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PubMed This is a summary of 17 peer-reviewed journal articles Updated
Urology · Posterior Hypospadias

The Path to Repair: Surgical Strategies and Planning

At a Glance

Posterior hypospadias typically requires a complex, staged surgical repair between 6 and 18 months of age. Preoperative hormone therapy is often used to enlarge the tissue, and finding a high-volume pediatric urologist is critical for ensuring a straight, functional outcome.

When planning for the repair of posterior hypospadias, the goal is to create a functional, straight penis with a urinary opening as close to the tip as possible [1][2]. Because this form of hypospadias is more complex, the treatment strategy often involves several specialized steps designed to ensure the best long-term outcome [3][4].

The first stage of surgery typically occurs when the child is between 6 and 18 months of age [5][4].

Preparing with Hormones

Before surgery, many urologists recommend preoperative hormonal stimulation (PHS). This typically involves either intramuscular (IM) testosterone injections or applying a testosterone cream/gel to the area for a few weeks [6][7]. (Note: While DHT (dihydrotestosterone) gel is sometimes discussed in medical literature, it is not FDA-approved or commercially available in the US and several other countries [8].)

  • The Goal: Hormones help increase the size of the penis and the width of the glans (the head of the penis) [6].
  • The Benefit: Having more tissue to work with can make the surgery technically easier and may improve the success rate of the repair [8][9].

Staged vs. Single-Stage Surgery

For milder cases, a single surgery might suffice. However, for posterior cases—especially those with severe chordee (curvature)—surgeons often prefer a staged (two-stage) repair [3][10].

  • Staged Repair (e.g., Bracka Procedure): This approach breaks the reconstruction into two separate operations, usually several months apart [3][11].
    • Stage 1: The surgeon straightens the penis and prepares the “foundation” for the new urethra. For a first-time repair, surgeons almost universally use the child’s own foreskin (preputial tissue) [12]. If the foreskin is unavailable or in complex re-operations, they may use a small graft of tissue from the mouth (buccal mucosa) [13].
    • Stage 2: The surgeon rolls the new tissue into a tube to complete the urethra [14].
    • Why it’s used: Staged repairs are often more reliable for severe cases, leading to fewer long-term complications like fistulas (accidental holes) or strictures (narrowing of the tube) [15][3].
  • Single-Stage Repair (e.g., TIP/Snodgrass): While this combines everything into one operation, it is generally associated with higher complication rates when used for the most severe posterior cases [3][15].

The Importance of Expertise

The success of a posterior hypospadias repair is highly dependent on the experience of the surgeon [16].

  • Volume Matters: Research suggests that surgeons who perform a high volume of these complex repairs (often cited as at least 50 cases) have more stable success rates [16][4].
  • Specialized Centers: These cases are best managed at children’s hospitals or specialized centers where a multidisciplinary team can provide ongoing support [3][4].

Seeking a Second Opinion

It is very common for parents to seek a second opinion before committing to a complex surgical plan. To make the most of a second opinion, ensure you have:

  1. Detailed operative notes (if any prior procedures were done).
  2. High-quality photos of the anatomy (if requested by the urologist).
  3. A summary of any genetic or endocrine testing results [17].

Finding a surgeon you trust and who specializes in these complex “proximal” repairs is the most important step in your child’s journey [16].

Common questions in this guide

What is the best age for posterior hypospadias surgery?
The first stage of surgery for posterior hypospadias typically takes place when a child is between 6 and 18 months of age. Performing the surgery during this window allows the surgeon to address the anatomy early in the child's development.
Why might my child need hormone therapy before hypospadias surgery?
Preoperative hormone therapy, such as testosterone injections or creams, helps temporarily increase the size of the penis. Having more tissue available makes the complex surgical repair technically easier and can improve the overall success rate of the procedure.
What is the difference between a staged and single-stage repair?
A single-stage repair completes the reconstruction in one operation, while a staged repair breaks the surgery into two separate operations several months apart. Staged repairs are generally preferred for severe posterior cases because they often have lower long-term complication rates.
How is severe penile curvature or chordee corrected?
In a staged repair, the surgeon typically focuses on straightening the penis and correcting the chordee during the first stage of the operation. Once the penis is straight and a foundation is built, the new urethra is reconstructed in the second stage.
What should I look for when choosing a surgeon for my child?
It is highly recommended to choose a pediatric urologist at a specialized children's center who performs a high volume of these specific procedures. Research suggests that surgeons who perform at least 50 complex repairs have more reliable and successful long-term outcomes.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.How many posterior (proximal) hypospadias repairs do you perform each year, and what is your success rate with these specific cases?
  2. 2.Why do you recommend [Staged vs. Single-stage] surgery for my child’s specific anatomy?
  3. 3.If we use preoperative hormone stimulation, what changes are you looking for before we proceed with surgery?
  4. 4.What is your plan for correcting the 'chordee' (curvature), and will that happen in the first or second stage?
  5. 5.Can you walk me through the typical recovery timeline and the long-term follow-up schedule as my child grows into puberty?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (17)
  1. 1

    Post-pubertal functional outcomes of one-stage anatomical reconstruction of the corpus spongiosum, bulbo-spongiosus muscle and dartos in 46 children with proximalhypospadias.

