Effect of Massage with Topical Corticosteroids on Recurrent Curvature in Staged Repair of Proximal Hypospadias: A Retrospective Study

Abstract

Objectives

Ventral penile curvature often accompanies severe hypospadias and poses a risk of recurrence after repair. We postulated that altered myofibroblastic activity at the repair site contributes to recurrent curvature. To address this mechanism, we adopted a specific clinical strategy in 2017. We instructed patients to apply upward massage to the ventral side of the penis using a topical corticosteroid ointment between the two stages of Bracka repair. The aim of this study was to assess the impact of this intervention on the recurrence of curvature after surgery.

Methods

A retrospective review of the medical records of all patients who underwent Bracka repair for hypospadias between January 2009 and May 2023 by a single senior surgeon was conducted. Patients were divided into two groups according to whether they received steroid treatment, and complication rates were compared. In the steroid group, parents applied Betnovate® 0.1% (betamethasone valerate) ointment twice daily with upward massage to the ventral penile surface, beginning in the second postoperative week after Bracka stage 1 surgery and continuing for three months. The primary outcome was recurrence of curvature during the second stage and at long-term follow-up, while secondary outcomes included dehiscence and fistula formation.

Results

The review included 60 patients (median age: 14 months [5–171]) who underwent Bracka repair for hypospadias, with 40 in the steroid group and 20 in the control group. The mean degrees of curvature at presentation were similar (91 and 89 degrees, respectively; p>0.05). Compared with the control group, the steroid group had a significantly smaller mean degree of curvature both at the second-stage operation (17 vs. 26 degrees, p=0.04) and during long-term follow-up (15 vs. 25 degrees, p=0.03). There were no steroid-related complications, and no significant differences in the incidences of dehiscence and fistula formation were observed between the groups (p>0.05).

Conclusion

Our findings suggest that the application of a topical corticosteroid ointment with upward massage to the ventral graft site between stages 1 and 2 of Bracka hypospadias repair may reduce the recurrence of curvature both during the second stage of repair and at long-term follow-up.

Ventral penile curvature is a common finding in severe hypospadias cases and remains a significant challenge in surgical management. Despite various reconstructive techniques, curvature recurrence is frequently encountered following hypospadias repair, often complicating long-term functional and aesthetic outcomes.^[1,2] In two-stage repair approaches, such as the Bracka technique, recurrence of curvature during the interval between the first and second stages can necessitate additional corrective procedures, affecting overall surgical success.^[3]

To minimize fibrosis and contracture at the repair site, various strategies have been investigated, including pharmacological interventions and mechanical therapies. Corticosteroids, known for their anti-inflammatory and immunosuppressive properties, have been shown to improve outcomes after hypospadias surgery by reducing excessive fibrosis and scar formation.^[4] Additionally, massage therapy has been widely used in various surgical fields to enhance tissue remodeling, improve blood flow, and reduce postoperative adhesions.^[5] Upward massage helps maintain tissue flexibility and prevents excessive contracture. Consequently, this mechanical intervention may improve long-term outcomes.

Since 2017, our clinical practice has incorporated a novel approach aimed at preventing curvature recurrence between stages 1 and 2 of Bracka repair. We instruct patients to apply a topical corticosteroid ointment with upward massage to the ventral grafted surface of the penis between the two stages of hypospadias repair. This study evaluates whether corticosteroid massage therapy reduces postoperative curvature recurrence. We compare outcomes between treated and untreated patients to determine its impact on the long-term success of staged hypospadias repair. Our hypothesis was that corticosteroid massage therapy applied between the two stages of hypospadias repair would reduce postoperative penile curvature recurrence.

Methods

This retrospective cohort study evaluated patients who underwent two-stage Bracka hypospadias repair between January 2009 and May 2023. All procedures were performed by a single senior surgeon (I.U.) at a high-volume center. All patients who underwent surgery during the study period were identified from hospital records and included in the analysis. A change in our clinical practice in mid-2017 introduced the use of topical corticosteroid massage therapy between the two stages of repair. Accordingly, patients operated on before this change comprised the control group, while those treated afterward comprised the steroid group. This study investigated the effectiveness of corticosteroid massage therapy in reducing the recurrence of postoperative penile curvature. The primary outcome was recurrence of curvature during the second stage and at long-term follow-up, while secondary outcomes included dehiscence and fistula formation. The exclusion criterion was lack of consent for the use of data in the study.

