Prospective microvessel density profiling across severity of hypospadias: understanding preputial tissue angiogenic deficit and the impact of preoperative testosterone stimulation.

BACKGROUND: Vascular adequacy of preputial tissue is a critical determinant of successful hypospadias repair. Previous studies have suggested reduced microvessel density (MVD) in hypospadias, but evidence is limited by heterogeneity and lack of standardized prospective data. This study aimed to evaluate MVD across hypospadias severity and assess the impact of preoperative testosterone stimulation. METHODS: A prospective observational study was conducted including children with distal and proximal hypospadias along with controls. Standardized dorsal preputial biopsies were analyzed using CD34 immunohistochemistry. MVD was quantified as vessels per high-power field (HPF). Proximal cases were analyzed separately based on testosterone exposure. Non-parametric statistical comparisons were performed between groups. RESULTS: MVD demonstrated a stepwise decline from control (45.4 ± 4.3 vessels/HPF) to distal (33.1 ± 7.4) and proximal hypospadias without testosterone (12.5 ± 3.7) (p < 0.0001). Testosterone significantly increased MVD in proximal cases (45.7 ± 10.8), restoring values to near-control levels (p = 0.48). Skin necrosis occurred in 6 cases and was associated with significantly lower MVD (12.2 ± 2.3 vs. 27.1 ± 3.2, p < 0.05). Three such cases progressed to urethrocutaneous fistula. CONCLUSION: Hypospadias is associated with a severity-dependent angiogenic deficit, most pronounced in proximal cases. Preoperative testosterone significantly enhances MVD, suggesting a modifiable microvascular component. Reduced MVD correlates with adverse outcomes, supporting its potential role as a predictive biomarker to reduce morbidity. Further longitudinal studies correlating MVD with surgical outcomes are warranted.