Introduction Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation. Objective To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up. Materials and methods Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n Z 208): indications for a twostage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n Z 93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months. Results For the primary repairs (n Z 208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n Z 93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8). Discussion In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the twostage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%. Conclusion The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity.