    S H, F A, A A, A B

    Journal of pediatric urology 2023; (19(4)):383-390 doi:10.1016/j.jpurol.2023.03.024.

    PMID: 37012103
  2. 2

    Does parental opinion differ from the health care team regarding cosmesis after hypospadias repair?

    Costa E, Fraga JC, Salle JP, Rosito N

    Revista da Associacao Medica Brasileira (1992) 2021; (67(1)):33-38 doi:10.1590/1806-9282.67.01.20200062.

    PMID: 34161487
  3. 3

    Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade.

    Babu R, Chandrasekharam VVS

    Journal of pediatric urology 2021; (17(5)):681-689 doi:10.1016/j.jpurol.2021.05.014.

    PMID: 34099397
  4. 4

    Surgery for Primary Proximal Hypospadias with Ventral Curvature >30°.

    Snodgrass W, Bush N

    Current urology reports 2015; (16(10)):69 doi:10.1007/s11934-015-0543-5.

    PMID: 26255068
  5. 5

    Practice patterns in the care of proximal hypospadias among pediatric urologists.

    Rague JT, Rosoklija I, Chu DI, et al.

    Journal of pediatric urology 2025; (21(5)):1195-1202 doi:10.1016/j.jpurol.2025.03.002.

    PMID: 40107954
  6. 6

    Usefulness topical di-hydro testosterone prior to proximal hypospadias repair in testosterone non-responders.

    Babu R, Chandrasekharam VVS

    Journal of pediatric urology 2025; (21(3)):633-638 doi:10.1016/j.jpurol.2025.01.020.

    PMID: 39919946
  7. 7

    Correlation of androgen receptor and SRD5A2 gene mutations with pediatric hypospadias in 46, XY DSD children.

    Fu XH, Zhang WQ, Qu XS

    Genetics and molecular research : GMR 2016; (15(1)):15018232 doi:10.4238/gmr.15018232.

    PMID: 27051040
  8. 8

    Preliminary Experience with Transdermal Preoperative Hormonal Treatment Before Severe Hypospadias Repair: Synergy Between Pediatric Surgeons and Endocrinologists.

    Lucaccioni L, Ghidini F, Repetto P, et al.

    Children (Basel, Switzerland) 2025; (12(3)) doi:10.3390/children12030296.

    PMID: 40150579
  9. 9

    Defining the role of pre-operative hormonal therapy in hypospadias.

    Taghavi K, O'Hagan LA, Hewitt JK, Mouriquand P

    Journal of paediatrics and child health 2022; (58(9)):1508-1519 doi:10.1111/jpc.16087.

    PMID: 35791898
  10. 10

    Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period.

    Pippi Salle JL, Sayed S, Salle A, et al.

    Journal of pediatric urology 2016; (12(1)):28.e1-7.

    PMID: 26279102
  11. 11

    The Impact of Postoperative Urinary Diversion on Surgical Outcomes of Hypospadias Repair: A Systematic Review and Meta-Analysis of Pediatric Literature.

    Escolino M, Caracò MS, Mazzone V, et al.

    Medicina (Kaunas, Lithuania) 2025; (61(9)) doi:10.3390/medicina61091659.

    PMID: 41011050
  12. 12

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

    Al-Adl AM, Abdel Aal AM, El-Karamany TM, Noureldin YA

    World journal of urology 2020; (38(11)):2873-2879 doi:10.1007/s00345-020-03075-5.

    PMID: 31938842
  13. 13

    The effect of staged TIP urethroplasty on proximal hypospadias with severe chordee.

    Xie Q, Liu Y, Zhao X, et al.

    Frontiers in surgery 2022; (9()):892048 doi:10.3389/fsurg.2022.892048.

    PMID: 36090335
  14. 14

    Staged transverse preputial island flap urethroplasty for proximal hypospadias: a single-center experience.

    Wang C, Song H, Zhang W

    Pediatric surgery international 2019; (35(7)):823-827 doi:10.1007/s00383-019-04480-7.

    PMID: 31049665
  15. 15

    Posterior hypospadias: Evaluation of a paradigm shift from single to staged repair.

    Badawy H, Orabi S, Hanno A, Abdelhamid H

    Journal of pediatric urology 2018; (14(1)):28.e1-28.e8 doi:10.1016/j.jpurol.2017.07.007.

    PMID: 28865886
  16. 16

    The learning curve in proximal hypospadias repair.

    Hisamatsu E, Sugita Y, Haruna A, et al.

    Journal of pediatric urology 2021; (17(3)):330.e1-330.e6 doi:10.1016/j.jpurol.2021.01.005.

    PMID: 33526367
  17. 17

    Utility of genetic work-up for 46, XY patients with severe hypospadias.

    Srivastava P, Tenney J, Lodish M, et al.

    Journal of pediatric urology 2023; (19(3)):261-272 doi:10.1016/j.jpurol.2022.11.023.

    PMID: 36496321

This page explains surgical strategies for posterior hypospadias for educational purposes. Your pediatric urologist is the best source for your child's specific treatment plan.

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