Distal Hypospadias Repair with Foreskin Preservation

BJU International, Volume 91, Issue 3: Pages 268-270, February 2003.

Glanular reconstruction and preputioplasty repair for distal hypospadias: a unique day-case method to avoid urethral stenting and preserve the prepuce

Northern Ireland Paediatric Surgical Service, The Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland

Accepted for publication 16 September 2002


To report the early outcome of > 200 boys who underwent a glanular reconstruction and preputioplasty (GRAP) repair for distal hypospadias, to assess the functional and anatomical outcome of the penis at least 10 years after surgery, and to compare these data with otherwise 'normal' aged-matched controls.


The GRAP repair is a novel method for the day-case reconstruction of distal hypospadias, and uniquely allows the anatomical reconstruction of the prepuce as part of penile reconstruction for hypospadias. We retrospectively reviewed the notes of 205 consecutive cases of distal hypospadias who had a GRAP repair carried out by one surgeon. Of these, there were 63 consecutive patients who had been repaired using the GRAP 10 years earlier. In these patients a questionnaire was used to assess their perception of the appearance of their penis, the urinary stream, any problems with the foreskin and their recollection of surgery. Similar questionnaire data, except for the latter, were obtained from aged-matched controls for comparison.


Of the 205 patients, 183 (89%) were day cases; the remaining 22 remained in hospital overnight for medical or social reasons. Sixteen (7%) developed a urethral fistula, the incidence of which correlated positively with the length of the repair. Four children (2%) were circumcised, in two for phimosis resulting in a spraying stream, in a third for dribbling after voiding, and the fourth for a cosmetically unsatisfactory foreskin. Questionnaire responses were received from 45 boys (71%), while 18 were untraceable. The mean (sd) age at surgery and at survey was 3.25 (2.6) and 14.26 (2.8) years, respectively. Forty-two (95%) children felt their penis was normal or only slightly different in appearance, two (5%) felt it looked fairly different and only one mostly avoided communal situations because of this. On voiding three boys (7%) sprayed most of the time while the remainder either never or sometimes sprayed. One youth sometimes had to sit to void because of difficulties in directing the stream; the rest (98%) always stood to void. There were no further circumcisions. These results were not significantly different from those of the age-matched controls. Most children had no (68%) or only slight (30%) recollection of hypospadias surgery.


The complication rate and patient satisfaction with GRAP is comparable with those of other techniques. GRAP is a simple day-case procedure with few complications, thus avoiding an overnight hospital admission for most patients. Importantly, the prepuce can be preserved and refashioned to give a good cosmetic result, with no phimosis, which is increasingly important as circumcision becomes less acceptable to both the general public and the medical profession.

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This file does not include the tables.


Any technique to repair distal hypospadias should be simple, easy, and result in satisfactory functional and cosmetic outcomes, with few complications.[1] Many techniques have been described which relocate the urethral meatus and correct chordee. We previously described a technique, glanular reconstruction and preputioplasty (GRAP) for distal hypospadias that meets these criteria and is suitable for day-case surgery with no need for urinary diversion. In addition, the unique advantage of the GRAP technique is that it preserves and improves the appearance of the foreskin, both of which we consider worthwhile goals.

We report the short-term outcome of > 200 consecutive children who have had a GRAP repair by one surgeon (V.E.B.) for distal hypospadias. To investigate the long-term results, in particular the patient's perception of the success or failure of the procedure, we surveyed a group whose hypospadias was repaired > 10 years previously. The significance of these functional and anatomical outcomes of the penis in these patients was compared with a group of age-matched controls.

Patients and Methods

Hospital patient-management systems were used to identify all boys undergoing a GRAP procedure by a one surgeon (V.E.B.). The degree of hypospadias was semi-quantified in most cases as a percentage of the total penile length compared with the distance from the tip of the glans penis to the meatus. Thus, glandular hypospadias is equivalent to 0-10%, coronal 10-20%, distal subcoronal 20-30% and proximal subcoronal 30-50%. Nine children with distal hypospadias were not classified and excluded from further study. The surgical technique used and peri-operative care were as previously described.[2] All children were reviewed after surgery, typically at 3-6 months when the short-term outcomes, e.g. the character of the urinary stream, the presence of chordee, meatal stenosis, phimosis or fistula, were assessed.

