Hypospadias Penile Skin Landmarks Technique for Preputial Reconstruction in Distal and Mid-penile Hypospadias Undergoing Tubularized Incised Plate Repair

ABSTRACT

Background:

Hypospadias repair has traditionally involved tubularized incised plate urethroplasty, often necessitating circumcision or preputial sacrifice due to dartos flap usage for waterproofing. However, many parents prefer preputial preservation for cultural and aesthetic reasons. No standardized technique currently exists for preputial reconstruction in distal and mid-penile hypospadias. We describe the hypospadias penile skin landmarks (HPS landmarks) technique based on ventral raphe classification and dorsal skin landmarks, a refined surgical approach leveraging natural penile skin creases to facilitate effective preputial reconstruction while maintaining functional and cosmetic outcomes.

Methods:

This prospective study, conducted at two centers in India (January 2021–June 2024), included 67 patients (6 months–18 years) with distal and mid-penile hypospadias. A new classification system for ventral raphe and dorsal skin landmarks was proposed to guide preputial reconstruction. Surgical principles involved three key steps: (1) identifying and marking anatomical skin landmarks, (2) selective tissue dissection and preservation, and (3) midline approximation for symmetrical preputial restoration. Functional and cosmetic outcomes, including urethral patency, urinary stream, preputial symmetry, and complications, were assessed postoperatively.

Results:

Among 67 cases (52 distal, 15 mid-penile hypospadias), the median age was 14 months, and the mean operative time was 110 ± 18 min. Urethrocutaneous fistula occurred in two patients (2.98%), preputial dehiscence in two (2.98%), and three (4.48%) exhibited persistent dorsal hooding. No cases of glans dehiscence, metal stenosis, or residual chordee were noted. Parental satisfaction was high, with favorable functional and aesthetic outcomes.

Conclusion:

The HPS landmarks technique provides a refined surgical approach to preputial reconstruction in distal and mid-penile hypospadias, preserving prepuce integrity while ensuring functional and cosmetic success. By leveraging anatomical skin creases using the described classification, this technique minimizes preputial complications and offers a culturally acceptable alternative for patients desiring preputial preservation. Further long-term studies are warranted to validate its widespread applicability.

INTRODUCTION

Hypospadias repair has evolved significantly over the past three decades, with the tubularized incised plate (TIP) urethroplasty, introduced by Snodgrass, remaining the predominant technique for distal and mid-penile hypospadias.[1] While the standard TIP repair has demonstrated high success rates, and enjoyed popularity amongst surgeons, it precludes a preputial reconstruction due to utilization of dartos flap for waterproofing, though the use of ventral dartos has been previously applied.[2,3] Therefore, preputial preservation remains a challenge after TIP, particularly in cases where parental preference dictates an intact prepuce. The conventional approach often necessitates sacrificing the prepuce, which is culturally and aesthetically undesirable in many regions. Many studies have proven that preputioplasty along with hypospadias repair in distal and mid-penile hypospadias is feasible with comparative outcomes.[4] However, no technique has been standardized so far.[5] Recognizing the distinct anatomical characteristics of hypospadias, including natural skin creases, landmarks, and raphe alignments, we have developed an innovative technique–the hypospadias penile skin landmarks (HPS Landmarks) technique–which leverages these anatomical landmarks for enhanced reconstructive and cosmetic outcomes. We also propose a new classification of variations of ventral raphe and dorsal penile skin landmarks in hypospadias which facilitates a more efficient preputioplasty by the described technique.

MATERIALS AND METHODS

This prospective study was conducted at two centers of India from January 2021 to June 2024 and included 67 randomly selected patients aged 6 months–18 years with distal and mid-penile hypospadias. Patients with proximal hypospadias, severe chordee and redo procedures were excluded from the study. The inclusion criteria comprised patients with mid-penile or distal hypospadias, with or without chordee. The chordee was corrected with ventral degloving, and if needed a dorsal plication using restricted dorsal skin lifting without dividing the preputial attachments proximally and distally to allow preputial reconstruction. The types of prepuce were not a contraindication for the procedure. Institution ethics committee approval was duly obtained. The anatomical variations in the ventral raphe of the prepuce in hypospadias cases were categorized into four distinct types [Figure 1a-d], aiding in surgical planning and reconstruction:

Figure 1.

