The elimination of complications in hypospadias surgery: a training in analytical thought or a mission impossible?

This is a critical review of 376 patients with hypospadias that were treated by the first author. The techniques used were a one-stage procedure for the correction of hypospadias without chordee (type I) and a two-stage procedure for hypospadias with chordee (type II). Development of these techniques was based on several conjectures: (a) A curvature of the penis can be caused by skin shortage alone; (b) persistent chordee is due to inadequate release of the corpora or to inadequate resurfacing of the corporal defect; and (c) fistulas can be caused by devascularisation of skin, by tension on the suture line, by superposition of skin wound and urethra, by infection, by perforation of skin, and by the evacuation of urine causing a separation of the wound edges. These conjectures were tested over a period of 30 years by a combination of measures involving: (a) The rotation in one or two stages of well-vascularised dorsal skin, using a backcut; (b) the omission of transcutaneous sutures and dressing; and (c) the diversion of urine through drainage incisions or fenestrated stent. These measures resulted in a dramatic reduction of the number of patients in need of a type II procedure. Persistent chordee, although rare, could always be corrected before a definitive urethroplasty was performed. Fistulas were almost completely eliminated.