How I devised my own Technique of Hypospadias Repair

Hypospadias is a very complex reconstructive operation. There are over 200 techniques of hypospadias repair described. Many of these techniques are not used anymore. Presently in hypospadias surgery, about 8-10 techniques are regularly employed by experts. This is because hypospadias is a very versatile and variable abnormality and no two cases with hypospadias have the same anatomy. The choice of what technique to be used in which patient is very crucial and comes only with experience. Because it is difficult to master so many techniques, some surgeons use only 1 technique for all hypospadias, which results in poor results in most of the patients. An ideal hypospadias expert should have mastered many techniques and should use the most appropriate technique in each patient.

One of the popular techniques in the repair of distal hypospadias is ‘urethral advancement’ technique. There are many different variations of using this technique, some are complete and some are partial advancements. I have used both complete and partial advancement techniques with good success. As my experience with hypospadias surgery increased, I refined and modified the urethral advancement technique so that the results are consistent and the complications are minimised. I named this the ‘DRAG’ (Dartos Release, Advancement and Glansplasty) technique and presented my technique and its initial results at an International Hypospadias meeting in Germany in 2015. As with most techniques of hypospadias repair, the most important secret for the success of DRAG technique is

1. Selecting the correct patient and the correct type of hypospadias for this technique
2. Fine dissection of the delicate tissues
3. Use of magnifying loupes for the fine surgery
4. Attention to detail
5. Use of fine sutures for the repair
6. Understanding hypospadias in general and the technique in particular

Subsequently I have taught this DRAG technique to many surgeons both from India and abroad, either by direct observation of my live surgery (many surgeons come to Hyderabad and spend a few weeks to months with me to learn hypospadias and other complex operations), or indirectly by discussions and reading my ‘Hypospadias Surgery: Science and Art’ book, published in 2019. Many surgeons have used it in their practice and expressed satisfaction with the good results that they got. I feel very happy that my modified technique ‘DRAG’ is helping many children from across the globe.

The biggest mistake that many young surgeons make with hypospadias operations is thinking that one technique that gave good results in some cases would give the same result in all cases. This is a very wrong notion. The ‘one size fits all’ theory never works in hypospadias surgery. The DRAG technique is suitable in only about 50-60% of distal hypospadias cases. In suitable cases, it gives excellent results >95% success and a complication rate of <5%. However, case selection is very important, to use it only in suitable cases. This case selection is best made on the operating table during the surgery. In other words, one should not DRAG too much!! This is true for all techniques of hypospadias repair. Any technique gives good results only with appropriate case selection.

It is very interesting that some parents ask me in the outpatient clinic “Doctor, are you going to use the TIP operation (or GAP or Mathieu or Duckett operation, the list can be endless) for my child?” This is the result of excessive google search! As I said before, most techniques of hypospadias repair are suitable only in the appropriate cases. When used in the wrong (unsuitable) case, they can cause horrible complications. I regularly see such complications in my practice coming from all over the country! So my advice to the parents is not to go into too many details of the techniques of hypospadias surgery, but to search for the right ‘Hypospadialogist’ surgeon for their child. The right surgeon will decide what is the best technique for your child’s hypospadias.