What are the Real Implications of Ventral Curvature in Distal Hypospadias
Melissa McGrath, BASc, Yacoub Jafar, MD, BRUNO LESLIE, MD, Luis H. Braga, MD, MSc, PhD.
McMaster University, Hamilton, ON, Canada.
Introduction: Ventral curvature (VC) assessment is one of the most critical steps in the repair of hypospadias. However, the implications of accurate measurement of VC in distal cases and its impact on the choice of subsequent surgical technique and clinical outcomes have yet to be objectively studied. Therefore, we sought to determine the rate of VC in distal hypospadias and how its severity affected the decision-making to proceed with single vs staged repair. Methods: We prospectively collected data on consecutive boys with distal hypospadias based on the initial location of the urethral meatus who underwent repair from 2015 to 2022. All patients had an erection test to confirm the degree of VC during the repair. VC was measured using a photograph angle measurement app. The following variables were captured: age at surgery, location of the urethral meatus, depth of glans groove, degree of VC before and after degloving, deviation of midline raphe and ventral skin deficiency (VSD). Results: Of 318 cases, 237 had distal penile hypospadias, 58 coronal, and 23 glanular defects. Median age at surgery was 17 months (IQR = 8). Thirty-seven had flat or no glans groove. VC was identified in 68% (n=216) patients, and ventral skin deficiency in 25%. Before degloving, VC was <30 in 78%, 30-70 in 20% and >70 in 2% of patients. After degloving, 76% had a completely straight penis, 19% had VC <30, and only 5% had curvature >30. VC was corrected by a stepwise approach, starting with the release of lateral chordee bands surrounding the spongiosum (n=171), proximal dissection beyond the penoscrotal junction (n=62), midline single-stitch dorsal plication (n=32) and urethral plate (UP) transection (n=2). Of those 14 patients with VC >30 after degloving (mean VC = 36±8.6), all had flat or no glans groove, 10 (71%) had deviation of the midline raphe, 4 VSD (29%) and 6 (43%) hypoplastic (thin) urethra with proximal division of spongiosum. Most (75%) underwent a dorsal inlay graft (DIG) or staged repair. Conclusion: Even though almost 70% of hypospadias patients with a distally located meatus have VC based on intraoperative erection test, only a minority (5%) have VC >30 (mean = 36) after degloving, indicating that a single-stage approach with minimal risk of VC recurrence can correct most distal cases. On the other hand, 70% of “distal” defects with VC >30 after degloving presented with flat or no glans groove and deviation of the midline raphe, which is suggestive of a more severe (proximal) phenotype, and, therefore, may call for UP augmentation either through a DIG or staged repair. Therefore, be aware of these “distal” hypospadias with hidden proximal characteristics, as failure to identify these phenotypes may result in inadequate VC correction and worse outcomes.
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