Natural crease classification and markings according to HPS technique. (a and b) Unilateral deviated raphe (Type 1), (c) Midline raphe (Type 2 and 3), (d) Double raphe (Type 4)

1. Type 1-Deviated raphe: The preputial raphe deviates toward the right or the left and goes toward the lateral aspect of the shaft, ending at the corner of the prepuce or continuing with the dorsolateral skin creases of prepuce, leading to an asymmetric distribution of preputial skin. This variation necessitates targeted incision placement and differential tissue mobilization to achieve symmetry

2. Type 2-Midline raphe reaching up to the meatus: The raphe follows a central course, reaching up to the meatus allowing a balanced distribution of preputial tissue, making it the most suitable for midline closure techniques

3. Type 3-Forked raphe: The preputial raphe divides in the midline at a variable distance proximal to the meatus like a Y and each limb goes towards the edges of the glans along with the preputial attachments

4. Type 4: Double raphe: Two almost parallel lines are seen and one of the double markings is more prominent and is in continuation with the scrotal raphe while the other line is shorter and fades proximally.

In addition, the hypospadias penile skin landmarks on dorsal skin are transverse or oblique prominent skin creases on the dorsal hood of prepuce which start near the most prominent part of the dorsal hood and run laterally up to the edges of the prepuce and may or may not join the ventral landmarks in their distal part [Figure 2a and b].

Figure 2.

Hypospadias penile skin landmarks on dorsal prepuce (a) and markings (b)

This classification provides a structured approach to addressing preputial asymmetry in hypospadias, aiding the preputial reconstruction. This study does not intend to compare the results of hypospadias with or without preputioplasty. Based on the above classification, the principles of the surgical technique were divided into three key principles [Figure 3a-c]. The first principle involved identifying and marking the natural raphe, beginning at the base and tracing along the ventral penile surface and marking it exactly along its course, based on Raphe classification proposed by us. In case of Type 4 raphe the dominant one is chosen to be preserved. The second principle focused on identifying aberrant peri-meatal skin, particularly dysplastic areas that could interfere with successful preputial reconstruction, to ensure only healthy tissue was utilized. The Third principle entailed locating the dorsal bilateral preputial landmarks and marking them to facilitate symmetric midline fusion of the laterally diverted dorsal/dorsolateral preputial skin and forming a functional and aesthetically acceptable prepuce and a median ventral raphe at the end of the procedure.

Figure 3.

Details of incisions according to HPS landmarks technique (a) Right sided raphe, (b) Midline raphe, (c) Left sided raphe, (red-raphe incision, green-urethroplasty incision, yellow-preputial incisions, blue-excision of hypoplastic prepuce)

