1 
 

Current Trends in Hypospadias Repair. Where are we Standing? 

Parisa Saeedi Sharifabad1, vahid Poudineh2, Mehran Hiradfar3,  Ahmad Mohammadipour4, 

Reza Shojaeian5 

1Associate professor of pediatric urology, Mashhad University of medical sciences 

Iran, Islamic Republic of 

2General Physician, Mashhad University of medical sciences 

Iran, Islamic Republic of 

3Associate professor of pediatric surgery, Mashhad University of medical sciences 

Iran, Islamic Republic of 

4Assistant professor of pediatric surgery, Golestan University of medical sciences 

Iran, Islamic Republic of 

5Assistant professor of pediatric, Mashhad University of medical sciences 

Iran, Islamic Republic of Head of pediatric surgery department – Akbar Children Hospital 

Akbar Children’s hospital; 14 Kaveh BLV; Mashhad; IRAN 

Phone: +989155150923 

Email: drshojaeian@ymail.com 

 

Hypospadias is a common congenital anomaly of male urogenital tract. The incidence of 

hypospadias is estimated as one affected boy in every 250 male live birth(1) while several 

reports and evidences indicate increasing rate of hypospadias.(2) 



 

2 
 

The history of hypospadias is backing to Roman emperor (3, 4) Different aspects of 

hypospadias such as it’s etiology, classification and treatment have been a place of 

discussion.(5) The choice of surgical technique depends on the surgeon’s personal experience 

and training.(6) Different specialties are involved in hypospadias surgical reconstruction 

including pediatric surgeons, pediatric urologists, general urologist and plastic surgeons and 

each group has their own principals and favorite techniques. (7) Several studies and reviews 

have been published to report the advantages and success rate of each method.(2, 8, 9)  

In this study we surveyed different groups of surgeons who are involved in hypospadias 

reconstruction about their preferences in treatment of various types of hypospadias. 

Method and materials: 

We designed a multiple choice questionnaire on google forms in English, including general 

questions such as name, age, email address, academic rank, duration of practice, estimated 

hypospadias reconstructive surgeries per month and finally their preferred method of treatment 

for three hypospadias cases that were introduced providing a brief history and some pictures, 

which is still available on line using the link: https://goo.gl/forms/jVRQRjLeqYt0Uqa93 

To determine the validity and reliability of the survey we distributed the printed version of 

questionnaire among some of audiences during Hypospadias and disorders of sexual 

development congress (HDSD) 2017 twice at the opening ceremony and gala dinner of 

congress and also take the expert opinion. 

Iranian pediatric surgeons, Iranian Pediatric urologists and Iranian urologists were invited to 

participate in this survey. Email address list was provided by Iranian society of pediatric 

surgeons and Iranian urological association contains 97 email address of surgeons in practice 

at the time of this study. 

https://goo.gl/forms/jVRQRjLeqYt0Uqa93


 

3 
 

A comprehensive search was performed in in PubMed central, Medline, Scopus, EMBASE, 

SciELO, Cochrane Database and google scholar from 2010 up to 2018 using combination of 

MeSH words of ‘Hypospadias ‘and ‘Surgery” and “Pediatrics” Total of 374 articles focusing 

on hypospadias reconstruction in pediatrics were identified.  Email address of corresponding 

author were available in 313 published articles. 291 Invitation E mails were sent after excluding 

duplicated addresses. All personal data of participants remained confidential and the study 

protocol was approved in ethical committee of Mashhad University of medical sciences with 

the confirmation code of IR.MUMS.MEDICAL.REC.1397.364. 

Results: 

Mean age of 170 surgeons who took part in this survey was 47.5±16.34 years. 42 professors 

(24.7%), 43 associate professors (25.3%) and 57 assistant professors (33.5%) participated in 

this study while the academic rank was not mentioned in 28 feedbacks (16.5%). 51 general 

urologists (30%), 61 pediatric surgeon (35.9%), 16 plastic surgeons (9.4%) and 42 pediatric 

urologists (24.7%) enrolled in this study. A high volume surgeon was defined as a surgeon with 

more than 50 hypospadias surgery per year (Almost 5 cases or more every month)(6) 61 low 

volume surgeons (35.9%) and 109 high volume surgeons (64.1%) were participated in our 

survey. Regarding the years of practice, 22 surgeons (12.9%) had less than 5 years surgical 

experience, 30 surgeons (17.7%) declared 5-10 years of experience and 118 surgeons (69.4%) 

were in practice for more than 10 years. 