Long-term outcomes and patient satisfaction were assessed using a questionnaire that was sent to a consecutive cohort of patients who had undergone surgery > 10 years previously. A section for other comments was included, so that patients could comment on anything important to them that had not been specifically requested. Clarification of response data was obtained by telephone in some cases. No patient was examined clinically. To assess the significance of these data, similar information was collected from aged-matched boys who had undergone appendicectomy and who were used as controls.

The chi-squared test with or without Yates' correction was used in assessing fistulae in the full cohort. The results from the questionnaires were analysed using Fisher's exact probability test and the chi-squared test.


In all, 214 consecutive children with distal hypospadias were identified who had had a GRAP repair, of whom 205 were suitable for further study. The position of the urethral meatus in these children is summarized in Table 1. While some children were admitted before surgery for social reasons, most operations, i.e. in 183 patients (89%), were undertaken as day cases.

Problems immediately after surgery were rare; seven children (3.4%) were admitted overnight with medical problems. Of these boys, two had difficulty in voiding, one of whom required catheter drainage of the bladder. Two patients with uncontrolled pain required analgesia, two had significant nausea and vomiting, and one had a penile haematoma. Fifteen children (7.3%) stayed for one night after repair, with no clearly documented clinical indication.

A fistula occurred in 15 patients (7%); of these, one is known to have healed spontaneously, eight have been corrected surgically on a day-case basis and one fistula was not initially recognized but reported at the 10-year follow-up. The last patient declined any further intervention. Of the remaining five boys, one was lost to review and the others have either had, or are awaiting, surgical repair of the fistula. There was a significant positive relationship between the length of the urethral repair and the incidence of fistulae (P = 0.004; Table 2. For the longer repairs the relative risk was up to 3.2. No child re-presented to the regional paediatric service with stenosis of the urethroplasty requiring dilatation.

At the review soon after repair the urinary stream was satisfactory in all but four children. Of these, one had postvoid dribbling caused by redundant foreskin and phimosis, two reported spraying and had phimosis. All three of these were treated by circumcision. The fourth child was noted at review to have a stream that 'was occasionally directed backwards' but no treatment has yet been undertaken.

Only two children were thought to have an unsatisfactory appearance at the early review, caused by the typical hypospadiac deformity of the preputial skin. One was circumcised while the other was managed expectantly. Therefore, 201 (98%) preputioplasties were considered satisfactory both in terms of function and appearance.

In eight boys chordee was noted after repair; four of these were considered minor and no surgery is planned. In three others this was corrected using a Z-plasty.

In all, 63 patients were repaired 10 years ago; of these, six could not be traced to a current address, either by hospital notes or via a family doctor. Forty-five replies (71%) were obtained, either in response to the postal questionnaire or by telephone for those who initially did not respond. One questionaire was only partially completed, by a child with learning difficulties. Another was returned unanswered by a mother who did not want her son to know he had undergone surgery. The results are shown in Table 3; the mean (range) age of those who replied is now 14.3 (10.25-20.75) years and the mean age at surgery was 3.25 (1-11) years.

Thirty-six boys (82%) thought the appearance of their penis was normal, six (14%) that it was slightly different and two (5%) that it was fairly different; none felt it was very different. Urine spraying (going in more than one direction) was reported never to occur in 21 (49%), sometimes in 19 (44%) and most times in three (7%) boys; none reported always spraying. They were also asked, if because of the spraying, they ever sat to pass urine; 42 (98%) said this was never the case and only one (2%) said this was sometimes the case. Only one boy (2%), as noted at the early review, had required circumcision to improve the cosmetic appearance. Forty-three boys (98%) had no fistula; one man (2%) had a fistula (distal) but which caused no problems and he declined further surgery.

The boys were also asked if they would try to avoid certain situations, e.g. communal showers, because of the appearance of their penis; 40 (93%) said this was never the case, two (5%) and one (2%), said, respectively, that this was sometimes and mostly the case. No child always avoided communal situations.

