BACKGROUND: Successful proximal hypospadias repair requires that ventral curvature (VC) be straightened, since persistent or recurrent curvature >30° has been associated with increased urethroplasty complications. This is challenging, however, given that bending averages 70º and can range to 130º. Although persistent / recurrent curvature has been identified within 6 months after repair, it may be difficult to diagnose in boys. Consequently, we determined outcomes of 3 corporotomies by repeating artificial erections at each subsequent operation of a 3-stage STAC repair done at least 6 months apart, and during reoperations for complications. METHODS: 3 corporotomies for ventral lengthening were made during stage 1 of primary or reoperative STAC repairs, releasing tension in the corporal sheath. VC was measured by goniometry. Repeat artificial erections were done at each subsequent stage or reoperation for complications. Tanner 5 adults ≥ 18 yrs were systematically queried regarding erectile dysfunction. The primary outcome was persistent VC of any degree. Secondary outcomes were ED in adults defined as inability to achieve or maintain an erection for intercourse or masturbation, or bleeding complications defined as any intervention on the Clavien Dindo scale. RESULTS: From 2019-2022, 228 consecutive patients underwent STAC with 3 corporotomies, comprising 131 primary repairs and reoperations in 70 boys and 27 adults (mean age 29, 18-55). VC averaged 66º (30-130), with 1 of every 3 primary cases measuring ≥ 90º. The last artificial erection was >12 months after straightening in all patients, averaging 21 months. 84% and 99% had no VC at stage 2 and 3, respectively. Residual VC in 16% averaged 23° (15-30), and was successfully straightened by a single Heineke-Mikulicz plication in all but 3 patients with 15°, 15°, and 30° after correction of 90°, 100° and 115°. No bleeding complications occurred intra- or post-operatively. No patient reported ED. A small bulge in a corporotomy was imbricated in 1 patient at stage 2 without recurrence. CONCLUSIONS:
To our knowledge, no other study has used systematic artificial erection to document outcomes 12 months or longer after straightening VC. We used 3 corporotomies to correct VC averaging 66° and ranging to 130º with outcomes verified in all patients at an average of nearly 2 years later. 16% had residual VC at stage 2 that was successfully managed by a single plication in most, as documented by another artificial erection at least 6 months later. We found 3 corporotomies safely and effectively corrected the high grade VC associated with proximal hypospadias. Our findings also show that artificial erection should be done at subsequent operations after initial straightening to detect residual curvature.