Technique [Figure 4a-i and Video 1: https://drive.google.com/file/d/1copLC0IOdMzgiIOJ8RSz0fzFolKYfCDq/view?usp=drive_link]: The patient is placed in a supine position under general anesthesia and a caudal block, and a stay suture is applied to the glans for gentle traction. The procedure begins with preoperative marking of penile skin creases including the ventral midline raphe, transverse/oblique creases, and dorsal or dorsolateral preputial lines around the dorsal preputial prominence (HPS landmarks), to guide reconstruction [Figures 1 and 2]. A U-shaped peri-meatal subcoronal/peri-meatal skin incision is made which is extended on both side of preputial wings as per hypospadias penile skin markings along natural creases. The glans landmarks are also marked for raising glans wings and markings of the proposed metal boundaries. Skin incisions are converted to full-thickness up to Buck’s fascia preserving splayed corpus spongiosum and only ventral degloving is done while preserving preputial integrity. Penile curvature is assessed after degloving using an artificial erection test and a chordee-free straight penis is ascertained. If ventral degloving does not correct the chordee then a dorsal plication is added using dorsal skin lifting without dividing the preputial attachments proximally and distally to allow preputial reconstruction later. Rest of the steps of urethral plate incision and glans mobilization of are similar to standard TIP ensuring adequate urethral caliber and tension free repair.[1] The urethroplasty is performed over a 7 Fr or 8 Fr infant feeding tube with 6-0 or 7-0 Polyglactin 910-suture. The corpus spongiosum is then mobilized bilaterally and approximated over the neourethra to provide ventral vascular support and prevent fistula formation. The glansplasty is performed over the distal part of the urethroplasty keeping them in line with the prepuce flaps which have been minimally separated into inner and outer layers by carrying the incisions up to the edges of the prepuce. The inner layer of the prepuce is in continuity with the mobilized glans wings, and care is taken during dissection of glans wings, as not to injure the inner prepuce. The glans wings are then approximated in the midline with sub cuticular sutures and the repair is continued on the inner prepuce skin to reconstruct the ventral frenulum of the glans. The length of this ventral frenulum corroborates with the length of the inner prepuce inside the preputial hood which is present around the glans dorsally, and it gives a uniform inner prepuce lining all-round the glans circumference. The neo ventral frenulum is then lifted upwards by gentle traction on the last suture and under the epithelial surface the dartos is reinforced as another layer which also stabilizes the prepuce and prevents a dehiscence.

Figure 4.

Steps of HPS landmarks technique (a) Markings, (b) After ventral degloving, (c) TIP incision, (d) Urethroplasty and spongioplasty, (e) Inner preputioplasty, (f) Everted inner prepuce, (g) Dartos repair, (h) Completed ventral view, (i) Completed dorsal view

To reinforce the repair, the dartos tissue just under the mobilized prepuce over the shaft of the penis, along the preputial incisions is mobilized medially and easily approximated in the midline over the spongiosum and carried down till the base of the penis to provide waterproofing, minimize tension on skin closure and provide a uniform dartos cover on ventral shaft till the root of the penis.

To complete the preputioplasty, the suture line on the inner prepuce is carried onwards and it comes to the external prepuce and the skin land marks, which were earlier on the dorsolateral aspect of the prepuce get aligned on the ventral side and a point to point midline approximation is done creating a ventral raphe in the middle. No prepuce is sacrificed, except for the very thin edges/corners and hypoplastic areas which are beyond the markings and seems to be devascularized.

A non-adherent dressing is applied, and a urinary stent is left in place for 10–12 days. Postoperative care includes the use of steroid cream after about 3–4 weeks of surgery, if necessary, to prevent preputial fibrosis and maintain retractility. Parents are advised against retraction of the prepuce until complete healing to ensure long term functionality, while cleaning of prepuce is taught after 15 days. Postoperative care included standardized protocols for dressing, catheter management, and scheduled follow-up assessments. Outcome measures focused on functional results, including urethral patency and urinary stream quality, as well as cosmetic outcomes such as preputial symmetry and overall appearance. In addition, complications such as fistula formation, stenosis, or wound dehiscence were recorded. The preputial complications recorded during follow-up include-dehiscence, preputial fistula, preputial narrowing, ventral scarring, dorsal hooding, and retractability. Parental satisfaction surveys were conducted to evaluate overall outcomes and acceptance of the procedure.