36 Iranian surgeons were participated in this survey and we received 18 emails from North 

America, 8 emails from South America, 48 emails from Europe 41 emails from Asia (apart 

from Iran), 16 emails from Africa and 3 emails from Australia. 



 

4 
 

Preferred method of surgery for a simple distal hypospadias was tubularized incised plate 

hypospadias repair (TIP) in 53.5%, Thiersch-Duplay in 18.8%, meatal advancement and 

glanduloplasty (MAGPI) in 14.1% and Mathieu procedure in 4.7%.  

8.8% of participants suggested not to operate this case until adulthood and waiting for the 

patient to decide by himself. 

Surgical procedure of choice for the proximal hypospadias without cordee was tubularized 

incised plate hypospadias repair (TIP) in 39.4%, two stage Urethroplasty in 24.7%, Island 

Onlay Flap in 21.2%, Tubuluraized Prepupital Island Flap in 10%, Sleeve Advanced 

Urethroplasty in 3.5% and Asopa Procedure 1.2%. 

Suggested technique of reconstruction in proximal hypospadias surgery with severe cordee was 

Two-stage Bracka in 59.4%, Two-stage Durham Smith in 24.7%, Modified Asopa (Hodson) 

procedure in 8.8%, One-stage Ducket procedure in 5.9% and Koyanagi Nonomura one-stage 

repair in 1.2%.  

Comparing the technique of choice regarding the specialty of surgeons, operation load and 

geographic patterns was done and summarized in table 1. 

Surgical approach to distal hypospadias and proximal hypospadias without cordee were 

significantly different between high volume and low volume surgeons. The most popular 

technique in distal hypospadias was TIP in both groups but MAGPI was more popular among 

low volume surgeons. Proximal hypospadias without cordee was mostly corrected by TIP in 

low volume surgeons while TIP, onley island flap and two stage urethroplasty were suggested 

with almost the same rate in high volume surgeons. Onley island flap had popularity among 

high volume surgeons but it was not suggested commonly with low volume surgeons. 

Trends in proximal hypospadias with severe cordee repair was almost the same in both low and 

high volume surgeons and two stage Bracka or Durham smith were more accepted techniques. 



 

5 
 

Comparison of surgical approach to hypospadias among different is summarized in table 3. 

Mathieu procedure was suggested by 13.9% Iranian surgeons for distal hypospadias repair 

while it was uncommon in other countries. MAGPI procedure was also more common among 

Iranian compare to other countries. American surgeons were more interested in two stage repair 

to reconstruct different type of proximal hypospadias. European surgeons suggested Koyanagi 

repair and were not interested in Durham smith for severe proximal hypospadias repair while 

other surgeons suggested two stage Bracka or Durham mainly. 

Discussion: 

In this international internet base survey on hypospadias reconstruction we assessed and 

compare recent trends among surgeons who are involved in hypospadias repair in different 

specialties and countries to inspect any consensus on hypospadias surgery to date. Previous 

surveys revealed growing trends to TIP for distal hypospadias and two stage repair for proximal 

hypospadias reconstruction(6, 8) 

TIP was also the most common reconstructive method for distal hypospadias among all 

specialties. Surgical approaches were quiet the same in pediatric surgeons and pediatric 

urologists while adult surgeons recommended watchful waiting and Mathieu technique. 

Different specialties had almost similar approach to proximal hypospadias although island flap 

was not popular among urologists and plastic surgeons. Growing tendency to TIP in treatment 

of proximal hypospadias without cordee was notable compare to previous reports.(6, 8)  

Tendency to postpone hypospadias reconstruction to preschool age in plastic surgeons was also 

reported in other surveys(6) while several published literatures recommended the second 6-

months of life as the ideal timing of hypospadias repair.(7)  Experts believed that complications 

increase above this optimal age of operation.(2) 



 

6 
 

The most common approach to distal hypospadias among both high and low volume surgeons 

was TIP but low volume surgeons were more interested to minimal interventions while high 

volume surgeons were mostly believed on optimal correction of distal hypospadias. Both high 

and low volume surgeons suggested TIP for Proximal hypospadias without cordee. Low 

volume surgeons that may represented by the new generation of surgeons were not interested 

in Onley island flap compare to their high volume colleagues. Other previous international 

surveys were also reported a growing trend toward two stage repair for reconstruction of 

proximal hypospadias. (6, 10) 

