Supplemental testosterone (T) is used to increase penile size in prepubertal boys. Its use in hypospadias surgery has been controversial for as long as it has been used. Those against raise concerns for increased inflammation and poor wound healing, putting the patient at higher risk for complication development. Those in favor hypothesize that the increase in glans width decreases glansplasty and urethroplasty complications by reducing the tension on the ventral aspect of the repair. Unfortunately, the literature to date remains mixed with no definitive recommendation for or against its use.¹

We recently published our experience with preoperative use of T for patients undergoing hypospadias surgery in The Journal of Urology^®.² In order to systematically examine the role of T use in our practice we incorporated standardized measurements of glans width in the office and operating room. Indications for preoperative T included small glans size and/or anatomical concerns that may hinder repair, such as a narrow glans groove. T administration was standardized, administered intramuscularly 5 and 2-3 weeks prior to surgery if 2 doses were administered or only at 2-3 weeks if a single dose was given (Figure 1). There was a clear increase in glans width for patients who received preoperative testosterone, as well as a dose-related response for 1 vs 2 doses, 2 vs 4 mm, respectively (Figure 2). We did not examine the impact on surgical outcomes as this study was not sufficiently powered to answer this question, instead focusing our efforts on identifying the quantitative change in glans width that one can expect with T administration.

Prior studies have looked at changes in penile length, but none have given an objective assessment of the change in glans width. The response generated in our large cohort will help surgeons determine the expected patient response to T for surgery. Ultimately, our study is limited by the fact that we were not sufficiently powered to assess the effect of increased glans width on surgical outcomes. Once we have accumulated a sufficient number of patients, we will be able to determine if the change in glans width does result in improved surgical outcomes.

Extending beyond the physiological response to T, examining the literature suggests that selective use of T may ultimately be its optimal use. In addition to, or perhaps independent of, a small glans size, a flattened glans groove requires deeper glans incisions and ventral tissue rotation. Depending upon the repair type–these concerns may be higher with a Thiersch-Duplay repair vs. a tubularized incised plate or island onlay type of repair–T supplementation may decrease the risk of complications with these specific variants. Patients with a prior hypospadias repair resulting in glans tissue loss or a scarred plate may also present unique challenges and could warrant T supplementation.

In our study of 579 patients, of whom 247 received T, no side effects were noted. A unique finding in our study was that the increased penile size in response to T persisted at the 2-year follow-up time point, with glans width equal for both groups even after the T was cleared from the boy’s system. This has important considerations–T was given for patients with smaller glans, and the fact that these patients normalized in size with their peers will have important considerations in the future as patients age. Patient-reported outcome measures suggest that smaller penile size is a concern for patients with hypospadias, and preoperative T may be able to mitigate this issue.

As much as we can glean from our study, the limitations of the literature to date amplify the need to study these patients in a systematic fashion with enough patients to determine the true effect on surgical outcomes. We continue our efforts to expand the usage of our standardized operative and perioperative notes at our own institutions. The Society for Pediatric Urology Hypospadias Task Force is making efforts toward establishing a multi-institutional database to increase our ability to collaborate across surgeons in hopes of answering not only the role of T in hypospadias management but also identifying other ways to improve surgical outcomes.