Steroid Group: After routine wound care with antibiotic ointments for the first two weeks, parents were instructed to apply Betnovate® 0.1% (betamethasone valerate) (Glaxo Wellcome Ltd.) ointment twice daily with upward massage to the ventral grafted surface of the penis. Caregivers were instructed to wear a single glove finger during application and to use approximately 0.1 g of ointment per dose, equivalent to the size of a lentil seed or half a pea. Massage was performed using gentle but firm upward strokes for approximately one minute per application to prevent tissue contraction and fibrosis. Topical corticosteroid therapy was discontinued after three months, but massage was continued using Vaseline until the second-stage operation.

Control Group: Patients did not receive corticosteroid therapy or massage; they received only routine wound care with antibiotic ointments for the first two weeks.

All patients underwent an erection test through corporal infusion of normal saline using a 23-gauge butterfly needle without tourniquet application. Ventral penile curvature was measured using a smartphone-based digital goniometer application (Angle Meter 360, v.1.9.3, by Alexey Kozlov) on photographs taken from a standard lateral view during both stages of the procedure. A minimum interval of six months was maintained between the first- and second-stage operations for all patients.

Medical records were reviewed to identify patient characteristics and treatment outcomes. Demographic data, information about preoperative hormone therapy, if any, and postoperative outcomes were collected for all patients. The primary outcome was recurrence of penile curvature, assessed both at the second-stage operation and during long-term follow-up. Secondary outcomes included rates of fistula formation and dehiscence. During follow-up clinic visits, outcomes and complications were assessed through physical examination and review of voiding videos recorded by caregivers. Curvature angles were also measured using a digital goniometer on photographs of spontaneous erections provided by caregivers during these visits.

Statistical Analysis

Continuous variables were presented as means with standard deviations or medians with interquartile ranges, depending on data distribution. Comparisons between groups were conducted using the independent t-test for normally distributed data and the Mann–Whitney U test for non-normally distributed data. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. A p-value<0.05 was considered statistically significant. JASP (Version 0.96.0; Amsterdam, The Netherlands: JASP Team) software was used for statistical analysis.

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki and was approved by the Institutional Ethics Review Board of İzmir Bakırçay University (Approval No. 1293; November 8, 2023). Informed consent for participation and data use was obtained from the legal guardians of all patients. The manuscript was prepared in accordance with the STROBE statement, adhering to it as closely as possible.^[6]

Results

Patient Characteristics

A total of 60 patients who underwent two-stage Bracka hypospadias repair were included. All patients or their legal guardians provided consent for the use of their data in the study, and there were no missing data for any patient. Mid-2017 served as the dividing point between the groups, as the introduction of topical corticosteroid massage therapy between the two stages of repair led to the formation of two cohorts. Patients operated on before this date comprised the control group, while those treated afterward formed the steroid group. The steroid group included 40 patients, whereas the control group included 20. The median age at the time of the first-stage repair was 14 months (range: 5–171 months), with no significant difference between the two groups (p>0.05). The mean preoperative penile curvature was similar between the groups, measuring 91° in the steroid group and 89° in the control group (p>0.05). The mean time interval between the two Bracka stages was 8 months (range: 6–24 months), with no significant difference between the two groups (p>0.05).

Preoperative Hormone Therapy

Topical testosterone, prescribed by a pediatric endocrinologist, was administered before the first-stage repair in patients with a penile length below 2 standard deviations. In the steroid group, 15 patients (37.5%) received preoperative hormone therapy, of whom 13 (86.7%) exhibited satisfactory penile growth. In the control group, 11 patients (55%) underwent hormone therapy, all of whom (100%) achieved satisfactory penile growth before surgery. No statistically significant difference was observed between the groups in terms of receiving preoperative hormone therapy or the resulting penile growth (p>0.05). In the entire cohort, undergoing hormone therapy was associated with more severe penile curvature (higher degrees of preoperative curvature), as expected (p=0.01).

