Hypospadias Surgery in Turkey

Hypospadias surgery is a surgical intervention aimed at moving the urethral opening to the tip of the penis and correcting accompanying curvatures. The procedure is planned in accordance with the principles of pediatric surgery and urology to ensure functional urinary flow and cosmetic integrity.

Within the scope of the question of when hypospadias surgery is performed, the ideal timing is generally between 6 and 18 months and is appropriate in terms of anesthesia safety and tissue healing. Early intervention reduces psychosocial effects and lowers the risk of complications by increasing the possibility of single-session repair.

Hypospadias surgery techniques include tubularized incised plasty, onlay graft, and two-stage repair. The choice is determined according to meatus location, degree of penile curvature, and tissue quality. The surgical goal is to obtain a straight penis, a terminally positioned meatus, and a urethra of sufficient caliber.

In the postoperative care process after hypospadias surgery, catheter use, dressing follow-up, and infection prophylaxis are important. Possible complications include fistula, meatal stenosis, and recurrent curvature. Regular check-ups ensure early diagnosis and the timely performance of necessary revisions.

What Is Hypospadias (Prophet Circumcision) and Which Structures in the Body Does It Affect?

During the miraculous developmental process in the womb, the urinary canal of male babies progresses toward the tip by joining along the underside of the penis, just like a zipper closing from bottom to top. This closure process takes place during certain weeks of pregnancy, and the process is completed when the urinary opening reaches the very tip. However, if this zipper-like closure process stops or is interrupted at any stage, the condition called hypospadias occurs. Wherever the zipper stopped, the urinary opening remains at that point.

This condition does not merely change the exit point of urine. The spongy tissue surrounding the urinary canal, called the “corpus spongiosum,” is also affected by this incomplete closure. Under normal conditions, this tissue surrounds and protects the urinary canal like a cushion, but in babies with hypospadias, it ends in a split form behind the urinary opening. In addition, hard fibrous bands that cause the penis to curve downward frequently accompany this anatomical deficiency. Therefore, hypospadias is not merely a procedure of changing the location of a hole, but a process of reconstructing incomplete tissues, correcting penile curvature if present, and establishing the infrastructure that will provide trouble-free urination and healthy sexual function in later life.

Why Does Hypospadias Occur in Babies and Which Factors Disrupt This Development?

The cause of hypospadias cannot be attributed to a single reason in the medical world; this condition is entirely the result of a multifactorial process. The period between the 8th and 14th weeks in the womb is the most critical and sensitive period during which the external genital organs are shaped and that zipper-like structure we mentioned closes. Even the slightest disruption during this process can change the course of development.

The development of male reproductive organs takes place largely under the control of male hormones such as testosterone and dihydrotestosterone. If these hormones are produced inadequately in the womb or if the penile tissue cannot respond sufficiently to the signals given by these hormones, the closure process of the urinary canal is left incomplete. Sometimes genetic inheritance also prepares the ground for this condition. A history of hypospadias in the family, in the father, or in uncles appears as very strong evidence of genetic predisposition.

The main risk factors that may prevent the closure of the urinary canal in this process are as follows:

• Genetic predisposition
• Hormonal imbalances
• Environmental toxins
• Advanced maternal age
• In vitro fertilization treatments

Each of the factors listed above may slow development at the cellular level. For example, certain environmental chemicals, agricultural pesticides, or some hormone-containing medications used unconsciously that the mother is exposed to in the first trimester of pregnancy may disrupt the normal developmental stages of the male fetus. Today, together with the increase in environmental factors, there has also been a marked increase in the frequency of this condition worldwide.

What Are the Degrees of Hypospadias and How Is It Anatomically Classified?

Where the urinary opening is located on the penis is the most critical and guiding element that determines the severity of the condition, the degree of the disease, and the type of surgical treatment to be applied. The farther the urinary opening is from the terminal point where it should be, the more complex the anatomical disorder is, and the more delicate, patient, and experienced the surgical repair requires. The classification is based on the sections of the penis.

The most common form is the mild condition in which the urinary opening opens onto the glans of the penis or the groove just below the glans. In this group, penile curvature is generally absent or very mild. Surgical success rates and aesthetic results are extremely gratifying. The second group consists of moderate cases in which the urinary opening opens onto the middle parts of the penile shaft. At this stage, tissue deficiency is more pronounced and the possibility of the penis curving downward increases.

