We initially determine if there is any disabling downward curvature (chordee) that requires correction, and perform a complete urethral evaluation to assess the presence or absence of stricture. Often the urethra can be repaired in one stage using redundant dorsal penile skin as a flap to create a new urethra with an opening at the tip of the penis.

When there is chordee, this can be due to a disproportionate development of the penis itself, but is more often due to tethering of the penis by the inelastic tissues in the area of the mal-developed urethra. This can be released at the time of surgery. The benefit is correction of the downward curvature and effective lengthening of the undersurface of the penis. However, this can then lead to the creation of a gap where there is a long segment of missing urethra, and circumferential tissue transfer is then required.

untreated-hypospadias
Untreated hypospadias. This patient was unable to have intercourse due to severe chordee.
chordee
Chordee, downward curvature of the penis that the patient did not consider disabling.

In 2003, we began using an innovative technique. Tissue from inside of the cheek (buccal mucosa graft) was used to create a new urethral strip (called the urethral plate). The excess skin from the top (dorsal) part of the penis was then used to complete the repair forming a tube of new urethra composed of both penile skin as a flap and the buccal tissue as a graft.

This technique was only once previously reported with short term follow-up with 2 patients. Subsequent to that surgery in 2003, we have used this new technique in 9 patients. With a follow-up of 8-88 months (mean 34), no patient developed a urethral stricture and all are currently without complication. Our results, which represent the largest series using this particular innovative technical modification in these severe cases, were presented at the 2010 Annual Meeting of the American Urological Association and will soon be submitted for publication.

Overall, hypospadias surgery can be accomplished with a high success rate and a low complication rate.