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Surgical management of primary severe hypospadias in children: an update focusing on penile curvature

Nature Reviews Urology volume 19, pages 147–160 (2022)Cite this article

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Abstract

Over the past two decades, assessment and treatment of associated curvature has emerged as a major issue in treating patients with proximal hypospadias. However, the cut-off for defining a curvature as clinically significant is still unclear, as not all patients are bothered by the same degree of curvature and, although the need for a method to assess the curvature objectively has been emphasized, no standard method yet exists. Curvature is multifactorial. The same degree of curvature can be due to any possible combination of skin and/or subcutaneous dartos tethering, a short urethral plate and an intrinsic corpora disproportion. Different strategies can be used to treat curvature, depending on the underlying cause, surgeon preferences, and the goals of the repair. In the past 10 years, use of urethral plate transection and ventral lengthening procedures has increased, although the lack of long-term follow-up data on ventral lengthening procedures suggests that the use of such procedures should be selective. Furthermore, straightening manoeuvres are influenced by the technique used for subsequent urethroplasty and, in turn, may influence the success rate of the urethroplasty. This Review provides a comprehensive overview of the major developments from the past 10 years in the management of severe proximal hypospadias in children.

Key points

  • For clinical practice, 30° is a reasonable cut-off to define clinically significant curvature, but many patients with a curvature above this cut-off point might not be bothered by the curvature.

  • Objective measurement of curvature is important, but difficult to achieve consistently in patients with hypospadias preoperatively, intraoperatively and especially during follow-up.

  • The same degree of curvature can be caused by different factors and can require different treatments; therefore, a systematic step-wise approach is recommended for management.

  • In general, preserving the urethral plate does not contribute to straightening, is not advantageous for the urethroplasty, and can increase the risk of curvature recurrence and result in a shorter penis.

  • Ventral lengthening procedures can be important for straightening a penis without foreshortening it, but should be used judiciously in the absence of long-term follow-up data.

  • Similar outcomes can be achieved using different urethroplasty techniques and an important component of hypospadias repair is a skin reconfiguration with ventral transfer of healthy and well-vascularized skin.

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Fig. 1: Assessing penile curvature.
Fig. 2
Fig. 3: Protractor for the measurement of curvature.
Fig. 4: Procedures for penile straightening after urethral plate transection.
Fig. 5

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Authors and Affiliations

  1. Paediatric Urology Unit, Department of Surgery, Bambino Gesù Children Hospital and Research Institute, Rome, Italy

    Marco Castagnetti

  2. Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy

    Marco Castagnetti

  3. Department of Paediatric Surgery and Urology, Reference Centre for Rare Urinary Tract Malformations (MARVU), Hôpital Robert Debré, APHP, Université de Paris, Paris, France

    Alaa El-Ghoneimi

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M.C. researched data for the article. Both authors made substantial contributions to discussion of content, wrote the article, and reviewed and edited the manuscript before submission.

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Correspondence to Marco Castagnetti.

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Castagnetti, M., El-Ghoneimi, A. Surgical management of primary severe hypospadias in children: an update focusing on penile curvature. Nat Rev Urol 19, 147–160 (2022). https://doi.org/10.1038/s41585-021-00555-0

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