Chapter 64

### Key Points

1. Higher rates of cryptorchidism and inguinal hernia.

2. Due to the higher incidence of DSD in patients with hypospadias and nonpalpable testicles an evaluation of these patients should be done.

3. Difficulty in passing a catheter at the time of hypospadias repair may be due to the presence of a utricle.

4. Imaging of the upper tracts in hypospadias patients is not routinely done unless there is another indication.

5. The components of hypospadias repair are: correction of chordee, urethroplasty, reconstruction of the glans, and skin coverage.

6. Currently, the repair of most hypospadias is based on the intact urethral plate.

7. The technique used is based on the location of the urethral meatus and the severity of the chordee.

8. Chordee correction should be done prior to urethroplasty.

9. Hypospadias surgeons should be comfortable performing repairs on the full spectrum of hypospadias as findings at the time of operation may reveal a more severe defect.

10. Early complications include bleeding, hematoma, and infection.

11. The rate of late complications is based on the degree of hypospadias and the type of repair used.

12. The overall reoperative rate is 9.8%.

13. Patients with fistulae or urethrocele should be evaluated for distal stenosis.

### Introduction

Hypospadias represents an arrest in development of the urethral spongiosum that results in hypoplasia of tissues that form the ventral surface of the penis. This manifests as a triangular defect with the apex at the division of the corpus spongiosum, the split corporeal tissue making up the sides, and the glands comprising the base. The result is 3 anatomic anomalies: a proximal location of the urethral meatus, ventral penile curvature, and a dorsal hooded foreskin. The diagnosis is not excluded if one of the above is not present (Fig. 64-1). Uncommonly, a variant of hypospadias is encountered in which the foreskin is completely intact. The diagnosis in these cases is often made at the time of newborn circumcision. This condition is often referred to as the “megameatus” variant of hypospadias.

###### Figure 64-1

A patient with proximal hypospadias showing the typical physical exam finding of a dorsal hooded foreskin, a proximal urethral opening, and ventral chordee.

#### Epidemiology

Hypospadias occurs in approximately 1 in 200 to 1 in 300 live births. Registry data show variation in the incidence between countries ranging from 0.2% in Sweden to 0.7% in the Netherlands. Several large registries of birth defects have reported an increase in the incidence of hypospadias over the past several decades. This may be explained by better reporting to registries of minor forms; however, several factors have been cited as causing a true increased incidence. Environmental “estrogen pollutants” which are thought to act as endocrine disruptors that effect fetal virilization have been implicated in this increase as well as an increase in testicular cancer and decreasing semen quality. Maternal estrogens such ...

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