Update on Management of Hypospadias

Good afternoon, good evening, or good morning, dear colleagues, uh, wherever you are in the world. My name is Eugene Minovich, and I would like to welcome you all to our Hyperspace session. It is my great privilege to introduce our next speaker. It's a real treat for all of us to have Doctor Warren Snodgrass talking about his favorite topic. Doctor Warren Snodgrass is well known around the globe as a trailblazer in the field of hypospediology and as a pensive, thought-provoking clinician. Without any further ado, Doctor Snodgrass podium is yours. Thanks so much. It's really a pleasure to be part of this conference and to talk to you about this subject. It's not my favorite subject. Now it's my only subject. This is Dr. Bush here standing next to me. This is a picture from our center. Uh, so we don't do anything except yus Spadius anymore and we work out of this place near Dallas. So what I want to talk about today, there's such an expansive list of topics we can discuss in Hyperspadius, but let's just zero in on doing it right from the very first time because then so many other topics kind of go away if we do that. And let's start out by defining what that means. So, I'm going to define a good outcome or a right outcome from surgery as being a normal penis. And now let's break down what does that mean? Well, a normal penis is straight. It has a slit meatus at the tip. There's no visible scars except for along a median raphae that men have or the circumcision line that people are accustomed to, and no lingering complications after things are said and done. So how often in hypospadius surgery can we expect to make a normal penis, and the data indicates that we should be able to accomplish that over 90% of the time when we're doing distal repairs. But the data also show that we can accomplish that in over 90% of proximal repairs, although I think most of the fellows and others who are watching will admit that that goal is not so easily achieved. So speaking of fellows, I know they're an integral part of this meeting. Let's just talk to them for a second and say, how do you know what you're learning is right? And so we did a survey a number of years ago, never published this. We did a survey of the fellows and just asked them, when you're done with your fellowship, How are you going to make decisions when you're in your practice? And we listed the usual scientific things, the academic things that we all work on. And then we also said, uh, your mentor's teaching, and, and we asked them, this was a simple multiple choice question, and here was the answer. So now with that in mind, let's talk about a routine case of distal hypospadius with mild core D, and this patient underwent a dorsallication and a tip repair. And here was the outcome from that. And so the parents went in for their postoperative visit and the surgeon told them, OK, this is what I see. They weren't sure about that, so they went for a second opinion, and the second doctor kind of said, Yeah, there's a small breakdown. So they ended up coming to see us. And this is what we saw. Not just the glands dehiscent, but also torsion from the skin deficiency and as you see here, great suggestion for ventral curvature, and that's exactly what we've found intraoperatively 35 degrees of ventral curvature despite that dorsal placation and that tension from that curvature exerted right on the glands to create that gland's dehiscence. Let's look at another case. Here's a boy who came with recurrent fistulas after a distal tip again with dorsalliccation. And once again, why did the fistula happen? Why did it happen again? Well, we found that the patient had 30 degrees of recurrent curvature, as you see right here, despite that dorsal placation. So what, what's the point in starting with these stories, and that's to say that these surgeons are all certified pediatric urologists, and not one of them measured the curvature that they encountered in the operating room, and they used lication to correct curvature greater than the data suggests they should do. We're going to talk about that. When problems happen, the fistula, the glands dehiscences, none of them mentioned any thought about being a potential recurrent curvature, and the one that underwent re-operation did not have a second artificial erection according to the records. So here's my point to you as trainees. These were all done at top-ranked programs by surgeons whose names you know and who you possibly personally work with. And fellows, of course, assisted on these cases, and this is exactly how we continue year after year and generation after generation to have problems. So how good are the mentors? How good are the people who teach us? Well, we don't really have data like this from the United States. This is a great study that they did in Holland a few years ago where they linked all the surgeons in the country at their major centers who do hypospadia surgery, and they had them fill out standardized data information. And accumulated that on 814, mostly distal cases, mostly tip repairs. Let's draw that 10% complication line right here and you see that most of the doctors, these are their major doctors and their major centers had complications above that 10%. And remember, these were mentors, so they were teaching their trainees these same mistakes that they were making. And we know that if you learn mistakes you're likely to repeat those mistakes. There's published data about that too. This is a paper from Mark Horwitz, and let's draw again the 10% line. He was looking at the time it took for his fistula rate to come down, and he attributed that reduction to doing a