Hypospadias repair moves the urinary opening to the tip of the penis, straightens any downward bend and reshapes the glans and foreskin, ideally between six and eighteen months of age. Distal forms are repaired in one operation, while proximal forms often need two stages for fewer complications. At Biruni Hospital in Istanbul, our pediatric urologists plan each repair, manage catheter care and follow boys through puberty.
About This Department
Pediatric Urology
In hypospadias, the opening of the urethra sits on the underside of the penis. Repair moves it to the tip, straightens the penis and restores a normal appearance.
Hypospadias repair is surgery for boys born with the urinary opening below its normal position at the tip of the penis, often with a downward bend and an incomplete foreskin. The operation builds a new urethral channel to the tip, corrects the bend and reshapes the glans and skin, usually between six and eighteen months of age. Distal hypospadias, near the tip, is repaired in one operation. In a review of 3,368 distal repairs, a fistula, a small leak along the new channel, followed 3.8 percent of tubularized incised plate repairs (Wilkinson and colleagues, Journal of Pediatric Urology, 2012). Proximal hypospadias, near the scrotum, is more complex. In 2,664 boys, complications occurred in 21 percent after two-stage repair and 42 percent after single-stage repair, and results improved in high-volume centers (Babu and Chandrasekharam, Journal of Pediatric Urology, 2021). This page explains types, timing, techniques, hormones before surgery, curvature, risks, catheter care, long-term follow-up, and how families from abroad arrange hypospadias repair at Biruni Hospital in Istanbul.
3.8
Percent fistula rate after tubularized incised plate repair of distal hypospadias
21
Percent complications after two-stage proximal repair, against 42 percent after single-stage repair
64
Percent fewer complications with hormone treatment before surgery in randomized trials
Free
Review of your son's photos and records by our pediatric urology team
The urinary opening, the meatus, lies on the underside of the penis, anywhere from just below the tip to the scrotum. The penis may bend downward on erection, called chordee. The foreskin is incomplete underneath, forming a hood on top.
Hypospadias develops in the first months of pregnancy, when the tissues that form the urethra do not close fully. It affects about one in 250 to 300 boys and runs in some families.
The foreskin is often used in the repair. Boys with hypospadias should not be circumcised before seeing a pediatric urologist.
Do not circumcise first
Keep the foreskin.
In hypospadias the foreskin provides extra skin that the surgeon may need to build the new urethra, cover it with a protective layer or close the skin underneath, and once it has been removed at a religious or newborn circumcision, the repair becomes harder and may need grafts from elsewhere. Families who plan circumcision for religious or cultural reasons can have it done during the hypospadias repair, when the surgeon decides how much foreskin to keep or remove.
Check with us first. Circumcise later.
Types of hypospadias
Classification by position of the opening
Type
Position of the opening
Share of cases
Distal, anterior
Near the tip, on the glans or just below
Most boys, about two thirds
Midshaft
Along the shaft
About one in six
Proximal, posterior
Base of the penis, scrotum or perineum
About one in six, most complex
The position of the opening after the skin is released, the degree of bend and the size of the glans and urethral plate together decide the technique.
Did something during pregnancy cause it?
In most boys no single cause is found. Genes, hormones during early pregnancy and, in some studies, low birth weight and assisted conception are linked with higher rates. Parents have done nothing wrong.
Assessment and timing
Checks before hypospadias repair
Check
Why
When
Examination of both testes
Undescended testes with hypospadias need further tests
First visit
Chromosome and hormone tests
Proximal hypospadias with undescended testes may signal a difference of sex development
When indicated
Penile size and glans width
Plan the technique and hormone treatment
First visit
Kidney ultrasound
Only if other anomalies present
Selected boys
Repair between six and eighteen months of age is standard. The child does not remember the operation, and the tissues heal well.
Older boys and adolescents can also be repaired successfully, and we also treat adults with previously unrepaired or failed repairs.
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Photographs
A side photograph of the erect penis, which parents can take during a diaper change, shows the degree of bend and helps planning.
We discuss the findings and the plan with the family before any decision.
