Operative treatment of severe forms of hypospadias.

Hypospadias is a polymorphic congenital malformation. Aside from the main defect-partial hypoplasia of the urethra--there are other associated malformations: meatal stenosis, penile curvature, penoscrotal skin malformations (pterygiae), partial aplasia of the ventral prepuce, and a large dorsal prepuce. Severe forms are accompanied by hypoplasia of the penis. Hypospadias can be divided into simple forms (anterior hypospadias), in which the meatus is located on the distal half of the penis, and severe forms (posterior hypospadias), in which the meatus is located on the proximal half of the penis, the penoscrotal border, scrotal sulcus, or perineum, either primarily or after elongation and chordectomy. The differences are not only morphological but have practical significance. These two types of hypospadias differ as to operative procedure, complications, and operative results, and cannot be compared with each other. Thus hypospadias must not be considered a single entity, as is often done in the literature, as this may lead to misinterpretation of results. Severe forms of hypospadias are a special problem which require more sophisticated corrective procedures; they are associated with a greater incidence of complications and the aesthetic result is not as good as in the other group. After disappointing results using the Denis-Browne, Cecil, and Broadbent methods, we modified Grob's preputial tube-plasty 15 years ago. This technique enables reconstruction of the urethra with a sufficiently large, well-vascularized, non-hair-bearing preputial skin. The new urethra is long and large enough, and grows along with the penis, avoiding secondary curvature. The incidence of postoperative fistulas is low, and secondary closure is simple and safe. The aesthetic result is also satisfactory. The disadvantage of this method, namely the three-stage operative procedure, is compensated for by the low incidence of fistulas, lower operative risk, and shorter duration of each operation, as well as the safety of the method. There is practically no risk of loss of the valuable dorsal preputial skin. For these reasons, even in the event of complications, the final result is always reliable. The simple operative technique and uncomplicated postoperative care also make this method suitable for smaller medical centers. The first stage of the procedure--formation of the preputial tube--can, if necessary, be combined with elongation and chordectomy, thereby saving one operative stage. The good functional and aesthetic results achieved in 196 patients, with no severe postoperative complications and only 37 instances of fistula formation justify further application of this method for the treatment of severe forms of hypospadias.