barrier layer, making some technical changes in the operation to get below that 10% mark took him over 120 cases. Because he either was not taught or he was taught but did not learn to do these key steps in the operation, and this is how many children suffered because of his lack of information on how to do the operation in the best way. That's not unique to him. Here's another paper, and they made some technical changes, saw a. Decline in their complication rate, but even at 250 cases, they're still twice higher than that 10% mark that we know that surgeons can achieve doing distal hypospadius repairs. So here's a key lesson that I hope in all the things I'm going to talk about, this may be the most important statement to remember. When complications happen, look in the mirror because the complications that we see are almost always mistakes that were made by the surgeon. So you as trainees, you may be learning the mistakes that your mentor teaches, and then you'll make some new ones on your own too. How do we know that? Well, I mean, we do nothing but hypospadius. We operate 4 days a week. We operate all day long and half of those cases are re-operations and we read the operative reports so we can see the mistakes that are in there. So with that as background, what do we do to get right? How do we get that over 90% success rate? And so here are two of the most important things. First, We have to do it in the best way that's known, and then, having chosen the right technique, we have to do the steps in the operation in the best way. Even if those are different than what you were told they were. So, the first thing, so here we're talking about hypospadius, but I'm starting the lecture not talking about urethroplasty. I'm talking about curvature of the penis. Because as we saw in those first two cases, it wasn't the urethroplasty that got those patients into trouble. It was the curvature, the persistent or recurrent curvature, because that explains many complications. after distal repairs as I showed you, and we published recently that 85% of the patients who came to us with routine complications after proximal repairs had persistent or recurrent curvature that averaged 50 degrees. So this is a crucial step in doing it right the first time. And how do we do it? Well, a lication is perfectly reasonable when there's curvature less than 30 degrees. We no longer do a Baskin lication because there's actually published data that if you just stitch right there as opposed to incising the tunic albigena and stitching. right there that you have a higher recurrence rate. So we made this adjustment a few years ago. We just make a puncture with an 11 blade and we sew a 50, single 5-0 prolene. If you need more stitches than one, you've got curvature more than 30 degrees and you're doing the wrong treatment. So what do you do when it is greater or 30 degrees or greater, then we treat that with 3 corparorotomies, ventral lengthening with 3 corpoorotomies. The first mark here through the greatest area of curvature, the other two slightly above and below it. These 3 incisions, as you see here, because that reliably straightens the curvature. So I keep saying 30 degrees. I showed you two cases with basically 130, 135 degrees. Well, this is 30 degrees right here, and I think most of you looking at that would think to yourself, Well, sure, I can do a dorsal implication. That looks like something I would dorsally placate without any worry about it. And so I'm going to encourage you to quit looking at it with your eye and start using an instrument to measure it. This is a goniometer. It's a type of protractor. You can use a regular protractor, whatever, but you need to measure because your eyes are not accurate. So this is one of the first things Doctor Bush brought that to our practice and we started using it and oh my gosh, did we realize that what we thought was 30 degrees, you know, like actually was quite a bit more in many cases and, and something like this, we would have thought that's almost nothing you can put a placation. Why does that not work? At some point, the force in a penis during erection is more than what a stitch can hold back. And we know, all of us know how much force is in a fully erect penis, both in a child and in an adult, and that tension on the underside will overcome the suture. You put it in, you check again, the penis looks straight, but that tension, which has not been relieved, it's only being corrected by the strength of that stitch. Well, this wins in most cases, and the curvature comes. Back and when it does, all that tension that it generates is directed right at the area where the surgery was done and so you get these problems that we all see. This was a surprise to me to realize that this was caused by ventral curvature, but we see this problem every single week in new patients in our practice from all over the country and actually from all over the world. But you know, you don't have to take my word for it. Here's a rather famous person who talked about dorsallication and all that's John Duckett for you folks who have heard the name but not seen the picture. And he actually wrote, so let's go back in history a bit, Cody excision to clean off. Off the cord tissues on the underneath of the penis was the most common way to correct curvature for a long time until artificial erection came along and showed that it was not so effective. And so John had been doing cordy excision, but then he started doing artificial erection and seeing the penis was still bent. Well, when the penis is bent, you have two options. You can Uh, shorten the longer side or you can lengthen the shorter side. And of