Two-stage repair of proximal hypospadias with moderate to severe chordee using inner preputial skin graft: prospective evaluation of functional and cosmetic outcomes

  • Ahmed M. Al-AdlEmail author
  • Ashraf M. Abdel Aal
  • Tarek M. El-Karamany
  • Yasser A. Noureldin
Original Article



To critically evaluate inner preputial graft (IPG) used in staged proximal hypospadias with severe chordee regarding cosmetic and functional outcomes.

Patients and methods

In this prospective study, patients with primary proximal hypospadias with moderate to severe chordee (> 30°) after penile degloving were considered candidates for staged repair between June 2011 to July 2017. After transection of the urethral plate (UP) and penile straightening, the bare shaft was covered with IPG. Tubularization of the graft was done as a second stage. Cosmetic and functional outcomes were assessed using HOSE score and uroflowmetry (UF). Additionally, factors influencing success were analyzed.


In all, 38 consecutive cases were included. Native meatus was at proximal penile in 17, penoscrotal in 11, scrotal in 7, and perineal in 3 cases. Median age was 26 and 32 months at the first stage and the second stage, respectively. Preoperative testosterone was given for ten patients with a small penis and/or severe curvature. The mean follow-up was 18 ± 8.2, median 15 months. Grafts took well in all cases after the first stage except one. Cosmetic success achieved in 33 (86.8%). A total of ten complications occurred in six cases. Unplanned intervention was needed in 5/38 cases. Functionally, UF study revealed normal flow in 7/23 (30.4%), equivocal in 11/23(47.8%), and obstructed flow in 5/23(21.7%).


Inner preputial graft use in proximal hypospadias with moderate to severe chordee seems to have a good technical outcome and functionally mimic the normal urethral function and could be considered an ideal option for substitution urethroplasty.


Hypospadias Proximal Severe chordee Graft Outcome 


Authors’ contribution

AMA: conception and design, data acquisition, data analysis and interpretation, drafting the manuscript and critical revision of the manuscript for scientific and factual content. AMAA: data acquisition and critical revision of the manuscript for scientific and factual content. TMEK: data acquisition and critical revision of the manuscript for scientific and factual content. YAN: data acquisition and interpretation, and critical revision of the manuscript for scientific and factual content.

Compliance with ethical standards

Conflict of interest

All authors declare no conflict of interest and no financial support.

Ethical statement

This study was conducted in concordance with the Declaration of Helsinki 2013 and in accordance with Benha Faculty of Medicine ethical standards, and after obtaining informed consents.

Supplementary material

345_2020_3075_MOESM1_ESM.tif (1.5 mb)
Qmax nomogram versus voided volume in 23 toilet-trained cases (TIF 1546 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of Urology, Faculty of MedicineBenha UniversityBenhaEgypt

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