A uniform surgical approach was seen in proximal hypospadias with severe cordee and both 

low and high volume surgeons suggested two stage repair. (Bracka or Durham smith)  

We studied the geographic pattern of surgical options in hypospadias repair. The results 

showed notable popularity of TIP and Thiersch-Duplay procedure in distal hypospadias repair 

while MAGPI and Mathieu techniques are less commonly used but Iranian surgeons were still 

interested in these methods. literature reported favorable outcome of TIP repair in distal 

hypospadias(9) although there is some concerns about meatal stenosis and abnormal 

uroflowmetry pattern after TIP repair(11) but  a consensus is evolving on the approach to distal 

hypospadias worldwide and recent recommendations are in favor of correction of distal 

hypospadias versus watchful waiting.(12) 

TIP is commonly used for correction of proximal hypospadias without cordee in Asia while 

various techniques were suggested in our survey from Europe. 

Two stage repair was the method of choice for severe proximal hypospadias with cordee in 

most of the feedbacks. There is technical variations among different surgeons and more 

challenges and complications should be expected in this field.(13) 



 

7 
 

This study was based on self-declaration and this was a limitation because some variables such 

as case load could be over-estimated by participants.  

Conclusion: 

• Some adult surgeons are still in favor of delayed or no intervention. 

• TIP is the most popular option for and distal proximal hypospadias without cordee 

hypospadias reconstruction  

• Most of surgeons suggested two stage repair for proximal hypospadias with severe 

cordee. 

  



 

8 
 

References: 

1. Horowitz M, Salzhauer E. The ‘learning curve’in hypospadias surgery. BJU 

international. 2006;97(3):593-6. 

2. Macedo Jr A, Rondon A, Ortiz V. Hypospadias. Current opinion in urology. 

2012;22(6):447-52. 

3. Lambert SM, Snyder HM, Canning DA. The history of hypospadias and hypospadias 

repairs. Urology. 2011;77(6):1277-83. 

4. Hadidi AT. History of hypospadias: Lost in translation. Journal of pediatric surgery. 

2017;52(2):211-7. 

5. Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypospadias dilemmas: a round 

table. Journal of Pediatric Urology. 2011;7(2):145-57. 

6. Springer A, Krois W, Horcher E. Trends in hypospadias surgery: results of a worldwide 

survey. European urology. 2011;60(6):1184-9. 

7. Manzoni G, Bracka A, Palminteri E, Marrocco G. Hypospadias surgery: when, what 

and by whom? BJU international. 2004;94(8):1188-95. 

8. Timmons M. The UK primary hypospadias surgery audit 2006–2007. Journal of plastic, 

reconstructive & aesthetic surgery. 2010;63(8):1349-52. 

9. Snodgrass WT, Bush N, Cost N. Tubularized incised plate hypospadias repair for distal 

hypospadias. Journal of Pediatric Urology. 2010;6(4):408-13. 

10. Cook A, Khoury AE, Neville C, Bagli DJ, Farhat WA, Salle JLP. A multicenter 

evaluation of technical preferences for primary hypospadias repair. The Journal of urology. 

2005;174(6):2354-7. 

11. Barbagli G, Perovic S, Djinovic R, Sansalone S, Lazzeri M. Retrospective descriptive 

analysis of 1,176 patients with failed hypospadias repair. The Journal of urology. 

2010;183(1):207-11. 

12. Bhandarkar K, Garriboli M. Repair of Distal Hypospadias: Cosmetic or 

Reconstructive? UROLOGY. 2019. 

13. Misra D, Elbourne C, Vareli A, Banerjee D, Joshi A, Friedmacher F, et al. Challenges 

in managing proximal hypospadias: A 17-year single-center experience. Journal of Pediatric 

Surgery. 2019;54(10):2125-9. 

  



 

9 
 

 

Table 1: Procedure of choice for various hypospadias scenarios regarding surgeons’ 

specialty and work load and geographic pattern  

 Proximai hypospadias 
with cordee (%) 

Proximal hypospadias without 

cordee (%) 
Distal hypospadias (%) 

M
o
d
ifie

d
 A

so
p
a
 (H

o
d

so
n

) 

O
n

e
 sta

g
e
 K

o
y

a
n

a
g

i 

T
w

o
-sta

g
e
 D

u
rh

a
m

 S
m

ith
 

T
w

o
-sta

g
e
 B

ra
c
k

a
 

O
n

e
-sta

g
e
 D

u
c
k

e
t  

T
w

o
-S

ta
g

e
 U

re
th

ro
p
la

sty
 

A
so

p
a
 P

ro
c
e
d

u
re

 

