Hypospadias surgery continues to tax the minds of paediatric urologists. Increasingly distal hypospadias surgery is becoming more and more conservative (in some cases, carrying out only foreskin reconstruction and leaving a mild hypospadias) and the role of foreskin reconstruction as well as a hypospadias repair is being revisited. This review article by one of the leading hypospadias surgeons in the world looks at outcomes of preserving the foreskin during distal hypospadias operations. Four hundred and twenty-eight tubularised incised plate (TIP) procedures (343 with circumcision, 85 with foreskin preservation) were prospectively analysed. After foreskin preservation procedures, retraction of the foreskin was deferred for six weeks. Median age was eight months (range 3-420) and follow-up seven months (1.5-97.5). Of the circumcision patients 8.7% had urethroplasty complications (16 fistulae, 13 glans dehiscence, one meatal stenosis due to balanitis xerotica obliterans (BXO) five-year postoperatively). Of the foreskin preservation group, 8% had urethropalsty complications (four fistulae, two glans dehiscence, one stricture of the foreskin). Skin complications occurred in 2% of the circumcision group and 2.3% of the foreskin preservation group, all requiring re-operation. This paper confirms that the trend toward foreskin preservation is justified in distal hypospadias surgery.