Curvature Recurrence

Patients who received topical corticosteroid massage therapy had significantly less curvature recurrence than the control group, both during the second-stage operation and in the long term (Fig. 1). At the time of the second-stage operation, the mean curvature was 17°±4.3° in the steroid group, compared with 26°±5.1° in the control group (p=0.04). During long-term follow-up, the mean residual curvature was 15°±3.8° in the steroid group and 25°±4.6° in the control group (p=0.03).

Figure 1.

Comparison of ventral penile curvature across operative phases.

The requirement for dorsal plication during the second-stage operation was also compared between the groups. The steroid group required significantly fewer dorsal plications than the control group (10% vs. 35%, respectively; p=0.02) (Fig. 2).

Figure 2.

Comparison of dorsal plication requirement during second stage surgery.

Secondary Outcomes

None of the patients reported steroid- or massage-related complications. The rates of surgical complications, namely dehiscence and fistula formation, did not differ significantly between the groups (p>0.05) (Table 1).

Table 1.

Comparison of complication rates

Complication	Steroid Group (n=40)	Control Group (n=20)	p
Dehiscence (any degree, including glanular)	13 (32%)	8 (40%)	0.58
Fistula	12 (30%)	7 (35%)	0.77
Meatal stenosis	1 (2.5%)	0 (0%)	1.00
Complication-free	18 (45%)	8 (40%)	0.79

Meatal stenosis was successfully dilated, and all fistulas were repaired as additional procedures. Most dehiscences were glanular, and because of satisfactory functional outcomes, the majority of families chose not to pursue surgical revision, whereas 7/21 opted for revision distal urethroplasty.

Discussion

Since its initial description in 1995, the Bracka repair has been widely accepted as a preferred staged approach for proximal hypospadias.^[7] However, the management of recurrent curvature following Bracka hypospadias repair remains a significant concern, particularly given the complexities associated with severe hypospadias. In recent years, recurrent curvature has received increasing attention, with more studies emphasizing its long-term impact on functional and cosmetic outcomes.^[1,2] Notably, Snodgrass and Bush have reported recurrence of ventral curvature even after seemingly successful initial correction, prompting renewed discussion regarding surgical strategy and the importance of long-term follow-up.^[1,8] The findings of our study suggest that the application of a topical corticosteroid ointment combined with upward massage to the ventral side of the penis can effectively reduce recurrence of curvature after surgical intervention. This approach is based on the hypothesis that myofibroblastic activity at the repair site drives recurrent curvature. Therefore, modulating this process both mechanically and pharmacologically may optimize surgical outcomes.

Topical corticosteroids are known for their anti-inflammatory properties, which can be beneficial in reducing scar tissue formation and promoting better healing in grafted areas. In the context of hypospadias repair, studies have indicated that the use of grafts, such as buccal mucosa or preputial skin, can lead to complications such as graft contracture and recurrent curvature if not properly managed.^[2,9–12] The role of corticosteroids in this setting is to minimize the inflammatory response that can lead to such complications, thereby potentially improving surgical outcomes.^[4] Additionally, the practice of upward massage to the ventral grafted area is supported by evidence from other surgical fields, such as the management of Peyronie’s disease, in which postoperative rehabilitation techniques, including massage, have been shown to enhance recovery and reduce curvature.^[13,14] This technique may help maintain graft flexibility and prevent the formation of tight scar tissue, which can contribute to curvature.

While our study utilized a pharmacological and mechanical approach through corticosteroid massage therapy, a recent prospective study from Taiwan introduced a purely mechanical intervention using penile taping between the two stages of hypospadias repair.^[15] In their protocol, the penis was taped to the pubic region for up to 23 hours a day following urethral plate transection, aiming to maintain ventral traction throughout healing. This method, termed “tissue traction therapy,” led to complete curvature resolution in more than 90% of cases without additional surgical procedures. The underlying mechanisms differ; the Taiwanese study relies on mechanotransduction, whereas our protocol combines manual manipulation with antifibrotic pharmacological support. However, both strategies share the ultimate goal of minimizing ventral curvature between surgical stages. In essence, our findings support the notion that sustained modulation of the healing process, whether through corticosteroid-mediated suppression of myofibroblast activity or mechanically guided tissue stretching, can significantly influence surgical outcomes by the time of the second-stage repair.