RESULTS

A total of 67 patients were evaluated postoperatively for functional and cosmetic outcomes. Overall, 52 distal hypospadias and 15 mid-penile hypospadias were operated. The median age was 14 months (7 cases were post-pubertal), and mean weight was 10.2 kilos. The mean operative duration was 110 (±18) min and mean blood loss was 25 (±10) cc. Mean follow-up duration was 24 + 11 months. There were no cases of glans dehiscence, metal stenosis, urethral stricture, or torsion. Urethrocutaneous fistula was observed in two patients which required a second surgery involving fistula isolation, suturing, and coverage with surrounding dartos tissue [Figure 5a]. One patient experienced superficial epithelial necrosis, which spontaneously healed without intervention. Residual chordee was not present, 3 patients needed a dorsal plication in the present study. However, two patients exhibited ventral bend without penile chordee due to hypertrophied scar tissue, which was managed conservatively with clobetasol propionate application and coconut oil massage [Figure 5b]. In both the cases, both patients reported straight natural erections and were not concerned about ventral hypertrophied scarring.

Figure 5.

Complications. (a) Urethrocutaneous fistula, (b) Ventral scarring and preputial fistula, (c) Dorsal hooding, (d) Preputial fistula

Preputial dehiscence was observed in two cases – one was repaired, while another developed delayed dehiscence at home after 15 days awaiting repair. The surgical technique was subsequently modified to prevent this complication. Three patients exhibited persistent prominent dorsal hooding of the prepuce (Monk’s hood prominence) and direction of urinary stream directed backwards. In one patient, a dorsal slit of prepuce and trimming the corners was done, partially exposing the tip of glans and the meatus and the other two were managed conservatively by teaching to hold the penis while micturating [Figure 5c]. Preputial fistula occurred in two patients early in the series, which was successfully repaired, and the technique was adjusted to prevent further occurrences [Figure 5d]. Two patients requested circumcision due to preputial stenosis, but two patients reported ventral urinary stream deviation due to the prepuce, which was managed with reassurance. The overall cosmetic satisfaction score showed good parental satisfaction. In the present study, 48, 71.64% were Type 1, 12, 17% were Type 2, 7, 10.44% Type 3, and 2, 2.98% Type 4 raphe; however, their correlation with the outcomes of the hypospadias or preputioplasty were not done. The results of the technique indicate that while minor complications were encountered, most were managed conservatively or addressed through modifications in the surgical technique, ensuring favorable functional and aesthetic outcomes after preputioplasty. The three-layered closure of prepuce - inner skin, dartos, and outer skin meticulously and preservation of vascularity were the key focus areas to improve the results of the preputial closure.

DISCUSSION

Preputial reconstruction in hypospadias was first described by Righini in 1969, and follows the principle of midline approximation of the ventral V-shaped defect after separating the inner and outer preputial layers.[6] Surgical modifications include Hayashi et al.’s approach, limiting midline approximation to preserve retractility while using transverse adaptation distally.[7] An alternative is combining preputioplasty with dorsal preputioplasty (Y-V or vertical incision with longitudinal closure) to enhance ventral tissue transfer. However, the issues of disfigurement, differential preputial bulk, asymmetry, closure under tension, dehiscence, and tightened prepuce are common.[2,8,9,10] We describe hypospadias prepuce skin (HPS) landmarks technique where the anatomical natural skin crease incisions are involved, and facilitates full-thickness midline closure similar to layered embryological fusion, offers anatomical closure of prepuce without compromising the urethral reconstruction.

The embryological failure of fusion of urethral plate, spongiosum, dartos, glans folds, and prepuce results in hypospadias.[11,12] The penile skin in hypospadias exhibits several distinct natural creases that play a role in penile development and reconstruction. The ventral midline raphe, a continuation of the median scrotal raphe, extends to the ventral prepuce. In addition, transverse or oblique creases, which have not been previously described in the literature, symmetrically converge towards the ventral raphe, primarily in the distal or mid-penile region. Another feature is the dorsal preputial prominence, often appearing as a single or dual prominence near the dorsal midline, reflecting the incomplete tubularization of penile tissues and thought to be having an abnormal concentration of dartos fibers under the dorsal hood of the prepuce. In normal penile development, these creases become inconspicuous as the penis undergoes complete tubularization. However, in hypospadias, their abnormal orientation serves as useful landmarks for reconstruction. Our classification of penile raphe in hypospadias is based on the embryological halt in the closure of prepuce at different stages of fusion leading to varied patterns, which needs a more detailed embryological study. The classification of raphe described by us is an important prerequisite in planning a preputioplasty to achieve a near normal looking midline raphe. The classification of Ventral Raphe and the dorsal skin landmarks adopted by us clearly describes the variations in the prepuce encountered in distal and mid-penile hypospadias. The ventral preputial morphology described by us may not be applicable to severe variety of hypospadias and may not allow preputial conservation. Moreover, the authors have not postulated that preputial anatomy, raphe anatomy, and classification proposed alter/predict the hypospadias outcome. In the present study, 48, 71.64% were Type 1, 12, 17% were Type 2, 7, 10.44% Type 3, and 2, 2.98% Type 4 raphe, is an area which has not been extensively studied so far.[13]

