Two-Stage Repair for Severe Hypospadias

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Abstract
In 39 patients a 2-stage modified Belt-Fuqua repair was performed for severe hypospadias and chordee. Patient age at initial surgery averaged 2 years and stage 2 was done 7 months later. Testosterone was given before stage 1 to 22 patients (56%) and before both stages to 13 (33%). Of 5 patients with intersex 2 had mixed gonadal dysgenesis, 1 was a true hermaphrodite and 2 were 46 XX male subjects. The preoperative meatal location was subglanular in 9 cases, mid shaft in 8, proximal shaft in 2, penoscrotal in 15 and perineal in 5. Those with subglanular meatus had hypoplastic distal urethras and severe chordee. A dorsal Nesbit procedure for chordee correction was done in 24 cases (62%). Neourethral length ranged from 3 to 7 cm. (average 4 cm.) and average followup was 16 months. Neourethral diverticula developed in 8 cases (21%) and they were repaired uneventfully an average of 7 months (range 2 to 24) after stage 2. Minor urethral strictures (3 distal and 4 proximal) were treated with a single visual internal urethrotomy and there was 1 (2.5%) urethrocutaneous fistula. All children had excellent cosmetic and functional outcomes. A staged approach allows for cosmetic reconstruction of the glans and mucosal collar during stage 1 and offers 2 opportunities to augment penile size with testosterone. Bladder or buccal mucosal grafts are avoided since the prepuce is always adequate. There are no hypospadias deformities, penile shaft torsion or asymmetry. Fistula formation is minimal and strictures are minor. The 2-stage repair remains a safe, reliable alternative for boys with severe hypospadias.