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Hypospadias affects around 1 in 400 boys. Glans width (GW) of <14mm has been shown to be an independent risk factor for urethroplasty complications following hypospadias repair. Testosterone (T) administration in prepubertal males increases both penile length and circumference. Its routine use remains controversial as the data on its potential benefit and impact on reducing complications is conflicting (androgens may affect wound healing or increase inflammation). Here Mittal et al. describe the effect of T on GW in a large cohort (579 boys). The authors have maintained a database (completed in prospective fashion) from 2015 onwards. Patients who underwent hypospadias surgery between 2016 and 2020 were included if the status of their T administration was known, intraoperative GW and either preoperative or postoperative GW was recorded. Callipers were used to measure the GW at its widest point. Dosing was at 2mg/kg, typically 20-30mg per injection (intra-muscular). Either single or double injections were provided. The decision to utilise T and dosing was at the discretion of the primary surgeon. Median age at surgery was 0.9 years. A total of 247 patients (42.7%) received T, while 333 (57.5%) did not. There was a significant difference in GW at surgery (16mm vs. 14mm) for those that received T compared to those that did not. The change in size was dose dependent (4mm increase for two doses vs. 2mm for single dose). Interestingly, T was used in 164 (47%) distal hypospadias, 18 (41%) mid-shaft hypospadias and 65 (37%) of proximal hypospadias. Results also suggest a persistence of response over time. This publication appears to be the largest data set reporting the effects of T administration prior to hypospadias surgery. The authors did not look at surgical outcomes, so it remains to be answered if T administration does indeed improve outcomes. I was somewhat surprised to see such a high rate of T use in all types of hypospadias (especially distal and mid-shaft subtypes). I generally only use T rarely and this would be in a highly select group of proximal hypospadias (with what I consider to be small penile size), where the benefits may be important in terms of facilitating a first stage repair. Further work is needed to try and determine which patients, if any, truly benefit from T prior to hypospadias surgery. It should be remembered that there could be downsides to unnecessary systemic androgen exposure (e.g. effects on long bone growth).

Quantifying glans width changes in response to preoperative androgen stimulation in patients undergoing hypospadias repair.
Mittal S, Eftekharzadeh S, Christianson S, et al.
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Neil Featherstone

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).

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