The role of preoperative hormonal treatment in surgical outcomes of proximal and midshaft hypospadias repair

Proximal and midshaft hypospadias represent the most challenging forms within the hypospadias spectrum, owing to severe ventral curvature, small glans size, poor tissue quality and persistently high postoperative complication rates. Preoperative hormonal treatment (PHT) with testosterone has been proposed as an adjunctive strategy to optimize local anatomy before reconstruction; however, its role in improving surgical outcomes remains debated. We conducted a retrospective, single-centre observational study including boys with proximal or midshaft hypospadias who underwent surgical repair between August 2001 and October 2025. During the study period, transdermal PHT was administered selectively according to predefined anatomical criteria, namely a glans width below 14 mm and/or ventral curvature greater than 30°. Hormonally treated patients were compared with untreated controls matched for hypospadias severity and age at surgical procedure. Genital measurements were recorded before and after PHT and surgical techniques and postoperative outcomes were analysed, including urethrocutaneous fistula, glans dehiscence, urethral stenosis, reintervention and cosmetic appearance assessed using the External Genitalia Score (EGS). Forty-eight patients were included, of whom 16 received PHT and 32 served as controls. Hormonal stimulation was associated with consistent increases in both glans width and penile shaft length, with large effect sizes on paired analyses, indicating a substantial anatomical response to therapy. The distribution of surgical techniques did not differ significantly between groups. Postoperative complications were frequent in both cohorts and occurred at comparable rates in hormonally treated and untreated patients. When stratified by hypospadias subtype, outcomes in proximal forms remained similar regardless of hormonal exposure, whereas among children with midshaft hypospadias a lower incidence of postoperative complications was observed in hormonally treated patients. Overall, selective and phenotype-driven PHT produced clinically meaningful preoperative anatomical changes but was not associated with a global reduction in postoperative complications in this cohort. Subgroup findings suggest that anatomical severity may influence the potential benefit of hormonal stimulation. These results support the use of individualized PHT in carefully selected patients and highlight the need for larger prospective studies focused on severe hypospadias phenotypes.