The third and most severe group consists of cases in which the urinary opening remains as far back as the root of the penis, the junction of the scrotal sacs, or the region between the anus and the scrotum. In these severe forms, the penis is generally buried between the scrotal sacs, there is a serious curvature, and the scrotal sacs may exhibit a split appearance right down the middle. These cases constitute one of the most difficult areas of reconstructive surgery. There is also a very special situation; sometimes, although the urinary opening is slightly wider than normal and mildly lower down, the baby’s foreskin may appear closed. This condition, also known as “hidden hypospadias,” is generally not noticed by the family and is only incidentally discovered when the foreskin is retracted during what is thought to be a normal circumcision procedure.

What Is the Most Accurate Timing for Hypospadias Surgery and Why Should Families Decide Early?

Undoubtedly, one of the most important steps in the treatment process is acting at the right time for surgery. In modern pediatric urology, the ideal surgical timing is shaped with great precision not only through physical recovery but also through the child’s psychological development, future toilet training, and the ability to tolerate surgical stress. Considering all these factors, the most ideal and safest window for surgery is between the sixth and twelfth months.

Although babies are more sensitive in terms of anesthesia in the first six months, from the sixth month onward their body systems mature considerably and anesthesia risks fall to the same level as in older children. After the age of one, especially from the eighteenth month onward, children begin to recognize their own bodies and explore their genital organs. A surgical intervention to the genital area during this discovery period may cause a fear the child cannot make sense of, a feeling that bodily integrity has been impaired, and therefore permanent psychological trauma.

The main advantages provided by surgical interventions performed in the early period are as follows:

• Rapid tissue healing
• Minimal scarring
• Prevention of psychological trauma
• Uninterrupted toilet training
• Ease of home care

When the baby is operated on before turning one year old, the event is not remembered in any way. The few days of postoperative restlessness pass quickly, and the child continues life without trauma as if they had had a completely normal anatomy from birth. In addition, home care and limiting the movements of a baby who still wears diapers and has not yet fully started walking and running are much easier compared with an active child.

What Preparations and Hormone Treatments Are Applied Before Surgery in Severe Hypospadias Cases?

Not every child is taken directly to the operating room; in some cases it is necessary to prepare a very good foundation before surgery. Especially in severe cases where the urinary opening is very low or in cases where the glans of the penis is not large enough for surgical procedures, hormone treatments are used to increase the success of the operation. The aim of these treatments is not to enlarge the penis permanently, but to temporarily increase the amount, flexibility, and blood supply of the tissues to be used during surgery.

Hormone treatments generally begin a few months before the surgery. Injections containing testosterone may be administered at certain intervals, or special hormone gels applied directly to the penile skin may be preferred. These gels absorbed through the skin stimulate the tissues in the area directly, increase the volume of the penis, and enrich the amount of tissue the surgeon will work on. Working with more abundant and better-vascularized tissue increases the likelihood of the sutures holding after the operation and significantly lowers the risk of unwanted holes (fistulas) forming.

The hormone treatments applied during this preparation process do not cause permanent side effects. The use of the medications is completely stopped approximately one month before surgery in order to reduce the tendency of the tissues to bleed and to relax the surgical field. In this way, both the tissue quality reaches the desired level and excessive bleeding of the tissues during surgery is prevented.

What Are the Current Surgical Methods Used in Hypospadias Surgery?

Hypospadias repair is a very dynamic field in which the science of medicine and the art of surgery truly come together, with no standard prescription, and which must be planned tailor-made according to each child’s anatomy. The choice of technique to be applied depends on many variables such as the location of the urinary opening, tissue flexibility, the presence of penile curvature, and the structure of the foreskin. Operations are performed under general anesthesia, using magnifying special glasses (loupes) to cause the least possible damage to the tissues, and with microscopic precision using sutures finer than human hair that dissolve spontaneously in the body.

Among the most frequently applied methods and those accepted as the “gold standard” today are the techniques using the urethral plate. In this method, the existing partial urinary canal is deepened with a fine incision, and the tissue is folded over itself to create a brand-new, completely natural-looking tube. Its surface is then covered and supported with healthy tissues. This technique makes it possible to create an aesthetically very successful, slit-like, and normal-looking urinary opening.