course, putting a stitch on that top side to shorten it is much easier than doing a ventral lengthening. And so he said, If there's curvature 20 or 30 degrees, you should do a dorsallication. As time went by, he got more confident with that and started saying, you know, you can really do a dorsallication or several lications and straighten just about anything. You almost never need to do ventral lengthening. Now remember, he's just eyeballing this, so we don't really know the extent of curvature that he was treating, but eventually he was treating essentially all curvature with those placations. But now we know that the people who've inherited his practice and the boys he operated on as children who are now grown up and you can't deny their curvature anymore, that they've quit doing this. They've gone back to less than what John even said. And so I know that Doug has said and written that he doesn't do placations basically at all anymore. So again, the best way to straighten curve, more than one way, the best way to do it are these 3 corpootomies, no grafting of this. The, the problem with a single incision of graft is that most boys with proximal hypospadius, the average is 70 degrees of ventral curvature, and even the advocates. A single incision corporotomy admit that when the curvature gets up to 60 degrees or more, it's hard for one incision to release it. We make 3 incisions that adjust and open according to what they need to be to be straight. We've published that this works in almost every case. It's durable. We repeat the artificial erection every time we operate or we operate for a fistula or whatever, and this does not cause erectile dysfunction. We don't have a single patient who's developed erectile dysfunction after it. And I've been doing 3 corporotomies like this for 20 years. Our practice is only hypospadius, so it's not only kids. Adults, teenagers and adults have hypospadius too. And so we have a lot of experience straightening adults. This guy right here, he had surgery as a kid. He had probably a dorsallication. It didn't work. It got pushed off. Surgeon tell them it'll be fine. I don't see any problems. And then when they go through puberty, it's not that they newly developed curvature, it's that you can't deny it anymore. And so we straighten this the same way we do in kids, 3 transverse corpoorotomies. Here he is back again. We've done an artificial erection. It's all healed. It's nice and straight. There's no erectile dysfunction. So, it's the curvature, which tells us which urethroplasty to do. And that's why we start our lecture talking about the curvature. So, when there is minimal or no curvature, if there's a mild degree of curvature less than 30 degrees, we'll do a dorsallication. So in that group of patients, we're going to do a tip repair. Everybody else who has more curvature than that, we're going to do a stag or a stack repair. So again, the curvature determines the operation. Not the mediata location. Please do not fall in the habit of walking in, taking a brief look at the child, going, oh, there's a distal meatus, telling them that's a distal hyperspace repair, etc. etc. because in most cases, this penis will be straight or will have less than 30 degrees of curvature, but not in all cases. I showed you already two cases earlier that had 30 degrees or more. This is a boy with even more curvature than that. This is not an operation that should be done using a lication and a tip repair. This should have a stag repair. What about this patient with penis scrotally looking hypospadius? This looks like a more severe situation, except that this penis was actually straight. Once this hyped up scrotum was dropped down, this is not what usually happens when the penis looks like this, but it does happen in about 1 out of 10 boys with that appearance, and that's a tip repair. So it's not the mediatal location, it's the curvature that determines the urethroplasty. So assuming that we have a straight penis, and that's going to be most boys with a distal meatus, then we're going to repair that with a tip repair. And the basic steps of the the operation, I hope you know, we marked the gland's wings where the visible junction. is we don't measure anything to do that. We always make an incision down to the underlying corpora, always, always from within the meatus to the tip of the urethral plate, not to the tip of the glands, but where the urethral plate ends. We always begin the tubularization at about this level, which is the mid portion of the glands, so that we don't make iatrogenic stenosis. We, we run that stitch down subepithelialally, tie a knot and run it back. And then we always cover with a darktose flap, which you can raise from the ventral side or the dorsal, but there's a, if you do the initial dissection in the right plane, there's always ventral darktos. You can just flip up to cover it and then we close the glands over that with one layer of 60 vicral suture, three interrupted subepithelial stitches. We never put any epithelial stitches in the glands ever. What if it's a proximal penis with less than 30 degrees of curvature? Well, you can do that with a tip repair. And here's an example of that with the urethral plate in size. Now, we're going to do the tubberization a little bit differently. We're going to interrupt the first layer with subepithelial seno viral sutures because this is a much longer suture line. It's really hard to maintain even tension and even um Um, approximation of the tissues over that kind of distance and then we're going to do a second layer of running and we're not going to do it the other way around because if you do, the fistula rate, published