There was no statistical difference between these patients and the controls on any of the variables (Table 3). Thirty boys (68%) did not remember the operation at all, 13 (30%) remembered it a little bit and only one (2%) claimed to remember it very clearly.


The repair of distal hypospadias with urinary diversion is thought necessary by some [3]. The data from the present 205 patients confirms that most can be treated with low morbidity, with no urinary diversion, by a day-case procedure. The incidence of complications was low, with only 1% being re-admitted, and only one (0.5%) requiring a catheter. This clearly facilitates day-case surgery and lessens the distress to the child. Only a few children will require an inpatient stay, but this is most commonly for social reasons.

The fistula rate of 7% with GRAP is comparable with that from other techniques (1.4-13%), being highest for more proximal disease (17.4%) [4,5]. However, considering that fistulae are repaired as a day-case, this increased risk is more than justified for most boys, who will only require one day-case procedure, even when the position of the urethral meatus is up to half of the penile length from its normal position. Significant stenosis, either proximal or distal, has not been reported with GRAP but does occur with other techniques.[5]

Many authors report a short-term follow-up or judge the outcome based on reports from parents or the attending physician rather than the patient [6,7]. We think that a satisfactory outcome from the surgical repair of distal hypospadias cannot be judged by anyone other than the patient. Also, dissatisfaction with the functional status or anatomical appearance of the penis may only become apparent long after the procedure to correct hypospadias [6]. Longitudinal data on functional and anatomical outcome, as well as patients' perceptions 10 years after surgery, are therefore important; the present questionnaire focused on these topics.

The results suggest that the long-term function and appearance of the penis after GRAP repair for distal hypospadias are not significantly different from that in age-matched controls. Particularly the risk of iatrogenic phimosis is no greater than in the normal population [8].

Early repair is clearly advantageous, with 97% of respondents having no or little recollection of their operation, while only one patient clearly remembered it. Our current policy is to operate on these boys as near to their first birthday as possible. This will hopefully reduce the risk of any adverse memories of the event.

In conclusion, these results confirm that GRAP is an appropriate and safe method for repairing distal hypospadias, compared with other techniques. It has the major advantages of facilitating day-case treatment with no stenting of the urethroplasty. In addition, it preserves the prepuce, that looks and functions normally compared with age-matched controls. While circumcision is necessary in a few patients, for either phimosis or unusual appearance, the risk of this being required is no greater than with the normal population. This is likely to become more important in the future because circumcision is becoming less acceptable to both the general public and the medical profession. From these results we recommend the GRAP repair for all boys with distal hypospadias.


  1. Rabinovitch HR. Experience with a modification of the Cloutier technique for hypospadias repair. J Urol 1988; 139: 1017-9 [PubMed]
  2. Gilpin D, Clements WDB, Boston VE. GRAP repair: single stage-reconstruction of hypospadias as an outpatient procedure. Br J Urol 1993; 71: 226-9
  3. Buson H, Smiley D. Distal hypospadias repair without stents: is it better? J Urol 1994; 151: 1059-60 [PubMed]
  4. Uygur MC. Lessons from 197 Mathieu hypospadias repairs performed at a single institution. Pediatr Surg Int 1998; 14: 192-4 [PubMed]
  5. Harris DL, Jeffrey RS. One stage repair of hypospadias using split preputial flaps (Harris). The first hundred patients treated. Br J Urol 1989; 63: 401-7 [PubMed]
  6. Mureau MAM, Froukje ME. Satisfaction with penile appearance after hypospadias surgery. The patient and surgeon view. J Urol 1996; 155: 703-6 [Abstract]
  7. Park JM, Faerber GJ. Longterm outcome evaluation of patients undergoing the meatal advancement and glanuloplasty procedure. J Urol 1995; 153: 1655-6 [Abstract]
  8. Rickwood AM, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000; 321: 792-3

Correspondence: V. Boston, Northern Ireland Paediatric Surgical Service, The Royal Belfast Hospital for Sick Children, 180 Falls Road, Belfast BT12 6BE, Northern Ireland, UK.
e-mail: VEBostonMD@aol.com


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