Repair of distal hypospadias
Distal hypospadias techniques, review of 3,368 repairs
Outcome
Tubularized incised plate
Mathieu flap
Urethral fistula
3.8 percent
5.3 percent
Narrowing of the new opening
3.1 percent
0.7 percent
Appearance of the opening
Vertical slit, natural
Rounder
The tubularized incised plate repair, also called Snodgrass repair, makes a lengthwise cut in the urethral plate, rolls it into a tube to the tip and covers it with a protective layer of tissue. The Mathieu repair uses a skin flap from below the opening. Both have low complication rates (Wilkinson and colleagues, 2012).
A one-stage repair takes one to two hours and is the standard for most boys with distal hypospadias.
Bring the opening to the tip of the glans.
Straighten the penis.
Reshape the glans and skin for a normal appearance.
Some families choose no surgery for very mild distal forms where the stream and appearance are acceptable.
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Very mild forms
When the opening sits on the glans and the boy urinates normally, surgery serves appearance only, and we discuss the option of waiting.
Repair of proximal hypospadias
Proximal repair, 2,664 boys in 26 studies
Approach
Complication rate
Note
Single stage, foreskin tube
42 percent
Remained high despite experience
Two stage, free foreskin graft
23 percent
Fewer fistulas and narrowing
Two stage, foreskin flap
20 percent
Improved with higher case load
In the first stage, the surgeon straightens the penis and places foreskin as a graft or flap on its underside. Six months later, once it has healed and softened, the second stage rolls this tissue into a new urethra (Babu and Chandrasekharam, 2021).
Why two operations instead of one?
Severe curvature and a short urethral plate leave too little healthy tissue to build a long new urethra in one step. Staging gives the transferred tissue time to establish its blood supply, which halved the complication rate in the meta-analysis. Each stage needs one anesthetic and a short hospital stay.
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Testes and sex development
Proximal hypospadias with an undescended testis needs hormone and genetic tests before surgery, to exclude a difference of sex development.
Experience matters
Hypospadias surgery rewards practice.
The meta-analysis found that complications after two-stage repair fell as the number of operations a center performed each year rose, supporting the idea of dedicated hypospadias teams, while single-stage repair of severe forms stayed difficult even in busy centers. Our pediatric urologists perform these operations every week, use magnifying loupes and fine absorbable stitches, and follow each boy through puberty.
Families can fairly put the same question to any team, how many repairs it performs each year and how it follows boys afterward, and a confident team will answer with real numbers and a clear plan for the years until puberty.
Hormones before surgery
Preoperative hormone stimulation, meta-analysis
Study type
Effect on complications
Quality
Three randomized trials
Fewer complications, relative risk 0.36
Moderate
Observational studies
No clear difference
Low, risk of bias
Side effects
Mild and temporary
Darker skin, hair, irritability
When we use it
Testosterone given as injections or cream for one to three months before surgery enlarges the glans and penis temporarily and improves blood supply. Randomized trials showed fewer complications, while observational studies did not (Chua and colleagues, Journal of Pediatric Urology, 2017).
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Our practice
We offer hormone treatment to boys with a small glans or proximal hypospadias, and surgery follows about one month after the last dose.
Straightening the penis
A bend that remains after repair causes problems in adult life. Straightening is checked during surgery with an artificial erection test.
How it is done
Releasing the skin often corrects mild bends.
Tightening the upper side corrects moderate bends.
Lengthening the underside corrects severe bends, sometimes in the first of two stages.
Techniques
Curvature correction
Degree of bend
Technique
Note
Under 30 degrees
Skin release, dorsal plication
Most distal cases
30 to 45 degrees
Plication or plate mobilization
Midshaft cases
Over 45 degrees
Ventral lengthening, staged repair
Proximal cases
Risks and fistula
Most complications appear in the first year and are fixed with a smaller second operation.
A fistula shows as urine coming out of a second small hole along the shaft. It does not close by itself and is repaired six months after the original operation.
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Other complications
Narrowing of the new opening or urethra, a pouch along the urethra, separation of the glans, remaining bend and skin irregularities. Each has its own repair.