fistula rate from the way we do it is 4%. Published fistula rate, if you run it and then throw interrupted stitches in, is 20%. It makes a difference how we do things. Then we never use dartos and a proximal repair to cover over the neourethra. We always use tunica vaginalis because it makes a better barrier layer. It is the most important thing is deeply incising the urethral plate when you're doing a tip repair. So we've published all of that that I've told you many, many times in many formats. It's on YouTube. We have this textbook, chapter, everything. So you can find that. But let's just boil it down to say this. This is our series of distal repairs we published a few years ago. So we're within that standard of greater than 90% success rate. And we did this on every single boy who met the criteria of having a distal meatus and a straight penis. We didn't use any other technique. We didn't do an advancement, a magpie, a flip flop. We didn't select patients for TIP and other patients for something else. Every single patient got the same operation, and we found that there was no contraindication to doing that. We're not the only ones to publish those results. It's a meta-analysis from a large series from centers around the world and you see that the overall success rate, again, is in that greater than 90% grouping. So what does that mean? That means that you can look at all of these patients here who have a wide variety of phenotype of distal hys space. They all have a straight penis and they've got all kinds of different urethral openings and glandular shapes and all of that. And you can do a tip on every single one of them. So you don't have to study the anatomy to say what operation am I gonna do. You can study the anatomy to say I've got to make sure I do the tip in the right way. You don't, some people will tell you, well, you've got to decide if this is a favorable plate or an unfavorable plate, or you have to check the width of the urethra plate because certain widths don't work good, or is the spongiosum good? And the fact is we never look at that factor. We never Ever measure the width to determine if we can do a tip repair or not, and we don't make any assessment of the spongiosum at all. We do it on every single patient, so whatever good or bad is mixed in, we do the same operation with good outcomes. So what are the problems that we see when we look through those operative records I already showed you that people who do dorsallication when there's curvature 30 degrees or more, well, they're just setting up for a complication. And the most common one when the penis is straight is a hesitancy or a failure to incise the urethral plate deeply and throughout the entire length. There's proof of that. This article was published, as you see, back in 2009, and the point of this article was if you had a width before you made the tip incision of less than 8 millimeters, that you were going to have a bad outcome, but they put this picture of what the urethral plate looked like after their incision. That's what they made as a tip incision and it hardly opened up any at all. That's what the tip incision that we make. So this isn't using a tip repair for unfavorable anatomy. This is not doing the tip repair in the right way. So, again, our experience, the data that we have, the data that other people published says That it's not the anatomy which creates complications from tip repair, it's mistakes the surgeon makes. So that's the majority of patients just off the street who need hyperspace repair, but then we have that harder group that is born with ventral curvature that's 30 degrees or more. What are we going to do with them? Well, we're not going to do dorsallication. I've already told you we're going to do ventral lengthening, and then that changes how we're going to do their urethroplasty. So let's look at that. But let's start by summarizing that this is really not so different. If it's a primary pair that we're doing a tip on, we're tubularizing an incised urethral plate. If there's curvature greater or equal to 30 degrees, we're going to make a neourethral plate, and then we're going to tubularize that, and making a neourethral plate is always a two-step process. When you look at boys with more severe hypospadius with curvature greater than 30 degrees, Then these are the three components. It's true of all hypospa surgery, but it's exaggerated in the boys with more severe hypospaus. We have to straighten the penis. It's going to be more challenging now. We've got to transfer skin because these boys are missing ventral skin. That's true in boys with distal hypospadius too, but the difference, the deficiency of skin is greater now in these kind of cases. And of course we have to do the urethroplasty. So the straightening, we're going to end up having to transsect the urethral plate and move it out of the way so we can do our corpoorotomies. We're going to have to transfer skin as we always do from dorsally to ventrally of varying degrees depending on the anatomy, and we're going to do the urethra. pla s ty but we're gonna have to add tissue to the urethral plate. So we're gonna make a neop plate, doing that with graft, and then we're gonna tubularize that at a subsequent stage. Now, how we put all of this together depends. In some cases we can straighten and graft in one operation, and that we're calling the straighten and graft operation or a stag, but there are other times which we'll explain where it's best not to do that, where it's best to straighten and stop, straighten and close the skin, and that's a stack. And then we're going to bring the patient back when this is healed and do our two-stage