Surgical Management of Primary Severe Hypospadias in Children: Systematic 20-Year Review

Purpose: We systematically reviewed the literature published during the last 20 years on the treatment of primary proximal hypospadias associated with severe ventral curvature. Materials and Methods: We reviewed studies published between 1990 and December 2009, searching for "hypospadias" in MEDLINE (R)/PubMed (R), EMBASE (R), Web of Science (R) and the Cochrane Library. Results: The search yielded 69 pertinent studies. These studies were generally of low quality (69.5% surgical series). Based on the literature, curvature should be addressed stepwise starting with ventral dissection that extends underneath the urethral plate (urethral plate mobilization). Contrary to former practice, urethral plate division seems to have more of a role if significant curvature persists. Dorsal plication seems sufficient to correct only minor degrees of curvature, while a minority of cases require ventral lengthening. No urethroplasty techniques appear to be definitively superior. After urethral plate division a staged urethroplasty has lower complication rates but a second operation is required, which might otherwise be avoided in approximately 70% of cases. Conclusions: The present systematic review shows the weak evidence backing current management of primary severe hypospadias. We even lack a clear-cut definition of severe hypospadias and associated curvature. Hence, while we developed general recommendations for treatment based on our review of available evidence, we emphasize the need to establish shared criteria for accurate preoperative or introperative patient stratification, and to define objective outcome measures and followup intervals for data reporting to make comparison of surgical approaches reliable.