Preoperative use of testosterone prior to distal hypospadias repair
Reviewed by Neil Featherstone

Preoperative hormonal stimulation has been utilised for >50 years in hypospadias surgery. Surgeons utilise testosterone (T) to increase penile size and glans width to try and improve clinical outcomes. However, a paucity of reliable data supporting its use has limited integration into clinical guidelines and routine administration remains controversial. Studies have varied in design, surgical technique, route / dosage of hormone administration and the phenotype severity of hypospadias (distal / proximal, chordee, depth of glans groove, glans width and tissue quality, etc.). This is a large retrospective review of patients who underwent distal hypospadias repair (distal and mid-shaft) with urethroplasty (2015-2021) by 11 individual urologists at a single institution. Patients receiving T were given 2mg/kg via IM injection. Single injections were administered five and two weeks before surgery for those receiving two doses, or at three to five weeks before surgery for one dose. Three hundred and sixty-eight patients underwent hypospadias repair. One hundred and thirty-three (36.1%) received preoperative T and 235 (63.9%) did not. Seventeen patients (12%) received one dose of T, 112 (84%) received two doses and four (3%) patients received three doses. Glans width at initial visit was significantly smaller in the T group (13.1mm vs. 14.6mm). Intraoperative glans width was significantly larger in the patients having received T (17.1mm vs. 14.6mm). The complication rate in the T group was 12% vs. 15.7 in the non-T group. Fistulae were the most common complication accounting for more than 50% of complications in either group. Most patients underwent a Thiersch-Duplay repair (195/235 - 83%). Multivariable logistic regression analysis showed T administration reduced the odds of postoperative complications; complication rates were 12% in the T group and 15.7% in the non-T group. Limitations include the retrospective nature of the study, differences in baseline characteristics, surgeon bias as to who received T and selection of repair type (there is a lack of a tubularised incised plate (TIP) cohort which is used in the majority of hypospadias repairs currently). Can these results be extrapolated to TIP repairs? Although the use of T within this institution appears to reduce complications, its utilisation in more than 1/3 of cases appears exceedingly high (compared to my own practice where it is seldom used in either distal or proximal repairs and better outcomes noted – less fistulae). Whether similar results would be seen if repeated in other centres has to be questioned.

Does preoperative testosterone administration decrease complications in distal hypospadias repair with urethroplasty?
Godlewski KF, Mittal S, Hyacinthe N, et al.
JOURNAL OF UROLOGY
2023;210(2):352-9.