urethroplasty. When you're starting out with any of these patients, no matter where the meatus is, here's another distal meatus. When you have suspicion that there may be curvature of 30 degrees or more and you see it right here, if you see a hump in the middle of the penis, these are signs that you probably have curvature that's 30 degrees or more. Don't deglove. Don't make a circumferential incision. You can get all the access you need by a ventral degloving incision. And you're saving the foreskin for later use depending on how the operation unfolds. You don't want to burn a bridge on the very first incision of the operation. Or another way to look at it, since I'm Texan, is the presence of a penis is not the need for degloving. Many surgeons think the opposite. I hope I can persuade you that's not the way to begin surgery. So when we are dealing with curvature, we're starting out the operation, whether it's going to be a stagger stack the exact same way. We're going to make a ventral degloving incision. We're going to take off all that dartose tissue and do an artificial erection. Then we're going to peel the urethra out of the way. As you see here, we can dissect it all the way up to the sphincter. We don't always need to do that, but you can. And now we're going to see exactly where the curvature is. The point of greatest curvature, we draw this line and then we go about 4 or 5 millimeters distal and proximal because the curvature is on an arc and we want to open it along that arc. So we make these 3 incisions and there we go. That's done. So whether you're going to do a stagger stack, you always do these steps right here. Look at the exposure. that we have, even though we haven't released the dorsal skin and what you're not seeing here, but you can see here, we have the tourniquet all the way around. All this skin has been released on the dorsal side. We just haven't cut it loose and laid it down, but we can get all around this penis. We have total control over it. So, are we going to do a stag or a stack? The number 1 deciding point is now we're going to bring that urethra back up. Is it going to reach past these 3 incisions? Is it going to come to lie right there or not? So in this case, sure enough, we bring the urethra up and it reaches beyond the 3 incisions, which means our graft will go onto intact corpora. So we make the urethrostomy, it's past those incisions. That's going to be a stag repair in most cases. Or we find that the urethra won't reach that high. In this case, the urethrostomy is here and there's incisions distal to that. You're not seeing them because we've already covered them with darktose, but you can imagine that this is on, on this picture is actually right here. And so we have exposed incision. And we've learned not to put a graft on top of those. I used to, but we've learned not to, and we've learned to cover those with Dartos. I'll explain in a minute, but if you put a graft on top of that Daose, it also does not have reliable healing. So for those reasons, we're going to stop. That's a stack repair. Straighten and close. The other factor that makes a difference is the skin. Because in a case like this where we have a lot of skin here, we can, we're not gonna need to move so much skin to the ventral side to cover the penis. And so, we can probably do a stag repair. But this patient has no ventral skin. So once we've straightened the penis, which is going to make it longer, then we have an even greater skin deficiency to cover. And so we're going to move a lot of skin under there. And so in that case we're going to do a stack repair because the skin needs to heal itself without being stressed to help the graft heal. Because grafts, when you put a graft down, graft revascularizes from the corpora that you lay it on and from the skin that you sew to its borders on either side. So if you put it onto the corporotomy incisions, sometimes it will heal and sometimes it won't. And if you have a large amount of transferred skin on the side of the penis, sometimes it can help the graft heal and sometimes it can't. We can prove that now using spy. We're having a lot of fun using this. So here's a typical case with a stack. So this boy, the urethra would not reach past the corpoorotomies and he had short skin. So we just did, here's his stack repair. When it's done, the, uh, incisions are all covered with darktos. The skin is all closed. We've done a propchiaplasty to save the skin for the next operation. And then we did the spy. And what we see is that the skin sure looks dark. Well, we know that this skin almost always heals healthy. But imagine if we also put a graft in there at this operation. Is this skin, which is going to struggle to survive and become supple itself, would it be able to additionally meet the needs of a graft placed at the same time? So here's another patient that had the stack repaired. This is what they look like when they come back. His penis looks entirely normal unless you saw the opening, you wouldn't even know he had any problems. Looks just like an uncircumcised penis. So now we've circumcised him and we've done his graft, and now we're doing the spy on him and what you see, we're lifting the sides of the skin on either side where it joins. So we're looking, we're lifting this this way and looking here, we're lifting this flap that way and looking there and you see great vascularity there. So doing it in steps avoided this situation. Or what about the boy who doesn't have such a bad situation in the first place, we decide to stag him at the same time. Well, here's the graph is up here and this all looks nice. There's no darkness here. The only darkness is actually below our urethrostomy, so we're not. So worried that that's going to impair graft healing. So the, the spy, we're not using it for decision making intraoperatively, but right now it seems to be reinforcing the decisions that we've made. So, we decided we're going to do a stag repair. So we've done our straightening. We've brought the urethra up, it reaches. Now, we, when we mobilize the urethra, we save the dartos and spongiosal tissues with it and then we use that just to cover over these incisions on either side. We want to make that area basically watertight, blood tight, if you will, so we cover it. So that's what you see here. It's all covered up. And so there's the urethrostomy right there. So that's where the graft is going to go, intact corpora, good skin with good dartose. There's our graft. 