The combined TIP urethroplasty with HPS landmarks preputioplasty technique described by us offers anatomical restoration, midline symmetry, preservation of vascularity, and tension-free repair, making it a culturally acceptable alternative for patients who prefer preputial preservation. By following natural anatomical landmarks, this approach ensures superior cosmetic and functional outcomes while minimizing complications. The HPS technique helps in correction of torsion and deviation of midline raphe which is an important cosmetic structure. Our innovation builds on the principles of TIP repair while addressing its limitations, offering a refined technique that enhances both patient satisfaction and surgical success.

Preputioplasty in TIP repair requires certain prerequisites, including adequate preputial tissue, the ability to achieve penile straightening through ventral dissection alone, and the absence of severe chordee. Following natural creases using HPS Landmarks Technique provides an outline of necessary markings and incision. Circumferential degloving should be avoided, as it can lead to significant preputial swelling, increasing the risk of failure and deformity. A key prerequisite for performing preputioplasty is that the prepuce remains available and is not utilized for urethroplasty or dartos flap cover. This can pose a challenge in cases of proximal hypospadias or when severe ventral curvature necessitates urethral plate transection. However, in distal hypospadias, where significant curvature is uncommon, this is rarely a concern. In such cases, TIP repair is the most frequently employed technique, preserving the prepuce. The concern about the lack of dartos flap cover as water-proofing is addressed by a meticulous spongioplasty over the urethroplasty and fashioning full-thickness preputial incisions allowing ventral dartos repair of the preputial skin during ventral skin repair.[14,15,16] Erdenetsetseg and Dewan suggested a single criterion for determining eligibility for preputioplasty: The ability to retract the prepuce after aligning its free edges during the outpatient evaluation and at the start of surgery.[17] In a study by Cimador et al., circumcision was performed in 27 out of 186 (14.5%) distal hypospadias cases due to significant asymmetry of the prepuce.[18] However, other studies have documented successful preputioplasty in all cases similar to our experience where no patient was deferred for the preputioplasty.[2,19]