S
le

e
v

e
 A

d
v

a
n

c
e
d
  

T
u
b

u
la

riz
e
d

 P
re

p
u

tia
l F

la
p

 

Isla
n
d

 O
n

la
y
 fla

p
 

T
IP

 

T
IP

 

T
h

ie
rsc

h
-D

u
p

la
y
 

M
a
th

ie
u
 

M
A

G
P

I 

W
a
tc

h
 a

n
d

 w
a
it 

S
u

r
g

e
o

n
’

s sp
e
c
ia

lty
 

General Urologist 

1
5
.7

 

1
1
.8

 

7
.8

 

1
3
.7

 

5
1
 

3
7
.3

 

1
9
.6

 

1
3
.7

 

2
 

2
 

2
5
.5

 

5
.9

 

6
2
.7

 

2
5
.5

 

3
.9

 

2
 

Pediatric surgeon 

3
.3

 

1
3
.1

 

1
.6

 

2
1
.3

 

6
0
.7

 

4
7
.5

 

2
4
.6

 

8
.2

 

3
.3

 

0
 

1
6
.4

 

6
.6

 

5
9
 

1
8
 

1
4
.8

 

1
.6

 

Pediatric urologist 

4
.8

 

1
6
.7

 

2
.4

 

2
3
.8

 

5
2
.4

 

3
5
.7

 

2
1
.4

 

4
.8

 

4
.8

 

2
.4

 

3
1
 

4
.8

 

5
7
.1

 

3
1
 

7
.1

 

0
 

Plastic surgeon 

1
8
.8

 

1
8
.8

 

1
2
.2

 

1
2
.5

 

3
7
.5

 

2
5
 

1
2
.5

 

1
8
.8

 

6
.3

 

0
 

3
7
.5

 

6
.3

 

5
6
.3

 

3
1
.3

 

7
.1

 

0
 

P Value 0.184 0.653 0.824 

P
a

tie
n

t v
o

lu
m

e
 

Low volume 

1
6
.4

 

2
3
 

8
.2

 

8
.2

 

4
4
.3

 

5
9
 

1
1
.5

 

9
.8

 

1
.6

 

1
.6

 

1
6
.4

 

3
.3

 

6
0
.7

 

2
7
.9

 

6
.6

 

1
.6

 

High volume 

4
.6

 

9
.2

 

2
.8

 

2
4
.8

 

5
8
.7

 

2
8
.4

 

2
6
.6

 

1
0
.1

 

4
.6

 

0
.9

 

2
9
.4

 

7
.3

 

5
8
.7

 

2
2
.9

 

1
0
.1

 

0
.9

 

P Value 0.001 0.04 0.693 

g
e
o

g
r
a

p
h

ic
 p

a
tte

r
n

 

America 

3
.8

 

7
.7

 

0
 

3
8
.5

 

5
0
 

3
4
.6

 

1
9
.2

 

0
 

0
 

0
 

4
6
.2

 

0
 

5
3
.8

 

4
2
.3

 

0
 

3
.8

 

Europe 

1
0
.4

 

1
4
.6

 

4
.2

 

2
5
 

4
5
.8

 

2
9
.2

 

3
3
.3

 

6
.3

 

8
.3

 

2
.1

 

2
0
.8

 

1
2
.5

 

6
6
.7

 

2
.1

 

  

Asia 

9
.1

 

9
.1

 

2
.3

 

9
.1

 

7
0
.5

 

2
9
.2

 

3
3
.3

 

6
.3

 

8
.3

 

2
.1

 

2
0
.8

 

1
2
.5

 

6
6
.7

 

2
.1

 

1
8
.8

 

0
 

Africa 

9
.1

 

9
.1

 

2
.3

 

9
.1

 

7
0
.5

 

5
6
.8

 

9
.1

 

6
.8

 

0
 

0
 

2
7
.3

 

2
.3

 

6
5
.9

 

2
2
.7

 

6
.8

 

2
.3

 

Iran 

1
3
.9

 

2
5
 

1
3
.9

 

2
.8

 

4
4
.4

 

4
4
.4

 

1
9
.4

 

1
6
.7

 

0
 

0
 

1
6
.7

 

5
.6

 

5
2
.8

 

3
8
.9

 

2
.8

 

0
 

P Value 0.004 0.001 0.002