The retrospective analysis of 60 patients undergoing Bracka repair provides evidence supporting the efficacy of the proposed intervention. The steroid group demonstrated a statistically significant reduction in the mean degree of curvature both at the second stage of repair and during long-term follow-up compared with the control group. The absence of steroid-related complications underscores the safety of this intervention, suggesting that it can be integrated into standard postoperative care without increasing the risk of adverse events. Although the complication rates in our cohort may appear elevated, it is important to recognize, as highlighted by Long and Canning in their review, that long-term complications following hypospadias repair are often underreported and likely more prevalent than generally perceived.^[10] The rates observed in our study are consistent with those reported by the limited number of centers that have published long-term outcomes for proximal hypospadias repair.^[2,11,12,16] Glanular dehiscences not requiring reoperation were also included in our complication count, which likely contributed to the higher rate.

Limitations

The retrospective design of the study introduces inherent limitations, including potential selection bias and temporal variability between the two cohorts. However, all procedures were performed by a single senior surgeon with more than 30 years of experience in hypospadias repair, and the comparable complication rates observed across both periods suggest that differences between the groups are unlikely to be attributable to surgical expertise. Although the findings offer valuable insight, their generalizability may be limited by the single-center setting and reliance on a single surgeon’s technique. In addition, compliance with home therapy was not objectively assessed and represents a limitation. Another limitation of our study is the combined nature of the intervention, which simultaneously involves both pharmacological (topical corticosteroid) and mechanical (upward massage) components. Because these two therapies were administered together in all patients within the treatment cohort, it is methodologically impossible to determine whether the observed reduction in recurrent curvature was primarily driven by the antifibrotic properties of the corticosteroid, the physical tissue manipulation provided by massage, or a synergistic effect of both. Future prospective studies with larger cohorts and randomized controlled designs are warranted to validate these findings and further elucidate the mechanisms by which corticosteroids and massage influence healing outcomes in hypospadias repair. This study should be interpreted as a hypothesis-generating, single-surgeon experience rather than definitive evidence of treatment efficacy.

Conclusion

In conclusion, this study demonstrates that the use of topical corticosteroid therapy combined with upward massage between the stages of Bracka hypospadias repair may reduce the recurrence of ventral curvature and the need for additional corrective procedures, such as dorsal plication. By targeting the healing process both pharmacologically and mechanically, this approach appears to support more favorable long-term surgical outcomes without increasing complication rates. These findings highlight the potential of noninvasive interventions to enhance tissue remodeling and underscore the need for further prospective studies to validate these results and refine postoperative protocols for proximal hypospadias repair.

Disclosures

Ethics Approval

Ethics committee approval for this study was obtained from the İzmir Bakırçay University (Approval no: 1293; date: November 8, 2023)

Informed consent

Informed consent for participation and data use was obtained from the legal guardians of all patients.

Conflict of Interest

The authors declare that there is no conflict of interest.

Financial Disclosure

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Use of AI for Writing Assistance

The authors used a large language model (ChatGPT, OpenAI) to assist with language editing and improvement of clarity in the manuscript. The AI tool was used solely for linguistic refinement, and no data analysis, interpretation, or generation of scientific content was performed by the AI. All content has been critically reviewed and approved by the authors, who take full responsibility for the integrity and accuracy of the work.

Authorship Contributions

Concept – I.U.; Design – I.U., S.T., A.T., H.U.; Supervision – I.U., S.T., A.T.; Data collection &/or processing – H.U., S.S.; Analysis and/or interpretation – H.U., S.S., S.T., A.T.; Literature search – H.U., I.U.; Writing – H.U., S.S., I.U.; Critical review – H.U., S.S., S.T., A.T., I.U.

Peer-review

Externally peer-reviewed.