92% success rate when we do it this way. And all these numbers that I quote you, these are all from our data recently reviewed. What if it's a stack repair? Now, the, you see the incisions, the urethrostomy is down here. We have exposed corpoorotomies up here. We have covered them with a dark dust flap. All we're going to do now is close the skin, let that all heal. I've already told you that we have success in almost 100% coming back with a straight penis and with healthy ventral skin. It is dramatic how doing this takes a gnarled up small bent penis with no ventral skin and makes something that looks like a normal penis except for the meatus being in the wrong place. So what does it look like when they come back? Well, there's that normal looking penis. You, you can't even see in this picture where his, you know, urethrostomy is. That looks like a normal uncircumcised penis. This is the typical appearance after a stack repair. So now, all we have to do is make a midline incision this way and a circumferential incision that way. We always check an artificial erection again, make sure it's straight. Then we always make sure we have adequate coverage for the penile shaft first. Always. What's left over is the graft for the urethra. And there you go. If you do it this way, so far in consecutive patients, we have not had to use oral graft in any primary repair. We've always had enough to cover the penile shaft and enough for the urethroplasty. So here we've quilted the graft into place. So now we've gone stag, we've gone stack, but they've both led to the same place. Time for the final operation. We have a nice neo urethral plate. It's good and healthy. We've got good shaft skin. We're not going to have to worry about a ecil or some kind of scrotal flap or a skin graft. We've taken care of all those things. We check again. That we have a straight penis. We mobilize that g gland's wings. The glands are smaller in these patients. We want to make sure it's good and wide so there's no tension when we close it. We're going to do that tubularization in two layers that first interrupted, the second continuous, just like in a proximal tip repair. We're going to cover it with tunica vaginalis flap, just like in a tip repair. We're going to do our glands plasty with 3 subepithelial stitches, no stitches through the glands. Just like a tip repair. So we're doing the same steps in, in these operations over and over so we get good at them. We're always going to save and close the mucosal collar. We never realized before how important that is, not just for aesthetics, but to buffer the glands from tension from the skin and to help prevent fistulas by having healthy tissue in this area, which is the most prone area to develop them in the first place. And then we end up with a normal penis. How often does that happen? Well, here's our success in primary repairs of the most severe hypospadius, 4% fistulas, as I told you before, because this is how we prevent that, and 8% glands dehiscence. We've reduced that by this extended dissection, which was more than. I was taught, so I had to learn that and that decreased our rate. And then if we say, OK, but what happens, we can close that fistula, Pennis is straight, urethra is healthy, we can close the fistula, glands dehiscence, we can reclose the glands. In most cases that works. So we have almost 100% success when we take this into account. First off, most of them don't have a complication. Most of the ones that do, we can fix with one additional operation. So you bring us the most severe boy with hypospadius, and we can bring them that we can make a normal penis. Which means you potentially can too. So when we're looking at a patients, can we, you know, predict for the family if it's going to be a stag or a stack? And yeah, more or less. If we see this kind of patient with a dysileatus, good skin, but curvature, well, that's probably going to be a stag repair or This patient with a proximal meatus, but more skin here to work with. Well, that's probably going to be a staggered pair. Probably. Again, we have to cover the incisions with the urethra, but that's probably what we're going to do. This patient, no way that patient's going to get a stack. There's no ventral skin. We're not going to risk putting a graft in that patient after we straighten them. Same with this patient. No way. First off, there's no ventral skin in this patient either, and the urethra is not going to reach up past those corpoorotomies in almost any of these boys. Or this patient who could be like this, but the bend is so far distally that you can't bring the urethra up there and still put a graft. So a very distal bend is another indication with these others to do a stack repair. So yes, we can have a pretty good idea of what we're going to do in most cases. So some of you want to object, Well, is