How will we know if something is wrong after surgery?
Watch the urine stream once the catheter is out. A thin, slow or spraying stream, straining, a second stream from the shaft or swelling during urination need review. We ask families to send a short video of urination at three months and at each follow-up.
The day of surgery
Fasting follows standard rules for children, solids six hours, breast milk four hours and clear fluids one hour before anesthesia.
A typical day
Step
Timing
Note
Arrival and checks
Morning
Numbing cream
Anesthesia
Parent present at induction
General with caudal block
Surgery
One to three hours
Longer for proximal repair
Recovery
Two hours
Catheter and dressing
Discharge
Same day or after one to two nights
Depends on repair
Pain relief
1
Caudal block
A local anesthetic injected near the base of the spine while the child sleeps numbs the area for six to twelve hours after surgery.
Dressing and catheter at home
Caring for the repair at home
Item
What to do
Duration
Dressing
Keep dry, double diaper
Until removal at day 3 to 7
Catheter or stent
Drains into the diaper
Five to ten days
Bathing
Short baths after dressing removal
From day 5 to 7
Medicines
Pain relief, antibiotic, bladder spasm medicine
As prescribed
A thin tube, the catheter or stent, drains urine while the new urethra heals and is removed at the clinic. Bladder spasms can cause brief discomfort or leakage around it, and medicine eases them.
Call us if you see
Sign
Possible cause
Action
No urine for several hours
Blocked catheter
Call at once
Fever
Infection
Call the same day
Bleeding soaking the dressing
Wound bleeding
Gentle pressure, call
Catheter falls out
Displacement
Call for advice
Mild swelling and bruising of the penis are normal and settle over two to three weeks.
1
Toys and activity
Avoid straddle toys, walkers and bicycles for three weeks.
Long-term follow-up
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Through puberty
Problems can appear years later as the penis grows, so we review boys at one year, before school, and around puberty, with urine flow tests when they are toilet trained.
Men who had hypospadias repair in childhood urinate standing, have erections and father children in the great majority, particularly after distal repair. Proximal forms need closer follow-up.
Talking with your son
Children ask questions when they notice differences.
Simple, honest answers at each age, that he had a small operation as a baby to make it work well, help a boy feel confident, and older boys can join the follow-up discussions.
Shame has no place here.
For families from abroad
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Length of stay
Plan for seven to ten days in Istanbul for a one-stage repair, so that the catheter can be removed and the stream checked before the flight home. Fitness to fly follows that check.
Two-stage repairs need two visits about six months apart. Send photographs of the penis from the side and below, any photographs of erections, information on the testes and earlier surgery.
2
After you return home
Follow-up continues by video and urination videos at one, three and twelve months.
One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number after you return. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.
Families planning circumcision at the same time tell us in advance, so that it is built into the plan.
Cost
What a quote covers
What a quote for hypospadias repair covers
Item
Included
Priced separately
Surgery
Pediatric urologist, anesthesia, operating room
Second stage
Hospital
Day case or one to two nights
Extra nights
Aftercare
Dressing and catheter removal, medicines, video follow-up
Hormone treatment, fistula repair
The price depends on the type of hypospadias, one or two stages and hormone treatment.
We quote after reviewing photographs and records, before you travel. Compare quotes for the same technique and ask about follow-up through puberty.
References
Wilkinson DJ, Farrelly P, Kenny SE. Outcomes in distal hypospadias. A systematic review of the Mathieu and tubularized incised plate repairs. J Pediatr Urol. 2012;8(3):307-312.
Babu R, Chandrasekharam VVS. Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft and foreskin pedicled flap) repair for proximal hypospadias in the last decade. J Pediatr Urol. 2021;17(5):681-689.
Chua ME, Gnech M, Ming JM, et al. Preoperative hormonal stimulation effect on hypospadias repair complications. Meta-analysis of observational versus randomized controlled studies. J Pediatr Urol. 2017;13(5):470-480.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Hilmi APAK, Pediatric Hematology and Oncology.
