possibilities regarding the remaining foreskin after urethral reconstruction:

• 1) Leave it as it is and perform either foreskin reconstruction or circumcision after 6 months.
• 2) Perform circumcision at the end of urethral reconstruction.
• 3) Perform foreskin reconstruction at the end of urethral reconstruction.

Professor Hadidi prefers to leave the foreskin as it is and deal with it according to the wishes of the parents, earliest 6 months after urethral reconstruction. This will be discussed in more detail at a later question.

About one third of patients referred to the Hypospadias Centre had a failed TIP procedure. The concept of the TIP procedure results in leaving a large raw surface in the reconstructed urethra. This raw surface usually contracts during healing, resulting in a very narrow urethra and persistent fistula. Occasionally, the whole wound disrupts completely, and urine comes out from the original opening. The condition becomes more complicated when the surgeon during the TIP procedure has excised the foreskin. This makes the job of correction more difficult as there is no excess skin available to reconstruct the narrow urethra.

A report from Anonymous Patient:

My Life With Hypospadias

The congenital malformation of the urethra is usually surgically corrected in early childhood. I am 28 years old now and I have not undergone this correction. It was not until puberty that I noticed that my penis actually looks slightly different from the other boys’ when the foreskin is retracted. Over time I felt ashamed, afraid of being exposed and did not want to stand in a row next to the others at the urinal. To avoid this I tried to go to the toilet alone or chose the cabin. To be made fun of for sitting down on a toilet while urinating was less annoying than a possible discovery of hypospadias, which caused me constant anxiety. Especially in puberty you don’t want to be “different”. I tried to suppress the malformation and avoided any sexual advances and contacts. It would certainly have been better if I had turned to my parents with this burden, but I was even ashamed to talk to them and did not bring the subject up to them. The repression eventually became part of my everyday life, subconsciously rather than self-protecting, because the panic and feeling of being different did affect my psyche.

It was only at the age of 20 that I learned by chance via the Internet that my congenital malformation of the urethra was a so-called hypospadias and that it occurs relatively frequently in newborn boys. The information on surgical corrections was mainly related to infants. Here it was always emphasized that an operation at the age between 12 and 18 months was the most advantageous. I assumed that a successful operative correction in adulthood was not a safe option due to the higher complication rate. I therefore rejected this option for the time being. Nevertheless, I felt better when I realized that I was not the only one who has this congenital malformation and that surgery was basically possible. From this point on, I felt a little safer with hypospadias and dared to allow physical contact. The women I met reacted very differently to hypospadias. I experienced rejection, indifference but also understanding. Nevertheless, getting to know each other is relatively difficult, as the malformation continues to be very unpleasant for me and for this reason I try to find out in advance how this person would react to such malformations. Of course, this does not always work as hoped and often seems contrived and awkward. A normal, relaxed getting to know each other is not possible for me.

The urethral malformation does not restrict me very much from a purely functional point of view, rather it represents a great psychological strain. Over time it becomes more and more difficult for me to live with it without having worries about it and I do suffer from it. I want a change and so I resumed the research on the topic of hypospadias corrections for adults and came across the website of the hypospadias centre of the Emma Klinik in Seligenstadt. The treatment spectrum on the main page already lists the surgical correction for adults. I arranged an appointment with Prof. Hadidi. Among other things, Prof. Hadidi explained to me straightforwardly and plausibly the possible risks of a surgical correction and seemed very professional to me. Especially the specialization in hypospadias as well as Prof. Hadidi’s expertise in adults and his international reach have convinced me. I am now awaiting the operation and hope that everything will go well.

Pin point meatus after TIP	More urine from fistula

We tell the parents not to look at the penis for one month after surgery until the swelling disappears and the wound has healed by 70%.

However, the mother should contact the surgeon when the child has severe pain or difficulty passing urine or cannot pass urine for more than 6 hours.

Normally, there is no need to go to your pediatrician regarding the operation. If there is real worry, you need to contact your surgeon.

However, if your son develops fever or other complaints not related to the operation, you should go to your pediatrician as is usually the case.

If your son has no (or little) pain when passing urine and the wound is not very swollen or red, it is almost certain that the fever has nothing to do with the hypospadias operation. You should contact your pediatrician to exclude flu, chest infection, teething, etc.

Professor Hadidi uses very fine absorbable sutures (finer than the human hair) and they dissolve spontaneously between 1-3 months after surgery, so there is no need to remove them. However, some of the threads may take longer than that in some patients. This is normal and should not alarm the parents or the patient. It is important not to try to pull them out, as this may interfere with the healing.