The primary concern is whether preputioplasty contributes to a higher complication rate in hypospadias repair with reference to skin complications and the likelihood of urethroplasty-related issues. While an earlier study by Klijn et al. suggested an increased risk of urethroplasty complications in distal hypospadias cases with preputioplasty, more recent research, found no significant difference in complication rates based on preputial preservation.[4,16,20,21] In addition, a meta-analysis using the Mantel–Haenszel and fixed-effect methods indicated that prepuce repair does not significantly elevate the risk of urethral fistula formation (odds ratio 1.25, 95% confidence interval 0.80–1.97).[21] Distal hypospadias correction combined with preputioplasty had complication rates similar to those of hypospadias repair with circumcision. In the present series urethrocutaneous fistula was seen in 2/67, 2.98% cases. Preputioplasty is associated with two main complications: Preputial dehiscence and secondary phimosis, with reported rates varying from 0% to 30%, and a cumulative prevalence of 7.7% [Table 1]. This variability may be influenced by factors such as follow-up duration, patient selection criteria, and surgical technique. However, studies have reported a failure rate up to 22% requiring secondary circumcision after preputioplasty, and foreskin retractability in only up to 80% patients.[22,23] In the present study, secondary procedure for prepuce was required in 6, (8.95%, two preputial dehiscence repair, two preputial fistula repair, one correction of dorsal hooding, and one circumcision). Preputial dehiscence can be either partial or complete. When partial dehiscence occurs between well-healed proximal and distal segments, it may lead to a preputial fistula. Reported incidence ranges from 0% to 30%, with a cumulative prevalence of 5.7%.[4,19,20] Partial dehiscence in the distal portion can often be managed conservatively, while cases involving preputial fistula or complete dehiscence may require surgical repair or redo preputioplasty. However, redo surgery carries a risk of recurrence, making circumcision an option unless parents are highly motivated to preserve the prepuce.[8] Mild preputial tightness usually improves over time and resolves with conservative management. A retractile prepuce is expected in adults after a preputioplasty, but data on phimosis risk after preputioplasty in hypospadias remains limited. Studies report phimosis in 9.5%–15% of cases, though only 0.2%–1.5% require surgery.[19,20,23,24] Postoperative edema, often resolving within weeks, and natural widening at puberty contribute to improving retractility over time according to our experience. Topical steroids, such as betamethasone, have shown success in treating secondary phimosis and long term outcomes are satisfactory.[2,10,25] However, in patients with prominent dorsal whorls and underlying bulky tissues, preputioplasty may not provide aesthetically satisfactory results as observed in the present study in 7.46% cases, however, they were managed with reassurance.[26] To assist patients and parents in making an informed decision, it is important to discuss all potential major and minor foreskin-related complications, along with their management options.

Table 1.

Complications associated with preputioplasty in hypospadias repair – literature vs present study

Complication	Reported in Literature	Present Study (n=67)
Urethrocutaneous Fistula	No significant increase with preputioplasty [OR 1.25; 95% CI: 0.80–1.97][21]	2 cases (2.98%)
Preputial Dehiscence	0%–30% incidence; cumulative ~5.7%–7.7% [4,19,20]	2 cases (2.98%) – both required surgical repair
Secondary Phimosis	9.5%–15% incidence; surgical intervention in 0.2%–1.5% [19,20,23,24]	1 case (1.49%) – managed with topical steroids
Failure Rate (requiring circumcision)	Up to 22%[22,23]	1 case (1.49%) – required circumcision
Foreskin Retractability	Achieved in up to 80% of cases[22,23]	Long-term data not specified
Preputial Fistula	Included in 0%–30% dehiscence rate; cumulative~5.7%[4,19,20]	2 cases (2.98%)
Redo Preputioplasty Required	Variable, based on complication type	3 cases (4.47%) – fistula/dehiscence/dorsal hooding
Unsatisfactory Aesthetic Result	Seen especially in bulky dorsal whorl cases [26]	5 cases (7.46%) – managed with reassurance
Postoperative Edema	Common; usually resolves spontaneously	Reported, but not quantified

The technical nuances of HPS Landmarks technique include classifying raphe, utilize ventral and dorsal landmarks and incisions described by us, dissection and reconstruction in three layers, providing an intermediate dartos layer, though its consistency varies among patients. In our experience, a careful dissection, full thickness incisions, and navigating the anatomical planes provide enough dartos for waterproofing followed by a layered closure of the ventral prepuce. Notable technical considerations include proper eversion of skin edges, creating a natural-looking median raphe, correcting the torsion using adjustments, meticulous suturing with 6-0 or 7-0 Polyglactin 910 or PDS sutures, and a specialized non sticking compressive closed dressing to avoid postperative edema.