it really reasonable to do 3 operations? Well, you know, I don't know. Duckett said you could do all operations in one stage, and yet the trend around the world is to get away from that. You can do that if you're willing to accept nearly 100% complications and a penis that usually doesn't look normal. Funny, during the time that Duckett was saying this, Ivor Brockco was saying you really should do all repairs, even distal repairs in two stages. And then Philadelphia and, and Texas Children's published recently in their two-stage repairs using buyer's flaps that 70% of those patients ended up with 3 or more operations. So how many repairs in our algorithm are going to need multiple stages? Well, first off, most boys with hypospadis have distal hypospaes with a straight penis, and they can have a tip repair. A few boys with proximal hypospadius have a straight penis, not many, but some do. They can have a tip repair. So that's going to be most. Those who have more severe curvature. Which is 30 degrees or more, that's the group that's going to need a multi-stage repair for primary surgery, so 10%, 1 out of every 10 patients. So this is not going back into the past. This is looking at the anatomy and saying we want to make a normal penis out of that. That's our goal because it's time for us as a profession to quit arguing about whether one stage or two stage and start saying how many stages does it take to make this into a normal penis because that's what the patient and the family care about. That should be our goal. So to do that, you have to use the best techniques. We don't know of any other technique that gives these results as well as and certainly not better than tip, stag, and stack. But you have to do the steps in them in the best way, which we think is the way that I have been showing you and what you can see on our videos. But to know for sure that you are doing it the best way, you've got to monitor your own work. You have to look at your own results. So I always end lectures by making this point that you've got to do self-assessment doing the three P's. I suggest to all of you that as you begin your practices, you just set up little databases of the things that you do often and just put some data in. I started a database for hypospadiia surgery in 2000 and we still use that database and some other ones that we've added since that time for hypospadius, and we put the data in every day at the end of the operation, every single patient, every single Da, the data goes in right then, it only takes me about 5 minutes to do that. So we put the data in at the time of the surgery and then we look at that on a regular basis. Anytime we have a question about something, we look it up or when we're locked down because of a pandemic, we have a lot of time to go back through and ask all kinds of questions and look at our data, which is where some of these updated numbers. Numbers came from. And once we know our results, we can see, oh wow, I wonder how we can make this part of it better. That's more fistulas than I thought we had. What can we change that will reduce that? The mistakes are ours. How do we figure out how to reduce those mistakes? So I started out the lecture by asking you, how do you learn, right? And I'm going to suggest that sure, we all learn from our mentors, but don't assume that just because you like your mentor or your mentor's famous or you're in a good program or whatever else, that your mentor is right about everything. None of us are. So also use this in addition to reviewing your own work. Let me just close by making this observation from my own past. I learned from a very good mentor. I learned the foundation of hypospaia surgery, but the things he taught me were good at that moment, but I very quickly learned that they were not the best way to fix things. I learned to do one-stage ducket repairs, and I had 100% complications. with those. I went to buyer's flats. I had 100% complications with those. I did not learn how to make a normal penis. So I got a good solid foundation in Hypospadius using fine instruments, careful technique. But I did not learn the best house to build on that foundation, and I've been building that house ever since I left my training. Which is not too much of a surprise because times change. I mean, that's what I looked like in those days. So thank you very much for your attention. This is our home now, the Hypospadia Specialty Center. This is our building. This is our surgery center. This is where we operate every single day. You can come visit us. Those of you who are immunized, you could come now, really, but you're welcome to come visit us. As I say, we operate, and most of what we do, 2/3 of our cases are proximal hypospadius and. Redo things. So you can come and spend just even a week or so with us and see all the things that we've talked about today. You can email us at these easy to remember email addresses. You can watch all of our videos on YouTube and you can always email us, uh, but you can join this Hypospadiology email group where a number of us around the world chat about things related to Hypospadius in an open forum. So thank you for your attention and I appreciate again uh being invited to speak. Well, thank you very much, Warren. It was a fantastic lecture and for those who didn't see your videos on YouTube, I strongly recommend to do that. I learned tremendous amount of, uh, from, from those videos. They're very, very well professionally done. I enjoy your comments and you really go above and beyond trying to teach us what to do and how to do it rightly. So we have uh quite a few case presentations which we would like to discuss and cover.