In very mild cases, without any need to create a tube, the tissues around the existing urinary opening are simply mobilized and gently moved to the point where they should be. However, in severe forms where tissue deficiency is extensive and the urinary opening has receded as far as the scrotum, the process works very differently. In these cases, since there is not enough tissue on the penile shaft to construct a tube, the new urinary canal is created using vascularized tissue pieces taken from the inner part of the foreskin. In fact, in some cases where very severe curvature and tissue deficiencies coexist, the repair cannot fit into a single operation. In such patients, the penis is first completely straightened and a tissue graft is placed. After waiting at least six months for the tissues to heal and mature, the process is completed with a second operation in which the new urinary canal is constructed.

What Is Penile Curvature (Chordee) Seen Together with Hypospadias and How Is It Corrected During Surgery?

In hypospadias surgery, simply extending the urinary canal is not enough; for healthy urination and a trouble-free sexual life in the future, the penis being completely straight is an indisputable prerequisite. The underdeveloped tissues and short coverings on the underside of the penis pull the penis downward and cause a curvature called “chordee.” The first and most critical step of the operation is determining the degree of this curvature and correcting it perfectly.

As soon as the surgery begins, before any incision is made, an artificial erection is created by injecting a special solution into the penile shaft. Thanks to this test, the surgeon has the opportunity to observe the curvature of the penis in its normal position and during erection with millimetric precision. The correction process is carried out step by step according to the severity of the curvature.

Sometimes, simply removing the fibrotic bands pulling the penis downward and freeing the skin is enough for the penis to become completely straight. However, if the curvature continues, anatomical balance is achieved by placing special folding sutures called “plication” on the longer upper part of the penis. This procedure resembles straightening a slanted fabric by tacking its longer side. In the most severe cases where the curvature is very pronounced and the tissues are short and hard as if ossified, all the structures causing the shortening are cut and removed, and the resulting tissue gaps are filled with grafts taken from other parts of the body. The stage of constructing the urinary canal is absolutely not started until it is confirmed that the penis is 100% straight.

What Are the Possible Undesirable Conditions (Complications) That May Be Encountered After Hypospadias Surgery?

As in the nature of every surgical procedure, despite high experience and advanced surgical techniques, there are some risks and undesirable conditions in hypospadias operations as well. The external genital area is a sensitive area in terms of the healing process due to its blood supply dynamics, the constant passage of urine through that region, and its anatomical location. Problems that may be encountered during the healing period generally show themselves within the first few weeks or months after surgery.

The undesirable conditions that should be carefully monitored after surgery are as follows:

• Urethrocutaneous fistula
• Meatal stenosis
• Wound dehiscence
• Local infection
• Recurrence of curvature

Among these problems, the most common is fistula formation. A fistula is the opening of a thin leakage hole due to inadequate healing between the newly constructed urinary canal and the skin tissue. In this case, when the child urinates, urine comes both from the normal opening at the tip and from this small opening on the underside. Another problem, stenosis, is the shrinking and narrowing over time of the newly formed urinary opening بسبب the wound-healing reaction. When stenosis develops, the child’s urinary stream becomes weak and the urine begins to come out as a thin thread. Both conditions are generally not processes that should cause panic; after the tissues have completely healed and softened, these problems can be permanently resolved with minor secondary corrective surgeries planned months later and lasting much less time.

What Should Be Considered During the Home Care Process After Hypospadias Surgery?

The success of the surgery depends not only on the surgeon’s meticulousness in the operating room but also tightly on the careful care process provided at home afterward. At the end of the operation, a silicone catheter (stent) is placed into the newly constructed narrow urinary canal in order to prevent the walls from sticking to each other and to allow urine to flow safely outward. This catheter remains inside for approximately one week depending on the degree of the disease.

In children who use diapers, the “double diaper method” is applied during this period to absolutely prevent stool from coming into contact with the surgical wound. This method is the most critical key to home care. A small hole is opened in the middle of the first inner diaper, and the penis and catheter are taken out through this hole into a second outer diaper. Thus, while the baby’s stool remains in the inner diaper, the urine continuously dripping from the catheter is collected sterilely in the outer diaper. This ingenious method protects the wound site perfectly from fecal infections.

The activities from which the child must definitely be kept away during the healing process are as follows:

• Riding a bicycle
• Horse riding
• Swimming in a pool
• Swimming in the sea
• Games open to impact

Until the surgical area is completely healed, the bathing routine is carried out in the form of wiping with a sponge. After the catheter is removed and the dressings are opened, tissue softening and the shedding of crusts are supported with wound care creams and warm sitz baths. It is extremely essential for families to use the prescribed antibiotic syrups and painkillers according to schedule so that the baby can have a comfortable recovery period.