Some may argue that without full degloving it would not be possible to perform a dorsal plication if chordee does not resolve with ventral degloving. Penile curvature is assessed after degloving using an artificial erection test, and rarely if still present (in three of our cases), the dissection over the Buck’s Fascia can be carried circumferentially around the shaft to have access to the dorsal aspect of the shaft of penis for dorsal plication, without dismantling the prepuce from the corona of the glans, and maintaining the natural normal relationship of dorsal prepuce attachment to the glans [Figure 6] The Type 1 (unilaterally deviated) raphe may predispose to torsion which is handled with adjusting sutures and in the present study none of the patients developed torsion.

Figure 6.

Shaft degloving without detaching the prepuce for dorsal plication

Preputioplasty in hypospadias repair cannot be regarded as an independent step; rather, it must be planned from the outset as an integral part of the entire procedure. Its feasibility is closely linked to the maneuvers required for penile straightening, the chosen urethroplasty technique, and the potential need for an additional flap as a barrier layer to cover the urethroplasty.[4] A key concern is whether preputioplasty increases the overall reoperation rate in hypospadias repair. However, recent studies reported no significant difference in reoperation rates between preputioplasty and circumcision after TIP repair.[2,4,14]

Glans morphology has also been identified as a determinant for a successful preputioplasty encouraging glans anthropometry before preputioplasty.[27,28] The wider glans not getting accommodated in the available preputial circumference may raise concerns about adequacy of the preputial opening after preputioplasty. However, our observations differ with the above concept as preputial morphology is the sole determinant of feasibility of the preputioplasty which follows the concept of anatomical landmarks in distal and mid-penile hypospadias.

The cosmetic appearance after preputioplasty is reasonably good long after the surgery as tissue becomes more supple with time. While short-term follow-up data is reported, the long term studies are limited.[9] The common cosmetic issues which bother the surgeons more than the parents are dorsal hooding giving an appearance of chordee, ventrally tucked prepuce, visible monks-hood, and irregular frenular skin.[29] In our experience, adult outcomes are awaited, but the parents showed a significant cosmetic satisfaction after the surgery in the present series. However, a long term evaluation is warranted. Based on the observations in the present study, one should consider relative contraindications of the procedure which includes: Any chordee which is not amenable to ventral degloving and dorsal plication, an explicit severe degree of monk’s hood which is likely to give an unacceptable cosmesis after preputioplasty, and torsion of the penis necessitating complete degloving and flap readjustments. The parents should be duly counseled about possible cosmetic outcomes and need of second corrective surgery in minority of the cases.

The present study has certain limitations including lack of randomization, lack of a control group of TIP without preputioplasty, shorter follow-up (24 months), and experience of only two centers with lack of multicenter data. A more robust statistical design can only be the scientifically certain way to prove superiority of the technique, which is not claimed in the present study. The evaluation of outcomes of the hypospadias using a more objective scoring system could not be applied in the present study, is another limitation. The uroflowmetry was performed in 6 patients with more than 2 years follow-up and revealed normal flow, however, it needs a larger cohort [Figure 7]. The present study postulated to classify raphe, identify anatomical landmarks of skin crease/raphe essential for preputial reconstruction, and describe a detailed technique of preputioplasty along with TIP which enhances the existing technical description of preputioplasty in TIP.[8,9,22,23,24,26,30,31] The relation of type of crease with the functional and cosmetic outcome was not evaluated in the present study and should be the further area of research. The relation of various types of raphe with variations in vascular anatomy is another area which may vary and influence outcomes, also need exploration. More studies involving randomized patient selection, inclusion of multiple centers, and performed by different surgeons are needed to address the limitations of the present study, strengthen the overall evidence base, and establish external validity.

Figure 7.

Uroflowmetry after 2 years of surgery showing normal flow

CONCLUSION

The HPS Landmarks technique provides a refined surgical approach to preputial reconstruction in distal and mid-penile hypospadias, preserving prepuce integrity while maintaining functional and cosmetic outcomes. By leveraging anatomical skin creases, this technique minimizes complications and improves surgical success of preputioplasty, making it a viable alternative for patients desiring preputial preservation. Further studies with long-term follow-up will validate its widespread applicability.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.