Second‐Stage Urethroplasty With Simultaneous Penoscrotal Transposition Correction in Proximal Hypospadias: Outcomes of a Modified Byars Two‐Stage Strategy

PURPOSE: To evaluate the outcomes of simultaneous penoscrotal transposition (PST) correction during second-stage urethroplasty in boys with severe proximal hypospadias, with particular emphasis on urethrocutaneous fistula formation at the penoscrotal junction and postoperative cosmetic outcomes. MATERIALS AND METHODS: We retrospectively reviewed 95 boys with proximal hypospadias associated with PST who underwent a modified Byars two-stage repair at a single tertiary referral center between October 2018 and December 2024. All patients underwent the same first-stage modified Byars procedure, in which the ventral skin flap was routinely anchored to the tunica albuginea to create a stable urethral plate for subsequent reconstruction. At the second stage, patients were divided according to whether PST was corrected concurrently. Group A (n = 44) underwent Thiersch-Duplay urethroplasty combined with PST correction using a modified Glenn-Anderson technique, whereas Group B (n = 51) underwent urethroplasty alone. Surgical outcomes were assessed using the Hypospadias Objective Scoring Evaluation (HOSE), and parental satisfaction with postoperative genital appearance was assessed using the Pediatric Penile Perception Score (PPPS). RESULTS: Median total HOSE scores were significantly higher in Group A than in Group B (16 [15-16] vs. 14 [13-15], p < 0.01). Median total PPPS scores were also higher in Group A than in Group B (12 [12-15] vs. 12.00 [10-12], p < 0.01). Urethral fistulas occurred in three of 44 patients (6.8%) in Group A and 11 of 51 patients (21.6%) in Group B (p = 0.04). Notably, no fistulas at the penoscrotal junction were observed in Group A, whereas six occurred in Group B. CONCLUSION: Within a modified Byars two-stage strategy incorporating standardized first-stage ventral flap anchoring, simultaneous correction of PST during second-stage urethroplasty was associated with better cosmetic and functional outcomes. This approach may help reduce fistula formation at the penoscrotal junction while avoiding an additional reconstructive procedure.