What is the recommended management for glanular hypospadias?

Management of Glanular Hypospadias

For glanular hypospadias, surgical repair using penile-preserving techniques such as urethromeatoplasty (MAGPI, GAP, or Firlit procedures) should be performed between 6-18 months of age, with the goal of achieving a normally positioned, slit-like meatus and excellent cosmetic outcome. 1, 2

Preoperative Evaluation

Before proceeding with surgery, complete the following assessments:

• Endocrinological evaluation is mandatory if the patient has proximal features (undescended testes) to exclude disorders of sexual development, though this is rarely needed for isolated glanular hypospadias 1
• Renal and bladder ultrasound should be performed to screen for urinary tract anomalies, particularly if there are any associated findings suggesting more proximal disease 1
• Physical examination should document the exact meatal position, glans width (normal is approximately 13mm), presence of chordee, penile torsion, and meatal stenosis 3

Surgical Technique Selection

The choice of surgical approach depends on meatal position and glans anatomy:

For Distal Glanular Hypospadias with Adequate Glans

• Urethromeatoplasty procedures (MAGPI, GAP, MIV glansplasty) are preferred as they are simple, reliable, and provide excellent cosmetic results 2
• Modified circumcision with Firlit procedure is particularly effective, with same-day discharge, no catheterization required, and minimal complications (meatal stenosis rate of 0% at 2-24 months follow-up) 4

For All Types of Glanular/Subcoronal Hypospadias

• Distal urethroplasty and glanuloplasty (DUG) procedure can be applied universally by first converting any glanular variant to a wide meatus through vertical meatoplasty (Heineke-Mikulicz principle), then performing Thiersh-Duplay tubularization 3
• This approach successfully corrects associated skin chordee, penile torsion, and meatal stenosis in the same operation 3
• Parameatal foreskin flap techniques (Mathieu, Barcat procedures) remain viable alternatives with overall success rates of 87-96% 5

Perioperative Pain Management

Implement a multimodal analgesic strategy:

• Ultrasound-guided caudal block with long-acting local anesthetics plus clonidine for intraoperative and immediate postoperative pain control 1
• Rectal NSAIDs (ibuprofen 10 mg/kg every 8 hours or diclofenac 0.5-1 mg/kg every 8 hours) combined with rectal paracetamol for baseline pain management 1

Surgical Principles

Key technical considerations include:

• Only techniques that assure a normal-appearing penis should be undertaken for glanular hypospadias, as these are cosmetically less aberrant than proximal variants 2
• Achieve a slit-like external urethral meatus positioned at the tip of the glans 3
• Mean operative time ranges from 106 minutes for complex procedures to shorter for simple urethromeatoplasty 3
• No routine catheterization is needed for most glanular repairs, particularly with Firlit technique 4

Critical Pitfalls to Avoid

• Do not operate on patients with undescended testes without first excluding disorders of sexual differentiation 1
• Avoid overly aggressive indication for DUG procedure in cases with long hypoplastic urethra extending to the distal penile shaft, as this increases risk of meatal regression 3
• Do not use potent topical steroids if lichen sclerosus is suspected, as this causes cutaneous atrophy 1
• Avoid repeated endoscopic procedures for recurrent strictures, as these compromise future reconstructive options 1

Postoperative Management

• Same-day discharge is achievable with simpler techniques 4
• Temporary dressing may be needed for mild immediate postoperative bleeding (occurs in approximately 18% of cases) 4
• Follow-up at 3 months to assess urinary stream, cosmetic outcome, and exclude meatal stenosis 1, 4
• Long-term follow-up extending to 24-40 months demonstrates sustained excellent outcomes with modern techniques 4, 3