Correction of Chordee in Proximal Hypospadias

Correction of chordee or penile curvature is widely considered the rate limiting step in determining whether hypospadias can be corrected in one or two stages regardless of the initial presentation of the meatal location. Hence, a boy presenting with a distal hypospadias meatus should not fool one into thinking that this will be a simple one-stage repair until all aspects of the penis are assessed.

Important questions include:

• Is the urethra hypoplastic below the meatus?
• What is the quality of the urethral plate?
• What is the glanular appearance?
• Is there a presence or absence of scrotal webbing?
• What is the degree and cause of chordee?

Chordee may be secondary to skin tethering, scrotal webbing, fibrous dartos tissue beneath the skin, a foreshortened urethra or corporal body disproportion. The latter is seen most commonly in the proximal cases. As one can imagine, management of chordee remains variable — often dictated by surgeon preference and experience.

Options for correction include:

• Simple penile degloving
• Release of any scrotal webbing
• Dorsal plication
• Transection of the urethral plate
• Ventral lengthening techniques with and without grafting

At Children’s Hospital of Philadelphia (CHOP), our preference is to perform penile lengthening grafting procedures for all patients with greater than 30 degrees ventral curvature post skin degloving. We are especially interested in how well we do with correcting severe chordee in proximal hypospadias.

Through our prospective hypospadias registry, we retrospectively looked at those patients undergoing repair of proximal hypospadias from 2016 to 2022. We specifically looked at:

• Initial meatal location
• Degree of chordee before and after skin degloving
• Pre- and postoperative measurements of ventral penile length
• Procedure to correct curvature
• Duration of follow-up

We also looked at the incidence of recurrent curvature by technique used for correction.

We evaluated a total of 191 patients undergoing proximal hypospadias repair of which 22 were performed as a single-stage repair. Of that total, 141 patients required ventral lengthening with a single corporotomy at the point of maximal bend and included 82 tunica vaginalis grafts, 57 dermal grafts and two subintestinal submucosal grafts (commercially available). Fifty-five patients (32%) in this cohort also had dorsal plication performed. Fifty (25%) patients did not require ventral lengthening for curvature and median follow-up was 1.7 years.

Pre-degloving revealed a median of 90-degrees ventral curvature versus 42.5-degrees post-degloving. The non-lengthening patients had a pre-degloving measurement of 45 degrees versus 20 degrees post degloving.

Median ventral length achieved by grafting was 18 mm. Recurrent curvature incidence was 4% overall with 2% for tunica vaginalis grafts and 2% for dermal grafts. There was also 4% recurrent curvature in the non-lengthening group. Of the eight patients with recurrent curvature, three were corrected by penile skin degloving alone, three required repeat grafting, and two required degloving and dorsal plication.

In conclusion, we have found that by using the aforementioned techniques, we were able to successfully correct chordee in 96% of the proximal hypospadias patients. We continue to evaluate and modify our techniques in our never-ending pursuit to improve outcomes and lower patient morbidity.