Technical challenge of the megameatus intact prepuce hypospadias variant: the pyramid procedure

An unusual variant of hypospadias is the focus of this report. This distal variant consists of a megameatus and urethra in the presence of intact foreskin. Recognition is important, not only because of the uncommon combination of findings, which run contrary to the classical presentation of most hypospadias, but also because of the technical shortcomings that are encountered during repair with standard techniques. The pyramid procedure is described, which allows for an end-on dissection of the distal megameatus-urethra, enabling a reduction in caliber of both while facilitating remodeling of the glans. The procedure has proved to be successful and reliable for this particular hypospadias variant. No complications have been encountered.